Relationships Between Components of Blood Pressure and Cardiovascular Events in Patients with Stable Coronary Artery Disease and Hypertension

Achievement of guideline-recommended target blood pressure is associated with reducing the risk of hemorrhagic and ischemic stroke in Japanese coronary artery disease patients -the CLIDAS study

The Japanese Society of Hypertension have established a blood pressure (BP) target of 130/80 mmHg for patients with coronary artery disease (CAD). We evaluated the data of 8793 CAD patients in the Clinical Deep Data Accumulation System database who underwent cardiac catheterization at six university hospitals and the National Cerebral and Cardiovascular Center (average age 70 ± 11 years, 78% male, 43% with acute coronary syndrome [ACS]). Patients were divided into two groups based on whether or not they achieved the guideline-recommended BP of <130/80 mmHg. We analyzed the relationship between BP classification and major adverse cardiac and cerebral event (MACCE) separately in two groups: those with ACS and those with chronic coronary syndrome (CCS). During an average follow-up period of 33 months, 710 MACCEs occurred. A BP below 130/80 mmHg was associated with fewer MACCEs in both the overall (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.70-1.00, p = 0.048) and the ACS group (HR 0.67, 95%CI 0.51-0.88, p = 0.003). In particular, stroke events were also lower among those with a BP below 130/80 mmHg in both the overall (HR 0.69, 95%CI 0.53-0.90, p = 0.006) and ACS groups (HR 0.44, 95%CI 0.30-0.67, p < 0.001). In conclusion, the achievement of BP guidelines was associated with improved outcomes in CAD patients, particularly in reducing stroke risk among those with ACS.

Association of plasma trans fatty acid concentrations with blood pressure and hypertension in U.S. adults

Objective

The present study aimed to evaluate the association of plasma trans fatty acids (TFAs) biomarkers with the risk of hypertension.

Methods

Using data from the National Health and Nutrition Examination Surveys (NHANES 2009-2010), we conducted a thorough analysis using both the traditional regression model and the Bayesian Kernel Machine Regression (BKMR) model to investigate the associations of individual TFAs and their mixtures with systolic blood pressure (SBP), diastolic blood pressure (DBP), and the risk of hypertension in a sample of 1,970 American adults.

Results

The concentrations of TFAs were natural logarithms (ln) transformed to approximate a normal distribution. Multivariate linear regression models showed that each 1-unit increase in ln-transformed plasma concentrations of palmitelaidic, elaidic, vaccenic, and linolelaidic acids was associated with separate 2.94-, 3.60-, 2.46- and 4.78-mm Hg and 2.77-, 2.35-, 2.03-, and 3.70- mm Hg increase in SBP and DBP, respectively (P < 0.05). The BKMR model showed positive associations between the four TFAs mixtures and SBP and DBP. In addition, linolelaidic acid contributed the most to an increased blood pressure. Similar results were observed with the threshold of hypertension (≥130/80 mm Hg).

Conclusion

Our findings provide preliminary evidence that plasma TFA concentrations are associated with increased blood pressure and the risk of hypertension in US adults. This study also suggests that linolelaidic acid might exhibit more deleterious effects on hypertension than other TFAs. Further studies should be conducted to validate these results.

[Twenty-year experience in strict versus non-strict control of arterial hypertension in a health center in Spain]

INTRODUCTION AND AIMS

During clinical trials effective reduction of blood pressure (BP) leads to a reduction in the incidence of cardiovascular (CV) morbimortality. Our main aim is to ascertain whether, under actual conditions of clinical practice, BP monitoring leads to a long-term reduction in CV events.

PATIENTS AND METHODS

The study was performed on 164 patients with hypertension (HT) selected among patients who came to family medicine consultations because of HT. An analysis was performed between patients who presented clinical BP lower than 140/90mmHg and those that had higher levels. When patients entered the study, they were followed up until a CV event occurred or up to a maximum of 20 years, at which time follow up ended.

RESULTS

Of the total of 164 patients, good control of BP was attained by 93 (56.7%), and 71 did not attain good control (42.2%). In the multivariate analysis, the only predictive variable for CV events was the lack of strict control of BP (HR: 2.93; 95% CI: 1.45-5.89; p=0.003), and the female sex was protective for CV events (HR: 0.37; 95% CI: 0.18-0.74; p=0.005).

CONCLUSIONS

The fundamental predictor variable of CV morbimortality in patients with HT is the lack of HT strict control; the women also had fewer CV complications.

