Aggressive Blood Pressure Lowering Is Dangerous: The J-Curve

Low on-treatment blood pressure and cardiovascular events in patients without elevated risk: a nationwide cohort study

Insufficient blood pressure control among patients with hypertension without elevated risk is a global concern, suggesting the need for treatment optimization. However, the potential harm of excessive blood pressure lowering among these patients is understudied. This study addressed this evidence gap by using nationally representative public health insurer database covering 30 million working-age population. Patients who were continuously using antihypertensive drugs with 10-year cardiovascular risk <10% were identified. They were categorized by on-treatment systolic and diastolic blood pressures. The primary outcome was a composite of myocardial infarction, stroke, heart failure hospitalization, and peripheral artery disease. Of 920,533 participants (mean age, 57.3 years; female, 48.3%; mean follow-up, 2.75 years), the adjusted hazard ratios for systolic blood pressure of <110, 110-119, 120-129 (reference), 130-139, 140-149, 150-159, and ≥160 mmHg were 1.05 (95% confidence interval: 0.99-1.12), 0.97 (0.93-1.02), 1 (reference), 1.05 (1.01-1.09), 1.15 (1.11-1.20), 1.30 (1.23-1.37), and 1.76 (1.66-1.86), respectively; and for diastolic blood pressure of <60, 60-69, 70-79 (reference), 80-89, 90-99, and ≥100 mmHg were 1.25 (1.14-1.38), 0.99 (0.95-1.04), 1 (reference), 1.00 (0.96-1.03), 1.13 (1.09-1.18), and 1.66 (1.58-1.76), respectively. Among low-risk patients with hypertension, diastolic blood pressure <60 mmHg was associated with increased cardiovascular events, while systolic blood pressure <110 mmHg was not. Compared to previous investigations in high-risk patients, the potential harm of excessive blood pressure lowering was less pronounced in low-risk patients with hypertension. The association between low on-treatment blood pressure and cardiovascular events has been understudied in low-risk patients with hypertension. In our study with nationally representative working-age adults from general population with hypertension without elevated risk, increased risk of cardiovascular events was observed in diastolic blood pressure of <60 mmHg, but not in systolic blood pressure of <110 mmHg. Those results contrasted with previous investigations in high-risk patients where the risk of low on-treatment blood pressure was more pronounced.

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.

mRNA Metabolism and Hypertension

Hypertension is the most frequent cardiovascular risk factor all over the world. It remains a leading contributor to the risk of cardiovascular events and death. In the year 2015, about 1.5 billion of adult people worldwide had hypertension (as defined by office systolic blood pressure ≥ 140 mmHg or office diastolic blood pressure ≥ 90 mmHg). Moreover, the number of hypertensive patients with age ranging from 30 to 79 years doubled in the last 30 years (from 317 million men and 331 million women in the year 1990 to 652 million men and 626 million women in 2019) despite stable age-standardized prevalence worldwide. Despite such impressive growth, the proportion of controlled hypertension is very low. A better understanding of the pathogenesis of hypertension may contribute to the development of innovative therapeutic strategies. In this context, alterations of the messenger RNA metabolism have been recently evaluated as contributors to the pathogenesis of hypertension, and pharmacological modulation of RNA metabolism is under investigation as potential and novel therapeutic armamentarium in hypertension.

Are U-shaped relationships between risk factors and outcomes artifactual?

BACKGROUND

The objective of this study was to evaluate whether the observed nadir in a U- or J-shaped relationship between a particular risk factor and a future health outcome is a function of the distribution of the risk factor in the sample being analyzed.

METHODS

Data from the ORIGIN trial were used to assess the relationship between three risk factors (weight, systolic blood pressure, and serum insulin) and the hazard of a major cardiovascular event comprising a nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. Three spline curves were generated for each risk factor. The first was based on all available data, the second for a subgroup with a higher mean risk factor level, and the third for a subgroup with a lower mean risk factor level. Nadir levels of the risk factor (i.e., risk factor levels predicting the lowest hazard) were then identified for each spline curve.

RESULTS

When compared to the nadir values based on all available data, nadir values for all three risk factors were higher for the subgroups with higher mean levels and lower for those with lower mean levels.

CONCLUSIONS

The distribution of a risk factor in the population is an important determinant of its nadir value. Populations with high or low values may have high and low nadirs, respectively. Identification of a nadir for a modifiable risk factor from epidemiologic relationships may therefore arise from this distribution bias and is therefore unrelated to therapeutic targets.

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.

