Managing hypertension in 2018: which guideline to follow?

Treatment of hypertension in the elderly: target the lowest well tolerated blood pressure

INTRODUCTION

Clinical trials have shown that antihypertensive treatment provides substantial benefits in older people. However, many challenges remain, including the ideal blood pressure (BP) target to be achieved. Because the elderly population is particularly vulnerable to adverse events, BP control should be carefully managed. Some studies have evaluated the cardiovascular effects of different BP targets in older patients, with mixed results and uncertainty about the most appropriate BP target. However, available data from pooled analyses suggest that intensive BP lowering provides greater cardiovascular protection than less intensive strategies in elderly hypertensive patients.

AREAS COVERED

Understanding the balance between the risks and benefits of intensive BP targets and individualizing treatment is essential to ensure that older hypertensive patients receive appropriate treatment to reduce the risk of cardiovascular complications. To this purpose, we reviewed data from clinical trials which investigated the protective effects of blood pressure lowering drugs in elderly hypertensive patients aged ≥65 years (publication before 31 August 2024, using Medline, SCOPUS, and Web of Science databases).

EXPERT OPINION

Current evidence suggests that age does not preclude an aggressive strategy for treating hypertension in elderly patients. Being 'tolerant' with one hand and 'intensive' with the other should become a universal standard in the management of elderly hypertensive patients. In conclusion, the lowest well-tolerated BP could be a simple and universally applicable BP target in the management of hypertensive patients, including the elderly.

The objectively measured walking speed and risk of hypertension in Chinese older adults: a prospective cohort study

This study aims to investigate the longitudinal association between objectively measured walking speed and hypertension and to explore the potential effect modification of obesity on this association in Chinese older adults. The data from the Chinese Health and Retirement Prospective Cohort Study (CHARLS) during 2011-2015 was used. Walking speed was assessed by measuring the participants' usual gait in a 2.5 m course, and it was divided into four groups according to the quartiles (Q1, Q2, Q3, and Q4). A total of 2733 participants ≥60 years old were eligible for the analyses. After a follow-up of 4 years, 26.9% occurred hypertension. An inverse association was observed between walking speed and the risk of hypertension. There was an interaction between body mass index (BMI) and walking speed for the hypertension risk (P = 0.010). the association of walking speed with hypertension was stronger in overweight and obese participants (Q2, OR: 0.54, 95%CI = 0.34-0.85, P = 0.009; Q3, OR: 0.69, 95%CI = 0.44-1.08, P = 0.106; Q4, OR: 0.62, 95%CI = 0.39-0.98, P = 0.039). However, this association was not significant among lean ones. A similar trend was observed for systolic and diastolic blood pressure. In conclusion, higher walking speed was longitudinally associated with a lower risk of hypertension in Chinese older adults, especially among overweight and obese participants.

Labor migration is associated with lower rates of underweight and higher rates of obesity among left-behind wives in rural Bangladesh: a cross-sectional study

BACKGROUND

Among Bangladeshi men, international labor migration has increased ten-fold since 1990 and rural to urban labor migration rates have steadily increased. Labor migration of husbands has increased household wealth and redefined women's roles, which have both positively and negatively impacted the health of wives "left behind". We examined the direct and indirect effects of husband labor migration on chronic disease indicators and outcomes among wives of labor migrants.

METHODS

We collected survey, anthropometric, and biomarker data from a random sample of women in Matlab, Bangladesh, in 2018. We assessed associations between husband's migration and indicators of adiposity and chronic disease. We used structural equation modeling to assess the direct effect of labor migration on chronic disease, undernutrition, and adiposity, and the mediating roles of income, food security, and proportion of food purchased from the bazaar. Qualitative interviews and participant observation were used to help provide context for the associations we found in our quantitative results.

FINDINGS

Among study participants, 9.0% were underweight, 50.9% were iron deficient, 48.3% were anemic, 39.6% were obese, 27.3% had a waist circumference over 35 in., 33.1% had a high whole-body fat percentage, 32.8% were diabetic, and 32.9% had hypertension. Slightly more women in the sample (55.3%) had a husband who never migrated than had a husband who had ever migrated (44.9%). Of those whose husband had ever migrated, 25.8% had a husband who was a current international migrant. Wives of migrants were less likely to be underweight, and more likely to have indicators of excess adiposity, than wives of non-migrants. Protection against undernutrition was attributable primarily to increased food security among wives of migrants, while increased adiposity was attributable primarily to purchasing a higher proportion of food from the bazaar; however, there was a separate path through income, which qualitative findings suggest may be related to reduced physical activity.

