A likely explanation for the J-curve of blood pressure cardiovascular risk

Blood pressure during long-term cilostazol-based dual antiplatelet therapy after stroke: a post hoc analysis of the CSPS.com trial

We determined the associations of follow-up blood pressure (BP) after stroke as a time-dependent covariate with the risk of subsequent ischemic stroke, as well as those of BP levels with the difference in the impact of long-term clopidogrel or aspirin monotherapy versus additional cilostazol medication on secondary stroke prevention. In a sub-analysis of a randomized controlled trial (CSPS.com), patients between 8 and 180 days after stroke onset were randomly assigned to receive aspirin or clopidogrel alone, or a combination of cilostazol with aspirin or clopidogrel. The percent changes, differences, and raw values of follow-up BP were examined. The primary efficacy outcome was the first recurrence of ischemic stroke. In a total of 1657 patients (69.5 ± 9.3 years, female 29.1%) with median 1.5-year follow-up, ischemic stroke recurred in 74 patients. The adjusted hazard ratio for ischemic stroke of a 10% systolic BP (SBP) increase from baseline was 1.19 (95% CI 1.03-1.36), that of a 10 mmHg SBP increase was 1.14 (1.03-1.28), and that of SBP as the raw value with the baseline SBP as a fixed (time-independent) covariate was 1.14 (1.00-1.31). Such significant associations were not observed in diastolic BP-derived variables. The estimated adjusted hazard ratio curves for the outcome showed the benefit of dual therapy over a wide SBP range between ≈120 and ≈165 mmHg uniformly. Lower long-term SBP levels after ischemic stroke were associated with a lower risk of subsequent ischemic events. The efficacy of dual antiplatelet therapy including cilostazol for secondary stroke prevention was evident over a wide SBP range.

Blood Pressure and Cardiovascular Risk in Women With Breast Cancer: The Pathways Heart Study

Background

Hypertension is an important contributor to cardiovascular disease (CVD) in breast cancer (BC) survivors; however, research on blood pressure (BP) and CVD outcomes in BC survivors is limited.

Objectives

The purpose of this study was to better characterize the association between BP and CVD in a large, longitudinal cohort of BC patients.

Methods

Women with invasive BC diagnosed from 2005 to 2013 at Kaiser Permanente Northern California were matched 1:5 to women without BC. Patient data were obtained from electronic health records. Multivariable Cox regression and penalized spline models were used to explore the linear and nonlinear relationship of systolic blood pressure (SBP) and diastolic blood pressure (DBP) on CVD outcomes.

Results

BC cases (n = 12,713) and controls (n = 55,886) had median follow-up of 9.6 years (IQR: 5.0-11.9 years). Women with BC had a mean age of 60.6 years; 64.8% were non-Hispanic White. For ischemic heart disease (IHD), every 10 mmHg increase in SBP and DBP was associated with 1.23 (95% CI: 1.14-1.33) and 1.10 (95% CI: 0.98-1.24) risk, respectively, in women with BC. For stroke, every 10 mmHg increase in SBP and DBP was associated with a 1.45 (95% CI: 1.34-1.58) and 1.91 (95% CI: 1.68-2.18) risk, respectively. A U-shaped relationship was observed between heart failure/cardiomyopathy and BP. The associations between BP and risk of IHD, stroke, and any primary CVD were not statistically different comparing women with BC to controls, but risks varied by BC status for heart failure/cardiomyopathy (P for interaction = 0.01).

Conclusions

Women with and without BC showed similar risks for IHD, stroke, and any primary CVD suggesting similar BP targets should be pursued regardless of BC survivorship status.

Hypoperfusion Intensity Ratio as an Indirect Imaging Surrogate in Patients With Anterior Circulation Large-Vessel Occlusion and Association of Baseline Characteristics With Poor Collateral Status

BACKGROUND

Collateral status (CS) plays a crucial role in infarct growth rate, risk of postthrombectomy hemorrhage, and overall clinical outcomes in patients with acute ischemic stroke (AIS) secondary to anterior circulation large-vessel occlusions (LVOs). Hypoperfusion intensity ratio has been previously validated as an indirect noninvasive pretreatment imaging biomarker of CS. In addition to imaging, derangements in admission laboratory findings can also influence outcomes in patients with AIS-LVO. Therefore, our study aims to assess the relationship between admission laboratory findings, baseline characteristics, and CS, as assessed by hypoperfusion intensity ratio in patients with AIS-LVO.

METHODS AND RESULTS

In this retrospective study, consecutive patients presenting with AIS secondary to anterior circulation LVO who underwent pretreatment computed tomography perfusion were included. The computed tomography perfusion data processed by RAPID (Ischema View, Menlo Park, CA) generated the hypoperfusion intensity ratio. Binary logistic regression models were used to assess the relationship between patients' baseline characteristics, admission laboratory findings, and poor CS. A total of 221 consecutive patients with AIS-LVO between January 2017 and September 2022 were included in our study (mean±SD age, 67.0±15.8 years; 119 men [53.8%]). Multivariable logistic regression showed that patients with AIS caused by cardioembolic and cryptogenic causes (adjusted odds ratio [OR], 2.67; 95% CI, 1.20-5.97; P=0.016), those who presented with admission National Institutes of Health Stroke Scale score ≥12 (adjusted OR, 3.12; 95% CI, 1.61-6.04; P=0.001), and male patients (adjusted OR, 2.06; 95% CI, 1.13-3.77; P=0.018) were associated with poor CS.

CONCLUSIONS

Stroke caused by cardioembolic or cryptogenic causes, admission National Institutes of Health Stroke Scale score of ≥12, and male sex were associated with poor CS, as defined by hypoperfusion intensity ratio in the patients with AIS-LVO.

Residual risk of cardiovascular complications in statin-using patients with type 2 diabetes: the Taiwan Diabetes Registry Study

BACKGROUND

The residual risks of atherosclerotic cardiovascular disease in statin-treated patients with diabetes remain unclear. This study was conducted to identify factors associated with these residual risks in patients with no prior vascular event.

METHODS

Data on 683 statin-using patients with type 2 diabetes mellitus (T2DM) from the Taiwan Diabetes Registry were used in this study. Patients aged < 25 or > 65 years at the time of diabetes diagnosis and those with diabetes durations ≥ 20 years were excluded. The United Kingdom Prospective Diabetes Study risk engine (version 2.01; https://www.dtu.ox.ac.uk/riskengine/ ) was used to calculate 10-year residual nonfatal and fatal coronary heart disease (CHD) and stroke risks. Associations of these risks with physical and biochemical variables, including medication use and comorbidity, were examined.

