Blood pressure variability and cardiovascular disease: systematic review and meta-analysis

Cumulative blood pressure predicts risk of cardiovascular outcomes in middle-aged and older population

BACKGROUND

Cardiovascular disease (CVD) remains a major health concern globally, contributing to a considerable disease burden. However, few studies have considered long-term cumulative blood pressure (cBP) exposure in middle-aged and older population in China. The aim of this study was to investigate whether long-term cBP was associated with subsequent cardiovascular outcomes among participants without CVD at baseline in Chinese over 45 years old.

METHODS

6435 participants in China of the CHARLS (The China Health and Retirement Longitudinal Study) were included. Cumulative BP was calculated as the area under the curve using measurements from wave 1 (2011) to wave 2 (2013). Outcomes included CVD, heart disease and stroke.

RESULTS

During a median follow-up period of 5 years, 1101 CVD events, 826 heart disease, and 351 stroke were recorded. Each 1-SD increase in cumulative systolic blood pressure (cSBP), cumulative diastolic blood pressure (cDBP), and cumulative mean arterial pressure (cMAP) was associated with increased risk of CVD (HR, 1.12; 95%, 1.05-1.20, HR, 1.14; 95%, 1.07-1.22, HR, 1.14; 95%, 1.07-1.22), heart disease (HR, 1.05; 95%, 0.97-1.13, HR, 1.09; 95%, 1.01-1.17, HR, 1.08; 95%, 1.00-1.16) and stroke (HR, 1.35; 95%, 1.21-1.51, HR, 1.31; 95%, 1.17-1.46, HR, 1.36; 95%, 1.22-1.51). The relationship between cBP and CVD has only been found in people younger than 60 years of age. A significant association was observed for cumulative pulse pressure (cPP) with stroke (HR, 1.23; 95%, 1.10-1.38). None nonlinear relationships were identified (p-nonlinear > .05). For the prediction of cardiovascular outcomes, cBP load outperformed baseline BP in terms of C statistics (p < .001).

CONCLUSIONS

Long-term cSBP, cDBP and cMAP were associated with subsequent CVD and only found in people younger than 60 years of age, whereas cPP was associated with stroke only across all ages. Cumulative BP may provide a better prediction of cardiovascular outcomes compared with single BP measurement. Efforts are required to control long-term BP in assessing cardiovascular risks.

Noncommunicable disease syndemic among the general population in Iran: a cross-sectional study

Objectives

This study aims to investigate the status of the NCD syndemic among individuals over 25 in all provinces of Iran.

Methods

This study was based on a national survey. Using a systematic cluster random sampling framework, 26,707 participants were selected from all 31 Iranian provinces. The data were analyzed for descriptive statistics by gender and age, followed by principal component analysis and logistic regression, using R software for the statistical analysis.

Results

There was an interaction between diabetes mellitus and cardiovascular diseases, in their association with healthy life lost due to disability in the Iranian adult population. Additionally, there was a clustering of diabetes mellitus and cardiovascular diseases, partly due to the shared specific causes such as obesity, hypertension, shared baseline features, and poverty.

Conclusions

The syndemic analysis showed that social inequalities in diabetes and cardiovascular disease arise not only from exposure levels but also from varying vulnerabilities and disease outcomes. Iran's health policy should prioritize reducing these health inequalities.

Cardiovascular autonomic function in middle-aged people with long-term cervical and upper thoracic spinal cord injuries

OBJECTIVES

To examine cardiovascular autonomic function in middle-aged people with long-term cervical and upper thoracic spinal cord injury (SCI) compared with the general population, and explore if the neurological level of injury (NLI) is related to cardiovascular autonomic function.

DESIGN

Population-based cross-sectional study with matched controls.

SETTING

Outpatient SCI unit in Southern Sweden.

PARTICIPANTS

Twenty-five individuals (20% women, mean age 58 years and mean time since injury 28 years, NLI C2-T6, American Spinal Injury Association Impairment Scale A-C) from the Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment (SPICA). Matched controls were obtained from the population-based Swedish CArdioPulmonary bioImage Study (SCAPIS) at a ratio of 5:1.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

24 h electrocardiography and deep breathing tests. 24 h ambulatory blood pressure (BP) monitoring and orthostatic BP tests.

RESULTS

In individuals with SCI compared with controls, heart rate variability (24h mean SD of the normal-to-normal interval 112 ms vs 145 ms, P < 0.001) and diastolic orthostatic BP increase (2.0 and 9.4 mmHg, P < 0.001), were significantly lower, whereas BP variability was significantly higher (24h mean systolic SDBP 17.8 mmHg vs 15.7 mmHg, P = 0.029). Circadian patterns of heart rate variability and BP (lack of nocturnal dip) were significantly different among the individuals with SCI than controls. Higher NLI was significantly (P < 0.05) correlated with impairments to various cardiovascular autonomic function variables.

CONCLUSIONS

This exploratory study indicates that cardiovascular autonomic function is impaired in middle-aged people with long-term cervical and upper thoracic SCI compared with the general non-SCI population, and more pronounced with a higher NLI. Future research is needed to understand the pathophysiological mechanisms underlying these impairments, and the prognostic significance for individuals with SCI.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03515122.

Interdialytic blood pressure variability and all-cause mortality in patients undergoing maintenance hemodialysis: a multicenter study using DialysisNet

BACKGROUND/AIMS

In this study, we aimed to analyze all-cause mortality according to interdialytic blood pressure variability (BPV) in patients undergoing hemodialysis.

METHODS

Data on predialysis blood pressure (BP) and clinical information were extracted from four dialysis units through the DialysisNet system, which enables efficient hemodialysis management using common data elements. Interdialytic BPV was evaluated as the coefficient of variation (CV) of predialysis BP at each dialysis session over a 12-month period. The CV of systolic BP (SBP) and diastolic BP (DBP) was divided into tertiles. The primary outcome was all-cause mortality according to the CV of predialysis SBP, which was analyzed using Cox regression analysis.

RESULTS

The data of 357 patients undergoing hemodialysis were analyzed. Compared with the first SBP CV tertile, the third tertile showed significantly increased all-cause mortality after adjustment (hazard ratio [HR], 2.11; 95% confidence interval [CI] 1.04-4.24). Compared with the first DBP CV tertile, the third tertile showed significantly increased mortality in univariable analysis (HR, 2.18; 95% CI 1.10-4.30) but not in multivariable analysis (HR, 1.88; 95% CI 0.89-3.95).

CONCLUSIONS

Increased interdialytic BPV in patients undergoing hemodialysis is associated with all-cause mortality. This was more prominent in SBP than in DBP. Particular attention should be paid to large BPVs in older adults, women, and patients with a relatively longer dialysis vintage.

Assessing the relationship between short-term blood pressure variability and glycation profile in young and middle-aged nondiabetic hypertensive individuals

INTRODUCTION

Elevated short-term blood pressure (BP) variability (BPV) has been associated with a poorer cardiovascular prognosis. The glycation profile is related to BPV in diabetic and prediabetic individuals. However, little is known about the relationship between glycation levels and BPV in hypertensive patients with optimal glycemic control.

OBJECTIVES

This observational study aimed to elucidate the relationship between glycated hemoglobin (HbA1c) levels and short-term BPV in young and middle-aged hypertensive patients over 18 years with HbA1c levels below 5.7%.

METHODS

We collected and analyzed data on 24-h ambulatory BP monitoring, demographic, epidemiological, clinical, and laboratory variables from 143 hypertensive patients. BPV was measured as the standard deviation (SD) and average real variability (ARV) in millimeters of mercury, as well as the dimensionless coefficient of variation (CV).

RESULTS

Depending on the index, each one unit increase in nighttime SD and CV indices was associated with a 17-24% higher likelihood of elevated HbA1c levels (higher than 5.2%). Regarding BPV dipping, each 1% decrease in nighttime SD and CV dipping was associated with a 10-20% higher risk of increased HbA1c levels. Additionally, each 1% decrease in nighttime ARV DBP dipping was also associated with a 10% higher risk of elevated HbA1c levels. A one-standardized-unit increase in the overall combined BPV index, as a pooled measure of BPV, was associated with a 45% higher likelihood of raised HbA1c levels.

CONCLUSION

Even within the optimal range, elevated HbA1c levels may reflect an underlying increase in BPV, which may be particularly relevant given the prognostic implications of short-term BPV.

Systolic blood pressure variability: risk of cardiovascular events, chronic kidney disease, dementia, and death

BACKGROUND AND AIMS

Earlier studies evaluated the association between systolic blood pressure variability (SBPV) measured during a single period and risk of health outcomes. This study expanded upon existing evidence by examining the association between changes in SBPV over time and clinical outcomes in primary care settings.

METHODS

Visit-to-visit SBPV was determined as standard deviation of ≥3 systolic blood pressure values measured at 5-10 (Period 1) and 0-5 (Period 2) years before enrolment in the UK Biobank. Cox proportional hazards models were used to evaluate associations of absolute changes in SBPV and SBPV change patterns between these two periods with risk of cardiovascular disease (CVD), coronary heart disease (CHD), stroke, atrial fibrillation and flutter (AF), heart failure (HF), chronic kidney disease (CKD), dementia, and overall mortality.

RESULTS

A total of 36 251 participants were included with a median follow-up time of 13.9 years. In the fully adjusted models, an increased SBPV from Period 1 to Period 2 was significantly associated with an increased risk of CVD, CHD, stroke, CKD, and overall mortality (all P for trend < .005), reflecting a 23%-33% increased risk comparing participants with an increase in SBPV above Tertile 3 with those below Tertile 1. An increase in SBPV from Period 1 to Period 2 appeared to be associated with an increased risk of AF, HF, and dementia; however, the associations did not reach statistical significance at P < .005. The restricted cubic spline analysis did not reveal non-linear associations, as all P-values for non-linearity were >.05. Regarding SBPV change patterns, compared with the participants with consistently low SBPV, participants with a consistently high SBPV during the two periods had an increased risk of CVD, CHD, stroke, AF, HF, CKD, and overall mortality, with a risk evaluation of 28%-46%. The observed associations remained largely unchanged across subgroup and sensitivity analyses.

CONCLUSIONS

An increase in SBPV over time was associated with an elevated risk of CVD, CKD, and overall mortality. These findings provide compelling evidence to inform the importance for the management of SBPV in clinical practice.

Higher blood pressure variability during hospitalization is associated with lower cerebral white matter integrity in COVID-19 patients

BACKGROUND

High blood pressure variability (BPV) is associated with cerebrovascular damage and dementia, but it is unknown whether short-term BPV during hospitalization is also associated with cerebral white matter (WM) damage. We examined whether BPV, measured in-hospital using continuous monitoring, is associated with WM microstructural integrity in COVID-19 patients.

