Differential influence of distinct components of increased blood pressure on cardiovascular outcomes: from the atherosclerosis risk in communities study

Vascular ageing: moving from bench towards bedside

Prevention of cardiovascular disease (CVD) remains one of the largest public health challenges of our time. Identifying individuals at increased cardiovascular risk at an asymptomatic, sub-clinical stage is of paramount importance for minimizing disease progression as well as the substantial health and economic burden associated with overt CVD. Vascular ageing (VA) involves the deterioration in vascular structure and function over time and ultimately leads to damage in the heart, brain, kidney, and other organs. Vascular ageing encompasses the cumulative effect of all cardiovascular risk factors on the arterial wall over the life course and thus may help identify those at elevated cardiovascular risk, early in disease development. Although the concept of VA is gaining interest clinically, it is seldom measured in routine clinical practice due to lack of consensus on how to characterize VA as physiological vs. pathological and various practical issues. In this state-of-the-art review and as a network of scientists, clinicians, engineers, and industry partners with expertise in VA, we address six questions related to VA in an attempt to increase knowledge among the broader medical community and move the routine measurement of VA a little closer from bench towards bedside.

Mid- to Late-Life Time-Averaged Cumulative Blood Pressure and Late-Life Retinal Microvasculature: The ARIC Study

Background The associations of time-averaged cumulative blood pressure (BP) from midlife to late life with microvasculature expressed as retinal vessel diameters is not well studied. The aim of this study was to evaluate the association of cumulative systolic BP and diastolic BP (DBP) with retinal vessel calibers, focusing on race differences. Methods and Results The analysis included 1818 adults from the ARIC (Atherosclerosis Risk in Communities) study attending the fifth visit (2011-2013; age 77±5 years, 17.1% Black participants). Time-averaged cumulative BPs were calculated as the sum of averaged BPs from adjacent consecutive visits (visits 1-5) indexed to total observation time (24±1 years). Summarized estimates for central retinal arteriolar equivalent and central retinal venular equivalent at the fifth visit represent average retinal vessel diameters. The arteriole:venule ratio was calculated. We tested for effect modification by race. Results from multiple linear regression models suggested that higher time-averaged cumulative DBP (β [95% CI] per 1-SD increase: -1.78 [-2.53, -1.02], P<0.001 and -0.005 [-0.009, -0.002], P=0.004, respectively) but not systolic BP (-0.52 [-1.30, 0.26], P=0.189 and 0.001 [-0.002, 0.005], P=0.485, respectively) was associated with smaller central retinal arteriolar equivalent and arteriole:venule ratio. The association between time-averaged cumulative DBP and arteriole:venule ratio was strongest in White participants (interaction P=0.007). The association of cumulative systolic BP and DBP with central retinal venular equivalent was strongest in Black participants (interaction P=0.015 and 0.011, respectively). Conclusions Exposure to higher BP levels, particularly DBP, from midlife to late life is associated with narrower retinal vessel diameters in late life. Furthermore, race moderated the association of cumulative BP exposure with retinal microvasculature.

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.

Relationship Between Blood Pressure Values, Depressive Symptoms, and Cardiovascular Outcomes in Patients With Cardiometabolic Disease

The authors studied the joint effect of blood pressure (BP) and depression on the risk of major adverse cardiovascular outcome in patients with existing cardiometabolic disease. A cohort of 35,537 patients with coronary heart disease, diabetes, or stroke underwent depression screening and BP measurement recorded concurrently. The authors used Cox's proportional hazards to calculate risk of major adverse cardiovascular event (MACE; myocardial infarction/heart failure/stroke or cardiovascular death) over 4 years associated with baseline BP and depression. A total of 11% (3939) had experienced a MACE within 4 years. Patients with very high systolic BP (160-240 mm Hg; hazard ratio, 1.28) and depression (hazard ratio, 1.22) at baseline had significantly higher adjusted risk. Depression had a significant interaction with systolic BP in risk prediction (P=.03). Patients with a combination of high systolic BP and depression at baseline had 83% higher adjusted risk of MACE, as compared with patients with reference systolic BP without depression. Patients with cardiometabolic disease and comorbid depression may benefit from closer monitoring of systolic BP.

Comparison of 4 Admission Blood Pressure Indexes for Predicting 30-Day Mortality in Patients With ST-Segment Elevation Myocardial Infarction

BACKGROUND

We compared admission systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP) in predicting 30-day all-cause mortality in patients with ST-segment elevation myocardial infarction (STEMI) without cardiogenic shock.

METHODS

A retrospective study was performed in 7,033 consecutive STEMI patients. Multivariate-adjusted hazard ratios (HRs) with a 10mm Hg increment and quartiles of each blood pressure were determined by Cox proportional hazard analyses; Wald χ (2) tests were used to compare the strength of relationships.

RESULTS

Totally 593 (8.4%) patients died during follow-up. Of 4 indexes, only SBP (HR 0.94 per 10mm Hg, 95% confidence interval (CI) 0.91 to 0.98; P = 0.001) and PP (HR 0.89 per 10 mmHg, 95% CI 0.85 to 0.94; P < 0.001) were significantly associated with 30-day all-cause mortality; these in the highest vs. lowest quartiles of SBP (≥140 vs. <110mm Hg) and PP (≥60 vs. <40mm Hg) had HRs of mortality of 0.70 (95% CI 0.55 to 0.87; P = 0.003) and 0.60 (95% CI 0.47 to 0.75; P < 0.001), respectively. Compared with SBP, PP was a better predictor for mortality no matter in men (χ (2) = 5.9 for per 10mm Hg, χ (2) = 10.8 for quartiles) or women (χ (2) = 15.1 for per 10mm Hg, χ (2) = 19.5 for quartiles), and the relationship remained significant after adjustment of SBP. There was a pattern of declining risk with increasing blood pressures for mortality, and this trend was mainly observed in age groups of more than 70 years.

