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Ghazi L, Cohen JB, Townsend RR, Drawz PE, Rahman M, Pradhan N, Cohen DL, Weir MR, Rincon-Choles H, Juraschek SP. Orthostatic hypotension, orthostatic hypertension, and ambulatory blood pressure in patients with chronic kidney disease in CRIC. J Hypertens 2024; 42:329-336. [PMID: 37889527 PMCID: PMC10842034 DOI: 10.1097/hjh.0000000000003604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
BACKGROUND Orthostatic changes in blood pressure (BP), either orthostatic hypotension or orthostatic hypertension (OHTN), are common among patients with chronic kidney disease. Whether they are associated with unique out-of-office BP phenotypes is unknown. METHODS CRIC is a prospective, multicenter, observational cohort study of participants with CKD. BP measured at 2 min after standing and ambulatory BP monitoring (ABPM) were obtained on 1386 participants. Orthostatic hypotension was defined as a 20 mmHg drop in SBP or 10 mmHg drop in DBP when changing from seated to standing positions. Systolic and diastolic night-to-day ratio was also calculated. OHTN was defined as a 20 or 10 mmHg rise in SBP or DBP when changing from a seated to a standing position. White-coat effect (WCE) was defined as seated minus daytime ambulatory BP. RESULTS Of the 1386 participants (age: 58 ± 10 years, 44% female, 39% black), 68 had orthostatic hypotension and 153 had OHTN. Postural reduction in SBP or DBP was positively associated with greater systolic and diastolic WCE and systolic and diastolic night-to-day ratio. Orthostatic hypotension was positively associated with diastolic WCE (β = 3 [0.2, 5.9]). Diastolic OHTN was negatively associated with systolic WCE (β = -4 [-7.2, -0.5]) and diastolic WCE (β = -6 [-8.1, -4.2]). CONCLUSION Postural change in BP was associated with WCE and night-to-day-ratio. Orthostatic hypotension was positively associated with WCE and OHTN was negatively associated with WCE. These findings strengthen observations that postural changes in BP may associate with distinct BP patterns throughout the day. These observations are informative for subsequent research tailoring orthostatic hypotension and OHTN treatment to specific BP phenotypes.
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Affiliation(s)
- Lama Ghazi
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, PA
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Paul E Drawz
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, OH
| | - Nishigandha Pradhan
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, OH
| | - Debbie L Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, PA
| | - Matthew R. Weir
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD
| | - Hernan Rincon-Choles
- Cleveland Clinic Foundation, Glickman Urological & Kidney Institute, Department of Nephrology, Cleveland, OH
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Zhao X, Tan RS, Garg P, Chai P, Leng S, Bryant JA, Teo LLS, Yeo TJ, Fortier MV, Low TT, Ong CC, Zhang S, Van der Geest RJ, Allen JC, Tan TH, Yip JW, Tan JL, Hughes M, Plein S, Westenberg JJM, Zhong L. Age- and sex-specific reference values of biventricular flow components and kinetic energy by 4D flow cardiovascular magnetic resonance in healthy subjects. J Cardiovasc Magn Reson 2023; 25:50. [PMID: 37718441 PMCID: PMC10506211 DOI: 10.1186/s12968-023-00960-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/30/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Advances in four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) have allowed quantification of left ventricular (LV) and right ventricular (RV) blood flow. We aimed to (1) investigate age and sex differences of 4D flow CMR-derived LV and RV relative flow components and kinetic energy (KE) parameters indexed to end-diastolic volume (KEiEDV) in healthy subjects; and (2) assess the effects of age and sex on these parameters. METHODS We performed 4D flow analysis in 163 healthy participants (42% female; mean age 43 ± 13 years) of a prospective registry study (NCT03217240) who were free of cardiovascular diseases. Relative flow components (direct flow, retained inflow, delayed ejection flow, residual volume) and multiple phasic KEiEDV (global, peak systolic, average systolic, average diastolic, peak E-wave, peak A-wave) for both LV and RV were analysed. RESULTS Compared with men, women had lower median LV and RV residual volume, and LV peak and average systolic KEiEDV, and higher median values of RV direct flow, RV global KEiEDV, RV average diastolic KEiEDV, and RV peak E-wave KEiEDV. ANOVA analysis found there were no differences in flow components, peak and average systolic, average diastolic and global KEiEDV for both LV and RV across age groups. Peak A-wave KEiEDV increased significantly (r = 0.458 for LV and 0.341 for RV), whereas peak E-wave KEiEDV (r = - 0.355 for LV and - 0.318 for RV), and KEiEDV E/A ratio (r = - 0.475 for LV and - 0.504 for RV) decreased significantly, with age. CONCLUSION These data using state-of-the-art 4D flow CMR show that biventricular flow components and kinetic energy parameters vary significantly by age and sex. Age and sex trends should be considered in the interpretation of quantitative measures of biventricular flow. Clinical trial registration https://www. CLINICALTRIALS gov . Unique identifier: NCT03217240.
