1
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Camafort M, Chung WJ, Shin JH. Role of ambulatory blood pressure monitoring in elderly hypertensive patients. Clin Hypertens 2022; 28:22. [PMID: 35773739 PMCID: PMC9248111 DOI: 10.1186/s40885-022-00205-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/10/2022] [Indexed: 01/02/2023] Open
Abstract
Background Arterial hypertension is facing some changes in the last years. Its prevalence is increasing in elderly subjects. This growing prevalence is due to longer survival of the population worldwide, among other factors. On the other hand, recent guidelines have insisted in the relevance of out of office blood pressure measurements, to improve diagnostic and management of hypertension. Therefore, elderly subjects with hypertension could benefit from out of office blood pressure measurements, like ambulatory blood pressure measurements; nevertheless, there are very few or no specific recommendations regarding this. Aim In this review, we will gather the most important information about this subject. Results As hypertension in the elderly has some specific characteristics related to aging of the cardiovascular system, the most important aspect could be that these characteristics make ambulatory blood pressure measurement suitable for its use in elderly. Among those a higher prevalence of white coat hypertension, white coat phenomenon, and a higher nocturnal blood pressure and higher prevalence of nondipper and riser pattern, represent aspects that should be considered for better diagnostic and an improved management. Conclusion As the prevalence of hypertension will grow in the next years, more studies specifically directed to this subject are needed. Supplementary Information The online version contains supplementary material available at 10.1186/s40885-022-00205-6.
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Affiliation(s)
- Miguel Camafort
- ESH Excellence Hypertension Center, Department of Internal Medicine, Geriatrics Section, Hospital Clinic, University of Barcelona, Barcelona, Spain. .,Research Group on Cardiovascular Risk, Nutrition and Aging, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain. .,Research Group CB06/03/0019, Biomedical Network Research Center in Obesity and Nutrition (CIBER-OBN), Institute of Health Carlos III (ISCIII), Ministry of Science, Innovation and Universities, Madrid, Spain.
| | - Wook-Jin Chung
- Department of Cardiovascular Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea.,Gachon Cardiovascular Research Institute, Gachon University, Incheon, Republic of Korea
| | - Jin-Ho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
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2
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Ambulatory diastolic blood pressure: a marker of comorbidity in elderly fit hypertensive individuals? J Geriatr Cardiol 2022; 19:254-264. [PMID: 35572223 PMCID: PMC9068589 DOI: 10.11909/j.issn.1671-5411.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Masked diastolic hypotension is a new blood pressure (BP) pattern detected by ambulatory blood pressure monitoring (ABPM) in elderly hypertensives. The aim of this study was to relate ABPM and comorbidity in a cohort of fit elderly subjects attending an outpatient hypertension clinic. METHODS Comorbidity was assessed by Charlson comorbidity index (CCI) and CHA2DS2VASc score. All subjects evaluated with ABPM were aged ≥ 65 years. CCI and CHA2DS2VASc score were calculated. Diastolic hypotension was defined as mean ambulatory diastolic BP < 65 mmHg and logistic regression analysis was carried out in order to detect and independent relationship between comorbidity burden and night-time diastolic BP < 65 mmHg. RESULTS We studied 174 hypertensive elderly patients aged 72.1 ± 5.2 years, men were 93 (53.4%). Mean CCI was 0.91 ± 1.14 and mean CHA2DS2VASc score of 2.68 ± 1.22. Subjects with night-time mean diastolic values < 65 mmHg were higher in females [54.7% vs. 45.3%, P = 0.048; odds ratio (OR) = 1.914, 95% CI: 1.047-3.500]. Logistic regression analysis showed that only CHA2DS2VASc score was independently associated with night-time mean diastolic values < 65 mmHg (OR = 1.518, 95% CI: 1.161-1.985; P = 0.002), but CCI was not. CONCLUSIONS ABPM and comorbidity evaluation appear associated in elderly fit subjects with masked hypotension. Comorbid women appear to have higher risk for low ambulatory BP.
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Kleipool EEF, Rozendaal ES, Mahadew SKN, Kramer MHH, van den Born BJH, Serné EH, Peters MJL, Muller M. The value of ambulatory blood pressure measurement to detect masked diastolic hypotension in older patients treated for hypertension. Age Ageing 2021; 50:1229-1235. [PMID: 33454734 DOI: 10.1093/ageing/afaa287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE assess how many patients with low ambulatory diastolic blood pressure (DBP) are not identified when relying on office DBP alone, and thus have 'masked diastolic hypotension'. DESIGN cross-sectional, retrospective cohort study. SETTING academic hospital. SUBJECTS 848 patients treated for hypertension who received ambulatory blood pressure monitoring (ABPM). METHODS cut-off value between on- and off-target systolic blood pressure (SBP): 140 mmHg. Cut-off for low office and/or ambulatory DBP: DBP ≤ 70 mmHg. 'Masked diastolic hypotension' was defined as office DBP > 70 mmHg and mean ambulatory DBP ≤ 70 mmHg. RESULTS mean age of the sample was 60 ± 13 years, 50% was female, 37% had diabetes, 42% preexisting cardiovascular disease (CVD), mean office blood pressure (BP) was 134/79 mmHg. In all patients (n = 848), low office DBP was present in n = 84(10%), while n = 183(22%) had low ambulatory DBP. In all patients with normal-to-high office DBP (n = 764), n = 122(16%) had 'masked diastolic hypotension'. In this group, ambulatory DBP was 14-19 mmHg lower than office DBP. Patients with low ambulatory DBP were older, had more (cardiovascular) comorbidities, and used more (antihypertensive) drugs. Antihypertensive drugs were lowered or discontinued in 30% of all patients with 'masked diastolic hypotension' due to side effects. CONCLUSIONS 'masked diastolic hypotension' is common among patients treated for hypertension, particularly in older patients with CVD (e.g. coronary artery disease, diabetes), patient groups in which the European Society of Cardiology/Hypertension guideline advises to prevent low DBP. Although it remains to be examined at which BP levels the harms of low DBP outweigh the benefits of lowering SBP, our observations are aimed to increase awareness among physicians.
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Affiliation(s)
- Emma E F Kleipool
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Eva S Rozendaal
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Shaya K N Mahadew
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Mark H H Kramer
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Bert-Jan H van den Born
- Department of Vascular/Internal Medicine, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Erik H Serné
- Department of Vascular/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Mike J L Peters
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
- Department of Vascular/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Majon Muller
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
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Papathanasiou IV, Papathanasiou C, Malli F, Tsaras K, Papagiannis D, Kontopoulou L, Kourkouta L, Tsalogliodou A, Tzavella F, Fradelos EC. The Effect of Spirituality on Mental Health Among Hypertensive Elderly People: A Cross-sectional Community-based Study. Mater Sociomed 2021; 32:218-223. [PMID: 33424452 PMCID: PMC7780778 DOI: 10.5455/msm.2020.32.218-223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Elderly suffering from hypertension may also experience other psychological disorders in their daily life, such as depression and anxiety. Moreover, they use spiritual practices to relieve symptoms or comorbidities of hypertension. All these practices produce a calming effect on them. Aim: This study aims at investigating the relation between spirituality and mental health among older adults with hypertension and their sociodemographic characteristics. Methods: A descriptive, cross-sectional study was conducted in Greece. A questionnaire consisting of the sociodemographic characteristics, the FACIT-Sp-12 scale and the General Health Questionnaire-28 (GHQ-28) was completed by a total of 134 hypertensive elderly (≥65 years of age) persons. Descriptive and inferential statistical methods were used. Results: The sample consisted of 42,5% males and 57,5% females, aged 65 to 95 years, with a mean age of 78,38 years (SD= 6,68). A statistically significant correlation was found between FACIT-Sp-12 total score and the “physical discomfort (r=-0,562 p<0.001), “anxiety” (r=-0,735 p<0.001), “social disfunctioning” (r=-0,650 p<0.001), “depression” (r=-0,735 p<0.001) and the total score of GHQ-28 (r=-0,735 p<0.001). Specifically, the higher the total score of spirituality among older hypertensive adults the lower the rates of psychosomatic disorders and the total burden of mental health (and vice versa). Conclusion: Results showed that younger elderly, living in urban areas and not experiencing any other chronic health conditions, have higher levels of spirituality compared to older. Also, a negative correlation was found between spirituality and mental health.
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Affiliation(s)
- Ioanna V Papathanasiou
- Nursing Department, University of Thessaly, Larissa, Greece.,Community Nursing Lab, Nursing Department, University of Thessaly, Larissa, Greece
| | | | - Foteini Malli
- Nursing Department, University of Thessaly, Larissa, Greece
| | | | - Dimitrios Papagiannis
- Nursing Department, University of Thessaly, Larissa, Greece.,Community Nursing Lab, Nursing Department, University of Thessaly, Larissa, Greece
| | - Lamprini Kontopoulou
- Nursing Department, University of Thessaly, Larissa, Greece.,Community Nursing Lab, Nursing Department, University of Thessaly, Larissa, Greece
| | - Lambrini Kourkouta
- Nursing Department, International Hellenic University, Thessaloniki, Greece
| | - Areti Tsalogliodou
- Nursing Department, International Hellenic University, Thessaloniki, Greece
| | | | - Evangelos C Fradelos
- Nursing Department, University of Thessaly, Larissa, Greece.,Community Nursing Lab, Nursing Department, University of Thessaly, Larissa, Greece
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5
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Abstract
Hypertension management is challenging in frail older adults. The balance between treatment risks and benefits may be difficult to achieve due to an increased vulnerability to treatment-related adverse events, and limited evidence is available to support clinical decisions. The effects of frailty on blood pressure are unclear, as well as its impact on antihypertensive treatment benefits. Appropriate blood pressure targets in frail patients are debated and the frailty measure which best inform clinical decisions in hypertensive patients has yet to be identified. Therefore, hypertension management in frail older adults still represents a 'gap in evidence'. Knowledge of currently available literature is a fundamental prerequisite to develop future research and may help to implement frailty assessment and improve hypertension management in this vulnerable population. Given these premises, we present a narrative review illustrating the most relevant issues that are a matter of debate and that should be addressed in future studies.
