Treatment of hypertension in the elderly: effects on blood pressure, heart rate, and physical fitness

Prevalence of Metabolic Syndrome According to Absolute and Relative Values of Muscle Strength in Middle-Aged and Elderly Women

Metabolic syndrome (MetS) increases with age, obesity, low physical activity, and decreased muscle strength. Although many studies have reported on grip strength and MetS, few studies have been conducted on leg strength. The purpose of this study was to analyze the prevalence of MetS according to absolute and relative leg strength values in middle-aged and older women. The participants were 1053 women who visited the healthcare center: middle-aged (n = 453) and older (n = 601). MetS was diagnosed using the criteria established by the third report of the National Cholesterol Education Program Adult Treatment Panel III and the World Health Organization's Asia Pacific guidelines for waist circumference. For leg strength, knee flexion and extension were performed using isokinetic equipment. Grip strength was measured using a grip dynamometer and classified into quartiles. Analysis of prevalence using logistic regression showed that MetS was present in 21.2% of middle-aged and 39.4% of older women. The lowest relative leg extension increased 2.5 times in the middle-aged and 1.5 times in older women (p < 0.05). However, leg flexion did not have a significant prevalence in either age group. The prevalence of MetS in middle-aged and older women with the lowest relative grip strength increased 1.5 and 1.2 times, respectively. Conversely, the lower the absolute leg extension strength, the lower the MetS prevalence was at 0.520 in middle-aged and 0.566 in older women (p < 0.05). In conclusion, the prevalence of MetS increased in women with low relative grip and leg strengths. Specifically, the lower the relative leg extension muscle strength, the higher the prevalence of MetS. In addition, the prevalence of MetS increased in the high-frequency alcohol consumption and non-physical activity group.

Effect of Angiotensin System Inhibitors on Physical Performance in Older People - A Systematic Review and Meta-Analysis

Objective

Preclinical and observational data suggest that angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) may be able to improve physical performance in older people via direct and indirect effects on skeletal muscle. We aimed to summarize current evidence from randomised controlled trials in this area.

Design

Systematic review and meta-analysis.

Setting and Participants

Randomized controlled trials enrolling older people, comparing ACEi or ARB to placebo, usual care or another antihypertensive agent, with outcome data on measures of physical performance.

Methods

We searched multiple electronic databases without language restriction between inception and the end of February 2020. Trials were excluded if the mean age of participants was <65 years or treatment was targeting specific diseases known to affect muscle function (for example heart failure). Data were sought on measures of endurance and strength. Standardized mean difference (SMD) treatment effects were calculated using random-effects models with RevMan software.

Results

Eight trials (952 participants) were included. Six trials tested ACEi, 2 trials tested ARBs. The mean age of participants ranged from 66 to 79 years, and the duration of treatment ranged from 2 months to 1 year. Trials recruited healthy older people and people with functional impairment; no trials specifically targeted older people with sarcopenia. Risk of bias for all trials was low to moderate. No significant effect was seen on endurance outcomes [6 trials, SMD 0.04 (95% CI –0.22 to 0.29); P = .77; I² = 53%], strength outcomes [6 trials, SMD –0.02 (95% CI –0.18 to 0.14), P = .83, I² = 21%] or the short physical performance battery [3 trials, SMD –0.04 (95% CI –0.19 to 0.11), P = .60, I² = 0%]. No evidence of publication bias was evident on inspection of funnel plots.

Conclusions and Implications

Existing evidence does not support the use of ACE inhibitors or angiotensin receptor blockers as a single intervention to improve physical performance in older people.

Do ACE inhibitors improve the response to exercise training in functionally impaired older adults? A randomized controlled trial

Background.

Loss of muscle mass and strength with ageing is a major cause for falls, disability, and morbidity in older people. Previous studies have found that angiotensin-converting enzyme inhibitors (ACEi) may improve physical function in older people. It is unclear whether ACEi provide additional benefit when added to a standard exercise training program. We examined the effects of ACEi therapy on physical function in older people undergoing exercise training.

Methods.

