Treatment of Hypertension in Patients With Coronary Artery Disease

The lowest well tolerated blood pressure: A personalized target for all?

The optimal blood pressure (BP) target for prevention of cardiovascular complications of hypertension remains uncertain. Most Guidelines suggest different targets depending on age, comorbidities and treatment tolerability, but the underlying evidence is not strong. Results of randomized strategy trials comparing lower (i.e., more intensive) versus higher (i.e., less intensive) BP targets should drive the definition. However, these trials tested different BP targets based on systolic BP, diastolic BP or combined systolic and diastolic BP goals. Overall, the more intensive treatment targets reduced the risk of major cardiovascular complications of hypertension when compared with the less intensive targets, despite a higher incidence of unwanted effects including, but not limited to, hypotension, electrolyte abnormalities and renal dysfunction. Consequently, some Guidelines defined low BP thresholds (i.e., 120/70 mmHg) not to exceed downward because of the expectation that unwanted effects may outweigh the outcome benefits. The present review discusses the evidence underlying the choice of BP targets, which remains an important step in the management of hypertensive patients. We conclude that, on the ground of the heterogeneity of available data in support to fixed BP targets, their definition should be personalized in all patients and based on best trade-off between efficacy and safety, i.e., the lowest well tolerated BP.

Emergency Neurosurgery in a Patient With Pacemaker: The Double Trouble

Perioperative management of a patient with multiple comorbidities, being taken up for an emergency neurosurgical procedure presents a unique set of challenges to the anesthetist as it requires quick preoperative evaluation in order to avoid any delay in the surgery and limit the extent of cerebral injury. This case report highlights the perioperative management of a 55-year-old obese male patient, with a history of hypertension and coronary artery disease with a permanent pacemaker presenting to the emergency with weakness of right upper and lower limbs, suggestive of an acute stroke due to intracerebral hemorrhage. The patient was taken up for emergency decompressive craniectomy in view of increasing intracranial pressure and deteriorating consciousness. The pacemaker could not be changed to asynchronous mode in the preoperative period due to the non-availability of a magnet and trained personnel from the company of the pacemaker to change the settings immediately. Intraoperatively, all the necessary precautions for the prevention of pacemaker-related complications were followed. After the completion of the surgery, the patient was shifted to the neuro-intensive care unit for postoperative management.

The Pivotal Role of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in Hypertension Management and Cardiovascular and Renal Protection: A Critical Appraisal and Comparison of International Guidelines

Arterial hypertension is the main preventable cause of premature mortality worldwide. Across Latin America, hypertension has an estimated prevalence of 25.5-52.5%, although many hypertensive patients remain untreated. Appropriate treatment, started early and continued for the remaining lifespan, significantly reduces the risk of complications and mortality. All international and most regional guidelines emphasize a central role for renin-angiotensin-aldosterone system inhibitors (RAASis) in antihypertensive treatment. The two main RAASi options are angiotensin-converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers (ARBs). Although equivalent in terms of blood pressure reduction, ACEis are preferably recommended by some guidelines to manage other cardiovascular comorbidities, with ARBs considered as an alternative when ACEis are not tolerated. This review summarizes the differences between ACEis and ARBs and their place in the international guidelines. It provides a critical appraisal of the guidelines based on available evidence from randomized controlled trials (RCTs) and meta-analyses, especially considering that hypertensive patients in daily practice often have other comorbidities. The observed differences in cardiovascular and renal outcomes in RCTs may be attributed to the different mechanisms of action of ACEis and ARBs, including increased bradykinin levels, potentiated bradykinin response, and stimulated nitric oxide production with ACEis. It may therefore be appropriate to consider ACEis and ARBs as different antihypertensive drugs classes within the same RAASi group. Although guideline recommendations only differentiate between ACEis and ARBs in patients with cardiovascular comorbidities, clinical evidence suggests that ACEis provide benefits in many hypertensive patients, as well as those with other cardiovascular conditions.

Wearable sensor platforms for real-time monitoring and early warning of metabolic disorders in humans

Nowadays, the prevalence of metabolic syndromes (MSs) has attracted increasing concerns as it is closely related to overweight and obesity, physical inactivity and overconsumption of energy, making the diagnosis and real-time monitoring of the physiological range essential and necessary for avoiding illness due to defects in the human body such as higher risk of cardiovascular disease, diabetes, stroke and diseases related to artery walls. However, the current sensing techniques are inconvenient and do not continuously monitor the health status of humans. Alternatively, the use of recent wearable device technology is a preferable method for the prevention of these diseases. This can enable the monitoring of the health status of humans in different health domains, including environment and structure. The use wearable devices with the purpose of facilitating rapid treatment and real-time monitoring can decrease the prevalence of MS and long-time monitor the health status of patients. This review highlights the recent advances in wearable sensors toward continuous monitoring of blood pressure and blood glucose, and further details the monitoring of abnormal obesity, triglycerides and HDL. We also discuss the challenges and future prospective of monitoring MS in humans.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Effectiveness and Tolerability of Bisoprolol/Perindopril Single-Pill Combination in Patients with Arterial Hypertension and a History of Myocardial Infarction: The PRIDE Observational Study

INTRODUCTION

This study assessed the real-life effectiveness of a single-pill combination (SPC) of bisoprolol/perindopril for controlling blood pressure (BP) and symptoms of angina in patients with hypertension and a history of myocardial infarction (MI).

METHODS

Eligible patients with arterial hypertension and a history of MI were aged 18-79 years and had initiated bisoprolol/perindopril SPC within 3 months of study enrollment as part of routine Russian clinical practice. The primary endpoint was mean change in systolic and diastolic BP (SBP/DBP) at week 12 compared with baseline (data collected retrospectively). Secondary endpoints were assessed at weeks 4 and 12 and included mean change in resting heart rate (HR), proportion of patients reaching target level of resting HR, antianginal effectiveness of the SPC, and proportion of patients reaching target BP levels.

RESULTS

A total of 504 patients were enrolled, of whom 481 comprised the full analysis set (mean age 61.4 ± 8.9 years, 68% men). Mean baseline SBP/DBP and HR values were 148.9 ± 16.8/87.7 ± 11.0 mmHg and 77.4 ± 10.5 bpm, respectively. Mean durations of hypertension and CAD were 12.8 ± 8.4 and 6.1 ± 6.3 years, respectively, and time since MI was 3.8 ± 5.3 years. At week 12, SBP/DBP had decreased by 24.9/12.2 mmHg (P < 0.001 vs baseline). Target BP (< 140/90 mmHg) was achieved by 69.8% and 95.9% of patients at weeks 4 and 12, respectively, and target HR (55-60 bpm) by 17.3% and 34.5% at weeks 4 and 12 versus 3.1% at baseline (P < 0.001). Reductions in angina attacks, nitrate consumption, and improvements in HR were statistically significant. Treatment was well tolerated.

CONCLUSION

Treatment of symptomatic patients with CAD, hypertension, and a history of MI with a bisoprolol/perindopril SPC was associated with significant decreases in SBP/DBP and a high proportion of patients achieving BP treatment goals. This was accompanied by improvements in angina symptoms and reductions in HR in a broad patient population representative of those seen in everyday clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04656847.

The association of ambient temperature variability with blood pressure in southern China

OBJECTIVES

Numerous studies have shown a positive relationship between temperature variability and mortality, but few studies have investigated the effect of temperature variability on blood pressure (BP). We aimed to estimate the effect of temperature variability on BP in Guangdong Province, southern China.

METHODS

Data on meteorological factors were obtained from the Guangdong Meteorological Center, and BP was collected from a series of cross-sectional surveys conducted in Guangdong Province, China, from 2004 to 2015. There were 38 088 participants aged 18 years and over. A generalized additive model was used to estimate the association between temperature variability and BP after adjusting for confounding variables.

RESULTS

Our study found a significant positive association between temperature variability and SBP, and this effect increased with the increment of exposure days in total population. The highest estimate was for temperature variability at 7 days lag (TV 0-7 ) with a 0.497 (95% confidence interval, 0.335-0.660) mmHg rise of SBP for each 1°C increase of TV 0-7 . The effects of TV 0-1 and TV 0-2 on SBP were higher for hypertensives than that for normotensives, and in warm season higher than that in cold season. However, we did not observe statistical significance between temperature variability and DBP.

CONCLUSIONS

There was a positive association between temperature variability and SBP in Guangdong Province, which should be considered in clinical management and epidemiological survey of hypertension.

Electrical Activity During Slow-Wave Sleep and the Relationship With Enlarged Perivascular Spaces in Arteriosclerotic Cerebral Small Vessel Disease

PURPOSE

We sought to analyze EEG spectral power during slow-wave sleep among patients with arteriosclerotic cerebral small vessel disease (CSVD) compared with community-dwelling individuals. We also sought to determine the relationship between EEG activity and the severity of enlarged perivascular spaces (EPVSs).