METHODS

We included hospitalized COVID-19 patients from the CORONavirus and Ischemic Stroke (CORONIS) study who underwent continuous vital signs monitoring using a wearable device during hospital admission and had MRI shortly after discharge. Systolic BPV was calculated as Average Real Variability (ARV) and Coefficient of Variation (CV) with 1-, 5- and 20-minute intervals. We used diffusion tensor imaging (DTI) to assess fractional anisotropy (FA) and peak width of skeletonized mean diffusivity (PSMD) as markers of WM integrity. Associations between BPV and WM integrity were examined with linear regression adjusted for age, mean systolic blood pressure, number of blood pressure measurements and type of respiratory support.

RESULTS

We included 47 COVID-19 patients (mean age: 59.6 years). Blood pressure was measured 6306 ± 4343 times per patient (median admission: 11 days [IQR 7.5-15.0]). Both higher ARV and CV were associated with lower WM microstructural integrity, reflected by lower FA (ARV: β=-0.40, p = 0.010; CV: β=-0.33, p = 0.026) and higher PSMD (CV: β = 0.28, p = 0.038) after adjustment for confounders. Correction for WM hyperintensities did not change these results.

CONCLUSIONS

High BPV during hospitalization is associated with lower WM integrity in COVID-19 patients, although causality needs to be demonstrated. Our findings need validation in hospitalized patients without COVID-19 to examine generalizability.

Blood pressure and the brain: the conundrum of hypertension and dementia

As the population ages, the anticipated rates of dementia worldwide are likely to increase dramatically, especially in low- and middle-income countries; thus, any opportunity to modify dementia risk is especially critical. Hypertension is one risk factor that is highly prevalent, consistently important for late-life brain health, and which could represent a target for prevention of dementia. Furthermore, hypertension is the most significant modifiable risk factor for stroke. This review will summarize existing literature linking hypertension with dementia and brain health more broadly, will discuss potential mechanisms linking hypertension with brain health, and will consider specific factors that may impact not only the relationship between hypertension and the brain but also the importance of treatment, including different associations over the life course.

Does mean systolic blood pressure less than 130 mm Hg ensure high rates of control to <140/<90 mm Hg? A cross-sectional analysis of two cohorts

OBJECTIVE

The purpose of this study was to determine how strongly mean systolic blood pressure (mSBP, mm Hg) was related to hypertension control and if an mSBP<130 was required to achieve ≥80% control to <140/<90.

DESIGN

mSBP and per cent control to <140/<90 at the last encounter were assessed in a cross-sectional analysis of two cohorts with hypertension: (1) randomised, controlled Systolic blood PRessure Intervention Trial (SPRINT) and (2) real-world American Medical Association's Measure Accurately, Act Rapidly, Partner with patients Hypertension programme.

SETTING

SPRINT randomised participants with hypertension to two SBP targets: <140 (standard treatment, SPRINT-S) and <120 (intensive treatment, SPRINT-I). MAP (Measure Accurately, Act Rapidly, Partner with patients) included adults with hypertension at five healthcare systems incentivised by payers to control BP to <140/<90.

PARTICIPANTS

SPRINT participants with year 2 data. Patients in MAP (had hypertension, were aged≥18 years, had ≥2 healthcare visits from November 2019 through October 2021 and received care from clinicians (n=544) with ≥24 patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

mSBP and control to <140/<90. In MAP, control to <140/<90 was assessed in clinicians grouped by 5 mm Hg increments in the mSBP of their patient panel.

RESULTS

In SPRINT-S (n=4303) and SPRINT-I (n=4323), mSBP values at the last visit were 136.7 and 121.7 with BP<140/<90 in 61% and 88% of participants, respectively. In MAP, mSBP at the last visit (n=168 978 patients) was 132.1 with BP<140/<90 in 70% of participants. Among clinicians with participant mSBP of 120 to <125, 88% of their patients were controlled to <140/<90, similar to SPRINT-I. Control fell to 79% of patients, with clinician-level mSBP of 125 to <130, 71%, with mSBP of 130 to <135 and 57%, with mSBP of 135 to <140 (similar to SPRINT-S); mSBP accounted for 80% of variance in clinician-level hypertension control.

CONCLUSIONS AND RELEVANCE

mSBP is strongly related to hypertension control. Moreover, mSBP<130 is required to attain control rates to <140/<90 in the range of 80% and higher.

Association Between Visit-to-Visit Blood Pressure Variability and Incidence of Atrial Fibrillation in Hypertensive Patients: A Post-Hoc Analysis of the SPRINT Trial

Visit-to-visit blood pressure variability (BPV) has been recognized as a cardiovascular risk factor, but its association with new-onset atrial fibrillation (AF) remains underexplored. This study investigated the relationship between BPV and AF incidence among hypertensive patients using data from the Systolic Blood Pressure Intervention Trial (SPRINT). Visit-to-visit BPV was quantified using standard deviation (SD), coefficient of variation (CV), and average real variability (ARV) of systolic and diastolic blood pressure measurements. Participants were stratified into three groups based on systolic BPV tertiles. AF cases were identified via follow-up electrocardiograms and reports of AF-related serious adverse events. After excluding individuals with baseline AF or missing BPV data, 7378 patients were analyzed over a median follow-up of 3.8 years. The incidence of new-onset AF increased across ascending tertiles of systolic BPV (CV), with rates of 2.5% (62 cases), 4.1% (104 cases), and 5.2% (127 cases) observed in the lowest to highest tertiles, respectively. After adjusting for age, race, blood pressure, and cardiovascular risk factors, the hazard ratios for AF in the second and third tertiles compared to the lowest tertile were 1.52 (95% CI: 1.10-2.09) and 1.83 (95% CI: 1.34-2.49), respectively. Consistent trends were noted for systolic BPV measured via SD and ARV, as well as diastolic BPV. These findings indicate that elevated visit-to-visit BPV independently predicts AF development in hypertensive populations. Assessing BPV may enhance risk stratification and identify patients at heightened risk for AF, underscoring its clinical relevance in hypertension management.

Hypotensive Episodes on 24-Hour Ambulatory Blood Pressure and Cognitive Function: Insights From the SPRINT Study

BACKGROUND

Hypotensive episodes detected by 24-hour ambulatory blood pressure (BP) monitoring capture daily cumulative hypotensive stress and could be clinically relevant to cognitive impairment, but this relationship remains unclear.

METHODS

We included participants from the Systolic Blood Pressure Intervention Trial (receiving intensive or standard BP treatment) who had 24-hour ambulatory BP monitoring measured near the 27-month visit and subsequent biannual cognitive assessments. We evaluated the associations of hypotensive episodes (defined as systolic BP drops of ≥20 mm Hg between 2 consecutive measurements that reached <100 mm Hg) and hypotensive duration (cumulative time of systolic BP <100 mm Hg) with subsequent cognitive function using adjusted linear mixed models. We further assessed 24-hour average BP and variability.

RESULTS

Among 842 participants with treated hypertension (mean age, 71±9 years; 29% women), the presence (versus absence) of recurrent hypotensive episodes (11%) was associated with lower digit symbol coding scores (difference in Z scores, -0.249 [95% CI, -0.380 to -0.119]) and their faster declines (difference in Z score changes, -0.128 [95% CI, -0.231 to -0.026]). A consistent dose-response association was also observed for longer hypotensive duration with worse Montreal Cognitive Assessment and digit symbol coding scores. The association with digit symbol coding scores remained significant after further adjusting for 24-hour average BP and variability and was not observed for hypotension defined by clinic, orthostatic, or 24-hour average BP. Intensive BP treatment increased 24-hour hypotensive episodes and modified its association with the decline in digit symbol coding score.

CONCLUSION

Twenty-four-hour hypotensive episodes were associated with worse cognitive function, especially in processing speed, and could be a novel marker for optimal BP control and dementia prevention.

Blood pressure variability as predictor of cancer therapy-related cardiovascular toxicity in patients with Multiple Myeloma

Blood pressure (BP) variability (BPV) is an independent predictor of cardiovascular (CV) events. The role of BPV in defining risk of cancer therapy-related cardiovascular toxicity (CTR-CVT) is currently unknown. The aims of this study were: (i) to evaluate BPV in a population of patients with Multiple Myeloma, undergoing proteasome inhibitors therapy; (ii) to assess the predictive value of BPV for CTR-CVT; (iii) to analyze clusters of subjects based on BPV. One hundred twenty-four patients underwent a baseline evaluation, including Ambulatory Blood Pressure Monitoring (ABPM), PWV, and Echocardiography. BPV was assessed through ABPM-based standard deviation (SD), weighted standard deviation (wSD), coefficient of variation (CoV), average real variability (ARV), and variability independent of the mean (VIM). Individuals who developed CTR-CVT had a higher baseline BPV. Furthermore, night-time BPV was associated with CTR-CVT, independently of age, smoking, BP, diabetes, dyslipidemia, and kidney function (night-time systolic CoV: adjusted OR 1.09 [1.01-1.21]; night-time systolic VIM: adjusted OR 1.18 [1.01-1.39]). Cut-offs for these BPV parameters were identified as predictors of CTR-CVT occurrence: 10.5 for night-time systolic CoV; 7.8 and 6.4 for systolic and diastolic night-time VIM. Clustering analysis identified subgroups of subjects characterized by the highest BPV, who had a greater prevalence of events, but no differences in other CV risk determinants. Short-term BPV is an independent predictor of CTR-CVT. BPV may enhance the precision of risk stratification in cancer patients, enabling identification of individuals at higher risk who would not be recognized, if traditional prognostic indicators were the sole applied criteria. On the left panel in the figure, the distribution of blood pressure variability (BPV) in the population according to cancer therapy-related cardiovascular toxicity occurrence; in the central panel, association of blood pressure variability with events and cutoffs values; in the right panel, clustering analysis results based on BPV levels. Histogram and radar plot represent events and BPV indexes distribution in the three clusters, respectively. ARV, average real variability; BPV, Blood Pressure Variability; CTR-CVT, cancer therapy-related cardiovascular toxicity; CoV, coefficient of variation; DBP, Diastolic blood pressure; SBP, Systolic blood pressure; SD, standard deviation; VIM, variability independent of the mean; wSD, weighted standard deviation.

Effect of amphetamines on blood pressure

BACKGROUND

Daily ingestion of amphetamines is common, as they are widely prescribed for attention-deficit hyperactivity disorder (ADHD) and other diagnoses. People also use amphetamines recreationally or in an attempt to boost cognitive or athletic performance. Amphetamines have the potential to increase blood pressure, and we do not know if the long-term benefits of daily amphetamine use outweigh the potential harms.

OBJECTIVES

Primary: to quantify the changes in systolic and diastolic blood pressure in children and adults taking amphetamines, compared to placebo. Secondary: to quantify the changes in heart rate in children and adults taking amphetamines, compared to placebo; to quantify the number of withdrawals due to adverse effects of amphetamine, compared to placebo.