CONCLUSIONS

Labor migration, and particularly international labor migration, intensifies the nutrition transition in Bangladesh through increasing wealth, changing how foods are purchased, and reducing physical activity, which both decreases risk for undernutrition and increases risk for excess adiposity.

Blood Pressure Screening Campaign in the Adult Population

Background: World Health Organization estimated that 1 in 4 men and 1 in 5 women have hypertension (HTN). Considering the impact of high blood pressure (BP) identification to prevent its related complications. Objectives: This study was performed to describe the first national BP screening program conducted in Babol, north of Iran. Methods: In this historical cohort carried out at Babol University of Medical Sciences, data related to the 2019 BP screening mass campaign in adult people ≥ 30 years were collected. BP less than 120/80 mm Hg was considered as normal, and mean BP ≥ 140/90 mm Hg or taking antihypertensive medication was defined as hypertension. When the systolic pressure was 120 - 139 or the diastolic pressure was 80 - 90 mm Hg, the person was classified as a prehypertensive case. Results: Totally, 220,241 adult people, with a mean age of 49.82 ± 14.26 years were screened, of whom 42,107 cases (19.1%; 95% CI: 18.95 - 19.28%) had hypertension, 112,406 cases (51.0%) had normal BP, and 65,728 cases (29.8%) were diagnosed as prehypertensive cases. After controlling for demographic covariates, the logistic regression models showed significantly higher odds of hypertension for married individuals (adjusted OR = 1.23; 95% CI: 1.19 - 1.27; P < 0.0001) and those living in urban regions (adjusted OR = 1.84; 95% CI: 1.79 - 1.88; P < 0.0001). The prevalence of hypertension showed no significant difference between men and women (P = 0.476). Conclusions: As nearly one in five adults had hypertension, and nearly 30% were diagnosed as prehypertensive individuals, a continuous BP screening program is recommended in this region. High BP was observed more in older and married cases and in people living in urban regions.

Genetic polymorphism of the prostasin gene in hypertensive pregnant Pakistani females

Objective

The study was performed to investigate the association of hypertension in pregnancy with prostasin gene polymorphism in Pakistani females.

Methods

This case-control study was performed at University of Karachi, Pakistan from April 2018 to May 2019. A total of 160 females, including 90 hypertensives and 70 healthy pregnant females, were recruited by purposive sampling after obtaining informed written consent. Genotyping was performed by polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP).

Results

The frequencies of the TC and CC genotypes were higher in hypertensive pregnant females compared to healthy controls. A significant difference was evident for CC (P=0.012) genotype; however, no significant difference was observed for TC (P=0.49) and TT genotypes (P=0.06) between control and hypertensive groups. The adjusted odds ratio for CC genotype was 6.2 (P=0.025) and 1.48 (P=0.44) for TC genotype compared to the TT genotype. There was a significantly higher prevalence of the C allele of the prostasin gene at rs12597511 in the hypertensive group, suggesting that this allele is a risk factor for hypertension and cardiovascular diseases.

Conclusion

C allele at rs12597511 of prostasin gene demonstrate as a risk factor for having hypertension in pregnancy.

The 2020 International Society of Hypertension global hypertension practice guidelines - key messages and clinical considerations

The International Society of Hypertension (ISH) has recently developed practice guidelines for the management of hypertension in adults aged ≥18 years. Conceptually, the 2020 ISH Guidelines are closer to the 2018 ESC/ESH Guidelines rather than to the 2017 ACC/AHA Guidelines. The ISH Guidelines have two distinctive features when compared with the 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) Guidelines and the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines. First, they are written in a concise and easy-to-read style; second, they focuses on practical issues related to the management of hypertension in 'high-income' as well as in 'low-income' countries, where there is limited access to resources for the diagnosis and treatment of hypertension. In our opinion, the 2020 ISH Guidelines share with the 2018 ESC/ESH Guidelines an important limitation which may impair the retention of these key aspects of Guidelines by physicians, with consequent difficult adoption in clinical practice. It consists in the definition of several blood pressure targets in relation to age, target organ damage and concomitant disease. We believe that results of randomized clinical trials and meta-analysis do not support the recommendation of differential BP targets, as well as of rigid 'safety boundaries'. This review critically examines similarities and differences across the three major Hypertension Guidelines, which include the definition of hypertension, drug treatment, and blood pressure targets, with emphasis on key messages relevant for clinical practice.

