Hypertension and the J-curve phenomenon: implications for tight blood pressure control

Impact of blood pressure and medication adherence on clinical outcomes in patients with hypertension

Background

Hypertension is a key risk factor for cardiovascular disease. Thus, effective blood pressure (BP) management and adherence to antihypertensive medications are crucial for reducing these risks in patients with hypertension. We evaluated the effect of BP and medication adherence on the clinical outcomes of patients with hypertension.

Methods

This is retrospective cohort study utilized data from the Korean National Health Insurance Database. We analyzed data from 238,950 patients with hypertension aged ≥20 who underwent at least two health checkups between 2009 and 2012. Patients were categorized according to their systolic BP (SBP) and medication adherence. The primary outcome was a composite of all-cause death, myocardial infarction, ischemic stroke, hemorrhagic stroke, and hospitalization for heart failure. Cox proportional hazard models were used to estimate hazard ratios (HR) for composite outcomes.

Results

Higher SBP groups were associated with increased risk of composite outcomes compared to the 120-129 mmHg group (<120 mmHg, HR 1.065; 130-139 mmHg, HR 1.056; 140-149 mmHg, HR 1.068; and ≥150 mmHg, HR 1.238). In addition, across all SBP categories, poor adherence significantly elevated the risk of composite outcomes, even after adjusting for confounding factors. Among all categories, patients with high SBP (≥150 mmHg) and poor adherence had the highest risk.

Conclusion

Higher SBP and poor medication adherence were independently associated with worse clinical outcomes in patients with hypertension. Strategies to enhance medication adherence and achieve optimal BP control are essential to reduce cardiovascular risk.

Implications of pulse wave velocity and central pulse pressure in heart failure with reduced ejection fraction

BACKGROUND

Carotid-femoral pulse wave velocity (cfPWV) and central pulse pressure (PP) are recognised as significant indicators of vascular health and predictors of cardiovascular outcomes. In this study, associations between central hemodynamics and left ventricular (LV) echocardiographic parameters were investigated in subjects with heart failure with reduced ejection fraction (HFrEF), comparing the results to healthy individuals.

METHODS AND RESULTS

This cross-sectional prospective controlled study included 50 subjects with HFrEF [mean LV ejection fraction (EF) 26 ± 6.5%] and 30 healthy controls (mean LVEF 65.9 ± 5.3%). Pulse wave analysis (PWA) and carotid-femoral pulse wave velocity (cfPWV) were used to measure central hemodynamics and arterial stiffness. The HFrEF group displayed higher cfPWV (8.2 vs. 7.2 m/s, p = 0.007) and lower central (111.3 vs. 121.7 mmHg, p = 0.001) and peripheral (120.1 vs. 131.5 mmHg, p = 0.002) systolic blood pressure. Central pulse pressure (PP) was comparable between the two groups (37.6 vs. 40.4 mmHg, p = 0.169). In the HFrEF group, cfPWV significantly correlated with left ventricular end-diastolic volume (LVEDV) index (mL/m2) and LVEF, with LVEDV index being a significant independent predictor of cfPWV (R2 = 0.42, p = 0.003). Central PP was significantly associated with heart rate, LVEF and LVEDV index, with the latter being a significant independent predictor of central PP (R2 = 0.41, p < 0.001). These correlations were not observed in healthy controls.

CONCLUSIONS

Significant associations between central hemodynamic measures and LV echocardiographic parameters were identified, suggesting the potential to use PWA and cfPWV as possible tools for managing HFrEF.

Treatment of hypertension in the elderly: target the lowest well-tolerated blood pressure

INTRODUCTION

Antihypertensive treatment provides substantial benefits in older people. However, many challenges remain, including the ideal blood pressure (BP) target to be achieved. Because the elderly population is particularly vulnerable to adverse events, BP control should be carefully managed. Some studies have evaluated the cardiovascular effects of different BP targets in older patients, with mixed results and uncertainty about the most appropriate BP target. However, pooled analyses suggest that intensive BP lowering provides greater cardiovascular protection than less intensive strategies in elderly hypertensive patients.

AREAS COVERED

Understanding the balance between the risks and benefits of intensive BP targets and individualizing treatment is essential to ensure that older patients receive appropriate treatment to reduce the risk of cardiovascular complications. We reviewed data from clinical trials which investigated the protective effects of BP lowering drugs in elderly hypertensive patients aged ≥65 years.

EXPERT OPINION

Evidence suggests that age does not preclude an aggressive strategy for treating hypertension in elderly patients. Being 'tolerant' with one hand and 'intensive' with the other should become a universal standard in the management of elderly hypertensive patients. The lowest well-tolerated BP could be a simple and universally applicable BP target in the management of hypertensive patients, including the elderly.

