Anti-hypertensive medications and cardiovascular events in older adults with multiple chronic conditions

The association between serum folate and elderly diastolic hypertension: results from the NHANES (2007-2018)

AIM

To explore the association between serum folate concentration and the prevalence of elderly diastolic hypertension. This study aims to identify potential relationships that could inform further research into the mechanisms underlying hypertension management.

METHODS

Data from six NHANES cycles (2007-2008, 2009-2010, 2011-2012, 2013-2014, 2015-2016, and 2017-2018) were analysed for individuals aged over 60. Weighted logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup and restricted cubic spline (RCS) regression explored the serum folate concentration and elderly diastolic hypertension relationship.

RESULTS

This study included 9,419 participants (4,734 females and 4,685 males) with a mean age of 70.0 ± 7.0 years. Among them, 360 were diagnosed with diastolic hypertension. In the fully adjusted model, there was a negative correlation between serum folate concentration and the prevalence of diastolic hypertension (OR 0.65; 95% CI: 0.52-0.82). When serum folate concentration levels were divided into quartiles (in μg/dL), the ORs for diastolic hypertension corresponding to Q2 (1.29-1.98), Q3 (1.99-3.08), and Q4 (3.09-5.56) levels compared to Q1 (0.18-1.28) were 1.41 (95% CI: 0.60-3.33), 0.48(95% CI: 0.20-1.16), and 0.35 (95% CI: 0.16-0.74), respectively, with a P for trend <.05. Restricted cubic spline plots showed a negative correlation between serum folate concentration and the prevalence of diastolic hypertension (non-linearity: p = .495). Subgroup analysis indicated that the negative correlation between serum folate concentration and the prevalence of diastolic hypertension was more significant in female participants (interaction p = .009).

CONCLUSION

Higher serum folate concentration is associated with a lower prevalence of diastolic hypertension in the elderly.

An emulated target trial analysis based on Medicare data suggested non-inferiority of Dabigatran versus Rivaroxaban

OBJECTIVES

Rivaroxaban and Dabigatran were the first two non-vitamin K antagonist oral anticoagulants (NOACs) for preventing stroke among non-valvular Atrial Fibrillation patients. This article aimed to evaluate the relative efficacy and safety of Rivaroxaban versus Dabigatran.

STUDY DESIGN AND SETTING

An emulated target trial analysis was conducted based on Medicare, in which we constructed three "randomized clinical trials" with well-defined inclusion/exclusion criteria, treatment regimens, and analysis procedures. We analyzed the individual trials, examined temporal variations, and generated unified results via pooled analysis.

RESULTS

With a two-year data collection window (2012-2013), 70,129 subjects were enrolled in the three emulated trials, with 36,269 and 34,089 in the Rivaroxaban and Dabigatran arms, respectively. Dabigatran (the reference group for hazard ratio - HR) was superior regarding time to any primary event (including ischemic stroke, other thromboembolic events, major bleeding, and death; HR 1.232, P-value 0.0025), major bleeding (HR 1.187, P-value <0.0001), and mortality (HR 1.488, P-value <0.0001). Differences regarding stroke and other thromboembolic events were not significant.

CONCLUSION

Dabigatran was found as superior for the Medicare patients with multiple chronic conditions. Temporal variations, which had been largely neglected in the literature, were observed. This study may provide new insight into treating AF with NOACs.

Treatment of Hypertension in Complex Older Adults: How Many Medications Are Needed?

Background: Many older adults with hypertension receive multiple antihypertensives. It is unclear whether treatment with several antihypertensive classes results in greater cardiovascular benefits than fewer antihypertensive classes. Objectives: We investigated (a) the longitudinal associations between treatment with ≥ 3 versus 1-2 classes and death and major adverse cardiovascular events (MACE) and (b) whether these associations varied by the presence of mobility disability. Methods: We included 6,011 treated hypertensive adults ≥65 from the Medical Expenditure Panel Survey (MEPS), a nationally representative community sample. Times to MACE and death were compared between those receiving ≥3 versus 1-2 classes using multivariable proportional hazards regression. We used inverse probability of treatment weighting to account for indication and contraindication bias. Results: There were no significant differences in the risk of mortality (hazard ratio [HR] = 0.96, p = .769) or MACE (HR = 1.10, p = .574) between the exposure groups, and there were no significant exposure × mobility disability interactions. Discussion: We found no benefit of ≥3 versus 1-2 antihypertensive classes in reducing mortality and cardiovascular events in a representative cohort of older adults, raising concern about the added benefit of additional antihypertensives in the real world.