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Affiliation(s)
- Xiaodan Zhao
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore
| | - Ru-San Tan
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- National Heart Centre Singapore, Singapore, Singapore
| | - Pankaj Garg
- Department of Cardiovascular Medicine, University of East Anglia, Norwich, UK
| | - Ping Chai
- National University Hospital Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shuang Leng
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Jennifer Ann Bryant
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- National Heart Centre Singapore, Singapore, Singapore
| | - Lynette L S Teo
- National University Hospital Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tee Joo Yeo
- National University Hospital Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Marielle V Fortier
- Duke-NUS Medical School, Singapore, Singapore
- KK Women's and Children's Hospital, Singapore, Singapore
- Singapore Institute for Clinical Sciences, A*STAR, Singapore, Singapore
| | - Ting Ting Low
- National University Hospital Singapore, Singapore, Singapore
| | - Ching Ching Ong
- National University Hospital Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shuo Zhang
- Philips Healthcare Germany, Hamburg, Germany
| | - Rob J Van der Geest
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Teng Hong Tan
- Duke-NUS Medical School, Singapore, Singapore
- KK Women's and Children's Hospital, Singapore, Singapore
| | - James W Yip
- National University Hospital Singapore, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ju Le Tan
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- National Heart Centre Singapore, Singapore, Singapore
| | - Marina Hughes
- Department of Cardiovascular Medicine, University of East Anglia, Norwich, UK
| | - Sven Plein
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Liang Zhong
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
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3
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Welsh TJ, Mitchell A. Centrally acting antihypertensives and alpha-blockers in people at risk of falls: therapeutic dilemmas-a clinical review. Eur Geriatr Med 2023; 14:675-682. [PMID: 37436689 PMCID: PMC10447259 DOI: 10.1007/s41999-023-00813-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/07/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE The aim of this clinical review was to summarise the existing knowledge on the adverse effects of alpha-blockers and centrally acting antihypertensives, the effect these may have on falls risk, and guide deprescribing of these medications. METHODS Literature searches were conducted using PubMed and Embase. Additional articles were identified by searching reference lists and reference to personal libraries. We discuss the place of alpha-blockers and centrally acting antihypertensives in the treatment of hypertension and methods for deprescribing. RESULTS Alpha-blockers and centrally acting antihypertensives are no longer recommended for the treatment of hypertension unless all other agents are contraindicated or not tolerated. These medications carry a significant falls risk and non-falls risk-associated side effects. Tools to aid and guide de-prescribing and monitoring of the withdrawal of these medication classes are available to assist the clinician including information on reducing the risk of withdrawal syndromes. CONCLUSIONS Centrally acting antihypertensives and alpha-blockers increase the risk of falls through a variety of mechanisms-principally by increasing the risk of hypotension, orthostatic hypotension, arrhythmias and sedation. These agents should be prioritised for de-prescribing in older frailer individuals. We identify a number of tools and a withdrawal protocol to aid the clinician in identifying and de-prescribing these medications.
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Affiliation(s)
- T J Welsh
- University of Bristol, Bristol, UK
- RICE-The Research Institute for the Care of Older People, The RICE Centre, Royal United Hospital, Bath, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - A Mitchell
- RICE-The Research Institute for the Care of Older People, The RICE Centre, Royal United Hospital, Bath, UK.
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK.
- Department of Life Sciences, University of Bath, Bath, UK.
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Wetzel S, Geldsetzer P, Mani SS, Gupta A, Singh K, Ali MK, Prabhakaran D, Tandon N, Sudharsanan N. Changing socioeconomic and geographic gradients in cardiovascular disease risk factors among Indians aged 15-49 years - evidence from nationally representative household surveys. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 12:100188. [PMID: 37384058 PMCID: PMC10305936 DOI: 10.1016/j.lansea.2023.100188] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 06/30/2023]
Abstract
Background Cardiovascular diseases (CVDs) are the leading cause of death in most low- and middle-income countries (LMICs). CVDs and their metabolic risk factors have historically been concentrated among urban residents with higher socioeconomic status (SES) in LMICs such as India. However, as India develops, it is unclear whether these socioeconomic and geographic gradients will persist or change. Understanding these social dynamics in CVD risk is essential for mitigating the rising burden of CVDs and to reach those with the greatest needs. Methods Using nationally representative data with biomarker measurements from the fourth (2015-16) and fifth (2019-21) Indian National Family and Health Surveys, we investigated trends in the prevalence of four CVD risk factors: smoking (self-reported), unhealthy weight (BMI ≥25 kgm2), diabetes (random plasma glucose concentration ≥200 mg/dL or self-reported diabetes), and hypertension (one of: average systolic blood pressure ≥140 mmHg, average diastolic blood pressure ≥90 mmHg, self-reported past diagnosis, or self-reported current antihypertensive medication use) among adults aged 15-49 years. We first described changes at the national level and then trends stratified by place of residence (urban versus rural), geographic region (northern, northeastern, central, eastern, western, southern), regional level of development (Empowered Action Group member state or not), and two measures of socioeconomic status: level of education (no education, primary incomplete, primary complete, secondary incomplete, secondary complete, higher) and wealth (quintiles). Findings Unhealthy weight increased among all social and geographic groups but both the absolute and the relative changes were substantially higher among people with low SES (as measured by education or wealth) and in rural areas. For diabetes and hypertension, the prevalence increased for those from disadvantaged groups while staying constant or even decreasing among the wealthier and more educated. In contrast, smoking consumption declined for all social and geographic groups. Interpretation In 2015-16, CVD risk factors were higher among more advantaged subpopulations in India. However, between 2015-16 and 2019-21, the prevalence of these risk factors grew more rapidly for less wealthy and less educated subpopulations and those living in rural areas. These trends have resulted in CVD risk becoming far more widespread throughout the population; CVD can no longer be characterized as a wealthy urban phenomenon. Funding This work was supported by the Alexander von Humboldt Foundation (grant received by NS); the Stanford Diabetes Research Center [grant received by PG] and the Chan Zuckerberg Biohub [grant received by PG].
