Blood pressure and cardiovascular outcomes in patients with diabetes and high cardiovascular risk

Intensive Blood Pressure Lowering in Individuals With Low Diastolic Blood Pressure and Elevated Troponin Levels in SPRINT

BACKGROUND

Among individuals with hypertension and low diastolic blood pressure (DBP), the optimal BP target remains controversial due to concerns that BP lowering may reduce coronary perfusion. We determined the impact of intensive BP control among individuals with elevated systolic BP who have low DBP and elevated hs-cTnT (high-sensitivity cardiac troponin T) levels.

METHODS AND RESULTS

A total of 8828 participants in SPRINT (Systolic Blood Pressure Intervention Trial) were stratified by baseline DBP. Those with low DBP (<70 mm Hg) were further stratified by elevated hs-cTnT (≥14 ng/L) at baseline. The effects of intensive versus standard BP lowering on a cardiovascular disease composite end point, all-cause death, and 1-year change in hs-cTnT were determined. The combination of low DBP/high hs-cTnT was independently associated with a higher risk for cardiovascular disease and all-cause death, as well as greater 1-year increases in hs-cTnT, compared with DBP ≥70 mm Hg. However, randomization to intensive versus standard BP lowering led to similar reductions in cardiovascular disease risk among individuals with low DBP/high hs-cTnT (hazard ratio [HR], 0.82 [95% CI, 0.57-1.19]), low DBP/low hs-cTnT (HR, 0.48 [95% CI, 0.29-0.79]), and DBP ≥70 mm Hg (HR, 0.73 [95% CI, 0.60-0.89]; P for interaction=0.20). Intensive BP lowering also led to a reduction in all-cause death that was similar across groups (P for interaction=0.57).

CONCLUSIONS

In this nonprespecified subgroup analysis of SPRINT, individuals with low DBP and elevated hs-cTnT, low DBP and nonelevated hs-cTnT, and DBP ≥70 mm Hg derived similar cardiovascular disease and mortality benefits from intensive BP lowering. These findings warrant confirmation in other studies.

Real-World Systolic and Diastolic Blood Pressure Levels and Cardiovascular Mortality in Patients With Type 2 Diabetes-Results From a Large Registry Cohort in Asia

BACKGROUND

Elevated blood pressure (BP) is associated with increased risk of cardiovascular mortality. However, there is ongoing debate whether intensive BP lowering may paradoxically increase the risk of cardiovascular disease (CVD), especially in patients with type 2 diabetes (T2D). We investigated the association of BP with risk of CVD mortality in patients with T2D.

METHODS AND RESULTS

We used data on 83 721 patients with T2D from a multi-institutional diabetes registry in Singapore from 2013 to 2019. BP was analyzed as categories and restricted cubic splines using Cox multivariable regression analysis stratified by preexisting CVD and age (<65 years versus ≥65 years). The primary outcome was CVD mortality, determined via linkage with the national registry. Among 83 721 patients with T2D (mean age 65.3 years, 50.6% women, 78.9% taking antihypertensive medications), 7.6 per 1000 person-years experienced the primary outcome. Systolic BP had a graded relationship with a significant increase in CVD mortality at levels >120 to 129 mm Hg. Diastolic BP levels >90 mm Hg were significantly associated with CVD mortality in those aged ≥65 years. In addition, diastolic BP <70 mm Hg was associated with a significantly higher risk of CVD mortality in all patients.

CONCLUSIONS

In patients with T2D, clinic systolic BP levels ≥130 mm Hg or diastolic BP levels ≥90 mm Hg are associated with higher risk of CVD mortality. Diastolic BP <70 mm Hg is also associated with the risk of adverse CVD outcomes, although reverse causality cannot be ruled out.

Diabetes foot complications and standardized mortality rate in type 2 diabetes

AIM

To quantify the impact of foot complications on mortality outcomes in people with type 2 diabetes (T2D), and how routinely measured factors might modulate that risk.

MATERIALS AND METHODS

Data for individuals with T2D for 2010-2020, from the Salford Integrated Care Record (Salford, UK), were extracted for laboratory and clinical data, and deaths. Annual expected deaths were taken from Office of National Statistics mortality data. An index of multiple deprivation (IMD) adjusted the standardized mortality ratio (SMR_IMD). Life years lost per death (LYLD) was estimated from the difference between expected and actual deaths.

RESULTS

A total of 11 806 T2D patients were included, with 5583 new diagnoses and 3921 deaths during 2010-2020. The number of expected deaths was 2135; after IMD adjustment, there were 2595 expected deaths. Therefore, excess deaths numbered 1326 (SMR_IMD 1.51). No foot complications were evident in n = 9857. This group had an SMR_IMD of 1.13 and 2.74 LYLD. In total, 2979 patients had any foot complication recorded. In this group, the SMD_IMR was 2.29; of these, 2555 (75%) had only one foot complication. Patients with a foot complication showed little difference in percentage HbA1c more than 58 mmol/mol. In multivariate analysis, for those with a foot complication and an albumin-to-creatinine ratio of more than 3 mg/mmol, the odds ratio (OR) for death was 1.93, and for an estimated glomerular filtration rate of less than 60 mL/min/1.73m2 , the OR for death was 1.92.

CONCLUSIONS

Patients with T2D but without a foot complication have an SMR_IMD that is only slightly higher than that of the general population. Those diagnosed with a foot complication have a mortality risk that is double that of those without T2D.

Impact of Preprocedural Diastolic Blood Pressure on Outcomes in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Recent US guidelines recommend lower blood pressure (BP) targets in hypertension, but aggressive lowering of diastolic BP (DBP) can occur at the expense of myocardial perfusion, particularly in the presence of coronary artery disease. We sought to establish the long-term impact of low DBP on mortality among patients undergoing percutaneous coronary intervention with well-controlled systolic BP.

METHODS

We analyzed data from 12 965 patients undergoing percutaneous coronary intervention between 2009 and 2018 from the Melbourne Interventional Group registry who had a preprocedural systolic BP of ≤140 mm Hg. Patients with ST-elevation myocardial infarction, cardiogenic shock, and out-of-hospital arrest were excluded. Patients were stratified into 5 groups according to preprocedural DBP: <50, 50 to 59, 60 to 69, 70 to 79, and ≥80 mm Hg. The primary outcome was long-term, all-cause mortality. Mortality data were derived from the Australian National Death Index.

RESULTS

Patients with DBP<50 mm Hg were older with higher rates of diabetes, renal impairment, prior myocardial infarction, left ventricular dysfunction, peripheral and cerebrovascular disease (all P<0.001). Patients with DBP<50 mm Hg had higher 30-day (2.5% versus 0.7% for the other 4 quintiles; P<0.0001) and long-term mortality (median, 3.6 years; follow-up, 29% versus 11%; P<0.0001). Cox-regression analysis revealed that DBP<50 mm Hg was an independent predictor of long-term mortality (hazard ratio [HR], 1.55 [95% CI, 1.20-2.00]; P=0.001).