Pathophysiological Association of Alzheimer's Disease and Hypertension: A Clinical Concern for Elderly Population

Alzheimer's disease (AD), the most common cause of dementia and the fifth leading cause of death in the adult population has a complex pathophysiological link with hypertension (HTN). A growing volume of published literature on a parallel elevation of blood pressure (BP), amyloid plaques, and neurofibrillary tangles formation in post-middle of human brain cells has developed new, widely accepting foundations on this association. In particular, HTN in elderly life mediates cerebral blood flow dysfunction, neuronal dysfunction, and significant decline in cognitive impairment, primarily in the late-life populace, governing the onset of AD. Thus, HTN is an established risk factor for AD. Considering the impact of AD, 1.89 million deaths annually, and the failure of palliative therapies to cure AD, the scientific research community is looking to adopt integrated approaches to target early modified risk factors like HTN to reduce AD burden. The current review highlights the significance and impact of HTN-based prevention in lowering the AD burden in the elderly by providing a comprehensive overview of the physiological relationship between AD and HTN with an in-detail explanation of the role and applications of pathological biomarkers in this clinical association. The review will gain worth in presenting new insights and providing inclusive discussion on the correlation between HTN and cognitive impairment. It will increase across a wider scientific audience to expand understanding of this pathophysiological association.

Long-Term Coronary Artery Disease Risk Prediction with Machine Learning Models

The heart is the most vital organ of the human body; thus, its improper functioning has a significant impact on human life. Coronary artery disease (CAD) is a disease of the coronary arteries through which the heart is nourished and oxygenated. It is due to the formation of atherosclerotic plaques on the wall of the epicardial coronary arteries, resulting in the narrowing of their lumen and the obstruction of blood flow through them. Coronary artery disease can be delayed or even prevented with lifestyle changes and medical intervention. Long-term risk prediction of coronary artery disease will be the area of interest in this work. In this specific research paper, we experimented with various machine learning (ML) models after the use or non-use of the synthetic minority oversampling technique (SMOTE), evaluating and comparing them in terms of accuracy, precision, recall and an area under the curve (AUC). The results showed that the stacking ensemble model after the SMOTE with 10-fold cross-validation prevailed over the other models, achieving an accuracy of 90.9 %, a precision of 96.7%, a recall of 87.6% and an AUC equal to 96.1%.

Answering Clinical Questions Using Machine Learning: Should We Look at Diastolic Blood Pressure When Tailoring Blood Pressure Control?

Background: The guidelines recommend intensive blood pressure control. Randomized trials have focused on the relevance of the systolic blood pressure (SBP) lowering, leaving the safety of the diastolic blood pressure (DBP) reduction unresolved. There are data available which show that low DBP should not stop clinicians from achieving SBP targets; however, registries and analyses of randomized trials present conflicting results. The purpose of the study was to apply machine learning (ML) algorithms to determine, whether DBP is an important risk factor to predict stroke, heart failure (HF), myocardial infarction (MI), and primary outcome in the SPRINT trial database. Methods: ML experiments were performed using decision tree, random forest, k-nearest neighbor, naive Bayesian, multi-layer perceptron, and logistic regression algorithms, including and excluding DBP as the risk factor in an unselected and selected (DBP < 70 mmHg) study population. Results: Including DBP as the risk factor did not change the performance of the machine learning models evaluated using accuracy, AUC, mean, and weighted F-measure, and was not required to make proper predictions of stroke, MI, HF, and primary outcome. Conclusions: Analyses of the SPRINT trial data using ML algorithms imply that DBP should not be treated as an independent risk factor when intensifying blood pressure control.

Association between Coronary Artery Plaque Progression and Liver Fibrosis Biomarkers in Population with Low Calcium Scores

Background: The severity of nonalcoholic fatty liver disease (NAFLD) has been found to be associated with atherosclerosis burden. However, whether liver fibrosis scores can be used to predict atherosclerosis progression, especially for patients with low calcium scores, remains undetermined. Methods: A total of 165 subjects who underwent repeated coronary computed tomography angiography (CCTA) and had low calcium scores (<100) were enrolled. The segment stenosis score (SSS) from the CCTA was measured, and the association between SSS progression and biochemical parameters was analyzed in addition to liver fibrosis scores, including nonalcoholic fatty liver disease fibrosis score (NFS), fibrosis-4 index (FIB-4), aspartate aminotransferase (AST) to platelet ratio index (APRI), and Forns score. Results: When compared with those without plaque at baseline (SSS = 0), subjects with plaque had higher blood pressure, higher coronary artery calcium (CAC) scores, and higher liver fibrosis scores, including Forns score, Fib-4, and NFS. During the medium follow-up interval of 24.7 months, 60 (39.4%) patients displayed SSS progression, while the remaining 105 (63.6%) patients showed no CAD progression. In a multivariate analysis, being male having a high diastolic blood pressure (DBP), and having a high NFS liver fibrosis score were independently associated with the odds ratio for SSS progression. Conclusions: Higher baseline blood pressure and liver fibrosis markers are associated with the presence of coronary artery disease (CAD) plaques in subjects in early CAD stages. For disease progression, the male gender, DBP, and NFS appear to be independently associated with coronary atherosclerosis plaque progression in subjects with low calcium scores.

