Cardiovascular Risk With and Without Antihypertensive Drug Treatment in the Japanese General Population

Cardiometabolic factors and population risks of cardiovascular disease in community-dwelling adults with varied blood pressure statuses

AIMS

To examine the differential associations between cardiometabolic risk factors and cardiovascular disease (CVD), and to evaluate the population-attributable fractions (PAFs) for CVD among community-dwelling adults with varied blood pressure (BP) statuses.

METHODS

This prospective cohort study included participants without prevalent CVD from a subcohort of the China Patient-Centred Evaluative Assessment of Cardiac Events Million Persons Project. Participants were divided into four BP groups according to the American College of Cardiology/American Heart Association guidelines. The study exposure comprised the selected cardiometabolic risk factors, including waist circumference (WC), body mass index, (BMI) heart rate, fasting blood glucose (FBG), low-density lipoprotein cholesterol, and remnant cholesterol. The outcome was hospitalizations for CVD. Cox proportional hazard models were conducted, and the PAFs were calculated in the analysis.

RESULTS

Among the 94 183 participants (39.0% were men, mean age: 54.2 years), 26.6% had Stage 1 hypertension and 30.8% had Stage 2 hypertension. A total of 6065 hospitalizations for CVD were captured after a median follow-up of 3.5 years. BP (per 1-standard deviation [SD]: hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.29, 1.40), FBG (per 1-SD: HR 1.16, 95% CI 1.14, 1.19) and WC (per 1-SD: HR 1.41, 95% CI 1.36, 1.47) were three major contributors to CVD events. BP status significantly modified the associations of abdominal obesity, suboptimal BMI, suboptimal heart rate and abnormal FBG with CVD, with stronger associations with CVD observed in optimal BP groups compared to hypertensive groups (p for risk factor-by-BP group interaction <0.05). Participants with all cardiometabolic risk factors were at the highest risk for CVD, accounting for 35.6% (95% CI 30.0, 40.8) of the PAF for CVD. Among the risk factors, BP control explained the highest PAF for CVD (15.1%, 95% CI 8.2, 21.4) The overall PAFs of cardiometabolic risk factors for CVD were higher among the normotensive participants compared to the hypertensive participants.

CONCLUSIONS

The awareness and control rates of hypertension were extremely low among Southern Chinese adults. BP status significantly modified the associations between cardiometabolic risk factors and CVD, and the overall PAFs for CVD were higher among people with normal BP. Dedicated efforts are needed to improve the management of cardiometabolic factors.

Association between time-of-day for eating, exercise, and sleep with blood pressure in adults with elevated blood pressure or hypertension: a systematic review

The purpose of this review is to synthesize results from studies examining the association between time-of-day for eating, exercise, and sleep with blood pressure (BP) in adults with elevated BP or hypertension. Six databases were searched for relevant publications from which 789 were identified. Ten studies met inclusion criteria. Four studies examined time-of-day for eating, five examined time-of-day for exercise, and one examined time-of-day for sleep and their associations with BP. Results suggested that later time-of-day for eating ( n  = 2/4) and later sleep mid-point ( n  = 1/1) were significantly related to higher BP in multivariable models, whereas morning ( n  = 3/5) and evening ( n  = 4/5) exercise were associated with significantly lower BP. Although this small body of work is limited by a lack of prospective, randomized controlled study designs and underutilization of 24 h ambulatory BP assessment, these results provide preliminary, hypothesis-generating support for the independent role of time-of-day for eating, exercise, and sleep with lower BP.

Systemic hemodynamic atherothrombotic syndrome: from hypothesis to evidence

Hypertension is a risk factor for cardiovascular disease (CVD). However, the association between blood pressure (BP) and CVD events has been based on mean BP alone. BP variability (BPV) is associated with increased organ damage and CVD events independently or beyond average home BP. To explain this association, we propose the systemic hemodynamic atherothrombotic syndrome (SHATS) hypothesis. The SHATS hypothesis indicates that hemodynamic stress increases vascular disease and vice versa, leading to a vicious cycle of the association between hemodynamic stress and a vascular disease; this association provides not only the risk but also the trigger for CVD events. The evidences of SHATS were gradually accumulating. We showed arterial stiffness synergistically amplified the association between hemodynamic stress and cardiac overload / CVD events in patients with at least one CVD risk factor.

The Prevention of the New Onset of Heart Failure in Hypertensive Patients

In 2014, Japan was estimated to have approximately 27 million patients with hypertension (HT), and the ultimate goal of treatment is to prevent complications of HT, including heart failure (HF). The major structural changes in the heart that cause HF are left ventricular (LV) hypertrophy (LVH) and the resulting LV diastolic dysfunction. However, in patients with HT with well-controlled blood pressure (BP), whether they are in HF stage A (only HT) or B (with organic heart disease) is often unclear. It has been reported that strict BP control suppresses LVH, and the improvement of LVH leads to the suppression of cardiovascular complications. Thus, detecting HF stage B HT and providing appropriate treatment lead to the suppression of HF onset. This review focuses on the detection and treatment of organic heart disease in HT.

Arterial Stiffness Is Associated With Small Vessel Disease Irrespective of Blood Pressure in Stroke-Free Individuals

BACKGROUND

Arterial stiffness and hypertension are important risk factors for cerebral small vessel disease (CSVD). Clinically, there are hypertensive patients with low pulse wave velocity (PWV) and nonhypertensive individuals with high PWV. We aimed to determine the effects of arterial stiffness on CSVD in normotensive individuals.

METHODS

An observational cross-sectional study was conducted in 1894 stroke-free participants who underwent brain magnetic resonance imaging and brachial-ankle pulse wave velocity (baPWV) measurements at a health checkup between 2013 and 2020. CSVD was defined as any of following: white matter hyperintensities, cerebral microbleeds, silent lacunar infarcts, and enlarged perivascular spaces. baPWV was measured using an automatic oscillometric device. Participants were divided into 4 groups according to the following cutoff points: low blood pressure (BP, <120/80 mm Hg) with low baPWV (<14.63 m/s, a cutoff value that predicted CSVD); high BP (≥120/80 mm Hg) with low baPWV; low BP with high baPWV (≥14.63 m/s); and high BP with high baPWV.

RESULTS

The mean age of the participants was 57±13 years (41% women). The prevalence of CSVD was 718 (38%), which was higher in the low BP with high baPWV (56%) and high BP with high baPWV (55%) groups than in the high BP with low baPWV (24%) and low BP with low baPWV (22%) groups. Compared with the low BP with low baPWV group, the low BP with high baPWV group (odds ratio, 1.63 [95% CI, 1.09-2.43]) and the high BP with high baPWV group (odds ratio, 1.86 [95% CI, 1.39-2.49]) had a significantly higher multivariable-adjusted risk for CSVD.

CONCLUSIONS

Individuals with a high baPWV had a higher prevalence of CSVD, independent of BP status. Higher arterial stiffness is likely to be a more important risk factor for CSVD than BP status in stroke-free individuals.

Different Home Blood Pressure Thresholds to Predict Perfect 24-Hour Ambulatory Blood Pressure Control in Treated Hypertension Based on an "All-in-One" Device

BACKGROUND

Home blood pressure (BP) is an important component of digital strategies for hypertension management. However, no studies have used the same device to investigate 24-hour BP control status in relation to different home BP control thresholds.

METHODS

Participants in the general practitioner-based, multicenter HI-JAMP study (Home-Activity Information and Communication Technology-Based Japan Ambulatory Blood Pressure Monitoring Prospective) underwent office BP measurement, then 24-hour ambulatory BP monitoring, then home BP monitoring for 5 days. A validated all-in-one BP monitoring device was used to measure office, home, and ambulatory BP. Baseline data were used to investigate ambulatory BP control status in individuals with well-controlled home BP based on the different guideline thresholds (125/75 mm Hg, 130/80 mm Hg, and 135/85 mm Hg).

