Lifestyle Factors and Antihypertensive Treatment on the Risks of Ischemic and Hemorrhagic Stroke

Healthy lifestyle, statin, and mortality in people with high CVD risk: A nationwide population-based cohort study

Objective

To examine the joint association of healthy lifestyles and statin use with all-cause and cardiovascular mortality in high-risk individuals, and evaluate the survival benefits by life expectancy.

Methods

During 2015-2021, participants aged 35-75 years were recruited by the China Health Evaluation And risk Reduction through nationwide Teamwork. Based on number of healthy lifestyles related to smoking, alcohol drinking, physical activity, and diet, we categorized them into: very healthy (3-4), healthy (2), and unhealthy (0-1). Statin use was determined by self-report taking statin in last two weeks.

Results

Among the 265,209 included participants at high risk, 6979 deaths were observed, including 3236 CVD deaths during a median 3.6 years of follow-up. Individuals taking statin and with a very healthy lifestyle had the lowest risk of all-cause (HR: 0.70; 95 %CI: 0.57-0.87) and cardiovascular mortality (0.56; 0.40-0.79), compared with statin non-users with an unhealthy lifestyle. High-risk participants taking statin and with a very healthy lifestyle had the highest years of life gained (5.90 years at 35-year-old [4.14-7.67; P < 0.001]) compared with statin non-users with an unhealthy lifestyle among high-risk people. And their life expectancy was comparable with those without high risk but with a very healthy lifestyle (4.49 vs. 4.68 years).

Conclusion

The combination of preventive medication and multiple healthy lifestyles was associated with lower risk of all-cause and cardiovascular mortality and largest survival benefits. Integrated strategy to improve long-term health for high-risk people was urgently needed.

Association of Lifestyle Factors and Antihypertensive Medication Use With Risk of All-Cause and Cause-Specific Mortality Among Adults With Hypertension in China

IMPORTANCE

The joint association of antihypertensive medication use and healthy lifestyle with mortality among individuals with hypertension is unclear.

OBJECTIVE

To examine the association of lifestyle factors combined with antihypertensive medication use, as well as changes in lifestyle, with all-cause and cause-specific mortality among individuals with hypertension.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Dongfeng-Tongji cohort, a long-term, prospective cohort including employees at a manufacturer in China, with baseline from 2008 to 2010. Participants with hypertension were followed up for a median (IQR) of 7.3 (5.7-10.3) years, ending in 2018. Data were analyzed from February to April 2021.

EXPOSURES

Lifestyle factors, including body mass index, smoking status, diet, physical activity, and sleep duration, were coded on a 3-point scale (range, 0-2, with higher score indicating a healthier lifestyle). Lifestyle was evaluated according to the total score of all 5 factors, and categorized into 3 groups: unfavorable (scores 0-4), intermediate (scores 5-7), and favorable (scores 8-10). Antihypertensive medication use was defined as use within the last 2 weeks.

MAIN OUTCOMES AND MEASURES

All-cause, cardiovascular, and cancer mortality were identified by linking the cohort database with the health care system through December 31, 2018.

RESULTS

A total of 14 392 participants (mean [SD] age, 65.6 [7.4] years; 7277 [50.6%] men and 7115 [49.4%] women) with hypertension were included, and 2015 deaths were documented, including 761 cardiovascular deaths and 525 cancer deaths. Compared with individuals not using antihypertensive medication and with a lifestyle score of 0 to 4, the combination of using antihypertensive medication and having a lifestyle score of 8 to 10 was associated with the lowest risk of all-cause mortality (hazard ratio [HR], 0.32; 95% CI, 0.25-0.42), cardiovascular mortality (HR, 0.33; 95% CI, 0.21-0.53), and cancer mortality (HR, 0.30; 95% CI, 0.19-0.47). In addition, improvement in lifestyle score after hypertension diagnosis was associated with lower risk of all-cause mortality (HR, 0.52; 95% CI, 0.36-0.76) and cardiovascular mortality (HR, 0.53; 95% CI, 0.30-0.94).

CONCLUSIONS AND RELEVANCE

These findings suggest that adherence to healthy lifestyle and antihypertensive medication treatment were associated with lower risk of mortality among adults with hypertension. These findings further support that, in addition to antihypertensive medication use, adopting a healthy lifestyle is associated with benefits in the prevention of premature death among individuals with hypertension.

