The significance of various blood pressure indices for long-term stroke, coronary heart disease, and all-cause mortality in men: the Israeli Ischemic Heart Disease study

Evaluating the relative importance of different blood pressure indices in screening for NAFLD: a survey report based on a health examination population

Objective

While hypertension is a well-recognized risk factor for non-alcoholic fatty liver disease (NAFLD), the specific roles of various common blood pressure measurements [diastolic blood pressure (DBP), systolic blood pressure (SBP), pulse pressure (PP), mean arterial pressure (MAP)] in detecting NAFLD and evaluating the associated risk in adults remain unclear.

Methods

A retrospective analysis was conducted on 14,251 adult participants undergoing health screenings in the NAfld in the Gifu Area, Longitudinal Analysis project (NAGALA). Following the Z-transformation of the independent variables, we evaluated the relationships between the four blood pressure indices and NAFLD through multivariable logistic regression models. This analysis documented the odds ratio (OR) and 95% confidence interval (CI) for each standard deviation (SD) increase. Additionally, the effectiveness of these indices in identifying NAFLD was comparatively analyzed using receiver operating characteristic (ROC) curves.

Results

After adequately adjusting for confounders, all blood pressure indices except PP showed a positive correlation with NAFLD. For each SD increment, MAP had the strongest association with NAFLD compared to SBP and DBP. This finding was confirmed in populations without exercise habits, under 60 years of age, with normal blood pressure, and in non-obese groups. Furthermore, based on ROC analysis, MAP was found to have the highest accuracy in identifying NAFLD compared to the other three blood pressure indices.

Conclusion

Among the four blood pressure indices evaluated, MAP demonstrates the greatest efficacy in identifying NAFLD and assessing its associated risk. These findings underscore the potential of MAP as the most promising blood pressure index for screening NAFLD.

Blood pressure levels within normotensive range are independently associated with increased risk of arterial stiffness in adults without hypertension or prehypertension

BACKGROUND AND AIMS

High blood pressure (BP) indices, including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and pulse pressure (PP) predict cardiovascular diseases and mortality. However, the association of these BP indices with arterial stiffness (AS) in the normotensive population (BP < 120/80 mmHg) remains unclear.

METHODS AND RESULTS

Study participants who underwent health checkups at a tertiary referred center were recruited between November 2018 to December 2019. 2129 participants were enrolled after excluding those aged <18 years old, with elevated BP, history of hypertension, cardiovascular disease, and stroke, or with incomplete data. The brachial-ankle pulse wave velocity (baPWV) values were examined for evaluation of AS. Participants with higher blood pressure indices had significantly higher baPWV. Multiple linear regression revealed that all BP indices were positively associated with baPWV. According to the binary logistic regression analysis, participants in the higher SBP and MAP quartiles were significantly related to AS. The odds ratio (OR) for SBP Q2, Q3 and Q4 vs. Q1 were 6.06, 10.06 and 17.78 whereas the OR for MAP Q2, Q3 and Q4 vs. Q1 were: 5.07, 5.28 and 10.34. For DBP and PP, only participants belonging to the highest quartile were associated with AS(OR for DBP Q4 vs. Q1: 2.51; PP Q4 vs Q1: 1.94).

CONCLUSIONS

BP indices were linearly related to the baPWV. Normotensive participants with higher quartiles of SBP, DBP, MAP, and PP, remained associated with increased AS. The SBP and MAP levels exhibited a more prominent relationship with AS.

School-based surveillance on visit-to-visit blood pressure variability and high blood pressure in children and adolescents

BACKGROUND

The predictive importance of visit-to-visit blood pressure variability (VVV) for high blood pressure (HBP) in a pediatric population has been largely unsettled. We aimed to evaluate it based on Health Promotion Program for Children and Adolescents (HPPCA), a school-based surveillance conducted from 2012 to 2018 in Suzhou, China.