Advances in the Treatment Strategies in Hypertension: Present and Future

Hypertension is the most frequent chronic and non-communicable disease all over the world, with about 1.5 billion affected individuals worldwide. Its impact is currently growing, particularly in low-income countries. Even in high-income countries, hypertension remains largely underdiagnosed and undertreated, with consequent low rates of blood pressure (BP) control. Notwithstanding the large number of clinical observational studies and randomized trials over the past four decades, it is sad to note that in the last few years there has been an impressive paucity of innovative studies. Research focused on BP mechanisms and novel antihypertensive drugs is slowing dramatically. The present review discusses some advances in the management of hypertensive patients, and could play a clinical role in the years to come. First, digital/health technology is expected to be increasingly used, although some crucial points remain (development of non-intrusive and clinically validated devices for ambulatory BP measurement, robust storing systems enabling rapid analysis of accrued data, physician-patient interactions, etc.). Second, several areas should be better outlined with regard to BP diagnosis and treatment targets. Third, from a therapeutic standpoint, existing antihypertensive drugs, which are generally effective and well tolerated, should be better used by exploiting available and novel free and fixed combinations. In particular, spironolactone and other mineral-corticoid receptor antagonists should be used more frequently to improve BP control. In particular, some drugs initially developed for conditions different from hypertension including heart failure and diabetes have demonstrated to lower BP significantly and should therefore be considered. Finally, renal artery denervation is another procedure that has proven effective in the management of hypertension.

Associations Between Achieved Ambulatory Blood Pressures and Its Changes With Adverse Outcomes in Resistant Hypertension: Was There a J-Curve for Ambulatory Blood Pressures?

[Figure: see text].

Association of visit-to-visit variability of systolic blood pressure with cardiovascular disease, chronic kidney disease and mortality in patients with hypertension

OBJECTIVE

This study aimed to evaluate the association between visit-to-visit variability of systolic blood pressure (SBP) and cardiovascular disease, chronic kidney disease, and mortality among hypertensive patients.

METHODS

A population-based cohort included 225 759 Chinese hypertensive adults without diabetes, cardiovascular disease, and chronic kidney disease during 2011-2012. SBP variability was determined based on standard deviations of SBP over the previous 5 years before baseline. Cox regressions adjusted with patients' baseline characteristics, mean, and temporal trend of SBP was applied to the associations between variability and incident cardiovascular disease, chronic kidney disease and all-cause mortality.

RESULTS

In all, 25 714 patients with cardiovascular disease, 27 603 with chronic kidney disease, and 16 778 deaths have occurred during the median follow-up of 70.5 months (1.2 million person-years). SBP variability was continuously and positively associated with higher cardiovascular disease, chronic kidney disease and mortality risk among hypertensive patients without evidence of a threshold. Each 10-mmHg increase in SD of SBP was associated with 35% [hazard ratio 1.35, 95% confidence interval (CI) 1.30-1.39], 39% (HR 1.39, 95% CI 1.35-1.43), and 40% (HR 1.40, 95% CI 1.34-1.45) higher risk of cardiovascular disease, chronic kidney disease and mortality, respectively. HRs were attenuated with increased age, mean SBP, and Charlson index, and decreased temporal trend of systolic blood pressure, but it remained significant and consistent in most of the different subgroups.

CONCLUSIONS

Findings suggested that SBP variability is a significant prognostic value, in addition to baseline or mean of SBP for the risk of cardiovascular disease and mortality.

Association of Mid- to Late-Life Blood Pressure Patterns With Risk of Subsequent Coronary Heart Disease and Death

