Antihypertensive Agents in Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Utilizing genetics and proteomics to assess the role of antihypertensive drugs in human longevity and the underlying pathways: a Mendelian randomization study

BACKGROUND

Antihypertensive drugs are known to lower cardiovascular mortality, but the role of different types of antihypertensive drugs in lifespan has not been clarified. Moreover, the underlying mechanisms remain unclear.

METHODS AND RESULTS

To minimize confounding, we used Mendelian randomization to assess the role of different antihypertensive drug classes in longevity and examined the pathways via proteins. Genetic variants associated with systolic blood pressure (SBP) corresponding to drug-target genes were used as genetic instruments. The genetic associations with lifespan were obtained from a large genome-wide association study including 1 million European participants from UK Biobank and LifeGen. For significant antihypertensive drug classes, we performed sex-specific analysis, drug-target analysis, and colocalization. To examine the mediation pathways, we assessed the associations of 2291 plasma proteins with lifespan, and examined the associations of drug classes with the proteins affecting lifespan. After correcting for multiple testing, genetically proxied beta-blockers (BBs), calcium channel blockers (CCBs), and vasodilators were related to longer life years (BBs: 2.03, 95% CI 0.78-3.28 per 5 mmHg reduction in SBP, CCBs: 3.40, 95% CI 1.47-5.33, and vasodilators: 2.92, 95% CI 1.08-4.77). The beneficial effects of BBs and CCBs were more obvious in men. ADRB1, CACNA2D2, CACNB3, CPT1A, CPT2, and EDNRA genes were related to extended lifespan, with CPT2 further supported by colocalization evidence. Eighty-six proteins were related to lifespan, of which four proteins were affected by CCBs. CDH1 may mediate the association between CCBs and lifespan.

CONCLUSIONS

Beta-blockers, CCBs, and vasodilators may prolong lifespan, with potential sex differences for BBs and CCBs. The role of CCBs in lifespan is partly mediated by CDH1. Prioritizing the potential protein targets can provide new insights into healthy aging.

Update of the clinical guideline for hypertension diagnosis and treatment in Iran

BACKGROUND

This article introduces the updated version of the Iranian guideline for the diagnosis and treatment of hypertension in adults. The initial version of the national guideline was developed in 2011 and updated in 2014. Among the reasons necessitating the update of this guideline were the passage of time, the incompleteness of the scopes, the limitation of the target group, and more important is the request of the ministry of health in Iran.

METHOD

The members of the guideline updating group, after reviewing the original version and the new evidence, prepared 10 clinical questions regarding hypertension, and based on the evidence found from the latest scientific documents, provided recommendations or suggestions to answer these questions.

RESULT

According to the updated guideline, the threshold for office prehypertension diagnosis should be considered the systolic blood pressure (SBP) of 130-139 mmHg and/or the diastolic blood pressure (DBP) of 80-89 mmHg, and in adults under 75 years of age without comorbidities, the threshold for office hypertension diagnosis should be SBP ≥ 140 mmHg and or DBP ≥ 90 mmHg. The goal of treatment in adults who lack comorbidities and risk factors is SBP < 140 mmHg and DBP < 90 mmHg. The first-line treatment recommended in people with prehypertension is lifestyle modification, while for those with hypertension, pharmacotherapy along with lifestyle modification. The threshold to start drug therapy is determined at SBP ≥ 140 mmHg and or DBP ≥ 90 mmHg, and the first-line treatment is considered a drug or a combined pill of antihypertensive drugs, including ACEIs, ARBs, thiazide and thiazide-like agents, or CCBs. At the beginning of the pharmacotherapy, the Guideline Updating Group members suggested studying serum electrolytes, creatinine, lipid profile, fasting sugar, urinalysis, and an electrocardiogram. Regarding the visit intervals, monthly visits are suggested at the beginning of the treatment or in case of any change in the type or dosage of the drug until achieving the treatment goal, followed by every 3-to-6-month visits. Moreover, to reduce further complications, it was suggested that healthcare unit employees use telehealth strategies.

CONCLUSIONS

In this guideline, specific recommendations and suggestions have been presented for adults and subgroups like older people or those with cardiovascular disease, diabetes mellitus, chronic kidney disease, and COVID-19.

Generalisability and potential deaths averted from intensive blood pressure treatment among the elderly population in the US and China: A nationally representative cross-sectional study

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) from the US and the Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial from China have consistently demonstrated clinical benefits from intensive blood pressure (BP) treatment among elderly adults with hypertension. However, we have little data on the generalisability and potential implications of a scale-up of intensive BP treatment to all eligible elderly in the US and China.