METHODS

Consecutive subjects with arteriosclerotic CSVD ( n = 36) and community-dwelling individuals ( n = 26) between 50 and 80 years of age were included. Nocturnal polysomnography was performed, and EEG spectral analysis was conducted during slow-wave sleep using the F4/M1 and C4/M1 channel. Regionalized EPVSs in the basal ganglia and centrum semiovale were assessed on a validated 4-point visual rating scale (0 = none, 1 = 1-10, 2 = 11-20, 3 = 21-40, and 4 = >40) using MRI.

RESULTS

CSVD group showed lower delta:beta ratios in the frontal ( P = 0.017) and central ( P = 0.038) regions after adjusting for age, sex, mini-mental state examination score, and arousal index. The significance still remained in the frontal region when including age, sex, mini-mental state examination, and apnea-hypopnea index as covariates ( P = 0.037). Among patients with arteriosclerotic CSVD, decreased delta power ( P = 0.031) and theta power ( P = 0.034) in the frontal region were associated with a higher degree of EPVSs in the centrum semiovale rather than in the basal ganglia. Delta power in the central region showed an extremely weak association with EPVSs in the centrum semiovale ( P = 0.047).

CONCLUSIONS

Among patients with arteriosclerotic CSVD, the intrusion of high-frequency EEG activity into slow-wave sleep was identified, and slow-wave activity during slow-wave sleep might be negatively associated with the severity of EPVSs in the centrum semiovale. Further studies are required to corroborate the conclusions.

Blood pressure targets for the treatment of people with hypertension and cardiovascular disease

BACKGROUND

This is the third update of the review first published in 2017. Hypertension is a prominent preventable cause of premature morbidity and mortality. People with hypertension and established cardiovascular disease are at particularly high risk, so reducing blood pressure to below standard targets may be beneficial. This strategy could reduce cardiovascular mortality and morbidity but could also increase adverse events. The optimal blood pressure target in people with hypertension and established cardiovascular disease remains unknown.

OBJECTIVES

To determine if lower blood pressure targets (systolic/diastolic 135/85 mmHg or less) are associated with reduction in mortality and morbidity compared with standard blood pressure targets (140 mmHg to 160mmHg/90 mmHg to 100 mmHg or less) in the treatment of people with hypertension and a history of cardiovascular disease (myocardial infarction, angina, stroke, peripheral vascular occlusive disease).

SEARCH METHODS

For this updated review, we used standard, extensive Cochrane search methods. The latest search date was January 2022. We applied no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) with more than 50 participants per group that provided at least six months' follow-up. Trial reports had to present data for at least one primary outcome (total mortality, serious adverse events, total cardiovascular events, cardiovascular mortality). Eligible interventions involved lower targets for systolic/diastolic blood pressure (135/85 mmHg or less) compared with standard targets for blood pressure (140 mmHg to 160 mmHg/90 mmHg to 100 mmHg or less). Participants were adults with documented hypertension and adults receiving treatment for hypertension with a cardiovascular history for myocardial infarction, stroke, chronic peripheral vascular occlusive disease, or angina pectoris.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included seven RCTs that involved 9595 participants. Mean follow-up was 3.7 years (range 1.0 to 4.7 years). Six of seven RCTs provided individual participant data. None of the included studies was blinded to participants or clinicians because of the need to titrate antihypertensive drugs to reach a specific blood pressure goal. However, an independent committee blinded to group allocation assessed clinical events in all trials. Hence, we assessed all trials at high risk of performance bias and low risk of detection bias. We also considered other issues, such as early termination of studies and subgroups of participants not predefined, to downgrade the certainty of the evidence. We found there is probably little to no difference in total mortality (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.91 to 1.23; 7 studies, 9595 participants; moderate-certainty evidence) or cardiovascular mortality (RR 1.03, 95% CI 0.82 to 1.29; 6 studies, 9484 participants; moderate-certainty evidence). Similarly, we found there may be little to no differences in serious adverse events (RR 1.01, 95% CI 0.94 to 1.08; 7 studies, 9595 participants; low-certainty evidence) or total cardiovascular events (including myocardial infarction, stroke, sudden death, hospitalization, or death from congestive heart failure (CHF)) (RR 0.89, 95% CI 0.80 to 1.00; 7 studies, 9595 participants; low-certainty evidence). The evidence was very uncertain about withdrawals due to adverse effects. However, studies suggest more participants may withdraw due to adverse effects in the lower target group (RR 8.16, 95% CI 2.06 to 32.28; 3 studies, 801 participants; very low-certainty evidence). Systolic and diastolic blood pressure readings were lower in the lower target group (systolic: mean difference (MD) -8.77 mmHg, 95% CI -12.82 to -4.73; 7 studies, 8657 participants; diastolic: MD -4.50 mmHg, 95% CI -6.35 to -2.65; 6 studies, 8546 participants). More drugs were needed in the lower target group (MD 0.56, 95% CI 0.16 to 0.96; 5 studies, 7910 participants), but blood pressure targets at one year were achieved more frequently in the standard target group (RR 1.20, 95% CI 1.17 to 1.23; 7 studies, 8699 participants).

AUTHORS' CONCLUSIONS

We found there is probably little to no difference in total mortality and cardiovascular mortality between people with hypertension and cardiovascular disease treated to a lower compared to a standard blood pressure target. There may also be little to no difference in serious adverse events or total cardiovascular events. This suggests that no net health benefit is derived from a lower systolic blood pressure target. We found very limited evidence on withdrawals due to adverse effects, which led to high uncertainty. At present, evidence is insufficient to justify lower blood pressure targets (135/85 mmHg or less) in people with hypertension and established cardiovascular disease. Several trials are still ongoing, which may provide an important input to this topic in the near future.

Comparison between Machine Learning and Multiple Linear Regression to Identify Abnormal Thallium Myocardial Perfusion Scan in Chinese Type 2 Diabetes

Type 2 diabetes mellitus (T2DM) patients have a high risk of coronary artery disease (CAD). Thallium-201 myocardial perfusion scan (Th-201 scan) is a non-invasive and extensively used tool in recognizing CAD in clinical settings. In this study, we attempted to compare the predictive accuracy of evaluating abnormal Th-201 scans using traditional multiple linear regression (MLR) with four machine learning (ML) methods. From the study, we can determine whether ML surpasses traditional MLR and rank the clinical variables and compare them with previous reports.In total, 796 T2DM, including 368 men and 528 women, were enrolled. In addition to traditional MLR, classification and regression tree (CART), random forest (RF), stochastic gradient boosting (SGB) and eXtreme gradient boosting (XGBoost) were also used to analyze abnormal Th-201 scans. Stress sum score was used as the endpoint (dependent variable). Our findings show that all four root mean square errors of ML are smaller than with MLR, which implies that ML is more precise than MLR in determining abnormal Th-201 scans by using clinical parameters. The first seven factors, from the most important to the least are:body mass index, hemoglobin, age, glycated hemoglobin, Creatinine, systolic and diastolic blood pressure. In conclusion, ML is not inferior to traditional MLR in predicting abnormal Th-201 scans, and the most important factors are body mass index, hemoglobin, age, glycated hemoglobin, creatinine, systolic and diastolic blood pressure. ML methods are superior in these kinds of studies.

Sex Differences in Characteristics, Treatments, and Outcomes Among Patients Hospitalized for Non-ST-Segment-Elevation Myocardial Infarction in China: 2006 to 2015

BACKGROUND

Sex differences in clinical characteristics and in-hospital outcomes among patients with non-ST-segment-elevation myocardial infarction have been described in Western countries, but whether these differences exist in China is unknown.

METHODS

We used a 2-stage random sampling design to create a nationally representative sample of patients admitted to 151 Chinese hospitals for non-ST-segment-elevation myocardial infarction in 2006, 2011, and 2015 and examined sex differences in clinical profiles, treatments, and in-hospital outcomes over this time. Multivariable logistic regression models adjusting for age or other potentially confounding clinical covariates were used to estimate these sex-specific differences.

RESULTS

Among 4611 patients, the proportion of women (39.8%) was unchanged between 2006 and 2015. Women were older with higher rates of hypertension, diabetes, and dyslipidemia. Among patients without contraindications, women were less likely to receive treatments than men, with significant differences for aspirin in 2015 (90.3% versus 93.9%) and for invasive strategy in 2011 (28.7% versus 45.7%) and 2015 (34.0% versus 48.4%). After adjusting for age, such differences in aspirin and invasive strategy in 2015 were not significant, but the difference in invasive strategy in 2011 persisted. The sex gaps in the use of invasive strategy did not narrow. From 2006 to 2015, a significant decrease in in-hospital mortality was observed in men (from 16.9% to 8.7%), but not in women (from 11.8% to 12.0%), with significant interaction between sex and study year (P=0.023). After adjustment, in-hospital mortality in women was significantly lower than men in 2006, but not in 2011 or 2015.