RESULTS

Data from 2269 patients were analyzed. For individuals with well-controlled home BP <135/85 mm Hg (59.5% of the total population), the prevalence of uncontrolled 24-hour (≥130/80 mm Hg), daytime (≥135/85 mm Hg), and nighttime ambulatory BP (≥120/70 mm Hg) was 19.9%, 18.5%, and 33.6%, respectively. Corresponding prevalence rates in the 42.7% of participants with well-controlled home BP <130/80 mm Hg were 13.4%, 12.9%, and 26.0%, and when well-controlled home BP was strictly defined as <125/75 mm Hg (23.9% of the population), prevalence of rates of uncontrolled 24-hour, daytime, and nighttime ambulatory BP were 7.0%, 9.0%, and 15.3%, respectively.

CONCLUSIONS

Home BP control status defined using different thresholds could predict 24-hour ambulatory BP control status in treated hypertension. One-third of individuals still had uncontrolled nocturnal hypertension when home BP was controlled to <135/85 mm Hg, but ambulatory BP was quite well controlled when home BP was <125/75 mm Hg.

Self-measured home blood pressure highlights cardiovascular risk in women: the HOMED-BP study

No studies examined sex differences in relation to the prognostic significance of self-measured home blood pressure (HBP). We compared the predictive power for the risk of cardiovascular events in 1547 women and 1516 men with hypertension using HBP captured at treatment-free baseline and during on-treatment follow-up, based on the Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) study. To express the change in risk for the composite cardiovascular endpoint associated with a 1-SD increase in HBP at baseline or on treatment, we derived multivariable-adjusted hazard ratios (HR) based on a Cox regression model. Over a median follow-up of 7.3 years, 100 composite events occurred, including 40 events in women. In women, systolic HBP both at baseline and on-treatment showed significant risk increment (at baseline: HR per 1-SD increment, 1.62; 95% confidence interval [CI], 1.17-2.24. on-treatment: HR, 1.74; 95% CI, 1.32-2.29). However, systolic HBP at baseline did not predict cardiovascular events in men (P = 0.25). On-treatment HBP was significantly associated with cardiovascular risk (P ≤ 0.012) irrespective of sex. Nevertheless, the point estimate of HR for systolic HBP in men (1.33) was less than that in women (1.74), and the interaction of sex with 1 SD-increase in systolic HBP in cardiovascular risk was significant irrespective of baseline (P = 0.039) or follow-up (P = 0.040) measurement when they were mutually adjusted. The increase in cardiovascular risk with the systolic HBP was steeper in women than in men for both baseline and on-treatment. The current findings unveil the importance of the control of systolic HBP, especially in women. Clinical Trial Registration: UMIN Clinical Trial Registry ( http://www.umin.ac.jp/ctr ), Unique identifier: C000000137.

Infused juice concentrate of Japanese plum Prunus mume attenuates inflammatory vascular remodeling in a mouse model of hypertension induced by angiotensin II

Fruit from the Prunus mume tree is a traditional food in Japan. Recently, bainiku-ekisu, an infused juice concentrate of Japanese Prunus mume, is attracting attention as a health promoting supplement. Angiotensin II (Ang II) plays a central role in development of hypertension. It has been reported that bainiku-ekisu treatment attenuates the growth-promoting signaling induced by Ang II in vascular smooth muscle cells. However, whether bainiku-ekisu has any effect on an animal model of hypertension remains unknown. Therefore, this study was designed to explore the potential anti-hypertensive benefit of bainiku-ekisu utilizing a mouse model of hypertension with Ang II infusion. Male C57BL/6 mice were infused with Ang II for 2 weeks and given 0.1% bainiku-ekisu containing water or normal water for 2 weeks with blood pressure evaluation. After 2 weeks, mice were euthanized, and the aortas were collected for evaluation of remodeling. Aortic medial hypertrophy was observed in control mice after Ang II infusion, which was attenuated in bainiku-ekisu group with Ang II infusion. Bainiku-ekisu further attenuated aortic induction of collagen producing cells and immune cell infiltration. Development of hypertension induced by Ang II was also prevented by bainiku-ekisu. Echocardiograph indicated protection of Ang II-induced cardiac hypertrophy by bainiku-ekisu. In vascular fibroblasts, bainiku-ekisu attenuated vascular cell adhesion molecule-1 induction, an endoplasmic reticulum stress marker, inositol requiring enzyme-1α phosphorylation, and enhancement in glucose consumption in response to Ang II. In conclusion, Bainiku-ekisu prevented Ang II-induced hypertension and inflammatory vascular remodeling. Potential cardiovascular health benefit to taking bainiku-ekisu should be further studied.

Current realities of home blood pressure monitoring from physicians' perspectives: results from Asia HBPM survey 2020

Uncontrolled hypertension is a significant problem in many parts of Asia. Effective management is essential to reduce the burden of hypertension. Home blood pressure monitoring (HBPM) is a promising tool that can aid in the diagnosis and management of hypertension. Experts from 11 countries/regions in Asia conceptualized a large-scale survey to examine the current realities of HBPM. A cross-sectional survey was conducted among health care professionals from China, India, Indonesia, Japan, Malaysia, the Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam between November 2019 and June 2021. Physicians' responses were summarized using descriptive statistics. A total of 7945 physicians participated in the survey. Among all respondents, 50.3% and 33.5% viewed HBPM as highly recognized by physicians and patients in their country/region, respectively. Lack of understanding of HBPM and concern with the accuracy and reliability of HBPM devices were identified as key barriers to HBPM recognition. Nearly all physicians (95.9%) reported recommending HBPM to their patients; however, they reported less than 50% of their patients measured home blood pressure (HBP). Among physicians who recommended HBPM, only 22.4% and 54.1% cited HBP diagnostic threshold values and timing of taking antihypertensive drugs that were consistent with available guidelines, respectively. The survey reveals that the recognition of HBPM as a valuable tool to diagnose and manage hypertension is suboptimal in most parts of Asia. Despite high recommendation of HBPM to hypertensive patients by physicians, there are considerable discrepancies between guidelines recommendations and practice realities. The recognition of HBPM as a valuable tool for the diagnosis and management of hypertension is suboptimal among both physicians and patients in Asia. A clear and consistent guidance for proper HBPM practice and use of validated and calibrated HBP monitors are among the top priorities to support the integration of HBPM into daily patient care. HBPM: home blood pressure monitoring, HBP: home blood pressure.

Risk factors for heart, cerebrovascular, and kidney diseases: evaluation of potential side effects of medications to control hypertension, hyperglycemia, and hypercholesterolemia

Background

Heart disease (HD), cerebrovascular disease (CBD), and kidney disease (KD) are serious diseases worldwide. These diseases constitute the leading causes of death worldwide and are costly to treat. An analysis of risk factors is necessary to prevent these diseases.

Data and Methods

Risk factors were analyzed using data from 2,837,334, 2,864,874, and 2,870,262 medical checkups obtained from the JMDC Claims Database. The side effects of medications used to control hypertension (antihypertensive medications), hyperglycemia (antihyperglycemic medications), and hypercholesterolemia (cholesterol medications), including their interactions, were also evaluated. Logit models were used to calculate the odds ratios and confidence intervals. The sample period was from January 2005 to September 2019.

Results

Age and history of diseases were found to be very important factors, and the risk of having diseases could be almost doubled. Urine protein levels and recent large weight changes were also important factors for all three diseases and made the risks 10%-30% higher, except for KD. For KD, the risk was more than double for individuals with high urine protein levels. Negative side effects were observed with antihypertensive, antihyperglycemic, and cholesterol medications. In particular, when antihypertensive medications were used, the risks were almost doubled for HD and CBD. The risk would be triple for KD when individuals were taking antihypertensive medications. If they did not take antihypertensive medications and took other medications, these values were lower (20%-40% for HD, 50%-70% for CBD, and 60%-90% for KD). The interactions between the different types of medications were not very large. When antihypertensive and cholesterol medications were used simultaneously, the risk increased significantly in cases of HD and KD.