CONCLUSIONS

In patients with well-controlled systolic BP undergoing percutaneous coronary intervention, low DBP (<50 mm Hg) is an independent predictor of long-term mortality.

The optimal definition and prediction nomogram for left ventricular remodelling after acute myocardial infarction

AIMS

Left ventricular (LV) remodelling after acute myocardial infarction (AMI) is associated with heart failure and increased mortality. There was no consensus on the definition of LV remodelling, and the prognostic value of LV remodelling with different definitions has not been compared. We aimed to find the optimal definition and develop a prediction nomogram as well as online calculator that can identify patients at risk of LV remodelling.

METHODS AND RESULTS

This prospective, observational study included 829 AMI patients undergoing percutaneous coronary intervention from January 2015 to January 2020. Echocardiography was performed within the 48 h of admission and at 6 months after infarction to evaluate LV remodelling, defined as a 20% increase in LV end-diastolic volume (LVEDV), a 15% increase in LV end-systolic volume (LVESV), or LV ejection fraction (LVEF) < 50% at 6 months. The impact of LV remodelling on long-term outcomes was analysed. Lasso regression was performed to screen potential predictors, and multivariable logistic regression analysis was conducted to establish the prediction nomogram. The area under the curve, calibration curve and decision curve analyses were used to determine the discrimination, calibration and clinical usefulness of the remodelling nomogram. The incidences of LV remodelling defined by LVEDV, LVESV and LVEF were 24.85% (n = 206), 28.71% (n = 238) and 14.60% (n = 121), respectively. Multivariable Cox regression models demonstrated that different definitions of LV remodelling were independently associated with the composite endpoint. However, only remodelling defined by LVEF was significantly connected with long-term mortality (hazard ratio = 2.78, 95% confidence interval 1.41-5.48, P = 0.003). Seven variables were selected to construct the remodelling nomogram, including diastolic blood pressure, heart rate, AMI type, stent length, N-terminal pro brain natriuretic peptide, troponin I, and glucose. The prediction model had an area under the receiver operating characteristics curve of 0.766. The calibration curve and decision curve analysis indicated consistency and better net benefit in the prediction model.

CONCLUSIONS

LV remodelling defined by LVEDV, LVESV and LVEF were independent predictors for long-term mortality or heart failure hospitalization in AMI patients after percutaneous coronary intervention. However, only remodelling defined by LVEF was suitable for predicting all-cause death. In addition, the nomogram can provide an accurate and effective tool for the prediction of postinfarct remodelling.

Instrumental variable model average with applications in Mendelian randomization

Mendelian randomization is a technique used to examine the causal effect of a modifiable exposure on a trait using an observational study by utilizing genetic variants. The use of many instruments can help to improve the estimation precision but may suffer bias when the instruments are weakly associated with the exposure. To overcome the difficulty of high-dimensionality, we propose a model average estimator which involves using different subsets of instruments (single nucleotide polymorphisms, SNPs) to predict the exposure in the first stage, followed by weighting the submodels' predictions using penalization by common penalty functions such as least absolute shrinkage and selection operator (LASSO), smoothly clipped absolute deviation (SCAD) and minimax concave penalty (MCP). The model averaged predictions are then used as a genetically predicted exposure to obtain the estimation of the causal effect on the response in the second stage. The novelty of our model average estimator also lies in that it allows the number of submodels and the submodels' sizes to grow with the sample size. The practical performance of the estimator is examined in a series of numerical studies. We apply the proposed method on a real genetic dataset investigating the relationship between stature and blood pressure.

Impact of pre-procedural diastolic blood pressure on major adverse cardiovascular events in non ST-segment elevation myocardial infarction patients following revascularization

Previous reports have observed a consistent J-shaped relationship between cardiac events and diastolic blood pressure (DBP). However, the EPHESUS study clearly showed that myocardial reperfusion abolished the J-shaped association, suggesting a different association pattern after revascularization. Therefore, in this study, we investigated the different patterns in which DBP affects cardiovascular risk in non ST-segment elevation myocardial infarction (NSTEMI) patients after revascularization, which may benefit the risk stratification for NSTEMI patients. We obtained the NSTEMI database from the Dryad data repository and analyzed the association between preprocedural DBP and long-term major adverse cardiovascular events (MACEs) in 1486 patients with NSTEMI following percutaneous coronary intervention (PCI). Multivariate regression models were used to assess the impact of DBP on outcomes in an adjusted fashion according to DBP tertiles. The p value for the trend was calculated using linear regression. When examined as a continuous variable, a multivariate regression analysis was repeated. Pattern stability was verified by interaction and stratified analyses. The median (interquartile range) age of the patients was 61.00 (53.00-68.00) years, and 63.32% were male. Cardiac death showed a graded increase as the DBP tertile increased (p for trend = 0.0369). When examined as a continuous variable, a 1 mmHg increase in DBP level was associated with an 18% higher risk of long-term cardiac death (95% CI: 1.01-1.36, p = 0.0311) and a 2% higher risk of long-term all-cause death (95% CI: 1.01-1.04; p = 0.0178). The association pattern remained stable when stratified by sex, age, diabetes, hypertension, and smoking status. An association between low DBP and higher cardiovascular risk was not observed in our study. We showed that higher preprocedural DBP increased the risk of long-term cardiac death and all-cause death in patients with NSTEMI following PCI.

[Individualising antihypertensive therapy in patients with diabetes. A guideline by the Austrian Diabetes Association (update 2023)]

Hypertension is one of the most important comorbidities of diabetes, contributing significantly to death and leading to macrovascular and microvascular complications. When assessing the medical priorities for patients with diabetes, treating hypertension should be a primary consideration. In the present review practical approaches to hypertension in diabetes, including individualized targets for preventing specific complications are discussed according to current evidence and guidelines. Blood pressure values of about 130/80 mm Hg are associated with the best outcome; most importantly, at least blood pressure values < 140/90 mm Hg should be achieved in most patients. Angiotensin converting enzyme inhibitors or angiotensin receptor blockers should be preferred in patients with diabetes, especially in those who also have albuminuria or coronary artery disease. Most patients with diabetes require combination therapy to achieve blood pressure goals; agents with proven cardiovascular benefit should be used (including, besides angiotensin converting enzyme inhibitors and alternatively angiotensin receptor blockers, dihydropyridin-calcium antagonists and thiazide diuretics), preferable in single-pill combinations. Once the target is achieved, antihypertensive drugs should be continued. Newer antidiabetic medications such as SGLT-2-inhibitors or GLP1-receptor agonists have also antihypertensive effects.

Pulse pressure and all-cause mortality in ischaemic heart failure patients: a prospective cohort study

BACKGROUND

Whether the association between pulse pressure (PP) and mortality varies with systolic blood pressure (SBP) in ischaemic heart failure (HF) with left ventricular systolic dysfunction (LVSD) is unknown.