Individual awareness and treatment effectiveness of hypertension among older adults in Ghana: evidence from the World Health Organization study of global ageing and adult health wave 2

INTRODUCTION

the aim of this study was to report the prevalence of hypertension, its awareness and treatment effectiveness among older adults (aged 50 years and above) in Ghana.

METHODS

the Ghana World Health Organization´s (WHO) Study on Global Aging and Adult Health (SAGE) wave 2 dataset was used in this study. The study adopted a cross-sectional study design. Information on self-reported hypertension as well as measured hypertension was analyzed. The level of awareness regarding hypertension and the effectiveness of treatment was determined using descriptive statistics. Factors associated with an individual´s awareness of their hypertensive status were determined using Rao-Scott Chi square test statistic and the predictors of unawareness of hypertension were determined using adjusted logistic regression analysis. A p-value of ≤0.05 was deemed significant.

RESULTS

information on 3,575 adults in Ghana aged 50 years or older was included in this analysis. The mean age of study participants was 65.1 ± 10.7 years with 59% being female. The prevalence of measured hypertension was 50.7% [95%CI=48.3-53.2]. The overall prevalence of hypertension among older adults in Ghana who were hypertensive but were not aware of it was 35.0% [95%CI=31.6-38.5]. Of the 332 individuals who self-reported being hypertensive, only 74 (22.2%) were on any form of treatment, with only 17 (5.1%) having their blood pressures well controlled.

CONCLUSION

approximately half of all older adults in Ghana have elevated blood pressures. Most of these are not aware of their elevated blood pressure and for those who are aware, very few are on treatment and even fewer have their blood pressure well controlled. Structured national population level screening and health promotion for elevated blood pressure by Ministry of Health/ Ghana Health Service is worthy of consideration.

Treatment strategies for isolated systolic hypertension in elderly patients

INTRODUCTION

Hypertension is a major and modifiable risk factor for cardiovascular disease. Its prevalence is rising as the result of population aging. Isolated systolic hypertension mostly occurs in older patients accounting for up to 80% of cases.

AREAS COVERED

The authors systematically review published studies to appraise the scientific and clinical evidence supporting the role of blood pressure control in elderly patients with isolated systolic hypertension, and to assess the influence of different drug treatment regimens on outcomes.

EXPERT OPINION

Antihypertensive treatment of isolated systolic hypertension significantly reduces the risk of morbidity and mortality in elderly patients. Thiazide diuretics and dihydropyridine calcium-channel blockers are the primary compounds used in randomized clinical trials. These drugs can be considered as first-line agents for the management of isolated systolic hypertension. Free or fixed combination therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and calcium-channel blockers or thiazide-like diuretics should also be considered, particularly when compelling indications such as coronary artery disease, chronic kidney disease, diabetes, and congestive heart failure coexist. There is also hot scientific debate on the optimal blood pressure target to be achieved in elderly patients with isolated systolic hypertension, but current recommendations are scarcely supported by evidence.

Management of hypertension in the very old: an intensive reduction of blood pressure should be achieved in most patients

There is large evidence that treatment of hypertension significantly reduces the risk of morbidity and mortality in the elderly. Although it is generally accepted that the benefit of antihypertensive treatment is largely explained by the reduction in systolic blood pressure, the optimal blood pressure target in elderly patients is still a topic of debate. Unfortunately, the clinical trials which demonstrated the benefit of antihypertensive treatment in old and very old patients with hypertension included relatively fit patients since frail patients were generally excluded. Available data suggest that when treating older adults, and especially frail older hypertensive adults, extra caution is appropriate in the setting of significant adverse events. Nonetheless, recent observations demonstrated a similar benefit from a more intensive compared with a less intensive blood pressure lowering in both fit and frail older adults. Of note, the rate of serious adverse events appears not dissimilar in the two treatment strategies, and not associated to frailty. Taken together, these findings support the concept that an intensive therapeutic strategy appears reasonable even in elderly hypertensive patients, particularly when the treatment is well tolerated.

The implications of blood pressure targets from the 2018 European Society of Cardiology hypertension guidelines in Asian patients: a systematic review and meta-analysis

BACKGROUND

The evidence for optimal blood pressure (BP) targets in Asian patients with hypertension is insufficient and controversial. Western guidelines should be used with caution in clinical practice until there is supporting evidence.

