Optimal blood pressure control in treated hypertensive patients. Report from the Department of Health Hypertension Care Computing Project (DHCCP)

Utility of urinary albumin excretion as an index for stratifying the residual cardiovascular risk in patients undergoing antihypertensive agents treatment

BACKGROUND

Patients treated with antihypertensive medication, even those with well controlled blood pressure (BP), are at higher risk for the development of atherosclerotic cardiovascular disease (ASCVD) in comparison to nonhypertensive individuals with optimal risk levels. We hypothesized that this residual risk could be stratified based on urinary albumin excretion (UAE).

METHODS

A total of 13 082 middle-aged and older individuals with SBP/DBP of less than 160/100 mmHg and urinary albumin-to-creatinine ratios (UACRs) of less than 300 mg/g, and who were free from ASCVD events, were followed to investigate the incidence of ASCVD. The baseline BP was classified into four categories: normal BP (BP1), high normal BP (BP2), elevated BP (BP3), and grade 1 hypertension (BP4) based on the 2019 Japanese Society of Hypertension guidelines.

RESULTS

After an average 10.6 ± 2.6 years of follow-up, the multivariable hazard ratio for the development of ASCVD (n = 994) was already increased in medicated hypertensive patients with BP1 in comparison with untreated individuals with BP1; however, among medicated hypertensive patients, this risk was separated between the UAE groups, which were classified according to the median UACR (male, 15.4 mg/g; female, 19.0 mg/g). In medicated hypertensive patients with any category of BP1-BP3, the adjusted risk of the development of ASCVD in those with lower and higher UACRs was comparable to that observed in untreated individuals in the BP1 and BP4 categories, respectively.

CONCLUSION

In medicated patients with well controlled hypertension, UAE is useful for stratifying the residual risk of developing ASCVD in comparison to nonhypertensive individuals with optimal risk levels.

Increased pulse pressure linked to dementia: further results from the Hypertension in the Very Elderly Trial - HYVET

OBJECTIVES

High blood pressure (BP) has been associated with increased risk of dementia. Concerns have been raised about lowering BP too far in the very elderly and thereby increasing risk. There is some evidence to suggest a potential 'J'-shaped relationship between DBP and risk of cognitive impairment. This was investigated using data from the HYpertension in the Very Elderly Trial (HYVET).

METHODS

HYVET was a double-blind, placebo-controlled trial of antihypertensives in patients aged at least 80 years with an untreated SBP of 160-199 mmHg. Active medication was indapamide sustained release 1.5 mg+/- perindopril 2-4 mg to reach goal pressure of less than 150/80 mmHg. Incident dementia was a secondary endpoint and was not significantly different between the two treatment groups. The relationship between pressure and incident dementia was assessed using Cox proportional hazards regression with BP entered as either a discrete (quartile analysis) or continuous predictor variable. Achieved BP was calculated as the mean of all pressures from the 9 month visit onwards.

RESULTS

During a mean follow-up of 2.2 years 263 incident cases of dementia were diagnosed. After adjustment for various covariates, baseline DBP was inversely related to incident dementia (P=0.0064). Achieved DBP did not predict later dementia in the placebo group (P=0.43), but showed a U-shaped relationship in the active treatment group (P=0.0195). The relationship between incident dementia and DBP did however not differ significantly between the placebo and active treatment groups (P=0.38). SBP was not associated with incident dementia, at baseline (P=0.62) or during follow-up (placebo group P=0.13, active group P=0.36). Wider achieved pulse pressure (PP) was associated with increased risk of dementia in both treatment groups (placebo P=0.032, active P=0.0046). The same tendency was observed for baseline PP (P=0.095).

CONCLUSION

Wider PP may possibly indicate an increased risk for dementia. Active treatment may act to change the shape of the relationship between DBP and dementia. Future studies need to focus on exploring the ideal goal pressure for this age group.