RESULTS

The 10-year risks of nonfatal CHD in oral anti-diabetic drug (OAD), insulin and OAD plus insulin groups were 11.8%, 16.0%, and 16.8%, respectively. The 10-year risks of nonfatal stroke in OAD, insulin and OAD plus insulin groups were 3.0%, 3.4%, and 4.3%, respectively. In the multivariate model, chronic kidney disease (CKD), neuropathy, insulin use, calcium-channel blocker (CCB) use, higher body mass indices (BMI), low-density lipoprotein (LDL), fasting glucose, log-triglyceride (TG), and log-alanine transaminase (ALT) levels were associated with an increased CHD risk. The residual risk of stroke was associated with CKD, neuropathy, CCB use, and lower LDL cholesterol levels, higher BMI and diastolic blood pressure.

CONCLUSION

This study indicated that insulin was probably a residual risk factor of CHD but not stroke, and that there was a possible presence of obesity paradox in patients with T2DM on statin therapy. In addition to lowering TG and normalizing fasting glucose levels, lower LDL cholesterol level is better for reduction of risk of CHD on statin therapy. On the other hand, lower LDL cholesterol level could potentially be related to higher risk of stroke among populations receiving statin therapy. These findings suggest potential therapeutic targets for residual cardiovascular risk reduction in patients with T2DM on statin therapy.

Impact of baseline blood pressure on adverse outcomes in Japanese patients with non-valvular atrial fibrillation: the J-RISK AF

Aims

This study aimed to investigate the impact of baseline blood pressure (BP) on adverse outcomes in patients with atrial fibrillation (AF), using a pooled analysis performed on data from J-RISK AF, a large-scale cohort of Japanese patients with AF.

Methods and results

Of the 16 918 patients from five major AF registries including the J-RHYTHM Registry, Fushimi AF Registry, Shinken Database, Keio interhospital Cardiovascular Studies, and Hokuriku-Plus AF Registry, 15 019 non-valvular AF (NVAF) patients with baseline BP values (age, 70.0 ± 11.0 years; men, 69.1%) were analysed. Incidence rates of adverse events were evaluated between patients divided into baseline systolic BP quartiles or at 150 mmHg. During the follow-up period of 730 days, ischaemic stroke, major bleeding, all-cause death, and cardiovascular death occurred in 277, 319, 718, and 275 patients, respectively. Hazard ratios (HRs) for ischaemic stroke and major bleeding were comparable among the quartiles, whereas HRs for all-cause and cardiovascular deaths in the lowest quartile with systolic BP <114 mmHg were significantly higher [HR 1.43, 95% confidence interval (CI) 1.13-1.81; and HR 1.47, 95% CI 1.01-2.12, respectively] than in the third quartile, even after adjusting for known confounding factors. In patients with a systolic BP of ≥150 mmHg, adjusted HR for major bleeding was significantly higher than that of <150 mmHg (HR 1.64, 95% CI 1.12-2.40).

Conclusion

In Japanese patients with NVAF, a baseline systolic BP <114 mmHg was significantly associated with higher all-cause and cardiovascular mortality. In contrast, a systolic BP ≥150 mmHg was an independent risk factor for major bleeding.

Low Diastolic Blood Pressure and Mortality in Older Women. Results From the Women's Health Initiative Long Life Study

BACKGROUND

Recommended systolic blood pressure targets often do not consider the relationship of low diastolic blood pressure (DBP) levels with cardiovascular disease (CVD) and all-cause mortality risk, which is especially relevant for older people with concurrent comorbidities. We examined the relationship of DBP levels to CVD and all-cause mortality in older women in the Women's Health Initiative Long Life Study (WHI-LLS).

METHODS

The study sample included 7,875 women (mean age: 79 years) who underwent a blood pressure measurement at an in-person home visit conducted in 2012-2013. CVD and all-cause mortality were centrally adjudicated. Hazard ratios (HRs) were obtained from adjusted Cox proportional hazards models.

RESULTS

After 5 years follow-up, all-cause mortality occurred in 18.4% of women. Compared with a DBP of 80 mm Hg, the fully adjusted HR for mortality was 1.33 (95% confidence interval [CI]: 1.04-1.71) for a DBP of 50 mm Hg and 1.67 (95% CI: 1.29-2.16) for a DBP of 100 mm Hg. The HRs for CVD were 1.14 (95% CI: 0.78-1.67) for a DBP of 50 mm Hg and HR 1.50 (95% CI: 1.03-2.17) for a DBP of 100 mm Hg. The nadir DBP associated with lowest mortality risk was 72 mm Hg overall.

CONCLUSIONS

In older women, consideration should be given to the potential adverse effects of low and high DBP. Low DBP may serve as a risk marker. DBP target levels between 68 and 75 mm Hg may avoid higher mortality risk.

Polymorphisms of microRNAs are associated with salt sensitivity in a Han Chinese population: the EpiSS study

The majority of single-nucleotide polymorphism (SNP) association studies of salt sensitivity (SS) have focused on SNPs in protein-coding genes rather than on SNPs in noncoding RNAs. This study attempted to identify the association between whole blood microRNA (miRNA)-related SNPs and the risk of SS in a Han Chinese population. A case-control study of 762 individuals was performed. A modified Sullivan's acute oral saline load and diuresis shrinkage test was used to assess SS. All SNPs were analysed by RT-PCR on a Sequenom Mass ARRAY Platform (Sequenom, San Diego, CA, USA). A genetic risk score (GRS) was used to evaluate the joint genetic effect. In total, 24 miRNA-related SNPs were genotyped, four of which (miR-1307-5p/rs11191676, miR-1307-5p/rs2292807, miR-145/rs41291957 and miR-4638-3p/rs6601178) were associated with both SS and salt sensitivity of blood pressure (SSBP) (p ≤ 0.05). MiR-382-5p/rs4906032 and miR-15b-5/rs10936201 were associated with SSBP. Weighted GRS showed that participants in the second, third and fourth quartiles had 1.760-fold (95% CI: 1.068-2.903), 2.450-fold (95% CI: 1.470-4.083) and 2.774-fold (95% CI: 1.680-4.582) increased risk of SS, respectively. Bioinformatics analysis indicated that these four SNP risk alleles may affect transcription factor binding and influence promoter activity. A total of six miRNA-related SNPs were found to be associated with SS or SSBP, and the presence of multiple risk alleles resulted in increased risk level.

Association of peridialytic, intradialytic, scheduled interdialytic and ambulatory BP recordings with cardiovascular events in hemodialysis patients

BACKGROUND

Ambulatory-BP-monitoring (ABPM) is recommended for hypertension diagnosis and management in hemodialysis patients due to its strong association with outcomes. Intradialytic and scheduled interdialytic BP recordings show agreement with ambulatory BP. This study assesses in parallel the association of pre-dialysis, intradialytic, scheduled interdialytic and ambulatory BP recordings with cardiovascular events.