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Affiliation(s)
- Sarah Wetzel
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Sneha Sarah Mani
- Graduate Group in Demography, University of Pennsylvania, PA, USA
| | - Aashish Gupta
- Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Harvard University, MA, USA
| | - Kavita Singh
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, Haryana, India
| | - Mohammed K. Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, India
- Public Health Foundation of India, India
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, India
| | - Nikkil Sudharsanan
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Behavioral Science for Disease Prevention and Health Care, Technical University of Munich, Munich, Germany
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Centanni M, Thijs A, Desar I, Karlsson MO, Friberg LE. Optimization of blood pressure measurement practices for pharmacodynamic analyses of tyrosine-kinase inhibitors. Clin Transl Sci 2022; 16:73-84. [PMID: 36152309 PMCID: PMC9841306 DOI: 10.1111/cts.13423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/23/2022] [Accepted: 09/14/2022] [Indexed: 02/06/2023] Open
Abstract
Blood pressure measurements form a critical component of adverse event monitoring for tyrosine kinase inhibitors, but might also serve as a biomarker for dose titrations. This study explored the impact of various sources of within-individual variation on blood pressure readings to improve measurement practices and evaluated the utility for individual- and population-level dose selection. A pharmacokinetic-pharmacodynamic modeling framework was created to describe circadian blood pressure changes, inter- and intra-day variability, changes from dipper to non-dipper profiles, and the relationship between drug exposure and blood pressure changes over time. The framework was used to quantitatively evaluate the influence of physiological and pharmacological aspects on blood pressure measurements, as well as to compare measurement techniques, including office-based, home-based, and ambulatory 24-h blood pressure readings. Circadian changes, as well as random intra-day and inter-day variability, were found to be the largest sources of within-individual variation in blood pressure. Office-based and ambulatory 24-h measurements gave rise to potential bias (>5 mmHg), which was mitigated by model-based estimations. Our findings suggest that 5-8 consecutive, home-based, measurements taken at a consistent time around noon, or alternatively within a limited time frame (e.g., 8.00 a.m. to 12.00 p.m. or 12.00 p.m. to 5.00 p.m.), will give rise to the most consistent blood pressure estimates. Blood pressure measurements likely do not represent a sufficiently accurate method for individual-level dose selection, but may be valuable for population-level dose identification. A user-friendly tool has been made available to allow for interactive blood pressure simulations and estimations for the investigated scenarios.
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Affiliation(s)
| | - Abel Thijs
- Department of Internal Medicine, Amsterdam UMCLocation VU UniversityAmsterdamThe Netherlands
| | - Ingrid Desar
- Department of Medical OncologyRadboud University Medical CenterNijmegenThe Netherlands
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“What if It’s not Just an Item of Clothing?” – A Narrative Review and Synthesis of the White Coat in the Context of Aged Care. Psychol Belg 2022; 62:62-74. [PMID: 35291725 PMCID: PMC8877653 DOI: 10.5334/pb.1138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/29/2022] [Indexed: 11/20/2022] Open
Abstract
Although increasingly disputed, the white coat uniform is ubiquitous in geriatric care, which may reflect a phenomenon called medicalisation of ageing. This narrative review is the first attempt at integrating several theoretical approaches, such as the “white coat effect” and “enclothed cognition”, in order to gain a comprehensive understanding of the use of this clothing item. Based on extensive empirical evidence, we will examine the consequences of wearing a uniform, not only on patients (in this case, older patients) and healthcare professionals, but also on their relationship. The white coat has powerful symbolic functions for healthcare professionals and is still preferred by older adults. However, the negative repercussions of wearing a uniform require us to question its use, particularly in environments where older persons live, such as nursing homes.