METHODS

A total of 330,618 participants had BP measurement in 2018 and ≥ 3 BP records during 2012-2017, were recruited from HPPCA. Absolute BP values (in mmHg) were converted into age-, sex- and height- normalized z-scores. VVV was expressed as standard deviation (SD), coefficient of variation (CV) or average real variability (ARV) of BP z-scores during 2012-2017. Logistic regression models were used to assess the associations between VVV and HBP in 2018.

RESULTS

In 2018, 42,554 (12.87%) subjects were defined as HBP. VVV, except for SBP-CV and DBP-CV, was significantly higher in the HBP group than normotensives group. After adjusting for covariates including mean BP values from 2012 to 2017, SBP-SD, SBP-ARV, DBP-SD and DBP-ARV, increased the risk of HBP by 5.70 [95% confidence interval (95% CI) 5.54-5.87], 4.10 (95% CI 4.01-4.20), 4.70 (95% CI 4.50-4.90) and 3.39 (95% CI 3.28-3.50) times, respectively. Notably, SBP-SD significantly improved risk discrimination of HBP based on other risk variables (c-statistics, net reclassification index and integrated discrimination improvement significantly increased).

CONCLUSIONS

Higher SD or ARV of BP, was independently related with higher probability of HBP in Chinese pediatric population. SBP-SD could be potentially helpful for detecting HBP. Future researches investigating the predictive value of VVV are warrant.

Effect of High-velocity Resistance Exercise on 24-h Blood Pressure in Hypertensive Older Women

This study investigated the acute post-exercise effect of high-velocity resistance exercise on ambulatory blood pressure in hypertensive older women. Fourteen volunteers (67.9±5.1 years) performed a high-velocity resistance exercise session (8 exercises using Thera-Band, 3 sets of 6 repetitions as fast as possible in the concentric phase with moderate intensity) and a control session, separated by a 7-10-day period. Ambulatory blood pressure was monitored following 12-h post-sessions and compared between conditions at 1 to 4-h, 5 to 8-h, and 9 to 12-h. Average 24-h ambulatory blood pressure, awake, asleep periods, and blood pressure load were also analyzed. There was a condition by time interaction for systolic ambulatory blood pressure over 12-h post-sessions (P=0.043). It was observed a lower systolic ambulatory blood pressure in the first 4-h period following the high-velocity resistance exercise session compared to the control session (-6.7 mmHg, 95% CI  - 11.6 to -1.8 mmHg; P=0.011). No changes were observed for diastolic ambulatory blood pressure over 12-h post-sessions as well as for the other variables analyzed (P>0.05). In summary, a single high-velocity resistance exercise session elicits a post-exercise antihypertensive effect and may be considered as a strategy to acutely improve blood pressure control in hypertensive older women.

Contribution of serum lipids as effect modifiers to a relationship between mean arterial pressure and coronary heart disease in Chinese rural population: the Henan Rural Cohort Study

OBJECTIVES

The aim of this study was to evaluate the relationship between mean arterial pressure (MAP) and coronary heart disease (CHD) in Chinese rural population. In addition, we hypothesised that this relationship might be mediated by some degree of serum lipids.

DESIGN

This is a cross-sectional study.

SETTING

The participants were from the Henan Rural Cohort Study, initiated in five rural areas (Tongxu county of Kaifeng city, Yima county of Sanmenxia city, Suiping county of Zhumadian city, Xinxiang county of Xinxiang city and Yuzhou county of Xuchang city) in Henan Province, China, during July 2015 and September 2017.

PARTICIPANTS

The study included 39 020 subjects aged 18-79 years as current research population.

OUTCOME MEASURES

Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using an electronic sphygmomanometer. MAP was calculated by one-third SBP plus two-thirds DBP. The study used restricted cubic splines and logistic regression models to evaluate the ORs and 95% CIs. Mediation analysis using bootstrap was performed to examine the contribution of serum lipids to MAP-related CHD.

RESULTS

The adjusted OR (95% CI) for the highest MAP quartile with the risk of CHD was 1.45 (1.24 to 1.69) compared with the lowest quartile. Simultaneously, each 1-SD increment in MAP was significantly associated with a 12% increased risk of CHD. A linear dose-response relationship between MAP and CHD was found (p value for non-linear=0.1169) in the fully adjusted model. We further reported that 36.07% of proportion explained risk of CHD was mediated through serum lipids.