Pre-dialysis diastolic blood pressure and intradialytic hypotension in patients undergoing maintenance haemodialysis

BACKGROUND

Intradialytic hypotension is a clinically relevant complication in haemodialysis patients. Pre-dialysis diastolic blood pressure is routinely measured. However, the association between pre-dialysis diastolic blood pressure and intradialytic hypotension is not well understood.

METHODS

Patient-level (N = 545) and haemodialysis session-level (N = 3261) data were collected; the exposure variable was pre-dialysis diastolic blood pressure. The primary outcome of interest was the development of intradialytic hypotension, defined as any nadir < 100 mmHg if the pre-dialysis systolic blood pressure was ≥ 160 mmHg, or any nadir < 90 mmHg if the pre-dialysis systolic blood pressure was < 160 mmHg. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using mixed-effects logistic regression for the association between pre-dialysis diastolic blood pressure and intradialytic hypotension, after adjusting for potential confounders.

RESULTS

Intradialytic hypotension occurred in 14.4% of the sessions. All sessions were divided into five categories according to pre-dialysis diastolic blood pressure. The adjusted ORs for intradialytic hypotension were 2.72 (95% CI 1.64-4.51), 1.07 (95% CI 0.68-1.66), 1.68 (95% CI 1.08-2.62), and 1.81 (95% CI 1.05-3.14) in sessions with pre-dialysis diastolic blood pressure of < 60 mmHg, ≥ 60 to < 70 mmHg, ≥ 80 to < 90 mmHg, and ≥ 90 mmHg, respectively, compared with the reference pre-dialysis diastolic blood pressure of ≥ 70 to < 80 mmHg. Cubic spline analyses revealed a reverse J-shaped association between pre-dialysis diastolic blood pressure and intradialytic hypotension.

CONCLUSIONS

Low and high pre-dialysis diastolic blood pressure levels were associated with intradialytic hypotension. This may help identify patients at a high risk of developing intradialytic hypotension.

The prognostic role of intra-aortic pulse pressure measured before percutaneous coronary intervention in patients with chronic coronary syndrome: a single-center, retrospective, observational cohort study

BACKGROUND

The relationship between pulse pressure and prognosis in patients with chronic coronary syndrome (CCS) is contradictory. In the present study, we aimed to examine the relationship between intra-aortic pulse pressure (IAPP) and major adverse cardiovascular events (MACE) in patients with CCS undergoing percutaneous coronary intervention (PCI).

METHODS

A total of 139 CCS patients who underwent elective PCI with regular one-year follow-up, were stratified into two subgroups according to IAPP. The primary outcomes included the occurrence of MACE, defined as cardiovascular death, acute myocardial infarction with ST-segment elevation (STEMI), acute myocardial infarction without ST-segment elevation (NSTEMI), target vessel revascularization (TVR), and stroke.

RESULTS

The mean age of the patients was 57.6 ± 10.4 years, 32% of whom were female. The mean IAPP, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were 54.0 ± 17.6 mmHg, 129.7 ± 20 mmHg, and 75.8 ± 11.8 mmHg, respectively. SBP, IAPP, and left ventricular ejection fraction (LVEF) were significantly higher in the high IAPP group (p < .001, p < .001, p = .001, respectively). The MACE rate was significantly higher in the low IAPP group than in the high IAPP group (30.4% vs. 8.6%, p = 0,001). The LVEF (OR = 0.93, CI:0.88-0.99, p = .025) and IAPP (OR = 0.89, CI:0.83-0.95, p = .001) were found to be independent predictors of MACE. The IAPP value of 39.5 mmHg was identified as an effective cutoff point for prediction of MACE-free survival rates (AUC:0.853, CI:0.768-0.937).

CONCLUSION

Invasively measured IAPP has prognostic information about cardiovascular outcomes in patients with CCS. The risk of MACE is significantly greater in CCS patients with low IAPP compared with those who have high IAPP values.