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7
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Sudharsanan N, Wetzel S, Nachtnebel M, Loun C, Phy M, Kol H, Bärnighausen T. Know-do gaps for cardiovascular disease care in Cambodia: Evidence on clinician knowledge and delivery of evidence-based prevention actions. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000862. [PMID: 36962790 PMCID: PMC10022025 DOI: 10.1371/journal.pgph.0000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/11/2022] [Indexed: 11/18/2022]
Abstract
Cardiovascular diseases (CVD) are the leading cause of death in Cambodia. However, it is unknown whether clinicians in Cambodia provide evidence-based CVD preventive care actions. We address this important gap and provide one of the first assessments of clinical care for CVD prevention in an LMIC context. We determined the proportion of primary care visits by adult patients that resulted in evidence-based CVD preventive care actions, identified which care actions were most frequently missed, and estimated the know-do gap for each clinical action. We used data on 190 direct clinician-patient observations and 337 clinician responses to patient vignettes from 114 public primary care health facilities. Our main outcomes were the proportion of patient consultations and responses to care vignettes where clinicians measured blood pressure, blood glucose, body mass index, and asked questions regarding alcohol, tobacco, physical activity, and diet. There were very large clinical care shortfalls for all CVD care actions. Just 6.4% (95% CI: 3.0%, 13.0%) of patients had their BMI measured, 8.0% (4.6%, 13.6%) their blood pressure measured at least twice, only 4.7% (1.9%, 11.2%) their blood glucose measured. Less than 21% of patients were asked about their physical activity (11.7% [7.0%, 18.9%]), smoking (18.0% [11.8%, 26.5%]), and alcohol-related behaviors (20.2% [13.7%, 28.9%]). We observed the largest know-do gaps for blood glucose and BMI measurements with smaller but important know-do gaps for the other clinical actions. CVD care did not vary across clinician cadre or by years of experience. We find large CVD care delivery gaps in primary-care facilities across Cambodia. Our results suggest that diabetes is being substantially underdiagnosed and that clinicians are losing CVD prevention potential by not identifying individuals who would benefit from behavioral changes. The large overall and know-do gaps suggest that interventions for improving preventive care need to target both clinical knowledge and the bottlenecks between knowledge and care behavior.
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Affiliation(s)
- Nikkil Sudharsanan
- Professorship of Behavioral Science for Disease Prevention and Health Care, Technical University of Munich, Munich, Germany
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Sarah Wetzel
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | | | - Chhun Loun
- Department of Preventive Medicine, Ministry of Health, Phnom Penh, Cambodia
| | - Maly Phy
- Department of Preventive Medicine, Ministry of Health, Phnom Penh, Cambodia
| | - Hero Kol
- Department of Preventive Medicine, Ministry of Health, Phnom Penh, Cambodia
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
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8
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Ghazi L, Drawz PE, Pajewski NM, Juraschek SP. The Association of Orthostatic Hypotension With Ambulatory Blood Pressure Phenotypes in SPRINT. Am J Hypertens 2021; 34:511-520. [PMID: 33186448 PMCID: PMC8140655 DOI: 10.1093/ajh/hpaa184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/26/2020] [Accepted: 11/06/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Clinic blood pressure (BP) when measured in the seated position, can miss meaningful BP phenotypes, including low ambulatory BP (white coat effects [WCE]) or high supine BP (nocturnal non-dipping). Orthostatic hypotension (OH) measured using both seated (or supine) and standing BP, could identify phenotypes poorly captured by seated clinic BP alone. METHODS We examined the association of OH with WCE and night-to-daytime systolic BP (SBP) in a subpopulation of SPRINT, a randomized trial testing the effects of intensive or standard (<120 vs. <140 mm Hg) SBP treatment strategies in adults at increased risk of cardiovascular disease. OH was assessed during follow-up (6, 12, and 24 months) and defined as a decrease in mean seated SBP ≥20 or diastolic BP ≥10 mm Hg after 1 min of standing. WCE, based on 24-hour ambulatory BP monitoring performed at 27 months, was defined as the difference between 27-month seated clinic and daytime ambulatory BP ≥20/≥10 mm Hg. Reverse dipping was defined as a ratio of night-to-daytime SBP >1. RESULTS Of 897 adults (mean age 71.5±9.5 years, 29% female, 28% black), 128 had OH at least once. Among those with OH, 15% had WCE (vs. 7% without OH). Moreover, 25% of those with OH demonstrated a non-dipping pattern (vs. 14% without OH). OH was positively associated with both WCE (OR=2.24; 95%CI: 1.28, 4.27) and reverse dipping (OR=2.29; 95% CI: 1.31, 3.99). CONCLUSIONS The identification of OH in clinic was associated with two BP phenotypes often missed with traditional seated BP assessments. Further studies on mechanisms of these relationships are needed. CLINICAL TRIALS REGISTRATION Trial Number NCT03569020.