Conclusion

It is very important for individuals with risk factors to improve their physical condition for the prevention of these diseases. Taking antihypertensive, antihyperglycemic, and cholesterol medications, especially antihypertensive medications, may be serious risk factors. Special care and additional studies are necessary to prescribe these medications, particularly antihypertensive medications.

Limitations

No experimental interventions were performed. As the dataset was comprised of the results of health checkups of workers in Japan, individuals aged 76 and above were not included. Since the dataset only contained information obtained in Japan and the Japanese are ethnically homogeneous, potential ethnic effects on the diseases were not evaluated.

Factors Associated with the Antihypertensive Effect of Esaxerenone and Serum Potassium Elevation: A Pooled Analysis of Seven Phase III Studies

INTRODUCTION

This study investigated factors associated with the antihypertensive effects of esaxerenone and the incidence of serum potassium elevation in patients with hypertension.

METHODS

Using pooled data from seven phase III studies, the study analyzed factors associated with changes in office systolic (SBP) and diastolic (DBP) blood pressure from baseline to 12 weeks, and factors associated with incidence of serum potassium levels ≥ 5.5 mEq/L in esaxerenone-treated patients.

RESULTS

Overall, 1466 and 1472 patients were included in the full analysis and safety analysis sets, respectively. Male sex (4.02/2.40 mmHg), weight ≥ 78.4 kg (4.62/2.09 mmHg), hypertension duration ≥ 10 years (2.66/1.71 mmHg), prior antihypertensive treatment (2.38/1.40 mmHg), plasma aldosterone concentration ≥ 120 pg/mL (1.66/1.17 mmHg), urinary albumin-to-creatinine ratio (UACR) ≥ 300 mg/gCr (8.94/4.85 mmHg) or 30-299 mg/gCr (5.17/4.15 mmHg), and smoking (2.62/1.27 mmHg) were associated with mean changes in SBP and DBP. Fasting blood glucose ≥ 126 mg/dL (- 2.73 mmHg) was associated with the mean change in SBP only, and older age (65-74 years, - 2.12 mmHg; and ≥ 75 years, - 3.06 mmHg) with mean change in DBP only. Factors significantly associated with incidence of serum potassium levels ≥ 5.5 mEq/L were higher baseline serum potassium (≥ 4.5 mEq/L, odds ratio [OR] 6.702); lower estimated glomerular filtration rate (≥ 90 mL/min/1.73 m², OR 0.148; 60-89 mL/min/1.73 m², OR 0.331 vs 30-59 mL/min/1.73 m², respectively); higher UACR (30-299 mg/gCr, OR 7.317); higher DBP (≥ 100 mmHg, OR 3.248); and grade I hypertension (OR 2.168).

CONCLUSION

Esaxerenone is effective in patients with a broad range of backgrounds, though some factors may predict increased benefit. Regarding elevated serum potassium, careful therapeutic management is recommended for patients with higher baseline serum potassium and reduced renal function.

CLINICAL TRIAL REGISTRATION

UMIN000047026.

Association Between Ambulatory Blood Pressure and Risk of Home Hypertension in a Normotensive Population: The Ohasama Study

BACKGROUND

We investigated the association between ambulatory blood pressure (BP) and the risk of home hypertension in a normotensive population and whether considering ambulatory BP improves the 10-year prediction model for home hypertension risk, which was developed in the previous Ohasama Study.

METHODS

In this prospective study, we followed up with 410 participants (83.2% women; age, 53.6 years) without a home and ambulatory hypertension in the general population of Ohasama, Japan. The Cox model was used to assess the hazard ratios (HRs) for home hypertension (home BP ≥ 135/≥85 mmHg or the initiation of antihypertensive treatment) and model improvement.

RESULTS

During a mean 14.2-year follow-up, 225 home hypertension incidences occurred. The HR (95% confidence interval) for home hypertension incidence per 1-SD higher (=6.76 mmHg) 24-hour systolic BP (SBP) was 1.59 (1.33 to 1.90), after adjustments for possible confounding factors, including baseline home SBP. Harrell's C-statistics increased from 0.72 to 0.73 (P = 0.11) when 24-hour SBP was added to the basic 10-year home hypertension prediction model, which includes sex, age, body mass index, smoking status, office SBP, and baseline home SBP. Continuous net reclassification improvement (0.53, P < 0.0001) and integrated discrimination improvement (0.028, P = 0.0014) revealed improvement in the model.

CONCLUSIONS

A total of 24-hour SBP could be an independent predictor of future home hypertension. Home BP and 24-hour BP can longitudinally influence each other in the long term.

Medical Telemonitoring for the Management of Hypertension in Older Patients in Japan

Hypertension is the most frequent modifiable risk factor associated with cardiovascular disease (CVD) morbidity and mortality. Even in older people, strict blood pressure (BP) control has been recommended to reduce CVD event risks. However, caution should be exercised since older hypertensive patients have increased physical vulnerability due to frailty and multimorbidity, and older patients eligible for clinical trials may not represent the general population. Medical telemonitoring systems, which enable us to monitor a patient's medical condition remotely through digital communication, have become much more prevalent since the coronavirus pandemic. Among various physiological parameters, BP monitoring is well-suited to the use of such systems, which enable healthcare providers to deliver accurate and safe BP management, even in the presence of frailty and/or living in geographically remote areas. Furthermore, medical telemonitoring systems could help reduce nonadherence to antihypertensive medications and clinical inertia, and also enable multi-professional team-based management of hypertension. However, the implementation of medical telemonitoring systems in clinical practice is not easy, and substantial barriers, including the development of user-friendly devices, integration with existing clinical systems, data security, and cost of implementation and maintenance, need to be overcome. In this review, we focus on the potential of medical telemonitoring for the management of hypertension in older people in Japan.

Heart diseases, hypertension and effects of antihypertensive medications: Is hypertension a true risk factor of heart diseases?

Background

Heart diseases (HD) are the leading cause of deaths in the world. Many studies have been done on the relationships among hypertension, HD and antihypertensive medications. Most of the studies find that hypertension is a significant risk factor of HD, but there are some studies in which hypertension is not a risk factor. As antihypertensive medications are routinely prescribed to prevent HD, it is necessary to evaluate the effects of these and other risk factors of HD.

Data and methods

The relationship between hypertension and HD was analyzed using 6,773,464 medical checkups obtained from the JMDC Claims Database obtained from January 2005 to September 2019. Factors potentially affecting HD, including blood pressures (BP) and usage of antihypertensive medications, were evaluated using 2,861,769 observations. To avoid the causality problem, probit models were used to analyze the probability of an individual who had no history of HD at year t developing HD by year t + 1.

Results

A positive relation between systolic blood pressure (SBP) and HD was found in the equation without any other covariates. However, the significant relation between HD and BP disappeared when the models contained various other factors as covariates. When a 10-year age or longer interval was used in the model, a positive relation between the two variables was found, suggesting that SBP works as a proxy variable. Taking antihypertensive medications greatly increases the probability of developing HD in the next year. Higher levels of cholesterols decrease the probability of developing HD.

Conclusion

Unlike many previous studies, no significant relationship between HD and hypertension was found in the models containing multiple covariates. The accepted relation might actually be spurious, and it is important to select covariates carefully. Taking antihypertensive medications appears to increase the probability of developing HD in the next year, suggesting the need for further research and greater caution in the use of antihypertensive medications.