Background: The elevated blood pressure (BP) at midlife or late-life is associated with cardiovascular disease and death. However, there is limited research on the association between the BP patterns from middle to old age and incident coronary heart disease (CHD) and death. Methods: A cohort of the Atherosclerosis Risk in Communities (ARIC) Study enrolled 9,829 participants who attended five in-person visits from 1987 to 2013. We determined the association of mid- to late-life BP patterns with incident CHD and all-cause mortality using multivariable-adjusted Cox proportional hazards models. Results: During a median of 16.7 years of follow-up, 3,134 deaths and 1,060 CHD events occurred. Compared with participants with midlife normotension, the adjusted hazard ratio for all-cause mortality and CHD was 1.14 (95% CI, 1.04-1.25) and 1.28 (95% CI, 1.10-1.50) in those with midlife hypertension, respectively. In further analyses, compared with a pattern of sustained normotension from mid- to late-life, there was no significant difference for the risk of incident death (HR, 1.15; 95% CI, 0.96-1.37) and CHD (HR, 1.33; 95% CI, 0.99-1.80) in participants with a pattern of midlife normotension and late-life hypertension with effective BP control. A higher risks of death and CHD were found in those with pattern of mid- to late-life hypertension with effective BP control (all-cause mortality: HR, 1.24; 95% CI, 1.08-1.43; CHD: HR, 1.65; 95% CI 1.30-2.09), pattern of midlife normotension and late-life hypertension with poor BP control (all-cause mortality: HR, 1.27; 95% CI, 1.12-1.44; CHD: HR, 1.53; 95% CI, 1.23-1.92), and pattern of mid- to late-life hypertension with poor BP control (all-cause mortality: HR, 1.49; 95% CI, 1.30-1.71; CHD: HR, 1.87; 95% CI, 1.48-2.37). Conclusions: The current findings underscore that the management of elderly hypertensive patients should not merely focus on the current BP status, but the middle-aged BP status. To achieve optimal reductions in the risk of CHD and death, it may be necessary to prevent, diagnose, and manage of hypertension throughout middle age.

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.

Treatment strategies for isolated systolic hypertension in elderly patients

INTRODUCTION

Hypertension is a major and modifiable risk factor for cardiovascular disease. Its prevalence is rising as the result of population aging. Isolated systolic hypertension mostly occurs in older patients accounting for up to 80% of cases.

AREAS COVERED

The authors systematically review published studies to appraise the scientific and clinical evidence supporting the role of blood pressure control in elderly patients with isolated systolic hypertension, and to assess the influence of different drug treatment regimens on outcomes.

EXPERT OPINION

Antihypertensive treatment of isolated systolic hypertension significantly reduces the risk of morbidity and mortality in elderly patients. Thiazide diuretics and dihydropyridine calcium-channel blockers are the primary compounds used in randomized clinical trials. These drugs can be considered as first-line agents for the management of isolated systolic hypertension. Free or fixed combination therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and calcium-channel blockers or thiazide-like diuretics should also be considered, particularly when compelling indications such as coronary artery disease, chronic kidney disease, diabetes, and congestive heart failure coexist. There is also hot scientific debate on the optimal blood pressure target to be achieved in elderly patients with isolated systolic hypertension, but current recommendations are scarcely supported by evidence.

Management of hypertension in the very old: an intensive reduction of blood pressure should be achieved in most patients

There is large evidence that treatment of hypertension significantly reduces the risk of morbidity and mortality in the elderly. Although it is generally accepted that the benefit of antihypertensive treatment is largely explained by the reduction in systolic blood pressure, the optimal blood pressure target in elderly patients is still a topic of debate. Unfortunately, the clinical trials which demonstrated the benefit of antihypertensive treatment in old and very old patients with hypertension included relatively fit patients since frail patients were generally excluded. Available data suggest that when treating older adults, and especially frail older hypertensive adults, extra caution is appropriate in the setting of significant adverse events. Nonetheless, recent observations demonstrated a similar benefit from a more intensive compared with a less intensive blood pressure lowering in both fit and frail older adults. Of note, the rate of serious adverse events appears not dissimilar in the two treatment strategies, and not associated to frailty. Taken together, these findings support the concept that an intensive therapeutic strategy appears reasonable even in elderly hypertensive patients, particularly when the treatment is well tolerated.

Systolic blood pressure trajectory and cardiovascular outcomes: An analysis using data in the Systolic Blood Pressure Intervention Trial

BACKGROUND

Blood pressure changes in response to medication intensification differ over time across individuals, and could affect their cardiovascular outcomes. We aimed to investigate the relationship between systolic blood pressure (SBP) trajectory and cardiovascular outcomes using data from the Systolic Blood Pressure Intervention Trial (SPRINT).

METHODS

Groups of SBP trajectory were modelled separately in the standard and intensive treatment groups. SBP at each site visit post randomisation were used for modelling by group-based trajectory with latent class growth model. We classified six SBP trajectories (on target [reference group], near target, and off target in the intensive treatment group; on target-below 130, on target-below 140, and off target in the standard treatment group). A Cox-proportional hazard model was used to analyse the effects of SBP trajectory on the primary composite outcome, death from any cause, and the composite of the primary outcome or death from any cause.