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Affiliation(s)
- Lama Ghazi
- Yale University, School of Medicine, Clinical and Translational Research Accelerator, New Haven, Connecticut, USA
| | - Paul E Drawz
- University of Minnesota Medical School, Department of Medicine, Division of Nephrology and Hypertension, Minneapolis, Minnesota, USA
| | - Nicholas M Pajewski
- Wake Forest School of Medicine, Department of Biostatistics and Data Science, Winston-Salem, North Carolina, USA
| | - Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Medicine, Division of General Medicine, Boston, Massachusetts, USA
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9
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Questioning a South African hypertension threshold of 150 mm Hg. THE LANCET. HEALTHY LONGEVITY 2021; 2:e247. [DOI: 10.1016/s2666-7568(21)00082-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/25/2021] [Indexed: 11/17/2022] Open
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10
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Bowling CB, Lee A, Williamson JD. Blood Pressure Control Among Older Adults With Hypertension: Narrative Review and Introduction of a Framework for Improving Care. Am J Hypertens 2021; 34:258-266. [PMID: 33821943 DOI: 10.1093/ajh/hpab002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/11/2020] [Accepted: 01/08/2021] [Indexed: 01/03/2023] Open
Abstract
Although antihypertensive medications are effective, inexpensive, and recommended by clinical practice guidelines, a large percentage of older adults with hypertension have uncontrolled blood pressure (BP). Improving BP control in this population may require a better understanding of the specific challenges to BP control at older age. In this narrative review, we propose a framework for considering how key steps in BP management occur in the context of aging characterized by heterogeneity in function, multiple co-occurring health conditions, and complex personal and environmental factors. We review existing literature related to 4 necessary steps in hypertension control. These steps include the BP measure which can be affected by the technique, device, and setting in which BP is measured. Ensuring proper technique can be challenging in routine care. The plan includes setting BP treatment goals. Lower BP goals may be appropriate for many older adults. However, plans must take into account the generalizability of existing evidence, as well as patient and family's health goals. Treatment includes the management strategy, the expected benefits, and potential risks of treatment. Treatment intensification is commonly needed and can contribute to polypharmacy in older adults. Lastly, monitor refers to the need for ongoing follow-up to support a patient's ability to sustain BP control over time. Sustained BP control has been shown to be associated with a lower rate of cardiovascular disease and multimorbidity progression. Implementation of current guidelines in populations of older adults may be improved when specific challenges to BP measurement, planning, treating, and monitoring are addressed.
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Affiliation(s)
- C Barrett Bowling
- U.S. Department of Veterans Affairs, Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Alexandra Lee
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Jeff D Williamson
- Department of Internal Medicine, Section on Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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11
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Cuspidi C, Facchetti R, Dell'Oro R, Quarti-Trevano F, Tadic M, Mancia G, Grassi G. Office and Out-of-Office Blood Pressure Changes Over a Quarter of Century: Findings From the PAMELA Study. Hypertension 2020; 76:759-765. [PMID: 32755470 DOI: 10.1161/hypertensionaha.120.15434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Findings regarding long-terms variations in blood pressure (BP) taken in different setting (ie, office, home, and ambulatory BP) in the community are scanty. We sought to assess this issue in members of the general population enrolled in the PAMELA (Pressioni Monitorate E Loro Associazioni) study. The study included 562 participants who attended the second and third survey of the PAMELA study performed after 10 and 25 years from the initial evaluation. Data collection included medical history, anthropometric parameters, office, home, ambulatory BP, and standard blood examinations. Office, home, and 24-hour systolic BP over the 25-year interval between the first and third survey increased in a parallel way (ie, 12%, 10%, and 15.5%). The increments in office, home, and 24-hour diastolic BP were lower than the systolic BP ones (ie, 3.3%, 5.6%, and 6.1%). Thus, the combined changes in systolic BP and diastolic BP from the first to the third data collection resulted in a marked increase in pulse pressure (ie, 29%, 19%, and 30%). The prevalence of hypertension assessed at office visits and out-of-office either by self-BP measurements at home and ambulatory blood pressure monitoring increased ≈3 to 4× (3.1 office, 3.3 home, 3.9 ABPM, respectively). This trend was associated with adiposity indexes and worsening of the glucose profile. This community-based longitudinal study suggests that the progressive and marked increase in hypertension with age, consistently documented with different BP measurement methods, represents an epochal challenge for the prevention of cardiovascular diseases, due to the rapid growth the elderly population worldwide.
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Affiliation(s)
- Cesare Cuspidi
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.C., R.F., R.D., F.Q.-T., G.G.).,Istituto Auxologico Italiano IRCCS, Milano, Italy (C.C.)
| | - Rita Facchetti
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.C., R.F., R.D., F.Q.-T., G.G.)
| | - Raffaella Dell'Oro
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.C., R.F., R.D., F.Q.-T., G.G.)
| | - Fosca Quarti-Trevano
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.C., R.F., R.D., F.Q.-T., G.G.)
| | - Marijana Tadic
- Department of Cardiology, University Hospital "Dr. Dragisa Misovic - Dedinje", Serbia (M.T.)
| | - Giuseppe Mancia
- University of Milano-Bicocca and Policlinico di Monza, Italy (G.M.)
| | - Guido Grassi
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy (C.C., R.F., R.D., F.Q.-T., G.G.)