Community-dwelling people aged ≥65 years with functional impairment were recruited through general (family) practices. All participants received progressive exercise training. Participants were randomized to receive either 4 mg perindopril or matching placebo daily for 20 weeks. The primary outcome was between-group change in 6-minute walk distance from baseline to 20 weeks. Secondary outcomes included changes in Short Physical Performance Battery, handgrip and quadriceps strength, self-reported quality of life using the EQ-5D, and functional impairment measured using the Functional Limitations Profile.

Results.

A total of 170 participants (n = 86 perindopril, n = 84 placebo) were randomized. Mean age was 75.7 (standard deviation [SD] 6.8) years. Baseline 6-minute walk distance was 306 m (SD 99). Both groups increased their walk distance (by 29.6 m perindopril, 36.4 m placebo group) at 20 weeks, but there was no statistically significant treatment effect between groups (−8.6m [95% confidence interval: −30.1, 12.9], p = .43). No statistically significant treatment effects were observed between groups for the secondary outcomes. Adverse events leading to withdrawal were few (n = 0 perindopril, n = 4 placebo).

Interpretation.

ACE inhibitors did not enhance the effect of exercise training on physical function in functionally impaired older people.

Novel intriguing strategies attenuating to sarcopenia

Sarcopenia, the age-related loss of skeletal muscle mass, is characterized by a deterioration of muscle quantity and quality leading to a gradual slowing of movement, a decline in strength and power, increased risk of fall-related injury, and, often, frailty. Since sarcopenia is largely attributed to various molecular mediators affecting fiber size, mitochondrial homeostasis, and apoptosis, the mechanisms responsible for these deleterious changes present numerous therapeutic targets for drug discovery. Resistance training combined with amino acid-containing supplements is often utilized to prevent age-related muscle wasting and weakness. In this review, we summarize more recent therapeutic strategies (myostatin or proteasome inhibition, supplementation with eicosapentaenoic acid (EPA) or ursolic acid, etc.) for counteracting sarcopenia. Myostatin inhibitor is the most advanced research with a Phase I/II trial in muscular dystrophy but does not try the possibility for attenuating sarcopenia. EPA and ursolic acid seem to be effective as therapeutic agents, because they attenuate the degenerative symptoms of muscular dystrophy and cachexic muscle. The activation of peroxisome proliferator-activated receptor γ coactivator 1α (PGC-1α) in skeletal muscle by exercise and/or unknown supplementation would be an intriguing approach to attenuating sarcopenia. In contrast, muscle loss with age may not be influenced positively by treatment with a proteasome inhibitor or antioxidant.

Angiotensin-converting enzyme inhibitor and statin use and incident mobility limitation in community-dwelling older adults: the Health, Aging and Body Composition study

OBJECTIVES

To evaluate whether the use of angiotensin-converting enzyme (ACE) inhibitors and statins is associated with a lower risk of incident mobility limitation in older community dwelling adults.

DESIGN

Longitudinal cohort study.

SETTING

Health, Aging and Body Composition (Health ABC) study.

PARTICIPANTS

Three thousand fifty-five participants who were well functioning at baseline (no mobility limitations).

MEASUREMENTS

Summated standardized daily doses (low, medium, high) and duration of ACE inhibitor and statin use were computed. Mobility limitation (two consecutive self-reports of having any difficulty walking one-quarter of a mile or climbing 10 steps without resting) was assessed every 6 months after baseline. Multivariable Cox proportional hazards analyses were conducted, adjusting for demographics, health status, and health behaviors.

RESULTS

At baseline, 15.2% used ACE inhibitors and 12.9% used statins; use of both was greater than 25% by Year 6. Over 6.5 years of follow-up, 49.8% had developed mobility limitation. In separate multivariable models, neither ACE inhibitor (multivariate hazard ratio (HR) = 0.95, 95% confidence interval (CI) = 0.82-1.09) nor statin use (multivariate HR = 1.02, 95% CI = 0.87-1.17) was associated with lower risk of mobility limitation. Similar findings were seen in analyses examining dose-response and duration-response relationships and a sensitivity analysis restricted to those with hypertension.

CONCLUSION

ACE inhibitors and statins widely prescribed to treat hypertension and hypercholesterolemia, respectively, do not lower risk of mobility limitation, an important indicator of quality of life.