CONCLUSIONS

Sex differences in cardiovascular risk factors and invasive strategy after non-ST-segment-elevation myocardial infarction were observed between 2011 and 2015 in China. Although sex gaps in in-hospital mortality were largely explained by age differences, efforts to narrow sex-related disparities in quality of care should remain a focus.

REGISTRATION

URL: http://www.

CLINICALTRIALS

gov; Unique identifier: NCT01624883.

Metabolic impact of the VDR rs1544410 in diabetic retinopathy

Aims

To investigate the association between BsmI and DM2 in patients with and without DR and to correlate with clinical parameters in a population in northeastern Brazil.

Methods

Cross-sectional case-control study in which data were collected from 285 individuals, including 128 patients with DM2 and 157 with DR. Clinical, biochemical and anthropometric parameters were analyzed, in addition to the single nucleotide polymorphism (SNP) BsmI of the VDR gene (rs1544410), genotyped by PCR-RFLP.

Results

In the DR group we found a greater number of patients using insulin therapy (p = 0.000) and with longer duration of DM2 (p = 0.000), in addition to higher serum creatinine values (p = 0.001). Higher fasting glucose levels and higher frequency of insulinoterapy were independently observed in patients with DR and b allele carriers, when compared to BB.

Conclusion

The association of the bb/Bb genotypes (rs1544410) of the VDR gene with increased blood glucose levels and insulinoterapy may represent worse glicemic control in rs1544410 b allele carriers in DR Latin American individuals.

Analysis of Coronary Artery Lesion Degree and Related Risk Factors in Patients with Coronary Heart Disease Based on Computer-Aided Diagnosis of Coronary Angiography

A combination of various risk factors results in the development of coronary heart disease. The earlier that one identifies and deals with reversible risk factors for coronary heart disease, the greater the chance of recovery. The main goal of this research is to learn whether risk variables are associated with greater extent of coronary artery disease in people with coronary heart disease. This article selects 290 patients who had had coronary angiography in our hospital from September 2018 to March 2019 using a retrospective research and analytic methodology. Coronary angiography split the patients into two groups: those with coronary heart disease and those without. To determine the correlation between risk factors and a score related to heart disease, computer-aided statistical analysis of data about the differences in those risk factors was performed. The results were analyzed using the Spearman correlation and partial correlation, and the relationship between risk factors and Gensini score was analyzed by multiple linear regression. For the analysis, binary logistic regression was used to calculate the correlation between the risk factors of coronary heart disease and the probability of developing coronary heart disease. The findings concluded that increased age, smoking, elevated hs-CRP, HbA1c, hypertension, diabetes, and hyperuricemia are all contributors to coronary heart disease. Coronary heart disease is an independent risk factor for this condition. Many of the factors that play a role in the long-term development of the severity of coronary artery disease, such as hypertension, diabetes, smoking, elevated hs-CRP, decreased HDL-C, raised LDL-C, and TG, are commonly found in men. hs-CRP is the primary risk factor for the degree of coronary artery stenosis and could contribute to the progression of the condition by playing a major role in creating more stenosis.

CE: Hypertensive Emergencies: A Review

ABSTRACT

While acute blood pressure elevations are commonly seen in the ED, not all require emergency treatment. True hypertensive emergencies are characterized by a rapid elevation in blood pressure to a level above 180/120 mmHg and are associated with acute target organ damage, which requires immediate hospitalization for close hemodynamic monitoring and IV pharmacotherapy. Recognizing the clinical signs and symptoms of hypertensive emergency, which may vary widely depending on the target organ involved, is critical. High blood pressure levels that produce no signs or symptoms of target organ damage may be treated without hospitalization through an increase in or reestablishment of previously prescribed oral antihypertensive medication. However, all patients presenting with blood pressure this high should undergo evaluation to confirm or rule out impending target organ damage, which differentiates hypertensive emergency from other hypertensive crises and is vital in facilitating appropriate emergency treatment. Drug therapy for hypertensive emergency is influenced by end-organ involvement, pharmacokinetics, potential adverse drug effects, and patient comorbidities. Frequent nursing intervention and close monitoring are crucial to recuperation. Here, the authors define the spectrum of uncontrolled hypertension; discuss the importance of distinguishing hypertensive emergencies from hypertensive urgencies; and describe the pathophysiology, clinical manifestations, and management of hypertensive emergencies.

Decreased nocturnal heart rate variability and potentially related brain regions in arteriosclerotic cerebral small vessel disease

Background

To assess heart rate variability (HRV) among patients with arteriosclerotic cerebral small vessel disease (CSVD) by comparing with control subjects, and to determine whether HRV parameters were related to structural alterations in brain regions involved in autonomic regulation among CSVD patients.

Methods

We consecutively recruited subjects aged between 50 and 80 years who visited the Stroke Prevention Clinic of our hospital and have completed brain magnetic resonance imaging examination from September 1, 2018 to August 31, 2019. Polysomnography and synchronous analyses of HRV were then performed in all participants. Multivariable binary logistic regression was used to identify the relationship between HRV parameters and CSVD. Participants were invited to further undergo three-dimensional brain volume scan, and the voxel based morphometry (VBM) analysis was used to identify gray matter atrophy.

Results

Among 109 participants enrolled in this study, 63 were assigned to the arteriosclerotic CSVD group and 46 to the control group. Lower standard deviation of normal-to-normal intervals (SDNN, OR = 0.943, 95% CI 0.903 to 0.985, P = 0.009) and higher ratio of low to high frequency power (LF/HF, OR = 4.372, 95% CI 1.033 to 18.508, P = 0.045) during the sleep period were associated with CSVD, independent of traditional cerebrovascular risk factors and sleep disordered breathing. A number of 24 CSVD patients and 21 controls further underwent three-dimensional brain volume scan and VBM analysis. Based on VBM results, SDNN during the awake time (β = 0.544, 95% CI 0.211 to 0.877, P = 0.001) and the sleep period (β = 0.532, 95% CI 0.202 to 0.862, P = 0.001) were both positively related with gray matter volume within the right inferior frontal gyrus only among CSVD patients.

Conclusions

Decreased nocturnal HRV is associated with arteriosclerotic CSVD independent of traditional cerebrovascular risk factors and sleep disordered breathing. The structural atrophy of some brain regions associated with cardiac autonomic regulation sheds light on the potential relationship.

Trial registration

Trial registration number: ChiCTR1800017902. Date of registration: 20 Aug 2018.

The Role of Blood Pressure in Carotid Plaque Incidence: Interactions With Body Mass Index, Age, and Sex-Based on a 7-Years Cohort Study

Background: Although high blood pressure (BP) is a risk factor for carotid plaque, its long-term prognostic value might be underestimated due to its confounding interactions with BMI, age, and gender. Therefore, we conducted a 7-year prospective cohort study to evaluate the prognostic value of BP for the incidence of carotid plaque. Methods: The subjects enrolled in 2011 were free of carotid plaque at baseline and were followed up in 2018. Multivariate Cox proportional-hazards models were used to evaluate the association between BP and carotid plaque incidence. Results: During the follow-up study, the incidence of carotid plaque was 36.5%. The significant positive linear trend showed that subjects with higher BP levels at baseline were more likely to develop carotid plaques at the end. Especially in the female subpopulation, after confounders being adjusted, the carotid plaque was associated with higher BP (adjusted HR 1.52, 95% CI 1.02-2.26), pulse pressure (PP) (adjusted HR 1.15, 95% CI 0.76-1.75), and mean arterial pressure (MAP) (adjusted HR 1.44, 95% CI 1.00-2.08). The adjusted HRs of hypertension, PP, and MAP (HR 27.71, 95% CI 2.27-338.64; HR 14.47, 95% CI 1.53-137.18; HR 9.97, 95% CI 1.29-77.28) were significantly higher after the potential antagonistic interactions between BP categorical indicators and age being adjusted, respectively. Conclusion: High BP indicators might be associated with higher HRs of carotid plaque after adjusting interactions between BP indicators and BMI, age, and gender, which suggests that the incidence of carotid plaque in female adults with high BP indicators might increase significantly with the increase of age.

Hemodynamic Characteristics of Patients With Suspected Coronary Heart Disease at Their Initial Visit

Purpose

It is difficult for doctors to decide whether patients with suspected coronary heart disease classified as Coronary Artery Disease Reporting and Data System (CAD-RADS) < 3 should be administered preventive treatment, or whether non-atherosclerotic chest pain should be considered. The aim of the current study was to investigate coronary hemodynamic characteristics in such patients, which may provide more information on their stenosis and be helpful for initial diagnoses.

Methods

Two patient-specific models were reconstructed based on the coronary computed tomographic angiography underwent in 2012. Patient 1 was classified as CAD-RADS 0, and was readmitted to hospital due to coronary artery disease within 5 years. Patient 2 was classified as CAD-RADS 2, and has experienced no adverse events to date. Computational fluid dynamics (CFD) analysis was used to obtain hemodynamic parameters including flow rate waveform, flow streamlines, time-average wall shear stress (TAWSS), and oscillatory shear index (OSI).