Comparison between Carotid Distensibility-Based Vascular Age and Risk-Based Vascular Age in Middle-Aged Population Free of Cardiovascular Disease

The concept of vascular age (VA) was proposed to provide patients with an understandable explanation of cardiovascular (CV) risk and to improve the performance of prediction models. The present study compared risk-based VA derived from Framingham Risk Score (FRS) and Systematic Coronary Risk Estimation (SCORE) models with value-based VA derived from the measurement of the common carotid artery (CCA) distensibility coefficient (DC), and it assessed the impact of DC-based VA on risk reclassification. In 528 middle-aged individuals apparently free of CV disease, DC was measured by radiofrequency-based arterial wall tracking that was previously utilised to establish sex- and age-specific reference values in a healthy population. DC-based VA represented the median value (50th percentile) for given sex in the reference population. FRS-based and SCORE-based VA was calculated as recommended. We observed a good agreement between DC-based and FRS-based VA, with a mean difference of 0.46 ± 12.2 years (p = 0.29), while the mean difference between DC-based and SCORE-based VA was higher (3.07 ± 12.7 years, p < 0.0001). When only nondiabetic individuals free of antihypertensive therapy were considered (n = 341), the mean difference dropped to 0.70 ± 12.8 years (p = 0.24). Substitution of chronological age with DC-based VA in FRS and SCORE models led to a reclassification of 28% and 49% of individuals, respectively, to the higher risk category. Our data suggest that the SCORE prediction model, in which diabetes and antihypertensive treatment are not considered, should be used as a screening tool only in healthy individuals. The use of VA derived from CCA distensibility measurements could improve the performance of risk prediction models, even that of the FRS model, as it might integrate risk prediction with additional risk factors participating in vascular ageing, unique to each individual. Prospective studies are needed to validate the role of DC-based VA in risk prediction.

Persistent vascular dysfunction following an acute nonpharmacological reduction in blood pressure in hypertensive patients

BACKGROUND

Vascular dysfunction, an independent risk factor for cardiovascular disease, often persists in patients with hypertension, despite improvements in blood pressure control induced by antihypertensive medications.

METHODS

As some of these medications may directly affect vascular function, this study sought to comprehensively examine the impact of reducing blood pressure, by a nonpharmacological approach (5 days of sodium restriction), on vascular function in 22 hypertensive individuals (14 men/8 women, 50 ± 10 years). Following a 2-week withdrawal of antihypertensive medications, two 5-day dietary phases, liberal sodium (liberal sodium, 200 mmol/day) followed by restricted sodium (restricted sodium, 10 mmol/day), were completed. Resting blood pressure was assessed and vascular function, at both the conduit and microvascular levels, was evaluated by brachial artery flow-mediated dilation (FMD), reactive hyperemia, progressive handgrip exercise, and passive leg movement (PLM).

RESULTS

Despite a sodium restriction-induced fall in blood pressure (liberal sodium: 141 ± 14/85 ± 9; restricted sodium 124 ± 12/79 ± 9 mmHg, P < 0.01 for both SBP and DBP), FMD (liberal sodium: 4.6 ± 1.8%; restricted sodium: 5.1 ± 2.1%, P = 0.27), and reactive hyperemia (liberal sodium: 548 ± 201; restricted sodium: 615 ± 206 ml, P = 0.08) were not altered. Similarly, brachial artery vasodilation during handgrip exercise was not different between conditions (liberal sodium: Δ0.36 ± 0.19 mm; restricted sodium: Δ0.42 ± 0.18 mm, P = 0.16). Lastly, PLM-induced changes in peak blood flow (liberal sodium: 5.3 ± 2.5; restricted sodium: 5.8 ± 3.6 ml/min per mmHg, P = 0.30) and the total vasodilatory response [liberal sodium: 2 (0.9-2.5) vs. restricted sodium: 1.7 (1.1-2.6) ml/min per mmHg; P = 0.5] were also not different between conditions.

CONCLUSION

Thus vascular dysfunction, at both the conduit and microvascular levels, persists in patients with hypertension even when blood pressure is acutely reduced by a nonpharmacological approach.

Cardiovascular risk in patients receiving antihypertensive drug treatment from the perspective of endothelial function

Blood-pressure-lowering therapy with antihypertensive drugs can reduce the risk of cardiovascular morbidity and mortality in patients with hypertension. However, patients treated with antihypertensive drugs generally have a worse prognosis than untreated individuals. Consistent with the results obtained from epidemiological studies, a clinical study showed that endothelial function was impaired more in treated patients with hypertension than in untreated individuals with the same blood pressure level, suggesting that blood-pressure-lowering therapy with currently available antihypertensive drugs cannot restore endothelial function to the level of that in untreated individuals. Several mechanisms of endothelial dysfunction in treated patients are postulated: irreversible damage to the endothelium caused by higher cumulative elevated blood pressure exposure over time; the persistence of the primary causes of hypertension even after the initiation of antihypertensive drug treatment, including an activated renin-angiotensin-aldosterone system, oxidative stress, and inflammation; and higher global cardiovascular risk related not only to conventional cardiovascular risk factors but also to undetectable nonconventional risk factors. Lifestyle modifications/nonpharmacological interventions should be strongly recommended for both untreated and treated individuals with hypertension. Lifestyle modifications/nonpharmacological interventions may directly correct the primary causes of hypertension, which can improve endothelial function and consequently reduce cardiovascular risk regardless of the use or nonuse of antihypertensive drugs.

Elucidation of a Causal Relationship Between Platelet Count and Hypertension: A Bi-Directional Mendelian Randomization Study

Hypertension has been reported as a major risk factor for diseases such as cardiovascular disease, and associations between platelet activation and risk for hypertension are well-established. However, the exact nature of causality between them remains unclear. In this study, a bi-directional Mendelian randomization (MR) analysis was conducted on 15,996 healthy Taiwanese individuals aged between 30 and 70 years from the Taiwan Biobank, recorded between 2008 and 2015. The inverse variance weighted (IVW) method was applied to determine the causal relationship between platelet count and hypertension with single nucleotide polymorphisms as instrumental variables (IVs). Furthermore, to check for pleiotropy and validity of the IVs, sensitivity analyses were performed using the MR-Egger, weighted median and simple median methods. This study provided evidence in support of a positive causal effect of platelet count on the risk of hypertension (odds ratio: 1.149, 95% confidence interval: 1.131-1.578, P < 0.05), using the weighted median method. A significant causal effect of platelet count on hypertension was observed using the IVW method. No pleiotropy was observed. The causal effect of hypertension on platelet count was found to be non-significant. Therefore, the findings from this study provide evidence that higher platelet count may have a significant causal effect on the elevated risk of hypertension for the general population of Taiwan.

Utility of urinary albumin excretion as an index for stratifying the residual cardiovascular risk in patients undergoing antihypertensive agents treatment

BACKGROUND

Patients treated with antihypertensive medication, even those with well controlled blood pressure (BP), are at higher risk for the development of atherosclerotic cardiovascular disease (ASCVD) in comparison to nonhypertensive individuals with optimal risk levels. We hypothesized that this residual risk could be stratified based on urinary albumin excretion (UAE).

METHODS

A total of 13 082 middle-aged and older individuals with SBP/DBP of less than 160/100 mmHg and urinary albumin-to-creatinine ratios (UACRs) of less than 300 mg/g, and who were free from ASCVD events, were followed to investigate the incidence of ASCVD. The baseline BP was classified into four categories: normal BP (BP1), high normal BP (BP2), elevated BP (BP3), and grade 1 hypertension (BP4) based on the 2019 Japanese Society of Hypertension guidelines.

RESULTS

After an average 10.6 ± 2.6 years of follow-up, the multivariable hazard ratio for the development of ASCVD (n = 994) was already increased in medicated hypertensive patients with BP1 in comparison with untreated individuals with BP1; however, among medicated hypertensive patients, this risk was separated between the UAE groups, which were classified according to the median UACR (male, 15.4 mg/g; female, 19.0 mg/g). In medicated hypertensive patients with any category of BP1-BP3, the adjusted risk of the development of ASCVD in those with lower and higher UACRs was comparable to that observed in untreated individuals in the BP1 and BP4 categories, respectively.