Blood pressure and mortality after percutaneous coronary intervention: a population-based cohort study

Revascularization procedures, including percutaneous coronary intervention (PCI), for coronary artery disease (CAD) are increasingly performed in Korea. However, studies on blood pressure control targets in these patients remain insufficient. To assess the relationship between baseline blood pressure and all-cause mortality in CAD patients who underwent PCI. A population-based retrospective cohort study based on the national claims database of the Korean National Health Insurance System, which represents the entire Korean population. A total 38,330 patients with a history of PCI for CAD between 2005 and 2008 were recruited and followed up for all-cause mortality until December 31, 2017. Baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured, and they were classified into eight SBP and DBP groups each. The hazard ratios (HRs) for all-cause mortality were measured for each group. The pattern of SBP and DBP in this population followed a J-curve relationship for all-cause mortality, with the nadir point at 119 and 74 mmHg, respectively. In subjects aged > 60 years, high SBP (≥ 160 mmHg) and high DBP (≥ 90 mmHg) were significantly related to death. Moreover, in subjects aged > 60 years, low DBP (< 70 mmHg) was significantly related to mortality. There is a J-curve relationship between baseline blood pressure and all-cause mortality in patients who underwent PCI, and intensive lowering of blood pressure may be beneficial for these patients. However, the elderly population needs more attention as excessive BP lowering, particularly DBP, could instead increase the risk of death.

The diastolic blood pressure J-curve revisited: An update

Hypertension remains a leading cause of morbidity and mortality. Recent treatment guidelines stress more strict systolic blood pressure (SBP) targets without regard for abnormally low achieved diastolic blood pressures (DBP). However, as DBP falls below a critical level, adverse events increase, the so-called J-shaped curve. Proponents argue that the low DBP is causative due to reduced coronary perfusion during diastole with obstructive coronary artery disease (CAD), whereas others postulate the J-curve represents reverse causality from underlying comorbidity. Most data are observational, derived from population-based cohorts or post-hoc analyses of randomized controlled trials (RCT) conducted for other reasons. The purpose of this review is to analyze the observational studies performed over the last decade addressing the J-curve, with consideration of earlier data. Overall, a J-curve exists, but it remains uncertain whether low DBP is causative or instead reflects reverse causation from either diseased vasculature (widened pulse pressure) or severe underlying comorbidity. The most convincing data for causation come from studies restricted to patients with documented CAD, with evidence suggesting revascularization may mitigate risk. RCTs are needed to determine if a low DBP should preclude intensification of therapy, especially with documented CAD. Firm recommendations cannot be made with contemporary data.

Appraisal of Guidelines for the Management of Blood Pressure in Patients with Diabetes Mellitus: The Consensuses, Controversies and Gaps

BACKGROUND

Currently available guidelines contain conflicting recommendations on the management of blood pressure (BP) in patients with diabetes mellitus (DM). Therefore, it is necessary to appraise the guidelines and summarize the agreements and differences among recommendations.

METHODS

Four databases and the websites of guideline organizations were searched for guidelines regarding BP targets and thresholds for pharmacologic therapy in DM patients, and the included guidelines were appraised with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

RESULTS

In 6,498 records identified, 20 guidelines met our inclusion criteria with 64.0% AGREE II scores (interquartile range, 48.5% to 72.0%). The scores of the European and American guidelines were superior to those of the Asian guidelines (both adjusted P<0.001). Most of the guidelines advocated systolic BP targets <130 mm Hg (12 guidelines, 60%) and diastolic BP targets <80 mm Hg (14 guidelines, 70%) in DM patients. Approximately half of the guidelines supported systolic BP thresholds >140 mm Hg (10 guidelines, 50%) and diastolic BP thresholds >90 mm Hg (nine guidelines, 45%). The tiny minority of the guidelines provided the relevant recommendations regarding the lower limit of official BP targets and the ambulatory BP monitoring (ABPM)/home BP monitoring (HBPM) targets and thresholds in DM patients.

CONCLUSION

The lower official BP targets (<130/80 mm Hg) in patients with DM are advocated by most of the guidelines, but they contain conflicting recommendations on the official BP thresholds. Moreover, the gaps regarding the lower limit of official BP targets and the ABPM/HBPM targets and thresholds need to be considered by future study.

Persistence of uncontrolled hypertension post-cardiac rehabilitation in stable coronary patients