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6
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Rivasi G, Lucenteforte E, Turrin G, Balzi D, Bulgaresi M, Nesti N, Giordano A, Rafanelli M, Lombardi N, Bonaiuti R, Vannacci A, Mugelli A, Di Bari M, Masud T, Ungar A. Blood pressure and long-term mortality in older patients: results of the Fiesole Misurata Follow-up Study. Aging Clin Exp Res 2020; 32:2057-2064. [PMID: 32227283 DOI: 10.1007/s40520-020-01534-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 03/12/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Optimal blood pressure (BP) control can prevent major adverse health events, but target values are still controversial, especially in older patients with comorbidities, frailty and disability. AIMS To evaluate mortality according to BP values in a cohort of older adults enrolled in the Fiesole Misurata Study, after a 6-year follow-up. METHODS Living status as of December 31, 2016 was obtained in 385 subjects participating in the Fiesole Misurata Study. Patients' characteristics were analysed to detect predictors of mortality. At baseline, all participants had undergone office BP measurement and a comprehensive geriatric assessment. RESULTS After a 6-year follow-up, 97 participants had died (25.2%). After adjustment for comorbidities and comprehensive geriatric assessment, mortality was significantly lower for SBP 140-159 mmHg as compared with 120-139 mmHg (HR 0.54, 95% CI 0.33-0.89). This result was also confirmed in patients aged 75 + (HR 0.49, 95% CI 0.29-0.85), and in those with disability (HR 0.36, 95% CI 0.15-0.86) or taking antihypertensive medications (HR 0.49, 95% CI 0.28-0.86). DISCUSSION An intensive BP control may lead to greater harm than benefit in older adults. Indeed, the European guidelines recommend caution in BP lowering in older patients, especially if functionally compromised, to minimize the risk of hypotension-related adverse events. CONCLUSIONS After a 6-year follow-up, mortality risk was lower in participants with SBP 140-159 mmHg as compared with SBP 120-139 mmHg, in the overall population and in the subgroups of subjects aged 75 + , with a disability or taking anti-hypertensive medications.
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Affiliation(s)
- Giulia Rivasi
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Ersilia Lucenteforte
- Department of Neuroscience, Psychology, Pharmacology & Children Health (NEUROFARBA), University of Florence, Florence, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giada Turrin
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Daniela Balzi
- Epidemiology Unit, Local Health Unit 10, Florence, Italy
| | - Matteo Bulgaresi
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Nicola Nesti
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Antonella Giordano
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Martina Rafanelli
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Niccolò Lombardi
- Department of Neuroscience, Psychology, Pharmacology & Children Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Roberto Bonaiuti
- Department of Neuroscience, Psychology, Pharmacology & Children Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Alfredo Vannacci
- Department of Neuroscience, Psychology, Pharmacology & Children Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Alessandro Mugelli
- Department of Neuroscience, Psychology, Pharmacology & Children Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Mauro Di Bari
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy
| | - Tahir Masud
- Department of Geriatric Medicine, Nottingham University Hospitals Trust NHS, Nottingham, UK
| | - Andrea Ungar
- University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50149, Florence, Italy.
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7
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Divisón-Garrote JA, de la Cruz JJ, de la Sierra A, Vinyoles E, Gorostidi M, Escobar-Cervantes C, Segura J, Barrios V, Ruilope LM, Banegas JR. Prevalence of office and ambulatory hypotension in treated hypertensive patients with coronary disease. Hypertens Res 2020; 43:696-704. [DOI: 10.1038/s41440-020-0462-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 06/08/2019] [Accepted: 06/17/2019] [Indexed: 12/20/2022]
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8
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Mangoni AA, Tommasi S, Zinellu A, Sotgia S, Bassu S, Piga M, Erre GL, Carru C. Methotrexate and Vasculoprotection: Mechanistic Insights and Potential Therapeutic Applications in Old Age. Curr Pharm Des 2019; 25:4175-4184. [DOI: 10.2174/1381612825666191112091700] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023]
Abstract
Increasing age is a strong, independent risk factor for atherosclerosis and cardiovascular disease. Key
abnormalities driving cardiovascular risk in old age include endothelial dysfunction, increased arterial stiffness,
blood pressure, and the pro-atherosclerotic effects of chronic, low-grade, inflammation. The identification of
novel therapies that comprehensively target these alterations might lead to a major breakthrough in cardiovascular
risk management in the older population. Systematic reviews and meta-analyses of observational studies have
shown that methotrexate, a first-line synthetic disease-modifying anti-rheumatic drug, significantly reduces
cardiovascular morbidity and mortality in patients with rheumatoid arthritis, a human model of systemic
inflammation, premature atherosclerosis, and vascular aging. We reviewed in vitro and in vivo studies
investigating the effects of methotrexate on endothelial function, arterial stiffness, and blood pressure, and the
potential mechanisms of action involved. The available evidence suggests that methotrexate might have beneficial
effects on vascular homeostasis and blood pressure control by targeting specific inflammatory pathways,
adenosine metabolism, and 5' adenosine monophosphate-activated protein kinase. Such effects might be
biologically and clinically relevant not only in patients with rheumatoid arthritis but also in older adults with high
cardiovascular risk. Therefore, methotrexate has the potential to be repurposed for cardiovascular risk
management in old age because of its putative pharmacological effects on inflammation, vascular homeostasis,
and blood pressure. However, further study and confirmation of these effects are essential in order to adequately
design intervention studies of methotrexate in the older population.
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Affiliation(s)
- Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Sara Tommasi
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Angelo Zinellu
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Salvatore Sotgia
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Stefania Bassu
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Matteo Piga
- Rheumatology Unit, University Clinic and AOU of Cagliari, Cagliari, Italy
| | - Gian L. Erre
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University Hospital (AOUSS) and University of Sassari, Sassari, Italy
| | - Ciriaco Carru
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
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9
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Kario K, Shin J, Chen C, Buranakitjaroen P, Chia Y, Divinagracia R, Nailes J, Hoshide S, Siddique S, Sison J, Soenarta AA, Sogunuru GP, Tay JC, Teo BW, Turana Y, Zhang Y, Park S, Van Minh H, Wang J. Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: The HOPE Asia Network. J Clin Hypertens (Greenwich) 2019; 21:1250-1283. [PMID: 31532913 PMCID: PMC8030405 DOI: 10.1111/jch.13652] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/07/2019] [Indexed: 01/03/2023]
Abstract
Hypertension is an important public health issue because of its association with a number of significant diseases and adverse outcomes. However, there are important ethnic differences in the pathogenesis and cardio-/cerebrovascular consequences of hypertension. Given the large populations and rapidly aging demographic in Asian regions, optimal strategies to diagnose and manage hypertension are of high importance. Ambulatory blood pressure monitoring (ABPM) is an important out-of-office blood pressure (BP) measurement tool that should play a central role in hypertension detection and management. The use of ABPM is particularly important in Asia due to the specific features of hypertension in Asian patients, including a high prevalence of masked hypertension, disrupted BP variability with marked morning BP surge, and nocturnal hypertension. This HOPE Asia Network document summarizes region-specific literature on the relationship between ABPM parameters and cardiovascular risk and target organ damage, providing a rationale for consensus-based recommendations on the use of ABPM in Asia. The aim of these recommendations is to guide and improve clinical practice to facilitate optimal BP monitoring with the goal of optimizing patient management and expediting the efficient allocation of treatment and health care resources. This should contribute to the HOPE Asia Network mission of improving the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia.
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Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular Medicine, Department of MedicineJichi Medical University School of MedicineTochigiJapan
| | - Jinho Shin
- Faculty of Cardiology ServiceHanyang University Medical CenterSeoulKorea
| | - Chen‐Huan Chen
- Department of MedicineSchool of Medicine National Yang‐Ming UniversityTaipeiTaiwan
| | - Peera Buranakitjaroen
- Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Yook‐Chin Chia
- Department of Medical Sciences, School of Healthcare and Medical SciencesSunway UniversityBandar SunwayMalaysia
- Department of Primary Care Medicine, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Romeo Divinagracia
- University of the East Ramon Magsaysay Memorial Medical Center Inc.Quezon CityPhilippines
| | - Jennifer Nailes
- University of the East Ramon Magsaysay Memorial Medical Center Inc.Quezon CityPhilippines
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of MedicineJichi Medical University School of MedicineTochigiJapan
| | | | - Jorge Sison
- Section of Cardiology, Department of MedicineMedical Center ManilaManilaPhilippines
| | - Arieska Ann Soenarta
- Department of Cardiology and Vascular Medicine, Faculty of MedicineUniversity of Indonesia‐National Cardiovascular Center, Harapan KitaJakartaIndonesia
| | - Guru Prasad Sogunuru
- MIOT International HospitalChennaiIndia
- College of Medical SciencesKathmandu UniversityBharatpurNepal
| | - Jam Chin Tay
- Department of General MedicineTan Tock Seng HospitalSingaporeSingapore
| | - Boon Wee Teo
- Division of Nephrology, Department of MedicineYong Loo Lin School of MedicineSingaporeSingapore
| | - Yuda Turana
- Faculty of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaJakartaIndonesia
| | - Yuqing Zhang
- Divisions of Hypertension and Heart Failure, Fu Wai HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Sungha Park
- Division of Cardiology, Cardiovascular HospitalYonsei Health SystemSeoulKorea
| | - Huynh Van Minh
- Department of Internal Medicine, University of Medicine and PharmacyHue UniversityHueVietnam
| | - Ji‐Guang Wang
- Department of Hypertension, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Shanghai Key Laboratory of Hypertension, Ruijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
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10
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Prevalence and related factors of office and home hypotension in older treated hypertensive patients. Aging Clin Exp Res 2019; 31:1011-1017. [PMID: 30276633 DOI: 10.1007/s40520-018-1045-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/24/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Older hypertensive adults under treatment are especially susceptible to hypotensive episodes, which entail an elevated risk. However, data on this subject are very scarce. AIM The purpose of this study was to determine the prevalence and predictors of office and home hypotension in older (≥ 65 years) treated hypertensive adults. METHODS Blood pressure (BP) was measured at the office and at home, using a validated oscillometric device. Office and home hypotension were defined as systolic BP (SBP) < 110 and/or diastolic BP (DBP) < 70 mmHg, and SBP < 105 and/or DBP < 65 mmHg, respectively. Masked hypotension was considered when office BP ≥ 110/70 and home BP < 105 and/or < 65 mmHg. We evaluated factors associated with hypotension both at the office and at home through multivariable models. RESULTS The prevalence of hypotension among the 302 patients included in the study was 29.8% at the office and 23.9% at home, whereas the prevalence of masked hypotension was 10.4%. Older age, lower body mass index and use of calcium channel blockers were associated with office hypotension, while older age, diabetes and ischemic heart disease were predictors for home hypotension. CONCLUSION Hypotension is frequent in older hypertensive adults under treatment. The presence of diabetes, ischemic heart disease and older age should alert for screening of hypotension at home to avoid overtreatment.