CONCLUSIONS

Pulse pressure was an independent predictor of mortality in patients with STEMI, and low admission blood pressure should serve as a warning sign.

Daily consumption of red grape cell powder in a dietary dose improves cardiovascular parameters: a double blind, placebo-controlled, randomized study

Consumption of polyphenol-rich food and food ingredient such as grape and grape products improved various cardiovascular parameters. In this study, we investigate the effect of dietary daily consumption of red grape cell powder (RGC) on blood pressure (BP) and flow-mediated dilatation (FMD) as well as on oxidative stress in 50 subjects with prehypertension and mild hypertension. The subjects were randomized into groups that consumed 200, 400 mg RGC or placebo daily for 12 weeks. RGC consumption was associated with an improvement of FMD (p = 0.013). There was a significant decrease in lipid peroxidation (p = 0.013) after 12 weeks in a combined RGC-treated group. The diastolic BP decreased significantly in the 200 mg RGC group compared to the placebo group (p = 0.032). Our results indicate that a daily supplementation, of red grape cell powder, for 12 weeks affects endothelial function, diastolic BP and oxidative stress without any adverse effects.

Cardiac target organ damage in hypertension: insights from epidemiology

Hypertension is an important risk factor implicated in the development of multiple common cardiac conditions, including coronary atherosclerosis, heart failure, and atrial fibrillation. Epidemiologic studies have provided insights into the shared pathogenesis of hypertension and subclinical as well as clinically evident cardiac diseases. The mechanistic common ground between chronic blood pressure elevation and cardiac disease likely begins early in life. Understanding these connections will aid ongoing efforts to identify individuals at risk, develop targeted therapeutics, and improve overall outcomes for individuals with elevated blood pressure in the population at large.

Associations between echocardiographic arterial compliance and incident cardiovascular disease in blacks: the ARIC study

BACKGROUND

Systemic arterial compliance is sometimes derived by echocardiographic stroke volume to pulse pressure ratios. Few studies have assessed echocardiographic arterial compliance in blacks or its associations with explicit, rather than composite, cardiovascular disease (CVD) outcomes.

METHODS

We analyzed a subset (n = 1,887) of blacks (mean age = 59 ± 6 years; 65% women) in the Atherosclerosis Risk in Communities study who were free of prevalent CVD and were imaged by echocardiography in 1993-1995. Arterial compliance was calculated by the aortic velocity time integral and brachial pulse pressure ratio (VTI/PP). Associations between VTI/PP and subsequent CVD (defined as first incident stroke, coronary event, or heart failure) were modeled by Cox regression after controlling for demographics, anthropometry, and cardiac risk factors. For comparison, CVD hazard ratios were also calculated for pulse pressure quartiles.

RESULTS

Over a mean follow-up of 13 ± 4 years, 237 subjects (12%) developed coronary disease, 322 (16%) developed heart failure, and 180 (9%) experienced a stroke. Hazard ratios contrasting lowest with highest quartiles of VTI/PP were 2.3 (95% confidence interval (CI) = 1.7-3.1) for composite CVD, 2.1 (95% CI = 1.3-3.2) for coronary disease, 2.5 (95% CI = 1.7-3.6) for heart failure, and 2.7 (95% CI = 1.6-4.5) for stroke. Hazard ratios contrasting widest with narrowest pulse pressure quartiles were 1.7 (95% CI = 1.3-2.2) for composite CVD, 1.6 (95% CI = 1.0-2.4) for coronary heart disease, 1.8 (95% CI = 1.2-2.6) for heart failure, and 2.3 (95% CI = 1.3-3.9) for stroke.

CONCLUSIONS

In blacks, the VTI/PP ratio has stronger associations with both composite and individual CVD outcomes than does pulse pressure.

Temporal trends in the population attributable risk for cardiovascular disease: the Atherosclerosis Risk in Communities Study

BACKGROUND

The extent to which the relative contributions of traditional cardiovascular risk factors to incident cardiovascular disease (CVD) may have changed over time remains unclear.

METHODS AND RESULTS

We studied 13 541 participants (56% women, 26% black) in the Atherosclerosis Risk in Communities Study, aged 52 to 66 years and free of CVD at exams in 1987 through 1989, 1990 through 1992, 1993 through 1995, or 1996 through 1998. At each examination, we estimated the population attributable risks (PAR) of traditional risk factors (hypertension, diabetes mellitus, obesity, hypercholesterolemia, and smoking) for the 10-year incidence of CVD. Overall, the PAR of all risk factors combined appeared to decrease from the late 1980s to the late 1990s (0.58 to 0.53). The combined PAR was higher in women than men in 1987 through 1989 (0.68 versus 0.51, P<0.001) but not by the late 1990s (0.58 versus 0.48, P=0.08). The combined PAR was higher in blacks than whites in the late 1980s (0.67 versus 0.57, P=0.049), and this difference was more pronounced by the late 1990s (0.67 versus 0.48, P=0.002). By the late 1990s, the PAR of hypertension had become higher in women than men (P=0.02) and also appeared higher in blacks than whites (P=0.08). By the late 1990s, the PAR of diabetes mellitus remained higher in women than men (P<0.0001) and in blacks than whites (P<0.0001).

CONCLUSIONS

The contribution to CVD of all traditional risk factors combined is greater in blacks than whites, and this difference may be increasing. The contributions of hypertension and diabetes mellitus remain especially high, in women as well as blacks. These findings underscore the continued need for individual as well as population approaches to CVD risk factor modification.