SEARCH METHODS

We used the Cochrane Hypertension Specialized Register, CENTRAL, MEDLINE, Embase and two clinical trial registers, together with reference checking and contact with study authors to identify the studies included in the review. We imposed no restrictions on language, publication year or publication status. The latest search date was March 2023.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that compared the effects of daily oral amphetamines versus placebo on blood pressure. There were no restrictions on participants' age or gender.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. Primary outcomes were change in systolic and diastolic blood pressure (measured in millimeters of mercury (mmHg) above atmospheric pressure; continuous outcomes). Secondary outcomes were heart rate (measured as beats per minute; continuous outcome) and withdrawals due to adverse effects (dichotomous outcome). We calculated continuous outcomes as mean differences (MD) with 95% confidence intervals (CI). We expressed withdrawals due to adverse effects as a risk ratio with 95% CI. We used a fixed-effect model to pool effect sizes from all studies.

MAIN RESULTS

We included 56 RCTs with a total of 10,583 participants, both adults and children. Most studies were conducted in North America (mainly the USA), followed by Europe. A few studies took place in Asia (Japan) and Australia. The studies tested racemic amphetamine, dextroamphetamine, mixed amphetamine salts, lisdexamfetamine dimesylate, methyl​enedioxy​methamphetamine (MDMA) and methylphenidate. The amphetamines were prescribed for ADHD, weight loss and other indications. In 48 RCTs, blood pressure was measured within 24 hours of the last dose. Based on data from all included studies, amphetamines increased systolic blood pressure (SBP) by 1.93 mmHg (95% CI 1.54 to 2.31) and diastolic blood pressure (DBP) by 1.84 mmHg (95% CI 1.51 to 2.16) (56 studies, 10,583 participants; high-certainty evidence for both). Amphetamines increased heart rate by 3.71 beats per minute (95% CI 3.27 to 4.14; 47 studies, 10,075 participants; high-certainty evidence). In a subgroup analysis limited to studies that gave participants amphetamines for at least eight weeks, the effects were similar, suggesting that these are sustained effects. These findings suggest that people taking daily oral amphetamines are at increased risk of adverse cardiovascular events. Participants in the amphetamine group were also more likely to withdraw from the study due to adverse effects compared to those given placebo (risk ratio 2.69, 95% CI 2.13 to 3.40; absolute risk increase of 4.3% over an average duration of 1 month; 42 studies, 8952 participants; high-certainty evidence). In general, the studies were well-executed, and the methodology was sound. We judged most studies to have a low risk of bias across most domains. Selection bias (random sequence generation and allocation concealment) was the domain most often rated as at unclear risk of bias, because the methods used were not reported. We judged 13 studies (23%) to have a high risk of bias in at least one of the seven domains, primarily due to high dropout rates, leading to a high risk of attrition bias.

AUTHORS' CONCLUSIONS

Daily oral amphetamines increase blood pressure, heart rate, and withdrawals due to adverse effects, with these effects observed across all time points, including shorter (≤ four weeks) and longer durations (> four weeks to < eight weeks; ≥ eight weeks) of use. Future trials should measure blood pressure using 24-hour ambulatory monitoring and assess the effect of long-term use.

Effect of adrenergic agonist oral decongestants on blood pressure

BACKGROUND

Adrenergic agonist oral decongestants are commonly taken daily over long periods of time to relieve sinus and nasal congestion. The mechanism of action of decongestants potentially increases blood pressure, and these effects may be acute or chronic. However, no systematic reviews to date have comprehensively assessed the chronic blood pressure effects of adrenergic agonist oral decongestants as a drug class, despite their widespread non-prescription availability.

OBJECTIVES

Primary objective To assess the effects of adrenergic agonist oral decongestants on systolic and diastolic blood pressure compared to placebo. Secondary objective To assess the effects of adrenergic agonist oral decongestants on heart rate and withdrawals due to adverse effects.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCT) up to July 2024: Cochrane Hypertension Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Register of Studies, Ovid MEDLINE, Ovid Embase, and ClinicalTrials.gov. There were no language, publication year, or publication status restrictions.

SELECTION CRITERIA

We included RCTs of at least seven days' duration with parallel groups (intervention and placebo) comparing adrenergic agonist oral decongestants versus placebo on blood pressure in people aged over six years.

DATA COLLECTION AND ANALYSIS

Two review authors (JJC and MC) independently assessed the trials for inclusion, extracted the data, and assessed the risk of bias from the included trials. In cases where there were disagreements, the third review author (JMW) adjudicated. For any missing or unclear information in the studies, we contacted the study author to request the missing information or seek clarification. The primary outcomes were systolic blood pressure and diastolic blood pressure. Secondary outcomes were heart rate and withdrawal due to adverse effects. We used a fixed-effect model to combine the effect sizes from all studies. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

Five RCTs randomizing 882 participants met the inclusion criteria. The shortest study duration was one week, and the longest study duration was 24 weeks. These studies measured blood pressure and heart rate after one to seven weeks of taking oral decongestants. The largest study included 568 people, and the smallest study included 18 people. The mean age of participants was 20.0 years, with 326 males and 591 females. The studies were conducted in the USA and Europe; most were set in the USA. Pharmaceutical companies funded three of the five included studies. The findings are relevant to all people using adrenergic agonist oral decongestants for seven days or longer regardless of comorbidities or pre-existing conditions. The adrenergic agonist oral decongestants included were ephedrine (one RCT), pseudoephedrine (one RCT), and phenylpropanolamine (three RCTs). Compared to placebo, adrenergic agonist oral decongestants may have little to no effect on systolic blood pressure, but the evidence is very uncertain (mean difference [MD] 0.91 mmHg, 95% confidence interval [CI] -0.57 to 2.38; 4 RCTs, 784 participants; I2 = 54%; very low-certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on diastolic blood pressure (MD 0.44 mmHg, 95% CI -0.59 to 1.48; 5 RCTs, 882 participants; I2 = 30%; low-certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on heart rate, but the evidence is very uncertain (MD 1.92 beats per minute, 95% CI -0.62 to 4.47; 2 RCTs, 190 participants; I2 = 79%; very low-certainty evidence). Adrenergic agonist oral decongestants may have little to no effect on the number of withdrawals due to adverse effects (risk ratio [RR] 1.20, 95% CI 0.37 to 3.88; 4 RCTs, 806 participants; low-certainty evidence; note 1 study reported withdrawals due to adverse effects but recorded 0 events in both groups. Thus, the RR and CIs were calculated from 3 studies rather than 4). Four studies were at overall high risk of bias, and one study was at overall low risk of bias.

AUTHORS' CONCLUSIONS

In this systematic review, chronic daily intake of adrenergic agonist oral decongestants had little to no effect on blood pressure, heart rate, and withdrawals due to adverse effects. People making decisions about using these medicines should consider the very low certainty of evidence and the theoretical risk of increased blood pressure. Independent trials free from biases that are designed to answer this question are required. The evidence was limited due to the small number of studies, and the blood pressure and heart rate not being measured at the optimal time after drug ingestion.

Ambulatory blood pressure monitoring before and after resection of catecholamine-secreting pheochromocytoma or paraganglioma

Pheochromocytomas/paragangliomas are catecholamine-secreting tumors that are a rare cause of hypertension and associated with high cardiovascular risk. We aimed to evaluate changes in 24-h ambulatory blood pressure (BP) monitoring (ABPM) following tumor resection. Individuals with evidence of pheochromocytoma/paraganglioma prospectively underwent 24-h ABPM and plasma and urine catecholamine measurement 2-3 weeks before and 6-8 weeks after pathologically-confirmed tumor resection. Patients with metastatic disease were excluded. Changes in office, 24-h, daytime, and nighttime mean systolic and diastolic BP and heart rate, 24-h BP and heart rate average real variability, and rates of controlled, sustained, white coat, and masked hypertension were assessed in paired analyses. There were 34 participants who completed 24-h ABPM before and after tumor resection. Mean age was 55 ± 13 years, with 21 (62%) women, median duration of hypertension of 3 years, and 6 (18%) participants with coronary artery disease. Serum and urine catecholamines normalized following tumor resection and participants were prescribed 1 ± 0.2 fewer antihypertensive medications. Office BP declined by a mean 10 ± 16/7 ± 9 mmHg, 24-h BP declined by 8 ± 14/4 ± 10 mmHg, with greater improvement in nighttime (9 ± 18/5 ± 13 mmHg) than daytime (7 ± 14/4 ± 9) ambulatory BP. Systolic BP variability and heart rate variability significantly improved. While the frequency of controlled hypertension increased (4 [12%] to 11 [32%]; p = 0.008), there was no significant change in masked hypertension (9 [26%] to 12 [35%]; p = 0.366). In conclusion, pheochromocytoma/paraganglioma resection was associated with improvement in 24-h BP and BP variability, particularly nighttime BP. ABPM may be useful following tumor resection to identify patients with unrecognized residual cardiovascular risk.

Blood pressure variability associated with in-hospital and 30-day mortality in heart failure patients: a multicenter cohort study

To investigate the association between blood pressure variability (BPV) and mortality (in-hospital and 30-day) among heart failure (HF) patients, and to examine these associations across patient subgroups. This multicenter retrospective cohort study analyzed 25,591 heart failure patients from two intensive care databases (eICU Collaborative Research Database [eICU-CRD] and the Medical Information Mart for Intensive Care IV [MIMIC-IV]). BPV was assessed using coefficient of variation of systolic (SBPV), diastolic (DBPV), and mean (MBPV) blood pressure measurements. Multivariable logistic regression and Cox proportional hazards models evaluated mortality associations, adjusting for clinical parameters. The observed mortality rates were 14.7% (in-hospital) and 17.3% (30-day). Higher BPV demonstrated significant associations with increased mortality risk, with SBPV showing the strongest relationship. For in-hospital mortality, each standard deviation increase in SBPV, DBPV, and MBPV corresponded to adjusted odds ratios of 1.56 (95% CI 1.51-1.62), 1.21 (95% CI 1.16-1.25), and 1.42 (95% CI 1.37-1.48), respectively. For 30-day mortality, adjusted hazard ratios were 1.37 (95% CI 1.33-1.41) for SBPV, 1.15 (95% CI 1.12-1.19) for DBPV, and 1.30 (95% CI 1.27-1.34) for MBPV. These associations remained robust across all patient subgroups. Increased blood pressure variability during hospitalization independently predicts higher in-hospital (14.7%) and 30-day mortality (17.3%) in HF patients, with SBPV showing the strongest association (OR: 1.56, 95% CI 1.51-1.62). BPV may serve as a valuable prognostic marker for risk stratification in hospitalized heart failure patients.