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11
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Niehoff KM, Mecca MC, Fried TR. Medication appropriateness criteria for older adults: a narrative review of criteria and supporting studies. Ther Adv Drug Saf 2019; 10:2042098618815431. [PMID: 30719279 PMCID: PMC6348576 DOI: 10.1177/2042098618815431] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/04/2018] [Indexed: 01/05/2023] Open
Abstract
Polypharmacy is common among older adults and is associated with adverse outcomes. Polypharmacy increases the likelihood of receiving a potentially inappropriate medication (PIM). PIMs have traditionally been defined as medications that have either no benefit (e.g. therapeutic duplication) or increased risk (e.g. altered pharmacodynamics/kinetics with aging). A growing literature supports the notion that these represent only a subset of the potential risks of medications prescribed to older adults. Different authors have proposed new sets of criteria for evaluating medication appropriateness. This narrative review had two objectives: 1) to summarize the contents of these criteria in order to obtain preliminary information about where clinical consensus exists regarding appropriateness; 2) The second was to describe studies examining the risks and benefits of medications identified by the criteria to determine the strength of the evidence supporting the derivation of these criteria. We identified 13 articles sharing overlapping criteria for evaluating appropriateness including: (1) delayed time to benefit; (2) altered benefit-harm ratios in the face of competing risks; (3) effects that do not match patients' goals; and (4) nonadherence. The similarities across the articles suggested strong clinical consensus; however, the articles presented little data directly supporting these criteria. Additional studies provide evidence for the proof of concept that average estimates of benefit and harm derived from randomized controlled trials may differ from the benefits and harms experienced by older persons. However, more data are required to characterize the benefits and harms of medications in the context of the regimen as a whole and the individual's health status.
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Affiliation(s)
- Kristina M. Niehoff
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marcia C. Mecca
- Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Terri R. Fried
- VA Connecticut Healthcare System, CERC 151B, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT USA
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12
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Night-time ambulatory blood pressure is the best pretreatment blood pressure predictor of 11-year mortality in treated older hypertensives. Blood Press Monit 2018; 23:237-243. [DOI: 10.1097/mbp.0000000000000331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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13
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Nguyen DN, Huyghens L, Parra J, Schiettecatte J, Smitz J, Vincent JL. Hypotension and a positive fluid balance are associated with delirium in patients with shock. PLoS One 2018; 13:e0200495. [PMID: 30086136 PMCID: PMC6080753 DOI: 10.1371/journal.pone.0200495] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 06/27/2018] [Indexed: 01/15/2023] Open
Abstract
The pathogenesis of delirium in critically ill patients is multifactorial. How hypotension and hypoxemia affect brain function and whether they can promote delirium remains unclear. A high cumulative positive fluid balance may also have a negative effect on brain function and promote delirium. We hypothesized that delirium would be more likely to develop in patients with low systemic arterial pressure, hypoxemia and a higher positive fluid balance, and investigated these associations in a prospective observational cohort study in patients with shock. After initial resuscitation, episodes of hypotension, defined as a mean arterial pressure (MAP) <65 mmHg or diastolic pressure <60 mmHg, and hypoxemia, defined as peripheral oxygen saturation (SpO2) <90% for more than one minute or any arterial oxygen concentration (PaO2) <90 mmHg, were recorded during the first 5 days of the ICU stay. Fluid balance was evaluated daily and the 5-day cumulative fluid balance recorded. Delirium was assessed using the Confusion Assessment Method for the ICU. A total of 252 patients were admitted with shock during the study period; 185 (73%) developed delirium. Patients who developed delirium also had more episodes of hypotension with a low MAP (p = 0.013) or diastolic pressure (p = 0.018) during the first five days of the ICU stay than those who did not. Patients with a higher cumulative fluid balance during the same period were also more likely to develop delirium (p = 0.01); there was no significant difference in the occurrence of hypoxemia between groups. Joint modeling, combining a linear-mixed model and an adjusted Cox survival model showed that low diastolic pressure (alpha effect = -0.058±0.0013, p = 0.043) and a positive cumulative fluid balance (alpha effect = 0.04±0.003, p = 0.021) were independently associated with delirium. In conclusion, low diastolic pressure and a cumulative positive fluid balance but not hypoxemia were independently associated with development of delirium in patients with shock.
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Affiliation(s)
- Duc Nam Nguyen
- Department of Critical Care Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Luc Huyghens
- Department of Critical Care Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Parra
- Department of Biostatistics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Johan Schiettecatte
- Laboratory of Clinical Chemistry & Radioimmunology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Johan Smitz
- Laboratory of Clinical Chemistry & Radioimmunology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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14
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Balietti P, Spannella F, Giulietti F, Rosettani G, Bernardi B, Cocci G, Bonfigli AR, Sarzani R. Ten-year changes in ambulatory blood pressure: The prognostic value of ambulatory pulse pressure. J Clin Hypertens (Greenwich) 2018; 20:1230-1237. [PMID: 29981188 DOI: 10.1111/jch.13344] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/22/2018] [Accepted: 06/07/2018] [Indexed: 11/27/2022]
Abstract
Blood pressure (BP) changes and risk factors associated with pulse pressure (PP) increase in elderly people have rarely been studied using ambulatory blood pressure monitoring (ABPM). The aim is to evaluate 10-year ambulatory blood pressure (ABP) changes in older hypertensives, focusing on PP and its associations with mortality. An observational study was conducted on 119 consecutive older treated hypertensives evaluated at baseline (T0) and after 10 years (T1). Treatment adherence was carefully assessed. The authors considered clinical parameters at T1 only in survivors (n = 87). Patients with controlled ABP both at T0 and T1 were considered as having sustained BP control. Change in 24-hour PP between T0 and T1 (Δ24-hour PP) was considered for the analyses. Mean age at T0: 69.4 ± 3.7 years. Females: 57.5%. Significant decrease in 24-hour, daytime, and nighttime diastolic BP (all P < .05) coupled with an increase in 24-hour, daytime, and nighttime PP (all P < .05) were observed at T1. Sustained daytime BP control was associated with lower 24-hour PP increase than nonsustained daytime BP control (+2.23 ± 9.36 vs +7.79 ± 8.64 mm Hg; P = .037). The association between sustained daytime BP control and Δ24-hour PP remained significant even after adjusting for age, sex, and 24-hour PP at T0 (β=0.39; P = .035). Both 24-hour systolic BP and 24-hour PP at T0 predicted mortality (adjusted HR 1.07, P = .001; adjusted HR 1.25, P < .001, respectively). After ROC comparison (P = .001), 24-hour PP better predicted mortality than 24-hour systolic BP. The data confirm how ABP control affects vascular aging leading to PP increase. Both ambulatory PP and systolic BP rather than diastolic BP predict mortality in older treated hypertensives.
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Affiliation(s)
- Paolo Balietti
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS-INRCA "U.Sestilli", Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche", Ancona, Italy
| | - Francesco Spannella
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS-INRCA "U.Sestilli", Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche", Ancona, Italy
| | - Federico Giulietti
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS-INRCA "U.Sestilli", Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche", Ancona, Italy
| | - Giulia Rosettani
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS-INRCA "U.Sestilli", Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche", Ancona, Italy
| | - Beatrice Bernardi
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS-INRCA "U.Sestilli", Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche", Ancona, Italy
| | - Guido Cocci
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS-INRCA "U.Sestilli", Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche", Ancona, Italy
| | - Anna R Bonfigli
- Clinical Research Office, IRCCS-INRCA "U.Sestilli", Ancona, Italy
| | - Riccardo Sarzani
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS-INRCA "U.Sestilli", Ancona, Italy.,Department of Clinical and Molecular Sciences, University "Politecnica delle Marche", Ancona, Italy
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15
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Garfinkel D. Poly-de-prescribing to treat polypharmacy: efficacy and safety. Ther Adv Drug Saf 2018; 9:25-43. [PMID: 29318004 PMCID: PMC5753993 DOI: 10.1177/2042098617736192] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/28/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate efficacy and safety of poly-de-prescribing (PDP) based on the Garfinkel method in older people with polypharmacy. METHODS A longitudinal, prospective, nonrandomized study in Israel was carried out between 2009 and 2016. Comprehensive geriatric assessments were performed at home in people age ⩾66 years consuming ⩾6 prescription drugs. Exclusion criteria were life expectancy <6 months and a seeming unwillingness to cooperate (poor compliance). PDP of ⩾3 prescription drugs was recommended. Follow up was at ⩾3 years. Between April 2015 and April 2016 Likert scale questionnaires were filled by all participants/families to evaluate overall satisfaction and clinical outcomes. The outcome measures were change in functional, mental and cognitive status, sleep quality, appetite, continence; major complication, hospitalizations, mortality, and family doctor's cooperation. RESULTS Poly-de-prescribing of ⩾3 drugs was eventually achieved by 122 participants (PDP group); ⩽2 drugs stopped by 55 'nonresponders' (NR group). The average age was 83.4 ± 5.3 in the PDP group, and 80.8 ± 6.3 in the NR group (p = 0.0045). Follow up was 43.6 ± 14 months (PDP) and 39.5 ± 16.6 months (NR) (p = 0.09). The prevalence of most diseases/symptoms was comparable except for a higher prevalence for dementia, incontinence and functional decline in the PDP group. The main barrier to de-prescribing was the family doctor's unwillingness to adopt PDP recommendations (p < 0.0001). The baseline median number of medications taken by both groups was 10 (IQR 8 to 12) (p = 0.55). On the last follow up, the drug count was 11 (IQR 8 to 12) in the NR group and 4 (IQR 2 to 5) in the PDP group (p =0.0001). The PDP group showed significantly less deterioration (sometimes improvement) in general satisfaction, functional, mental and cognitive status, sleep quality, appetite, sphincter control, and the number of major complications was significantly reduced (p < 0.002 in all). The rate of hospitalizations and mortality was comparable. Health improvement occurred within 3 months after de-prescribing in 83%, and persisted for ⩾2 years in 68%. CONCLUSIONS This self-selected sample longitudinal research strongly suggests that the negative, usually invisible effects of polypharmacy are reversible. PDP is well tolerated and associated with improved clinical outcomes, in comparison with outcomes of older people who adhere to all clinical guidelines and take all medications conventionally. Future double-blind studies will probably prove beneficial economic outcomes as well.