Methods

We used two nationally representative data sets from China (Health and Retirement Longitudinal Study (CHALRS), 2011-2012) and the US (National Health and Nutrition Examination Survey (NHANES), 2007-2012) and linked them with CHARLS follow-up data (2013) and the National Death Index (1999-2015), respectively. We estimated the percentage, number, and characteristics of elderly (≥60 years old) meeting the STEP and SPRINT eligibility criteria, and deaths that would be prevented or postponed with the implementation of intensive BP treatment.

Results

Among the Chinese adults aged 60 years and over, 38.89% (95% confidence interval (CI) = 36.97-40.84) or 85.39 (95% CI = 81.14-89.64) million subjects met the STEP criteria, and 40.90 million (47.90%) adults were not taking antihypertensive medications. In the US, 23.77% (95% CI = 22.32%-25.28) or 12.46 (95% CI = 11.68-13.24) million elderly were eligible for the SPRINT, and 5.78 million (46.36%) were untreated. Overall, 0.07 (95% CI = 0.06-0.08) million deaths in the US and 0.31 (95% CI = 0.25-0.39) in China would be averted annually if intensive BP treatment was implemented, while 120 000 and 680 000 of hypotension cases would be identified yearly inthe US and China, respectively.

Conclusions

A substantial percentage of Chinese and the US elderly meet the eligibility criteria for STEP and SPRINT. If intensive BP treatment was adopted, 70 000 and 310 000 deaths would be prevented or postponed yearly in the US and China, respectively.

Comparison between the world health organization (WHO) and international society of hypertension (ISH) guidelines for hypertension

The global burden of hypertension remains an unsolved problem, especially in low- and middle-income countries (LMICs). For this reason, clinical practice guidelines containing the latest evidence-based recommendations are crucial in the management of hypertension. It is noteworthy that guidelines simply translated from those of high-income countries (HICs) are not the solution to the problem of hypertension in LMICs. Among the numerous guidelines available, those of the World Health Organisation and the International Society of Hypertension are the latest to be published as of the writing of this article. In this review, we conducted both general and specific comparisons between the recommendations supplied by both guidelines. Differences in aspects of hypertension management such as the timing of antihypertensive initiation, assessment of comorbidities and cardiovascular risk factors, pharmacological therapy selection, and blood pressure target and reassessment are explored. Lastly, the implications of the differences found between the two guidelines in both LMICs and HICs are discussed.Key messagesCurrently, with low treatment and control rates, hypertension remains a burden in low- and middle-income countries (LMICs).The lack of customised guidelines for LMICs cannot be solved simply by adopting guidelines from high-income countries.The World Health Organisation (WHO) recently published a clinical guideline for the pharmacological management of hypertension in LMICs. We compare select recommendations from the guidelines to those published by the International Society of Hypertension.

[Effect of modification of antihypertensive medications on the association of nitrogen dioxide long-term exposure and chronic kidney disease]

OBJECTIVE

To investigate the potential effect of modification of antihypertensive medications on the association of nitrogen dioxide (NO₂) long-term exposure and chronic kidney disease (CKD).

METHODS

Data of the national representative sample of adult population from the China National Survey of Chronic Kidney Disease (2007-2010) were included in the analyses, and exposure data of NO₂ were collected and matched. Generalized mixed-effects models were used to analyze the associations between NO₂ and CKD, stratified by the presence of hypertension and taking antihypertensive medications. The stratified exposure-response curves of NO₂ and CKD were fitted using the natural spine smoothing function. The modifying effects of antihypertensive medications on the association and the exposure-response curve of NO₂ and CKD were analyzed.

RESULTS

Data of 45 136 participants were included, with an average age of (49.5±15.3) years. The annual average exposure concentration of NO₂ was (7.2±6.4) μg/m³. Altogether 6 517 (14.4%) participants were taking antihypertensive medications, and 4 833 (10.7%) participants were identified as having CKD. After adjustment for potential confounders, in the hypertension population not using antihypertensive medications, long-term exposure to NO₂ was associated with a significant increase risk of CKD (OR: 1.38, 95%CI: 1.24-1.54, P < 0.001); while in the hypertension population using antihypertensive medications, no significant association between long-term exposure to NO₂ and CKD (OR: 0.96, 95%CI: 0.86-1.07, P=0.431) was observed. The exposure-response curve of NO₂ and CKD suggested that there was a non-linear trend in the association between NO₂ and CKD. The antihypertension medications showed significant modifying effects both on the association and the exposure-response curve of NO₂ and CKD (interaction P < 0.001).

CONCLUSION

The association between long-term exposure to NO₂ and CKD was modified by antihypertensive medications. Taking antihypertensive medications may mitigate the effect of long-term exposure to NO₂ on CKD.