OBJECTIVE

To evaluate the association between PP and all-cause mortality in ischaemic HF patients with SBP status at admission.

PATIENTS AND METHODS

This prospective cohort study included 1581 ischaemic HF patients with LVSD. A total of 23.3% (n = 368) and 22.2% (n = 351) of the participants had SBP <110 mmHg and SBP >140 mmHg, respectively, with more than 80% of participants being male. Restricted cubic spline was performed to determine whether a nonlinear relationship existed between PP and all-cause mortality risk. A multivariable Cox proportional hazards model was used to assess the association between PP and all-cause mortality.

RESULTS

After a median of follow-up of 3.0 years, 257 events (16.4%) were observed in the cohort. There was a J-shaped relationship between PP and all-cause mortality (P value for nonlinearity = 0.020), with a risk nadir of approximately 46-49 mmHg. All-cause mortality risk varied with SBP status. Higher PP was associated with worse prognosis when the SBP was ≥110 mmHg, whereas the relationship did not reach statistical significance when the SBP was <110 mmHg.

CONCLUSION

A J-shaped relationship between PP and all-cause mortality was observed in ischaemic HF patients with LVSD, and higher PP was associated with worse prognosis only in those with SBP ≥110 mmHg. Further studies are needed to corroborate these findings.KEY MESSAGESA J-shaped relationship between pulse pressure and all-cause mortality was observed in ischaemic heart failure patients with left ventricular systolic dysfunction, with a risk nadir of approximately 46-49 mmHg.All-cause mortality risk varied with systolic blood pressure status, and higher pulse pressure was associated with worse prognosis when systolic blood pressure was above 110 mmHg.

Influence of hypertension duration and blood pressure levels on cardiovascular disease and all-cause mortality: A large prospective cohort study

Background and objects

A longer duration of hypertension (HTN) has been suggested to be associated with a greater risk of cardiovascular disease (CVD). Whether such an association is similar for mortality risk, and whether HTN duration is associated with CVD/mortality beyond blood pressure (BP) control levels are yet to be assessed. We aimed to examine the associations of HTN duration and the combination of HTN duration and systolic blood pressure (SBP)/diastolic blood pressure (DBP) with risks of CVD and all-cause mortality.

Methods

We used data on ∼450,000 UK residents. Participants were categorized by HTN status and HTN duration. The primary outcome was a composite of non-fatal myocardial infarction, non-fatal stroke and CVD death. We also explored the results for the above-mentioned CVD outcomes separately. All-cause mortality was also used as a secondary outcome. The age at HTN diagnosis was obtained by self-report. HTN duration was calculated as baseline age minus age at diagnosis.

Results

Among all participants, compared with non-hypertensive participants, those with a longer HTN duration had increased risks of CVD and all-cause mortality. These associations persisted among hypertensive patients. Specifically, compared with patients with HTN durations of < 5 y, patients with a HTN duration of 5 to < 10 y, 10 to < 15 y, and ≥ 15 y had adjusted HRs (95% CI) of 1.09 (1.03, 1.17), 1.21 (1.13, 1.31), and 1.38 (1.29, 1.48) for composite CVD (P-trend < 0.001); and 1.03 (0.97, 1.08), 1.09 (1.02, 1.16), and 1.17 (1.11, 1.24) for all-cause mortality (P-trend < 0.001). When compared with hypertensive patients with BP < 140/90 mmHg and a HTN duration of < 5 y, adjusted HRs of CVD and all-cause mortality were 1.35 (1.15, 1.57) and 1.26 (1.11, 1.42) for those with BP < 140/90 mmHg and a duration of ≥ 15 y, and 1.43 (1.26, 1.60) and 1.13 (1.03, 1.25) for those with BP ≥ 140/90 mmHg and durations of ≥ 15 y, respectively.

Conclusion

A longer HTN duration was associated with increased risks of CVD and overall death in a linear fashion, and these associations were independent of BP control levels.

Association between Coronary Artery Plaque Progression and Liver Fibrosis Biomarkers in Population with Low Calcium Scores

Background: The severity of nonalcoholic fatty liver disease (NAFLD) has been found to be associated with atherosclerosis burden. However, whether liver fibrosis scores can be used to predict atherosclerosis progression, especially for patients with low calcium scores, remains undetermined. Methods: A total of 165 subjects who underwent repeated coronary computed tomography angiography (CCTA) and had low calcium scores (<100) were enrolled. The segment stenosis score (SSS) from the CCTA was measured, and the association between SSS progression and biochemical parameters was analyzed in addition to liver fibrosis scores, including nonalcoholic fatty liver disease fibrosis score (NFS), fibrosis-4 index (FIB-4), aspartate aminotransferase (AST) to platelet ratio index (APRI), and Forns score. Results: When compared with those without plaque at baseline (SSS = 0), subjects with plaque had higher blood pressure, higher coronary artery calcium (CAC) scores, and higher liver fibrosis scores, including Forns score, Fib-4, and NFS. During the medium follow-up interval of 24.7 months, 60 (39.4%) patients displayed SSS progression, while the remaining 105 (63.6%) patients showed no CAD progression. In a multivariate analysis, being male having a high diastolic blood pressure (DBP), and having a high NFS liver fibrosis score were independently associated with the odds ratio for SSS progression. Conclusions: Higher baseline blood pressure and liver fibrosis markers are associated with the presence of coronary artery disease (CAD) plaques in subjects in early CAD stages. For disease progression, the male gender, DBP, and NFS appear to be independently associated with coronary atherosclerosis plaque progression in subjects with low calcium scores.

Clinical benefit of systolic blood pressure within the target range among patients with or without diabetes mellitus: a propensity score-matched analysis of two randomized clinical trials

BACKGROUND

Recent guidelines recommended a systolic blood pressure (SBP) target of < 130 mmHg for patients with or without diabetes but without providing a lower bound. Our study aimed to explore whether additional clinical benefits remain at achieved blood pressure (BP) levels below the recommended target.

METHODS

We performed a secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) among the non-diabetic population and the Action to Control Cardiovascular Risk in Diabetes BP (ACCORD-BP) trial among diabetic subjects. We used the propensity score method to match patients from the intensive BP group to those from the standard group in each trial. Individuals with different achieved BP levels from the intensive BP group were used as "reference." For each stratum, the trial-specific primary outcome (i.e., composite outcome of myocardial infarction (MI), acute coronary syndrome not resulting in MI, stroke, acute decompensated heart failure (HF), or cardiovascular death for SPRINT; non-fatal MI, non-fatal stroke, or cardiovascular death for ACCORD-BP) was compared by Cox regression.