METHODS

We prospectively followed 242 hemodialysis patients with valid 48-h ABPMs for a median of 45.7 months to examine the association of pre-dialysis, intradialytic, intradialytic plus pre/post-dialysis readings, scheduled interdialytic BP, and 44-h ambulatory BP with outcomes. The primary end-point was a composite one, composed of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary revascularization procedure or peripheral revascularization procedure.

RESULTS

Cumulative freedom from the primary end-point was significantly lower with increasing 44-h SBP (group 1, < 120 mmHg, 64.2%; group 2, ≥ 120 to < 130 mmHg 60.4%, group 3, ≥ 130 to < 140 mmHg 45.3%; group 4, ≥ 140 mmHg 45.5%; logrank-p = 0.016). Similar were the results for intradialytic (logrank-p = 0.039), intradialytic plus pre/post-dialysis (logrank-p = 0.044), and scheduled interdialytic SBP (logrank-p = 0.030), but not for pre-dialysis SBP (logrank-p = 0.570). Considering group 1 as the reference group, the hazard ratios of the primary end-point showed a gradual increase with higher BP levels with all BP metrics, except pre-dialysis SBP. This pattern was confirmed in adjusted analyses. An inverse association of DBP levels with outcomes was shown with all BP metrics, which was no longer evident in adjusted analyses.

CONCLUSIONS

Averaged intradialytic and scheduled home BP measurements (but not pre-dialysis readings) display similar prognostic associations with 44-h ambulatory BP in hemodialysis patients and represent valid metrics for hypertension management in these individuals.

Blood pressure prior to percutaneous coronary intervention is associated with the risk of end-stage renal disease: a nationwide population based-cohort study

Background

Hypertension is the most important modifiable risk factor for mortality and morbidity in chronic kidney disease and coronary artery syndrome. The effect of hypertension prior to percutaneous coronary intervention (PCI) on the development of end-stage renal disease (ESRD) is unknown.

Methods

We used nationally representative data from the Korean National Health Insurance System-140,164 subjects were enrolled during 2010-2015; they were free of ESRD at enrolment, underwent PCI, and were followed up until 2017. Blood pressure (BP) was measured within at least 2 years prior to PCI. The primary outcome was the development of ESRD.

Results

During a median follow-up of 5.4 years, 2,082 participants (1.5%) developed ESRD. The highest systolic BP group (>160 mmHg) showed a higher hazard ratio (3.69; 95% confidence interval, 2.61-5.23) than the reference group (110-119 mmHg). Similar results were observed in the highest diastolic BP group (>120 mmHg), which showed a higher hazard ratio than the reference group (70-79 mmHg). However, ESRD risk showed a J-shaped relationship with baseline systolic and diastolic BP at 113 and 74 mmHg in diabetes mellitus subgroup, respectively, after adjustment for potential confounders.

Conclusion

Our study showed that a high systolic or diastolic BP prior to PCI was independently associated with an increased incidence of ESRD.

Time-evolving coupling functions for evaluating the interaction between cerebral oxyhemoglobin and arterial blood pressure with hypertension

PURPOSES

This study aimed to investigate the network coupling between arterial blood pressure (ABP) and changes in cerebral oxyhemoglobin concentration (Δ [O₂ Hb]/Δ [HHb]) oscillations based on dynamical Bayesian inference in hypertensive subjects.

METHODS

Two groups of subjects, consisting of 30 healthy (Group Control, 55.1 ± 10.6 y), and 32 hypertensive individuals (Group AH, 58.9 ± 8.7 y), participated in this study. A functional near-infrared spectroscopy system was used to measure the Δ [O₂ Hb] and Δ [HHb] signals in the bilateral prefrontal cortex (LPFC/RPFC), motor cortex (LMC/RMC), and occipital lobe (LOL/ROL) during the resting state (12 min). Based on continuous wavelet analysis and coupling functions, the directed coupling strength (CS) between ABP and cerebral hemoglobin was identified and analyzed in three frequency intervals (I: 0.6-2 Hz, II: 0.145-0.6 Hz, III: 0.01-0.08 Hz). The Pearson correlations between the CS and blood pressure parameters were calculated in the hypertension group.

RESULTS

In interval I, Group AH exhibited a significantly higher CS for the coupling from ABP to Δ [O₂ Hb] than Group Control in LMC, RMC, LOL, and ROL. In interval III, the CS from ABP to Δ [O₂ Hb] in LPFC, RPFC, LMC, RMC, LOL, and ROL was significantly higher in Group AH than in Group Control. For the patients with hypertension, diastolic blood pressure was negatively and pulse pressure was positively related to the CS from ABP to Δ [O₂ Hb] oscillations in interval III.

CONCLUSIONS

The higher CS from ABP to Δ [O₂ Hb] in interval I indicated that the components of cardiac activity in cerebral hemoglobin oscillations were more directly responsive to the changes in systematic ABP in patients with hypertension than in healthy subjects. Meanwhile, the higher CS from ABP to Δ [O₂ Hb] in interval III indicated that the cerebral hemoglobin oscillations were susceptible to changes in blood pressure in hypertensive subjects. The results may serve as evidence of impairment in cerebral autoregulation after hypertension. The Pearson correlation results showed that diastolic blood pressure and pulse pressure might be regarded as predictors of cerebral autoregulation function in patients with hypertension, and may be useful for hypertension stratification. This study provides novel insights into the interaction mechanism between ABP and cerebral hemodynamics and could help in the development of new assessment techniques for cerebral vascular disease.

Evaluation of Optimal Diastolic Blood Pressure Range Among Adults With Treated Systolic Blood Pressure Less Than 130 mm Hg

Importance

Extremely low diastolic blood pressure has been reported to be associated with increased adverse cardiovascular events (ie, the diastolic J-shape phenomenon); however, current US guidelines recommend an intensive blood pressure target of less than 130/80 mm Hg without mentioning the lower limits of diastolic blood pressure.

Objectives

To evaluate whether there is a diastolic J-shape phenomenon for patients with an treated systolic blood pressure of less than 130 mm Hg and to explore the safe and optimal diastolic blood pressure ranges for this patient population.

Design, Setting, and Participants

This cohort study analyzed outcome data of patients at high cardiovascular risk who were randomized to intensive or standard blood pressure control and achieved treated systolic blood pressure of less than 130 mm Hg in the Systolic Blood Pressure Intervention Trial (SPRINT) and Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial. Data were collected from October 2010 to August 2015 (SPRINT) and from September 1999 to June 2009 (ACCORD-BP). Data were analyzed from January to May 2020.

Exposure

Treated diastolic blood pressure, divided in intervals of less than 60, 60 to less than 70, 70 to less than 80, and 80 mm Hg and greater.

Main Outcomes and Measures

The primary outcome was a composite of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. A composite cardiovascular outcome, including cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke, was among the key secondary outcomes.