CONCLUSIONS

Increased MAP was a significant marker of CHD in Chinese rural population. Meanwhile, the relationship was mediated by some degree of serum lipids, and triglyceride was the strongest mediator.

TRIAL REGISTRATION NUMBER

Henan Rural Cohort study has been registered at Chinese Clinical Trial Register (ChiCTR-OOC-15006699) and the stage it relates to is Post-results.

Subgroups of lifestyle patterns among hypertension patients: a latent-class analysis

BACKGROUND

Hypertension remains one of the most important preventable risk factors for diseases and death. Identifying clustered patterns of modifiable lifestyle risk factors for hypertension and demographics factors related to these clustered patterns allows for targeting health prevention interventions. Therefore, this study aims to identify latent classes of hypertensive patients' lifestyle risk factors based on the clustering of four modifiable lifestyle risk factors: eating, physical activity patterns, smoking habits, and blood pressure control.

METHODS

A total of 750 patients (Mage = 65.38 years, SDage = 9.2 years) with diagnosed hypertension in urban and rural primary health care centers in Takab (Iran) were recruited randomly from August 2016 to February 2017. Latent class analysis was performed by using proc. LCA in SAS 9.2.

RESULTS

Three classes of lifestyle patterns were identified. About 14.4% of hypertensive patients were categorized in a low-risk class (I), 54.6% in an intermediate-risk class (II), and 31% in a high-risk class (III) of lifestyle. A one-year increase in age significantly increases the risk of membership in classes II and III. Similarly, being widowed or divorced increases the risk of membership in classes II and III. Also, having a higher education level decreases the risk of membership in classes II and III.

CONCLUSIONS

This study contributes to the literature on lifestyle behaviors among older adults and provides evidence that there are considerable differences in lifestyle behaviors between subgroups of older adult patients. The three profiles of hypertensive patients' conditions suggest that because behaviors often occur simultaneously within an individual level, a latent-class approach helps cluster co-occurrence risk behaviors and focuses on interventions targeted to several healthy behaviors among high-risk patients.

Significant Correlation between Brachial Pulse Pressure Index and Renal Resistive Index

BACKGROUND

The renal resistive index (RI) is calculated as (peak systolic velocity - minimum diastolic velocity)/peak systolic velocity, and has been significantly associated with renal function. Pulse pressure index (PPI) is derived from a formula similar to renal RI, i.e. (systolic blood pressure - diastolic blood pressure)/systolic blood pressure. The purpose of this study was to investigate whether brachial PPI had a significant correlation with renal RI and could be used in identifying patients with impaired renal function.

METHODS

We consecutively enrolled 255 patients referred for echocardiographic examination. The renal RI was measured from Doppler ultrasonography and blood pressure was measured from an ABI-form device.

RESULTS

Patients with brachial PPI ≥ 0.428 (mean value of brachial PPI) had a lower estimated glomerular filtration rate (eGFR) than those with brachial PPI < 0.428 (p < 0.001). After the multivariate analysis was completed, brachial PPI had a significant correlation with renal RI (unstandardized coefficient β = 0.53, p < 0.001). The areas under the curve for brachial PPI and renal RI in prediction of eGFR < 45 mL/min/1.73 m(2) were 0.682 and 0.893 (both p < 0.001), respectively.

CONCLUSIONS

Brachial PPI was significantly correlated with renal RI. Patients with higher brachial PPI had a more reduced renal function. Hence, brachial PPI may be able to quickly reflect the intrarenal vascular hemodynamics, and may serve as an important tool for screening and follow-up for patients with abnormal renovascular resistance.

KEY WORDS

Chronic kidney disease; Pulse pressure index; Resistive index.

Associations of pulse pressure index with left ventricular filling pressure and diastolic dysfunction in patients with chronic kidney disease

BACKGROUND

Patients with chronic kidney disease (CKD) often have poor vascular compliance and poor left ventricular diastolic dysfunction (LVDD). The pulse pressure index (PPI) defined as ((systolic blood pressure - diastolic blood pressure)/systolic blood pressure) reflects vascular compliance. Vascular compliance is reportedly associated with left ventricular diastolic function. This study of CKD patients investigated whether PPI correlates with the ratio of transmitral E wave velocity (E) to early diastole mitral annulus velocity (Ea) or with LVDD.