RESULTS

A non-linear association was observed between the mean achieved BP and incidence of composite cardiovascular events, regardless of treatment allocation. The significant treatment benefit for primary outcome remained at SBP 110-120 mmHg (hazard ratio, 0.59 [95% CI, 0.46, 0.76] for SPRINT; 0.67 [0.52, 0.88] for ACCORD-BP) and SBP 120-130 mmHg for SPRINT (0.47 [0.34, 0.63]) but not for ACCORD-BP (0.93 [0.70, 1.23]). The results were similar for the secondary outcomes including all-cause mortality, cardiovascular mortality, MI, stroke, and HF. Intensive BP treatment benefits existed among patients maintaining a diastolic BP of 60-70 mmHg but were less distinct.

CONCLUSIONS

The treatment benefit persists at as low as SBP 110-120 mmHg irrespective of diabetes status. Achieved very low BP levels appeared to increase cardiovascular events and all-cause mortality.

Association Between Admission Pulse Pressure and Long-Term Mortality in Elderly Patients With Type 2 Diabetes Mellitus Admitted for Acute Coronary Syndrome: An Observational Cohort Study

Objective

The aim of this study was to assess the effect of pulse pressure (PP) at admission on long-term cardiac and all-cause mortality among elderly patients with type 2 diabetes mellitus (T2DM) admitted for acute coronary syndrome (ACS).

Methods

This is a retrospective observational study. The patients aged at least 65 years with T2DM and ACS from January 2013 to April 2018 were enrolled and divided into 4 groups according to admission PP: <50 mmHg; 50–59 mmHg; 60–69 mmHg, and ≥70 mmHg. Multivariate Cox proportional hazard regression analyses and restricted cubic spline were performed to determine the association between PP and outcomes (cardiac and all-cause death).

Results

A total of 2,587 consecutive patients were included in this cohort study. The mean follow-up time was 39.2 months. The incidences of cardiac death and all-cause death were 6.8% (n = 176) and 10.8% (n = 280), respectively. After multivariate adjustment in the whole cohort, cardiac and all-cause mortality were significantly higher in PP <50 mmHg group and PP ≥70 mmHg group, compared with PP 50–59 mmHg group. Further analysis in acute myocardial infarction (AMI) subgroup confirmed that PP <50 mmHg was associated with cardiac death [hazard ratios (HR) 2.92, 95% confidence interval (CI) 1.45–5.76, P = 0.002] and all-cause death (HR 2.08, 95% CI 1.20–3.58, P = 0.009). Meanwhile, PP ≥70 mmHg was associated with all-cause death (HR 1.78, 95% CI 1.05–3.00, P = 0.031). However, admission PP did not appear to be a significant independent predictor in unstable angina pectoris (UAP) subgroup. There is a U-shaped correlation between PP and cardiac and all-cause mortality in the whole cohort and UAP subgroup and a J-shaped correlation in the AMI subgroup, both with a nadir at 50–59 mmHg.

Conclusion

In elderly patients with T2DM admitted for ACS, admission PP is an independent and strong predictor for long-term cardiac and all-cause mortality, especially in patients with AMI.

Comprehensive Management of Cardiovascular Risk Factors for Adults With Type 2 Diabetes: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death in patients with diabetes. Cardiovascular disease in diabetes is multifactorial, and control of the cardiovascular risk factors leads to substantial reductions in cardiovascular events. The 2015 American Heart Association and American Diabetes Association scientific statement, "Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence," highlighted the importance of modifying various risk factors responsible for cardiovascular disease in diabetes. At the time, there was limited evidence to suggest that glucose-lowering medications reduce the risk of cardiovascular events. At present, several large randomized controlled trials with newer antihyperglycemic agents have been completed, demonstrating cardiovascular safety and reduction in cardiovascular outcomes, including cardiovascular death, myocardial infarction, stroke, and heart failure. This AHA scientific statement update focuses on (1) the evidence and clinical utility of newer antihyperglycemic agents in improving glycemic control and reducing cardiovascular events in diabetes; (2) the impact of blood pressure control on cardiovascular events in diabetes; and (3) the role of newer lipid-lowering therapies in comprehensive cardiovascular risk management in adults with diabetes. This scientific statement addresses the continued importance of lifestyle interventions, pharmacological therapy, and surgical interventions to curb the epidemic of obesity and metabolic syndrome, important precursors of prediabetes, diabetes, and comorbid cardiovascular disease. Last, this scientific statement explores the critical importance of the social determinants of health and health equity in the continuum of care in diabetes and cardiovascular disease.

The diastolic blood pressure J-curve revisited: An update

Hypertension remains a leading cause of morbidity and mortality. Recent treatment guidelines stress more strict systolic blood pressure (SBP) targets without regard for abnormally low achieved diastolic blood pressures (DBP). However, as DBP falls below a critical level, adverse events increase, the so-called J-shaped curve. Proponents argue that the low DBP is causative due to reduced coronary perfusion during diastole with obstructive coronary artery disease (CAD), whereas others postulate the J-curve represents reverse causality from underlying comorbidity. Most data are observational, derived from population-based cohorts or post-hoc analyses of randomized controlled trials (RCT) conducted for other reasons. The purpose of this review is to analyze the observational studies performed over the last decade addressing the J-curve, with consideration of earlier data. Overall, a J-curve exists, but it remains uncertain whether low DBP is causative or instead reflects reverse causation from either diseased vasculature (widened pulse pressure) or severe underlying comorbidity. The most convincing data for causation come from studies restricted to patients with documented CAD, with evidence suggesting revascularization may mitigate risk. RCTs are needed to determine if a low DBP should preclude intensification of therapy, especially with documented CAD. Firm recommendations cannot be made with contemporary data.

Association of Blood Pressure with Cardiovascular Outcome and Mortality: Results from the KNOW-CKD Study

BACKGROUND

Optimal BP control is a major therapeutic strategy to reduce adverse cardiovascular events and mortality in patients with CKD. We studied the association of BP with adverse cardiovascular outcome and all-cause death in patients with CKD.

METHODS

Among 2,238 participants from the KoreaN cohort study for Outcome in patients With CKD, 2,226 patients with baseline BP measurements were enrolled. Main predictor was SBP categorized by 5 levels: <110, 110-119, 120-129, 130-139, and ≥140 mmHg. Primary endpoint was a composite outcome of all-cause death or incident cardiovascular events. We primarily used marginal structural models using averaged and the most recent time-updated SBPs.

RESULTS

During a median follow-up of 10233.79 person-years (median 4.60 years), the primary composite outcome occurred in 240 (10.8%) participants, with a corresponding incidence rate of 23.5 (95% CI, 20.7-26.6) per 1,000 patient-years. Marginal structural models with averaged SBP showed a U-shaped relationship with the primary outcome. Compared to time-updated SBP of 110-119 mmHg, hazard ratios (95% CI) for <110, 120-129, 130-139, and ≥140 mmHg were 2.47 (1.48-4.11), 1.29 (0.80-2.08), 2.15 (1.26-3.69), and 2.19 (1.19-4.01), respectively. Marginal structural models with the most recent SBP also showed similar findings.