RESULTS

The respective mean SBP was 119 ± 5, 128 ± 6, 141 ± 8, 124 ± 4, 136 ± 4, and 147 ± 6 mm Hg. With respect to the primary composite outcomes, the standard-on target (below 130) had the highest risk (adjusted hazard ratio [lower to upper confidence interval], 2.525 [1.865-3.420]), despite its mean SBP was the second lowest of the six groups. The standard-on target (below 140) had a higher risk (1.323 [1.056-1.657]) when compared with the intensive-on target. However, the standard-on target (below 140) had a similar risk (1.12 [0.861-1.458]) when compared with the intensive-near target, despite an 8 mm Hg difference in mean SBP (136 vs 128 mm Hg, P < .001).

CONCLUSION

An SBP treatment target of <120 mm Hg was only associated with a better cardiovascular outcome compared with a treatment target of <140 mm Hg, provided that the target of <120 mm Hg was reached.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01206062. Registered 21 September 2010.

Influence of Age on Upper Arm Cuff Blood Pressure Measurement

Blood pressure (BP) is a leading global risk factor. Increasing age is related to changes in cardiovascular physiology that could influence cuff BP measurement, but this has never been examined systematically and was the aim of this study. Cuff BP was compared with invasive aortic BP across decades of age (from 40 to 89 years) using individual-level data from 31 studies (1674 patients undergoing coronary angiography) and 22 different cuff BP devices (19 oscillometric, 1 automated auscultation, 2 mercury sphygmomanometry) from the Invasive Blood Pressure Consortium. Subjects were aged 64±11 years, and 32% female. Cuff systolic BP overestimated invasive aortic systolic BP in those aged 40 to 49 years, but with each older decade of age, there was a progressive shift toward increasing underestimation of aortic systolic BP (P<0.0001). Conversely, cuff diastolic BP overestimated invasive aortic diastolic BP, and this progressively increased with increasing age (P<0.0001). Thus, there was a progressive increase in cuff pulse pressure underestimation of invasive aortic PP with increasing decades of age (P<0.0001). These age-related trends were observed across all categories of BP control. We conclude that cuff BP as an estimate of aortic BP was substantially influenced by increasing age, thus potentially exposing older people to greater chance for misdiagnosis of the true risk related to BP.

Blood pressure, heart rate, and mortality in chronic obstructive pulmonary disease: the SUMMIT trial

Aims

To characterize the relationship between blood pressure (BP) or heart rate and mortality and morbidity in chronic obstructive pulmonary disease (COPD).

Methods and results

We performed post hoc analysis of baseline BP or heart rate and all-cause mortality and cardiovascular events in the SUMMIT trial. SUMMIT was a randomized double-blind outcome trial of 16 485 participants (65 ± 8 years, 75% male, and 47% active smokers) enrolled at 1368 sites in 43 countries. Participants with moderate COPD with or at risk for cardiovascular disease (CVD) were randomized to placebo, long-acting beta agonist, inhaled corticosteroid, or their combination. All-cause mortality increased in relation to high systolic [≥140 mmHg; hazard ratio (HR) 1.27, 95% confidence interval (CI) 1.12-1.45] or diastolic (≥90 mmHg; HR 1.35, 95% CI 1.14-1.59) BP and low systolic (<120 mmHg; HR 1.36, 95% CI 1.13-1.63) or diastolic (<80 mmHg; HR 1.15, 95% CI 1.00-1.32) BP. Higher heart rates (≥80 per minute; HR 1.39, 95% CI 1.21-1.60) and pulse pressures (≥80 mmHg; HR 1.39, 95% CI 1.07-1.80) were more linearly related to increases in all-cause mortality. The risks of cardiovascular events followed similar patterns to all-cause mortality. Similar findings were observed in subgroups of patients without established CVD.

Conclusion

A 'U-shaped' relationship between BP and all-cause mortality and cardiovascular events exists in patients with COPD and heightened cardiovascular risk. A linear relationship exists between heart rate and all-cause mortality and cardiovascular events in this population. These findings extend the prognostic importance of BP to this growing group of patients and raise concerns that both high and low BP may pose health risks.

Blood pressure level associated with lowest cardiovascular event in hypertensive diabetic patients

BACKGROUND

The ACCORD BP trial failed to show the benefit of strict blood pressure (BP) control on cardiovascular events in diabetics with high cardiovascular risk. However, this result cannot be generalized to all diabetics. We investigated whether lower mean BP in diabetic people with hypertension is associated with better prognosis.

METHODS

Participants from the Korea National Health Insurance Service Health Examinee Cohort who were diagnosed with diabetes and hypertension between 2003 and 2006 were included in the analysis (N = 7926). Mortality and cardiovascular events were compared among three groups according to mean SBP (<130, 130-<140, ≥140 mmHg) and mean DBP (<80, 80-<90, ≥ 90 mmHg) recorded during follow-up health examinations for up to 11 years.