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12
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Bromfield SG, Booth JN, Loop MS, Schwartz JE, Seals SR, Thomas SJ, Min YI, Ogedegbe G, Shimbo D, Muntner P. Evaluating different criteria for defining a complete ambulatory blood pressure monitoring recording: data from the Jackson Heart Study. Blood Press Monit 2018; 23:103-111. [PMID: 29240564 PMCID: PMC6250566 DOI: 10.1097/mbp.0000000000000309] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We determined differences in the prevalence of blood pressure (BP) phenotypes and the association of these phenotypes with left ventricular hypertrophy (LVH) for individuals who fulfilled and did not fulfill various criteria used for defining a complete ambulatory blood pressure monitoring (ABPM) recording. METHODS We analyzed data for 1141 participants from the Jackson Heart Study. Criteria evaluated included having greater than or equal to 80% of planned readings with more than or equal to one reading per hour (Spanish ABPM Registry criteria), more than or equal to 70% of planned readings with a minimum of 20 daytime and seven nighttime readings (2013 European Society of Hypertension criteria), greater than or equal to 14 daytime and greater than or equal to seven nighttime readings (2003 European Society of Hypertension criteria), more than or equal to 10 daytime and more than or equal to 5 nighttime readings (International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcome criteria), and greater than or equal to 14 daytime readings (UK National Institute of Health and Clinical Excellence criteria). RESULTS Between 45.0% (Spanish ABPM Registry) and 91.8% (UK National Institute of Health and Clinical Excellence) of the participants fulfilled the different criteria for a complete ABPM recording. Across the various criteria evaluated, 55.5-57.8% of participants had nocturnal hypertension and 62.8-66.8% had nondipping systolic BP. Among participants with clinic-measured systolic/diastolic BP of more than or equal to 140/90 mmHg, 22.9-26.5% had white-coat hypertension. The prevalence of daytime, 24-h, sustained, and masked hypertension differed by up to 2% for participants fulfilling each criterion. The association of BP phenotypes with LVH was similar for participants who fulfilled versus those who did not fulfill different criteria (each P>0.05). CONCLUSION Irrespective of the criteria used for defining a complete ABPM recording, the prevalence of BP phenotypes and their association with LVH were similar.
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Affiliation(s)
| | - John N. Booth
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew S. Loop
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Joseph E. Schwartz
- Department of Medicine, Columbia University Medical Center, New York, NY
- Department of Psychiatry and Behavioral Sciences, Stony Brook University, Stony Brook, NY
| | - Samantha R. Seals
- Department of Mathematics and Statistics, University of West Florida, Pensacola, FL
| | - S. Justin Thomas
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL
| | - Yuan-I Min
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Gbenga Ogedegbe
- Department of Population Health, New York University Langone Medical Center, New York, NY
| | - Daichi Shimbo
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
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13
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Declining blood pressure and intensification of blood pressure management among people over 80 years: cohort study using electronic health records. J Hypertens 2017; 35:1276-1282. [PMID: 28441696 PMCID: PMC5404403 DOI: 10.1097/hjh.0000000000001291] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: Management of high blood pressure (BP) in people over 80 years is controversial, but there is limited information available concerning the uptake of hypertension treatment at this age. Objective: To evaluate use of antihypertensive drugs and changes in SBP and DBP from 2001 to 2014 in men and women aged 80 years and over. Methods: Cohort study using primary care electronic health records of 265 225 participants from the UK Clinical Practice Research Datalink. Records of BP and antihypertensive medications were analysed. Linear trends were estimated by frailty category in multiple regression models. Results: Data were analysed for 116 401 men and 148 824 women. The proportion with BP recorded increased from 51% in 2001 to 78% in 2014. The proportion of patients prescribed antihypertensive medications increased from 64 to 76%. Mean SBP declined from 150 (SD 20) mmHg in 2001 to 135 (16) mmHg in 2014. In ‘fit’ participants, the decline in SBP was 12.4 (95% confidence interval 11.9–13.0) mmHg/decade in those treated for hypertension and 8.5 (7.8–9.1) mmHg in those not treated. The decline in SBP was smaller as frailty increased. The proportion of all participants with BP less than 140/90 mmHg increased from 14 to 44% in the study period. Conclusion: In octogenarians, BP treatment has intensified between 2001 and 2014. BP values have declined in both treated and untreated participants, with a substantial increase in the proportion achieving conventional BP targets.
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14
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Muntner P, Abdalla M, Correa A, Griswold M, Hall JE, Jones DW, Mensah GA, Sims M, Shimbo D, Spruill TM, Tucker KL, Appel LJ. Hypertension in Blacks: Unanswered Questions and Future Directions for the JHS (Jackson Heart Study). Hypertension 2017; 69:761-769. [PMID: 28320850 PMCID: PMC5472537 DOI: 10.1161/hypertensionaha.117.09061] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Paul Muntner
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.).
| | - Marwah Abdalla
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - Adolfo Correa
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - Michael Griswold
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - John E Hall
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - Daniel W Jones
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - George A Mensah
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - Mario Sims
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - Daichi Shimbo
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - Tanya M Spruill
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - Katherine L Tucker
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
| | - Lawrence J Appel
- From the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham (P.M.); Department of Medicine, Columbia University Herbert and Florence Irving Medical Center, New York, NY (M.A., D.S.); Department of Medicine, Jackson Heart Study (A.C., D.W.J., M.S.), Department of Data Science (M.G.), and Department of Physiology and Biophysics, Mississippi Center for Obesity Research (J.E.H.), University of Mississippi Medical Center, Jackson; Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.); Department of Population Health, NYU School of Medicine, New York, NY (T.M.S.); Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell (K.L.T.); and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.)