CONCLUSIONS

In Korean patients with CKD, there was a U-shaped association of SBP with the risk of adverse clinical outcome. Our findings highlight the importance of BP control and suggest a potential hazard of SBP <110 mmHg.

Echocardiography Predictors of Survival in Hypertensive Patients With Left Ventricular Hypertrophy

BACKGROUND

Left ventricular hypertrophy (LVH) is a well-known target organ damage. Concentric hypertrophy is the strongest predictor of increased risk of cardiovascular events, but the predictive value of individual echocardiographic parameters remains unclear.The aim of this study was to search for echocardiographic and hemodynamic variables associated with concentric and eccentric remodeling and their association with long-term cardiovascular outcomes.

METHODS

Patients with echocardiography performed within 1 year prior to the initial clinic visit were included into the study. Logistic regression and multivariable Cox-proportional hazards were calculated according to several risk factors and variables. Additionally, cubic spline interpolation was used.

RESULTS

We observed 690 patients for 10 years. There was a total of 177 major adverse cardiac and cerebrovascular events (MACCE) and 90 deaths over a 10-year period. Left ventricular concentric hypertrophy is associated with worse outcomes than eccentric hypertrophy in hypertensive subjects. Interestingly, different echocardiographic parameters contributed to risk depending on type of hypertrophy. In concentric hypertrophy, relative wall thickness provides linear prediction of risk for all-cause mortality (ACM) and composite endpoint. Systolic blood pressure is a significant predictor of MACCE. Blood pressure variability also showed significant predictive value for MACCE and ACM.

CONCLUSIONS

These data indicate risk stratification based on LVH need to consider different measures based on the type of remodeling.

Are there sex differences in the effect of type 2 diabetes in the incidence and outcomes of myocardial infarction? A matched-pair analysis using hospital discharge data

BACKGROUND

To analyze incidence, use of therapeutic procedures, and in-hospital outcomes in patients with ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) according to the presence of type 2 diabetes (T2DM) in Spain (2016-2018) and to investigate sex differences.

METHODS

Using the Spanish National Hospital Discharge Database, we estimated the incidence of myocardial infarctions (MI) in men and women with and without T2DM aged ≥ 40 years. We analyzed comorbidity, procedures, and outcomes. We matched each man and woman with T2DM with a non-T2DM man and woman of identical age, MI code, and year of hospitalization. Propensity score matching was used to compare men and women with T2DM.

RESULTS

MI was coded in 109,759 men and 44,589 women (30.47% with T2DM). The adjusted incidence of STEMI (IRR 2.32; 95% CI 2.28-2.36) and NSTEMI (IRR 2.91; 95% CI 2.88-2.94) was higher in T2DM than non-T2DM patients, with higher IRRs for NSTEMI in both sexes. The incidence of STEMI and NSTEMI was higher in men with T2DM than in women with T2DM. After matching, percutaneous coronary intervention (PCI) was less frequent among T2DM men than non-T2DM men who had STEMI and NSTEMI. Women with T2DM and STEMI less frequently had a code for PCI that matched that of non-T2DM women. In-hospital mortality (IHM) was higher among T2DM women with STEMI and NSTEMI than in matched non-T2DM women. In men, IHM was higher only for NSTEMI. Propensity score matching showed higher use of PCI and coronary artery bypass graft and lower IHM among men with T2DM than women with T2DM for both STEMI and NSTEMI.

CONCLUSIONS

T2DM is associated with a higher incidence of STEMI and NSTEMI in both sexes. Men with T2DM had higher incidence rates of STEMI and NSTEMI than women with T2DM. Having T2DM increased the risk of IHM after STEMI and NSTEMI among women and among men only for NSTEMI. PCI appears to be less frequently used in T2DM patients After STEMI and NSTEMI, women with T2DM less frequently undergo revascularization procedures and have a higher mortality risk than T2DM men.

Impact of diabetes on coronary severity and cardiovascular outcomes in patients with heterozygous familial hypercholesterolaemia

AIMS

Type 2 diabetes mellitus (T2DM) is an independent risk factor for cardiovascular disease. However, the association between T2DM and coronary artery disease (CAD) in patients with heterozygous familial hypercholesterolaemia (HeFH) has not been thoroughly evaluated. Our study aimed to assess the effect of T2DM on CAD severity and hard cardiovascular endpoints in a HeFH cohort.

METHODS AND RESULTS

A total of 432 patients with HeFH with a molecular and/or clinical Dutch Lipid Clinic Network score ≥6 (definite and probable) were enrolled. Patients were divided into a T2DM group (n = 99) and a non-T2DM group (n = 333). The severity of coronary stenosis was assessed by the number of diseased vessels and Gensini, SYNTAX, and Jeopardy scores. Hard endpoints included a composite of non-fatal myocardial infarction, non-fatal stroke, and cardiac death. Cox regression and Kaplan-Meier analyses were used to evaluate the effect of T2DM on hard cardiovascular endpoints. The prevalence of CAD was higher in patients with T2DM compared with those without (96.0% vs. 77.5%, respectively; P < 0.001). Patients with T2DM demonstrated a greater number of diseased vessels (P = 0.029) and more severe coronary lesions with high Gensini, SYNTAX, and Jeopardy score tertiles (P = 0.031, P = 0.001, and P = 0.024, respectively). During a median of 3.75 years up to a maximum of 9 years of follow-up, hard endpoints occurred in 13 of 99 patients with T2DM and 16 of 333 without T2DM at baseline. Compared with patients without T2DM, patients with T2DM were at a significantly greater risk of hard endpoints [multivariate adjusted hazard ratio (HR) 2.32, 95% confidence interval (CI) 1.02-4.84; P = 0.025]. Additionally, patients with T2DM and good glucose control (HbA1c < 7.0%) were at a lower risk of hard endpoints compared with those with poor glucose control (HbA1c ≥ 7.0%, HR 0.08, 95% CI 0.01-0.56; P = 0.011).

CONCLUSION

We conclude that T2DM is an independent predictor of CAD severity when assessed by number of diseased vessels, Gensini, SYNTAX, Jeopardy scores, and hard cardiovascular endpoints, suggesting that T2DM could be further used for risk stratification of patients with HeFH.

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.

Do the 2017 blood pressure cut-offs improve 10-year cardiovascular disease mortality risk prediction?

BACKGROUND AND AIMS

High blood pressure (BP) is a significant predictor for cardiovascular disease (CVD) mortality. The 2017 American College of Cardiology/American Heart Association guideline reclassified the BP categories; however, its impact on CVD mortality prediction is still unclear. Our study aimed to examine whether the application of new BP cut-offs could improve 10-year CVD mortality prediction among US adults.