Cardiorespiratory fitness and quality-of-life analysis posttreatment in breast cancer survivors

This study compared VO(2peak), treatment frequency and dosage, and QOL between 22 post-treated breast cancer survivors (CATotal) and 22 apparently healthy, age-matched women (CO). The CATotal group included 11 with no history of any other co-morbidities (CA) and 11 with controlled hypertension (CA + H). VO(2peak) was measured using the Bruce Protocol. QOL was measured using the SF-36 survey. Significant differences were observed in VO(2peak) between CATotal and CO (p = 0.014), CA and CA + H (p = 0.001), and CA + H and CO (p = 0.001). Physical, emotional, and mental health domains of the SF-36 were significantly different between CATotal and CO (p = 0.006, 0.001, and 0.05 respectively). These results suggest that breast cancer survivors with controlled hypertension can experience a significant reduction in VO(2peak) when compared to apparently healthy, age-matched controls. Also, treatment frequency and dosage affected QOL in this group of survivors.

Optimal management of sarcopenia

Sarcopenia is the progressive generalized loss of skeletal muscle mass, strength, and function which occurs as a consequence of aging. With a growing older population, there has been great interest in developing approaches to counteract the effects of sarcopenia, and thereby reduce the age-related decline and disability. This paper reviews (1) the mechanisms of sarcopenia, (2) the diagnosis of sarcopenia, and (3) the potential interventions for sarcopenia. Multiple factors appear to be involved in the development of sarcopenia including the loss of muscle mass and muscle fibers, increased inflammation, altered hormonal levels, poor nutritional status, and altered renin-angiotensin system. The lack of diagnostic criteria to identify patients with sarcopenia hinders potential management options. To date, pharmacological interventions have shown limited efficacy in counteracting the effects of sarcopenia. Recent evidence has shown benefits with angiotensin-converting enzyme inhibitors; however, further randomized controlled trials are required. Resistance training remains the most effective intervention for sarcopenia; however, older people maybe unable or unwilling to embark on strenuous exercise training programs.

Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension

BACKGROUND

ACE inhibitors are widely prescribed for hypertension so it is essential to determine and compare their effects on blood pressure (BP), heart rate and withdrawals due to adverse effects (WDAE).

OBJECTIVES

To quantify the dose-related systolic and/or diastolic BP lowering efficacy of ACE inhibitors versus placebo in the treatment of primary hypertension.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to February 2007), EMBASE (1988 to February 2007) and reference lists of articles.

SELECTION CRITERIA

Double-blind, randomized, controlled trials evaluating the BP lowering efficacy of fixed-dose monotherapy with an ACE inhibitor compared with placebo for a duration of 3 to 12 weeks in patients with primary hypertension.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias and extracted data. Study authors were contacted for additional information. WDAE information was collected from the trials.

MAIN RESULTS

Ninety two trials evaluated the dose-related trough BP lowering efficacy of 14 different ACE inhibitors in 12 954 participants with a baseline BP of 157/101 mm Hg. The data do not suggest that any one ACE inhibitor is better or worse at lowering BP. A dose of 1/8 or 1/4 of the manufacturer's maximum recommended daily dose (Max) achieved a BP lowering effect that was 60 to 70% of the BP lowering effect of Max. A dose of 1/2 Max achieved a BP lowering effect that was 90% of Max. ACE inhibitor doses above Max did not significantly lower BP more than Max. Combining the effects of 1/2 Max and higher doses gives an estimate of the average trough BP lowering efficacy for ACE inhibitors as a class of drugs of -8 mm Hg for SBP and -5 mm Hg for DBP. ACE inhibitors reduced BP measured 1 to 12 hours after the dose by about 11/6 mm Hg.

AUTHORS' CONCLUSIONS

There are no clinically meaningful BP lowering differences between different ACE inhibitors. The BP lowering effect of ACE inhibitors is modest; the magnitude of trough BP lowering at one-half the manufacturers' maximum recommended dose and above is -8/-5 mm Hg. Furthermore, 60 to 70% of this trough BP lowering effect occurs with recommended starting doses. The review did not provide a good estimate of the incidence of harms associated with ACE inhibitors because of the short duration of the trials and the lack of reporting of adverse effects in many of the trials.