The new US and European guidelines in hypertension: A multi-dimensional analysis

The Systolic Blood Pressure Intervention Trial (SPRINT) compared the clinical outcomes between target systolic blood pressure (SBP) levels between 140 and 120 mmHg or lower. Both,the 2017 ACC/AHA and the 2018 ESC/ESH guidelines in hypertension are derived from the SPRINT trial and advise initiation and/or intensification of treatment at lower blood pressure thresholds. The ACC/AHA guidance supersedes the 2014 Eight Joint National Committee guideline (JNC-8) which advised initiation of treatment when the BP was 140/90 mmHg or higher; in adults 60 years or over, the target was 150/90 mmHg. Compared to JNC-8, the new guidelines lower the SBP target by 10 mmHg in patients under age of 60 years, and by 20 mmHg in the elderly. We performed a qualitative multi-dimensional analysis in order to answer two key questions: will the new guidelines deliver the stated benefits? and, will translation to the clinic be simple, risk-free, and affordable? A major investment by national healthcare administrations will be necessary for the initiation and support of this program but this decision can only be justified by a valid expectation of clinical benefit. At this time, a definitive answer is not available and a "wait and see" attitude appears appropriate and reasonable. In the interim, efforts are best directed to the immediate problem of untreated hypertension worldwide.

J-shaped curve for cardiovascular mortality: systolic or diastolic blood pressure?

Aggressive reduction of blood pressure (BP) may increase cardiovascular events (the J-curve phenomenon) in certain populations. There is a high number of available studies of antihypertensive treatment that provide strong evidence for J-shaped relationships between both diastolic and systolic BP and main cardiovascular outcomes. Nonetheless, most available studies were observational, and randomized trials might not have or lost their statistical power in post-hoc analysis. Contrariwise, most of prospective trial to demonstrate the benefits of intensive blood pressure control were inconclusive. Therefore, further studies are still necessary in order to clarify this issue.

Comparative effectiveness of antihypertensive drugs in nondiabetic patients with hypertension: A population-based study

The authors compared the effectiveness of thiazide diuretic (TD), angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), and calcium channel blocker (CCB) monotherapies for the treatment of nondiabetic hypertension using MarketScan Databases 2010-2014. Multivariable Cox regression models assessed whether the addition of a new antihypertensive drug, treatment discontinuation, or switch and major cardiovascular or cerebrovascular events varied across groups. A total of 565 009 patients started monotherapy with ACEIs (43.6%), CCBs (23.6%), TDs (18.8%), or ARBs (14.0%). Patients who took TDs had a higher risk for either drug addition or discontinuation than patients who took ACEIs (hazard ratio [HR], 0.69 [95% CI, 0.68-0.70] vs HR, 0.81 [95% CI, 0.80-0.81]), ARBs (HR, 0.67 [95% CI, 0.66-0.68] vs HR, 0.66 [95% CI, 0.65-0.67]), and CCBs (HR, 0.85 [95% CI, 0.84-0.87] vs HR, 0.94 [95% CI, 0.93-0.95]). Conversely, patients who took TDs experienced a lower risk of clinical events compared with patients who took ACEIs (HR, 1.24 [95% CI, 1.15-1.33]), ARBs (HR, 1.28 [95% CI, 1.18-1.39]), and CCBs (HR, 1.35 [95% CI, 1.25-1.46]). Our results provide a strong rationale for choosing TDs as first-line monotherapy for the control of hypertension.

Antihypertensive Medication Adherence and Risk of Cardiovascular Disease Among Older Adults: A Population-Based Cohort Study

BACKGROUND

Antihypertension medication (antihypertensive) adherence lowers risk of cardiovascular disease (CVD); few studies have examined this association among older adults.

METHODS AND RESULTS

We assessed this association among Medicare fee-for-service beneficiaries aged 66 to 79 years who were newly diagnosed with hypertension and initiated on antihypertensives in 2008-2009 (n=155 597). We calculated proportion of days covered (PDC) during follow-up, using proportional subdistribution hazard models, to examine association between antihypertensive adherence and a composite CVD outcomes, including first incident of fatal/nonfatal acute myocardial infarction, ischemic heart disease, stroke/transient ischemic attack, and heart failure. During follow-up (median 5.8 years and 798 621 person-years), we documented 47 198 CVD events. Among beneficiaries, 60.8%, 30.3%, and 8.9% had PDC ≥80%, 40% to 79%, and <40%. Crude incidence of CVD events were 40.1 (95% CI, 40.0-40.1), 93.9 (93.8-93.9), and 98.1 (98.1-98.2) per 1000 person-years for PDC ≥80%, 40% to 79%, and <40%, respectively. Adjusted hazard ratios for CVD events were 1.0 (<40% as reference), 1.0 (0.97-1.03) for 40% to 79%, and 0.44 (0.42-0.45) for ≥80% (P<0.001). Dose-response analysis suggested a nonlinear relationship between PDC and risk for CVD events with a protective effect of ≥80%. The pattern of associations between PDC and ischemic heart disease, stroke/transient ischemic attack, and heart failure were largely consistent as for CVD events and across different groups.