METHODS AND RESULTS

This population-based cohort study linked data from the US National Health and Nutrition Examination Survey (1988-1994 and 1999-2004) and National Death Index (up to December 31, 2015). We constructed original and modified, using new BP cut-offs, Systematic COronary Risk Evaluation models to predict 10-year CVD mortality. We measured model discrimination and calibration using the Harrell's C statistic and calibration plots, respectively. We calculated the net reclassification index to evaluate the reclassification. In addition, we compared the sensitivity, specificity, predictive values (PVs), and likelihood ratios (LRs). Among 28,964 adults (aged ≥ 20 years), 1493 have died of CVD within ten years of follow-up. The modified models had improvements in calibration and reclassification instead of discrimination compared to the original models. The modified models have higher sensitivity and negative PV; however, they have lower specificity, positive PV, positive LR, and negative LR.

CONCLUSIONS

The modified models failed to improve the discrimination of 10-year CVD mortality. However, they could increase the calibration and reclassification and capture more participants with high CVD risk. More studies are needed on the potential use of the new BP cut-offs in the CVD primary prevention.

Blood pressure and mortality in patients with type 2 diabetes and a recent coronary event in the ELIXA trial

BACKGROUND

The relationship between blood pressure and mortality in type 2 diabetes (T2DM) is controversial, with concern for increased risk associated with excessively lowered blood pressure.

METHODS

We evaluated whether prior cardiovascular disease (CVD) altered the relationship between baseline blood pressure and all-cause mortality in 5852 patients with T2DM and a recent acute coronary syndrome (ACS) who participated in the ELIXA (Evaluation of Lixisenatide in Acute Coronary Syndrome) trial. Risk of death was assessed in Cox models adjusted for age, sex, race, heart rate, BMI, smoking, diabetes duration, insulin use, HbA1c, eGFR, brain natriuretic peptide (BNP), urine albumin/creatinine ratio, treatment allocation and prior coronary revascularization.

RESULTS

Although overall there was no significant association between systolic blood pressure (SBP) and mortality (hazard ratio per 10 mmHg lower SBP 1.05 (95% CI 0.99-1.12) P = 0.10), lower SBP was significantly associated with higher risk of death (hazard ratio per 10 mmHg lower SBP 1.13 (95% CI 1.04-1.22) P = 0.002) in 2325 patients with additional CVD (index ACS+ at least one of the following prior to randomization: myocardial infarction other than the index ACS, stroke or heart failure). In 3527 patients with only the index ACS no significant association was observed (hazard ratio per 10 mmHg lower SBP 0.95 (0.86-1.04) P = 0.26; P for interaction 0.005).

CONCLUSIONS

The association between blood pressure and mortality was modified by additional CVD history in patients with type 2 diabetes and a recent coronary event. When blood pressures measured after an acute coronary event are used to assess the risk of death in patients with type 2 diabetes, the cardiovascular history needs to be taken into consideration. Trial registration ClinicalTrials.gov number NCT01147250, first posted June 22, 2010.

Analysis of clinical trials of new drugs in China as of 2019

The research and development (R&D) of new drugs indicates scientific progress and economic development. However, little is known regarding ongoing or recent clinical trials in China. We analyzed data from clinical trials published before December 31, 2019, and found that the annual registration numbers are increasing annually in the country. Based on clinical indications, most tested drugs target cancers, nervous system, infections, and the cardiovascular system. Furthermore, clinical trials are mostly concentrated in Beijing, Shanghai, and Jiangsu, and conducted by large pharmaceutical companies, with multiple trials for several generic drugs. Going forward, it will be necessary to promote R&D in China of clinically relevant innovative drugs, drug delivery systems, and novel traditional Chinese medicine (TCM) and biological products, as well as to have a balanced distribution of clinical trials to sustainably meet public health needs.

Cardiovascular outcomes and achieved blood pressure in patients with and without diabetes at high cardiovascular risk

AIMS

Studies have shown a non-linear relationship between systolic blood pressure (SBP) and diastolic blood pressure (DBP) and outcomes, with increased risk observed at both low and high blood pressure (BP) levels. We hypothesized that the BP-risk association is different in individuals with and without diabetes at high cardiovascular risk.

METHODS AND RESULTS

We identified patients with (N = 11 487) or without diabetes (N = 19 450), from 30 937 patients, from 133 centres in 44 countries with a median follow-up of 56 months in the ONTARGET/TRANSCEND studies. Patients had a prior history of stroke, myocardial infarction (MI), peripheral artery disease, or were high-risk diabetics. Patients in ONTARGET had been randomized to ramipril 10 mg daily, telmisartan 80 mg daily, or the combination of both. Patients in TRANSCEND were ACE intolerant and randomized to telmisartan 80 mg daily or matching placebo. We analysed the association of mean achieved in-trial SBP and DBP with the composite outcome of cardiovascular death, MI, stroke and hospitalization for congestive heart failure (CHF), the components of the composite, and all-cause death. Data were analysed by Cox regression and restricted cubic splines, adjusting for risk markers including treatment allocation and accompanying cardiovascular treatments. In patients with diabetes, event rates were higher across the whole spectrum of SBP and DBP compared with those without diabetes (P < 0.0001 for the primary composite outcome, P < 0.01 for all other endpoints). Mean achieved in-trial SBP ≥160 mmHg was associated with increased risk for the primary outcome [diabetes/no diabetes: adjusted hazard ratio (HR) 2.31 (1.93-2.76)/1.66 (1.36-2.02) compared with non-diabetics with SBP 120 to <140 mmHg], with similar findings for all other endpoints in patients with diabetes, and for MI and stroke in patients without diabetes. In-trial SBP <120 mmHg was associated with increased risk for the combined outcome in patients with diabetes [HR 1.53 (1.27-1.85)], and for cardiovascular death and all-cause death in all patients. In-trial DBP ≥90 mmHg was associated with increased risk for the primary outcome [diabetes/no diabetes: HR 2.32 (1.91-2.82)/1.61 (1.35-1.93) compared with non-diabetics with DBP 70 to <80 mmHg], with similar findings for all other endpoints, but not for CHF hospitalizations in patients without diabetes. In-trial DBP <70 mmHg was associated with increased risk for the combined outcome in all patients [diabetes/no diabetes: HR 1.77 (1.51-2.06)/1.30 (1.16-1.46)], and also for all other endpoints except stroke.

CONCLUSION

High on treatment BP levels (≥160 or ≥90 mmHg) are associated with increased risk of cardiovascular outcomes and death. Also low levels (<120 or <70 mmHg) are associated with increased cardiovascular outcomes (except stroke) and death. Patients with diabetes have consistently higher risks over the whole BP range, indicating that achieving optimal BP goals is most impactful in this group. These data favour guidelines taking lower BP boundaries into consideration, in particular in diabetes.

CLINICAL TRIAL REGISTRATION

http://clinicaltrials.gov.Unique identifier: NCT00153101.