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Affiliation(s)
- Doron Garfinkel
- Geriatric Palliative service, E. Wolfson Medical Center, Holon 58100 & Homecare hospice, Israel Cancer Association, Israel
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16
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Diastolic hypotension due to intensive blood pressure therapy: Is it harmful? Atherosclerosis 2017; 265:29-34. [DOI: 10.1016/j.atherosclerosis.2017.07.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/12/2017] [Accepted: 07/18/2017] [Indexed: 11/19/2022]
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17
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Divisón-Garrote JA, Ruilope LM, de la Sierra A, de la Cruz JJ, Vinyoles E, Gorostidi M, Escobar-Cervantes C, Velilla-Zancada SM, Segura J, Banegas JR. Magnitude of Hypotension Based on Office and Ambulatory Blood Pressure Monitoring: Results From a Cohort of 5066 Treated Hypertensive Patients Aged 80 Years and Older. J Am Med Dir Assoc 2017; 18:452.e1-452.e6. [DOI: 10.1016/j.jamda.2017.01.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 01/23/2017] [Indexed: 01/30/2023]
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18
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Divisón-Garrote JA, Banegas JR, De la Cruz JJ, Escobar-Cervantes C, De la Sierra A, Gorostidi M, Vinyoles E, Abellán-Aleman J, Segura J, Ruilope LM. Hypotension based on office and ambulatory monitoring blood pressure. Prevalence and clinical profile among a cohort of 70,997 treated hypertensives. ACTA ACUST UNITED AC 2016; 10:714-23. [DOI: 10.1016/j.jash.2016.06.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/11/2016] [Accepted: 06/18/2016] [Indexed: 10/21/2022]
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19
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Weiss JW. The Continued Quest for Optimal BP Targets in Older Adults with Kidney Disease. Clin J Am Soc Nephrol 2016; 11:753-755. [PMID: 27103622 PMCID: PMC4858475 DOI: 10.2215/cjn.03100316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Jessica W Weiss
- Division of Nephrology and Hypertension, Department of Internal Medicine, Oregon Health and Science University, Portland, Oregon
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20
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Cardiovascular risk stratification and blood pressure variability on ambulatory and home blood pressure measurement. Curr Hypertens Rep 2015; 16:470. [PMID: 25097109 DOI: 10.1007/s11906-014-0470-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
UNLABELLED Variability is a phenomenon attributed to most biological processes and is a particular feature of blood pressure (BP) that concerns many physicians regarding the clinical meaning and the impact on their clinical practice. In this review, we assessed the role of different indices of BP variability in cardiovascular risk stratification. We reviewed the indices of BP variability derived from ambulatory BP monitoring (day-to-night ratio, morning surge of BP, and short-term BP variability) and home BP measurement (standardized conventional BP measurement and self-BP measurement), and summarized our recent results with the intention to provide a clear message for clinical practice. CONCLUSION BP variability, either derived from ambulatory BP measurement or home BP measurement does not substantially refine cardiovascular risk prediction over and beyond the BP level. Practitioners should be aware that BP level remains the main modifiable risk factor derived from BP measurement and contributes to improving the control of hypertension and adverse health outcomes.
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21
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Gutiérrez-Misis A, Sánchez-Santos MT, Banegas JR, Castell MV, González-Montalvo JI, Otero A. Walking speed and high blood pressure mortality risk in a Spanish elderly population. J Hum Hypertens 2015; 29:566-72. [PMID: 25880596 DOI: 10.1038/jhh.2015.32] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 03/01/2015] [Accepted: 03/04/2015] [Indexed: 01/13/2023]
Abstract
This study analyzed the relationship between blood pressure and all-cause mortality according to objectively measured walking speed in a Mediterranean population-based sample of older persons. We used data from the longitudinal 'Peñagrande' Cohort Study, initiated in 2008 in a sex- and age-stratified random sample of 1250 people aged ⩾65 years living in Madrid (Spain). A total of 814 individuals participated in the first study wave. The average of two standardized blood pressure readings was used. Walking speed was measured over a 3-m walk and classified as faster (⩾0.8 m s(-1)) or slower. A total of 314 individuals were slower walkers, 475 were faster walkers and 25 did not complete the walk test. Cox proportional hazards models stratified by walking speed were used to assess the association between blood pressure and all-cause death. Non-linear relationship between BP and mortality was explored by a restricted cubic spline analysis. There were 171 deaths from study entry through 31 March 2013. Systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mmHg were associated with higher mortality than blood pressure values above 140 and 90 mm Hg, respectively, but this association reached statistical significance only for systolic blood pressure and only in the slower walkers. In conclusion, systolic blood pressure levels <140 mm Hg were found associated with higher risk of total mortality among slower walkers in an old Spaniard population cohort.
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Affiliation(s)
| | - M T Sánchez-Santos
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - J R Banegas
- 1] Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain [2] IdiPAZ, CIBER of Epidemiology and Public Health, Madrid, Spain
| | - M V Castell
- 1] Centro de Salud Dr Castroviejo, Primary Care, IdiPAZ, Madrid, Spain [2] IdiPAZ, Madrid, Spain
| | - J I González-Montalvo
- 1] IdiPAZ, Madrid, Spain [2] Department of Geriatrics, La Paz University Hospital, Madrid, Spain
| | - A Otero
- 1] Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, Madrid, Spain [2] IdiPAZ, Madrid, Spain
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22
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Franklin SS, Gokhale SS, Chow VH, Larson MG, Levy D, Vasan RS, Mitchell GF, Wong ND. Does low diastolic blood pressure contribute to the risk of recurrent hypertensive cardiovascular disease events? The Framingham Heart Study. Hypertension 2014; 65:299-305. [PMID: 25421982 DOI: 10.1161/hypertensionaha.114.04581] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Whether low diastolic blood pressure (DBP) is a risk factor for recurrent cardiovascular disease (CVD) events in persons with isolated systolic hypertension is controversial. We studied 791 individuals (mean age 75 years, 47% female, mean follow-up time: 8±6 years) with DBP <70 (n=225) versus 70 to 89 mm Hg (n=566) after initial CVD events in the original and offspring cohorts of the Framingham Heart Study. Recurrent CVD events occurred in 153 (68%) participants with lower DBP and 271 (48%) with higher DBP (P<0.0001). Risk of recurrent CVD events in risk factor-adjusted Cox regression was higher in those with DBP <70 mm Hg versus DBP 70 to 89 mm Hg in both treated (hazard ratio, 5.1 [95% confidence interval: 3.8-6.9] P<0.0001) and untreated individuals (hazard ratio, 11.7 [95% confidence interval: 6.5-21.1] P<0.0001; treatment interaction: P=0.71). Individually, coronary heart disease, heart failure, and stroke recurrent events were more likely with DBP <70 mm Hg versus 70 to 89 mm Hg (P<0.0001). To examine for an effect of wide pulse pressure on excess risk associated with low DBP, we defined 4 binary groupings of pulse pressure (≥68 versus <68 mm Hg) and DBP (<70 versus 70-89 mm Hg). CVD incidence rates were higher only in the group with pulse pressure ≥68 and DBP <70 mm Hg (76% versus 46%-54%; P<0.001). Persons with isolated systolic hypertension and prior CVD events have increased risk for recurrent CVD events in the presence of DBP <70 mm Hg versus DBP 70 to 89 mm Hg, whether treated or untreated, supporting wide pulse pressure as an important risk modifier for the adverse effect of low DBP.