Results

Patient 1 exhibited no physiological characteristics of right coronary artery flow waveform, large areas of low TAWSS, and slow blood flow in the proximal and middle segments of the left anterior descending branch. Patient 2 exhibited reduced coronary supply, small and separate areas of abnormal TAWSS, and a higher left anterior descending branch OSI than patient 1.

Conclusion

Hemodynamic abnormalities may play an important role in the prognosis of patients with coronary stenosis, and patient-specific hemodynamic characteristics may facilitate more accurate initial diagnosis, and better management. Overall hemodynamics (along the whole vessel) warranted attention at the time of the initial visit in patients classified as CAD-RADS < 3.

Weight changes in hypertensive patients with phlegm-dampness syndrome: an integrated proteomics and metabolomics approach

BACKGROUND

Hypertension (HTN) patients who have phlegm-dampness syndrome (PDS) tend to be obese and have worse outcomes. However, the association of body weight (BW) changes and mechanisms underlying the pathophysiology of HTN-PDS are not well elucidated. This study aims to identify the longitudinal observations associated with the circulating markers discriminating BW changes of individuals with HTN-PDS.

METHODS

An integrative approach relying on metabolomics and proteomics was applied to serum samples from HTN-PDS patients in a prospective cohort to identify the plausible mechanistic pathways underpinning HTN-PDS pathophysiology. Study participants were determined to have experienced a weight change if they showed a 5%-15% increase/reduction in BW at the end of the follow-up period. The joint pathway analysis and network analysis were performed using Ingenuity Pathway Analysis (IPA®) on the serum samples obtained from the participants over the period.

RESULTS

The study involved 22 HTN-PDS patients who were overweight initially and were able to lose enough weight and 24 HTN-PDS individuals who developed overweight from normal BMI during a one-year follow-up. Our analysis suggested three types of phosphatidylcholine (PC) were altered. PC (22:2(13Z,16Z)/24:1(15Z)) and LysoPC (16:1(9Z)) were decreased in Queryweight gain samples, whereas the levels of PC (14:0/16:0) were increased in weight loss samples. The metabolomic analysis suggested 24 metabolites associated with HTN-PDS. Of them, 13 were up-regulated and 11 were down-regulated. The two-dimensional difference gel electrophoresis (2D DIGE) identified 45 phosphorylated proteins got altered in the HTN-PDS patients, wherein 23 were up-regulated and 22 were down-regulated. Integrated proteomic and metabolomics analyse acknowledged biomarkers PC, Complement C3, C4a/C4b, A2M and SERPINF1 as strong predictors for BW changes in HTN-PDS patients.

CONCLUSION

The combined serum proteomic and metabolomic profiling reveals a link between BW change and the complement system activity, altered phosphatidylcholine metabolism in HTN-PDS patients. Future studies with larger cohorts are required to strengthen and validate these findings.

Prevalence and association of lifestyle and medical-, psychiatric-, and pain-related comorbidities in patients with migraine: A cross-sectional study

BACKGROUND AND OBJECTIVES

Migraine has been associated with many comorbidities. However, lifestyle factors and the presence of comorbid diseases have not previously been extensively studied in the same sample. This study aimed to compare the prevalence of unhealthy lifestyle factors and comorbid diseases between patients with migraine and migraine-free controls with subgroup analyses to determine the pathophysiology and possible consequences.

METHODS

This cross-sectional study recruited 1257 patients with migraine between the ages of 20 and 65 years from a headache outpatient clinic in Taiwan and 496 non-migraine controls. All participants completed questionnaires regarding demographics, migraine diagnosis, sleep, headache burden, and medical, pain, and psychiatric conditions. Participants also underwent a structured interview. The associations between comorbidities and migraine were investigated and further stratified by sex and aura.

RESULTS

Patients with migraine with aura had an unhealthier lifestyle compared with controls in the form of current smoking status (15.5% [67/431] vs. 11.5% [57/496], p = 0.013). Furthermore, medical- (e.g., thyroid disease; 7.2% [91/1257 vs. 2.8% [14/496]; p = 0.006), psychiatric- (e.g., depression; 6% [76/1257 vs. 2.6% [13/496]; p = 0.031), and pain-related (e.g., fibromyalgia; 8% [101/1257 vs. 3.2% [16/496]; p = 0.006) comorbidities were more prevalent in patients compared with controls. Subgroup analyses revealed that chronic migraine, migraine with aura, and female sex were associated with a greater number of significant comorbidities than episodic migraine, migraine without aura, and male patients with migraine, respectively.

CONCLUSION

Individuals seeking treatment for migraine reported greater levels of smoking and medical, psychiatric, and pain conditions than non-treatment-seeking healthy controls who were recruited from the community. Understanding the relationship between migraine and comorbid diseases may improve medical care as well as the quality of life.

The safety of cardioselective β1-blockers in asthma: literature review and search of global pharmacovigilance safety reports

Introduction

Beta-blockers are key in the management of cardiovascular diseases but blocking airway β₂-receptors can cause severe and sometimes fatal bronchoconstriction in people with asthma. Although cardioselective β₁-blockers may be safer than non-selective β-blockers, they remain relatively contraindicated and under-prescribed. We review the evidence of the risk associated with cardioselective β₁-blocker use in asthma.

Methods

We searched “asthma” AND “beta-blocker” in PubMed and EmbaseOvid from start to May 2020. The World Health Organization (WHO) global database of individual case safety reports (VigiBase) was searched for reports of fatal asthma or bronchospasm and listed cardioselective β₁-blocker use (accessed February 2020). Reports were examined for evidence of pre-existing asthma.

Results

PubMed and EmbaseOvid searches identified 304 and 327 publications, respectively. No published reports of severe or fatal asthma associated with cardioselective β₁-blockers were found. Three large observational studies reported no increase in asthma exacerbations with cardioselective β₁-blocker treatment. The VigiBase search identified five reports of fatalities in patients with pre-existing asthma and reporting asthma or bronchospasm during cardioselective β₁-blocker use. Four of these deaths were unrelated to cardioselective β₁-blocker use. The circumstances of the fifth death were unclear.

Conclusions

There were no published reports of cardioselective β₁-blockers causing asthma death. Observational data suggest that cardioselective β₁-blocker use is not associated with increased asthma exacerbations. We found only one report of an asthma death potentially caused by cardioselective β₁-blockers in a patient with asthma in a search of VigiBase. The reluctance to use cardioselective β₁-blockers in people with asthma is not supported by this evidence.

There are no published reports of asthma deaths associated with cardioselective β1-blocker use and only one possible death in WHO VigiBase reports. Despite widespread concerns, asthma deaths associated with cardioselective β1-blockers are very rare.https://bit.ly/3if6TuY

When evidence is lacking: a mixed-methods approach for the development of practice guidance in liver transplantation

Background

Most interventions for conditions with a small cohort size, such as transplantation, are unlikely to be part of a clinical trial. When condition-specific evidence is lacking, expert consensus can offer more precise guidance to improve care. Management of cardiovascular risk in liver-transplant recipients is one example for which clinicians have, to date, adapted evidence-based guidelines from studies in the general population. However, even when consensus is achieved, implementation of practice guidance is often inadequate and protracted. We report on a novel mixed-methods approach, the Northwestern Method©, for the development of clinical-practice guidance when condition-specific evidence is lacking. We illustrate the method through the development of practice guidance for managing cardiovascular risk in liver-transplant recipients.

Methods

The Northwestern Method© consists of (i) adaptation of relevant, existing, evidence-based clinical-practice guidelines for the target population; (ii) consensus by experts of the proposed practice guidance; (iii) identification of barriers to guidance adherence in current practice; and (iv) recommendation for implementation and dissemination of the practice guidance. The method is based on an iterative, user-centered approach in which the needs, wants, and limitations of all end users, including patients, are attended to at each stage of the design and development process.

Conclusions

The Northwestern Method© for clinical-practice-guidance development uses a mixed-methods approach to bring together broad representation from multiple disciplines and practice settings to develop consensus considering the unique needs and preferences of patients, caregivers, and practitioners who are directly impacted by clinical-practice-guidance recommendations. We hypothesize that a priori involvement of end users in the guidance-development process will lead to sustainable implementation of guidance statements into clinical practice.