In stable coronary heart disease, uncontrolled risk factors are strongly associated with incident myocardial infarction. We analysed the management of hypertension in 746 stable coronary patients recruited between 2005 and 2015 in a single-centre prospective study. Risk factors and pharmacological treatments were documented prior to and immediately after cardiac rehabilitation, and 1 year later. One year post-cardiac rehabilitation, all cardiovascular risk factors were significantly better controlled with the notable exception of hypertension: blood pressure (BP) <140/90 mmHg in 60% of the total population vs 49% (N = 450) of hypertensive patients (20% or 10%, according to the ACC/AHA 2017 or ESH/ESC guidelines, respectively). Of those who had achieved normotension by the end of cardiac rehabilitation, 42% had uncontrolled hypertension again 1 year later; in addition, body weight had increased, while physical activity and antihypertensive drug use had dropped (differences between controlled or uncontrolled hypertension at 1 year post-cardiac rehabilitation, NS). Three factors were correlated with BP elevations: discontinuation of betablockade: +7.9 mmHg; age >65 years: +6.2 mmHg; diabetes mellitus: +7.6 mmHg. Only 48% hypertensive patients were on guideline-recommended antihypertensive polytherapy. Although 28% were still hypertensive post-cardiac rehabilitation, and hypertension remained uncontrolled in 70% 1 year later, 61% antihypertensive prescriptions were not adjusted post-cardiac rehabilitation. One year post-cardiac rehabilitation, hypertension was the only cardiovascular risk factor that had not improved. This can be attributed to three main reasons, all associated with BP elevations: precipitous reduction in betablockade, physicians' inertia when faced with uncontrolled hypertension and lack of adherence to international guidelines.

Intensive blood pressure lowering in different age categories: insights from the Systolic Blood Pressure Intervention Trial

AIMS

The 2018 ESC/ESH guidelines for hypertension recommend differential management of patients who are <65, 65-79, and ≥80 years of age. However, it is unclear whether intensive blood pressure lowering is well-tolerated and modifies risk uniformly across the age spectrum.

METHODS AND RESULTS

SPRINT randomized 9361 high-risk adults without diabetes and age ≥50 years with systolic blood pressure 130-180 mmHg to either intensive or standard antihypertensive treatment. The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. The primary safety endpoint was composite serious adverse events. We assessed whether age modified the efficacy and safety of intensive vs. standard blood pressure lowering using Cox proportional-hazards regression and restricted cubic splines. In all, 3805 (41%), 4390 (47%), and 1166 (12%) were <65, 65-79, and ≥80 years. Mean age was similar between the two study groups (intensive group 67.9 ± 9.4 years vs. standard group 67.9 ± 9.5 years; P = 0.94). Median follow-up was 3.3 years. In multivariable models, age was linearly associated with the risk of stroke (P < 0.001) and non-linearly associated with the risk of primary efficacy events, death from cardiovascular causes, death from any cause, heart failure, and serious adverse events (P < 0.001). The safety and efficacy of intensive blood pressure lowering were not modified by age, whether tested continuously or categorically (P > 0.05).

CONCLUSION

In SPRINT, the benefits and risks of intensive blood pressure lowering did not differ according to the age categories proposed by the ESC/ESH guidelines for hypertension.

TRIAL REGISTRATION

SPRINT (Systolic Blood Pressure Intervention Trial); ClinicalTrials.gov Identifier: NCT01206062, https://clinicaltrials.gov/ct2/show/NCT01206062.

Trimetazidine and Bisoprolol to Treat Angina in Symptomatic Patients: Post Hoc Analysis From the CHOICE-2 Study

Introduction

Angina is the cardinal symptom of chronic coronary syndrome (CCS), which is the leading cause of death worldwide. As such, the control of angina is important. The current guidelines recommend beta blockers (BB) or calcium channel blockers to reduce angina, yet many patients with stable angina remain symptomatic. It has been suggested that combining trimetazidine (TMZ), an anti-ischemic agent, with a BB is beneficial for symptomatic patients. Bisoprolol, a BB, is often used to treat patients with CCS, yet no data are currently available regarding the efficacy of bisoprolol combined with TMZ in patients who remain symptomatic despite receiving bisoprolol.

Methods

The aim of this post-hoc analysis of the CHOICE-2 study was to evaluate the efficacy and safety of TMZ 35 mg twice daily in combination with different bisoprolol doses in symptomatic patients with stable angina patients receiving hemodynamic therapy in a real-world clinical setting.

Results

This analysis involved 221 patients (mean [± standard deviation] age 64.8 ± 8.9 years) with stable angina. The mean number of weekly angina episodes gradually fell from 6.2 ± 5.3 at inclusion (M0) to 1.5 ± 1.9 at 6 months after treatment initiation (M6) with combined TMZ–bisoprolol therapy (P < 0.001). The number of patients assessed to be angina-free increased almost sixfold from 5.4% (12/221) at M0 to 33.9% (74/221) at M6. Exercise capacity improved, as measured by walking distance, from 308 ± 207 m at M0 to 497 ± 253 m at M6 (P < 0.05). The number of patients with Canadian Cardiovascular Society class 1 angina increased by tenfold during the study, whereas those with class 3 angina decreased by threefold.