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Affiliation(s)
- Stanley S Franklin
- From the Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine (S.S.F., S.S.G., V.H.C., N.D.W.); Framingham Heart Study, MA (M.G.L., D.L., R.S.V., G.F.M.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); Departments of Biostatistics (M.G.L.) and Epidemiology (R.S.V.), Boston University School of Public Health, MA; Population Sciences Branch, National Heart, Lung and Blood Institute, Bethesda, MD (D.L.); and Sections of Preventive Medicine and Epidemiology, and Cardiology, Department of Medicine, Boston University School of Medicine, MA (R.S.V.).
| | - Sohum S Gokhale
- From the Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine (S.S.F., S.S.G., V.H.C., N.D.W.); Framingham Heart Study, MA (M.G.L., D.L., R.S.V., G.F.M.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); Departments of Biostatistics (M.G.L.) and Epidemiology (R.S.V.), Boston University School of Public Health, MA; Population Sciences Branch, National Heart, Lung and Blood Institute, Bethesda, MD (D.L.); and Sections of Preventive Medicine and Epidemiology, and Cardiology, Department of Medicine, Boston University School of Medicine, MA (R.S.V.)
| | - Vincent H Chow
- From the Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine (S.S.F., S.S.G., V.H.C., N.D.W.); Framingham Heart Study, MA (M.G.L., D.L., R.S.V., G.F.M.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); Departments of Biostatistics (M.G.L.) and Epidemiology (R.S.V.), Boston University School of Public Health, MA; Population Sciences Branch, National Heart, Lung and Blood Institute, Bethesda, MD (D.L.); and Sections of Preventive Medicine and Epidemiology, and Cardiology, Department of Medicine, Boston University School of Medicine, MA (R.S.V.)
| | - Martin G Larson
- From the Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine (S.S.F., S.S.G., V.H.C., N.D.W.); Framingham Heart Study, MA (M.G.L., D.L., R.S.V., G.F.M.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); Departments of Biostatistics (M.G.L.) and Epidemiology (R.S.V.), Boston University School of Public Health, MA; Population Sciences Branch, National Heart, Lung and Blood Institute, Bethesda, MD (D.L.); and Sections of Preventive Medicine and Epidemiology, and Cardiology, Department of Medicine, Boston University School of Medicine, MA (R.S.V.)
| | - Daniel Levy
- From the Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine (S.S.F., S.S.G., V.H.C., N.D.W.); Framingham Heart Study, MA (M.G.L., D.L., R.S.V., G.F.M.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); Departments of Biostatistics (M.G.L.) and Epidemiology (R.S.V.), Boston University School of Public Health, MA; Population Sciences Branch, National Heart, Lung and Blood Institute, Bethesda, MD (D.L.); and Sections of Preventive Medicine and Epidemiology, and Cardiology, Department of Medicine, Boston University School of Medicine, MA (R.S.V.)
| | - Ramachandran S Vasan
- From the Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine (S.S.F., S.S.G., V.H.C., N.D.W.); Framingham Heart Study, MA (M.G.L., D.L., R.S.V., G.F.M.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); Departments of Biostatistics (M.G.L.) and Epidemiology (R.S.V.), Boston University School of Public Health, MA; Population Sciences Branch, National Heart, Lung and Blood Institute, Bethesda, MD (D.L.); and Sections of Preventive Medicine and Epidemiology, and Cardiology, Department of Medicine, Boston University School of Medicine, MA (R.S.V.)
| | - Gary F Mitchell
- From the Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine (S.S.F., S.S.G., V.H.C., N.D.W.); Framingham Heart Study, MA (M.G.L., D.L., R.S.V., G.F.M.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); Departments of Biostatistics (M.G.L.) and Epidemiology (R.S.V.), Boston University School of Public Health, MA; Population Sciences Branch, National Heart, Lung and Blood Institute, Bethesda, MD (D.L.); and Sections of Preventive Medicine and Epidemiology, and Cardiology, Department of Medicine, Boston University School of Medicine, MA (R.S.V.)
| | - Nathan D Wong
- From the Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine (S.S.F., S.S.G., V.H.C., N.D.W.); Framingham Heart Study, MA (M.G.L., D.L., R.S.V., G.F.M.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); Departments of Biostatistics (M.G.L.) and Epidemiology (R.S.V.), Boston University School of Public Health, MA; Population Sciences Branch, National Heart, Lung and Blood Institute, Bethesda, MD (D.L.); and Sections of Preventive Medicine and Epidemiology, and Cardiology, Department of Medicine, Boston University School of Medicine, MA (R.S.V.)
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Peralta CA, Katz R, Newman AB, Psaty BM, Odden MC. Systolic and diastolic blood pressure, incident cardiovascular events, and death in elderly persons: the role of functional limitation in the Cardiovascular Health Study. Hypertension 2014; 64:472-80. [PMID: 24935945 PMCID: PMC4134400 DOI: 10.1161/hypertensionaha.114.03831] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 05/14/2014] [Indexed: 12/24/2022]
Abstract
Whether limitation in the ability to perform activities of daily living (ADL) or gait speed can identify elders in whom the association of systolic and diastolic blood pressure (DBP) with cardiovascular events (CVDs) and death differs is unclear. We evaluated whether limitation in ADL or gait speed modifies the association of systolic blood pressure or DBP with incident CVD (n=2358) and death (n=3547) in the Cardiovascular Health Study. Mean age was 78±5 and 21% reported limitation in ≥1 ADL. There were 778 CVD and 1289 deaths over 9 years. Among persons without and those with ADL limitation, systolic blood pressure was associated with incident CVD: hazard ratio [HR] (per 10-mm Hg increase) 1.08 (95% confidence interval, 1.03, 1.13) and 1.06 (0.97, 1.17), respectively. ADL modified the association of DBP with incident CVD. Among those without ADL limitation, DBP was weakly associated with incident CVD, HR 1.04 (0.79, 1.37) for DBP >80, compared with <65 mm Hg. Among those with ADL limitation, DBP was inversely associated with CVD: HR 0.65 (0.44, 0.96) for DBP 66 to 80 mm Hg and HR 0.49 (0.25, 0.94) for DBP >80, compared with DBP ≤65. Among people with ADL limitation, a DBP of 66 to 80 had the lowest risk of death, HR 0.72 (0.57, 0.91), compared with a DBP of ≤65. Associations did not vary by 15-feet walking speed. ADL can identify elders in whom diastolic hypotension is associated with higher cardiovascular risk and death. Functional status, rather than chronologic age alone, should inform design of hypertension trials in elders.
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Affiliation(s)
- Carmen A Peralta
- From the Department of Medicine, University of California, San Francisco (C.A.P.), Nephrology Division, San Francisco VA Medical Center, CA (C.A.P.); Kidney Research Institute (R.K.) and Cardiovascular Health Research Unit (B.M.P.), University of Washington, Seattle; Department of Epidemiology, University of Pittsburgh, PA (A.B.N.); College of Public Health and Human Sciences, Oregon State University, Corvallis (M.C.O.).
| | - Ronit Katz
- From the Department of Medicine, University of California, San Francisco (C.A.P.), Nephrology Division, San Francisco VA Medical Center, CA (C.A.P.); Kidney Research Institute (R.K.) and Cardiovascular Health Research Unit (B.M.P.), University of Washington, Seattle; Department of Epidemiology, University of Pittsburgh, PA (A.B.N.); College of Public Health and Human Sciences, Oregon State University, Corvallis (M.C.O.)
| | - Anne B Newman
- From the Department of Medicine, University of California, San Francisco (C.A.P.), Nephrology Division, San Francisco VA Medical Center, CA (C.A.P.); Kidney Research Institute (R.K.) and Cardiovascular Health Research Unit (B.M.P.), University of Washington, Seattle; Department of Epidemiology, University of Pittsburgh, PA (A.B.N.); College of Public Health and Human Sciences, Oregon State University, Corvallis (M.C.O.)
| | - Bruce M Psaty
- From the Department of Medicine, University of California, San Francisco (C.A.P.), Nephrology Division, San Francisco VA Medical Center, CA (C.A.P.); Kidney Research Institute (R.K.) and Cardiovascular Health Research Unit (B.M.P.), University of Washington, Seattle; Department of Epidemiology, University of Pittsburgh, PA (A.B.N.); College of Public Health and Human Sciences, Oregon State University, Corvallis (M.C.O.)
| | - Michelle C Odden
- From the Department of Medicine, University of California, San Francisco (C.A.P.), Nephrology Division, San Francisco VA Medical Center, CA (C.A.P.); Kidney Research Institute (R.K.) and Cardiovascular Health Research Unit (B.M.P.), University of Washington, Seattle; Department of Epidemiology, University of Pittsburgh, PA (A.B.N.); College of Public Health and Human Sciences, Oregon State University, Corvallis (M.C.O.)
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Siennicki-Lantz A, André-Petersson L, Wollmer P, Elmståhl S. Depressive symptoms, atherosclerotic burden and cerebral blood flow disturbances in a cohort of octogenarian men from a general population. BMC Psychiatry 2013; 13:347. [PMID: 24369109 PMCID: PMC3878789 DOI: 10.1186/1471-244x-13-347] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 12/20/2013] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim of this study was to examine in elderly men a relationship between depressive symptoms, peripheral vascular disease and cerebral blood flow (CBF). METHODS Population-based cohort study started with an examination of 809 men at age 55, followed by the first (age 68ys) and second follow up (age 82ys). 128 survivors were examined at age 82 with 99mTc-HMPAO-SPECT to estimate CBF, Zung-Self-Rating-Depression Scale (ZSDS), and Ankle-Brachial Index (ABI). Analysis was performed on men free from stroke and dementia which defined the final study population to 120 subjects. RESULTS ZSDS in the whole cohort ranged from 0.26 to 0.71 (reference 0.25-1.0). As the frequency of depressive symptoms was low, the case group (n = 31) was defined by ZSDS index above 75th percentile (≥0.48), comprising 9 subjects with mild depression (ZSDS 0.55-0.71) and 22 subjects at 88th percentile and above of the normal range (ZSDS index 0.48-0.54). Cases were more often current smokers at age 68 (44% vs. 24%; p = .02) and had lower systolic blood presure (SBP), lower social and physical activity, and suffered from fatigue, nausea, freezing and leg edema at age 82. Within the case group, ZSDS-index correlated negatively with CBF in subcortical area (r = -.42*), left and right thalamus (r = -.40*, r = -.46**), and right basal nuclei (r = -.35*). ZSDS-index correlated also with ABI at age 82 (right leg r = -.40*; left leg r = -.37*), and with Δ between ABI at age 82 and 68 (right r = -.36*; left r = -.46**). Despite decreasing SBP from age 68 to 82, adjusted multiple regression analysis showed in the case group that higher SBP determined CBF changes in the frontal and parietal areas, independently of ZSDS index, Δ ABI, and smoking. CONCLUSION In this population-based cohort of octogenarian men free from stroke or dementia, a proportion of subjects with depressive symptoms was low. Still, men with borderline or mild depression scores had lower social and physical activity, persistent smoking habit, worse peripheral circulation in legs, and cerebral perfusion changes in basal nuclei, thalamus and subcortical white matter. Regional CBF decline could be partly mediated by higher SBP.