METHODS

This study enrolled 511 CKD patients who had been referred for echocardiographic examination. Blood pressure was automatically measured with an ABI-form device. The LVDD was defined as E-to-transmitral A wave velocity ratio of ≥0.9, Ea <8 cm/s, or E/Ea ≥15.

RESULTS

Compared with those with E/Ea <15, patients with E/Ea ≥15 had significantly higher systolic blood pressure, pulse pressure, and PPI (all P < 0.001). Multivariable analysis showed that PPI was independently associated with E/Ea (unstandardized coefficient β = 1.348; P < 0.001) and with LVDD (odds ratio = 1.441 per 0.064 increase; P < 0.001).

CONCLUSIONS

This study showed that increased PPI significantly correlates with elevated E/Ea and LVDD in CKD patients. Because PPI can be rapidly acquired during blood pressure measurement, it may be helpful for identifying CKD patients with a high left ventricular filling pressure and LVDD.

Dietary pattern and hypertension in Korean adults

OBJECTIVE

To assess the dietary pattern associated with hypertension and pre-hypertension among Korean male and female adults.

DESIGN

Cross-sectional study from a representative sample of the Korean population.

SETTING

The Korea National Health and Nutrition Examination Survey IV, which was conducted in 2007 and 2008.

SUBJECTS

Males and females (n 5308) over the age of 20 years.

RESULTS

Scores for three major dietary patterns ('whole food', 'Western' and 'drinking') were generated using a factor analysis of thirty predefined food groups based on the food items consumed. We used polytomous logistic regression analyses to obtain odds ratios and 95% confidence intervals for pre-hypertension and hypertension. Participants with a high drinking pattern score (moderate to high alcohol intake, salted fermented seafood intake) had a significantly higher prevalence of pre-hypertension or hypertension than those with a lower drinking pattern score; odds for the top quintile v. the bottom quintile were OR = 1·56 (95% CI 1·23, 1·99; P trend = 0·001) for pre-hypertension and OR = 3·05 (95% CI 2·12, 4·40; P trend < 0·001) for hypertension. The whole food pattern was not associated with either pre-hypertension or hypertension, while the Western pattern was associated with the prevalence of hypertension only among men.

CONCLUSIONS

Our finding warrants further prospective studies to examine whether alcohol drinking and salty food consumption increase the risk of developing hypertension in Koreans.

Clinic and ambulatory blood pressure lowering effect of aliskiren/amlodipine/hydrochlorothiazide combination in patients with moderate-to-severe hypertension: a randomized active-controlled trial

OBJECTIVES

To evaluate the clinic and ambulatory blood pressure (BP)-lowering efficacy and safety of an aliskiren/amlodipine/hydrochlorothiazide (HCT) triple combination compared with the component dual combinations, in patients with moderate-to-severe hypertension.

METHODS

This 8-week, double-blind, randomized, active-controlled study, after 1-4 weeks single-blind placebo run-in period, randomized 1191 patients to receive once-daily aliskiren/amlodipine 150/5 mg (n = 287), aliskiren/HCT 150/12.5 mg (n = 298), amlodipine/HCT 5/12.5 mg (n = 296), or aliskiren/amlodipine/HCT 150/5/12.5 mg (up-titrated from aliskiren/HCT 150/12.5 mg after initial 3 days) (n = 310) for 4 weeks, followed by forced titration to double the initial dose for the next 4 weeks.