CONCLUSION

In medicated patients with well controlled hypertension, UAE is useful for stratifying the residual risk of developing ASCVD in comparison to nonhypertensive individuals with optimal risk levels.

Long-term evolution of ambulatory blood pressure and cardiovascular events in hypertensive patients

Ambulatory blood pressure monitoring (ABPM) is now considered the gold standard to evaluate BP, and predicts related cardiovascular risk. However, no study has reported the association of long-term changes in ABPM with the incidence of cardiovascular events, therefore the objective of this work. We included patients from the Bordeaux cohort of hypertensive patients, who had undergone at least two ABPM; the first was performed before or after antihypertensive treatment was started, and the second was the last recording available before any cardiovascular event. We included 591 patients (mean age, 54 years) with a 7-year average interval between the first and last ABPM, a 10-year average follow-up, and a total of 111 cardiovascular events. The patients were divided into four groups: G0, first and last 24 h systolic blood pressure (SBP) < 130; G1, first 24 h SBP ≥ 130, last 24 h SBP < 130; G2, first 24 h SBP < 130, last 24 h SBP ≥ 130; and G3, first 24 h SBP ≥ 130, last 24 h SBP ≥ 130 mmHg. Baseline ABPM better predicted future events than the last ABPM. G0 and G2 had similar survival. G1 and G3 had a worse prognosis than G0 and G2, while G1 had an intermediate risk between G0 and G3, indicating some benefit of treatment. In conclusion, our study showed the prognostic value of the first ABPM recorded in hypertensive patients and the persistence of risk when 24 h BP is controlled by antihypertensive treatment.

A 10-year longitudinal study of deep white matter lesions on magnetic resonance imaging

PURPOSE

Deep white matter lesions (DWMLs), T2 high-intensity areas in the subcortical white matter on magnetic resonance imaging (MRI), are a clinical phenotype of cerebral small vessel disease. Factors such as age and hypertension have been reported to significantly contribute to the presence and severity of DWMLs in cross-sectional studies. We herein report a 10-year longitudinal study on DWMLs in elderly Japanese subjects to reveal the clinical variables contributing to the progression of DWMLs.

METHODS

A total of 469 Japanese subjects were invited to participate in the study. Of the participants at baseline, 259 subjects completed the revisit MRI study 10 years later. In those 259 subjects, we evaluated the correlation between the progression of DWMLs and clinical variables, such as the gender, age, and overt vascular risk factors. To clarify the role of hypertension, 200 subjects with grade 1 DWMLs at baseline were categorized into three groups according to their status of hypertension and its treatment.

RESULTS

Of the 200 subjects with grade 1 DWMLs, 47 subjects (23.5%) showed progression of DWMLs (progression group). In the progression group, the percentage of subjects with hypertension and the systolic blood pressure values were higher than in the non-progression group. In addition, subjects ≥ 60 years old at baseline tended to show deterioration of DWMLs in the group with hypertension without antihypertensive treatment.

CONCLUSION

The results of this 10-year longitudinal study imply a positive correlation between long-standing hypertension and the progression of DWMLs.

A Combination of Blood Pressure and Total Cholesterol Increases the Lifetime Risk of Coronary Heart Disease Mortality: EPOCH-JAPAN

AIM

Lifetime risk (LTR) indicates the absolute risk of disease during the remainder of an individual's lifetime. We aimed to assess the LTRs for coronary heart disease (CHD) mortality associated with blood pressure (BP) and total cholesterol levels in an Asian population using a meta-analysis of individual participant data because no previous studies have assessed this risk.

METHODS

We analyzed data from 105,432 Japanese participants in 13 cohorts. Apart from grade 1 and 2-3 hypertension groups, we defined "normal BP" as systolic/diastolic BP ＜130/＜80 mmHg and "high BP" as 130-139/80-89 mmHg. The sex-specific LTR was estimated while considering the competing risk of death.

RESULTS

During the mean follow-up period of 15 years (1,553,735 person-years), 889 CHD deaths were recorded. The 10-year risk of CHD mortality at index age 35 years was ≤ 0.11%, but the corresponding LTR was ≥ 1.84%. The LTR of CHD at index age 35 years steeply increased with an increase in BP of participants with high total cholesterol levels [≥ 5.7 mmol/L (220 mg/dL)]. This risk was 7.73%/5.77% (95% confidence interval: 3.53%-10.28%/3.83%-7.25%) in men/women with grade 2-3 hypertension and high total cholesterol levels. In normal and high BP groups, the absolute differences in LTRs between the low and high total cholesterol groups were ≤ 0.25% in men and ≤ 0.40% in women.

CONCLUSIONS

High total cholesterol levels contributed to an elevated LTR of CHD mortality in hypertensive individuals. These findings could help guide high-risk young individuals toward initiating lifestyle changes or treatments.

Blood Pressure and Chronic Kidney Disease Stratified by Gender and the Use of Antihypertensive Drugs

Background

The present study assessed the association between blood pressure (BP) and the risk of chronic kidney disease (CKD) according to gender and the use of antihypertensive drugs using data from a large‐scale health checkup.

Methods and Results

We conducted a retrospective cohort study using the JMDC database, which contains annual health checkup data of Japanese employees and their dependents aged <75 years. We included 154 692 participants (men, 69.68%; mean age, 44.74 years) without CKD. CKD was indicated by an estimated glomerular filtration rate <60 mL/min per 1.73 m² or the presence of proteinuria. During the mean follow‐up period of 4.78 years, new‐onset CKD occurred in 14 888 participants. When the normal BP group (systolic/diastolic BP <120/<80 mm Hg) without treatment was used as a reference, the hazard ratios of the high BP (130–139/80–89 mm Hg) and grade 1 (140–159/90–99 mm Hg) and grade 2 or 3 hypertension (≥160/≥100 mm Hg) groups were 1.11 (95% CI, 1.06–1.17), 1.36 (95% CI, 1.28–1.45), and 1.76 (95% CI, 1.56–1.99) for untreated men, respectively. However, in treated men, even normal BP was associated with a 1.5‐fold higher risk of CKD. The association between BP and the risk of CKD was weaker in untreated women than in untreated men. The risk of CKD in treated women with normal BP was similar to that of untreated women with normal BP.

Conclusions

Gender differences were found in the association between BP and CKD risk. Kidney function in treated individuals should be followed carefully, especially in men.

Blood pressure levels and risk of cardiovascular disease mortality among Japanese men and women: the Japan Collaborative Cohort Study for Evaluation of Cancer Risk (JACC Study)

OBJECTIVE

To examine the association of blood pressure (BP) with cardiovascular mortality in real-world settings and investigate whether that association varied by use of antihypertensive medication at baseline.

METHODS

Data from 27 728 Japanese men and women, aged 40-79 years, free of stroke, coronary heart disease, cancer, and kidney disease at entry (1988-1990) were used in this study. Mortality surveillance was completed through 2009, resulting in 449 800 person-years of follow-up. Hazard ratios for cardiovascular mortality were analysed by BP category (based on 2018 European guidelines) at admission.

RESULTS

There were 1477 deaths from cardiovascular diseases (CVDs). Relative to high-normal BP at admission, the multivariable hazard ratios (95% confidence intervals) of CVD were 0.85 (0.69-1.04) for optimal BP; 0.96 (0.81-1.15) for normal BP; 1.26 (1.09-1.46) for Grade 1 hypertension; and 1.55 (1.31-1.84) for Grade 2-3 hypertension. A similar linear association was observed among persons not taking antihypertensive medication at admission. Among patients treated for hypertension, a U-shaped association with CVD mortality was observed; hazard ratios = 2.31 (1.25-4.27), 1.68 (1.05-2.69), 1.56 (1.10-2.22), and 1.63 (1.13-2.36), respectively. Similar patterns were observed for stroke and coronary heart disease, although not always statistically significant.