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Affiliation(s)
- Arkadiusz Siennicki-Lantz
- Division of Geriatric Medicine, Department of Health Sciences, Skane University Hospital, Jan Waldenströmsgata 35, CRC, Building 28, floor 13, SE-205 02 Malmö, Sweden.
| | - Lena André-Petersson
- Department of Clinical Sciences, Skåne University Hospital in Malmö, Malmö, Sweden
| | - Per Wollmer
- Clinical Physiology and Nuclear Medicine Unit, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Sölve Elmståhl
- Division of Geriatric Medicine, Department of Health Sciences, Skane University Hospital, Jan Waldenströmsgata 35, CRC, Building 28, floor 13, SE-205 02 Malmö, Sweden
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Siennicki-Lantz A, André-Petersson L, Elmståhl S. Decreasing blood pressure over time is the strongest predictor of depressive symptoms in octogenarian men. Am J Geriatr Psychiatry 2013; 21:863-71. [PMID: 23567417 DOI: 10.1016/j.jagp.2012.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 06/29/2011] [Accepted: 07/26/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to examine the longitudinal impact of blood pressure variations and vascular risk factors on depressive symptoms in the elderly. DESIGN Longitudinal and cross-sectional cohort study. SETTING Urban population of elderly men, city of Malmö, Sweden. PARTICIPANTS A total of 809 randomly included men took part in a prospective cohort study, "Men born in 1914", and 171 survivors reached the age of 81 years. MEASUREMENTS Depressive symptoms were estimated at the age of 81 using the Zung Self-Rating Depression Scale (ZSDS). Vascular risk factors were identified at both 68 and 81 years of age. RESULTS At the age of 68, diagnosis of hypertension and on-going antihypertensive therapy were more frequent in subjects with high than low ZSDS scores. In contrast, at age 81, the highest ZSDS scores correlated with low systolic blood pressure (SBP). Declining SBP between the ages of 68 and 81 was more frequent in high-scoring than in low-scoring groups. Subjects with high ZSDS scores took more drugs and had more clinical diagnoses at age 81. Those taking hypnotics and sedatives had higher ZSDS scores, lower SBP at 81, and showed more frequent decrease in SBP during the observation period. CONCLUSION Depressive symptoms in octogenarian men could be predicted by hypertension earlier in life, and were strongly associated with decreasing SBP during the last decade.
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Affiliation(s)
- Arkadiusz Siennicki-Lantz
- Division of Geriatric Medicine, Department of Health Sciences, Skane University Hospital in Malmö, Lund University, Sweden.
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Krakoff LR. Ambulatory blood pressure improves prediction of cardiovascular risk: implications for better antihypertensive management. Curr Atheroscler Rep 2013; 15:317. [PMID: 23423525 DOI: 10.1007/s11883-013-0317-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Accurate measurement of arterial pressure is necessary for diagnosis of hypertension and for assessment of its therapy. The development and growing application of ambulatory blood pressure monitoring (ABPM) furthers these goals. Use of ABPM has defined white coat hypertension (WCH) and masked hypertension (MH), important prognostic diagnoses. ABPM categorizes blood pressure in several ways that increase accuracy for diagnosis and prediction of cardiovascular risk. Measurements of blood pressure throughout the day, at night during sleep, during the morning surge, and, in some instances selected intervals can be especially valuable for both research and clinical management. ABPM is being explored for its value in measuring pulse pressure and a derived index of arterial stiffness. ABPM has also shown to be valuable for defining the effects of antihypertensive drugs therapy. Results of such studies are crucial for advancing antihypertensive management. This review will summarize the important and emerging role of ABPM in defining risk for cardiovascular disease.
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Affiliation(s)
- Lawrence R Krakoff
- Mount Sinai Medical Center/Medical School, One Gustave L Levy Place, Box 1030, New York, NY 10029, USA.
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Asociación entre presión arterial y mortalidad en una cohorte de individuos de edad igual o superior a 65 años de España: un modelo dinámico. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2012.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gutiérrez-Misis A, Sánchez-Santos MT, Banegas JR, Zunzunegui MV, Sánchez-Martinez M, Castell MV, Otero A. Association between blood pressure and mortality in a Spanish cohort of persons aged 65 years or over: a dynamic model. ACTA ACUST UNITED AC 2013; 66:464-71. [PMID: 24776049 DOI: 10.1016/j.rec.2012.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Few studies have used time-dependent correction to analyze the relationship between blood pressure and all-cause mortality, and to our knowledge none has been performed in older people from the Mediterranean area. This study aimed to estimate the relationship between baseline blood pressure and blood pressure as a time-dependent covariate with the risk of all-cause mortality in a population cohort of persons aged 65 or older in Spain. METHODS Data were taken from the population-based study "Aging in Leganés" with 17 years of follow-up, launched in 1993 in a random sample (n=1560) of persons aged ≥65 years. Mortality was assessed in 2010. Cox proportional hazards models were fitted to examine the effects on mortality of blood pressure at baseline and of blood pressure as a time-dependent covariate. RESULTS The lowest mortality was observed at baseline systolic blood pressure of 136 mmHg and time-dependent covariate value of 147 mmHg. The highest risk of mortality for time-dependent covariates occurred with systolic blood pressure <115 mmHg and >93 mmHg and diastolic blood pressure <80 mmHg. Diastolic blood pressure over 85 mmHg did not increase the risk of death. CONCLUSIONS Based on the dynamic association between blood pressure and mortality, a U-shaped relationship was found for systolic blood pressure and a negative relationship for diastolic blood pressure and all-cause mortality. The lowest mortality corresponded to a systolic blood pressure level slightly over the diagnostic hypertension value and suggests that a value of 140 mmHg is not adequate as a diagnostic and therapeutic threshold in an elderly population.
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Affiliation(s)
- Alicia Gutiérrez-Misis
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Salud Dr. Castroviejo, Atención Primaria, IdiPAZ, Madrid, Spain.
| | - María T Sánchez-Santos
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid (UAM), Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - José R Banegas
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain; IdiPAZ, CIBER de Epidemiología y Salud Pública, Madrid, Spain
| | - María V Zunzunegui
- Département de Médecine Sociale et Préventive, Université de Montréal, Montreal, Québec, Canada
| | | | - María V Castell
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Salud Dr. Castroviejo, Atención Primaria, IdiPAZ, Madrid, Spain
| | - Angel Otero
- Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain; Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid (UAM), Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
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Xu T, Zhang YQ, Tan XR. The dilemma of nocturnal blood pressure. J Clin Hypertens (Greenwich) 2012; 14:787-91. [PMID: 23126351 PMCID: PMC8108933 DOI: 10.1111/jch.12003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 07/07/2012] [Accepted: 07/17/2012] [Indexed: 02/05/2023]
Abstract
During the past decades, blood pressure (BP) measurement technique has evolved rapidly from the traditionally manual measuring to fully automatic monitoring. In terms of management of BP, there have been tremendous changes from the controlling of daytime BP, nondipping pattern to nocturnal BP (NBP). Since the focus has turned to NBP, a number of dilemmas of NBP measurement have gradually emerged in clinical practice and research settings, including methods for monitoring NBP, different period definition of nocturnal time, different diagnostic thresholds of abnormal NBP, whether to control abnormal NBP, and how to manage abnormal NBP. Currently, these issues have hindered progress in the appropriate management of hypertensive patients. Therefore, the purpose of this review is to concisely discuss the dilemmas of NBP.
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Affiliation(s)
- Tan Xu
- Department of Cardiology, First Affiliated Hospital of Shantou University Medical College, ShanTou, Guangdong, China.
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Blood pressure control in Italy: analysis of clinical data from 2005-2011 surveys on hypertension. J Hypertens 2012; 30:1065-74. [PMID: 22573073 DOI: 10.1097/hjh.0b013e3283535993] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Blood pressure (BP) control is poorly achieved in hypertensive patients, worldwide. AIM We evaluated clinic BP levels and the rate of BP control in hypertensive patients included in observational studies and clinical surveys published between 2005 and 2011 in Italy. METHODS We reviewed the medical literature to identify observational studies and clinical surveys on hypertension between January 2005 and June 2011, which clearly reported information on clinic BP levels, rates of BP control, proportions of treated and untreated patients, who were followed in different clinical settings (mostly in general practice, and also in outpatient clinics and hypertension centres). RESULTS The overall sample included 158 876 hypertensive patients (94 907 women, mean age 56.6 ± 9.6 years, BMI 27.2 ± 4.2 kg/m(2), known duration of hypertension 90.2 ± 12.4 months). In the selected studies, average SBP and DBP levels were 145.7 ± 15.9 and 87.5 ± 9.7 mmHg, respectively; BP levels were higher in patients followed in hypertension centres (n = 10 724, 6.7%; 146.5 ± 17.3/88.5 ± 10.3 mmHg) than in those followed by general practitioners (n = 148 152, 93.3%; 143.5 ± 13.9/84.8 ± 8.9 mmHg; P < 0.01). More than half of the patients were treated (n = 91 318, 57.5%); among treated hypertensive patients, only 31 727 (37.0%) had controlled BP levels. CONCLUSION The present analysis confirmed inadequate control of BP in Italy, independently of the clinical setting. Although some improvement was noted compared with a similar analysis performed between 1995 and 2005, these findings highlight the need for a more effective clinical management of hypertension.
