Safety and feasibility of achieving lower systolic blood pressure goals in persons with type 2 diabetes: the SANDS trial

Randomised controlled trials of antihypertensive therapy: does exclusion of orthostatic hypotension alter treatment effect? A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Management of antihypertensive therapy is challenging in patients with symptomatic orthostatic hypotension, a population often excluded from randomised controlled trials of antihypertensive therapy. In this systematic review and meta-analysis, we sought to determine whether the association of antihypertensive therapy and adverse events (e.g. falls, syncope), differed among trials that included or excluded patients with orthostatic hypotension.

METHODS

We performed a systematic review and meta-analysis of randomised controlled trials comparing blood pressure lowering medications to placebo, or different blood pressure targets on falls or syncope outcomes and cardiovascular events. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall in subgroups of trials that excluded patients with orthostatic hypotension and trials that did not exclude patients with orthostatic hypotension, and tested P for interaction. The primary outcome was fall events.

RESULTS

46 trials were included, of which 18 trials excluded orthostatic hypotension and 28 trials did not. The incidence of hypotension was significantly lower in trials that excluded participants with orthostatic hypotension (1.3% versus 6.2%, P < 0.001) but not incidences of falls (4.8% versus 8.8%; P = 0.40) or syncope (1.5% versus 1.8%; P = 0.67). Antihypertensive therapy was not associated with an increased risk of falls in trials that excluded (OR 1.00, 95% CI; 0.89-1.13) or included (OR 1.02, 95% CI; 0.88-1.18) participants with orthostatic hypotension (P for interaction = 0.90).

CONCLUSIONS

The exclusion of patients with orthostatic hypotension does not appear to affect the relative risk estimates for falls and syncope in antihypertensive trials.

Association between antihypertensive treatment and adverse events: systematic review and meta-analysis

OBJECTIVE

To examine the association between antihypertensive treatment and specific adverse events.

DESIGN

Systematic review and meta-analysis.

ELIGIBILITY CRITERIA

Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up.

INFORMATION SOURCES

Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020.

MAIN OUTCOME MEASURES

The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ2).

RESULTS

Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ2=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ2=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ2=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ2=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ2=0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction.

CONCLUSIONS

This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function.

REGISTRATION

PROSPERO CRD42018116860.

Addressing Orthostatic Hypotension in Heart Failure: Pathophysiology, Clinical Implications and Perspectives

Heart failure (HF)is a condition at high risk for orthostatic hypotension (OH)given the large proportion of patients at an advanced age and high burden of comorbidities contributing to OH, as well as a high prevalence of medications with neurovascular and volume modulating properties. Early identification of OH in HF seems to be crucial as OH can have an impact on patient symptoms, activity level and independence, be a marker of specific pathophysiological changes or be an indicator of need for personalized treatment. OH might contribute significantly to bad enough prognosis in HF, as, besides a risk of falls and cognitive decline, it was found to be associated with cardiovascular morbidity and mortality. In this review, we aimed to incentivize the routine use of orthostatic testing in HF, as well as stimulate future research in this field, which could lead to significant advances in the treatment and outcomes.

Carotid Intima-Media Thickness Progression as Surrogate Marker for Cardiovascular Risk: Meta-Analysis of 119 Clinical Trials Involving 100 667 Patients

BACKGROUND

To quantify the association between effects of interventions on carotid intima-media thickness (cIMT) progression and their effects on cardiovascular disease (CVD) risk.

METHODS

We systematically collated data from randomized, controlled trials. cIMT was assessed as the mean value at the common-carotid-artery; if unavailable, the maximum value at the common-carotid-artery or other cIMT measures were used. The primary outcome was a combined CVD end point defined as myocardial infarction, stroke, revascularization procedures, or fatal CVD. We estimated intervention effects on cIMT progression and incident CVD for each trial, before relating the 2 using a Bayesian meta-regression approach.