Blockade of insulin receptor signaling in the medullary cardiovascular centers impairs open-loop arterial baroreflex function via attenuated neural arc in healthy male rats

Evidence suggests that brain insulin availability acutely modulates arterial baroreflex function. However, little is known about the impact of blocking brain insulin receptor (IR) signaling on arterial baroreflex. We hypothesized that blockade of IR signaling in the brain acutely impairs arterial baroreflex function. Our hypothesis was tested using baroreflex open-loop analysis to evaluate the two subsystems of the arterial baroreflex: the carotid sinus pressure (CSP)-sympathetic nerve activity (SNA) relationship (the neural arc) and the SNA-arterial pressure (AP) relationship (the peripheral arc). In anesthetized healthy male rats, the bilateral carotid sinus baroreceptor regions were surgically isolated from the systemic circulation, and then CSP was changed stepwise from 60 to 180 mmHg before and over 120 min after lateral intracerebroventricular (ICV) administration of either artificial cerebrospinal fluid (control solution) or IR antagonist GSK1838705. ICV injection of GSK1838705 significantly decreased renal SNA (RSNA), AP, and heart rate during stepwise CSP input over a period of 120 min after administration (p < .05). The maximum gain of the neural arc was significantly reduced 120 min after ICV injection of GSK1838705 (p = .002). Furthermore, GSK1838705 significantly attenuated the operating-point RSNA (p = .025) and AP (p < .001) as estimated by the baroreflex equilibrium diagram. Moreover, 120-min baroreflex stimulation via stepwise CSP input significantly increased c-Fos expression in IR-positive neurons in medullary cardiovascular centers (p < .001). Our findings suggest that IR signaling in the brain can modulate AP regulation via alteration of the neural arc of the arterial baroreflex.

Early prediction of cardiovascular events following treatments in female breast cancer patients: Application of real-world data and artificial intelligence

•Application of real-world data and artificial intelligence in detecting cardiotoxicity following cancer treatment. •Clinical features have been used to develop prediction models. •Important features include age, tumor size, hypertension, HbA1c, HDL, creatinine, bilirubin, BUN, ALT, and diabetes. •This study offers potential approaches for cardio-oncology clinical practice.

Physical activity, fitness, and cardiac autonomic function among adults born postterm

Recent studies have suggested that adverse outcomes of postterm birth (≥42 completed weeks of gestation), including increased cardiometabolic risk factors, impaired glucose metabolism, and obesity, may extend into adulthood. We studied interconnected determinants of cardiovascular health, including physical activity (PA; based on accelerometry for 2 weeks), muscular strength (measured by handgrip strength), cardiorespiratory fitness (CRF; measured by 4-min step test), and cardiac autonomic function (heart rate [HR] recovery, HR variability, and baroreflex sensitivity) among 46-year-old adults from the Northern Finland Birth Cohort born postterm (n = 805) and at term (n = 2645). Adults born postterm undertook vigorous PA 2.0 min day-1 (95% CI, 0.4-3.7) less than term-born adults when adjusted for sex, age, and maternal- and pregnancy-related covariates in multiple linear regression. Postterm birth was associated with reduced CRF, based on a higher peak HR (2.1 bpm; 95% CI, 0.9-3.4) and slower HR recovery 30 s after the step test (-0.7 bpm; 95% CI, -1.3 to -0.1). Postterm birth was associated with less PA of vigorous intensity and CRF and slower HR recovery in middle age. Our findings reinforce previous suggestions that postterm birth should be included as a perinatal risk factor for adult cardiometabolic disease.

Time in Target Range for Blood Pressure and Adverse Health Outcomes: A Systematic Review

BACKGROUND

Blood pressure (BP) time in target range (TTR) reflects the proportion of time that BP measurement is within a specified target range. We aim to summarize the evidence for relationships between TTR and adverse health outcomes.

METHODS

Seven databases were searched. After quality assessment and data extraction, meta-analyses were performed to generate pooled estimates of the association (hazard ratios) between TTR and health outcomes. Primary outcomes were all-cause mortality and cardiovascular death. Secondary outcomes included major adverse cardiovascular events, myocardial infarction, stroke, heart failure, atrial fibrillation, and adverse kidney events.

RESULTS

In all, 21 studies were included, mostly rated at low risk of bias. TTR was defined by systolic BP (SBP) in 15 studies and by both SBP and diastolic BP in 6 studies. Per SD increase of TTR was associated with significantly decreased risks of all-cause mortality (110-130 mm Hg SBP TTR: hazard ratios, 0.85 [95% CI, 0.82-0.89]; 120-140 mm Hg SBP TTR: 0.81 [95% CI, 0.70-0.94]; and 70-80 mm Hg diastolic BP TTR: 0.88 [95% CI, 0.83-0.93]), cardiovascular death (110-130 mm Hg SBP TTR: 0.83 [95% CI, 0.78-0.87]; 120-140 mm Hg SBP TTR: 0.76 [95% CI, 0.65-0.89]; and 70-80 mm Hg diastolic BP TTR: 0.85 [95% CI, 0.80-0.90]), major adverse cardiovascular events (120-140 mm Hg SBP TTR: 0.76 [95% CI, 0.70-0.83]), and heart failure (110-130 mm Hg SBP TTR: 0.84 [95% CI, 0.76-0.93] and 120-140 mm Hg SBP TTR: 0.78 [95% CI, 0.68-0.89]). However, there was not sufficient support for the association of TTR with myocardial infarction, stroke, atrial fibrillation, or adverse kidney events.

CONCLUSIONS

Higher TTR was associated with reduced risks of all-cause mortality, cardiovascular death, major adverse cardiovascular events, and heart failure, highlighting the importance of sustained BP control in clinical practice.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023486437.

Variability in Cardiometabolic Parameters and All-Cause and Cause-Specific Mortality in Older Adults: Evidence From 2 Prospective Cohorts

INTRODUCTION

The aim of this study is to assess the individual and joint associations of variability in multiple cardiometabolic parameters with mortality risk across older populations.

METHODS

A total of 51,551 Chinese elderly participants (aged ≥60 years) with ≥3 measurements of systolic blood pressure, visceral adiposity index, fasting blood glucose, and low-density lipoprotein cholesterol during 2018-2022 were included. Variability metrics included SD, coefficient of variation, average real variability, and variability independent of the mean (used in primary analysis). Participants were classified on the basis of the number of high-variability (highest quartile of variability) parameters into 4 categories: with 0, 1, 2, and 3-4 high-variability cardiometabolic parameters. Cox regression analyses were performed in 2024. Findings were then externally validated using the Health and Retirement Study (Waves 8-15).

RESULTS

Higher systolic blood pressure, visceral adiposity index, fasting plasma glucose, and low-density lipoprotein cholesterol variability were associated with greater all-, cardiovascular-, and other-cause mortality risk. Compared with those of subjects with no high-variability parameters measured as the variability independent of the mean, the hazard ratios (95% CI) of all-cause mortality were 1.30 (1.16, 1.44) for 1 parameter, 1.86 (1.66, 2.09) for 2 parameters, and 2.02 (1.75, 2.32) for 3-4 parameters. Consistent results were noted for cardiovascular-, cancer-, and other-cause mortality using other variability indices and in various sensitivity and subgroup analyses. These associations were validated in the Health and Retirement Study (n=1,991).

CONCLUSIONS

Increased variability in cardiometabolic parameters is associated with elevated risks of all-cause and cause-specific mortality among older adults in China. Reducing variability of these parameters could serve as a target to increase life expectancy in older populations.

Promoting Resiliency to Stress in the Vascular Endothelium

By 2050, roughly 60% of the population will have cardiovascular disease. While a substantial amount of data has been generated over the last few decades that has aided in our understanding of cardiovascular disease pathology, less is known about how to increase resiliency to cardiovascular risk factors that individuals are exposed to on a daily basis. The vascular endothelium is considered the first line of defence against circulating noxious stimuli and, when dysfunctional, is an early risk factor for the development of cardiovascular disease. A vast amount of data has been generated demonstrating how external stress impairs the vascular endothelium; however, there is a paucity of knowledge regarding how to amplify protective pathways and ward off stress and the development of disease, which is the focus of this review. Targeting known protective endothelial pathways may be feasible to increase resiliency to vascular stress. Leveraging stress to boost defence mechanisms within the vascular endothelium is also proposed and may help identify novel therapeutic targets to protect individuals from the stress of everyday life.

Clinic, Ambulatory and Home Blood Pressure Monitoring for Metabolic Syndrome: Time to Change the Definition?

Background and Objectives: Metabolic syndrome (MetS) is considered a global epidemic, and its diagnosis is crucial, allowing early intervention and management. The main aim of this study was to examine any possible blood pressure (BP) differences based on office and out-of-office measurements in patients with and without MetS, and to investigate if any of these measurements correlated better with MetS. The secondary aim was to investigate any possible cardiovascular risk differences. Materials and Methods: The study population consisted of individuals attending the outpatient hypertension clinic. Office and out-of-office BP measurements were recorded in all of the patients, as well as different cardiovascular risk scores and echocardiography. MetS was defined according to ACC/AHA criteria. Results: A total of 282 (39.9% men) individuals (56.8 ± 15.8 years) were analyzed; 60.8% of them had MetS. The patients with MetS had a significantly higher systolic BP (SBP) in all of the BP measurements, higher ASCVD risk (22% vs. 12%), Framingham risk scores (11.8% vs. 6.9%), a significantly higher prevalence of LVH (49.2% vs. 22.7%) and early vascular aging (54.8% vs. 27.4%) compared with the patients without MetS (p < 0.05 for all). In a univariate analysis, MetS was significantly correlated with the average 24h SBP, daytime and nighttime ambulatory SBP, office SBP, and home SBP in the morning (p < 0.05). No significant differences were observed for any of the DBP measurements. Finally, 50.5% of the MetS patients had sustained hypertension, 15.2% masked hypertension, and 11.5% white-coat hypertension based on ABPM, and these values were 45.1%, 19.3%, and 13.6%, respectively, based on HBPM. Furthermore, most of the MetS patients had non-dipping hypertension (56.4%). Conclusions: The present findings highlight the importance of out-of-office BP measurements in the diagnosis of MetS, since both a high office and out-of-office SBP were significant features of the syndrome (whereas this was not the case with DBP). This is further supported by the increased prevalence of different hypertension phenotypes observed in the MetS patients. Higher ASCVD risk scores and LVH and EVA prevalence were also related to MetS, thus strongly supporting the necessity for early detection and treatment.