RESULTS

Baseline mean sitting SBP and DBP (msSBP/msDBP) was comparable among treatment groups. The aliskiren/amlodipine/HCT combination resulted in significant least squares mean reduction in msSBP/msDBP from baseline to endpoints (week 4, -30.7/-15.9  mmHg; week 8, -37.9/-20.6  mmHg), superior (P < 0.001) to each of the dual combinations. The triple combination was associated with -27.8  mmHg reduction in msSBP at week 2, significantly better than the dual combinations (P < 0.05). Significantly greater mean SBP/DBP-lowering effect for triple vs. dual combinations was also demonstrated through 24-h, daytime, and night-time ambulatory BP measurements. Significantly greater (P < 0.001) BP control (msSBP/msDBP < 140/90  mmHg) was achieved with triple combination in patients with moderate-to-severe (62.3%) and severe (57.5%) hypertension.

CONCLUSION

Aliskiren/amlodipine/HCT at 150/5/12.5 mg (week 4) and 300/10/25 mg (week 8) provided statistically superior reductions in msSBP/msDBP and greater BP control rates vs. the dual combinations, and was well tolerated. The improved efficacy of BP reduction was evident within 2 weeks of initiating triple therapy even at low dose.

Betel quid chewing in rural Bangladesh: prevalence, predictors and relationship to blood pressure

BACKGROUND

Betel quid is chewed by 600 million people worldwide and it has been linked to obesity and cardiovascular disease. The purpose of our study was to examine the prevalence and predictors of betel quid chewing in a rural area of Bangladesh, and determine its effects on body mass index (BMI) and blood pressure.

METHODS

In this population-based prospective study, we analysed data on 19 934 Bangladeshi adults. Linear and multivariate logistic regression was used to determine the socio-demographic predictors of betel quid chewing and the effect of betel quid on change in BMI and on systolic and diastolic blood pressure, pulse pressure, arterial pressure, overweight or obesity, and hypertension.

RESULTS

At baseline, betel quid was chewed by 33.2% of the cohort (35.5% of men, 31.6% of women). In a subsample in which we collected methods of use, 17.5% chewed it without tobacco and 82.5% chewed it with tobacco. In multivariate analysis, betel quid chewing was associated with female sex, older age, tobacco smoking and lower socio-economic status, as measured by fewer years of formal education and not owning land. Betel quid was chewed more times per day among women and older persons. At follow-up, persons who chewed betel quid without tobacco had higher systolic blood pressure, diastolic blood pressure and arterial pressure in comparison with never users. After controlling for other explanatory variables, chewing betel quid without tobacco was associated with general hypertension [odds ratio (OR) 1.48, 95% confidence interval (CI) 1.04-2.10] and systolic hypertension (OR 1.55, 95% CI 1.01-2.37). We did not observe associations of betel quid chewing with BMI or overweight.

CONCLUSIONS

Betel quid chewing is likely contributing to high blood pressure in Bangladesh, particularly among women.

Late-life dementia predicts mortality beyond established midlife risk factors

OBJECTIVES

to compare the mortality rates of elderly demented and nondemented subjects and the differential association of midlife risk factors with mortality according to dementia status.

DESIGN

: Prospective historical study.

SETTINGS

community based.

PARTICIPANTS

from the 10,059 male Jewish civil servants who participated in the Israel Ischemic Heart Disease study in the 1960s, the 1,713 who were evaluated for dementia in 1999/2000 and who were unequivocally classified as demented or nondemented.

MEASUREMENTS

: Midlife sociodemographic and cardiovascular risk factors, late-life dementia, and mortality.

RESULTS

over a period of 6 years, 718 (42%) subjects died. Of the 307 demented subjects, 71.8% died and of the 1,407 nondemented subjects, 35.4% died. Multivariate survival analyses showed that compared with subjects without dementia, demented subjects had a hazard ratio [HR] for mortality of 2.27 (95% confidence interval [CI] 1.92-2.68). Other risk factors associated with mortality were socioeconomic status (HR 0.94 [0.88-1.00]), higher systolic (HR 1.16 per 20 mm Hg [1.06-1.28 mm Hg]) and diastolic blood pressure (HR 1.15 per 10 mm Hg [1.06-1.25 mm Hg]), and ever smoking (HR 1.38 [1.18-1.61]). Midlife total cholesterol was not associated with mortality (1.01 per 40 mg/dL [0.93-1.10 mg/dL]). None of the interactions of the risk factors with dementia was significant.