The effect of glucagon-like peptide-1 receptor agonists liraglutide and semaglutide on cardiovascular and renal outcomes across baseline blood pressure categories: Analysis of the LEADER and SUSTAIN 6 trials

It is unknown if the cardioprotective and renal effects of glucagon-like peptide-1 receptor agonists are consistent across blood pressure (BP) categories in patients with type 2 diabetes and at high risk of cardiovascular events. Using data from the LEADER (9340 patients) and SUSTAIN 6 (3297 patients) trials, we evaluated post hoc the cardiorenal effect of liraglutide and semaglutide on major adverse cardiovascular events (MACE) and nephropathy by baseline BP categories using a Cox proportional hazards model (treatment and subgroup as factors; adjusted for cardiorenal risk factors). Data from the two trials were analysed separately. In the LEADER and SUSTAIN 6 trials, the prevalence of stage 1 hypertension was 30% and 31%, respectively, and of stage 2 hypertension 41% and 43%, respectively. There was no statistical heterogeneity across the BP categories for the effects of liraglutide (P = .06 for MACE; P = .14 for nephropathy) or semaglutide (P = .40 for MACE; P = .27 for nephropathy) versus placebo. This implies that liraglutide and semaglutide may be beneficial for patients with type 2 diabetes, irrespective of their baseline BP.

Effect of Low Diastolic Blood Pressure to Cardiovascular Risk in Patients With Ischemic Stroke or Transient Ischemic Attacks Under Different Systolic Blood Pressure Levels

Background: In the context of recently updated strategies of pressure management, there is a paucity of evidence on the effect of diastolic blood pressure (DBP) level on adverse events among stroke patients. This study aimed to examine the effect of low DBP (<60 mmHg) under different levels of systolic blood pressure (SBP) on the risk of composite events and stroke recurrence among patients with ischemic stroke (IS) or transient ischemic attack (TIA).

Material and Methods: This study was conducted in 2,325 patients with IS or TIA. DBP values were categorized into <60, 60–70, 70–80 (reference), 80–90, and ≥90 mmHg in the main sample and were further categorized as <60 and ≥60 mmHg (reference) when patients were stratified according to SBP levels (<140, <130, and <120 mmHg). The outcomes were defined as recurrent stroke and cumulative composite events (defined as the combination of nonfatal myocardial infarction, nonfatal congestive heart failure, and death) at 1 year.

Results: During 1 year of follow-up, a total of 95 composite events and 138 stroke recurrences were identified. The patients with low DBP showed a significantly higher risk of composite events [hazard ratio (HR) = 4.86, 95% confidence interval (CI) = 2.54–8.52], especially the elderly patients (≥60 years); however, this result was not observed for stroke recurrence (HR = 0.90, 95% CI = 0.46–1.74). With the reduction of the SBP levels, the proportion of patients with low DBP increased (6.87, 12.67, and 34.46%), and the risk for composite events persisted.

Conclusions: Along with the new target levels of SBP suggested by updated criteria, there is a trend for DBP to be reduced to a harmfully low level, which was associated with an increased risk of composite events among patients with IS or TIA.

Diabetes mellitus is associated with high sleep-time systolic blood pressure and non-dipping pattern

INTRODUCTION

Compared to clinic blood pressure (BP), sleep-time BP and non-dipping BP pattern are better predictors of target organ damage and cardiovascular sequalae.

AIM

In a retrospective study, we determined whether diabetes mellitus (DM) status is associated with high sleep-time BP and non-dipping pattern.

METHODS

We analyzed 1092 patients who underwent ambulatory BP monitoring between 2015 and 2017 in a tertiary cardiology institution. During a 24-hour period, BP was automatically measured every 15 minutes between 7:00 AM and 11:59 PM and every 30 minutes thereafter.

RESULTS

Compared with the non-DM group (n = 910), the DM group (n = 182) had a higher 24-hour systolic BP (137 ± 17 vs. non-DM, 132 ± 14 mmHg, p < 0.001) and sleep-time systolic BP (132 ± 20 vs. 123 ± 16 mmHg, p < 0.001), and was more likely to exhibit non-dipping (63% vs 42%, p˂0.001). The DM group was also less likely to meet the guideline-recommended target of 120/70 mmHg for the sleep-time BP measured via ambulatory monitoring (22% vs. 34%, p = 0.002). After adjusting for the effects of age, sex, body mass index, smoking, urea, eGFR, previous myocardial infarction, previous percutaneous coronary intervention, previous coronary artery bypass surgery, and previous stroke, DM remained a significant independent predictor of a higher 24-hour systolic BP (coefficient: 2.8, 95% confidence interval: 0.1-5.5, p = 0.042) and higher sleep-time systolic BP (coefficient: 4.2, 95% confidence interval: 1.1-7.3, p = 0.008). There was a trend toward more sleep-time non-dipping BP pattern (odds ratio: 1.4, 95% confidence interval: 1.0-2.0, p = 0.087) in the DM group.

CONCLUSION

DM is independently associated with suboptimal 24-hour BP control. This association is mainly attributed to a high sleep-time systolic BP.

[Individualising antihypertensive therapy in patients with diabetes. A guideline by the Austrian Diabetes Association (Update 2019)]

Hypertension is one of the most important comorbidities of diabetes, contributing significantly to death and leads to macrovascular and microvascular complications. When assessing the medical priorities for patients with diabetes, treating hypertension should be a primary consideration. In the present review practical approaches to hypertension in diabetes, including individualized targets for preventing specific complications are discussed according to current studies and guidelines. According to recent studies, blood pressure values of about 130/80 mm Hg are associated with the best outcome. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers are the most effective drugs for treating hypertension in diabetes. Calcium antagonists or diuretics are acceptable as second-line agents. Once the target is achieved, antihypertensive drugs should be continued. Newer antidiabetic medications such as SGLT-2-inhibitors or GLP1-receptor agonists have also antihypertensive effects.