The correlation between age, blood pressure variability and estimated pulse wave velocity

Studies have separately compared the association of age with blood pressure variability (BPV) or pulse wave velocity (PWV). We aimed to establish the association between age and metrics of short-term BPV and PWV in the same sample. 508 under 60 years (< 60) and 141 in their sixties (≥ 60) measured blood pressure (OBP), and PWV using the oscillometric technique (br-PWV). They recorded an ambulatory BP monitoring (ABPM) to obtain variables for systolic (SBPV) and diastolic BPV (DBPV). We also estimated PWV using formulas. We calculated the Pearson correlation coefficient (r) and determination coefficient (R2) of all parameters with age. The correlation between age and PWV was very strong (br-PWV; r = 0.901; p < 0.001). It was poor for SBPV, 24-h weighted SD r = 0.492; p < 0.001, and not significant for DBPV, 24-h weighted SD r = 0.220; p < 0.001. The correlation and determination values were generally better in the group comprising ≥ 60-years, with R2 values robust for PWV (br-PWV = 0.812) weaker for SBPV (24-h weighted SD = 0.243) and deemed irrelevant for DBPV (24-h weighted SD = 0.048). Our study shows that PWV metrics are firmly and significantly more influenced by age than short-term BPV.

Blood pressure variability: a review

Blood pressure variability (BPV) predicts cardiovascular events independent of mean blood pressure. BPV is defined as short-term (24-h), medium or long- term (weeks, months or years). Standard deviation, coefficient of variation and variation independent of the mean have been used to quantify BPV. High BPV is associated with increasing age, diabetes, smoking and vascular disease and is a consequence of premature ageing of the vasculature. Long-term BPV has been incorporated into cardiovascular risk models (QRISK) and elevated BPV confers an increased risk of cardiovascular outcomes even in subjects with controlled blood pressure. Long-acting dihydropyridine calcium channel blockers and thiazide diuretics are the only drugs that reduce BPV and for the former explains their beneficial effects on cardiovascular outcomes. We believe that BPV should be incorporated into blood pressure management guidelines and based on current evidence, long-acting dihydropyridines should be preferred drugs in subjects with elevated BPV.

Day-to-day blood pressure variability in older persons - optimizing measurement

BACKGROUND

Higher blood pressure variability (BPV) is associated with adverse clinical outcomes but lack of standardized methodology hampers clinical translation. Day-to-day BPV seems most promising for an older population, especially those with cognitive impairment. This study aimed to determine the optimal number of measurements for obtaining day-to-day BPV in this population.

METHODS

We included 127 patients attending the geriatric outpatient memory clinic, who measured blood pressure for seven days, morning and evening. Blood pressure measurements of day one were discarded and the coefficient of variation was calculated to assess BPV. Concordance between 7-day BPV (CV7days) and a reduced number of measurement days (CV6days - CV3days) was analysed with Bland-Altman plots, intraclass correlation coefficient (ICC), and an a priori determined threshold of a 95% confidence interval (CI) with a lower bound of 0.75.

RESULTS

The mean age was 74.6 ± 8.6 years, 49% were female, and had dementia or mild cognitive impairment in 37% and 33% respectively. Reducing the number of measurement days resulted in wider limits of agreement. Concordance decreased when reducing measurement days and reached our predefined threshold with four measurement days (ICC = 0.91, 95% CI = 0.87 - 0.93). BPV derived from five measurement days showed a similar relationship with diagnosis as our reference BPV value obtained with seven days.

CONCLUSION

Our results suggest that systolic home blood pressure should be measured in the morning and evening for at least five consecutive days in duplicate to obtain reliable day-to-day BPV values in older adults with cognitive complaints.

Impact of the National Essential Public Health Service Package on Blood Pressure Control in Chinese People With Hypertension: Retrospective Population-Based Longitudinal Study

Background

The National Essential Public Health Service Package (NEPHSP) was launched in 2009 to tackle poor blood pressure control in Chinese people with hypertension; however, it's effect is still unclear.

Objective

In a retrospective population-based longitudinal study, we aimed to evaluate effect of the NEPHSP on blood pressure control.

Methods

A total of 516,777 patients registered in the NEPHSP were included. The blood pressure control data were assessed based on the Residence Health Record System dataset. We longitudinally evaluated the effects of the NEPHSP on blood pressure control by analyzing changes in blood pressure at quarterly follow-ups. Both the degree and trend of the blood pressure changes were analyzed. We conducted stratified analysis to explore effects of the NEPHSP on blood pressure control among subgroups of participants with specific characteristics.

Results

The mean baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 147.12 (SD 19.88) mm Hg and 85.11 (SD 11.79) mm Hg, respectively. The control rates of baseline SBP and DBP were 39.79% (205,630/516,777) and 69.21% (357,685/516,777). Compared to baseline, the mean SBP decreased in each quarter by 5.06 mm Hg (95% CI -5.11 to -5.00; P<.001), 6.69 mm Hg (95% CI; -6.74 to -6.63; P<.001), 10.30 mm Hg (95% CI -10.34 to -10.23; P<.001), and 6.63 mm Hg (95% CI -6.68 to -6.57; P<.001). The SBP control rates increased in each quarter to 53.12% (274,493/516,777; β coefficient=0.60, 95% CI 0.59-0.61; P<.001), 56.61% (292,537/516,777; β coefficient=0.76, 95% CI 0.75-0.77; P<.001), 63.4% (327,648/516,777; β coefficient=1.08, 95% CI 1.07-1.09; P<.001), and 55.09% (284,711/516,777; β coefficient=0.69, 95% CI 0.68-0.70; P<.001). Compared to baseline, the mean DBP decreased in each quarter by 1.75 mm Hg (95% CI -1.79 to -1.72; P<.001), 2.64 mm Hg (95% CI -2.68 to -2.61; P<.001), 4.20 mm Hg (95% CI -4.23 to -4.16; P<.001), and 2.64 mm Hg (95% CI -2.68 to -2.61; P<.001). DBP control rates increased in each quarter to 78.11% (403,641/516,777; β coefficient=0.52, 95% CI 0.51-0.53; P<.001), 80.32% (415,062/516,777; β coefficient=0.67, 95% CI 0.66-0.68; P<.001), 83.17% (429,829/516,777; β coefficient=0.89, 95% CI 0.88-0.90; P<.001), and 79.47% (410,662/516,777; β coefficient=0.61, 95% CI 0.60-0.62; P<.001). The older age group had a larger decrease in their mean SBP (β coefficient=0.87, 95% CI 0.85-0.90; P<.001) and a larger increase in SBP control rates (β coefficient=0.054, 95% CI 0.051-0.058; P<.001). The participants with cardiovascular disease (CVD) had a smaller decrease in their mean SBP (β coefficient=-0.38, 95% CI -0.41 to -0.35; P<.001) and smaller increase in SBP control rates (β coefficient=-0.041, 95% CI -0.045 to -0.037; P<.001) compared to the blood pressure of participants without CVD.

Conclusions

The NEPHSP was effective in improving blood pressure control of Chinese people with hypertension. Blood pressure control of older individuals and those with CVD need to be intensified.

Atlas of multilineage stem cell differentiation reveals TMEM88 as a developmental regulator of blood pressure

Pluripotent stem cells provide a scalable approach to analyse molecular regulation of cell differentiation across developmental lineages. Here, we engineer barcoded induced pluripotent stem cells to generate an atlas of multilineage differentiation from pluripotency, encompassing an eight-day time course with modulation of WNT, BMP, and VEGF signalling pathways. Annotation of in vitro cell types with reference to in vivo development reveals diverse mesendoderm lineage cell types including lateral plate and paraxial mesoderm, neural crest, and primitive gut. Interrogation of temporal and signalling-specific gene expression in this atlas, evaluated against cell type-specific gene expression in human complex trait data highlights the WNT-inhibitor gene TMEM88 as a regulator of mesendodermal lineages influencing cardiovascular and anthropometric traits. Genetic TMEM88 loss of function models show impaired differentiation of endodermal and mesodermal derivatives in vitro and dysregulated arterial blood pressure in vivo. Together, this study provides an atlas of multilineage stem cell differentiation and analysis pipelines to dissect genetic determinants of mammalian developmental physiology.

Mechanism of action of exercise regulating intestinal microflora to improve spontaneous hypertension in rats

Hypertension is a prevalent cardiovascular disease. Exercise is widely recognized as an effective treatment for hypertension, and it may also influence the composition of the intestinal microflora. However, it remains unclear whether exercise can specifically regulate the intestinal microflora in the context of hypertension treatment. In this study, tail blood pressure in spontaneously hypertensive rats (SHR) was measured using a blood pressure meter after exercise intervention and fecal bacteria transplantation following exercise. Blood lipid levels were assessed using an automatic biochemical analyzer, and 16S rRNA sequencing was employed to analyze the intestinal microflora. Histological examinations of ileal tissue were conducted using HE and Masson staining. Intestinal permeability, inflammatory status, and sympathetic activity were evaluated by measuring the levels of diamine oxidase, D-lactic acid, C-reactive protein, interleukin-6, tumor necrosis factor-α, lipopolysaccharide, norepinephrine, angiotensin II, cyclic adenosine monophosphate, and cyclic guanosine monophosphate. Exercise was found to reduce blood pressure and blood lipid levels in SHR. It also improved the composition of the intestinal microflora, as evidenced by a reduced Firmicutes/Bacteroidetes ratio, an increase in bacteria that produce acetic and butyric acid, and higher Chao 1 and Shannon diversity indices. Furthermore, exercise reduced the thickness of the fibrotic and muscular layers in the ileum, increased the goblet cell/villus ratio and villus length, and decreased intestinal permeability, inflammatory markers, and sympathetic nerve activity. The intestinal microbial flora regulated by exercise demonstrated similar effects on hypertension. In conclusion, exercise appears to regulate the intestinal microflora, and this exercise-induced change in flora may contribute to improvements in hypertension in rats.

The prognostic association of triglyceride-glucose index and its derived indicators with stable coronary artery disease patients undergoing percutaneous coronary intervention

Aims

Research on the triglyceride-glucose (TyG) index in patients with stable coronary artery disease (SCAD) remains relatively limited. Therefore, this study aims to investigate the association of the TyG index and its derived indicators, including the baseline TyG index, the baseline triglyceride glucose-body mass index (TyG-BMI), the mean TyG index, and the triglyceride glucose index-standard deviation (TyG-SD), with the prognosis of SCAD patients undergoing percutaneous coronary intervention (PCI).

Methods

This retrospective study enrolled 2,306 patients. The Cox proportional hazards model was utilized to evaluate the association between the four TyG indicators and major adverse cardiovascular and cerebrovascular events (MACCE). The predictive ability of the four TyG indicators for MACCE was assessed using the time-dependent receiver operating characteristic (ROC) curve. Kaplan-Meier survival analysis was employed to assess the prognostic differences among groups.

Results

After a median follow-up of 26.1 months, a total of 352 patients (15.3%) experienced MACCE. The Cox regression analysis revealed that under a fully adjusted model, when the four TyG indicators were stratified by tertiles, patients in the highest tertile of each TyG indicator had a significantly increased risk of MACCE compared to those in the lowest tertile. Specifically, the hazard ratio for baseline TyG index was 1.653 (95% confidence intervals (CI): 1.234-2.214), for baseline TyG-BMI was 2.467 (95%CI: 1.849-3.293), for mean TyG index was 2.451 (95%CI: 1.794-3.349), and for TyG-SD was 1.896 (95%CI: 1.430-2.513). Time-dependent ROC curve demonstrated that the mean TyG index had the strongest predictive ability for MACCE at each follow-up time point. The Kaplan-Meier analysis results showed that when the four TyG indicators were grouped by tertiles, there were significant differences in the cumulative incidence of MACCE among the three groups for each indicator (P < 0.05).