RESULTS

We analyzed data of 119 randomized, controlled trials involving 100 667 patients (mean age 62 years, 42% female). Over an average follow-up of 3.7 years, 12 038 patients developed the combined CVD end point. Across all interventions, each 10 μm/y reduction of cIMT progression resulted in a relative risk for CVD of 0.91 (95% Credible Interval, 0.87-0.94), with an additional relative risk for CVD of 0.92 (0.87-0.97) being achieved independent of cIMT progression. Taken together, we estimated that interventions reducing cIMT progression by 10, 20, 30, or 40 μm/y would yield relative risks of 0.84 (0.75-0.93), 0.76 (0.67-0.85), 0.69 (0.59-0.79), or 0.63 (0.52-0.74), respectively. Results were similar when grouping trials by type of intervention, time of conduct, time to ultrasound follow-up, availability of individual-participant data, primary versus secondary prevention trials, type of cIMT measurement, and proportion of female patients.

CONCLUSIONS

The extent of intervention effects on cIMT progression predicted the degree of CVD risk reduction. This provides a missing link supporting the usefulness of cIMT progression as a surrogate marker for CVD risk in clinical trials.

Hypertension Treatment and Control and Risk of Falls in Older Women

BACKGROUND/OBJECTIVES

A lower risk of falls is commonly cited as a reason to treat hypertension conservatively in older individuals. We examined the effect of hypertension treatment and control status and measured blood pressure (BP) level on the risk of falls in older women.

DESIGN/SETTING

Prospective cohort study.

PARTICIPANTS

A total of 5971 women (mean age 79 years; 50.4% white, 33.1% black, 16.5% Hispanic/Latina) enrolled in the Women's Health Initiative and Objective Physical Activity and Cardiovascular Health study.

MEASUREMENTS

BP was measured by trained nurses, and hypertension treatment was assessed by medication inventory. Participants mailed in monthly calendars to self-report falls for 1 year.

RESULTS

Overall, 70% of women had hypertension at baseline (53% treated and controlled, 12% treated and uncontrolled, 5% untreated). There were 2582 women (43%) who reported falls in the 1 year of surveillance. Compared with nonhypertensive women, when adjusted for fall risk factors and lower limb physical function, the incidence rate ratio (IRR) for falls was 0.82 (confidence interval [CI] = 0.74-0.92) in women with treated controlled hypertension (p = .0008) and 0.73 (CI = 0.62-0.87) in women with treated uncontrolled hypertension (p = .0004). Neither measured systolic nor diastolic BP was associated with falls in the overall cohort. In women treated with antihypertensive medication, higher diastolic BP was associated with a lower risk of falls in a model adjusted for fall risk factors (IRR = 0.993 per mm Hg; 95% CI = 0.987-1.000; p = .04). The only class of antihypertensive medication associated with an increased risk of falls compared with all other types of antihypertensive drugs was β-blockers.

CONCLUSION

Women in this long-term research study with treated hypertension had a lower risk of falls compared with nonhypertensive women. Diastolic BP (but not systolic BP) is weakly associated with fall risk in women on antihypertensive treatment (<1% decrease in risk per mm Hg increase). J Am Geriatr Soc, 2019. J Am Geriatr Soc 67:726-733, 2019.

Thresholds and Targets for Hypertension Management in Adults With Type 2 Diabetes Should Remain at 130/80 mmHg: What's the Evidence?

Hypertension and diabetes are common comorbidities and are both modifiable risk factors for cardiovascular disease and death. Lowering blood pressure reduces target organ damage and prevents cardiovascular disease outcomes. The harmonized Canadian clinical practice guidelines for managing hypertension in people with diabetes provides health-behaviour advice and medical therapy recommendations for a threshold blood pressure of 130/80 mmHg and above and to target blood pressure to below 130/80 mmHg. We have reviewed the studies supporting these recommendations and others, and they appear to be at odds with the guidelines, including those for elderly people and patients with pre-existing cardiovascular disease.

Impaired Orthostatic Blood Pressure Recovery Is Associated with Unexplained and Injurious Falls

OBJECTIVES

Cardiovascular disorders are recognized as important modifiable risk factors for falls. However, the association between falls and orthostatic hypotension (OH) remains ambivalent, particularly because of poor measurement methods of previous studies. The goal was to determine for the first time to what extent OH (and variants) are risk factors for incident falls, unexplained falls (UF), injurious falls (IF) and syncope using dynamic blood pressure (BP) measurements in a population study.

DESIGN

Nationally representative longitudinal cohort study-The Irish Longitudinal Study on Ageing (TILDA)-wave 1 (2009-2011) with 2-year follow-up at wave 2 (2012-2013).

SETTING

Community-dwelling adults.