CONCLUSION

BP categories at baseline were linearly and positively associated with CVD mortality overall and also among participants not taking antihypertensive medication. A higher risk of mortality from CVD was observed among patients already treated for hypertension with optimal and normal BPs than those with high-normal BP, suggesting the importance of careful monitoring of BP and comorbidities of such patients.

Lack of a significant legacy effect of baseline blood pressure 'treatment naivety' on all-cause and cardiovascular mortality in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial

OBJECTIVES

To investigate legacy effects at 14-year follow-up of all-cause and cardiovascular disease (CVD) mortality in 'treatment-naive' or 'previous treatment' groups based on blood pressure (BP)-lowering treatment status at baseline.

METHODS

A post-hoc observational study of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. We excluded participants with a previous history of CVD events. Cox proportional hazard model and 95% confidence interval were used to estimate the effects of treatment naive on mortality outcomes. Moreover, a subgroup analysis by estimated 10-year Framingham risk score was performed.

RESULTS

In multivariable models adjusting for baseline and in-trial characteristics (BP values and number of BP medications as time-dependent variables), there was no statistically significant difference in 5 and 14-year all-cause mortality with a hazard ratio of 0.93 (95% confidence interval 0.80-1.09) and hazard ratio 0.95 (0.88-1.03) and in 5 and 14-year CVD mortality hazard ratio 0.94 (0.72-1.23) and hazard ratio 0.93 (0.80-1.08). In subgroup by absolute CVD risk, no heterogeneity of the association between treatment naive and short-term or long-term all-cause or CVD mortality were found. All comparisons are between the treatment-naive and previous treatment groups.

CONCLUSION

Physicians are concerned about 'legacy effects' of not treating individuals with a BP of 140 mmHg or over and low absolute risk. When treatment intensification was taken into consideration in the primary prevention population in this study, no adverse legacy effect as a result of baseline BP 'treatment naivety' was evident in 14 years of follow-up. The nonsignificant associations were consistent across the CVD risk subgroups. However, the results may be biased due to unobserved residual confounding and therefore should be interpreted with caution.

Cardiovascular risk and blood pressure lowering treatment among elderly individuals: Evidence for Cardiovascular Prevention from Observational Cohorts in Japan

OBJECTIVE

There is little evidence to support an increased risk of blood pressure (BP) elevation among elderly individuals receiving antihypertensive drug treatment.

METHODS

To clarify the impact on BP level and residual cardiovascular risk in treated elderly individuals, we analysed individual participant data of 26 133 residents aged 60-89 years from seven Japanese general populations and cross-classified participants by age category, 60-74 (young-old) versus 75-89 years (old-old), and by usage of antihypertensive medication at baseline survey (1980-1995).

RESULTS

During a median follow-up period of 12.7 years, 2451 cardiovascular deaths were observed. Multivariable-adjusted hazard ratios of cardiovascular mortality in treated participants compared with untreated participants were 1.30 [95% confidence intervals, 1.16-1.46) and 1.35 (95% confidence interval, 1.16-1.56) in young-old and old-old participants, respectively. Irrespective of antihypertensive medication, the risk increase of total cardiovascular and stroke mortality with elevation of BP was significant among young-old (P ≤ 0.0013), but not significant among old-old participants (P ≥ 0.061).

CONCLUSION

Although impact on BP was more evident among young-old than old-old individuals, clinicians who prescribe antihypertensive medication to elderly patients should consider that such patients require further monitoring.

A Community-Based Intervention for Improving Medication Adherence for Elderly Patients with Hypertension in Korea

The chronic disease management program, a community-based intervention including patient education, recall and remind service, and reduction of out-of-pocket payment, was implemented in 2005 in Korea to improve patients’ adherence for antihypertensive medications. This study aimed to assess the effect of a community-based hypertension intervention intended to enhance patient adherence to prescribed medications. This study applied a non-equivalent control group design using the Korean National Health Insurance Big Data. Hongcheon County has been continuously implementing the intervention program since 2012. This study involved a cohort of patients with hypertension aged >65 and <85 years, among residents who lived in the study area for five years (between 2010 and 2014). The final number of subjects was 2685 in both the intervention and control region. The indirect indicators were analyzed as patients’ adherence and level of continuous treatment using the difference-in-difference regression. The proportion of hypertensive patients who continuously received insurance benefits for >240 days in 2014 was 81.0% in the intervention region and 79.7% in the control region. The number of dispensations per prescription and the dispensation days per hypertensive patient in the intervention region increased by approximately 10.88% and 2.2 days on average by month, respectively, compared to those in the control region. The intervention program encouraged elderly patients with hypertension to receive continuous care. Another research is needed to determine whether further improvement in the continuity of comprehensive care will prevent the progression of cardiovascular diseases.

Impact of Hypertension on Hospitalizations for Cardiovascular Diseases in a Worksite Population: An Epidemiologic Study Using Claims Data for Workers

BACKGROUND

Few of studies investigated the effect of antihypertensives among working population. We aimed to describe the impact of hypertension with and without antihypertensives on hospitalizations because of cardiovascular diseases (CVDs) in the Japanese working population.

METHODS

This retrospective study included adults aged 40-64 years whose systolic and diastolic blood pressure (BP) readings taken between 2008 and 2015 were available in the Japanese claims database. Individuals were categorized as treated (T) or untreated (UT) depending on their hypertension treatment history. Time to first CVD-related hospitalization was compared among individuals with different BP levels using Cox models that included baseline characteristics with either baseline BP level or a time-dependent variable reflecting BP changes over time.

RESULTS

Of 740,784 UT individuals (male: 61.9%, mean age: 47.9 years), 2,121 individuals were hospitalized due to a CVD over a 957.3-day average follow-up. Among 72,828 T individuals (male: 74.3%, mean age: 53.7 years), the corresponding figure was 470 individuals over an 813.4-day average follow-up. The risk of hospitalization increased with baseline hypertension severity among UT (hazard ratios [HRs] = 1.93, 2.82, and 6.32 for grade 1, grade 2, and grade 3, respectively; P < 0.0001, reference: optimal) but not among T individuals. UT individuals with hypertension at any given time had a significantly higher probability of hospitalization compared to nonhypertensive individuals (HR = 1.74, P < 0.0001).

CONCLUSIONS

This study adds quantitative evidence on the impact of hypertension on the risk of CVD-related hospitalization in the Japanese working population. It suggests that antihypertensive treatment had beneficial effects in this relatively young, working population aged 40-64 years.

Lifetime Risk of Stroke and Coronary Heart Disease Deaths According to Blood Pressure Level

Lifetime risk (LTR) provides an absolute risk assessment during the remainder of one’s life. Few studies have focused on the LTRs of stroke and coronary heart disease (CHD), categorized by fine blood pressure in Asian populations. We aimed to assess it using a large database of a meta-analysis with the individual participant data. The present meta-analysis included 107 737 Japanese (42.4% men; mean age, 55.1 years) from 13 cohorts. During the mean follow-up of 15.2±5.3 years (1 559 136 person-years), 1922 died from stroke and 913 from CHD. We estimated risks after adjusting for competing risk of death other than the outcome of interest. The 10-year risk of stroke and CHD deaths at index age of 35 years was ≤1.9% and ≤0.3%, respectively. The LTRs of stroke death at the index age of 35 years (men/women) were 6.1%/4.8% for optimal, 5.7%/6.3% for normal, and 6.6%/6.0% for high-normal blood pressure groups, and 9.1%/7.9% for grade 1, 14.5%/10.3% for grade 2, and 14.6%/14.3% for grade 3 hypertension groups. The LTRs of CHD death similarly elevated with an increase in blood pressure but were lower (≤7.2%) than those of stroke death. In conclusion, blood pressure was clearly associated with an elevated LTR of stroke or CHD death, although the LTR of CHD death was one-half of that of stroke death in an Asian population. These results would help young people with hypertension to adopt a healthy lifestyle or start antihypertensive therapy early.