CONCLUSIONS

Antihypertensive adherence was associated with a significantly lower risk of CVD events among older adults. There appeared to be a threshold effect in reducing CVD events at around PDC 80%, above which the risk for CVD reduced substantially.

Non-adherence to antihypertensive medication: The role of mental and physical comorbidity

BACKGROUND

Multiple parameters influence adherence to drug treatment, including socio-economic, healthcare, condition, therapy, and patient-related factors. However, studies of the impact of patient-related factors, particularly regarding comorbid conditions, have produced conflicting results.

OBJECTIVES

To analyse the association between mental and physical comorbidity and non-adherence to antihypertensive medication in patients attending primary care, after including a comprehensive range of chronic comorbidities and potential confounders.

METHODS

Cross-sectional study of 113,397 adults with a diagnosis of hypertension in 2010 assigned to the public health service of a region in northeastern Spain. Pharmacy billing records were linked to data from electronic health records at individual level. Non-adherence was defined as an antihypertensive medication possession ratio (MPR) <80%. Multivariable logistic regression models were used to estimate the odds ratio for non-adherence. Potential predictors included mental and physical comorbidity, age, sex, blood pressure level, nationality, rurality, polypharmacy, and number of visits to the GP and to different specialties.

RESULTS

One fifth of the study population showed poor adherence levels. Female sex, younger age, foreign nationality, living in a rural area, low blood pressure levels, polypharmacy, and mental comorbidity were positively and significantly associated with non-adherence. Conversely, non-adherence was negatively and significantly associated with the presence of cardiovascular risk factors and higher annual rates of GP visits.

CONCLUSION

The majority of patient-related determinants identified here (e.g., the presence of mental comorbidity, polypharmacy, foreign nationality) underscores the need for a patient- rather than a disease-centred care approach, as well as adequate physician-patient communication.

Benefits and risks of antihypertensive medications in the elderly

Hypertension is highly prevalent in older age and accounts for a large proportion of cardiovascular (CV) morbidity and mortality worldwide. Isolated systolic hypertension is more common in the elderly than younger adults and associated with poor outcomes such as cerebrovascular disease and acute coronary events. International guidelines are inconsistent in providing recommendations on optimal blood pressure targets in hypertensive elderly patients as a result of the limited evidence in this population. Evidence from clinical trials supports the use of antihypertensive drugs in hypertensive elderly patients due to benefits in reducing CV disease and mortality. However, elderly participants in these trials may not be typical of elderly patients seen in routine clinical practice, and the potential risks associated with use of antihypertensive drugs in the elderly are not as well studied as younger participants. Therefore, the purpose of this review was to provide a comprehensive summary of the benefits and risks of the use of antihypertensive drugs in elderly patients (aged ≥65 years), highlighting landmark clinical trials and observational studies. We will focus on specific outcomes relating to the benefits and risks of these medications in hypertensive elderly patients, such as CV disease, cognitive decline, dementia, orthostatic hypotension, falls, fractures, cancer and diabetes, in order to provide an update of the most relevant and current evidence to help inform clinical decision-making.

Systematic review of clinical practice guidelines recommendations about primary cardiovascular disease prevention for older adults

BACKGROUND

Clinical care for older adults is complex and represents a growing problem. They are a diverse patient group with varying needs, frequent presence of multiple comorbidities, and are more susceptible to treatment harms. Thus Clinical Practice Guidelines (CPGs) need to carefully consider older adults in order to guide clinicians. We reviewed CPG recommendations for primary cardiovascular disease (CVD) prevention and examined the extent to which CPGs address issues important for older people identified in the literature.

METHODS

We searched: 1) two systematic reviews on CPGs for CVD prevention and 2) the National CPG Clearinghouse, G-I-N International CPG Library and Trip databases for CPGs for CVD prevention, hypertension and cholesterol. We conducted our search between April and December 2013. We excluded CPGs for diabetes, chronic kidney disease, HIV, lifestyle, general screening/prevention, and pregnant or pediatric populations. Three authors independently screened citations for inclusion and extracted data. The primary outcomes were presence and extent of recommendations for older people including discussion of: (1) available evidence, (2) barriers to implementation of the CPG, and (3) tailoring management for this group.