Results

A total of 7515 patients (mean [SD] age, 65.6 [8.7] years; 4553 [60.6%] men) were included in this analysis. The nominally lowest risk was observed at a diastolic blood pressure between 70 and 80 mm Hg for the primary outcome, the composite cardiovascular outcome, nonfatal myocardial infarction, and cardiovascular death. A mean diastolic blood pressure of less than 60 mm Hg was associated with significantly increased risk of the primary outcome (hazard ratio [HR], 1.46; 95% CI, 1.13-1.90; P = .004), the composite cardiovascular outcome (HR, 1.74; 95% CI, 1.26-2.41; P = .001), nonfatal myocardial infarction (HR, 1.73; 95% CI, 1.15-2.59; P = .008), and nonfatal stroke (HR, 2.67; 95% CI, 1.26-5.63; P = .01).

Conclusions and Relevance

This cohort study found that lowering diastolic blood pressure to less than 60 mm Hg was associated with increased risk of cardiovascular events in patients with high cardiovascular risk and an treated systolic blood pressure less than 130 mm Hg. The finding that a diastolic blood pressure value between 70 and 80 mm Hg was an optimum target for this patient population merits further study.

Reconsidering the cut-off diastolic blood pressure for predicting cardiovascular events: a nationwide population-based study from Korea

AIMS

It is unclear whether a J-curve association exists in cardiovascular risk prediction and how independently systolic and diastolic blood pressure (BP) predict cardiovascular outcomes. This study evaluated the association of systolic and diastolic BP with major cardiovascular events to clarify these issues.

METHODS AND RESULTS

Antihypertensive medication-naïve subjects with available BP measurements and no history of cardiovascular events were extracted from the National Health Insurance Services Health Screening Cohort. The study endpoint was a composite of cardiac death, myocardial infarction, stroke, and heart failure. The study population comprised 290 600 subjects (median follow-up duration 6.7 years). The risk for major cardiovascular events was lowest at systolic and diastolic BPs of 90-99 mmHg and 40-49 mmHg, respectively, above which BPs demonstrated a log-linear risk prediction. Systolic and diastolic BPs were highly correlated. The risk prediction of diastolic BP was inconsistent when stratified by systolic BP. A wider pulse pressure rather than a higher diastolic BP was significantly associated with cardiovascular outcomes among men aged ≥55 years. In addition, the difference between diastolic BPs of <80 mmHg and 80-89 mmHg mostly disappeared after statistical adjustment or stratification.

CONCLUSION

Elevated BP is a strong predictor of future cardiovascular events including cardiac death, myocardial infarction, stroke, and heart failure. This study showed that the log-linear relationship between BP and cardiovascular events extended down to a BP of ≥90/40 mmHg. Although hypertension is defined using a lower systolic BP cut-off of ≥130 mmHg, the diastolic BP component of ≥80 mmHg seems disproportionately low.

The association between blood pressure and long-term outcomes of patients with ischaemic cardiomyopathy with and without surgical revascularization: an analysis of the STICH trial

Aims

Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy.

Methods and results

The influence of BP during a median follow-up of 9.8 years was studied in a total of 1212 patients with ejection fraction ≤35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized to CABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5 years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8 years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5 years (χ2 and P-values: 7.08, P = 0.069; 8.72, P = 0.033; 9.86; P = 0.020; 8.31, P = 0.040; 14.52, P = 0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85 mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups.

Conclusion

A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HF patients. The results imply that the optimal SBP might be in the range 120-130 mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

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.).

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.

Lower Systolic Blood Pressure and Cardiovascular Event Risk Stratified by Renal Resistive Index in Hospitalized Cardiovascular Patients: J-VAS Study

BACKGROUND

The threshold of blood pressure (BP) reduction in cardiovascular patients is debatable due to the J-shaped curve phenomenon, which is particularly observed in patients with increased arterial stiffness. The renal resistive index (RRI) correlates well with systemic arterial stiffness; therefore, we aimed to demonstrate the role of RRI in guiding the choice of optimal BP.

METHODS

A retrospective analysis of prospectively collected data of the hospitalized cardiovascular patients at Jichi Medical University Hospital. All patients had the RRI measurement performed and were assigned to a higher (RRI ≥ 0.8) or lower RRI group. Each group was subdivided by quartiles of the BP at discharge. The primary endpoints were fatal and nonfatal cardiovascular events, including heart failure, acute coronary syndrome, acute aortic disease, acute arterial occlusion, and stroke.

RESULTS

The mean follow-up period was 1.9 years (3,365 person-years), n = 1,777 (mean age 64.7 years). There were 252 cardiovascular events occurred, 24.0% and 12.2% in the higher and lower RRI populations, P < 0.001. In the higher RRI group, the lowest systolic BP (SBP) quartile (<105 mm Hg) was a risk factor for cardiovascular events when compared with the highest SBP quartile (≥130 mm Hg; adjusted hazard ratio, 2.42; 95% confidence interval, 1.17-5.03; P = 0.017). A 1 SD decrease of SBP (17.5 mm Hg) was associated with a 25% increase in the risk of cardiovascular events. In the lower RRI group, these associations were not observed.

CONCLUSIONS

Lower SBP at discharge was associated with a risk of cardiovascular events in the hospitalized cardiovascular patients with RRI ≥ 0.8.

Central and peripheral pulse wave velocity and subclinical myocardial stress and damage in older adults

Background

Arterial stiffness independently predicts cardiovascular disease. However, few studies have evaluated the associations of central and peripheral pulse wave velocity (PWV) with biomarkers of both myocardial stress (natriuretic peptide [NT-proBNP]) and damage (high-sensitivity cardiac troponin-T [hs-cTnT]) among persons without cardiac disease.

Methods

We examined 3,348 participants (67–90 years) without prevalent cardiac disease in the Atherosclerosis Risk in Communities (ARIC) Study (2011–13). The cross-sectional associations of PWV quartiles for central arterial segments (carotid-femoral, heart-carotid, heart-femoral) and peripheral artery (femoral-ankle) with NT-proBNP and hs-cTnT were evaluated accounting for potential confounders.

Results

Most PWV measures demonstrated J- or U-shaped associations with the two cardiac biomarkers. The highest (Q4) vs. second lowest (Q2) quartile of central PWV measures (carotid-femoral, heart-carotid, heart-femoral PWV) were associated with higher levels of NT-proBNP independently of demographic characteristics. The associations were less evident for hs-cTnT. These associations were attenuated after adjusting for traditional cardiovascular risk factors, but the heart-carotid PWV-NT-proBNP relationship remained borderline significant (difference in log-NT-proBNP = 0.08 [-0.01, 0.17] in Q4 vs. Q2, p = 0.07). Peripheral PWV demonstrated inverse associations. Higher values of NT-proBNP were seen in the lowest vs. second lowest quartile of all PWV measures.