CONCLUSIONS

dementia was associated with more than double the risk of mortality, but this increased risk did not reflect exacerbation by midlife sociodemographic and cardiovascular risk factors. Our findings suggest that the dementing process itself or its consequences may go beyond well-established midlife risk factors for mortality.

High pulse pressure is associated with increased risk of stroke in Japanese: the JMS Cohort Study

BACKGROUND

The relationship between pulse pressure (PP) and stroke has been described in populations outside Japan. Here, we investigated the relationship between PP and stroke incidence in Japan.

METHODS

Study subjects were 11,097 people (4315 men and 6782 women) in 12 rural areas of Japan enrolled in the Jichi Medical School Cohort Study, a population-based prospective study. The subjects were divided into quintiles of PP. Baseline data were obtained by questionnaire and health checkups between April 1992 and July 1995, and the incidence of all strokes and stroke subtypes was monitored.

RESULTS

A total of 412 strokes were observed during a mean follow-up period of 10.7 years. After adjusting for age, smoking status, drinking status, total cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, body mass index and diabetes mellitus, hazard ratios [HRs] in the second to fifth quintiles of PP for all strokes were 1.06 (95% confidence interval [CI] 0.69-1.64), 1.53 (CI 1.02-2.28), 2.02 (CI 1.38-2.96) and 2.22 (CI 1.53-3.20) compared with the first quintile using Cox's proportional hazard model, respectively.

CONCLUSION

Our findings suggest high PP is at an increased risk of stroke.

Radial augmentation index unmasks premature coronary artery disease in younger males

OBJECTIVE

The augmentation index, a marker of arterial wave reflection, is considered to indicate cardiovascular risk burden, particularly in younger persons. We assessed whether the easily obtainable radial augmentation index (rAIx) is superior to systolic blood pressure (SBP) or pulse pressure (PP) in detecting atherosclerotic vascular disease at an early age.

METHODS

We determined rAIx by applanation tonometry, SBP and PP in 152 male patients with or without invasively documented coronary artery disease (CAD). Ejection fraction (EF) was visually estimated by echocardiography or left ventricular angiography.

RESULTS

In younger patients (age < or =60 years, EF > or =30%), rAIx was significantly higher in patients with CAD (79.8+/-13.5%, n=31) compared with patients without CAD (68.5+/-22.0%, n=21; P = 0.04), whereas SBP (121+/-16 vs. 131+/-18 mmHg, P=0.04) and PP (48.7+/-9.4 vs. 56.3+/-12.1 mmHg, P=0.01) were even lower in patients with CAD compared with patients without CAD. In patients aged < or =60 years, rAIx was highest when EF was less than 30% (90.0+/-9.2%) compared with patients with EF 30-54% (80.7+/-11.5%) or EF > or =55% (72.1+/-20.4%, P=0.01). In contrast, in patients above 60 years of age, rAIx, SBP or PP did not differ between patients with or without CAD and the rAIx tended to be lowest in patients with severely reduced EF (P=0.07).

CONCLUSION

We conclude that premature vascular disease in younger patients with CAD is reflected only by an elevated rAIx, and not by SBP or PP. The rAIx is not suited to distinguish between older patients with high or low cardiovascular risk. Age seems to influence the interplay between rAIx and systolic heart function.

Glucometabolic state of in-hospital primary hypertension patients with normal fasting blood glucose in a sub-population of China

BACKGROUND

There is a high prevalence of abnormal glucometabolism (AGM) in patients with coronary heart disease (CHD) and primary hypertension (PH). However, little is known about the glucometabolic state of PH patients with normal fasting blood glucose (FBG).

METHODS

Oral glucose tolerance test (OGTT) was performed for 445 in-hospital PH patients with normal FBG and re-performed for those patients with impaired glucose tolerance (IGT) during the follow-up period.