PARTICIPANTS

Four thousand one hundred twenty-seven participants were randomly sampled from the population of older adults aged ≥50 years resident in Ireland.

MEASUREMENTS

Continuous BP recordings measured during active stands were analyzed. OH and variants (initial OH and impaired orthostatic BP stabilization OH(40)) were defined using dynamic BP measurements. Associations with the number of falls, UF, IF, and syncope reported 2 years later were assessed using negative binomial and modified Poisson regression as appropriate.

RESULTS

Participants had a mean age of 61.5 (8.2) years (54.2% female). OH(40) was associated with increased relative risk of UF (RR: 1.52 95% CI: 1.03-2.26). OH was associated with all-cause falls (IRR: 1.40 95% CI: 1.01-1.96), UF(RR: 1.81 95% CI: 1.06-3.09), and IF(RR: 1.58 95% CI: 1.12-2.24). IOH was not associated with any outcome.

CONCLUSION

With the exception of initial orthostatic hypotension, beat-to-beat measures of impaired orthostatic BP recovery (delayed recovery OH (40) or sustained orthostatic hypotension OH) are independent risk factors for future falls, unexplained falls, and injurious falls.

The ideal blood pressure target to prevent cardiovascular disease in type 2 diabetes: a neutral viewpoint

Type 2 diabetes mellitus (T2DM) and essential hypertension are often associated, and retrospective data analyses suggest an association between lower blood pressure (BP) values and lower cardiovascular (CV) risk in patients with T2DM. However, the most recent intervention trials fail to demonstrate a further CV risk reduction, for BP levels <130/80 mm Hg, when compared to levels <140/90 mm Hg. Moreover, a J-shaped, rather than a linear, relationship of BP reduction with incident CV events has been strongly suggested. We here debate the main available evidences for and against the concept of 'the lower the better', in the light of the main intervention trials and meta-analyses, with a particular emphasis on the targets to be pursued in elderly patients. Finally, the most recent guidelines of the scientific societies are critically discussed.

Several steps/day indicators predict changes in anthropometric outcomes: HUB City Steps

Background

Walking for exercise remains the most frequently reported leisure-time activity, likely because it is simple, inexpensive, and easily incorporated into most people’s lifestyle. Pedometers are simple, convenient, and economical tools that can be used to quantify step-determined physical activity. Few studies have attempted to define the direct relationship between dynamic changes in pedometer-determined steps/day and changes in anthropometric and clinical outcomes. Hence, the objective of this secondary analysis was to evaluate the utility of several descriptive indicators of pedometer-determined steps/day for predicting changes in anthropometric and clinical outcomes using data from a community-based walking intervention, HUB City Steps, conducted in a southern, African American population. A secondary aim was to evaluate whether treating steps/day data for implausible values affected the ability of these data to predict intervention-induced changes in clinical and anthropometric outcomes.

Methods

The data used in this secondary analysis were collected in 2010 from 269 participants in a six-month walking intervention targeting a reduction in blood pressure. Throughout the intervention, participants submitted weekly steps/day diaries based on pedometer self-monitoring. Changes (six-month minus baseline) in anthropometric (body mass index, waist circumference, percent body fat [%BF], fat mass) and clinical (blood pressure, lipids, glucose) outcomes were evaluated. Associations between steps/day indicators and changes in anthropometric and clinical outcomes were assessed using bivariate tests and multivariable linear regression analysis which controlled for demographic and baseline covariates.

Results

Significant negative bivariate associations were observed between steps/day indicators and the majority of anthropometric and clinical outcome changes (r = -0.3 to -0.2: P < 0.05). After controlling for covariates in the regression analysis, only the relationships between steps/day indicators and changes in anthropometric (not clinical) outcomes remained significant. For example, a 1,000 steps/day increase in intervention mean steps/day resulted in a 0.1% decrease in %BF. Results for the three pedometer datasets (full, truncated, and excluded) were similar and yielded few meaningful differences in interpretation of the findings.

Conclusions

Several descriptive indicators of steps/day may be useful for predicting anthropometric outcome changes. Further, manipulating steps/day data to address implausible values has little overall effect on the ability to predict these anthropometric changes.