Conclusions

Central stiffness measures showed stronger associations with cardiac biomarkers (particularly NT-proBNP) than peripheral measures among older adults without cardiac disease. Our findings are consistent with the concept of ventricular-vascular coupling and suggest that central rather than peripheral arterial hemodynamics are more closely related to myocardial stress rather than damage.

Klf4 has an unexpected protective role in perivascular cells within the microvasculature

Recent smooth muscle cell (SMC) lineage-tracing studies have revealed that SMCs undergo remarkable changes in phenotype during development of atherosclerosis. Of major interest, we demonstrated that Kruppel-like factor 4 (KLF4) in SMCs is detrimental for overall lesion pathogenesis, in that SMC-specific conditional knockout of the KLF4 gene ( Klf4) resulted in smaller, more-stable lesions that exhibited marked reductions in the numbers of SMC-derived macrophage- and mesenchymal stem cell-like cells. However, since the clinical consequences of atherosclerosis typically occur well after our reproductive years, we sought to identify beneficial KLF4-dependent SMC functions that were likely to be evolutionarily conserved. We tested the hypothesis that KLF4-dependent SMC transitions play an important role in the tissue injury-repair process. Using SMC-specific lineage-tracing mice positive and negative for simultaneous SMC-specific conditional knockout of Klf4, we demonstrate that SMCs in the remodeling heart after ischemia-reperfusion injury (IRI) express KLF4 and transition to a KLF4-dependent macrophage-like state and a KLF4-independent myofibroblast-like state. Moreover, heart failure after IRI was exacerbated in SMC Klf4 knockout mice. Surprisingly, we observed a significant cardiac dilation in SMC Klf4 knockout mice before IRI as well as a reduction in peripheral resistance. KLF4 chromatin immunoprecipitation-sequencing analysis on mesenteric vascular beds identified potential baseline SMC KLF4 target genes in numerous pathways, including PDGF and FGF. Moreover, microvascular tissue beds in SMC Klf4 knockout mice had gaps in lineage-traced SMC coverage along the resistance arteries and exhibited increased permeability. Together, these results provide novel evidence that Klf4 has a critical maintenance role within microvascular SMCs: it is required for normal SMC function and coverage of resistance arteries. NEW & NOTEWORTHY We report novel evidence that the Kruppel-like factor 4 gene ( Klf4) has a critical maintenance role within microvascular smooth muscle cells (SMCs). SMC-specific Klf4 knockout at baseline resulted in a loss of lineage-traced SMC coverage of resistance arteries, dilation of resistance arteries, increased blood flow, and cardiac dilation.

Estimated glomerular filtration rate and the risk-benefit profile of intensive blood pressure control amongst nondiabetic patients: a post hoc analysis of a randomized clinical trial

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT; ClinicalTrials.gov, NCT01206062) reported reduced cardiovascular events by intensive blood pressure (BP) control amongst hypertensive patients without diabetes. However, the risk-benefit profile of intensive BP control may differ across estimated glomerular filtration rate (eGFR) levels.

METHODS

This is a post hoc analysis of the SPRINT. Nondiabetic hypertensive adults (n = 9361) with eGFR >20 mL per min per 1.73 m² were enrolled from 102 US facilities between November 2010 and March 2013 and were followed up until August 2015 (median follow-up, 3.26 years). Patients were randomly assigned to either a systolic BP target of <120 or <140 mmHg (for intensive or standard treatment, respectively). The outcomes of interests were the development of (i) fatal and nonfatal major cardiovascular events and (ii) acute kidney injury (AKI).

RESULTS

The cardiovascular benefit from intensive treatment was attenuated with lower eGFR (P_interaction  = 0.019), whereas eGFR did not modify the adverse effect on AKI (P_interaction  = 0.179). Amongst 891 participants with eGFR <45 mL per min per 1.73 m² , intensive treatment did not reduce the cardiovascular outcome (54/446 vs. 54/445 events in the standard group, respectively; hazard ratio [HR], 0.92; 95% CI, 0.62-1.38) with an absolute rate difference (ARD) of -0.02 (95% CI, -0.07 to +0.03) per 100 patient-years, whereas it increased AKI (62/446 vs. 38/445 events in the standard group; HR, 1.73; 95% CI, 1.12-2.66) with an ARD of +1.93 (95% CI, +1.88 to +1.97) per 100 patient-years.

CONCLUSIONS

Intensive BP control may provide little or no benefit and even be harmful for patients with moderate-to-advanced chronic kidney disease.

The J-shaped Curve for Blood Pressure and Cardiovascular Disease Risk: Historical Context and Recent Updates

PURPOSE OF REVIEW

The definition and treatment of hypertension have both changed dramatically over the last century, with recent trials suggesting benefit for lower blood pressure (BP) targets than ever before considered. However, tempering the enthusiasm for more intensive BP targets are long-held concerns that BP reduction below a certain threshold may pose dangers, the so-called "J-curve." In this review, we summarize the evidence for a J-curve in the treatment of hypertension.

RECENT FINDINGS

The Systolic Blood Pressure Intervention Trial (SPRINT) reported that achieving a systolic BP target of 120 mmHg reduces cardiovascular disease in high-risk individuals, supporting more intensive BP reduction. However, contemporary observational studies consistently demonstrate a BP J-curve, the threshold of which is often close to the SPRINT target. Studies also suggest that the BP level of this J-curve may vary based on patient characteristics, including age and comorbidities. There is also more compelling evidence for the specific presence of a J-curve between diastolic BP and coronary events, in contrast to conflicting evidence of a J-curve with systolic BP and cardiovascular disease more generally. There is increased risk of coronary events below a diastolic BP of 60-70 mmHg. In comparison, the presence of a systolic J-curve is less clear and some persons at high risk may actually benefit from systolic levels down to 120 mmHg. Therefore, we suggest a personalized approach to BP management considering individual risks, benefits, and preferences when choosing therapeutic targets. Further, well-designed studies are required to support our suggestions and to define J-curve thresholds more clearly.

Considerations for Optimal Blood Pressure Goals in the Elderly Population: A Review of Emergent Evidence

Recent hypertension clinical trials and national guideline updates have created a debate on the most appropriate treatment goals in elderly patients with hypertension. In 2014, recommendations by the Eighth Joint National Committee allowed a more lenient goal for patients 60 years and older compared with previous guidelines. Since then, several large clinical trials and meta-analyses have added more information regarding strict versus lenient treatment goals. Most recently, the American College of Cardiology and American Heart Association Task Force published their highly anticipated hypertension guideline developed in conjunction with nine additional interdisciplinary organizations. This review discusses the culmination of emerging data to provide more insight into the treatment of hypertension in the elderly. A literature search was conducted using PubMed, the Cumulative Index of Nursing and Allied Health, the Cochrane database, and by hand-searching references from relevant articles. The following key terms were used: hypertension, blood pressure, systolic, and elderly. Available literature suggests that it is reasonable to target an office systolic blood pressure of less than 130 mm Hg in elderly patients with hypertension. An individualized approach is reasonable for those who are institutionalized, with high comorbidity burden, or have a short life expectancy. A diastolic blood pressure of less than 60 mm Hg should be avoided due to the potential for an increase in cardiovascular risk. The method of blood pressure measurement is extremely important to consider when determining the blood pressure goal, and proper procedures for accurate blood pressure measurement must be followed. Other factors important to consider may include the patient's comorbidities, frailty, as well as the patient's potential for adverse drug reactions.