Low on-treatment blood pressure and cardiovascular events in patients without elevated risk: a nationwide cohort study

Insufficient blood pressure control among patients with hypertension without elevated risk is a global concern, suggesting the need for treatment optimization. However, the potential harm of excessive blood pressure lowering among these patients is understudied. This study addressed this evidence gap by using nationally representative public health insurer database covering 30 million working-age population. Patients who were continuously using antihypertensive drugs with 10-year cardiovascular risk <10% were identified. They were categorized by on-treatment systolic and diastolic blood pressures. The primary outcome was a composite of myocardial infarction, stroke, heart failure hospitalization, and peripheral artery disease. Of 920,533 participants (mean age, 57.3 years; female, 48.3%; mean follow-up, 2.75 years), the adjusted hazard ratios for systolic blood pressure of <110, 110-119, 120-129 (reference), 130-139, 140-149, 150-159, and ≥160 mmHg were 1.05 (95% confidence interval: 0.99-1.12), 0.97 (0.93-1.02), 1 (reference), 1.05 (1.01-1.09), 1.15 (1.11-1.20), 1.30 (1.23-1.37), and 1.76 (1.66-1.86), respectively; and for diastolic blood pressure of <60, 60-69, 70-79 (reference), 80-89, 90-99, and ≥100 mmHg were 1.25 (1.14-1.38), 0.99 (0.95-1.04), 1 (reference), 1.00 (0.96-1.03), 1.13 (1.09-1.18), and 1.66 (1.58-1.76), respectively. Among low-risk patients with hypertension, diastolic blood pressure <60 mmHg was associated with increased cardiovascular events, while systolic blood pressure <110 mmHg was not. Compared to previous investigations in high-risk patients, the potential harm of excessive blood pressure lowering was less pronounced in low-risk patients with hypertension. The association between low on-treatment blood pressure and cardiovascular events has been understudied in low-risk patients with hypertension. In our study with nationally representative working-age adults from general population with hypertension without elevated risk, increased risk of cardiovascular events was observed in diastolic blood pressure of <60 mmHg, but not in systolic blood pressure of <110 mmHg. Those results contrasted with previous investigations in high-risk patients where the risk of low on-treatment blood pressure was more pronounced.

Randomized controlled trials of biomarker targets

INTRODUCTION

Randomized controlled trials are used to estimate the causal effect of a treatment on a health outcome of interest in a patient population. Often the specified treatment in a randomized controlled trial is a medical intervention-such as a drug or procedure-experienced directly by the patient. Sometimes the "treatment" in a randomized controlled trial is a target-such as a goal biomarker measurement-that the patient's physician attempts to reach using available medications or procedures. Large randomized controlled trials of biomarker targets are common in clinical research, and trials have been conducted to compare targets in the management of hypertension, diabetes, anemia, and acute respiratory distress syndrome. However, different randomized controlled trials intended to evaluate the same biomarker targets have produced conflicting recommendations, and meta-analyses that aggregate results of trials of biomarker targets have been inconclusive.

METHODS

We use causal reasoning to explain why randomized controlled trials of biomarker targets can arrive at conflicting or misleading conclusions. We describe four key threats to the validity of trials of targets: (1) intention-to-treat analysis can be misleading when a direct effect of target assignment on the outcome exists due to lack of blinding; (2) incomparability in results across trials of targets; (3) time-varying adaptive treatment strategies; and (4) Goodhart's law, "when a measure becomes a target, it ceases to be a good measure."

RESULTS

We illustrate these findings using evidence from 15 randomized controlled trials of blood pressure targets for management of hypertension. Randomized trials of blood pressure targets exhibit substantial variation in the trial patient populations and antihypertensives used to achieve the blood pressure targets assigned in the trials. The trials did not compare or account for time-varying treatment strategies used to reach the randomized targets. Possible "off-target" effects of antihypertensive medications needed to reach lower blood pressure targets may explain the absence of a clear benefit from intensive blood pressure control.

DISCUSSION

Researchers should critically assess meta-analyses of trials of targets for variation in the types, distributions, and off-target effects of therapies studied. Trial investigators should release detailed information about the biomarker targets compared in new randomized trials, as well as confounders, treatments delivered, and outcomes. New randomized controlled trials should experimentally compare treatment algorithms incorporating biomarkers, rather than targets alone. Causal inference methodology that adjusts for time-varying confounding should be used to compare time-varying treatment strategies in observational settings.