Standardized treatment to improve hypertension control in primary health care: The HEARTS in the Americas Initiative

Hypertension is the leading risk factor for cardiovascular disease (CVD) worldwide. Despite the availability of effective antihypertensive medications, the control of hypertension at a global level is dismal, and consequently, the CVD burden continues to increase. In response, countries in Latin America and the Caribbean are implementing the HEARTS in the Americas, a community-based program that focuses on increasing hypertension control and CVD secondary prevention through risk factor mitigation. One key pillar is the implementation of a standardized hypertension treatment protocol supported by a small, high-quality formulary. This manuscript describes the methodology used by the HEARTS in the Americas program to implement a population-based standardized hypertension treatment protocol. It is rooted in a seamless transition from existing treatment practices to best practice using pharmacologic protocols built around a core set of ideal antihypertensive medications. In alignment with recent major hypertension guidelines, the HEARTS in the Americas protocols call for the rapid control of blood pressure, through the use of two antihypertensive medications, preferably in the form of a single pill, fixed-dose combination, in the initial treatment of hypertension. To date, the HEARTS in the Americas program has seen the improvement in antihypertensive medication formularies and the establishment of pharmacologic treatment protocols tailored to individual participating countries. This has translated to significant increases in hypertension control rates post-program implementation in these jurisdictions. Thus, the HEARTS in the Americas program could serve as a model, for not only the Americas Region but globally, and ultimately decrease the burden of CVD.

Blood pressure targets for the treatment of people with hypertension and cardiovascular disease

BACKGROUND

This is the second update of the review first published in 2017. Hypertension is a prominent preventable cause of premature morbidity and mortality. People with hypertension and established cardiovascular disease are at particularly high risk, so reducing blood pressure to below standard targets may be beneficial. This strategy could reduce cardiovascular mortality and morbidity but could also increase adverse events. The optimal blood pressure target in people with hypertension and established cardiovascular disease remains unknown.

OBJECTIVES

To determine if lower blood pressure targets (135/85 mmHg or less) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (140 to 160/90 to 100 mmHg or less) in the treatment of people with hypertension and a history of cardiovascular disease (myocardial infarction, angina, stroke, peripheral vascular occlusive disease).

SEARCH METHODS

For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCTs) up to November 2019: Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE (from 1946), Embase (from 1974), and Latin American Caribbean Health Sciences Literature (LILACS) (from 1982), along with the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. We applied no language restrictions.

SELECTION CRITERIA

We included RCTs with more than 50 participants per group that provided at least six months' follow-up. Trial reports had to present data for at least one primary outcome (total mortality, serious adverse events, total cardiovascular events, cardiovascular mortality). Eligible interventions involved lower targets for systolic/diastolic blood pressure (135/85 mmHg or less) compared with standard targets for blood pressure (140 to 160/90 to 100 mmHg or less). Participants were adults with documented hypertension and adults receiving treatment for hypertension with a cardiovascular history for myocardial infarction, stroke, chronic peripheral vascular occlusive disease, or angina pectoris.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed search results and extracted data using standard methodological procedures expected by Cochrane. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

We included six RCTs that involved 9484 participants. Mean follow-up was 3.7 years (range 1.0 to 4.7 years). All RCTs provided individual participant data. None of the included studies was blinded to participants or clinicians because of the need to titrate antihypertensives to reach a specific blood pressure goal. However, an independent committee blinded to group allocation assessed clinical events in all trials. Hence, we assessed all trials at high risk of performance bias and low risk of detection bias. Other issues such as early termination of studies and subgroups of participants not predefined were also considered to downgrade the quality evidence. We found there is probably little to no difference in total mortality (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.91 to 1.23; 6 studies, 9484 participants; moderate-quality evidence) or cardiovascular mortality (RR 1.03, 95% CI 0.82 to 1.29; 6 studies, 9484 participants; moderate-quality evidence). Similarly, we found there may be little to no differences in serious adverse events (RR 1.01, 95% CI 0.94 to 1.08; 6 studies, 9484 participants; low-quality evidence) or total cardiovascular events (including myocardial infarction, stroke, sudden death, hospitalization, or death from congestive heart failure) (RR 0.89, 95% CI 0.80 to 1.00; 6 studies, 9484 participants; low-quality evidence). The evidence was very uncertain about withdrawals due to adverse effects. However, studies suggest more participants may withdraw due to adverse effects in the lower target group (RR 8.16, 95% CI 2.06 to 32.28; 2 studies, 690 participants; very low-quality evidence). Systolic and diastolic blood pressure readings were lower in the lower target group (systolic: mean difference (MD) -8.90 mmHg, 95% CI -13.24 to -4.56; 6 studies, 8546 participants; diastolic: MD -4.50 mmHg, 95% CI -6.35 to -2.65; 6 studies, 8546 participants). More drugs were needed in the lower target group (MD 0.56, 95% CI 0.16 to 0.96; 5 studies, 7910 participants), but blood pressure targets were achieved more frequently in the standard target group (RR 1.21, 95% CI 1.17 to 1.24; 6 studies, 8588 participants).

AUTHORS' CONCLUSIONS

We found there is probably little to no difference in total mortality and cardiovascular mortality between people with hypertension and cardiovascular disease treated to a lower compared to a standard blood pressure target. There may also be little to no difference in serious adverse events or total cardiovascular events. This suggests that no net health benefit is derived from a lower systolic blood pressure target. We found very limited evidence on withdrawals due to adverse effects, which led to high uncertainty. At present, evidence is insufficient to justify lower blood pressure targets (135/85 mmHg or less) in people with hypertension and established cardiovascular disease. Several trials are still ongoing, which may provide an important input to this topic in the near future.

The effect of diurnal temperature range on blood pressure among 46,609 people in Northwestern China

BACKGROUND

A large number of studies have found a positive association between diurnal temperature range (DTR) and cardiovascular diseases (CVDs) incidence and mortality. Few studies regarding the effects of DTR on blood pressure (BP) are available.

OBJECTIVE

To investigate the effects of DTR on BP in Jinchang, northwestern China.

METHODS

Based on a prospective cohort research, a total of 46,609 baseline survey data were collected from 2011 to 2015. The meteorological observation data and environmental monitoring data were collected in the same period. The generalized additive model (GAM) was used to estimate the relationship between DTR and BP after adjusting for confounding variables.

RESULTS

Our study found that there was a positive linear correlation between DTR and systolic blood pressure (SBP) and plus pressure (PP), and a negative linear correlation between DTR and diastolic blood pressure (DBP). With a 1 °C increase of DTR, SBP and PP increased 0.058 mmHg (95%CI: 0.018-0.097) and 0.114 mmHg (95%CI: 0.059-0.168) respectively, and DBP decreased 0.039 mmHg (95%CI:-0.065 ~ -0.014). There was a significant interaction between season and DTR on SBP and PP. DTR had the greatest impact on SBP and PP in hot season. The association between DTR and BP varied significantly by education level.

CONCLUSION

There was a significant association between DTR and BP in Jinchang, an area with large temperature change at high altitudes in northwestern China. These results provide new evidence that DTR is an independent risk factor for BP changes among general population. Therefore, effective control and management of BP in the face of temperature changes can help prevent CVDs.

Validez y confiabilidad del cuestionario Orientación ante la Vida de Antonovsky (SC-29 ítems), versión en español

Introducción: El cuestionario Orientación ante la Vida mide el sentido de coherencia, un concepto relacionado con el uso de los recursos de afrontamiento que influyen positivamente en una mejor calidad de vida y bienestar de aquellos adultos con enfermedad cardiovascular. Objetivo: Determinar la validez y confiabilidad del cuestionario Orientación ante la Vida de Antonovsky, en adultos con hipertensión arterial. Método: Estudio de tipo metodológico en el que se realizó la adaptación cultural y se determinó la validez facial, de contenido, de constructo y confiabilidad. En la adaptación cultural se siguió un proceso de traducción, consenso y retrotraducción. La validez facial y de contenido se cumplió mediante el juicio de expertos, utilizando las pruebas estadísticas de coeficiente kappa de Fleiss e índice de Lawshe modificado. En la validez de constructo y prueba de confiabilidad participaron 220 personas. La confiabilidad se calculó mediante la prueba estadística de alfa de Cronbach. Resultados: En la validez facial, el instrumento reportó un índice kappa de Fleiss mayor a 0,41, interpretado como un acuerdo moderado. El índice de validez de contenido fue satisfactorio con 0,87, el análisis factorial exploratorio reportó tres factores con una varianza total explicada del 36,21 %. El alfa de Cronbach fue de 0,82 para la escala total. Conclusiones: La versión en español del ins­trumento Orientación ante la Vida presenta un adecuado índice de validez de contenido y confiabilidad para uso en el contexto local. Es necesario continuar su aplicación en otros grupos y momentos para continuar refinando su validez.

Hemodynamic effects of the dipeptidyl peptidase-4 inhibitor linagliptin with renin-angiotensin system inhibitors in type 2 diabetic patients with albuminuria

Objective:

Concomitant treatment with angiotensin-converting enzyme (ACE) inhibitors and dipeptidyl peptidase-4 (DPP-4) inhibitors is increasingly common. Pharmacological studies have suggested a potential adverse drug interaction between ACE inhibitors and DPP-4 inhibitors resulting in unfavorable hemodynamic changes; very few studies have examined such an interaction between angiotensin II receptor blockers (ARBs) and DPP-4 inhibitors. We investigated blood pressure (BP) and heart rate (HR) during treatment with the DPP-4 inhibitor linagliptin in individuals receiving either ACE inhibitors or ARBs in the MARLINA-T2D trial.