Conclusion

Higher levels of the TyG index and its derived indicators were each independently and positively associated with the risk of MACCE in SCAD patients undergoing PCI. Among these indicators, the mean TyG index demonstrated the greatest predictive value for the risk of MACCE at each follow-up time point. Consequently, tracking the long-term trends of the TyG index may be prioritized in clinical practice.

Intermittent documentation of blood pressure values does not provide comprehensive evaluation of the hemodynamic response during continuous intravenous medication administration

Blood pressure (BP) is a dynamic measure that is frequently discussed in static terms. There exist many limitations in current documentation systems whereby documented BP values may not be reflective of the dynamic variability of BP. This study used an observational, prospective, non-randomized study design to examine the variability in BP response during intravenous vasoactive medication administration in an intensive care unit setting. Subjects admitted to a neuroscience intensive care unit were monitored continuously during a 12-hour period. The BP values include systolic BP, diastolic BP, and mean arterial pressure. Intermittent values from an intra-arterial figurecatheter (a-line) and continuously sampled values from an a-line obtained using continuous data acquisition (CDA) software, were compared to intermittently sampling of cuff-based BP measurements documented in the medical record. The 30 patients provided 1,220,511 BP observations from CDA, 944 from a-line documentation, and 416 from cuff-based BP documentation. The systolic BP was used as a goal parameter for 23 (77%) of the patients. Repeated measures models demonstrated that on average cuff-based differed from intermittent a-line and from CDA (p < .005) for all BP values. No differences between a-line and CDA were observed. Concordance correlation coefficients ranged from 0.56 to 0.72 for a-line, cuff-based BP, and CDA, indicating moderate agreement. Using intermittently documented BP values does not fully represent the dynamic nature of BP over time.

Therapeutic Potential of GLP-1 Receptor Agonists in Diabetes and Cardiovascular Disease: Mechanisms and Clinical Implications

BACKGROUND

Glucagon-like peptide-1 (GLP-1) is a crucial incretin hormone secreted by intestinal endocrine L cells. Given its pivotal physiological role, researchers have developed GLP-1 receptor agonists (GLP-1 RAs) through structural modifications. These analogues display pharmacological effects similar to those of GLP-1 but with augmented stability and are regarded as an effective means of regulating blood glucose levels in clinical practice.

OBJECTIVE

This review aims to comprehensively summarize the role of GLP-1 RAs in the management of diabetes mellitus (DM) and cardiovascular disease (CVD), with a particular emphasis on the underlying signal transduction pathways and their therapeutic potential.

METHODS

A comprehensive review was carried out through literature research.

RESULTS AND DISCUSSION

In pancreatic β-cells, GLP-1 RAs regulate the secretion of insulin and glucagon in a glucosedependent manner by influencing signaling pathways such as cAMP, PI3K, and MAPK. They also contribute to the regulation of blood glucose levels by promoting the proliferation of β-cells and inhibiting apoptosis in these cells. Recent comprehensive studies have also demonstrated the favorable impact of GLP-1 RAs on cardiovascular wellbeing. In addition to the cardiovascular protection afforded by glucose metabolism regulation, a large body of evidence from animal and cellular studies has corroborated the beneficial effects of GLP-1 RAs on conditions such as heart failure (HF), hypertension, and ischemic cardiomyopathy. These benefits are mainly attributed to the alleviation of inflammatory responses, reduction of oxidative stress, and prevention of cell apoptosis. Clinical data shows that GLP-1 RAs can reduce the risk of major adverse cardiovascular events (MACE) in diabetic patients.

CONCLUSION

GLP-1 RAs play an important role in the management of both diabetes and cardiovascular diseases. They show potential therapeutic value through the modulation of multiple signal transduction pathways. However, there may still be some issues in practical applications that require further research and resolution.

Blood Pressure Variability and Cognition in Black and White Older Adults Over 18 Years of Follow-up: A Population-Based Cohort Study

BACKGROUND AND OBJECTIVES

Hypertension is a well-established cardiovascular risk factor for cognitive function. As blood pressure fluctuates because of aging-related changes, we examined the association between visit-to-visit blood pressure variability (BPV) and cognition in older adults.

METHODS

This prospective observational cohort study included 4,770 individuals aged older than 65 years with repeated blood pressure assessment participating in the Chicago Health and Aging Project, a bi-racial population-based study lasting from 1993 to 2012. Blood pressure was measured by research staff every 3 years over 18 of follow-up. Systolic and diastolic BPV was calculated as the sum of the absolute difference in blood pressure between successive measurements, divided by the number (n - 1) of assessments. Cognition was assessed by standardized cognitive tests, and z-scores for the composite cognitive score were computed. Multivariable adjusted linear regression models were used to evaluate the association of systolic and diastolic BPV during the study period with cognition at the last visit.

RESULTS

Of 4,770 individuals, 2,998 (62.9%) were women, 3,146 (66.0%) were Black, and the mean (SD) age at baseline was 71.3 (5.3) years. The mean systolic BPV was 17.7 mm Hg in Black individuals and 16.0 mm Hg in White participants. Higher systolic and diastolic BPV was associated with lower cognitive scores at the end of follow-up. Compared with individuals in the first tertile of systolic BPV (lower BPV), participants with third tertile (higher BPV) had lower cognitive scores by 0.074 standardized units (β -0.074; 95% CI -0.131 to -0.018), corresponding to 1.8 years older in cognitive age. This relationship differed by race, being significant only in older Black adults. Black individuals in the third tertile of systolic BPV had lower cognitive scores by 0.115 standardized units (β -0.115; 95% CI -0.183 to -0.047) compared with those in the first tertile, corresponding to 2.8 years older in cognitive age. Similar findings were observed for diastolic BPV.

DISCUSSION

Elevated BPV, particularly in older Black adults, was associated with a lower cognitive score, suggesting routine assessment for blood pressure to identify and mitigate the adverse role of BPV in cognitive functioning in older adults.

Patient-specific multifactorial mortality risk assessment using classification and regression tree analysis in the context of ambulatory blood pressure monitoring

BACKGROUND

Ambulatory blood pressure monitoring is essential for understanding blood pressure patterns beyond clinical visits, aiding in risk assessment, treatment evaluation, and managing hypertension. This retrospective cohort study aimed to identify risk factors for all-cause mortality and major cardiovascular events in patients who underwent ambulatory blood pressure monitoring.

METHODOLOGY

Eligible participants aged 18 or older, with an estimated glomerular filtration rate (eGFR) > 60 ml/min/1.73 m2, who underwent ambulatory blood pressure monitoring for various reasons, were included in the study. Data were gathered through telephone interviews, electronic health records, and the national health record system. Descriptive analysis and classification and regression tree modeling were used to uncover significant risk factors related to all-cause mortality and cardiovascular events, and to assess the model's performance compared to traditional Cox survival analysis.

RESULTS

The study included 1291 patients, primarily male (51.8%) with a mean age of 61.1 ± 15.2 years. During a mean follow-up of 46.9 months, 76 (5.9%) patients died of any cause, and 195 (15.1%) had a cardiovascular event. The highest survival rates were observed in patients with a diastolic blood pressure (BP) dipping percentage between - 2% and 29%, nighttime systolic BP variability below 32 mmHg, and age below 72. Conversely, smokers with a diastolic BP dipping percentage below - 10% showed the lowest survival rates. The best cardiovascular outcomes were observed in patients with diastolic BP dipping above - 11%, nighttime mean systolic BP < 144 mmHg, no statin use, normotensive status, and daytime mean heart rate ≥ 60 bpm. Conversely, the worst outcomes were seen in patients with diastolic BP dipping below - 11% and a morning surge ≥ 14 mmHg. In all-cause mortality and cardiovascular event analysis, the combined model demonstrated excellent calibration and predictive power, like the classification and regression tree model and traditional analysis.

CONCLUSION

These findings highlight the potential of a combined model for assessing mortality and cardiovascular event risk in patients who have undergone ambulatory blood pressure monitoring.

Association Between Blood Pressure Variation During Dialysis and Cardio-Cerebrovascular Events

In hemodialysis patients, blood pressure variability (BPV) is associated with cardiovascular events and all-cause mortality. However, previous research has predominantly concentrated on the predialysis BPV. In contrast, intradialytic BPV, reflecting the cardiovascular regulatory function during the process of rapid clearance of volume overload, holds greater relevance to the prognosis of patients. In this study, a latent category trajectory model was used to identify the patterns of intradialytic BPV and analyze the association between intradialytic BPV and the cardio-cerebrovascular events and other clinical outcomes. We found the variation of intradialytic systolic blood pressure (SBP) was associated with the risk of cardio-cerebrovascular events in hemodialysis patients. Patients in "SBP Class 4" and "SBP Class 3" subgroups were associated with the occurrence of cardio-cerebrovascular events and the number of cardio-cerebrovascular event hospitalizations during the follow-up period. This indicates that the variation pattern of intradialytic SBP results from the comprehensive action of various BP regulatory mechanisms in the body, which can reflect the level of cardiovascular regulatory function in hemodialysis patients and serve as a predictor of recent adverse cardio-cerebrovascular events.

Higher Long-Term Visit-to-Visit Blood Pressure Variability Is Associated With Severe Cerebral Small Vessel Disease in the General Population

Long-term visit-to-visit blood pressure (BP) variability is linked to various diseases, but its impact on cerebral small vessel disease (cSVD) burden, and its features remains uncertain. We analyzed 1284 participants from the Kailuan cohort (2006-2022). Visit-to-visit systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) variability were categorized into tertiles (low, middle, high). Magnetic resonance imaging identified white matter hyperintensities (WMH), lacunae of presumed vascular origin (LA), cerebral microbleeds (CMBs), and visible perivascular spaces (PVS). Total cSVD burden was classified as none (0), mild (1), moderate (2), or severe (3-4) based on the presence of these features. Logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs). High SBP variability was associated with moderate cSVD burden (OR = 1.89, 95% CI: 1.09-3.29) and PVS (OR = 1.62, 95% CI: 1.10-2.39). High DBP variability was associated with LA (OR = 1.74, 95% CI: 1.06-2.84). High PP variability showed a significant risk for severe cSVD burden (OR = 2.49, 95% CI: 1.34-4.63). These associations were modified by age and hypertension status. Among young adults (age < 60 years), high PP variability was associated with severe cSVD burden (OR = 3.33, 95% CI: 1.31-8.44), LA (OR = 3.02, 95% CI: 1.31-6.93), and PVS (OR = 1.86, 95% CI: 1.20-2.88). The risk effects of SBP and PP variability on cSVD burden were significant only in participants with hypertension. High long-term visit-to-visit BP variability (BPV), particularly in combination with hypertension, is a significant risk factor for total cSVD. Special attention should be given to PP variability in younger adults.