Edoxaban Versus Warfarin Stratified by Average Blood Pressure in 19 679 Patients With Atrial Fibrillation and a History of Hypertension in the ENGAGE AF-TIMI 48 Trial

Hypertension is a risk factor for both stroke and bleeding in patients with atrial fibrillation. Data are sparse regarding the interaction between blood pressure and the efficacy and safety of direct oral anticoagulants. In the ENGAGE AF-TIMI 48 trial (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation–Thrombolysis in Myocardial Infarction 48), 19,679 patients with atrial fibrillation and hypertension were categorized according to average systolic blood pressure (SBP) and diastolic blood pressure (DBP). The primary efficacy and safety end points were the time to the first stroke or systemic embolic event and the time to the first International Society of Thrombosis and Hemostasis major bleeding event, respectively. Risk was calculated using Cox proportional hazards models based on average SBP and DBP and adjusting for 18 clinical characteristics. The efficacy and safety of a higher dose edoxaban regimen (60/30 mg) versus warfarin were evaluated with stratification by average SBP and DBP. Stroke/systemic embolic event occurred significantly more frequently in patients with elevated average SBP (hazard ratio, 2.01; 95% CI, 1.50–2.70 for SBP ≥150 mm Hg relative to 130–139 mm Hg) or DBP (hazard ratio, 2.36; 95% CI, 1.76–3.16 for DBP ≥90 mm Hg relative to 75–<85 mm Hg). The higher dose edoxaban regimen reduced stroke/systemic embolic event across the full range of SBP ( P interaction =0.55) and DBP ( P interaction =0.44) compared with warfarin. The higher dose edoxaban regimen reduced the risk of major bleeding events, including intracranial hemorrhage, without modification by average SBP ( P interaction =0.29). The relative safety of edoxaban was most pronounced in patients with elevated DBP ( P interaction =0.007). The efficacy and safety of edoxaban were consistent across the full range of SBP, while the superior safety of edoxaban was most pronounced among patients with elevated DBP.

Anti-androgenic therapy with finasteride in patients with chronic heart failure - a retrospective propensity score based analysis

Sex hormones influence the prevalence and the outcome of heart diseases. The conversion of testosterone to its more active metabolite dihydrotestosterone drives cardiac growth and dysfunction, while inhibition of this step by the anti-androgenic drug finasteride counteracts these pathological processes in preclinical models. In this retrospective, observational study, we aim to investigate whether finasteride, which is in clinical use mainly for prostate disease, might ameliorate cardiac hypertrophy and heart failure in patients. Retrospective chart review of 1041 medical cases with heart failure between 1995 and 2015 was conducted. Stratification was performed by concomitant prostate treatment status (tamsulosin versus finasteride). A propensity score analysis yielded a total of 328 matched medical cases without residual differences in the baseline patient characteristics. In this propensity score matched samples, anti-androgenic therapy with finasteride was associated with significantly reduced left ventricular hypertrophy (interventricular septal thickness 13.3 ± 2.4 mm control vs. 12.6 ± 2.1 mm finasteride group (p = 0.029); estimated average treatment effects on the treated: −0.7 mm, 95% CI mean difference −1.3 to −0.1). In this retrospective analysis anti-androgenic therapy with finasteride for prostate disease was associated with attenuated cardiac hypertrophy in patients with heart failure. Therefore, our data encourage further analysis of this approach in larger heart failure patient cohorts.

Age-specific associations between systolic blood pressure and cardiovascular mortality

OBJECTIVE

We aimed to identify the following in all age groups among individuals without known hypertension and CVD: (1) Whether a systolic blood pressure (SBP) of 130-139 mm Hg elevates cardiovascular disease (CVD) mortality. (2) Whether SBP shows a linear association with cause-specific CVD mortality.

METHODS

We used the Korean National Health Insurance sample data (n=429 220). Participants were categorised into three groups by age (40-59 years, 60-69 years and 70-80 years).

RESULTS

During 10.4 years of follow-up, 4319 cardiovascular deaths occurred. A positive and graded association was generally observed between SBP and overall and cause-specific CVD mortality regardless of age, except for ischaemic heart disease (IHD) mortality in those aged 70-80 years. Among those aged 70-80 years, the HRs (95% CIs) for overall CVD mortality were 1.08 (0.92-1.28), 1.14 (0.97-1.34) and 1.34 (1.14-1.58) for SBP values of 120-129 mm Hg, 130-139 mm Hg and 140-149 mm Hg, respectively, compared with SBP <120 mm Hg. For total stroke mortality, the corresponding HRs were 1.29 (1.02-1.64), 1.37 (1.09-1.72) and 1.52 (1.20-1.93), while for IHD mortality, the corresponding HRs were 0.90 (0.64-1.26), 0.86 (0.62-1.19) and 1.29 (0.93-1.78), respectively. Non-linear associations were significant for IHD.

CONCLUSIONS

In the elderly Korean population, SBPs of 130-139 mm Hg elevated total stroke mortality, but not IHD mortality, compared with normal blood pressure, and a linear association was not observed for IHD mortality in the range <140 mm Hg.

Risk factors for repeat percutaneous coronary intervention in young patients (≤45 years of age) with acute coronary syndrome

Background

The incidences of premature coronary heart disease present a rising trend worldwide. The possible risk factors that may predict the incidence of repeat percutaneous coronary intervention (PCI) in premature acute coronary syndrome (ACS) remains unclear.

Methods

A total of 203 patients ≤45 years with ACS from Chinese PLA General Hospital who have undergone angiography twice were included in this report. Data were collected from medical records of patients during hospitalization. Baseline characteristics which have significant differences in the univariate analysis were enrolled into the multiple logistic regression analysis. According to the odds ratio (OR) of these variables, different values were assigned to build a risk model to predict the possible risk of the premature ACS patients undergoing repeat PCI.

Results

Of the 203 young patients, 88 patients (43.3%) underwent repeat PCI. The intermit time (OR 1.002, (95% CI [1.001–1.002])), diastolic blood pressure of second procedure (OR 0.967, (95% CI [0.938–0.996])), stent diameter (OR 0.352, (95% CI [0.148–0.840])), HbA1C of the first procedure (OR 1.835, (95% CI [1.358–2.479])), and Troponin T of the second procedure (OR 1.24, (95% CI [0.981–1.489])) were significantly associated with the incidence of repeat PCI in patients with premature ACS. An aggregate score between 0 and 6 was calculated based on these cutpoints.

Conclusion

For young patients with premature ACS, risk of undergoing repeat PCI was high. HbA1C was a significant, independent predictor for the incidence of repeat revascularization, and weighed more than traditional lipid profile. The glucose metabolism and disorders in patients with premature ACS should be routinely screened.

Understanding the Haemodynamics of Hypertension

PURPOSE OF REVIEW

This article introduces the haemodynamic principles that underpin the pathophysiology of hypertension and introduces a rational physiological approach to appropriate pharmacologic treatment.

RECENT FINDINGS

Outdated understanding of haemodynamics based on previous measurement systems can no longer be applied to our understanding of the circulation. We question the current view of hypertension as defined by a predominantly systolic blood pressure and introduce the concept of vasogenic, cardiogenic and mixed-origin hypertension. We postulate that failure to identify the individual's haemodynamic pattern may lead to the use of inappropriate medication, which in turn may be a major factor in patient non-compliance with therapeutic strategies. A population-based approach to treatment of hypertension may lead to suboptimal functional dynamics in the individual patient. Finally, we question the validity of current guidelines and published evidence relating morbidity and mortality to the future treatment of hypertension. The importance of individual haemodynamic profiles may be pivotal in the understanding, diagnosis and treatment of hypertension if optimal control with minimal adverse effects is to be achieved. Research based on individual haemodynamic patterns is overdue.