Relation of Diastolic Blood Pressure and Coronary Artery Calcium to Coronary Events and Outcomes (From the Multi-Ethnic Study of Atherosclerosis)

Diastolic blood pressure has a J-curve relation with coronary heart disease and death. Because this association is thought to reflect reduced coronary perfusion at low diastolic blood pressure, we hypothesized that the J-curve would be most pronounced in persons with coronary artery calcium. In 6,811 participants from the Multi-Ethnic Study of Atherosclerosis, we used Cox models to examine if diastolic blood pressure category is associated with coronary heart disease events, stroke, and mortality. Analyses were conducted in the sample overall and after stratification by coronary artery calcium score. In multivariable-adjusted analyses, compared with diastolic blood pressure of 80 to 89 mm Hg (reference), persons with diastolic blood pressure <60 mm Hg had increased risk of coronary heart disease events (hazard ratio 1.69 [95% confidence interval 1.02 to 2.79]) and all-cause mortality (hazard ratio 1.48 [95% confidence interval 1.10 to 2.00]), but not stroke. After stratification, associations of diastolic blood pressure <60 mm Hg with events were present only in participants with coronary artery calcium >0. Diastolic blood pressure <60 mm Hg was not associated with events when coronary artery calcium was zero. However, the association between diastolic blood pressure and events did not demonstrate statistical interaction when stratified by presence or absence of coronary calcium. We also found no interaction in the association between low diastolic blood pressure and events based on race. In conclusion, diastolic blood pressure <60 mm Hg was associated with increased risk of coronary heart disease events and all-cause mortality in the sample overall, but this association appeared strongest in individuals with subclinical atherosclerosis.

Incident Cardiovascular Disease Among Adults With Blood Pressure <140/90 mm Hg

BACKGROUND

Data from before the 2000s indicate that the majority of incident cardiovascular disease (CVD) events occur among US adults with systolic and diastolic blood pressure (SBP/DBP) ≥140/90 mm Hg. Over the past several decades, BP has declined and hypertension control has improved.

METHODS

We estimated the percentage of incident CVD events that occur at SBP/DBP <140/90 mm Hg in a pooled analysis of 3 contemporary US cohorts: the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), the MESA (Multi-Ethnic Study of Atherosclerosis), and the JHS (Jackson Heart Study) (n=31 856; REGARDS=21 208; MESA=6779; JHS=3869). Baseline study visits were conducted in 2003 to 2007 for REGARDS, 2000 to 2002 for MESA, and 2000 to 2004 for JHS. BP was measured by trained staff using standardized methods. Antihypertensive medication use was self-reported. The primary outcome was incident CVD, defined by the first occurrence of fatal or nonfatal stroke, nonfatal myocardial infarction, fatal coronary heart disease, or heart failure. Events were adjudicated in each study.

RESULTS

Over a mean follow-up of 7.7 years, 2584 participants had incident CVD events. Overall, 63.0% (95% confidence interval [CI], 54.9-71.1) of events occurred in participants with SBP/DBP <140/90 mm Hg; 58.4% (95% CI, 47.7-69.2) and 68.1% (95% CI, 60.1-76.0) among those taking and not taking antihypertensive medication, respectively. The majority of events occurred in participants with SBP/DBP <140/90 mm Hg among those <65 years of age (66.7%; 95% CI, 60.5-73.0) and ≥65 years of age (60.3%; 95% CI, 51.0-69.5), women (61.4%; 95% CI, 49.9-72.9) and men (63.8%; 95% CI, 58.4-69.1), and for whites (68.7%; 95% CI, 66.1-71.3), blacks (59.0%; 95% CI, 49.5-68.6), Hispanics (52.7%; 95% CI, 45.1-60.4), and Chinese-Americans (58.5%; 95% CI, 45.2-71.8). Among participants taking antihypertensive medication with SBP/DBP <140/90 mm Hg, 76.6% (95% CI, 75.8-77.5) were eligible for statin treatment, but only 33.2% (95% CI, 32.1-34.3) were taking one, and 19.5% (95% CI, 18.5-20.5) met the SPRINT (Systolic Blood Pressure Intervention Trial) eligibility criteria and may benefit from a SBP target goal of 120 mm Hg.

CONCLUSIONS

Although higher BP levels are associated with increased CVD risk, in the modern era, the majority of incident CVD events occur in US adults with SBP/DBP <140/90 mm Hg. While absolute risk and cost-effectiveness should be considered, additional CVD risk-reduction measures for adults with SBP/DBP <140/90 mm Hg at high risk for CVD may be warranted.

Ambulatory Pulse Wave Velocity Is a Stronger Predictor of Cardiovascular Events and All-Cause Mortality Than Office and Ambulatory Blood Pressure in Hemodialysis Patients

Arterial stiffness and augmentation of aortic blood pressure (BP) measured in office are known cardiovascular risk factors in hemodialysis patients. This study examines the prognostic significance of ambulatory brachial BP, central BP, pulse wave velocity (PWV), and heart rate-adjusted augmentation index [AIx(75)] in this population. A total of 170 hemodialysis patients underwent 48-hour ambulatory monitoring with Mobil-O-Graph-NG during a standard interdialytic interval and followed-up for 28.1±11.2 months. The primary end point was a combination of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. Secondary end points included: (1) all-cause mortality; (2) cardiovascular mortality; and (3) a combination of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, resuscitation after cardiac arrest, coronary revascularization, or hospitalization for heart failure. During follow-up, 37(21.8%) patients died and 46(27.1%) had cardiovascular events. Cumulative freedom from primary end point was similar for quartiles of predialysis-systolic BP (SBP), 48-hour peripheral-SBP, and central-SBP, but was progressively longer for increasing quartiles for 48-hour peripheral-diastolic BP and central-diastolic BP and shorter for increasing quartiles of 48-hour central pulse pressure (83.7%, 71.4%, 69.0%, 62.8% [log-rank P=0.024]), PWV (93.0%, 81.0%, 57.1%, 55.8% [log-rank P<0.001]), and AIx(75) (88.4%, 66.7%, 69.0%, 62.8% [log-rank P=0.014]). The hazard ratios for all-cause mortality, cardiovascular mortality, and the combined outcome were similar for quartiles of predialysis-SBP, 48-hour peripheral-SBP, and central-SBP, but were increasing with higher ambulatory PWV and AIx(75). In multivariate analysis, 48-hour PWV was the only vascular parameter independently associated with the primary end point (hazard ratios, 1.579; 95% confidence intervals, 1.187-2.102). Ambulatory PWV, AIx(75), and central pulse pressure are associated with increased risk of cardiovascular events and mortality, whereas office and ambulatory SBP are not. These findings further support that arterial stiffness is the prominent cardiovascular risk factor in hemodialysis.