Methods:

In this study, 360 individuals with type 2 diabetes and albuminuria receiving unchanged doses of ACE inhibitors or ARBs were randomized to linagliptin or placebo. Twenty-four-hour ambulatory BP monitoring, an exploratory endpoint, was conducted at baseline and after 24 weeks.

Results:

Ambulatory BP monitoring data were available for 208 individuals (linagliptin: n = 111; placebo: n = 97). Baseline mean ± SD 24-h SBP and DBP were 132.5 ± 12.4 mmHg and 75.9 ± 9.4 mmHg, respectively; mean 24-h HR was 76.3 ± 10.1 bpm. At week 24, no overall effect of the DPP-4 inhibitor versus placebo was seen on mean 24-h SBP, DBP, or HR. Furthermore, in the subgroups receiving either an ACE inhibitor or an ARB, no effect on these hemodynamic parameters was seen as a result of concomitant DPP-4 inhibitor treatment.

Conclusion:

Adding linagliptin to treatment with ACE inhibitors or ARBs was not associated with any hemodynamic changes, supporting their concomitant use in individuals with type 2 diabetes and albuminuria.

The differences in self-perceptions of aging, health-related quality of life and their association between urban and rural Chinese older hypertensive patients

Background

Most hypertensive clients are elderly, whose health-related quality of life (HRQL) may be associated with self-perceptions of aging (older individuals’ beliefs about their own aging). Meanwhile, culture and health disparities between rural and urban populations are substantial. Whether there are differences in self-perceptions of aging, HRQL, and their association among elderly hypertensive clients in urban and rural areas remains unknown. The objective of this study was to investigate and compare self-perceptions of aging and HRQL and their association among urban and rural older Chinese hypertensive clients.

Methods

A cross-sectional investigation was conducted in 15 urban community clinics and 22 village clinics from Suzhou, China. Older hypertensive adults were invited to complete a self-administered questionnaire addressing socio-demographic and clinical information, HRQL and self-perceptions of aging.

Results

There were 492 urban participants and 537 rural participants included in the analyses. The physical (40.0 ± 12.1 vs. 30.9 ± 8.9, P <  0.001) and mental (51.5 ± 8.3 vs. 46.0 ± 7.8, P <  0.001) HRQL scores of urban participants were all higher than those of rural ones. Urban participants’ scores on dimensions of “timeline cyclical”, “consequences negative”, and “control negative” of self-perceptions of aging questionnaire (APQ) were lower than those of rural participants (P <  0.001, respectively), while the scores on dimensions of “consequences positive” and “control positive” were higher (P <  0.001, respectively). Adjusted multivariate linear regression showed that participants who had worse self-perceptions of aging had poorer HRQL. Some APQ dimensions associated with urban or rural hypertensive elders’ HRQL were different.

Conclusions

Older hypertensive clients in rural areas have poorer self-perceptions of aging and HRQL than those in urban areas. Health care professionals should pay more attention to HRQL and self-perceptions of aging of older hypertensive clients in rural areas.

The Role of Arterial Stiffness and Central Hemodynamics in Heart Failure

Whereas traditional understanding of left ventricular afterload was focused on a steady-state circulation model with continuous pressures and flow, a more realistic concept is emerging, taking the pulsatile nature of the heart and the arterial system into account. The most simple measure of pulsatility is brachial pulse pressure, representing the pulsatility fluctuating around the mean blood pressure level. Brachial pulse pressure is widely available, fundamentally associated with the development and treatment of heart failure (HF), but its analysis is often confounded in patients with established HF. The next step of analysis consists of arterial stiffness, central (rather than brachial) pressures, and of wave reflections. The latter are closely related to left ventricular late systolic afterload, ventricular remodeling, diastolic dysfunction, exercise capacity, and, in the long term, the risk of new-onset HF. Wave reflection may also evolve as a suitable therapeutic target for HF with preserved and reduced ejection fraction. A full understanding of ventricular-arterial coupling, however, requires dedicated analysis of time-resolved pressure and flow signals. This review provides a summary of current understanding of pulsatile hemodynamics in HF.

Österreichischer Blutdruckkonsens 2019

Erhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.

Average Clinician-Measured Blood Pressures and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus and Ischemic Heart Disease in the EXAMINE Trial

Background

Blood pressure (BP) treatment goals in patients with diabetes mellitus and increased cardiovascular risk remain controversial. Our study objective was to determine cardiovascular outcomes according to achieved BPs over the average follow‐up period in the EXAMINE (Examination of Cardiovascular Outcomes With Alogliptin Versus Standard of Care) trial.

Methods and Results

EXAMINE was a cardiovascular outcomes trial in 5380 patients with type 2 diabetes mellitus and recent acute coronary syndromes. Risks of major adverse cardiac events and cardiovascular death or heart failure were analyzed using a Cox proportional hazards model with adjustment for baseline covariates in 10‐mm Hg increments of clinician‐measured systolic BP from ≤100 to >160 mm Hg and diastolic BP from ≤60 to >100 mm Hg averaged during the 24 months after randomization. Based on 2015 guidelines from the American College of Cardiology, the American Heart Association and the American Society of Hypertension and 2017 American Diabetes Association guidelines, systolic BPs of 131 to 140 mm Hg and diastolic BPs of 81 to 90 mm Hg were the reference groups. A U‐shaped relationship between cardiovascular outcomes and BPs was observed. Importantly, compared with the systolic BP reference group, adjusted hazard ratios for major adverse cardiac events and cardiovascular death or heart failure were significantly higher in patients with systolic BPs <130 mm Hg. Similarly, compared with the diastolic BP reference group, adjusted hazard ratios for major adverse cardiac events and for cardiovascular death or heart failure were significantly higher for diastolic BPs <80 mm Hg.

Conclusions

In patients with type 2 diabetes mellitus and recent acute coronary syndrome, average BPs <130/80 mm Hg were associated with worsened cardiovascular outcomes. These data suggest that intensive control of BP in patients with type 2 diabetes mellitus and ischemic heart disease should be evaluated in a prospective randomized trial.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00968708.

See Editorial by https://doi.org/10.1161/JAHA.118.010752

The Ongoing Saga of Optimal Blood Pressure Level in Patients With Diabetes Mellitus and Coronary Artery Disease

See Article by White et al .

Hypertension and patients with acute coronary syndrome: Putting blood pressure levels into perspective

Arterial hypertension is a well-established cardiovascular risk factor, and blood pressure (BP) control has largely improved the prognosis of hypertensive patients. A number of studies have assessed the role of BP levels in the prognosis of patients with acute coronary syndromes. Pathophysiologic links of hypertension to acute myocardial infarction (MI) include endothelial dysfunction, autonomic nervous system dysregulation, impaired vasoreactivity, and a genetic substrate. A history of hypertension is highly prevalent among patients presenting with MI, and some, but not all, studies have associated it with a worse prognosis. Some data support that low levels of admission and in-hospital BP may indicate an increased risk for subsequent events. Risk scores used in patients with MI have, therefore, included BP levels and a history of hypertension in their variables. Of note, good long-term BP control, ideally initiated prior to discharge, should be pursued in order to improve secondary prevention.

Blood pressure lowering effects of a novel isometric exercise device following a 4-week isometric handgrip intervention

Background: Hypertension is the leading risk factor for global mortality. Isometric resistance exercise training reduces blood pressure (BP). However, the protocols used are often limited by cost/immobility and the use of rigid exercise modalities. In response, a novel more versatile, isometric exercise (IE) device, the IsoBall (IB) was created.

Purpose: The aim of this study was to test the BP-lowering effectiveness of this prototype.

Methods: Twenty-three healthy participants (29.10±2.19 years old, 173.95±3.83 cm, 75.43±5.06 kg, SBP 127.10±10.37 mmHg, DBP 70.40±6.77 mmHg) were randomly allocated to either a control group (CON) or 2 isometric handgrip (IHG) training groups that used the Zona plus (ZON) and IB devices. The intervention groups completed 3 sessions each week of 4, 2 min IHG at 30% maximal voluntary contraction, with a 1-min rest, for 4 weeks. Resting BP, heart rate (HR) and IHG strength were measured in all groups at baseline and postintervention.

Results: Postintervention systolic BP (SBP) was significantly lower in both ZON (114.5±8.2 mmHg, p = 0.000) and IB (119.9±7.0 mmHg, p = 0.000) compared to control (131.0±12.4 mmHg). Postintervention diastolic BP (DBP) was reduced in both intervention groups (ZON 66.6±7.4 mmHg, p = 0.004; IB 65.7±10.0 mmHg, p = 0.012) compared to CON (71.1±8.8 mmHg). Mean arterial pressure (MAP) was reduced in both groups (ZON 82.6±6.8 mmHg, p = 0.000; IB 84.3±9.1 mmHg, p = 0.000) compared to control (91.0±9.7 mmHg). No significant changes were seen in HR or strength (p > 0.05).