Artificial Intelligence and Cardiovascular Risk Prediction: All That Glitters is not Gold

Artificial intelligence (AI) is a broad term referring to any automated systems that need 'intelligence' to carry out specific tasks. During the last decade, AI-based techniques have been gaining popularity in a vast range of biomedical fields, including the cardiovascular setting. Indeed, the dissemination of cardiovascular risk factors and the better prognosis of patients experiencing cardiovascular events resulted in an increase in the prevalence of cardiovascular disease (CVD), eliciting the need for precise identification of patients at increased risk for development and progression of CVD. AI-based predictive models may overcome some of the limitations that hinder the performance of classic regression models. Nonetheless, the successful application of AI in this field requires knowledge of the potential pitfalls of the AI techniques, to guarantee their safe and effective use in daily clinical practice. The aim of the present review is to summarise the pros and cons of different AI methods and their potential application in the cardiovascular field, with a focus on the development of predictive models and risk assessment tools.

Treatment strategies for isolated systolic hypertension in elderly patients

INTRODUCTION

Hypertension is a major and modifiable risk factor for cardiovascular disease. Its prevalence is rising as the result of population aging. Isolated systolic hypertension mostly occurs in older patients accounting for up to 80% of cases.

AREAS COVERED

The authors systematically review published studies to appraise the scientific and clinical evidence supporting the role of blood pressure control in elderly patients with isolated systolic hypertension, and to assess the influence of different drug treatment regimens on outcomes.

EXPERT OPINION

Antihypertensive treatment of isolated systolic hypertension significantly reduces the risk of morbidity and mortality in elderly patients. Thiazide diuretics and dihydropyridine calcium-channel blockers are the primary compounds used in randomized clinical trials. These drugs can be considered as first-line agents for the management of isolated systolic hypertension. Free or fixed combination therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and calcium-channel blockers or thiazide-like diuretics should also be considered, particularly when compelling indications such as coronary artery disease, chronic kidney disease, diabetes, and congestive heart failure coexist. There is also hot scientific debate on the optimal blood pressure target to be achieved in elderly patients with isolated systolic hypertension, but current recommendations are scarcely supported by evidence.

ANMCO/GICR-IACPR/SICI-GISE Consensus Document: the clinical management of chronic ischaemic cardiomyopathy

Stable coronary artery disease (CAD) is a clinical entity of great epidemiological importance. It is becoming increasingly common due to the longer life expectancy, being strictly related to age and to advances in diagnostic techniques and pharmacological and non-pharmacological interventions. Stable CAD encompasses a variety of clinical and anatomic presentations, making the identification of its clinical and anatomical features challenging. Therapeutic interventions should be defined on an individual basis according to the patient's risk profile. To this aim, management flow charts have been reviewed based on sustainability and appropriateness derived from recent evidence. Special emphasis has been placed on non-pharmacological interventions, stressing the importance of lifestyle changes, including smoking cessation, regular physical activity, and diet. Adherence to therapy as an emerging risk factor is also discussed.

Risk factors for short- and long-term mortality in very old patients with Clostridium difficile infection: A retrospective study

AIM

Most cases of Clostridium difficile infections (CDI) occur in patients aged 65 years and older. Older age is associated with increased mortality. Risk factors for mortality in patients aged 80 years and older are not well recognized.

METHODS

We analyzed retrospective data including 184 patients aged 80 years and older hospitalized with CDI during 2009-2014. We aimed to delineate risk factors for short- and long-term mortality.

RESULTS

The 30-day mortality was 33.2%; 1-year mortality was 64.7%. Median survival was 110 days (interquartile range 24-655 days). All four patients who underwent colectomy died. Risk factors for 30-day mortality in multivariate analysis were diabetes mellitus, low albumin and therapy other than metronidazole monotherapy, the latter probably reflecting higher severity of disease rather than a true predictor of mortality. Risk factors for long-term mortality analyzed in Cox regression were albumin ≤2.5 g/dL (HR 0.58, 95% CI 0.395-0.850), presentation with sepsis (HR 0.597, 95% CI 0.408-0.873), a non-independent activities of daily living baseline status (HR 0.460, 95% CI 0.236--0.897) and Charlson score (HR 0.867, 95% CI 0.801-0.938). None of the traditional severity indices for CDI (such as leukocytosis or creatinine increase) proved to be predictors of mortality over the age of 80 years.

CONCLUSIONS

The prognosis of old patients with CDI is dismal. Considering the high mortality, efforts to prevent CDI should be first priority in patients aged 80 years and older. Assessment of albumin levels should be part of the evaluation at presentation and considered when choosing treatment, rather than standard severity indexes for CDI. Geriatr Gerontol Int 2017; 17: 1378-1383.