Associations Between Blood Pressure and Outcomes Among Blacks in the Jackson Heart Study

BACKGROUND

In 2014, new hypertension guidelines liberalized blood pressure goals for persons 60 years and older. Little is known about the implications for blacks.

METHODS AND RESULTS

Using data from 2000 through 2011 for 5280 participants in the Jackson Heart Study, a community-based black cohort in Jackson, Mississippi, we examined whether higher blood pressure was associated with greater risk of mortality and heart failure hospitalization, and whether the risk was the same across age groups. We investigated associations between baseline blood pressure and both mortality and heart failure hospitalization. We also tested for interactions between age and blood pressure in the mortality model. Median systolic and diastolic blood pressures at baseline were 125 mm Hg (25th-75th percentile, 114-137 mm Hg) and 79 mm Hg (72-86 mm Hg), respectively. Median follow-up was 9 years for mortality and 7 years for heart failure hospitalization. After multivariable adjustment, every 10 mm Hg increase in systolic blood pressure was associated with greater risks of mortality (hazard ratio, 1.12; 95% CI, 1.06-1.17) and heart failure hospitalization (1.07; 95% CI, 1.00-1.14). The mortality risk per 10 mm Hg increase in systolic blood pressure was greater in participants younger than 60 years (1.26; 95% CI, 1.13-1.42) than among participants 60 years and older (1.09; 95% CI, 1.03-1.15).

CONCLUSIONS

Adults in all age groups were at greater risk of mortality as systolic blood pressure increased. In the context of the 2014 hypertension guidelines, these findings should be considered when determining treatment goals in black patients.

Relationship of Blood Pressure With Mortality and Cardiovascular Events Among Hypertensive Patients aged ≥ 60 years in Rural Areas of China: A Strobe-Compliant Study

The Eighth Joint National Committee (JNC-8) panel recently recommended a systolic blood pressure (BP) threshold of ≥ 150 mmHg for the initiation of drug therapy and a therapeutic target of <150/90 mmHg in patients ≥ 60 years of age. However, results from some post-hoc analysis of randomized controlled trials and observational studies did not support these recommendations. In the prospective cohort study, 5006 eligible hypertensive patients aged ≥ 60 years from rural areas of China were enrolled for the present analysis. The association between the average follow-up BP and outcomes (all-cause and cardiovascular death, incident coronary heart disease [CHD], and stroke), followed by a median of 4.8 years, were evaluated using Cox proportional hazards models adjusting for other potential confounders. The relationship between BP (systolic or diastolic) showed an increased or J-shaped curve association with adverse outcomes. Compared with the reference group of BP <140/90 mmHg, the risk of all-cause death (hazard ratio [HR]: 2.698; 95% confidence interval [CI]: 1.989-3.659), cardiovascular death (HR: 2.702; 95% CI: 1.855-3.935), incident CHD (HR: 3.263; 95% CI: 2.063-5.161), and stroke (HR: 2.334; 95% CI: 1.559-3.945) was still significantly increased in the group with BP of 140-149/<90 mmHg. Older hypertensive patients with BP of 140-149/<90 mmHg were at higher risk of developing adverse outcomes, implying that lenient BP control of 140-149/<90 mmHg, based on the JNC-8 guidelines, may not be appropriate for hypertensive patients aged ≥ 60 years in rural areas of China.

Does low diastolic blood pressure contribute to the risk of recurrent hypertensive cardiovascular disease events? The Framingham Heart Study

Whether low diastolic blood pressure (DBP) is a risk factor for recurrent cardiovascular disease (CVD) events in persons with isolated systolic hypertension is controversial. We studied 791 individuals (mean age 75 years, 47% female, mean follow-up time: 8±6 years) with DBP <70 (n=225) versus 70 to 89 mm Hg (n=566) after initial CVD events in the original and offspring cohorts of the Framingham Heart Study. Recurrent CVD events occurred in 153 (68%) participants with lower DBP and 271 (48%) with higher DBP (P<0.0001). Risk of recurrent CVD events in risk factor-adjusted Cox regression was higher in those with DBP <70 mm Hg versus DBP 70 to 89 mm Hg in both treated (hazard ratio, 5.1 [95% confidence interval: 3.8-6.9] P<0.0001) and untreated individuals (hazard ratio, 11.7 [95% confidence interval: 6.5-21.1] P<0.0001; treatment interaction: P=0.71). Individually, coronary heart disease, heart failure, and stroke recurrent events were more likely with DBP <70 mm Hg versus 70 to 89 mm Hg (P<0.0001). To examine for an effect of wide pulse pressure on excess risk associated with low DBP, we defined 4 binary groupings of pulse pressure (≥68 versus <68 mm Hg) and DBP (<70 versus 70-89 mm Hg). CVD incidence rates were higher only in the group with pulse pressure ≥68 and DBP <70 mm Hg (76% versus 46%-54%; P<0.001). Persons with isolated systolic hypertension and prior CVD events have increased risk for recurrent CVD events in the presence of DBP <70 mm Hg versus DBP 70 to 89 mm Hg, whether treated or untreated, supporting wide pulse pressure as an important risk modifier for the adverse effect of low DBP.

Optimal blood pressure in patients with atrial fibrillation (from the AFFIRM Trial)

Many medications used to treat atrial fibrillation (AF) also reduce blood pressure (BP). The relation between BP and mortality is unclear in patients with AF. We performed a post hoc analysis of 3,947 participants from the Atrial Fibrillation Follow-Up Investigation of Rhythm Management trial. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) at baseline and follow-up were categorized by 10-mm Hg increments. The end points were all-cause mortality (ACM) and secondary outcome (combination of ACM, ventricular tachycardia and/or fibrillation, pulseless electrical activity, significant bradycardia, stroke, major bleeding, myocardial infarction, and pulmonary embolism). SBP and DBP followed a "U-shaped" curve with respect to primary and secondary outcomes after multivariate analysis. A nonlinear Cox proportional hazards model showed that the incidence of ACM was lowest at 140/78 mm Hg. Subgroup analyses revealed similar U-shaped curves. There was an increased ACM observed with BP <110/60 mm Hg (hazard ratio 2.4, p <0.01, respectively, for SBP and DBP). In conclusion, in patients with AF, U-shaped relation existed between BP and ACM. These data suggest that the optimal BP target in patients with AF may be greater than the general population and that pharmacologic therapy to treat AF may be associated with ACM or adverse events if BP is reduced to <110/60 mm Hg.