Time to Clinical Benefit of Intensive Blood Pressure Lowering in Patients 60 Years and Older With Hypertension: A Secondary Analysis of Randomized Clinical Trials

Importance

Recent guidelines recommend a systolic blood pressure (BP) goal of less than 150 mm Hg or even 130 mm Hg for adults aged 60 years or older. However, harms from intensive BP treatments occur immediately (eg, syncope, fall), and benefits for cardiovascular event reduction emerge over time. Therefore, harms with low chance of benefit need to be clearer, particularly for those with limited life expectancy.

Objective

To estimate the time needed to potentially derive clinical benefit from intensive BP treatment in patients 60 years and older.

Design, Setting, and Participants

This secondary analysis included individual patient data from published randomized clinical trials with 27 414 patients 60 years or older with hypertension. Patient-level survival data were reconstructed when the original data were not available. Published trials were identified by searching PubMed until October 15, 2021.

Exposures

Intensive BP lowering vs standard BP lowering with the treat-to-target design.

Main Outcomes and Measures

Major adverse cardiovascular event (MACE) defined by each trial, which was broadly similar with all trials including myocardial infarction, stroke, and cardiovascular mortality.

Results

Six trials (original data from 2 trials and reconstructed data from 4 trials) with 27 414 participants (mean age, 70 years; 56.3% were women) were included in the analysis. Intensive BP treatment with a systolic BP target below 140 mm Hg was significantly associated with a 21% reduction in MACE (hazard ratio, 0.79; 95% CI, 0.71-0.88; P < .001). On average, 9.1 (95% CI, 4.0-20.6) months were needed to prevent 1 MACE per 500 patients with the intensive BP treatment (absolute risk reduction [ARR], 0.002). Likewise, 19.1 (95% CI, 10.9-34.2) and 34.4 (95% CI, 22.7-59.8) months were estimated to avoid 1 MACE per 200 (ARR, 0.005) and 100 (ARR, 0.01) patients, respectively.

Conclusions and Relevance

In this analysis, findings suggest that for patients 60 years and older with hypertension, intensive BP treatment may be appropriate for some adults with a life expectancy of greater than 3 years but may not be suitable for those with less than 1 year.

Do we AGREE on the targets of antihypertensive drug treatment in older adults: a systematic review of guidelines on primary prevention of cardiovascular diseases

Background

translation of the available evidence concerning primary cardiovascular prevention into clinical guidance for the heterogeneous population of older adults is challenging. With this review, we aimed to give an overview of the thresholds and targets of antihypertensive drug therapy for older adults in currently used guidelines on primary cardiovascular prevention. Secondly, we evaluated the relationship between the advised targets and guideline characteristics, including guideline quality.

Methods

we systematically searched PubMed, Embase, Emcare and five guideline databases. We selected guidelines with (i) numerical thresholds for the initiation or target values of antihypertensive drug therapy in context of primary prevention (January 2008–July 2020) and (ii) specific advice concerning antihypertensive drug therapy in older adults. We extracted the recommendations and appraised the quality of included guidelines with the AGREE II instrument.

Results

thirty-four guidelines provided recommendations concerning antihypertensive drug therapy in older adults. Twenty advised a higher target of systolic blood pressure (SBP) for octogenarians in comparison with the general population and three advised a lower target. Over half of the guidelines (n = 18) recommended to target a SBP <150 mmHg in the oldest old, while four endorsed targets of SBP lower than 130 or 120 mmHg. Although many guidelines acknowledged frailty, only three gave specific thresholds and targets. Guideline characteristics, including methodological quality, were not related with the recommended targets.

Conclusion

the ongoing debate concerning targets of antihypertensive treatment in older adults, is reflected in an inconsistency of recommendations across guidelines. Recommended targets are largely set on chronological rather than biological age.

Classical risk factors for primary coronary artery disease from an aging perspective through Mendelian Randomization

The significance of classical risk factors in coronary artery disease (CAD) remains unclear in older age due to possible changes in underlying disease pathologies. Therefore, we conducted Mendelian Randomization approaches to investigate the causal relationship between classical risk factors and primary CAD in different age groups. A Mendelian Randomization study was conducted in European-ethnicity individuals from the UK Biobank population. Analyses were performed using data of 22,313 CAD cases (71.6% men) and 407,920 controls (44.5% men). Using logistic regression analyses, we investigated the associations between standardized genetic risk score and primary CAD stratified by age of diagnosis. In addition, feature importance and model accuracy were assessed in different age groups to evaluate predictive power of the genetic risk scores with increasing age. We found age-dependent associations for all classical CAD risk factors. Notably, body mass index (OR 1.22 diagnosis < 50 years; OR 1.02 diagnosis > 70 years), blood pressure (OR 1.12 < 50 years; OR 1.04 > 70 years), LDL cholesterol (OR 1.16 < 50 years; OR 1.02 > 70 years), and triglyceride levels (OR 1.11 < 50 years; 1.04 > 70 years). In line with the Mendelian Randomization analyses, model accuracy and feature importance of the classical risk factors decreased with increasing age of diagnosis. Causal determinants for primary CAD are age dependent with classical CAD risk factors attenuating in relation with primary CAD with increasing age. These results question the need for (some) currently applied cardiovascular disease risk reducing interventions at older age.