RESULTS

Diabetes mellitus (DM), IGT, and AGM (including IGT and DM) accounted for 4.4, 24.5, and 28.9% of patients, respectively. Prevalence of AGM in patients with higher haemoglobin A(1c) (HbA(1c)) (> or =6.0%), risk factors (CHD, overweight, hyperlipidaemia, proteinuria) was significantly higher than that in patients without these factors. Regression analysis showed that age, overweight, proteinuria, HbA(1c), and CRP were the independent risk factors of AGM. Follow-up data in 98 IGT patients showed that no improvement of glucometabolism was found, but contrarily, a significant increase of new onset of impaired fasting glucose (IFG) and DM was found after 9 months (P < 0.05), even if diet control and moderate exercise were adopted.

CONCLUSIONS

AGM is prevalent and underestimated in PH patients with normal FBG, and it will develop even if therapeutic life-style changes are adopted. Except for FBG, more attention should be paid to postprandial blood glucose. OGTT should be a routine procedure for PH patients, especially in-hospital PH patients, regardless of normal FBG, and active drug intervention for IGT patients with PH may be recommended.

Four blood pressure indexes and the risk of stroke and myocardial infarction in Japanese men and women: a meta-analysis of 16 cohort studies

BACKGROUND

Information has been sparse on the comparison of 4 blood pressure (BP) indexes (systolic BP [SBP], diastolic BP, pulse pressure, and mean BP [MBP]) in relation to long-term incidence of stroke and myocardial infarction, particularly in middle-aged and older Asians.

METHODS AND RESULTS

The Japan Arteriosclerosis Longitudinal Study Group conducted a meta-analysis of 16 cohort studies in Japan. A total of 48,224 men and women 40 to 89 years of age participated at baseline, and 1231 stroke events and 220 myocardial infarction events occurred during an average 8.4-year follow-up. Multivariate-adjusted hazard ratios with a 1-SD higher value for each BP index were determined by Poisson regression. Analyses were also done in 4 age-sex groups. All 4 BP indexes were significantly related to all stroke risk. Stroke risk was most strongly related to MBP and SBP in both sexes and most weakly related to pulse pressure. Both stroke subtypes, ischemic and hemorrhagic, were most strongly related to MBP and SBP in both sexes. In addition, in men and women 70 to 89 years of age, MBP or SBP showed the strongest relation to all stroke risk. Myocardial infarction risk was most strongly related to SBP or MBP in both sexes. For any end points in any age-sex groups, pulse pressure was not the strongest predictor.

CONCLUSIONS

The long-term incident risk of stroke and myocardial infarction associated with high BP in East Asian populations should be assessed mainly on the basis of SBP. MBP also may be an important predictor, but pulse pressure is a less important predictor for cardiovascular disease risk.

Pulse pressure index (pulse pressure/systolic pressure) may be better than pulse pressure for assessment of cardiovascular outcomes

Pulse pressure (PP) is emerging as a major pressure predictor of cardiac disease. However, there are two major limitations for PP as an evaluation index. First, PP has alterability in the same individual. Second, PP is "floating", it has no relation to an absolute BP level. In order to overcome the defects of PP, we propose a novel parameter, "pulse pressure/systolic pressure" called "pulse pressure index (PPI)" for assessment of cardiovascular outcomes. On the basis of elastic chamber theory, the following equation can be derived: PPI=pulse pressure/systolic pressure=(Cs-Cd)/(Cs-C(0)), (Cs, Cd and C(0), arterial compliance at systolic pressure, diastolic pressure and zero-pressure, respectively). PPI can overcome the defects of PP and become a useful index in clinical evaluation for assessment of cardiovascular outcomes.

Linear Relationship Between Blood Pressure and Stroke: The Jichi Medical School Cohort Study

Hypertension is a major risk for stroke; a linear or J-shaped relationship between blood pressure (BP) and stroke have been reported. The authors examined the relationship between systolic and diastolic BP and risk of stroke in the general population in Japan. The study included 11,097 men and women who were divided into quintiles by systolic BP and diastolic BP in each sex. Follow-up duration was 10.7 years. In men, risks of second to fifth quintiles of systolic BP for all stroke were 1.5 (95% confidence interval [CI], 0.7-3.0), 2.2 (CI, 1.2-4.2), 3.0 (CI, 1.7-5.5), and 4.2 (CI, 2.4-7.6) compared with a reference of the first quintile using Cox's proportional hazard model, respectively. In women, risk of second to fifth quintiles of systolic BP for all stroke were 1.2 (95% CI, 0.6-2.4), 1.5 (CI, 0.8-2.9), 2.2(CI, 1.2-4.1), and 3.1 (CI, 1.7-5.6), respectively. Systolic BP and diastolic BP were related to stroke incidence linearly in the general Japanese population. Systolic BP was slightly more predictive of the risk of stroke than diastolic BP.