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15
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Ravindrarajah R, Hazra NC, Hamada S, Charlton J, Jackson SHD, Dregan A, Gulliford MC. Systolic Blood Pressure Trajectory, Frailty, and All-Cause Mortality >80 Years of Age: Cohort Study Using Electronic Health Records. Circulation 2017; 135:2357-2368. [PMID: 28432148 DOI: 10.1161/circulationaha.116.026687] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 03/29/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical trials show benefit from lowering systolic blood pressure (SBP) in people ≥80 years of age, but nonrandomized epidemiological studies suggest lower SBP may be associated with higher mortality. This study aimed to evaluate associations of SBP with all-cause mortality by frailty category >80 years of age and to evaluate SBP trajectories before death. METHODS A population-based cohort study was conducted using electronic health records of 144 403 participants ≥80 years of age registered with family practices in the United Kingdom from 2001 to 2014. Participants were followed for ≤5 years. Clinical records of SBP were analyzed. Frailty status was classified using the e-Frailty Index into the categories of fit, mild, moderate, and severe. All-cause mortality was evaluated by frailty status and mean SBP in Cox proportional-hazards models. SBP trajectories were evaluated using person months as observations, with mean SBP and antihypertensive treatment status estimated for each person month. Fractional polynomial models were used to estimate SBP trajectories over 5 years before death. RESULTS During follow-up, 51 808 deaths occurred. Mortality rates increased with frailty level and were greatest at SBP <110 mm Hg. In fit women, mortality was 7.7 per 100 person years at SBP 120 to 139 mm Hg, 15.2 at SBP 110 to 119 mm Hg, and 22.7 at SBP <110 mm Hg. For women with severe frailty, rates were 16.8, 25.2, and 39.6, respectively. SBP trajectories showed an accelerated decline in the last 2 years of life. The relative odds of SBP <120 mm Hg were higher in the last 3 months of life than 5 years previously in both treated (odds ratio, 6.06; 95% confidence interval, 5.40-6.81) and untreated (odds ratio, 6.31; 95% confidence interval, 5.30-7.52) patients. There was no evidence of intensification of antihypertensive therapy in the final 2 years of life. CONCLUSIONS A terminal decline of SBP in the final 2 years of life suggests that nonrandomized epidemiological associations of low SBP with higher mortality may be accounted for by reverse causation if participants with lower blood pressure values are closer, on average, to the end of life.
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Affiliation(s)
- Rathi Ravindrarajah
- From Department of Primary Care and Public Health Sciences (R.R., N.C.H., S.H., J.C., A.D., M.C.G.), Department of Clinical Gerontology (J.C., S.H.D.J.), King's College London, UK; Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan (S.H.); and National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' National Health Service Foundation Trust, London, UK (A.D., M.C.G.).
| | - Nisha C Hazra
- From Department of Primary Care and Public Health Sciences (R.R., N.C.H., S.H., J.C., A.D., M.C.G.), Department of Clinical Gerontology (J.C., S.H.D.J.), King's College London, UK; Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan (S.H.); and National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' National Health Service Foundation Trust, London, UK (A.D., M.C.G.)
| | - Shota Hamada
- From Department of Primary Care and Public Health Sciences (R.R., N.C.H., S.H., J.C., A.D., M.C.G.), Department of Clinical Gerontology (J.C., S.H.D.J.), King's College London, UK; Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan (S.H.); and National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' National Health Service Foundation Trust, London, UK (A.D., M.C.G.)
| | - Judith Charlton
- From Department of Primary Care and Public Health Sciences (R.R., N.C.H., S.H., J.C., A.D., M.C.G.), Department of Clinical Gerontology (J.C., S.H.D.J.), King's College London, UK; Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan (S.H.); and National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' National Health Service Foundation Trust, London, UK (A.D., M.C.G.)
| | - Stephen H D Jackson
- From Department of Primary Care and Public Health Sciences (R.R., N.C.H., S.H., J.C., A.D., M.C.G.), Department of Clinical Gerontology (J.C., S.H.D.J.), King's College London, UK; Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan (S.H.); and National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' National Health Service Foundation Trust, London, UK (A.D., M.C.G.)
| | - Alex Dregan
- From Department of Primary Care and Public Health Sciences (R.R., N.C.H., S.H., J.C., A.D., M.C.G.), Department of Clinical Gerontology (J.C., S.H.D.J.), King's College London, UK; Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan (S.H.); and National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' National Health Service Foundation Trust, London, UK (A.D., M.C.G.)
| | - Martin C Gulliford
- From Department of Primary Care and Public Health Sciences (R.R., N.C.H., S.H., J.C., A.D., M.C.G.), Department of Clinical Gerontology (J.C., S.H.D.J.), King's College London, UK; Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan (S.H.); and National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' National Health Service Foundation Trust, London, UK (A.D., M.C.G.)