Conclusion

The TMZ–bisoprolol combination is a rapidly effective treatment for reducing the frequency of angina attacks and the use of short-acting nitrates in patients with stable angina in a real-world clinical setting. The benefits of this combination therapy was observed as early as 2 weeks after treatment initiation and the treatment was well tolerated.

Trial Registration

ISRCTN identifier: ISRCTN65209863

Blood pressure and long-term mortality in older patients: results of the Fiesole Misurata Follow-up Study

BACKGROUND

Optimal blood pressure (BP) control can prevent major adverse health events, but target values are still controversial, especially in older patients with comorbidities, frailty and disability.

AIMS

To evaluate mortality according to BP values in a cohort of older adults enrolled in the Fiesole Misurata Study, after a 6-year follow-up.

METHODS

Living status as of December 31, 2016 was obtained in 385 subjects participating in the Fiesole Misurata Study. Patients' characteristics were analysed to detect predictors of mortality. At baseline, all participants had undergone office BP measurement and a comprehensive geriatric assessment.

RESULTS

After a 6-year follow-up, 97 participants had died (25.2%). After adjustment for comorbidities and comprehensive geriatric assessment, mortality was significantly lower for SBP 140-159 mmHg as compared with 120-139 mmHg (HR 0.54, 95% CI 0.33-0.89). This result was also confirmed in patients aged 75 + (HR 0.49, 95% CI 0.29-0.85), and in those with disability (HR 0.36, 95% CI 0.15-0.86) or taking antihypertensive medications (HR 0.49, 95% CI 0.28-0.86).

DISCUSSION

An intensive BP control may lead to greater harm than benefit in older adults. Indeed, the European guidelines recommend caution in BP lowering in older patients, especially if functionally compromised, to minimize the risk of hypotension-related adverse events.

CONCLUSIONS

After a 6-year follow-up, mortality risk was lower in participants with SBP 140-159 mmHg as compared with SBP 120-139 mmHg, in the overall population and in the subgroups of subjects aged 75 + , with a disability or taking anti-hypertensive medications.

Low on-treatment diastolic blood pressure and cardiovascular outcome: A post-hoc analysis using NHLBI SPRINT Research Materials

Recent studies including the SPRINT trial have shown beneficial effects of intensive systolic blood pressure reduction over the standard approach. The awareness of the J-curve for diastolic blood pressure (DBP) causes some uncertainty regarding the net clinical effects of blood pressure reduction. The current analysis was performed to investigate effects of low on-treatment DBP on cardiovascular risk in the SPRINT population. The primary composite outcome was the occurrence of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure or death from cardiovascular causes. The prevalence of primary outcomes was significantly higher in subjects within low DBP in both standard (44-67 mmHg [10.8%] vs 67-73 mmHg [6.7%] vs 73-78 mmHg [5.1%] vs 78-83 mmHg [4.4%] vs 83-113 mmHg [4.3%], p < 0.001) and intensive treatment (38-61 mmHg [6.7%] vs 61-66 mmHg [4.1%] vs 66-70 mmHg [4.5%] vs 70-74 mmHg [2.7%] vs 74-113 mmHg [3.4%], p < 0.001) arms. After adjusting for covariates, low DBP showed no significant effects on cardiovascular risk. Therefore, while reaching blood pressure targets, low DBP should not be a matter of concern.

Diastolic Blood Pressure J-Curve Phenomenon in a Tertiary-Care Hypertension Clinic

Supplemental Digital Content is available in the text.

Concerns exist regarding the potential increased cardiovascular risk from lowering diastolic blood pressure (DBP) in hypertensive patients. We analyzed 30-year follow-up data of 10 355 hypertensive patients attending the Glasgow Blood Pressure Clinic. The association between blood pressure during the first 5 years of treatment and cause-specific hospital admissions or mortality was analyzed using multivariable adjusted Cox proportional hazard models. The primary outcome was a composite of cardiovascular admissions and deaths. DBP showed a U-shaped association (nadir, 92 mm Hg) for the primary cardiovascular outcome hazard and a reverse J-shaped association with all-cause mortality (nadir, 86 mm Hg) and noncardiovascular mortality (nadir, 92 mm Hg). The hazard ratio for the primary cardiovascular outcome after adjustment for systolic blood pressure was 1.38 (95% CI, 1.18–1.62) for DBP <80 compared with DBP of 80 to 89.9 mm Hg (referrant), and the subdistribution hazard ratio after accounting for competing risk was 1.33 (1.17–1.51) compared with DBP ≥80 mm Hg. Cause-specific nonfatal outcome analyses showed a reverse J-shaped relationship for myocardial infarction, ischemic heart disease, and heart failure admissions but a U-shaped relationship for stroke admissions. Age-stratified analyses showed DBP had no independent effect on stroke admissions among the older patient subgroup (≥60 years of age), but the younger subgroup showed a clear U-shaped relationship. Intensive blood pressure reduction may lead to unintended consequences of higher healthcare utilization because of increased cardiovascular morbidity, and this merits future prospective studies. Low on-treatment DBP is associated with increased risk of noncardiovascular mortality, the reasons for which are unclear.