Nocturnal blood pressure in primary open-angle glaucoma

PURPOSE

To evaluate the nocturnal blood pressure (BP) dipping-pattern in patients with manifest primary open-angle glaucoma (POAG) and to find possible associations with the severity of visual field damage.

METHODS

A number of 314 patients suffering from POAG were consecutively enrolled in this cross-sectional hospital-based study. Each patient had diurnal intraocular pressure (IOP) measurements, 24-hr BP monitoring and computerized perimetry with the Humphrey 30-2 sita Standard program. Inclusion criteria were a mean IOP of less than 15 mmHg with fluctuations of less than 5 mmHg and a visual acuity of at least 20/40. One eye was randomly selected. Based on the night-day BP ratio, a mean arterial nocturnal BP drop of less than 10% was considered as non-dipping, between 10% and 20% as physiological dipping and of more than 20% as over-dipping.

RESULTS

Glaucoma patients with daytime systemic normotension on the average had more visual field loss in the over-dipper group (MD = - 16.6 dB, IQR = -18.9 to -2.7 dB) than glaucoma patients with daytime systemic hypertension, who had less visual field defects in the over-dipper group (MD = -3.9 dB, IQR = -6.2 to -1.9 dB) (p = 0.004). This result was also found taking age, glaucoma duration, visual acuity, gender, systemic and topical medication as covariates into account.

CONCLUSIONS

To judge the nocturnal BP situation of an individual patient, it is important to do this in relation to the daytime BP level. Twenty-four-hour BP evaluation might be important for all patients with POAG, as nocturnal BP could be a modifiable risk factor for glaucoma severity and progression.

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.

Association between blood pressure and disability-free survival among community-dwelling elderly patients receiving antihypertensive treatment

A reduction of elevated blood pressure (BP) is an important treatment goal in elderly hypertensive patients. However, excessive reduction of systolic BP (SBP) and/or diastolic BP (DBP) might be harmful in such patients. We investigated whether this was the case with regard to risk of incident disability or death in community-dwelling elderly subjects. We analyzed 570 patients receiving antihypertensive treatment aged 65-94 years. The endpoint was the composite outcome of incident disability, defined as first certification of a support/care need or death. Relationships among each of the four classes of SBP or DBP and the risk of incident disability or death were estimated using the Cox proportional hazards model. Over four years, 77 (13.5%) incident disabilities or deaths occurred. After adjustment for age, sex and variables selected according to their univariate analysis P-value <0.20, the risk of events was significantly higher in subjects with baseline SBP<120 mm Hg (hazard ratio (HR)=2.81, P=0.023) and ⩾160 mm Hg (HR=4.32, P<0.001), compared with subjects with baseline SBP of 140-159 mm Hg, who showed the lowest incidence of events. This J-curve relationship was observed in very elderly patients (⩾75 years) but not in younger patients. Patients with SBP<120 mm Hg tended to have a higher risk of incident disability caused by cerebral events, and those with SBP⩾160 mm Hg had a higher risk of incident disability caused by falls/bone fractures. These observations indicate that excessive BP reduction could cause discontinuance of disability-free survival in community-dwelling elderly patients.

Tight Versus Standard Blood Pressure Control in Patients With Hypertension With and Without Cardiovascular Disease

An excessive blood pressure (BP) reduction might be dangerous in high-risk patients with cardiovascular disease. In the Studio Italiano Sugli Effetti CARDIOvascolari del Controllo della Pressione Arteriosa SIStolica (Cardio-Sis), 1111 nondiabetic patients with systolic BP ≥150 mm Hg were randomly assigned to a systolic BP target <140 mm Hg (standard control) or <130 mm Hg (tight control). We stratified patients by absence (n=895) or presence (n=216) of established cardiovascular disease at entry. Antihypertensive treatment was open-label and tailored to each patient’s needs. After 2-year follow-up, the primary end point of the study, electrocardiographic left ventricular hypertrophy, occurred less frequently in the tight than in the standard control group in the patients without (10.8% versus 15.2%) and with (14.1% versus 23.5%) established cardiovascular disease ( P for interaction=0.82). The main secondary end point, a composite of cardiovascular events and all-cause death, occurred less frequently in the tight than in the standard control group both in patients without (1.47 versus 3.68 patient-years; P =0.016) and with (7.87 versus 11.22 patient-years; P =0.049) previous cardiovascular disease. In a multivariable Cox model, allocation to tight BP control reduced the risk of cardiovascular events to a similar extent in patients with or without overt cardiovascular disease at randomization ( P for interaction=0.43). In conclusion, an intensive treatment aimed to lower systolic BP<130 mm Hg reduced left ventricular hypertrophy and improved clinical outcomes to a similar extent in patients with hypertension and without established cardiovascular disease.