Dietary salt intake is not associated with risk of stroke: A Mendelian randomization study

Previous studies have demonstrated a correlation between dietary salt intake and stroke; however, there was a lack of conclusive evidence regarding a causal connection between them. We undertook a two-sample Mendelian randomization (MR) study to examine their potential association. The genome-wide data for dietary salt intake was sourced from genome-wide association study that involved 462,630 samples. Genetic instruments for stroke were also obtained from genome-wide association study, which included 446,696 samples. Both samples were from European. The inverse variance weighting was used as the main method in MR analysis. We also performed several complementary MR methods, including MR-Egger, position weighted median, simple model, and weighted model. Our results showed that there was no causal relationship between dietary salt intake and stroke, which was genetically determined (fixed-effects inverse variance weighted: odds ratio, 0.95; 95% confidence interval, 0.74-1.21; P  = .67). Neither Cochran Q test (P = .52) nor MR-Egger method (P = .48) found obvious heterogeneity; in addition, the MR pleiotropy residual sum and outliers global test (P = .52) and MR-Egger regression intercept (P = .74) also showed no pleiotropy. The result of our MR study showed that there was no direct causal relationship between dietary salt intake and stroke risk. More studies were required to further confirm the stability of this relationship and to trying applied the findings to the clinic.

Abnormal Autonomic Nervous Regulation in Patients with Globus Pharyngeus

BACKGROUND

Globus pharyngeus could be described as a benign sensation of lump or foreign object in the throat. The etiology of the globus as a solitary syndrome is still unknown, but it is proposed that stress could have an important role in symptom emergence.

AIMS

To evaluate the autonomic nervous regulation in patients with globus compared to healthy controls in reaction to stress.

METHODS

Patients included in the study were diagnosed based on ROME IV criteria for Disorders of Gut Brain Interaction. Besides globus, the patients did not suffer any other substantial medical condition. As a control group, measurement of healthy volunteers was performed. Both groups underwent the same stress protocol assessment in the same laboratory settings. The protocol consist of two types of stressors: cold pressor test and mental arithmetic test to test different types of autonomic reactivity.

RESULTS

Baroreflex sensitivity was significantly decreased in patients compared to controls in all phases of the protocol. Low-frequency band of systolic blood pressure variability was significantly increased during both stress phases in patients compared to controls. High-frequency band of heart rate variability was significantly decreased in patients compared to controls during the both of the stress phases.

CONCLUSION

The results of this study shows discrete abnormalities in complex autonomic reflex control which are predominantly manifested in response to stressful stimuli indicating altered neurocardiac regulation as a reaction to stress associated with globus pharynegus. This fact could have an important role in the personalized management of globus patients such as biofeedback.

Higher intraindividual variability of body mass index is associated with elevated risk of COVID-19 related hospitalization and post-COVID conditions

BACKGROUND

Cardiometabolic diseases are risk factors for COVID-19 severity. The extent that cardiometabolic health represents a modifiable factor to mitigate the short- and long-term consequences from SARS-CoV-2 remains unclear. Our objective was to evaluate the associations between intraindividual variability of cardiometabolic health indicators and COVID-19 related hospitalizations and post-COVID conditions (PCC) among a relatively healthy population.

METHODS

This retrospective, multi-site cohort study was a post-hoc analysis among individuals with cardiometabolic health data collected during routine blood donation visits in 24 US states (2009-2018) and who responded to COVID-19 questionnaires (2021-2023). Intraindividual variability of blood pressure (systolic, diastolic), total circulating cholesterol, and body mass index (BMI) were defined as the coefficient of variation (CV) across all available donation timepoints (ranging from 3 to 74); participants were categorized into CV quartiles. Associations were evaluated by multivariable binomial regressions.

RESULTS

Overall, 3344 participants provided 42,090 donations (median 9 [IQR 5, 17]). The median age was 48 years (38, 56) at the first study donation. 1.2% (N = 40) were hospitalized due to COVID-19 and 15.5% (N = 519) had PCC. Higher BMI variability was associated with greater risk of COVID-19 hospitalization (4th quartile aRR 4.15 [95% CI 1.31, 13.11], p = 0.02; 3rd quartile aRR 3.41 [95% CI 1.09, 10.69], p = 0.04). Participants with higher variability of BMI had greater risk of PCC (4th quartile aRR 1.29 [95% CI 1.02, 1.64]; p = 0.04). Intraindividual variability of blood pressure (systolic, diastolic) and total circulating cholesterol were not associated with COVID-19 hospitalization or PCC risk (all p > 0.05). From causal mediation analysis, the association between the highest quartiles of BMI variability and PCC was not mediated by hospitalization (p > 0.05).

CONCLUSIONS

Higher intraindividual variability of BMI was associated with COVID-19 hospitalization and PCC risk. Our findings underscore the need for further elucidating mechanisms that explain these associations and importance for consistent maintenance of body weight.

Assessment of blood pressure variability: characteristics and comparison of blood pressure measurement methods

Previous studies have reported that blood pressure variability (BPV) is associated with the risk of cardiovascular events independent of blood pressure (BP) levels. While there is little evidence from intervention trials examining whether suppressing BPV is useful in preventing cardiovascular disease, it is suggested that detection of abnormally elevated BPV may be useful in reducing cardiovascular events adding by complementing management of appropriate BP levels. Cuffless BP devices can assess beat-to-beat BPV. Although cuffless BP monitoring devices have measurement accuracy issues that need to be resolved, this is an area of research where the evidence is accumulating rapidly, with many publications on beat-to-beat BPV over several decades. Ambulatory BP monitoring (ABPM) can assess 24-hour BPV and nocturnal dipping patterns. Day-to-day BPV and visit-to-visit BPV are assessed by self-measured BP monitoring at home and office BP measurement, respectively. 24 h, day-to-day, and visit-to-visit BPV have been reported to be associated with cardiovascular prognosis. Although there have been several studies comparing whether ABPM and self-measured BP monitoring at home is the superior measurement method of BPV, no strong evidence has been accumulated that indicates whether ABPM or self-measured home BP is superior. ABPM and self-measured BP monitoring have their own advantages and complement each other in the assessment of BPV.

Effects of dynamic, isometric, and combined resistance training on ambulatory blood pressure in treated men with hypertension: a randomized controlled trial

Ambulatory blood pressure (ABP) monitoring is a widespread recommendation for the diagnosis and management of hypertension. Dynamic resistance training (DRT) and isometric handgrip training (IHT) have been recommended for hypertension treatment, but their effects on ABP have been poorly studied. Additionally, combined dynamic and isometric handgrip resistance training (CRT) could produce an additive effect that has yet to be tested. Thus, this randomized controlled trial was designed to evaluate the effects of DRT, IHT and CRT on mean ABP and ABP variability. Fifty-nine treated men with hypertension were randomly allocated to 1 of four groups: DRT (8 dynamic resistance exercises, 50% of 1RM, 3 sets until moderate fatigue), IHT (4 sets of 2 min of isometric handgrip at 30% of MVC), CRT (DRT + IHT) and control (CON - 30 min of stretching). Interventions occurred 3 times/week for 10 weeks, and ABP was assessed before and after the interventions. ANOVAs and ANCOVAs adjusted for pre-intervention values were employed for analysis. Mean 24-h, awake and asleep BPs did not change in either group throughout the study (all, P > 0.05). Nocturnal BP fall as well as the standard deviation, coefficient of variation and the average real variability of ABP also did not change significantly in either group (all, P < 0.05). Changes in all these parameters adjusted to the pre-intervention values were also similar among the four groups (all, p > 0.05). In treated men with hypertension, 10 weeks of DRT, IHT or CRT does not decrease ABP levels nor change ABP variability.

Visit-to-visit blood pressure variability and progression of white matter hyperintensities over 14 years

Purpose: There is evidence that blood pressure variability (BPV) is associated with cerebral small vessel disease (SVD) and may therefore increase the risk of stroke and dementia. It remains unclear if BPV is associated with SVD progression over years. We examined whether visit-to-visit BPV is associated with white matter hyperintensity (WMH) progression over 14 years and MRI markers after 14 years.

Materials and methods: We included participants with SVD from the Radboud University Nijmegen Diffusion tensor Magnetic resonance-imaging Cohort (RUNDMC) who underwent baseline assessment in 2006 and follow-up in 2011, 2015 and 2020. BPV was calculated as coefficient of variation (CV) of BP at all visits. Association between WMH progression rates over 14 years and BPV was examined using linear-mixed effects (LME) model. Regression models were used to examine association between BPV and MRI markers at final visit in participants.

Results: A total of 199 participants (60.5 SD 6.6 years) who underwent four MRI scans and BP measurements were included, with mean follow-up of 13.7 (SD 0.5) years. Systolic BPV was associated with higher progression of WMH (β = 0.013, 95% CI 0.005 - 0.022) and higher risk of incident lacunes (OR: 1.10, 95% CI 1.01-1.21). There was no association between systolic BPV and grey and white matter volumes, Peak Skeleton of Mean Diffusivity (PSMD) or microbleed count after 13.7 years.

Conclusions: Visit-to-visit systolic BPV is associated with increased progression of WMH volumes and higher risk of incident lacunes over 14 years in participants with SVD. Future studies are needed to examine causality of this association.

Elevated blood pressure variability is associated with an increased risk of negative health outcomes in adults aged 65 and above-a systematic review and meta-analysis

BACKGROUND

The clinical relevance of blood pressure variability (BPV) is still unknown, despite increasing evidence associating BPV to negative health outcomes (NHOs). There is currently no gold standard to define high BPV and normal reference values for BPV are lacking.

AIM

The primary aim was to examine whether high BPV can predict NHO in adults aged ≥65. The predictive value of BPV was compared to mean BP (mBP) when both parameters were available.

METHODS

PubMed and Web of Science were systematically screened; 49 articles (12 retrospective, 18 prospective and 19 cross-sectional studies) were included and evaluated for methodological quality. Meta-analyses were conducted to examine the association of BPV (and mBP when available) with NHO.

RESULTS

Systolic BPV and systolic mBP seem to indicate at least comparable odds for cardiovascular disease (BPV: odds ratio (OR) = 1.33 (95% CI: 1.19-1.48, P < .00001) vs mBP: OR = 1.06 (95% CI: 1.03-1.09, P = .0002)) and cerebral deterioration (BPV: OR = 1.28 (95% CI: 1.17-1.41, P < .00001) vs mBP: OR = 1.06 (95% CI: 1.04-1.09, P < .00001)). Increased diastolic BPV was associated with higher odds of cerebral deterioration (OR = 1.18 (95% CI: 1.04-1.35), P = .01).