Effect of Systolic and Diastolic Blood Pressure on Cardiovascular Outcomes

BACKGROUND

The relationship between outpatient systolic and diastolic blood pressure and cardiovascular outcomes remains unclear and has been complicated by recently revised guidelines with two different thresholds (≥140/90 mm Hg and ≥130/80 mm Hg) for treating hypertension.

METHODS

Using data from 1.3 million adults in a general outpatient population, we performed a multivariable Cox survival analysis to determine the effect of the burden of systolic and diastolic hypertension on a composite outcome of myocardial infarction, ischemic stroke, or hemorrhagic stroke over a period of 8 years. The analysis controlled for demographic characteristics and coexisting conditions.

RESULTS

The burdens of systolic and diastolic hypertension each independently predicted adverse outcomes. In survival models, a continuous burden of systolic hypertension (≥140 mm Hg; hazard ratio per unit increase in z score, 1.18; 95% confidence interval [CI], 1.17 to 1.18) and diastolic hypertension (≥90 mm Hg; hazard ratio per unit increase in z score, 1.06; 95% CI, 1.06 to 1.07) independently predicted the composite outcome. Similar results were observed with the lower threshold of hypertension (≥130/80 mm Hg) and with systolic and diastolic blood pressures used as predictors without hypertension thresholds. A J-curve relation between diastolic blood pressure and outcomes was seen that was explained at least in part by age and other covariates and by a higher effect of systolic hypertension among persons in the lowest quartile of diastolic blood pressure.

CONCLUSIONS

Although systolic blood-pressure elevation had a greater effect on outcomes, both systolic and diastolic hypertension independently influenced the risk of adverse cardiovascular events, regardless of the definition of hypertension (≥140/90 mm Hg or ≥130/80 mm Hg). (Funded by the Kaiser Permanente Northern California Community Benefit Program.).

Achievement of target SBP without attention to decrease in DBP can increase cardiovascular morbidity in treated arterial hypertension: the Campania Salute Network

OBJECTIVES

Results of the SPRINT study have influenced recent guidelines on arterial hypertension, in the identification of target SBP, but scarce attention has been paid to the consequences on DBP. However, there is evidence that reducing DBP too much can be harmful.

METHODS

We analyzed outcome in 4005 treated hypertensive patients (22% obesity, 8% diabetes and 21% current smoking habit) with target attended office SBP less than 140 mmHg, in relation to quintiles of DBP, cardiovascular risk profile and target organ damage (LV hypertrophy, carotid plaque and left atrial dilatation). Composite fatal and nonfatal cardiovascular event was the outcome variable in this analysis (stroke and myocardial infarction, sudden cardiac death, heart failure requiring hospitalization, transient ischemic attack, myocardial revascularization, de novo angina, carotid stenting and atrial fibrillation).

RESULTS

Lower DBP was associated with greater proportion of women and diabetes, older age, decline in kidney function and greater values of LV mass index and left atrial volume and greater prevalence of carotid plaque (all 0.04 < P < 0.0001). The lowest quintile of DBP (74.1 ± 3.7 mmHg) was associated with 1.49 higher hazard of composite cardiovascular events, independently of significant effect of older age, female sex, LV hypertrophy and borderline effect of left atrial dilatation (0.04 < P < 0.001).

CONCLUSION

Increased risk associated with aggressive reduction of DBP should be balanced with the advantage of reducing aggressively SBP to predict the net benefit of antihypertensive treatment, especially in the oldest old individuals.

Long-term clinical outcomes according to the mean observed blood pressure in patients with coronary artery disease after drug-eluting stent implantation

BACKGROUND

A recent guideline emphasized strict blood pressure (BP) control for the patients at high risk for cardiovascular events. However, there are little data about the relationship between BP control and clinical outcome in Korea. We sought to evaluate the clinical outcomes according to the mean observed BP in patients with coronary artery disease (CAD) who had undergone drug-eluting stent (DES) implantation.

METHODS

We reviewed records of 1010 CAD patients with DES from 2010 through 2011. After excluding in-hospital mortality cases (n = 79), we categorized patients into two groups based on the average SBP (SBP) at the outpatient clinic: mean SBP 120 mmHg or less (n = 290) and mean SBP greater than 120 mmHg (n = 641). Primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCEs), defined as cardiac death, myocardial infarction, repeat target vessel revascularization, or stroke. Propensity score matching was performed to adjust for differences in baseline clinical variables. Median follow-up duration was 77.7 (36.6-87.3) months.