Natriuretic peptides and cardio-renal disease

The natriuretic peptide (NP) system is an important endocrine, autocrine and paracrine system, consisting of a family of peptides which provide cardiac, renal and vascular effects that, through their beneficial physiological actions, play a key role in maintaining overall cardiovascular health. Traditionally, the pathophysiological origins of cardio-renal disease have been viewed as the domain of the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system (SNS), with inappropriate activation of both systems leading to deleterious changes in cardio-renal function and structure. Therapies designed to suppress the RAAS and the SNS have been routinely employed to address the consequences of cardio-renal disease. However, it is now becoming increasingly apparent that enhancing the beneficial physiological effects of the NP system may represent an attractive alternative therapeutic approach to counter the pathophysiological effects of disease. In particular, innovative therapeutic strategies aimed at enhancing the physiological benefits afforded by NPs while simultaneously suppressing the RAAS are generating increasing interest as potential treatment options for the management of cardio-renal disease.

Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people

BACKGROUND

The associations of blood pressure with the different manifestations of incident cardiovascular disease in a contemporary population have not been compared. In this study, we aimed to analyse the associations of blood pressure with 12 different presentations of cardiovascular disease.

METHODS

We used linked electronic health records from 1997 to 2010 in the CALIBER (CArdiovascular research using LInked Bespoke studies and Electronic health Records) programme to assemble a cohort of 1·25 million patients, 30 years of age or older and initially free from cardiovascular disease, a fifth of whom received blood pressure-lowering treatments. We studied the heterogeneity in the age-specific associations of clinically measured blood pressure with 12 acute and chronic cardiovascular diseases, and estimated the lifetime risks (up to 95 years of age) and cardiovascular disease-free life-years lost adjusted for other risk factors at index ages 30, 60, and 80 years. This study is registered at ClinicalTrials.gov, number NCT01164371.

FINDINGS

During 5·2 years median follow-up, we recorded 83,098 initial cardiovascular disease presentations. In each age group, the lowest risk for cardiovascular disease was in people with systolic blood pressure of 90-114 mm Hg and diastolic blood pressure of 60-74 mm Hg, with no evidence of a J-shaped increased risk at lower blood pressures. The effect of high blood pressure varied by cardiovascular disease endpoint, from strongly positive to no effect. Associations with high systolic blood pressure were strongest for intracerebral haemorrhage (hazard ratio 1·44 [95% CI 1·32-1·58]), subarachnoid haemorrhage (1·43 [1·25-1·63]), and stable angina (1·41 [1·36-1·46]), and weakest for abdominal aortic aneurysm (1·08 [1·00-1·17]). Compared with diastolic blood pressure, raised systolic blood pressure had a greater effect on angina, myocardial infarction, and peripheral arterial disease, whereas raised diastolic blood pressure had a greater effect on abdominal aortic aneurysm than did raised systolic pressure. Pulse pressure associations were inverse for abdominal aortic aneurysm (HR per 10 mm Hg 0·91 [95% CI 0·86-0·98]) and strongest for peripheral arterial disease (1·23 [1·20-1·27]). People with hypertension (blood pressure ≥140/90 mm Hg or those receiving blood pressure-lowering drugs) had a lifetime risk of overall cardiovascular disease at 30 years of age of 63·3% (95% CI 62·9-63·8) compared with 46·1% (45·5-46·8) for those with normal blood pressure, and developed cardiovascular disease 5·0 years earlier (95% CI 4·8-5·2). Stable and unstable angina accounted for most (43%) of the cardiovascular disease-free years of life lost associated with hypertension from index age 30 years, whereas heart failure and stable angina accounted for the largest proportion (19% each) of years of life lost from index age 80 years.

INTERPRETATION

The widely held assumptions that blood pressure has strong associations with the occurrence of all cardiovascular diseases across a wide age range, and that diastolic and systolic associations are concordant, are not supported by the findings of this high-resolution study. Despite modern treatments, the lifetime burden of hypertension is substantial. These findings emphasise the need for new blood pressure-lowering strategies, and will help to inform the design of randomised trials to assess them.

FUNDING

Medical Research Council, National Institute for Health Research, and Wellcome Trust.

The age-related hemodynamic changes of blood pressure and their impact on the incidence of cardiovascular disease and stroke: new evidence

There is a linear change in blood pressure (BP) with the advancement of age from predominantly diastolic BP (DBP) in the young to predominantly systolic BP (SBP) in the old. This change is caused by the stiffening of the large arteries and the loss of elastic recoil as a result of replacement of the elastic fibers with collagen fibers. The result of this ageing process leads to an increase in pulse wave velocity and widening of pulse pressure. These hemodynamic changes are associated with an increased incidence in cardiovascular diseases (CVDs) and strokes. Recently, an inverse relationship with stroke risk was noted when the DBP was <71 mm Hg in persons older than 60 years. Accordingly, when treating SBP in the elderly, care should be taken not to lower the DBP below this level in order to minimize the risk for CVD and stoke.

Blood pressure and mortality in U.S. veterans with chronic kidney disease: a cohort study

BACKGROUND

The ideal blood pressure (BP) to decrease mortality rates in patients with non-dialysis-dependent chronic kidney disease (CKD) is unclear.

OBJECTIVE

To assess the association of BP (defined as the combination of systolic BP [SBP] and diastolic BP [DBP] at the individual level) with death in patients with CKD.

DESIGN

Historical cohort between 2005 and 2012.

SETTING

All U.S. Department of Veterans Affairs health care facilities.

PATIENTS

651 749 U.S. veterans with CKD.

MEASUREMENTS

All possible combinations of SBP and DBP were examined in 96 categories from lowest (<80/<40 mm Hg) to highest (>210/>120 mm Hg), in 10-mm Hg increments. Associations with all-cause mortality were examined in time-dependent Cox models with adjustment for relevant confounders.

RESULTS

Patients with SBP of 130 to 159 mm Hg combined with DBP of 70 to 89 mm Hg had the lowest adjusted mortality rates, and those in whom both SBP and DBP were concomitantly very high or very low had the highest mortality rates. Patients with moderately elevated SBP combined with DBP no less than 70 mm Hg had consistently lower mortality rates than did patients with ideal SBP combined with DBP less than 70 mm Hg. Results were consistent in subgroups of patients with normal and elevated urinary microalbumin-creatinine ratios.

LIMITATION

Mostly male patients, inability to establish causality, and large number of patients missing proteinuria measurement.

CONCLUSION

The optimal BP in patients with CKD seems to be 130 to 159/70 to 89 mm Hg. It may not be advantageous to achieve ideal SBP at the expense of lower-than-ideal DBP in adults with CKD.

PRIMARY FUNDING SOURCE

National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, and U.S. Department of Veterans Affairs.