Pooled Analysis of the Associations between Body Mass Index, Total Cholesterol, and Liver Cancer-related Mortality in Japan

Objective: We employed a large-scale pooled analysis to investigate the association of liver cancer-related mortality with being overweight/obese and total cholesterol (TC) levels, since limited and inconsistent data on these associations exist in Japan. Methods: A total of 59,332 participants (23,853 men and 35,479 women) from 12 cohorts without a history of cancer who were followed for a median of 14.3 years were analyzed. A sex-specific stratified Cox proportional hazards model adjusted for age and other potential confounders was used to calculate hazard ratios (HRs) and 95% confidence intervals (CI) for liver cancer-related mortality. Results: A total of 447 participants (266 men and 181 women) died of liver cancer within the follow-up period. Individuals classified as having a high BMI (≥25.0 kg/m2) and low TC levels (<160 mg/dL) had a significantly increased risk for liver cancer-related mortality (HR 7.05, 95% CI 4.41–11.26 in men; HR 8.07, 95% CI 4.76–13.67 in women) when compared with those in the intermediate BMI (18.5–24.9 kg/m2) and TC (160–219 mg/dL) categories. These associations remained after limiting the follow-up duration to >5 years. Conclusion: Being overweight/obese, combined with low TC levels, was strongly associated with liver cancer-related mortality in the EPOCH-JAPAN.

Association of extremely high levels of high-density lipoprotein cholesterol with cardiovascular mortality in a pooled analysis of 9 cohort studies including 43,407 individuals: The EPOCH-JAPAN study

BACKGROUND

The effect of very high or extremely high levels of high-density lipoprotein cholesterol (HDL-C) on cardiovascular disease (CVD) is not well described. Although a few recent studies have reported the adverse effects of extremely high levels of HDL-C on CVD events, these did not show a statistically significant association between extremely high levels of HDL-C and cause-specific CVD mortality. In addition, Asian populations have not been studied.

OBJECTIVE

We examine the impact of extremely high levels of HDL-C on cause-specific CVD mortality using pooled data of Japanese cohort studies.

METHODS

We performed a large-scale pooled analysis of 9 Japanese cohorts including 43,407 participants aged 40-89 years, dividing the participants into 5 groups by HDL-C levels, including extremely high levels of HDL-C ≥2.33 mmol/L (≥90 mg/dL). We estimated the adjusted hazard ratio of each HDL-C category for all-cause death and cause-specific deaths compared with HDL-C 1.04-1.55 mmol/L (40-59 mg/dL) using a cohort-stratified Cox proportional hazards model.

RESULTS

During a 12.1-year follow-up, 4995 all-cause deaths and 1280 deaths due to overall CVD were identified. Extremely high levels of HDL-C were significantly associated with increased risk of atherosclerotic CVD mortality (hazard ratio = 2.37, 95% confidence interval: 1.37-4.09 for total) and increased risk for coronary heart disease and ischemic stroke. In addition, the risk for extremely high HDL-C was more evident among current drinkers.

CONCLUSION

We showed extremely high levels of HDL-C had an adverse effect on atherosclerotic CVD mortality in a pooled analysis of Japanese cohorts.

Endothelial Function Is Impaired in Patients Receiving Antihypertensive Drug Treatment Regardless of Blood Pressure Level: FMD-J Study (Flow-Mediated Dilation Japan)

Hypertension is associated with endothelial dysfunction. Blood pressure significantly correlates with endothelial function in antihypertensive drug-naive subjects. The purpose of this study was to determine whether treatment status affects the relationship between blood pressure and endothelial function. We measured flow-mediated vasodilation (FMD) in 2297 subjects, including 1822 antihypertensive drug-naive subjects and 475 treated hypertensive patients. FMD significantly decreased in relation to increase in systolic blood pressure (8.2±3.1% in subjects with systolic blood pressure of <120 mm Hg, 7.5±2.8% for 120-129 mm Hg, 7.1±2.8% for 130-139 mm Hg, and 6.7±2.6% for ≥140 mm Hg; P<0.001). Systolic blood pressure was independently associated with FMD in untreated subjects. In contrast, there was no significant relationship between systolic blood pressure and FMD in treated hypertensive patients (4.6±3.1% in treated hypertensives with systolic blood pressure of <120 mm Hg, 4.8±2.7% for 120-129 mm Hg, 4.9±2.8% for 130-139 mm Hg, and 4.5±2.3% for ≥140 mm Hg; P=0.77). Propensity score matching analysis revealed that the prevalence of endothelial dysfunction defined as FMD of less than the division point for the lowest tertile, and the middle tertile of FMD was significantly higher in treated hypertensive patients than in untreated subjects in all systolic blood pressure categories. Endothelial function assessed by FMD was impaired regardless of the level of blood pressure achieved by antihypertensive drug treatment in hypertensive patients.

Observational study and participant-level meta-analysis on antihypertensive drug treatment-related cardiovascular risk

Although antihypertensive therapy reduces cardiovascular risk, individuals who are treated with antihypertensive medication generally have a worse prognosis for cardiovascular disease than untreated people. We recently evaluated the impact of conventional blood pressure level based on two Japanese individual participant databases and found that conventional blood pressure at baseline was not or was weakly associated with cardiovascular events among patients under antihypertensive drug medication. In the general population in Ohasama and the Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressures study, self-measured home blood pressure significantly predicted cardiovascular outcomes in patients under antihypertensive treatment. Hypertension is a chronic disease, and blood pressure must be evaluated with repeated measurements over a long period of time. Therefore, although not proven by a randomized controlled trial, it is likely that the long-term management of hypertension by antihypertensive drug treatment should be based on self-measured home blood pressure. We should also pay careful attention to the residual cardiovascular risk in treated patients.

Age-specific impact of diabetes mellitus on the risk of cardiovascular mortality: An overview from the evidence for Cardiovascular Prevention from Observational Cohorts in the Japan Research Group (EPOCH-JAPAN)

Background

Diabetes mellitus is a strong risk factor for cardiovascular disease. However, the age-specific association of diabetes with cardiovascular risk, especially in the elderly, remains unclear in non-Western populations.

Methods

A pooled analysis was conducted using 8 cohort studies (mean follow-up period, 10.3 years) in Japan, combining the data from 38,854 individual participants without history of cardiovascular disease. In all, 1867 of the participants had diabetes, defined based on the 1998 World Health Organization criteria. The association between diabetes and the risk of death from cardiovascular disease, coronary heart disease (CHD), and stroke was estimated using a stratified Cox model, accounting for variability of baseline hazard functions among cohorts.

Results

During the follow-up, 1376 subjects died of cardiovascular disease (including 268 of coronary heart disease and 621 of stroke). Diabetes was associated with an increased risk of cardiovascular death after multivariable adjustment (hazard ratio [HR] 1.62; 95% confidence interval [CI], 1.35–1.94). Similarly, diabetes was a risk factor for CHD (HR 2.13; 95% CI, 1.47–3.09) and stroke (HR 1.40; 95% CI, 1.05–1.85). In the age-stratified analysis of the risk of cardiovascular death, the relative effects of diabetes were consistent across age groups (p for heterogeneity = 0.18), whereas the excess absolute risks of diabetes were greater in participants in their 70s and 80s than in younger subjects.

Conclusions

The management of diabetes is important to reduce the risk of death from cardiovascular disease, not only in midlife but also in late life, in the Japanese population.

•

We conducted meta-analysis of individual data from 8 Japanese cohorts (n = 38,854).

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Diabetes raised cardiovascular mortality in Japan.

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Impact of diabetes on cardiovascular death was similar across 10-year age groups.