The effects of control of systolic and diastolic hypertension on cardiovascular and all-cause mortality in a community-based population cohort

The objective of this study (follow-up of 26,113 people) was to investigate differences in the risk of cardiovascular disease (CVD) and all-cause mortality among hypertensive people according to the control of systolic blood pressure (SBP) and diastolic blood pressure (DBP). People with a history of coronary heart disease, heart failure, cancer or incomplete data at baseline (n=1113) were excluded from the study. The participants were classified into six groups according to their blood pressure status. Treated hypertensive individuals with controlled SBP and DBP did not experience an increase in all-cause mortality compared with normotensive people. The increase in all-cause mortality was 1.48-fold (95% confidence interval (CI) 1.09-2.01) among those who were treated with antihypertensive drugs and had only their DBP controlled and 1.45-fold (95% CI 1.04-2.02) among those who were treated and had only their SBP controlled. Treated patients with both SBP and DBP controlled did not have an increased risk of CVD mortality when compared with normotensive people. The risk of CVD mortality was statistically significantly higher in treated hypertensive people with SBP alone, DBP alone or both SBP and DBP uncontrolled. Our study indicates that uncontrolled SBP alone and DBP alone are risk factors of all-cause and CVD mortality.

Evidence for aggressive blood pressure-lowering goals in patients with coronary artery disease

Lowering blood pressure (BP) reduces the risk of major cardiovascular mortality and morbidity. Current consensus targets for BP reduction are less than 140/90 mm Hg in uncomplicated hypertension and less than 130/80 mm Hg in those patients with diabetes, chronic kidney disease, and coronary artery disease or in those who are at high risk for developing coronary artery disease (defined as a Framingham risk score of > or = 10%). There is solid epidemiologic evidence for lower BP targets, supported by some clinical studies with surrogate end points. On the other hand, there are meager data from clinical trials using hard end points, and there is a concern that overly aggressive BP lowering, especially of diastolic BP, may impair coronary perfusion, particularly in patients with left ventricular hypertrophy and/or coronary artery disease. This review evaluates the evidence for the benefit of lower BP targets in hypertension management.

Blood Pressure Categories and Cardiovascular Risk Factors in Japan: The Jichi Medical School (JMS) Cohort Study

Few studies have reported on risk factors by blood pressure categories based on antihypertensive treatment in the general population. We examined the associations between blood pressure categories and other risk factors in Japan. Cross-sectional study, multicenter population-based study was designed. A total of 11,302 men and women were eligible. Data were obtained from April 1992 to July 1995 in 12 rural districts in Japan. Subjects were divided into three categories: normotensives (with blood pressure <140/90 mmHg), treated hypertensives (antihypertensive treatment regardless of current blood pressure), and nontreated hypertensives (blood pressure >or=140/90 mmHg without hypertensive treatment). The proportions of normotensives, treated hypertensives, and nontreated hypertensives were 63%, 10%, and 27% among men, and 67%, 13%, and 20% among women, respectively. Total cholesterol, triglyceride, blood glucose, and body mass index were higher in treated or nontreated hypertensives than in normotensives. Fibrinogen, factor VIIc, and physical activity index were higher in treated hypertensives than in normotensives. High-density lipoprotein (HDL) cholesterol was higher in normotensives than in treated or nontreated hypertensives in women; but no tendency was shown in men. The proportions of dyslipidemia, impaired glucose tolerance, and metabolic syndrome were significantly higher in treated and nontreated hypertensives than in normotensive men and women. In conclusion, cardiovascular risk factors were higher in hypertensives with or without treatment than in normotensives in a general population in Japan.

The impact of hypertension on systolic and diastolic left ventricular function. A tissue Doppler echocardiographic study

BACKGROUND

The purpose of this study is to assess the impact of hypertension on systolic function and diastolic function using 2-dimensional echocardiography, conventional Doppler imaging of the transmitral inflow, and tissue Doppler imaging (TDI) of the mitral annulus.

METHODS

From an outpatient clinic population, 414 consecutive patients underwent 2-dimensional echocardiography, conventional Doppler imaging of the transmitral inflow, and TDI of the septal, lateral, inferior, and posterior walls near the mitral annulus. Parameters of systolic left ventricular (LV) function and diastolic LV function were assessed. Patients were divided according to the presence or absence of systemic hypertension (blood pressure > or = 140/90 mm Hg on > or = 3 measurements or treatment with antihypertensive medication).