Conclusion: The results of this study indicate that both the ZON and IB devices elicit significant SBP, DBP and MAP reductions. Despite the ZON group having larger reductions in BP, no significant differences were found between the two devices. Thus, this study indicates the IB device to be an effective alternative to the ZON that can also be used to perform other IE modalities.

Beta-blocker therapy reduces mortality in patients with coronary artery disease treated with percutaneous revascularization: a meta-analysis of adjusted results

AIMS

The long-term impact of beta blockers on prognosis in patients treated with contemporary therapies for coronary artery disease remains to be defined.

METHODS AND RESULTS

All observational studies evaluating the impact of beta blockers in patients treated with coronary revascularization and contemporary therapies and adjusted with multivariate analysis were included. All-cause death was the primary endpoint, while Major Adverse Cardiac Events (MACE) (composite endpoint of all-cause death or myocardial infarction, MI) and MI were secondary endpoints. A total of 26 studies were included, with 863 335 patients. After 3 (1-4.3) years, long-term risk of all-cause death was lower in patients on beta blockers [odds ratio, OR 0.69 (0.66-0.72)], both for Acute Coronary Syndrome (ACS) [OR 0.60 (0.56-0.65)], and stable angina patients [OR 0.84 (0.78-0.91)], independently from ejection fraction [OR 0.64 (0.42-0.98) for reduced ejection fraction and OR 0.79 (0.69-0.91) for preserved ejection fraction]. The risk of long-term MACE was lower but NS for ACS patients treated with beta blockers [OR 0.83 (0.69-1.00)], as in stable angina. Similarly, risk of MI did not differ between patients treated with beta blockers or without beta blockers [OR 0.99 (0.89-1.09), all 95% confidence intervals]. Using meta-regression analysis, the benefit of beta blockers was increased for those with longer follow-up. The number needed to treat was 52 to avoid one event of all-cause death for ACS patients and 111 for stable patients.

CONCLUSION

Even in percutaneous coronary intervention era, beta blockers reduce mortality in patients with coronary artery disease, confirming their protective effect, which was consistent for both ACS and stable patients indifferently of preserved or reduced ejection fraction.

MicroRNA-374b induces endothelial-to-mesenchymal transition and early lesion formation through the inhibition of MAPK7 signaling

Endothelial–mesenchymal transition occurs during intimal hyperplasia and neointima formation via mechanisms that are incompletely understood. Endothelial MAPK7 signaling is a key mechanosensitive factor that protects against endothelial–mesenchymal transition, but its signaling activity is lost in vessel areas that are undergoing pathological remodeling. At sites of vascular remodeling in mice and pigs, endothelial MAPK7 signaling was lost. The TGFβ‐induced microRNA‐374b targets MAPK7 and its downstream effectors in endothelial cells, and its expression induces endothelial–mesenchymal transition. Gain‐of‐function experiments, where endothelial MAPK7 signaling was restored, precluded endothelial–mesenchymal transition. In human coronary artery disease, disease severity is associated with decreased MAPK7 expression levels and increased miR‐374b expression levels. Endothelial–mesenchymal transition occurs in intimal hyperplasia and early lesion formation and is governed in part by microRNA‐374b‐induced silencing of MAPK7 signaling. Restoration of MAPK7 signaling abrogated these pathological effects in endothelial cells expressing miR‐374b. Thus, our data suggest that the TGFβ‐miR‐374b‐MAPK7 axis plays a key role in the induction of endothelial–mesenchymal transition during intimal hyperplasia and early lesion formation and might pose an interesting target for antiatherosclerosis therapy. © 2018 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.

Multiscale mathematical modeling vs. the generalized transfer function approach for aortic pressure estimation: a comparison with invasive data

We aimed to evaluate the performance of a mathematical model and currently available non-invasive techniques (generalized transfer function (GTF) method and brachial pressure) in the estimation of aortic pressure. We also aimed to investigate error dependence on brachial pressure errors, aorta-to-brachial pressure changes and demographic/clinical conditions. Sixty-two patients referred for invasive hemodynamic evaluation were consecutively recruited. Simultaneously, the registration of the aortic pressure using a fluid-filled catheter, brachial pressure and radial tonometric waveform was recorded. Accordingly, the GTF device and mathematical model were set. Radial invasive pressure was recorded soon after aortic measurement. The average invasive aortic pressure was 141.3 ± 20.2/76 ± 12.2 mm Hg. The simultaneous brachial pressure was 144 ± 17.8/81.5 ± 11.7 mm Hg. The GTF-based and model-based aortic pressure estimates were 133.1 ± 17.3/82.4 ± 12 and 137 ± 21.6/72.2 ± 16.7 mm Hg, respectively. The Bland-Altman plots showed a marked tendency to pressure overestimation for increasing absolute values, with the exclusion of mathematical model diastolic estimations. The systolic pressure was increased from the aortic to radial locations (7.5 ± 19 mm Hg), while the diastolic pressure was decreased (3.8 ± 9.8 mm Hg). The brachial pressure underestimated the systolic and overestimated diastolic intra-arterial radial pressure. GTF errors were independently correlated with the variability in pulse pressure amplification and with the brachial error. Errors of the mathematical model were related to only demographic and clinical conditions. Neither a multiscale mathematical model nor a generalized transfer function device substantially outperformed the oscillometric brachial pressure in the estimation of aortic pressure. Mathematical modeling should be improved by including further patient-specific conditions, while the variability in pulse pressure amplification may hamper the performance of the GTF method in patients at the risk of coronary artery disease.

Obstructive sleep apnea and self-reported functional impairment in revascularized patients with coronary artery disease in the RICCADSA trial

PURPOSE

Daytime sleepiness, a frequent symptom of obstructive sleep apnea (OSA), can impact functional status. In patients with coronary artery disease (CAD) and concomitant OSA, the distinction between sleep-related functional impairment from underlying CAD versus OSA is unclear. This study evaluated the impact of OSA on sleep-related functional impairment in patients with CAD and compared the effect of 1-year continuous positive airway pressure (CPAP) use on change in impairment between those with and without excessive daytime sleepiness (EDS) and OSA. We hypothesized that sleep-related functional impairment is impacted by EDS independent of OSA in patients with CAD.

METHODS

One hundred five CAD patients without OSA and 105 with moderate-to-severe OSA from the RICCADSA trial were matched on disease severity and included in the current substudy. Of those with OSA, 80 were allocated to CPAP. Functional Outcomes of Sleep Questionnaire (FOSQ) score < 17.9 corresponded to sleep-related functional impairment.

RESULTS

Following revascularization, CAD patients with and without OSA frequently report sleep-related functional impairment (35% and 27.3%, respectively; p = .29). Moderate-to-severe OSA was not related to baseline FOSQ scores < 17.9 in regression analyses; EDS was (OR 4.82, 95% CI 2.12-11.0; p < .001). CPAP use significantly improved FOSQ scores from baseline to 1-year follow-up in OSA patients with EDS (17.2 ± 2.0 to 18.15 ± 1.7, p = .002) despite suboptimal adherence.

CONCLUSIONS

Sleep-related functional impairment may be reflective of persistent EDS, independent of OSA. Diagnosing OSA and initiating treatment are worthwhile in individuals with CAD and EDS, as both are important to guide appropriate therapy in patients with CAD.

Optimal medical treatment of hypertension in patients with coronary artery disease

INTRODUCTION

Coronary artery disease (CAD) remains the leading cause of mortality and morbidity worldwide, and hypertension is its most prevalent modifiable risk factor. Patients with CAD and concomitant hypertension are a special population with distinct physiologic and structural alterations. Optimal blood pressure (BP) control in this population has been linked with reduction in adverse outcomes, however, excessive lowering of BP could jeopardize myocardial and cerebral perfusion. Areas covered: Authors highlight the prevalence of the CAD and hypertension dyad, as well as the implications of various structural and physiological changes in this population. Subsequently, available data on optimal BP targets in such patients, and lastly the J-curve phenomenon as well as antihypertensive agent use are discussed. Expert commentary: Current guideline recommendations are based on data from trials such as SPRINT and ACCORD which did not specifically focus on the CAD population. Based on data from observational studies and post hoc analyses, the best therapeutic systolic (SBP) and diastolic (DBP) targets may be ~ 130 mmHg and ~ 80 mmHg, respectively. Caution should be taken to not lower SBP below 120 mmHg and DBP below 60 mmHg.

Low Diastolic Blood Pressure Is Associated With Angina in Patients With Chronic Coronary Artery Disease

BACKGROUND

In patients with coronary artery disease (CAD), low diastolic blood pressure (DBP) is associated with increased risk of myocardial infarction, but its association with angina is unknown.