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Aguiar PM, Balisa-Rocha BJ, Brito GC, Lyra DP. Pharmaceutical care program for elderly patients with uncontrolled hypertension. J Am Pharm Assoc (2003) 2012; 52:515-8, 1 p following 518. [DOI: 10.1331/japha.2012.11015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Minimizing inappropriate medications in older populations: a 10-step conceptual framework. Am J Med 2012; 125:529-37.e4. [PMID: 22385783 DOI: 10.1016/j.amjmed.2011.09.021] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 09/14/2011] [Accepted: 09/14/2011] [Indexed: 11/20/2022]
Abstract
The increasing burden of harm resulting from the use of multiple drugs in older patient populations represents a major health problem in developed countries. Approximately 1 in 4 older patients admitted to hospitals are prescribed at least 1 inappropriate medication, and up to 20% of all inpatient deaths are attributable to potentially preventable adverse drug reactions. To minimize this drug-related iatrogenesis, we propose a quality use of medicine framework that comprises 10 sequential steps: 1) ascertain all current medications; 2) identify patients at high risk of or experiencing adverse drug reactions; 3) estimate life expectancy in high-risk patients; 4) define overall care goals in the context of life expectancy; 5) define and confirm current indications for ongoing treatment; 6) determine the time until benefit for disease-modifying medications; 7) estimate the magnitude of benefit versus harm in relation to each medication; 8) review the relative utility of different drugs; 9) identify drugs that may be discontinued; and 10) implement and monitor a drug minimization plan with ongoing reappraisal of drug utility and patient adherence by a single nominated clinician. The framework aims to reduce drug use in older patients to the minimum number of essential drugs, and its utility is demonstrated in reference to a hypothetic case study. Further studies are warranted in validating this framework as a means for assisting clinicians to make more appropriate prescribing decisions in at-risk older patients.
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Astengo M, Bonetto M, Isaia G, Comba M, Fonte G, Bo M. Blood pressure variations and low blood pressure values at home after hospital discharge in older hypertensives. Eur J Prev Cardiol 2012; 19:460-6. [DOI: 10.1177/1741826711403067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Blood pressure (BP) variations occurring after hospital discharge in a population of older hypertensives have not been previously investigated. Design: elderly (≥65 years) hypertensives admitted to the geriatric acute ward of a university-teaching hospital were enrolled in this prospective observational study. Methods: Exclusion criteria were terminal illness, discharge to institution, and changes in antihypertensive regimen. BP was recorded in the emergency room, at ward admission, daily during hospital stay, and at discharge. Home self blood pressure measurement was performed after discharge. Results: The study population included 106 patients. There was a significant decrease in systolic BP (SBP) and diastolic BP (DBP) throughout the study time points. SBP and DBP decreased after discharge (from 135.1 ± 15.0 to 131.5 ± 16.1 mmHg and from 77.2 ± 8.4 to 71.6 ± 8.7 mmHg, respectively), the difference being significant only for DBP ( p = 0.000). We further observed higher prevalence of critically low BP values (SBP <120 mmHg and DBP <70 mmHg) at home (23.6% and 48.1%, respectively) compared to discharge (8.5% and 9.4%, p = 0.006 and p = 0.000, respectively). Conclusions: We observed a decrease in BP values, and particularly DBP values, after hospital discharge, in a sample of older hypertensives. Critically low BP values were observed at home in a high proportion of subjects, suggesting wise use of antihypertensive therapy at discharge and early monitoring of BP values at home.
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Affiliation(s)
- Marco Astengo
- Geriatric Section, Department of Medical and Surgical Disciplines, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Martina Bonetto
- Geriatric Section, Department of Medical and Surgical Disciplines, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Gianluca Isaia
- Geriatric Section, Department of Medical and Surgical Disciplines, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Monica Comba
- Geriatric Section, Department of Medical and Surgical Disciplines, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Gianfranco Fonte
- Geriatric Section, Department of Medical and Surgical Disciplines, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Mario Bo
- Geriatric Section, Department of Medical and Surgical Disciplines, San Giovanni Battista Hospital, University of Torino, Torino, Italy
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Differing pattern of ambulatory blood pressure in very elderly men expresses dynamics in atherosclerotic load in the senescence. Int J Hypertens 2012; 2012:417291. [PMID: 22216405 PMCID: PMC3246735 DOI: 10.1155/2012/417291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 09/19/2011] [Indexed: 12/02/2022] Open
Abstract
To assess an impact of vascular risk factors on ambulatory blood pressure measurement (ABPM) in the elderly, we followed up a population-based cohort of men from 68 until 82 years, when 104 survivors underwent ABPM. Results. At age 68, hypertension and high clinic blood pressure (CBP) did not predict ABPM level. Smoking and low ankle-brachial index (ABI) predicted higher ABPM variability and pulse pressure (PP), but not absolute ABPM values. At age 82, hypertension, high or increasing CBP, strongly positively correlated with all variables of ABPM. Carotid stenosis, low or declining ABI during followup, correlated with higher nocturnal ABPM and PP. Concluding. Hypertension and vascular risk factors in a cohort of 68-year-old men do not result in higher ABPM at age 82, possibly due to inflection point in their pressure development. Higher ABPM reflects instead an increasing CBP and aggravating atherosclerosis during the preceding decade in that part of the cohort with previously favorable risk factor status.
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Ambulatory blood pressure monitoring in the elderly. Int J Hypertens 2011; 2012:548286. [PMID: 22229085 PMCID: PMC3249829 DOI: 10.1155/2012/548286] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 09/08/2011] [Indexed: 12/03/2022] Open
Abstract
The incidence of hypertension is high in the elderly and is present in 2/3 of the patients older than 65 years. Prevalence can reach 90% in patients older than 80 years. The presence of isolated systolic hypertension (ISH) is characteristic of this population. However, the prevalence of hypertension by ambulatory blood pressure monitoring (ABPM) is not well known. In this study, we analyzed the special characteristics of hypertension in this population, giving special emphasis on ABPM readings.
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Siennicki-Lantz A, Elmståhl S. Phenomenon of declining blood pressure in elderly--high systolic levels are undervalued with Korotkoff method. BMC Geriatr 2011; 11:57. [PMID: 21967408 PMCID: PMC3197481 DOI: 10.1186/1471-2318-11-57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 10/03/2011] [Indexed: 11/17/2022] Open
Abstract
Background Systolic blood pressure (SBP) decline has been reported in octogenarians. The aim was to study if it could be observed while measuring SBP with two methods: Korotkoff (K-BP) and Strain-Gauge-Finger-Pletysmography (SG-BP), and which of them were more reliable in expressing vascular burden. Methods A cohort of 703 men from a population of Malmö, Sweden, were included in "Men born in 1914-study" and followed-up at ages: 68 and 81 years. 176 survivors were examined with K-BP and SG-BP at both ages, and 104 of them with Ambulatory Blood Pressure at age 81/82. Ankle Brachial Index (ABI) was measured on both occasions, and Carotid Ultrasound at age 81. Results From age 68 to 81, mean K-BP decreased in the cohort with mean 8.3 mmHg, while SG-BP increased with 13.4 mmHg. K-BP decreased in 55% and SG-BP in 31% of the subjects. At age 81, K-BP was lower than SG-BP in 72% of subjects, and correlated to high K-BP at age 68 (r = --.22; p < .05). SG-BP at age 81 was correlated with mean ambulatory 24-h SBP (r = .480; p < .0001), daytime SBP (r = .416; p < .0001), nighttime SBP (r = .395; p < .0001), and daytime and nighttime Pulse Pressure (r = .452; p < .0001 and r = .386; p < .0001). KB-BP correlated moderately only with nighttime SBP (r = .198; p = .044), and daytime and nightime pulse pressure (r = .225; p = .021 and r = .264; p = .007). Increasing SG-BP from age 68 to 81, but not K-BP, correlated with: 24-h, daytime and nighttime SBP, and mean daytime and nighttime Pulse Pressure. Increasing SG-BP was also predicted by high B-glucose and low ABI at age 68, and correlated with carotid stenosis and low ABI age 81, and the grade of ABI decrease over 13 years. Conclusion In contrast to K-BP, values of SG-BP in octogenarians strongly correlated with Ambulatory Blood Pressure. The SG-BP decline in the last decade was rare, and increasing SG-BP better than K-BP reflected advanced atherosclerosis. It should be aware, that K-BP underdetected 46% of subjects with SG-BP equal/higher than 140 mmHg at age 81, which may lead to biased associations with risk factors due to differential misclassification by age.
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Scott I, Jayathissa S. Quality of drug prescribing in older patients: is there a problem and can we improve it? Intern Med J 2011; 40:7-18. [PMID: 19712203 DOI: 10.1111/j.1445-5994.2009.02040.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Older patients are at high risk of suboptimal prescribing (overuse, underuse and misuse of drugs), which can lead to serious adverse drug reactions (ADR). About one in four patients admitted to hospital are prescribed at least one inappropriate medication and up to 20% of all inpatient deaths are attributed to potentially preventable ADR. Lists of drugs to avoid (unnecessary or where risks outweigh benefits) and drugs not to be omitted (strong indications if there are no contraindications) can assist in identifying suboptimal prescribing although, to date, no trials have established the ability of such screening, by itself, to improve prescribing quality. Remedial strategies proven to be effective in randomized trials include detailed appraisal of medication lists by multidisciplinary teams, which involve geriatricians and close liaison with specialist clinical pharmacists. A multifaceted quality improvement strategy is proposed that includes an aspirational target of no more than five different drugs be regularly prescribed to vulnerable older patients. Achieving this target involves prioritizing drug selection on the basis of strength of indication which may run counter to current disease-specific clinical guideline recommendations based on trials that have excluded most older patients. Such a strategy is worthy of further evaluation in a multicentre randomized trial.