OBJECTIVE

Systematically synthesize the evidence on the efficacy of achieving the strict 2018 European Society of Cardiology (ESC) guideline BP targets versus standard BP targets in Asian patients.

DATA SOURCES

We searched PubMed, Web of Science, Scopus, the Cochrane Central Register of controlled trials, and additional databases to retrieve relevant Asian studies.

STUDY SELECTION

Randomized controlled trials (RCTs) and observational studies that reported clinical endpoints, had a minimal follow-up period of one year and included Asian patients older than 18 years with essential hypertension.

DATA EXTRACTION

Two investigators independently conducted the study selection with any discrepancies resolved between team members.

DATA SYNTHESIS

We selected 15 studies for analysis (4 RCTs, 7 observational studies, and 4 post-hoc analyses). The evidence for the strict BP targets in elderly patients was insufficient. In middle-aged patients, the meta-analysis of observational studies revealed a significant reduction in major adverse cardiac events (MACCE) (hazard ratio (HR)=0.78; 95% confidence interval (CI: 0.74-0.81). For studies that reported results for patients of any age, the tight systolic BP-lowering therapy was associated with a decrease in MACCE (HR=0.80; 95% CI: 0.69-0.92), stroke (HR=0.82; 95% CI: 0.71-0.94), but not in cardiac events (HR=0.91; 95% CI: 0.72-1.14, P=.41), all-cause (HR=0.80; 95% CI: 0.57-1.13) and cardiovascular mortality (HR=0.73; 95% CI: 0.40-1.33, P=.30). Similar findings were obtained for the strict diastolic BP targets.

CONCLUSION

Our findings provide evidence for Asian patients that support the efficacy of the strict antihypertensive treatment with BP targets proposed by the 2018 ESC hypertension guidelines for the prevention of cardiovascular events. However, these data were obtained from only observational studies and the results were not confirmed by RCTs, probably due to insufficient power. Therefore, further high-quality RCTs are crucial.

LIMITATIONS

Use of aggregated data, the subgroup and meta-regression analyses are inconclusive, limited to English language, unable to estimate summary measures for some outcomes, publication bias difficult to assess, and unclear that results could be extrapolated.

REGISTRATION

The protocol registered in PROSPERO (CRD42018115570).

CONFLICT OF INTEREST

None.

Searching for optimal blood pressure targets in type 2 diabetic patients with coronary artery disease

BACKGROUND

Controversies exist regarding the optimal blood pressure (BP) level that is safe and provides cardiovascular protection in patients with type 2 diabetes mellitus (T2DM) and coexistent coronary artery disease. Several new glucose-lowering agents have been found to lower BP as well, making the interaction between BP and T2DM even more complex.

METHODS

With the reference to recent literature, this review article describes the potential mechanisms of increased risk of hypertension in T2DM and outlines the possible optimal BP levels based upon recommendations on the management of hypertension by the current guidelines, in combination with our research findings, for type 2 diabetic patients with coronary artery disease.

RESULTS

The development of hypertension in T2DM involves multiple processes, including enhanced sympathetic output, inappropriate activation of renin-angiotensin- aldosterone system, endothelial dysfunction induced through insulin resistance, and abnormal sodium handling by the kidney. Both AGE-RAGE axis and adipokine dysregulation activate intracellular signaling pathways, increase oxidative stress, and aggravate vascular inflammation. Pancreatic β-cell specific microRNAs are implicated in gene expression and diabetic complications. Non-pharmacological intervention with lifestyle changes improves BP control, and anti-hypertensive medications with ACEI/ARB, calcium antagonists, β-blockers, diuretics and new hypoglycemic agent SGLT2 inhibitors are effective to decrease mortality and prevent major adverse cardiovascular events. For hypertensive patients with T2DM and stable coronary artery disease, control of BP < 130/80 mmHg but not < 120/70 mmHg is reasonable, whereas for those with chronic total occlusion or acute coronary syndromes, an ideal BP target may be somewhat higher (< 140/90 mmHg). Caution is advised with aggressive lowering of diastolic BP to a critical threshold (< 60 mmHg).

CONCLUSIONS

Hypertension and T2DM share certain similar aspects of pathophysiology, and BP control should be individualized to minimize adverse events and maximize benefits especially for patients with T2DM and coronary artery disease.