Hypothetical blood-pressure-lowering interventions and risk of stroke and dementia

We aimed to study the effects of hypothetical interventions on systolic blood pressure (SBP) and smoking on risk of stroke and dementia using data from 15 years of follow-up in the Rotterdam Study. We used data from 4930 individuals, aged 55-80 years, with no prior history of stroke, dementia or cognitive impairment, followed for 15 years within the Rotterdam Study, a population-based cohort. We defined the following sustained interventions on SBP: (1) maintaining SBP below 120 mmHg, (2) maintaining SBP below 140 mmHg, (3) reducing SBP by 10% if above 140 mmHg, (4) reducing SBP by 20% if above 140 mmHg, and a combined intervention of quitting smoking with each of these SBP-lowering strategies. We considered incident stroke and incident dementia diagnoses as outcomes. We applied the parametric g-formula to adjust for baseline and time-varying confounding. The observed 15-year risk for stroke was 10.7%. Compared to no specified intervention (i.e., the "natural course"), all interventions that involved reducing SBP were associated with a stroke risk reduction of about 10% (e.g., reducing SBP by 20% if above 140 mmHg risk ratio: 0.89; 95% CI 0.76, 1). Jointly intervening on SBP and smoking status further decreased the risk of stroke (e.g., risk ratio: 0.83; 95% CI 0.71, 0.94). None of the specified interventions were associated with a substantive change in dementia risk. Our study suggests that a joint intervention on SBP and smoking cessation during later life may reduce stroke risk, while the potential for reducing dementia risk were not observed.

Lifestyle Changes in Relation to Initiation of Antihypertensive and Lipid-Lowering Medication: A Cohort Study

Background Lifestyle modification is a key component of cardiovascular disease prevention before and concurrently with pharmacologic interventions. We evaluated whether lifestyle factors change in relation to the initiation of antihypertensive or lipid-lowering medication (statins). Methods and Results The study population comprised 41 225 participants of the FPS (Finnish Public Sector) study aged ≥40 years who were free of cardiovascular disease at baseline and responded to ≥2 consecutive surveys administered in 4-year intervals in 2000-2013. Medication use was ascertained through pharmacy-claims data. Using a series of pre-post data sets, we compared changes in body mass index, physical activity, alcohol consumption, and smoking between 8837 initiators and 46 021 noninitiators of antihypertensive medications or statins. In participants who initiated medication use, body mass index increased more (difference in change 0.19; 95% CI, 0.16-0.22) and physical activity declined (-0.09 metabolic equivalent of task hour/day; 95% CI, -0.16 to -0.02) compared with noninitiators. The likelihood of becoming obese (odds ratio: 1.82; 95% CI, 1.63-2.03) and physically inactive (odds ratio: 1.08; 95% CI, 1.01-1.17) was higher in initiators. However, medication initiation was associated with greater decline in average alcohol consumption (-1.85 g/week; 95% CI, -3.67 to -0.14) and higher odds of quitting smoking (odds ratio for current smoking in the second survey: 0.74; 95% CI, 0.64-0.85). Conclusions These findings suggest that initiation of antihypertensive and statin medication is associated with lifestyle changes, some favorable and others unfavorable. Weight management and physical activity should be encouraged in individuals prescribed these medications.

Red and Processed Meat Consumption and Risk for All-Cause Mortality and Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Cohort Studies

This article has been corrected. The original version (PDF) is appended to this article as a Supplement.

BACKGROUND

Dietary guidelines generally recommend limiting intake of red and processed meat. However, the quality of evidence implicating red and processed meat in adverse health outcomes remains unclear.

PURPOSE

To evaluate the association between red and processed meat consumption and all-cause mortality, cardiometabolic outcomes, quality of life, and satisfaction with diet among adults.

DATA SOURCES

EMBASE (Elsevier), Cochrane Central Register of Controlled Trials (Wiley), Web of Science (Clarivate Analytics), CINAHL (EBSCO), and ProQuest from inception until July 2018 and MEDLINE from inception until April 2019, without language restrictions, as well as bibliographies of relevant articles.

STUDY SELECTION

Cohort studies with at least 1000 participants that reported an association between unprocessed red or processed meat intake and outcomes of interest.

DATA EXTRACTION

Teams of 2 reviewers independently extracted data and assessed risk of bias. One investigator assessed certainty of evidence, and the senior investigator confirmed the assessments.

DATA SYNTHESIS

Of 61 articles reporting on 55 cohorts with more than 4 million participants, none addressed quality of life or satisfaction with diet. Low-certainty evidence was found that a reduction in unprocessed red meat intake of 3 servings per week is associated with a very small reduction in risk for cardiovascular mortality, stroke, myocardial infarction (MI), and type 2 diabetes. Likewise, low-certainty evidence was found that a reduction in processed meat intake of 3 servings per week is associated with a very small decrease in risk for all-cause mortality, cardiovascular mortality, stroke, MI, and type 2 diabetes.

LIMITATION

Inadequate adjustment for known confounders, residual confounding due to observational design, and recall bias associated with dietary measurement.

CONCLUSION

The magnitude of association between red and processed meat consumption and all-cause mortality and adverse cardiometabolic outcomes is very small, and the evidence is of low certainty.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42017074074).

Effects of Lipid-Lowering and Antihypertensive Treatments in Addition to Healthy Lifestyles in Primary Prevention: An Analysis of the HOPE-3 Trial

Background

It is not clear whether the effects of lipid‐lowering or antihypertensive medications are influenced by adherence to healthy lifestyle factors. We assessed the effects of both drug interventions in subgroups by the number of healthy lifestyle factors in participants in the HOPE‐3 (Heart Outcomes Prevention Evaluation) trial.