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Affiliation(s)
- I Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
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Mata-Cases M, De Prado-Lacueva C, Salido-Valencia V, Fernández-Bertolín E, Casermeiro-Cortés J, García-Durán M, Jabalera-López S, Fernández-Sanmartín MI. Incidence of complications and mortality in a type 2 diabetes patient cohort study followed up from diagnosis in a primary healthcare centre. Int J Clin Pract 2011; 65:299-307. [PMID: 21314867 DOI: 10.1111/j.1742-1241.2010.02503.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
AIMS To determine the microvascular and macrovascular complications and mortality incidence rates and to identify the related factors in patients recently diagnosed with type 2 diabetes between 1991 and 2000 and followed until 2006. METHODS Retrospective longitudinal study in a primary healthcare center. Patients without any measure of glycaemia in the 3 years previous to diabetes diagnosis were excluded. Annual incidence rates for microvascular and macrovascular complications and mortality were estimated. Analysis of KaplanMeier survival curves and Cox proportional risk models by gender were done. RESULTS Of 469 patients [mean age: 60.4 (SD 10.7) years, 53.9% women], 80 died principally of tumoral (38.7%) and cardiovascular (30%) causes. The mean follow-up period was 8.81 years. (SD 3.21). The complication rates per 1000 patients/year (95% CI) were: microvascular complications 29.11 (22.97-36.38), macrovascular complications 24.10 (19.05-30.08) and mortality 19.23 (15.25-23.93), all of those being significantly greater in males except for cerebrovascular disease. Complications and mortality were associated with age, HbA1c, HDL-cholesterol, blood pressure and smoking with a different significance for each gender. HbA1c was related to microvascular complications in both sexes and to macrovascular complications only in women. CONCLUSION The annual rates for death and complications in a Mediterranean type 2 diabetic patient cohort followed from diagnosis were lower than those published in Anglo-Saxon countries. Males showed higher death and complication rates except in terms of cerebrovascular disease. Predictors of complication and death were different depending on gender. In terms of mortality, unlike in other studies, only one-third of the deaths were for cardiovascular causes.
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Affiliation(s)
- M Mata-Cases
- Primary Healthcare Center La Mina, SAP Litoral, Barcelona Family and Community Medicine Teaching Unit, Institut Català de la Salut, Sant Adrià de Besòs (Barcelona), Spain.
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Hansen TW, Li Y, Boggia J, Thijs L, Richart T, Staessen JA. Predictive role of the nighttime blood pressure. Hypertension 2010; 57:3-10. [PMID: 21079049 DOI: 10.1161/hypertensionaha.109.133900] [Citation(s) in RCA: 428] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Numerous studies addressed the predictive value of the nighttime blood pressure (BP) as captured by ambulatory monitoring. However, arbitrary cutoff limits in dichotomized analyses of continuous variables, data dredging across selected subgroups, extrapolation of cross-sectional studies to prospective outcomes, and lack of comprehensive adjustments for confounders make interpretation of the literature difficult. We reviewed prospective studies with total mortality or a composite cardiovascular end point as an outcome in relation to the level and the circadian profile of systolic BP. We analyzed studies in hypertensive patients (n = 23 856) separately from those in individuals randomly recruited from populations (n = 9641). We pooled summary statistics and individual subject data, respectively. In both patients and populations, in analyses in which nighttime BP was additionally adjusted for daytime BP and vice versa, nighttime BP was a stronger predictor than daytime BP. With adjustment for the 24-hour BP, both the night-to-day BP ratio and dipping status remained significant predictors of outcome but added little prognostic value over and beyond the 24-hour BP level. In the absence of conclusive evidence proving that nondipping is a reversible risk factor, the option whether or not to restore the diurnal blood pressure profile to a normal pattern should be left to the clinical judgment of doctors and should be individualized for each patient. Current guidelines on the interpretation of ambulatory BP recording need to be updated.
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Affiliation(s)
- Tine W Hansen
- Department of Clinical Physiology, Research Center for Prevention and Health, Nuclear Medicine and PET, Rigshospitalet, Copenhagen University Hospital, Faculty of Health Sciences, Rigshospitalet, Copenhagen, Denmark.
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Corona G, Monami M, Boddi V, Rastrelli G, Melani C, Balzi D, Sforza A, Forti G, Mannucci E, Maggi M. Pulse pressure independently predicts major cardiovascular events in younger but not in older subjects with erectile dysfunction. J Sex Med 2010; 8:247-54. [PMID: 20722787 DOI: 10.1111/j.1743-6109.2010.01966.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Pulse pressure (PP; i.e., the arithmetic difference between systolic and diastolic blood pressure) has been suggested to be an independent cardiovascular risk (CV) factor in the general population. We previously also reported a negative association between PP and arteriogenic erectile dysfunction (ED). This finding has recently been questioned. AIM To verify the association of PP with ED severity and to evaluate its role in predicting forthcoming CV events. METHODS This is an observational prospective cohort study evaluating a consecutive series of 1,687 patients attending our Andrological Unit for ED. MAIN OUTCOME MEASURES Several hormonal and biochemical parameters were studied, along with SIEDY structured interviews and penile Doppler ultrasound. RESULTS Subjects with PP in the lowest quartile (I: 20-45; II: 46-55; III: 56-62; IV: 63-115 mm Hg) had a significant reduction in the risk of severe ED (RR = 0.60[0.47-0.76]; P < 0.0001). When the same analysis was repeated as a function of age quartile (I = 17-44, II = 45-55, III = 56-62, and IV = 63-88 years old), after adjusting for testosterone levels, mean blood pressure, Chronic Disease Score, and body mass index, PP was inversely related to ED only in the youngest age group. During a mean follow up of 4.4 ± 2.6 years, 147 major cardiovascular events (MACE) were observed. In a Cox regression model, after adjusting for possible confounding factors, a lower PP was associated with a lower risk of MACE in the whole sample and in younger subjects, but not in the older ones. CONCLUSIONS Checking for blood pressure in ED subjects and calculating PP should become a routine practice in sexual medicine. In younger individuals, low PP reflects not only sexual health (better erection) but also cardiovascular health (less prevalence of MACE).
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Affiliation(s)
- Giovanni Corona
- Andrology Unit, Department of Clinical Physiopathology, University of Florence, Florence, Italy
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Frankel FM, Duong N, Shil AB. Association of hypertension with mortality. Am J Hypertens 2010; 23:452. [PMID: 20404799 DOI: 10.1038/ajh.2010.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Abstract
Hypertension is an important risk factor for cardiovascular morbidity and mortality, particularly in the elderly. Blood pressure elevation in the elderly is due to structural and functional changes that occur with aging. Treatment of hypertension reduces the risk of stroke, heart failure, myocardial infarction, all-cause mortality, cognitive impairment, and dementia in elderly patients with hypertension. A healthy lifestyle helps hypertension management, with benefits extending beyond lowering of blood pressure. Several classes of antihypertensive drugs are effective in preventing cardiovascular events. Treatment decisions should be guided by the presence of compelling indications such as diabetes or heart failure and by the tolerability of individual drugs or drug combinations in individual patients. The concomitant intake of certain medications that counter the effects of antihypertensive drugs and the frequent occurrence of orthostatic hypotension complicate treatment in older patients and drive down blood pressure control rates.
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Affiliation(s)
- Maria Czarina Acelajado
- Vascular Biology and Hypertension Program of Division of Cardiovascular Disease, Department of Medicine, School of Medicine, University of Alabama at Birmingham, USA.
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Nikolov NM, Fontes ML, White WD, Aronson S, Bar-Yosef S, Gaca JG, Podgoreanu MV, Stafford-Smith M, Newman MF, Mathew JP. Pulse pressure and long-term survival after coronary artery bypass graft surgery. Anesth Analg 2009; 110:335-40. [PMID: 19996138 DOI: 10.1213/ane.0b013e3181c76f87] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Data from longitudinal studies reveal that widened pulse pressure (PP) is a major predictor of coronary heart disease and mortality, but it is unknown whether PP similarly decreases survival after coronary artery bypass graft (CABG) surgery for coronary heart disease. We therefore assessed long-term survival in patients with increased PP at the time of presentation for CABG surgery. METHODS In this retrospective observational study of patients undergoing CABG surgery between January 1993 and July 2004, 973 subjects were included for assessment of long-term survival. Baseline arterial blood pressure (BP) measurements were defined as the median of the first 3 measurements recorded by the automated record keeping system before induction of anesthesia. The effect of baseline PP on survival after surgery was evaluated using a Cox proportional hazards regression model and bootstrap resampling with baseline mean arterial BP, systolic BP, diastolic BP, diabetes, Hannan risk index, aprotinin use, and cardiopulmonary bypass time as covariates. RESULTS There were 220 deaths (22.9%) during the follow-up period (median, 7.3 yr [Q1: 5, Q3: 10 yr]) including 94 deaths from cardiovascular causes. Increased baseline PP was a significant predictor of reduced long-term survival (P < 0.001) along with Hannan risk index (P < 0.001), duration of cardiopulmonary bypass (P < 0.001), and diabetes (P < 0.001). Baseline systolic (P = 0.40), diastolic (P = 0.38), and mean arterial BPs (P = 0.78) were not associated with long-term survival. The hazard ratio for PP (adjusted for other covariates in the model) was 1.11 (1.05-1.18) per 10-mm Hg increase. CONCLUSIONS An increase in perioperative PP is associated with poor long-term survival after CABG surgery. Together with our previous report linking PP to in-hospital fatal and nonfatal vascular complications, the established models for surgical risk assessment, patient counseling, and treatment should be revised to include PP.
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Affiliation(s)
- Nikolay M Nikolov
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Schwarz U. The hypertension paradox. N Engl J Med 2009; 361:2195-6; author reply 2196-7. [PMID: 19940307 DOI: 10.1056/nejmc0908990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Ungar A, Di Bari M, Marchionni N. Response Letter to Drs. Aronow and Kim. J Am Geriatr Soc 2009. [DOI: 10.1111/j.1532-5415.2009.02548.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Aronow WS. Data are needed on target blood pressure for elderly people. J Am Geriatr Soc 2009; 57:2177-2178. [PMID: 20121982 DOI: 10.1111/j.1532-5415.2009.02538.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
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Kim DH. Low Diastolic Blood Pressure and Mortality in Elderly People. J Am Geriatr Soc 2009; 57:2176-7. [DOI: 10.1111/j.1532-5415.2009.02543.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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