RESULTS

A complete echocardiographic evaluation was obtained in 397 patients. Among these, 269 (68%) had hypertension. There was no difference with respect to age between patients with and without hypertension. Patients with hypertension had higher LV mass index and relative wall thickness and lower TDI peak systolic velocity (V(S)) when compared with patients without hypertension. In addition, indices of diastolic LV function were significantly impaired in hypertensive patients.

CONCLUSIONS

Quantitative echocardiography using TDI reveals that hypertensive patients with preserved global LV systolic function often have combined impairment of systolic function and diastolic function.

Hypertension Control as Predictor of Mortality in Treated Men and Women, Followed for up to 30 Years

PURPOSE

To examine the prognosis of treated, hypertensive individuals in the Reykjavik Study.

METHODS

A population-based longitudinal study of 9328 men and 10 062 women. Subjects were included in the study during the period 1967-1996. Two groups of treated, hypertensive subjects were defined at baseline: with controlled blood pressure and with uncontrolled blood pressure. Main outcome measures were cardiovascular disease (CVD) mortality and all-cause mortality.

RESULTS

Of the hypertensive men 24.8% were treated, and of those 38.3% were controlled, and of the hypertensive women 45.3% were treated, and of those 52.7% were controlled. Comparing treated and uncontrolled (systolic blood pressure (SBP) > or =160 mmHg and/or diastolic blood pressure (DBP) > or =95 mmHg) versus treated and controlled hypertensive subjects, followed for up to 30 years, the uncontrolled men and women were at significantly higher risk of CVD mortality, hazard ratio (HR) = 1.47 (95% confidence interval (CI): 1.06-2.02) and HR 1.70 (CI: 1.23-2.36), respectively, showing the benefit of hypertension control. The risk of all-cause mortality was increased for treated, uncontrolled men and women, compared with those who were treated and controlled, but did not reach significance. When analyzing blood pressure as a continuous variable among treated, hypertensive subjects, SBP was a better predictor than DBP of CVD mortality and all-cause mortality in women. This was not the case in men.

CONCLUSIONS

Control of blood pressure among hypertensive-treated subjects at baseline was associated with a lower risk of CVD mortality during follow-up. SBP was the single best predictor of CVD mortality and all-cause mortality in treated women. The uncontrolled women were at a higher risk than the uncontrolled men.

Low diastolic blood pressure and mortality in a population-based cohort of 16913 hypertensive patients in North Karelia, Finland

OBJECTIVE

To examine the relationship between mortality and diastolic blood pressure during treatment.

DESIGN

A prospective follow-up of a population-based dynamic cohort of hypertensive patients.

SETTING

Province of North Karelia, eastern Finland.

PATIENTS

A cohort of 16 913 North Karelian hypertensive patients in hypertension register of the North Karelia Project, who had been followed up since 1972 until the end of 1985. Most of these patients had been under antihypertensive drug therapy during the follow-up.

MAIN OUTCOME MEASURES

Death: all deaths (n = 4490), deaths from cardiovascular disease (n = 2995) and deaths from non-cardiovascular disease (n = 1495).

RESULTS

Of all deaths, 17% of those among men and 24% of those among women were of patients with mean diastolic blood pressures less than 90 mmHg. We found a U-shaped relationship between diastolic blood pressure and total, cardiovascular and non-cardiovascular mortalities. We investigated this relationship in more detail using Cox regression model. Low diastolic blood pressure was associated independently with increased mortality for the patients aged 50 years or more at baseline. The occurrence of cardiac failure and other cardiovascular complications of hypertension were more important determinants of mortality than was low diastolic blood pressure alone.

CONCLUSIONS

We demonstrated that there is an association between low diastolic blood pressure and mortality for treated hypertensive patients aged 50-69 years. The clinical importance of this relationship for patients without any cardiovascular complications of hypertension seems negligible. For patients with complications, these complications are likely to be primary factors causing greater than normal mortality and low diastolic blood pressure is mostly a secondary phenomenon. Our data do not lend support to speculations that there is overtreatment of hypertension, which would increase mortality through making diastolic blood pressures too low.