RESULTS

The mean SBP greater than 120 mmHg had higher prevalence of cardiovascular risk factors, such as diabetes (38.4 vs. 27.2%, P = 0.001), hypertension (58.8 vs. 32.4%, P < 0.001), and chronic kidney disease (3.3 vs. 1.0%, P = 0.043) than mean SBP 120 mmHg or less. MACCE incidence was significantly lower in the mean SBP 120 mmHg or less than in the mean SBP greater than 120 mmHg (14.3 vs. 22.0%, P = 0.007) at 77.7 months. Even after propensity score matching, the mean SBP 120 mmHg or less showed significantly reduced MACCE rate (14.3 vs. 22.8%, P = 0.007).

CONCLUSION

Mean observed SBP 120 mmHg or less was associated with a lower incidence of future adverse outcomes in CAD patients with DES.

What's new in the ESC 2018 guidelines for arterial hypertension : The ten most important messages

The new guidelines on hypertension of the European Society of Cardiology (ESC) 2018 have refined the treatment cut-offs and therapy decisions in adults. This review highlights important recommendations of the guidelines and also on the situation of hypertension in Austria. The general treatment targets of blood pressure have been lowered to at least 130/80 mmHg for most patients. The definition of hypertension is specified as a repeated systolic blood pressure in the office of ≥140 and or diastolic BP ≥90 mmHg. For home blood pressure monitoring, an average value of ≥135/85 mmHg is now defined as hypertension. Ambulatory 24h-blood pressure measurement is recommended for diagnosis of hypertension and to demask lack of nocturnal blood pressure dipping. Whether drug treatment should be initiated immediately or after a delay with lifestyle intervention is focused on the individual high or low cardiovascular risk of the patients and the degree of hypertension. For most patients a combination therapy with single pill is now recommended as initial therapy for hypertension from the start. The salt consumption should be reduced in the majority of patients. The new guidelines have clarified the treatment of hypertension in different comorbidities.

Low Diastolic Blood Pressure Is Associated With Angina in Patients With Chronic Coronary Artery Disease

BACKGROUND

In patients with coronary artery disease (CAD), low diastolic blood pressure (DBP) is associated with increased risk of myocardial infarction, but its association with angina is unknown.

OBJECTIVES

The goal of this study was to examine the association of low DBP and angina in patients with CAD.

METHODS

The study assessed the frequency of angina (measured by using the Seattle Angina Questionnaire-Angina Frequency score) according to DBP in patients with known CAD from 25 U.S. cardiology clinics. Hierarchical logistic regression was used to test the association between DBP and angina, with a spline term for DBP to assess nonlinearity.

RESULTS

Among 1,259 outpatients with CAD, 411 (33%) reported angina in the prior month, with higher rates in the lowest DBP quartile (40 to 64 mm Hg: 37%). In the unadjusted model, DBP was associated with angina with a J-shaped relationship (p = 0.017, p for nonlinearity = 0.027), with a progressive increase in odds of angina as DBP decreased below ∼70 to 80 mm Hg. This association remained significant after sequential adjustment for demographic characteristics (p = 0.002), comorbidities (p = 0.002), heart rate (p = 0.002), systolic blood pressure (p = 0.046), and antihypertensive antianginal medications (p = 0.045).

CONCLUSIONS

In patients with chronic CAD, there seemed to be an association between lower DBP and increased odds of angina. If validated, these findings suggest that clinicians should consider less aggressive blood pressure control in patients with CAD and angina.

Gender difference in the relationship between uric acid and pulse pressure among Korean adults

Hyperuricemia is associated with cardiovascular disease, but the relationship between uric acid (UA) and pulse pressure (PP) is unclear. Therefore, the present study assesses the relationship between UA and PP among Korean adults. Data from 6,310 subjects (2,800 men and 3,510 women) in the seventh Korean National Health and Nutrition Examination Survey (2016) were analyzed. After adjusting for related variables, the odds ratios (ORs) of hyperuricemia (UA ≥ 7.0 mg/dL in men or ≥ 6.0 mg/dL in women) in the high PP group (PP > 65.0 mmHg) in overall populations (OR, 1.563; 95% confidence interval [CI], 1.144-2.136) and women (OR, 1.631; 95% CI, 1.046-2.544) were significantly higher than those in normal PP, but not in men (OR, 1.309; 95% CI, 0.840-2.040). In conclusion, uric acid was positively associated with pulse pressure in women, but not in men.