OBJECTIVES

The goal of this study was to examine the association of low DBP and angina in patients with CAD.

METHODS

The study assessed the frequency of angina (measured by using the Seattle Angina Questionnaire-Angina Frequency score) according to DBP in patients with known CAD from 25 U.S. cardiology clinics. Hierarchical logistic regression was used to test the association between DBP and angina, with a spline term for DBP to assess nonlinearity.

RESULTS

Among 1,259 outpatients with CAD, 411 (33%) reported angina in the prior month, with higher rates in the lowest DBP quartile (40 to 64 mm Hg: 37%). In the unadjusted model, DBP was associated with angina with a J-shaped relationship (p = 0.017, p for nonlinearity = 0.027), with a progressive increase in odds of angina as DBP decreased below ∼70 to 80 mm Hg. This association remained significant after sequential adjustment for demographic characteristics (p = 0.002), comorbidities (p = 0.002), heart rate (p = 0.002), systolic blood pressure (p = 0.046), and antihypertensive antianginal medications (p = 0.045).

CONCLUSIONS

In patients with chronic CAD, there seemed to be an association between lower DBP and increased odds of angina. If validated, these findings suggest that clinicians should consider less aggressive blood pressure control in patients with CAD and angina.

Blood pressure targets for the treatment of people with hypertension and cardiovascular disease

BACKGROUND

This is the first update of the review published in 2017. Hypertension is a prominent preventable cause of premature morbidity and mortality. People with hypertension and established cardiovascular disease are at particularly high risk, so reducing blood pressure to below standard targets may be beneficial. This strategy could reduce cardiovascular mortality and morbidity but could also increase adverse events. The optimal blood pressure target in people with hypertension and established cardiovascular disease remains unknown.

OBJECTIVES

To determine if 'lower' blood pressure targets (≤ 135/85 mmHg) are associated with reduction in mortality and morbidity as compared with 'standard' blood pressure targets (≤ 140 to 160/90 to 100 mmHg) in the treatment of people with hypertension and a history of cardiovascular disease (myocardial infarction, angina, stroke, peripheral vascular occlusive disease).

SEARCH METHODS

For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to February 2018: Cochrane Hypertension Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), and Latin American Caribbean Health Sciences Literature (LILACS) (from 1982), along with the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. We applied no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that included more than 50 participants per group and provided at least six months' follow-up. Trial reports had to present data for at least one primary outcome (total mortality, serious adverse events, total cardiovascular events, cardiovascular mortality). Eligible interventions involved lower targets for systolic/diastolic blood pressure (≤ 135/85 mmHg) compared with standard targets for blood pressure (≤ 140 to 160/90 to 100 mmHg).Participants were adults with documented hypertension and adults receiving treatment for hypertension with a cardiovascular history for myocardial infarction, stroke, chronic peripheral vascular occlusive disease, or angina pectoris.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed search results and extracted data using standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included six RCTs that involved a total of 9484 participants. Mean follow-up was 3.7 years (range 1.0 to 4.7 years). All RCTs provided individual participant data.We found no change in total mortality (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.91 to 1.23) or cardiovascular mortality (RR 1.03, 95% CI 0.82 to 1.29; moderate-quality evidence). Similarly, we found no differences in serious adverse events (RR 1.01, 95% CI 0.94 to 1.08; low-quality evidence) or total cardiovascular events (including myocardial infarction, stroke, sudden death, hospitalization, or death from congestive heart failure) (RR 0.89, 95% CI 0.80 to 1.00; low-quality evidence). Studies reported more participant withdrawals due to adverse effects in the lower target arm (RR 8.16, 95% CI 2.06 to 32.28; very low-quality evidence). Blood pressures were lower in the lower target group by 8.9/4.5 mmHg. More drugs were needed in the lower target group, but blood pressure targets were achieved more frequently in the standard target group.

AUTHORS' CONCLUSIONS

We found no evidence of a difference in total mortality, serious adverse events, or total cardiovascular events between people with hypertension and cardiovascular disease treated to a lower or to a standard blood pressure target. This suggests that no net health benefit is derived from a lower systolic blood pressure target. We found very limited evidence on adverse events, which led to high uncertainty. At present, evidence is insufficient to justify lower blood pressure targets (≤ 135/85 mmHg) in people with hypertension and established cardiovascular disease. More trials are needed to examine this topic.

NOVEL COMBINATION OF THE ANGIOTENSIN CONVERTING ENZYME INHIBITOR PERINDOPRIL AND HIGHLY SELECTIVE β-ADRENOBLOCKER BISOPROLOL: PRIME AMONG THE EQUAL

The article is focused on a broad evidence of antihypertension efficacy of perindopril and bisoprolol. The issues considered, of the drugs usage in patients with arterial hypertension, ischemic heart disease and chronic heart failure according to the international and local clinical guidelines. Special attention is paid for the influence of perindopril and bisoprolol on prognosis — the risk of cardiovascular complications from the evidence based medicine perspective. The data provided on a novel unique combination of these medications, and the benefits are accounted, as the mechanism of complimentary interaction; the results of randomized trials, clinical trials provided, that point on the high potential of this sort of combinational treatment.

Donor artery stenosis interactions with diastolic blood pressure on coronary collateral flow in type 2 diabetic patients with chronic total occlusion

Background

We investigated whether and to what extent stenosis of predominant collateral donor artery (PCDA) affects coronary collateral flow in relation to blood pressure (BP) in type 2 diabetic patients with chronic total occlusion (CTO).

Methods

Collateral flow index (CFI) as derived from intracoronary pressure distal to occluded segment and mean aortic pressure in 220 type 2 diabetic patients and 220 propensity score matched non-diabetic controls undergoing percutaneous coronary intervention for CTO. The severity of PCDA stenosis was graded according to lumen diameter narrowing.

Results

CFI decreased stepwise from mild to severe stenosis of the PCDA and was lower in diabetic patients with moderate or severe PCDA stenosis than in non-diabetic controls (0.36 ± 0.10 vs. 0.45 ± 0.08, P < 0.001; 0.29 ± 0.09 vs. 0.35 ± 0.08, P = 0.008). When the PCDA was mildly stenotic, CFI increased initially along with a reduction in diastolic BP, and decreased when diastolic BP was below 60 mmHg in diabetic patients (0.38 ± 0.16 vs. 0.57 ± 0.09, P < 0.001). In the presence of moderate PCDA stenosis, diabetic patients had significantly lower CFI compared to non-diabetic controls, with a relative reduction of 19.8% at diastolic BP 70–79 mmHg, 28.2% at 60–69 mmHg and 38.2% below 60 mmHg (all P < 0.05). A severe PCDA stenosis resulted in a more pronounced decrease in CFI, with a relative reduction of 37.3% for diabetics compared to non-diabetics when diastolic BP was below 60 mmHg (P = 0.050).

Conclusions

In the setting of CTO, donor artery stenosis confers greater risk for reduced coronary collateral flow when diastolic BP is decreased. Even a moderate stenosis in the PCDA may be associated with lower collateral flow as diastolic BP decreases below 80 mmHg in type 2 diabetic than in non-diabetic patients.

Intensive Blood Pressure Lowering in Patients With and Patients Without Type 2 Diabetes: A Pooled Analysis From Two Randomized Trials

OBJECTIVE

The Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD-BP) study did not find a significant beneficial effect of intensive systolic blood pressure (SBP) lowering on cardiovascular events in hypertensive patients with type 2 diabetes mellitus (T2DM), while the Systolic Blood Pressure Intervention Trial (SPRINT) did find a significant beneficial effect in patients without T2DM. The objective of this analysis was to assess the effect of both T2DM and baseline cardiovascular disease risk on the treatment effect of intensive blood pressure lowering.

RESEARCH DESIGN AND METHODS

The individual patient data from the ACCORD-BP and SPRINT studies were pooled and follow-up durations harmonized. Both studies randomized hypertensive patients to an SBP target of <120 mmHg or a target of <140 mmHg. The composite primary end point consisted of unstable angina, myocardial infarction, acute heart failure, stroke, and cardiovascular death. The interaction between intensive blood pressure lowering and both T2DM and 10-year cardiovascular risk was assessed using Cox proportional hazards models.

RESULTS

The cohort consisted of 14,094 patients with mean age 66 ± 8.9 years and mean baseline SBP 139.5 ± 15.6 mmHg; 33.6% had T2DM. The hazard ratio for the primary composite end point was 0.82 (95% CI 0.73-0.93), P = 0.0017. The interaction between intensive blood pressure lowering and T2DM was nonsignificant (P = 0.13). The 10-year cardiovascular risk was higher in primary prevention patients with T2DM, but risk did not interact with the treatment effect (P = 0.84).

CONCLUSIONS

Intensive blood pressure lowering may have a similar favorable effect and appears to decrease cardiovascular events in both patients with and patients without T2DM.