Prevalence and predictors of abnormal arterial function in statin-treated type 2 diabetes mellitus patients

Arterial dysfunction (AD) in type 2 diabetes mellitus (T2DM) predicts cardiovascular events. The objective was to investigate the prevalence and predictors of AD in statin-treated T2DM patients. We measured flow-mediated (FMD) and nitrate-mediated (NMD) brachial artery dilatation in 86 statin-treated T2DM patients. Patients were classified into 2 groups: normal arterial function (FMD ≥3.7% with NMD ≥11.9%) or AD (FMD <3.7% with or without NMD <11.9%). Endothelial dysfunction without smooth muscle cell dysfunction (ED) was defined as FMD less than 3.7% with NMD of at least 11.9%, and endothelial dysfunction with smooth muscle cell dysfunction (ED/SMD) was defined as FMD less than 3.7% with NMD less than 11.9%. Predictors of arterial function were investigated using linear and logistic regression methods. The prevalence of AD was 33.7% (23.2% with ED and 10.5% with ED/SMD). In multivariate linear regression, history of hypertension (P < .01), statin dose (P < .05), and estimated glomerular filtration rate (eGFR) (P = .02) were significant predictors of FMD. Sex (P < .01) and creatinine (P = .03) or eGFR (P = .02) predicted NMD. In multivariate logistic regression, the independent predictors of AD were history of hypertension (odds ratio [OR], 8.79; 95% confidence interval, 2.14-36.12; P < .01), age (OR, 1.08; 1.01-1.17; P = .03), and statin dose (OR, 0.33; 0.12-0.87; P = .02). A history of hypertension (OR, 8.99; 1.87-43.26; P < .01) was the sole independent predictor of ED; eGFR (OR, 0.01; 0.00-0.26; P < .01) independently predicted ED/SMD. Our data suggest that one third of statin-treated diabetic patients have residual AD, mainly due to ED alone. Earlier identification and treatment of hypertension and renal impairment may improve AD and further decrease cardiovascular risk in such patients.

Relationship of glycemia control to lipid and blood pressure lowering and atherosclerosis: the SANDS experience

OBJECTIVES

Cardiovascular disease prevention for patients with type 2 diabetes is accomplished through hypertension and dyslipidemia management. Although studies have established strategies for lowering low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP), none have examined whether glycemia influences ability to achieve lipid and BP targets. This post hoc analysis from the Stop Atherosclerosis in Native Diabetics Study examines the role of baseline glycemia in achieving standard and aggressive targets and outcomes after 36 months.

METHODS

Diabetic individuals aged > 40 years with no cardiovascular events (n = 499) were randomized to aggressive versus standard targets for LDL-C, non-high-density lipoprotein cholesterol (non-HDL-C) and systolic BP (SBP). Management algorithms were used for both groups. Carotid ultrasound and echocardiography were performed at baseline and after 36 months.

RESULTS

No differences were observed in baseline hemoglobin A1c between treatment groups nor any significant change in A1c after 36 months in either group. Baseline A1c, however, was significantly and negatively related to achieving LDL-C (P = .007), non-HDL-C (P = .03) and SBP targets (P = .007) and to changes in LDL-C (P = .007), non-HDL-C (P = .03) and SBP (P = .001) in both groups. Baseline A1c failed to predict progression of carotid intima medial thickness (CIMT) (P = .42) or left ventricular mass index (LVMI) (P = .10), nor was it related to the effects of lipid and BP lowering on CIMT and LVMI over 36 months.

CONCLUSIONS

In diabetic adults with no cardiovascular disease events, A1c was negatively associated with ability to achieve LDL-C, non-HDL-C and SBP goals but was not independently related to treatment-associated changes in CIMT or LVMI over 36 months.

Establishing targets for hypertension control in patients with comorbidities

Most current guidelines recommend tighter blood pressure (BP) control in hypertensive patients with comorbidities. These recommendations are based on epidemiologic data indicating that cardiovascular risk increases at lower BP levels in hypertensive patients with comorbidities than in those without comorbidities. Hypertension guidelines usually reflect outcomes from previous studies, but current recommendations for patients with comorbidities have preceded the evidence. We review recent studies investigating whether these new targets can be achieved, whether they are well tolerated, and whether they positively affect the outcomes. The results of the few current studies about outcomes in lower BP target groups are either negative or somewhat--but not decidedly--positive. There is a need for new trials designed to evaluate the validity of current recommendations for tighter BP control in hypertensive patients with comorbidities. Additionally, existing data from published trials could be reanalyzed to provide further clarification.