Relative Contributions of Arterial Stiffness and Hypertension to Cardiovascular Disease: The Framingham Heart Study

BACKGROUND

The presence and implications of abnormal arterial stiffness, a potential independent predictor of outcomes, in community-dwelling treated hypertensives is unknown. Furthermore, limited data exist regarding the risk of cardiovascular disease (CVD) associated with arterial stiffness across the entire range of blood pressure.

METHODS AND RESULTS

We measured carotid-femoral pulse wave velocity (PWV) and classical CVD risk factors in 2127 community-dwelling participants (mean age 60 years, 57% women) of The Framingham Offspring Cohort. The participants were divided into 4 groups according to hypertension (yes/no, defined as blood pressure ≥140/90 mm Hg or use of antihypertensive treatment) and PWV status (high/low based on age- and sex-specific median values) and followed up for CVD events (CVD death, myocardial infarction, unstable angina, heart failure, and stroke). Sixty percent (233 of 390) of controlled and 90% (232 of 258) of uncontrolled treated hypertensives had high PWV. The multivariable-adjusted risk for CVD events (n=248, median follow-up 12.6 years) rose from normotension with low PWV (reference) to normotension with high PWV (hazard ratio 1.29, 95% CI 0.83-2.00) and from hypertension with low PWV (hazard ratio 1.54, 95% CI 1.01-2.36) to hypertension with high PWV (hazard ratio 2.25, 95% CI 1.54-3.29).

CONCLUSIONS

A substantial proportion of treated hypertensives have high arterial stiffness, a finding that may explain some of the notable residual CVD risk associated with even well-controlled hypertension. High PWV is associated with a trend towards increasing CVD risk in both nonhypertensives and hypertensives, a finding that may support the use of arterial stiffness measurements in both populations.

Cardiovascular Risk in Hypertension in Relation to Achieved Blood Pressure Using Automated Office Blood Pressure Measurement

The SPRINT (Systolic Blood Pressure Intervention Trial) reported that some older, higher risk patients might benefit from a target systolic blood pressure (BP) of <120 versus <140 mm Hg. However, it is not yet known how the BP target and measurement methods used in SPRINT relate to cardiovascular outcomes in real-world practice. SPRINT used the automated office BP technique, which requires the patient to be resting quietly and alone, with multiple readings being recorded automatically using an electronic oscillometric sphygmomanometer. We studied the relationship between achieved automated office BP at baseline and cardiovascular events in 6183 community-dwelling residents of Ontario aged ≥66 years who were receiving antihypertensive therapy and followed for a mean of 4.6 years. Adjusted hazard ratios (95% confidence intervals) were computed for 10 mm Hg increments in achieved automated office BP at baseline using Cox proportional hazards regression and the BP category with the lowest event rate as the reference category. Based on 904 fatal and nonfatal cardiovascular events, the nadir of cardiovascular events was at the systolic pressure category of 110 to 119 mm Hg, which was lower than the next highest category of 120 to 129 mm Hg (hazard ratio 1.30 [1.01, 1.66]). The hazard ratio for diastolic pressure was relatively unchanged above 60 mm Hg. Pulse pressure exhibited an increase in hazard ratio (1.33 [1.02, 1.72]) at ≥80 mm Hg. These results using automated office BP measurement in a usual treatment setting extend the finding in SPRINT of an optimum target systolic BP of <120 mm Hg to routine clinical practice.

Longitudinal Trends in Hypertension Management and Mortality Among Octogenarians: Prospective Cohort Study

The role of hypertension management among octogenarians is controversial. In this long-term follow-up (>10 years) study, we estimated trends in hypertension prevalence, awareness, treatment, and control among octogenarians, and evaluated the relationship of systolic blood pressure (SBP) ranges with mortality. Data were based on the English Longitudinal Study of Ageing (ELSA). Outcome measures were hypertension prevalence, awareness, treatment and control, and cardiovascular disease, and all-cause mortality events. Participants were separated into 8 categories of SBP values (<110, 110-119, 120-129, 130-139, 140-149, 150-159, 160-169, and >169 mm Hg). Among 2692 octogenarians, mean SBP levels declined from 147 mm Hg in 1998/2000 to 134 mm Hg in 2012/2013. The decline was of lower magnitude in the 50 to 79 years old subgroup (n=22007). Hypertension prevalence and awareness were 40% and 13%, respectively, higher among octogenarians than the 50 to 79 years of age subgroup, but hypertension treatment rates were similar (≈90%). Around 47% of the treated octogenarians achieved conventional BP targets (<140/90 mm Hg), increasing to 59% when assessed against revised targets (<150/90 mm Hg). All-cause mortality rates were higher (hazard ratio, 1.55; 95% confidence interval, 0.89-2.72) at lower extremes of SBP values (<110 mm Hg). The lowest cardiovascular disease and all-cause mortality risk among treated octogenarians was observed for an SBP range of 140 to 149 mm Hg (1.04, 0.60-1.78) and 160 to 169 mm Hg (0.78, 0.51-1.21). An increasing trend in hypertension awareness and treatment was observed in a large sample of community-dwelling octogenarians. The results do not support the view that more stringent BP targets may be associated with lower mortality.

Abnormal Pulsatile Hemodynamics in Hypertensive Patients With Normalized 24-Hour Ambulatory Blood Pressure by Combination Therapy of Three or More Antihypertensive Agents

It remains uncertain whether intensive antihypertensive therapy can normalize pulsatile hemodynamics resulting in minimized residual cardiovascular risks. In this study, office and 24-hour ambulatory systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure, carotid-femoral pulse wave velocity (PWV), and forward (Pf) and reflected (Pb) pressure wave from a decomposed carotid pressure wave were measured in hypertensive participants. Among them, 57 patients whose 24-hour SBP and DBP were normalized by three or more classes of antihypertensive medications were included. Another 57 age- and sex-matched normotensive participants were randomly selected from a community survey. The well-treated hypertensive patients had similar 24-hour SBP, lower DBP, and higher PP values. The treated patients had higher PWV (11.7±0.3 vs 8.3±0.2 m/s, P<.001), Pf, Pb, Pb/Pf, and left ventricular mass index values. After adjustment for age, sex, body mass index, and office SBP, the differences for PWV, Pb, and Pb/Pf remained significant. Hypertensive patients whose 24-hour SBP and DBP are normalized may still have markedly increased arterial stiffness and wave reflection.

Serum Uric Acid and Mortality Form Cardiovascular Disease: EPOCH-JAPAN Study

AIM

To investigate the relationship between serum uric acid levels and cardiovascular disease in Asians.

METHODS

We examined the above relationship using the data of Evidence for Cardiovascular Prevention from Observational Cohorts in Japan (EPOCH-JAPAN Study). The data of 36,313 subjects (15,628 men and 20,685 women aged 35-89 years without histories of stroke, coronary heart disease, or cancer at baseline) were used for the analyses. Sex-specific hazard ratios (HRs) of mortality from cardiovascular disease were estimated according to the quintiles of serum uric acid using Cox hazard models stratified by cohorts.

RESULTS

During 441,771 person-years of follow-up, we documented 1,288 cardiovascular deaths. A J- or U-shaped relationship between serum uric acid level and cardiovascular disease mortality was observed. Compared with the lowest quintile of serum uric acid levels, the highest quintile was associated with an increased cardiovascular disease mortality in men [HR: 1.28; 95% confidence interval (CI): 1.01-1.63] and women (HR: 1.51; 95% CI: 1.14-1.99). However, there was no significant association with mortality from stroke, coronary heart disease or heart failure in both men and women.

CONCLUSION

This large pooled analysis in Japan suggested a J- or U-shaped relationship between serum uric acid levels and cardiovascular mortality. The highest quintile of serum uric acid levels was associated with increased cardiovascular disease mortality in both Japanese men and women.