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16
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Kelly MS, Saseen JJ, Marrs JC. Assessment of achieved systolic blood pressure in newly treated hypertensive patients aged 60-79 years before and after Eighth Joint National Committee recommendations. Ther Adv Cardiovasc Dis 2016; 11:63-71. [PMID: 28033742 DOI: 10.1177/1753944716684463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine whether patients who were newly prescribed antihypertensive therapy after the Eighth Joint National Committee (JNC 8) update were treated to a relaxed systolic blood pressure (SBP) goal compared with patients treated before the update. METHODS A retrospective cohort study approved by the Colorado Multiple Institutional Review Board. Patients aged 60-79 years, without diabetes or chronic kidney disease (CKD), newly treated for hypertension at a University of Colorado primary care clinics were included. The mean first-achieved and last-stable SBPs of patients newly prescribed antihypertensive medications from 1 January 2012 to 31 December 31 2013 (before cohort) were compared with patients newly prescribed antihypertensive therapy from 1 January 2014 to 1 October 2015 (after cohort). The mean number of antihypertensive medications at first-achieved SBP, the time to first-achieved SBP, and the class of initial antihypertensive medications were also evaluated. RESULTS A total of 128 patients were included, 64 patients in each cohort. The coprimary outcome of first-achieved mean SBP did not differ between the groups (131.3 mmHg versus 130.2 mmHg; p = 0.65). Last-stable mean SBP values were also similar between the groups (130.2 mmHg versus 129.5 mmHg; p = 0.74). Angiotensin converting enzyme inhibitors (ACE-I) were the most frequently initiated antihypertensive agent in both cohorts (43.8% versus 48.4%; p = 0.72). CONCLUSIONS Our findings suggest that the JNC 8 recommendations did not alter SBP goals among patients aged 60-79 years newly treated for hypertension at University of Colorado primary care clinics.
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Affiliation(s)
| | - Joseph J Saseen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Joel C Marrs
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, 12850 E. Montview Blvd., Room V20-2128, Aurora, CO 80045, USA
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17
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Is white-coat hypertension associated with increased cardiovascular and mortality risk? J Hypertens 2016; 34:1655-8. [DOI: 10.1097/hjh.0000000000000983] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Ozturk C, Ozturk A, Demir M, Yildirim AO, Balta S, Aparci M, Unlu M, Demirkol S. Blood Pressure Variability Provides Useful and Prognostic Information on the White-Coat Effect Among Older Patients. J Clin Hypertens (Greenwich) 2016; 18:825. [DOI: 10.1111/jch.12796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Cengiz Ozturk
- Department of Cardiology; Gulhane Medical Faculty; Ankara Turkey
| | - Ahmet Ozturk
- Department of Geriatric Medicine; Gulhane Medical Faculty; Ankara Turkey
| | - Mustafa Demir
- Department of Cardiology; Gulhane Medical Faculty; Ankara Turkey
| | | | - Sevket Balta
- Department of Cardiology; Gulhane Medical Faculty; Ankara Turkey
| | - Mustafa Aparci
- Department of Cardiology; Kasimpasa Military Hospital; Istanbul Turkey
| | - Murat Unlu
- Department of Cardiology; Gulhane Medical Faculty; Ankara Turkey
| | - Sait Demirkol
- Department of Cardiology; Gulhane Medical Faculty; Ankara Turkey
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19
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Reynolds K, Bowling CB, Sim JJ, Sridharan L, Harrison TN, Shimbo D. The Utility of Ambulatory Blood Pressure Monitoring for Diagnosing White Coat Hypertension in Older Adults. Curr Hypertens Rep 2016; 17:86. [PMID: 26400076 DOI: 10.1007/s11906-015-0599-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The beneficial effect of antihypertensive medication on reducing the risk of cardiovascular disease (CVD) events is supported by data from randomized controlled trials of older adults with hypertension. However, in clinical practice, overtreatment of hypertension in older adults may lead to side effects and an increased risk of falls. The diagnosis and treatment of hypertension is primarily based on blood pressure measurements obtained in the clinic setting. Ambulatory blood pressure monitoring (ABPM) complements clinic blood pressure by measuring blood pressure in the out-of-clinic setting. ABPM can be used to identify white coat hypertension, defined as elevated clinic blood pressure and non-elevated ambulatory blood pressure. White coat hypertension is common in older adults but does not appear to be associated with an increased risk of CVD events among this population. Herein, we review the current literature on ABPM in the diagnoses of white coat hypertension in older adults, including its potential role in preventing overtreatment.
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Affiliation(s)
- Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 South Los Robles, 2nd Floor, Pasadena, CA, 91101, USA.
| | - C Barrett Bowling
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VAMC, 1670 Clairmont Road (11B), Decatur, GA, 30033, USA.
- Emory University, 1841 Clifton Road, Atlanta, GA, 30329, USA.
| | - John J Sim
- Kaiser Permanente Los Angeles Medical Center, 4700 Sunset Blvd, Los Angeles, CA, 90027, USA.
| | - Lakshmi Sridharan
- Columbia University Medical Center, 622 West 168th Street, PH 9-310, New York, NY, 10032, USA.
| | - Teresa N Harrison
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 South Los Robles, 2nd Floor, Pasadena, CA, 91101, USA.
| | - Daichi Shimbo
- Columbia University Medical Center, 622 West 168th Street, PH 9-310, New York, NY, 10032, USA.
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