CONCLUSION

High systolic BPV and high systolic mBP are associated with 33% and 6% higher odds of cardiovascular disease in adults aged ≥65, respectively. High BPV is also related to an 18%-28% and 11% increased odds of cerebral deterioration and poor stroke recovery. An overview of cut-off values is provided for the most often reported BPV parameters in literature, which can be used as a guideline to identify elevated BPV in clinical practice.

Impact of pulse pressure variability evaluated by visit-to-visit on heart failure events in patients with hypertension: insights from the SPRINT trial

OBJECTIVES

In adult hypertensive patients, blood pressure variability is considered a risk factor for heart failure. The relationship between pulse pressure variability and the risk of heart failure remains unclear. This study aims to explore the impact of pulse pressure variability (PPV) on heart failure through a secondary analysis of the SPRINT randomized controlled trial.

METHODS

The data were derived from the SPRINT (Systolic Blood Pressure Intervention Trial) study. The trial recruited participants 50 years or older, with SBP ≥ 130 mm Hg and at least one additional CVD risk factor. We calculated pulse pressure based on the systolic and diastolic blood pressure obtained during follow-up, and used the coefficient of variation to represent pulse pressure variability (PPV) for statistical analysis. We considered the incidence of acute decompensated heart failure as the outcome measure. We employed multivariable Cox regression analysis to examine the relationship between PPV and the risk of heart failure occurrence. Additionally, we used a restricted cubic spline model to analyze the dose-response relationship between PPV and the risk of heart failure occurrence.

RESULTS

In this study, a total of 9429 participants were included. During a median follow-up time of 3.87 years, 188 new cases of heart failure were observed. The mean age of the study population was 67.9 ± 9.4 years and 3382 participants (35.5%) were females. The average PPCV was 13.85 ± 5.37%. The results from the multivariable Cox regression analysis indicated that the risk of heart failure increased by 3% for every 1% increase in PPCV (HR = 1.030 [95% CI 1.016-1.044]; P < 0.001).

CONCLUSIONS

The study found that PPV is an independent risk factor for the occurrence of heart failure. This underscores the importance of maintaining long-term stability in pulse pressure, in preventing the development of heart failure.

Longitudinal analysis of blood pressure control and influencing factors among 32 701 primary care hypertensive patients with or without diabetes: a prospective cohort study in Jianye District, China

BACKGROUND

We aimed to explore the variation in blood pressure (BP) control in primary care hypertensive patients with or without diabetes, and investigate potential factors associated with inadequate BP control during follow-up.

METHODS

Primary care hypertensive patients with and without diabetes were recruited in 2020 from Jianye District of Nanjing and prospectively followed up until 2023. Effective BP control was measured in terms of consistent normal readings of systolic BP <140 mmHg and of diastolic BP <90 mmHg based on the most recent assessment during the follow-up period. We used the negative binomial model with total person-years as an offset to evaluate whether the study population would achieve BP control after the 3-y follow-up period in terms of rate ratio (RR) and 95% CI. We further conducted subgroup analysis based on the absence or presence of clinically confirmed diabetes and BP stability at baseline.

RESULTS

Of a total of 32 701 patients with hypertension, compared with those without comorbid diabetes and stable BP at baseline, patients with comorbid diabetes and unstable BP at baseline were less likely to have effective BP control at follow-up (adjusted RR=2.01, 95% CI 1.89 to 2.15). We observed an elevated risk of ineffective BP control at follow-up in those aged 60-70 y (1.69; 95% CI 1.56 to 1.83) or ≥70 y (1.73; 95% CI 1.59 to 1.88), females (1.09; 95% CI 1.03 to 1.16), those with a higher waist-to-height ratio (1.25; 95% CI 1.17 to 1.34), overweight/obese in terms of body mass index (1.16; 95% CI 1.09 to 1.23) or regularly consuming alcohol (1.26; 95% CI 1.16 to 1.37). Higher educational attainment indicated a reduced risk of ineffective BP control at follow-up (0.68; 95% CI 0.63 to 0.75).

CONCLUSIONS

Achieving effective BP control remains a persistent challenge, especially for patients with comorbid hypertension and diabetes. In the absence of any novel strategies for hypertension care, the existing multidisciplinary care approaches could be repurposed and integrated for effective management of the aforementioned comorbid conditions in primary care settings.

Association of variabilities in body mass index and metabolic parameters with post-kidney transplantation renal outcomes

Metabolic syndrome is a significant risk factor for poor graft outcomes in kidney transplant (KT) patients. However, the effects of variability in metabolic parameters on graft outcomes in KT patients have not been completely elucidated. A total of 852 KT patients were included from the Korean Organ Transplantation Registry. The study exposure was variability in body mass index (BMI) or other metabolic parameters measured at 6 months, 1 year, and 2 years after KT. Patients were classified into tertiles according to the degree of variability. The primary outcome was a composite of adverse kidney outcomes, such as death-censored graft loss or ≥ 30% decline in estimated glomerular filtration rate. The adverse kidney outcomes occurred in 73 (8.6%) participants. The high-BMI variability group had a higher risk for adverse kidney outcomes compared to the low-variability group. High variabilities in triglyceride, fasting blood glucose, and systolic blood pressure were also associated with adverse kidney outcomes. Furthermore, high variability in metabolic syndrome-related composite indices, such as the triglyceride and glucose index and metabolic variability scores, showed a higher risk for adverse kidney outcomes. In conclusion, high variability in metabolic parameters could be associated with an increased risk of adverse kidney outcome in KT patients.

Systemic Immune Inflammatory Index as Predictor of Blood Pressure Variability in Newly Diagnosed Hypertensive Adults Aged 18-75

Background: Accumulating evidence from clinical trials, large registries, and meta-analyses of population studies shows that increased Blood Pressure Variability (BPV) is predictive of Cardiovascular (CV) outcomes, independently of the average Blood Pressure (BP) values. One of the mechanisms explaining the relationship between BPV and target organ damage is the inflammatory response. The Systemic Immune Inflammation Index (SII), which relies on peripheral blood cell counts, including platelets, neutrophils, and lymphocytes, has emerged as a predictor of prognosis and outcomes in various diseases. The aim of this study was to investigate the association of the SII with Ambulatory Blood Pressure Variability (ABPV) in newly diagnosed hypertensive patients. Methods: This study was designed as a cross-sectional observational study. A total of 1606 consecutive newly diagnosed Hypertension (HT) patients were included in the study. The population was evaluated across 3 different categories according to HT grades (5 groups), eligibility for antihypertensive therapy (2 groups) and ABPV levels (2 groups). Results: Significant differences were observed between ABPV groups in terms of Neutrophil to Lymphocyte ratio, Platelet to Lymphocyte ratio, glucose, SII, high-sensitive CRP, HT grade, Inter-Ventricular Septum, Posterior Wall thickness, and Left Ventricular Mass (p < 0.005). There was a significant relationship between SII and ABPV (r: 0.619, p < 0.05). At the cutoff value of 580.49, SII had 77% sensitivity and 71% specificity for ABPV > 14 (AUC: 0.788). Conclusions: SII may assist in developing an early treatment approach to minimize complications in patients with high ABPV who are at a higher risk of CV events.

Cost-effectiveness of strengthening blood pressure classification in South Korea: comparing the 2017 ACC/AHA and KSH guidelines

BACKGROUND

Hypertension is a significant risk factor for cardiovascular disease (CVD), with hypertension-related deaths increasing annually. While South Korea uses the Korean Society of Hypertension (KSH) guideline of 140/90 mmHg, the American College of Cardiology (ACC) and American Heart Association (AHA) updated their guidelines in 2017 to 130/80 mmHg. This study evaluates the cost-effectiveness of transitioning to the 2017 ACC/AHA guidelines by estimating early treatment impacts and potential CVD risk reduction.

METHODS

A Markov state-transition simulation model with a 10-year horizon was used to estimate cost-effectiveness, focusing on strengthening target blood pressure. Quality-adjusted life years (QALYs) served as the measure of effectiveness. Cohorts of 10,000 individuals representing South Koreans in their 20s through 80s were compared in scenario analyses from the healthcare system perspective. A 4.5% annual discount rate was applied to costs and effectiveness. Primary outcomes were incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB). The willingness-to-pay (WTP) threshold was < KRW 30,000,000/QALY gained. Probabilistic sensitivity analyses (PSAs) addressed model input parameter uncertainties.

RESULTS

The base-case analysis showed an ICER value of KRW 1,328,395/QALY gained across all populations. ICER values increased with age, from - KRW 3,138,071/QALY for 20-year-olds to KRW 16,613,013/QALY for individuals over 80. The 60s age group showed the greatest benefit with an incremental QALY gain of 0.46. All scenarios had ICERs below the WTP threshold, with a PSA probability of 98.0% that strengthening blood pressure classification could be cost-effective.

CONCLUSIONS

This economic evaluation found that adopting the 2017 ACC/AHA guidelines may result in early treatment, reduce the potential incidence of CVD events, and be cost-effective across all age groups. The study findings have implications for policymakers deciding whether and when to revise official guidelines regarding target blood pressure levels, considering the impacts on public health and budgetary concerns.

Beat-to-beat analysis of hemodynamic response to mental and psychological stress in sickle cell anemia

Objectives

Vaso-occlusive crises (VOCs) are a hallmark symptom of sickle cell disease (SCD). Physical stressors can trigger decreased microvascular blood flow and increase the risk for VOCs. However, the effect of mental and psychological stressors on vascular physiology in SCD is not well-established. We hereby examined fluctuations in continuous blood pressure (BP) to evaluate hemodynamic changes in SCD patients during mental and psychological stress.

Methods

Thirteen SCD (HbSS) subjects from the Children's Hospital Los Angeles and 11 healthy (HbAA) volunteers were recruited. Continuous BP was recorded as subjects participated in two mental and one psychological stress tasks. Systolic beat-to-beat BP variability (BPV) measurements were calculated for each subject. Three very short-term BPV metrics served as outcome measures: standard deviation, coefficient of variation, and average real variability. Linear mixed effects models evaluated associations between patient factors and outcome measures.

Results

SCD patients were associated with increased systolic BPV and exhibited a distinct increase in BPV in response to psychological stress. All subjects exhibited a decrease in systolic BPV in response to mental stress tasks. During mental stress, both groups displayed increased augmentation index, reflective of stress-induced vasoconstriction, while psychological stress in SCD patients led to both decreased mean arterial pressure and increased AI, suggestive of uncompensated vasoconstriction.

Conclusion

These findings emphasize the impact of mental and psychological stressors on vascular function in SCD, the potential for monitoring physiological signals to predict VOC events, and the importance of counseling SCD patients on lifestyle practices to reduce their stress to prevent pain.