Methods and Results

In this primary prevention trial, 4 healthy lifestyle factors (nonsmoking status, physical activity, optimal body weight, and healthy diet) were recorded in 12 521 participants who were at intermediate risk of cardiovascular disease (CVD) and were randomized to rosuvastatin, candesartan/hydrochlorothiazide, their combination, or matched placebos. Median follow‐up was 5.6 years. The outcome was a composite of CVD events. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression models. Participants with ≥2 healthy lifestyle factors had a lower rate of CVD compared with those with fewer factors (HR: 0.85; 95% CI, 0.73–1.00). Rosuvastatin reduced CVD events in participants with ≥2 healthy lifestyle factors (HR: 0.74; 95% CI, 0.62–0.90) and in participants with <2 factors (HR: 0.79; 95% CI, 0.61–1.01). Consistent results were observed with combination therapy (≥2 factors: HR: 0.74; 95% CI, 0.57–0.97; <2 factors: HR: 0.61; 95% CI, 0.43–0.88). Candesartan/hydrochlorothiazide tends to reduce CVD only in participants with <2 healthy lifestyle factors (HR: 0.78; 95% CI, 0.61–1.00).

Conclusions

Healthy lifestyles are associated with lower CVD. Rosuvastatin alone and combined with candesartan/hydrochlorothiazide is beneficial regardless of healthy lifestyle status; however, the benefit of antihypertensive treatment appears to be limited to patients with less healthy lifestyles.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00239681.

Reduced Kidney Function Is Associated With Cardiometabolic Risk Factors, Prevalent and Predicted Risk of Cardiovascular Disease in Chinese Adults: Results From the REACTION Study

Background

Chronic kidney disease (CKD) increases cardiovascular disease (CVD) risk. However, the association of mildly reduced kidney function with CVD risk is unclear.

Methods and Results

This study investigated the association of estimated glomerular filtration rate (eGFR) with prevalent CVDs, 10‐year Framingham risk for coronary heart disease (CHD), and 10‐year risk of atherosclerotic cardiovascular diseases (ASCVD) in 239 832 participants from the baseline of the Risk Evaluation of cAncers in Chinese diabeTic Individuals: a lONgitudinal study. With an interviewer‐assisted questionnaire, we collected information on CVD, including reported CHD, stroke, or myocardial infarction. Chronic Kidney Disease–Epidemiology Collaboration (CKD‐EPI) equation was used to calculate eGFR. Compared with individuals with normal eGFR (≥90 mL/min per 1.73 m²), those with decreased eGFR (75–89, 60–74, and <60 mL/min per 1.73 m²) had higher risk of prevalent obesity, diabetes mellitus, hypertension, and dyslipidemia in both men and women (P for trend all <0.001). Moreover, a significantly higher 10‐year Framingham risk for CHD and 10‐year risk for ASCVD was observed in both men and women with mildly decreased eGFR (60–89 mL/min per 1.73 m²).

Conclusions

Even mildly reduced eGFR (under 90 mL/min per 1.73 m²) is associated with elevated 10‐year Framingham risk for CHD and 10‐year ASCVD risk among Chinese adults.

Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Kidney function and the risk of cardiovascular disease in patients with type 2 diabetes

The association of estimated glomerular filtration rate (GFR) with cardiovascular disease risk among patients with type 2 diabetes is unclear. Here we prospectively investigated the race-specific association of estimated GFR with the risk of coronary heart disease and stroke among 11,940 Caucasian and 16,451 African-American patients. During mean follow-up of 6.1-6.8 years, 6647 coronary heart disease and 2750 stroke incident cases were identified. Age- and sex-adjusted hazard ratios of coronary heart disease associated with baseline estimated GFR (90 or more, 75-89, 60-74, 30-59, and 15-29 ml/min per 1.73 m2) were 1.00, 1.04, 1.13, 1.37, and 2.07 (significant trend) for African Americans, and 1.00, 1.09, 1.10, 1.31, and 2.18 (significant trend) for Caucasians, respectively. A significantly increased stroke risk was observed among both African-American and Caucasian participants with an estimated GFR under 60 ml/min per 1.73 m2. When using the updated mean values of estimated GFR, these significant associations became stronger. Participants with mildly decreased estimated GFR (60-89 ml/min per 1.73 m2) during follow-up were also at a significantly higher risk of coronary heart disease and stroke. Thus, even mildly reduced estimated GFR at baseline (under 75 ml/min per 1.73 m2) and during follow-up (under 90 ml/min per 1.73 m2) increased the risk of incident coronary heart disease and stroke among both African-American and Caucasian type 2 diabetes patients.

Considerations in women with hypertension

Cardiovascular disease is the most common cause of death in women in the United States, and hypertension is a major contributor to cardiovascular mortality. The incidence of hypertension in women is steadily increasing, paralleling the epidemics of obesity and diabetes. Blood pressure control rates among women are suboptimal, even when secondary causes are identified and treated. There are few high-quality data describing specific hypertension-related outcomes in women. Some data comparing hypertensive women to age-matched men suggest advantages to sex-specific strategies, but further study is needed to determine optimal regimens for women throughout their lives. Pregnancy and menopause present unique, complex challenges in hypertension management.