Achieving lipid targets in adults with type 2 diabetes: the Stop Atherosclerosis in Native Diabetics Study

BACKGROUND

Although lipid management in diabetes is standard practice, goals often are neither met nor maintained. Strategies for achieving lower targets have not been explored. The Stop Atherosclerosis in Native Diabetics Study randomized patients with diabetes to standard versus aggressive lipid and blood pressure goals for 36 months.

OBJECTIVE

To report strategies used to achieve and maintain lipid goals and to report adverse events (AEs).

METHODS

Adults with type 2 diabetes and no history of cardiovascular disease (N = 499) were randomized to standard (low-density lipoprotein cholesterol [LDL-C] ≤ 100 mg/dL, non-high-density lipoprotein cholesterol [non-HDL-C] ≤ 130 mg/dL) or aggressive (LDL-C ≤ 70 mg/dL, non-HDL-C ≤ 100 mg/dL) targets. An algorithm was started with statin monotherapy, with intestinally acting agents added as required to reach LDL-C targets.Triglyceride [TG]-lowering agents were next used to reach non-HDL-C goals. Lipid management was performed by mid-level practitioners, with physician consultation, by the use of point-of-care lipid determinations.

RESULTS

On average, both groups achieved the LDL-C and non-HDL-C goals within 12 months and maintained them throughout the study. At 36 months, mean (SD) LDL-C and non-HDL-C were 72 (24) and 102 (29) mg/dL in the aggressive group (AGG) and 104 (20) and 138 (26) mg/dL, respectively, in the standard group (STD); systolic blood pressure targets were 115 and 130 mmHg, respectively. A total of 68% of participants reached target LDL-C for greater than 50% of the visits and 46% for greater than 75% of visits. At 36 months, the AGG averaged 1.5 lipid lowering medications and the STD 1.2. Statins were used in 91% and 68% of the AGG and STD; ezetimibe by 31% and 10%; fibrates by 8% and 18%. No serious AEs were observed; AEs occurred in 18% of the AGG and 14% of the STD.

CONCLUSION

Standard and aggressive lipid targets can be safely maintained in diabetic patients. Standardized algorithms, point-of-care lipid testing, and nonphysician providers facilitate care delivery.

PREVENTION OF ATHEROSCLEROSIS WITH LDL-C LOWERING - LIPOPROTEIN CHANGES AND INTERACTIONS: THE SANDS STUDY

BACKGROUND: Lowering low-density lipoprotein cholesterol (LDL-C) with statins reduces atherosclerosis. LDL and high-density lipoprotein (HDL) are commonly measured by their cholesterol content, but non-HDL cholesterol, LDL particle number (LDL-P), or total apolipoprotein B (apoB) may better predict cardiovascular risk. Few studies have examined relations among lipoprotein levels and composition before and after interventions to lower LDL-C and non-HDL-C. OBJECTIVE: To measure changes in carotid artery intimal media thickness (CIMT) and lipid concentration and composition during 36 months of statin therapy. METHODS: Analyses were conducted on 418 diabetic individuals, with complete data and no prior cardiovascular events, who were randomized to aggressive (AG) versus standard (STD) treatment for LDL-C, non-HDL-C, and systolic blood pressure (SBP) as part of the Stop Atherosclerosis in Native Diabetics Study (SANDS). RESULTS: The AG group achieved average LDL-C and non-HDL-C of 71mg/dL and 100mg/dL and a decrease in CIMT. No significant interactions were observed between treatment effect and initial levels of LDL-C, non-HDL-C, HDL-C, triglycerides, apoB, or LDL-P. Decreases in LDL-C (p<.005) and non-HDL-C (p<.001) were independently correlated with CIMT regression in the AG group. Changes in apoB and LDL-P showed borderline correlations with CIMT regression (p=.07 and p=.09). CONCLUSIONS: In diabetic adults with no prior cardiovascular events, treatment to current targets for lipids and SBP reduces atherosclerosis progression and when more aggressive targets are met, atherosclerosis regresses. The aggressive targets for LDL-C and non-HDL-C appeared to be the main determinants of CIMT regression and were more predictive of this outcome than changes in LDL-P or apoB.