Predictive Utility of Pulse Pressure and Other Blood Pressure Measures for Cardiovascular Outcomes

Data are sparse regarding the actual predictive utility of pulse pressure and other blood pressure measures for cardiovascular events. We included all of the participants from the Chicago Heart Association Detection Project in Industry who were free of cardiovascular disease and not receiving antihypertensive treatment at baseline (1967–1973). Baseline blood pressure measures were assessed for predictive utility for fatal and nonfatal events over 33 years. Among 36 314 participants (mean age: 39±13 years; 43.4% women), there were 11 452 deaths: 745 were attributed to stroke, 2812 to coronary disease, and 599 to heart failure. Of the 16 393 participants who attained Medicare eligibility, 3050, 1367, and 2207 had ≥1 hospitalization for stroke, myocardial infarction, or heart failure, respectively. In univariate analyses, hazards ratios for stroke death per SD of pulse, systolic, and diastolic pressure, respectively, were 1.49, 1.75, and 1.71. Likelihood ratio χ 2 (134.3, 302.0, and 232.6, respectively), Bayes information criteria values (15 142, 14 974, and 15 044, respectively), and areas under receiver-operating characteristic curves (0.59, 0.64, and 0.63, respectively) all indicated better predictive utility for systolic and diastolic compared with pulse pressure. Results for coronary or heart failure death and stroke, myocardial infarction, or heart failure hospitalization were similar. Pulse pressure had weaker predictive utility at all ages but particularly for those <50 years. In this large cohort study, pulse pressure had predictive utility for cardiovascular events that was inferior to systolic or diastolic pressure. These findings support the approach of current guidelines in the use of systolic and diastolic blood pressure to assess risk and the need for treatment.

Abdominal aortic aneurysm and cerebral aneurysm present different pathological evolutions and responses to pharmacological therapy

Over-degradation of extracellular components by matrix metalloproteinases (MMPs) has been implicated as an important characteristic during the pathological evolution of the abdominal aortic aneurysm (AAA) and cerebral aneurysm (CA), which contribute to progressive dilation of vascular wall. However, mRNA and protein expression of local rennin-angiotensin system (RAS) components are found down-regulated in CA walls, which is contrary to long-holding concept that local RAS will be activated in response to increased hemodynamic stress and contributes to thickening of arterial wall. Similarly, MMPs inhibition by doxycycline effectively ameliorate AAA expansion in basic and clinical researches, but can not reduce the incidence of CA formation in rat. These evidences may suggest that suppression of RAS favors the regression of AAA, but at an increased risk of CA rupture. As the strategies of RAS blockade have became the optimal antihypertensive drugs of choice in clinical arena, the discrepant responses to pharmacologic intervention of AAA and CA should be received considerable attentions, due to their high prevalence in hypertensive population. Here we proposed that AAA and CA, outward remodeling of elastic and muscular arteries respectively, presented with different pathological evolutions and distinct responses to drug intervention, i.e., RAS and MMPs inhibition. It can not be excluded that the potentially deleterious effects of RAS inhibition on CA may be masked by the beneficial action of controlled blood pressure, and the propagation of CA will be exacerbated once suboptimal dose have been prescribed, or under the condition of stress, even drug withdrawal. If the paradoxical outcomes of these two kinds of arterial remodeling were proven true in basic research, clinical use of RAS blockade should be prudent in hypertensive patients, and routine procedures to detect the existence of CA should be considered. Therefore, in depth investigation in their responses to pharmacological approaches will provide us with more insights into the pathogenesis of arterial aneurysm.