Epidemiology of risk in hypertensives: experience in treated patients

Knowledge of the epidemiology of cardiovascular disease (CVD) in hypertensive patients derives primarily from observation of populations composed largely of untreated subjects. Increasingly, however, individuals with elevated blood pressure are treated. An 18-year observational study of 8690 participants in a systematic hypertension control project reveals that cardiovascular events continue to be the principal morbid and mortal outcomes. Over time, the incidence of stroke and heart attack remained stable, whereas congestive heart failure (CHF), as a first event, increased tenfold after 10 years. Diabetes and evidence of vascular disease at entry predicted morbidity. Persisting cardiovascular morbidity in the face of satisfactory blood pressure control suggests the need for additional preventive intervention.

Distribution and determinants of cardiovascular events during 20 years of successful antihypertensive treatment

OBJECTIVE

To define the distribution and determinants of cardiovascular disease events among participants undergoing long-term antihypertensive therapy, and to stratify them into risk groups on the basis of pretreatment clinical profiles.

DESIGN

A prospective cohort study of participants in a worksite-based antihypertensive treatment program in New York city (1973-1994).

PATIENTS

We studied 8690 systematically treated patients who had at least 6 months of follow-up (average of 5.7 years) and, at entry, had had a systolic blood pressure of > or = 160 mmHg or a diastolic blood pressure of > or = 95 mmHg (after 1992 > or = 140/90 mmHg), or had been being administered antihypertensive medication.

MAIN OUTCOME MEASURES

Blood pressure and incidence of morbid and mortal cardiovascular events.

RESULTS

Blood pressure control (to 140 +/- 3/87 +/- 7 mmHg) was achieved by the first year and maintained through 18 years of therapy. In nearly 50,000 person-years of follow-up, there were 468 cardiovascular disease events [myocardial infarction including revascularization (282), strokes (93), congestive heart failure (30) and other cardiovascular deaths (63)]. Deaths from cardiovascular disease events accounted for 68% of all deaths. Myocardial infarction was most common throughout, but congestive heart failure incidence surpassed stroke incidence after 10 years. A scheme for risk stratification was constructed after analysis of the independent association of baseline factors and incident cardiovascular events. Upon the basis of ease of ascertainment and their demonstrated associations with occurrence of cardiovascular disease during treatment, we selected five pretreatment factors (history of heart attack, stroke, diabetes, age > or = 55 years and pulse pressure > or = 60 mmHg) to stratify patients into four groups. Those with no risk factor had a low risk (n=2999), those with one had a moderate risk (3042), those with two had a high risk (2237), and those with three or more had a very high risk (412). Overall, the unadjusted rates of incidence of cardiovascular disease events per 1000 person-years for patients in very high and low risk groups differed by factors of six and 14 for men and women, respectively.

CONCLUSION

These results demonstrate that long-term control of blood pressure can be achieved in a general population. Nevertheless, cardiovascular disease events still accounted for most morbidity and mortality among these 'recovered' hypertensive patients. At entry, on the basis of readily identifiable characteristics, it was possible to stratify patients according to likelihood of subsequent events occurring despite control of blood pressure. This scheme could provide the basis for targeting more aggressive therapy where the potential for further cardioprotection is greatest.

Assessment of Left Atrial Appendage Structure and Function by Transesophageal Echocardiography: A Review

This article examines the transesophageal echocardiographic assessment of the left atrial appendage anatomy and function in individuals without significant structural heart disease and in those with atrial fibrillation with or without cardioembolism or mitral valve stenosis. We also summarize the available data in the usefulness of transesophageal echocardiographic studies in patients undergoing cardioversion for atrial fibrillation and percutaneous balloon valvuloplasty for mitral stenosis. Also, potential limitations and ongoing developments in the use of transesophageal echocardiography in the assessment of the left atrial appendage are outlined, and recommendations are given for the uniform reporting of quantitative data.