Targeting TMEM16A-encoded Ca2+-activated Cl- channels: a new paradigm for antihypertensive therapy?

Hypertension is the leading risk factor for the development of heart diseases and stroke. Many hypertensive patients experience undesirable side effects to conventional antihypertensive pharmacotherapy. Cil et al. documented the antihypertensive profile of a novel molecule, TM_inh-23 (2-bromodifluoroacetylamino-5,6,7,8-tetrahydro-4H-cyclohepta[b]thiophene-3-carboxylic acid o-tolylamide), in the spontaneously hypertensive rat model of systemic hypertension. They showed that this agent reduces blood pressure by inhibiting transmembrane member 16A-encoded calcium-activated chloride channels in vascular myocytes from resistance arteries. If validated, TM_inh-23 could become a useful clinical tool.

Use of advanced statistical techniques to predict all-cause mortality in the Systolic Blood Pressure Intervention Trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) was conducted in patients with hypertension and additional risk for cardiovascular disease who were randomized to the intensive blood pressure group targeting systolic blood pressure (SBP) less than 120 mm Hg and to the standard group where the target was less than 140 mm Hg. Analyses were done in the matched group of participants with the same gender, same age (±2 years) and same SBP (±3 mm Hg) at three months of treatment regardless of initial randomization to intensive or standard group (shaded area in Figure 1).

Methods and results

During 3.26 years of follow-up, intensive group participants had 14.8 mm Hg lower SBP and received on average one more (2.8 vs. 1.8) blood pressure lowering medications. This was associated with lower all-cause mortality in the intensive treatment group (hazard ratio, 0.73; 95% CI, 0.60 to 0.90, p = 0.003). The effect on SBP was achieved at 3 months and remained unchanged thereafter. This paper addresses two questions with respect to all-cause mortality in SPRINT in the matched set. 1) What is the effect of receiving more than one drug on all-cause mortality. Conditional logistic regression for all-cause mortality with respect to number of drugs indicated that during the 3.26 years of follow-up persons who received more than one drug were more likely to die (coefficient = 0.5039, OR = 1.6552, p = 0.0322) than patients who received one drug. 2) Was there a U curve relationship between on treatment SBP and all-cause mortality? A U curve fitting a quadratic equation (parabola) of SBP and all-cause death was observed. This was seen in the patients randomized to the standard target group in unadjusted analyses as well as in analyses adjusted for demographics or all covariates (p < 0.001 for all). The U curves in the combined group and the intensive treatment group were less pronounced.

Conclusion

SPRINT participants who were matched for gender, age, and SBP at 3 months, and received more than one drug had higher all-cause mortality during the 3.26 years of follow-up. Those who were randomized to standard treatment target had a U curve relationship between SBP at three months and all-cause mortality. The U curves in the combined group and the intensive treatment group were less pronounced.

Antihypertensive Agents in Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND

This systematic review summarizes the benefits of treating blood pressure (BP) in individuals 65 years and older.

METHODS

We included randomized trials that evaluated BP-lowering medications or BP targets in individuals 65 years and older. Trials were selected and appraised by pairs of independent reviewers.

RESULTS

We included 19 trials (42,134 patients). In individuals 65 years or older, antihypertensive therapy was associated with a reduction in all-cause mortality [relative risk: 0.88 (95% CI: 0.81 to 0.94); high certainty evidence; mean follow-up 31 months], cardiovascular mortality, myocardial infarction, heart failure, stroke, and chronic kidney disease. Individuals 75 years or older had a significant reduction in the risk of all-cause and cardiovascular mortality, stroke, and heart failure. Strict systolic BP targets (<120 mm Hg and <130 mm Hg) were associated with a significant reduction in the risk of all-cause and cardiovascular mortality and heart failure, whereas more liberal systolic targets (<150 mm Hg and <160 mm Hg) were associated with lower risk of heart failure and stroke. Older adults with type 2 diabetes mellitus (DM) had lower risk of chronic kidney disease without a significant reduction in other outcomes. However, there was no significant difference in estimates (i.e., interaction) between those with and without DM.

CONCLUSIONS

Individuals aged 65 years and older or 75 years and older who receive antihypertensive therapy have statistically significant reduction in the risk of all-cause and cardiovascular mortality, heart failure, and stroke. There was no statistically significant difference in estimates between those with and without DM.