RESULTS

We found 47 eligible CPGs. There was no mention of older people in 4 (9 %) of the CPGs. Benefits were discussed more frequently than harms. Twenty-three CPGs (49 %) discussed evidence about potential benefits and 18 (38 %) discussed potential harms of CVD prevention in older people. Most CPGs addressed one or more barriers to implementation, often as a short statement. Although 27 CPGs (58 %) mentioned tailoring management to the older patient context (e.g. comorbidities), concrete guidance was rare.

CONCLUSION

Although most CVD prevention CPGs mention the older population to some extent, the information provided is vague and very limited. Older adults represent a growing proportion of the population. Guideline developers must ensure they consider older patients' needs and provide appropriate advice to clinicians in order to support high quality care for this group. CPGs should at a minimum address the available evidence about CVD prevention for older people, and acknowledge the importance of patient involvement.

Long-Lasting Reduction of Blood Pressure by Electroacupuncture in Patients with Hypertension: Randomized Controlled Trial

Background: Acupuncture at specific acupoints has experimentally been found to reduce chronically elevated blood pressure. Objective: To examine effectiveness of electroacupuncture (EA) at select acupoints to reduce systolic blood pressure (SBP) and diastolic blood pressures (DBP) in hypertensive patients. Design: Two-arm parallel study. Patients: Sixty-five hypertensive patients not receiving medication were assigned randomly to one of the two acupuncture intervention (33 versus 32 patients). Intervention: Patients were assessed with 24-hour ambulatory blood pressure monitoring. They were treated with 30-minutes of EA at PC 5-6+ST 36-37 or LI 6-7+GB 37-39 once weekly for 8 weeks. Four acupuncturists provided single-blinded treatment. Main outcome measures: Primary outcomes measuring effectiveness of EA were peak and average SBP and DBP. Secondary outcomes examined underlying mechanisms of acupuncture with plasma norepinephrine, renin, and aldosterone before and after 8 weeks of treatment. Outcomes were obtained by double-blinded evaluation. Results: After 8 weeks, 33 patients treated with EA at PC 5-6+ST 36-37 had decreased peak and average SBP and DBP, compared with 32 patients treated with EA at LI 6-7+GB 37-39 control acupoints. Changes in blood pressures significantly differed between the two patient groups. In 14 patients, a long-lasting blood pressure-lowering acupuncture effect was observed for an additional 4 weeks of EA at PC 5-6+ST 36-37. After treatment, the plasma concentration of norepinephrine, which was initially elevated, was decreased by 41%; likewise, renin was decreased by 67% and aldosterone by 22%. Conclusions: EA at select acupoints reduces blood pressure. Sympathetic and renin-aldosterone systems were likely related to the long-lasting EA actions.

Carotid atherosclerosis and cardiovascular health metrics in old subjects from the AGES-Reykjavik study

BACKGROUND

Ideal cardiovascular (CV) health by simultaneous presence of 7 ideal health metrics (blood pressure, cholesterol, glucose, smoking, BMI, physical activity and diet) has been defined by the American Heart Association. In the current study we investigated the association of a CV health score (range 0-14), on the extent and progression of carotid atherosclerosis, assessed as carotid intima-media thickness (cIMT) and total plaque area (TPA) by ultrasound at 5 years interval.

METHODS AND RESULTS

A total of 219 participants (age 75.6 ± 5.1) from the Age, Gene/Environment Susceptibility (AGES)-Reykjavik study were studied. Men with poor (low) CV health score had greater TPA than those with more optimal (high) score (61.5 (SD: 32.3), 44.4 (24.2) and 37.7 (23.2) mm(2) for those with CV health score ≤6, 7-9 and ≥10 respectively, p < 0.05). In linear analysis for men, log TPA was 0.088 mm(2) (SE: 0.040 p < 0.05) smaller for each additional point in the CV health score. CV health score was not associated with TPA in women, or cIMT in either sex. TPA increased in both sexes between visits. However, CV health score did not predict carotid atherosclerosis progression.

CONCLUSIONS

CV health score is associated with TPA in older men but not in women. Men with poor CV health score at the baseline visit had more extensive carotid atherosclerosis than those with better CV health score, although it did not predict the progression of carotid atherosclerosis.