RESULTS

Significant reductions in the risk of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, and end-stage renal disease were observed in patients with a mean SBP of 130 mmHg to less than 140 mmHg, as compared with patients with a mean SBP of at least 140 mmHg. The additional clinical benefit of a mean SBP of less than 130 mmHg was unclear. Lower risk of all-cause death, cardiovascular mortality, and nonfatal strokes was observed in patients with a mean DBP of 80 mmHg to less than 90 mmHg. A mean DBP of less than 80 mmHg was associated with further reduction in all-cause mortality, cardiovascular mortality, ischaemic stroke, and total stroke.

CONCLUSION

A mean BP of less than 140/80 mmHg was associated with further reduction in the risk of all-cause mortality, cardiovascular mortality, and nonfatal cardiovascular events in diabetic hypertensive patients.

Association of Blood Pressure and Risk of Cardiovascular and Chronic Kidney Disease in Hong Kong Hypertensive Patients

Supplemental Digital Content is available in the text.

The association between systolic blood pressure, cardiovascular disease, and chronic kidney disease remains unclear. This study aimed to evaluate these relationships. A population-based cohort of 267 469 adult patients with hypertension but without diabetes mellitus, cardiovascular disease, or chronic kidney disease were identified. Using baseline and repeated systolic blood pressure (average of all systolic blood pressure measurements in the past 5 years), the risks of cardiovascular disease and chronic kidney disease associated with systolic blood pressure were evaluated by Cox regression. Subgroup analyses were conducted by baseline characteristics. Over 1.4 million person-years follow-up (median 6 years), 29 500 cardiovascular disease and 30 993 chronic kidney disease events diagnosed. A J-shape association between baseline systolic blood pressure and risks of cardiovascular disease and chronic kidney disease was observed. Using repeated systolic blood pressure, a positive and log-linear association was identified. There was no evidence of a threshold down to the repeated systolic blood pressure of 120 mm Hg. Increases of 10 mm Hg of repeated systolic blood pressure was associated with a 16% (hazard ratio, 1.15; [95% CI, 1.13–1.16]), 11% (1.11; [1.08–1.13]), and 22% (1.22; [1.20–1.24]) higher risk of composite of cardiovascular disease and chronic kidney disease, individual cardiovascular disease and chronic kidney disease, respectively. Strength of the associations was similar across different subpopulations. This study showed that hypertensive patients with elevated repeated systolic blood pressure are at increased risk of cardiovascular disease or chronic kidney disease, irrespective of different characteristics. Very low single measurement of systolic blood pressure may be a potential indicator for poor health, but there seems to be no threshold for usual systolic blood pressure.

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.

Effect of Achieved Systolic Blood Pressure on Cardiovascular Outcomes in Patients With Type 2 Diabetes: A Population-Based Retrospective Cohort Study

OBJECTIVE

The objective of this study was to compare the incidence of cardiovascular disease (CVD) among patients with type 2 diabetes mellitus (T2DM) with treated hypertension who achieved systolic blood pressures (SBPs) of <120, <130, and <140 mmHg after an increase in their antihypertensive regimen.

RESEARCH DESIGN AND METHODS

A retrospective cohort study was conducted on 28,014 primary care adult patients with T2DM with no prior diagnosis of CVD and who achieved SBP readings <140 mmHg after an increase in the number of antihypertensive medications prescribed. Using an extension of propensity score matching, a total of 2,079, 10,851, and 15,084 matched patients with achieved SBP measurements of <120, <130, and <140 mmHg were identified. The association between achieved SBP and incident CVD were evaluated using Cox regressions. Subgroup analyses were conducted by stratifying patients' baseline characteristics.

RESULTS

Over a median follow-up period of 4.8 years, the incidence of CVD in patients with achieved SBP measures of <120, <130, and <140 mmHg were 318 (15.3%; incidence rate [IR] 34.3/1,000 person-years [PY]), 992 (9.1%; IR 20.4/1,000 PY), and 1,635 (10.8%; IR 21.4/1,000 PY). Achieved SBP <120 mmHg was associated with a higher risk of CVD compared with achieved SBP <130 mmHg (hazard ratio [HR] 1.75 [95% CI 1.53, 2.00]) and achieved SBP <140 mmHg (HR 1.67 [95% CI 1.46, 1.90]). There was a significant reduction in CVD risk in patients <65 years (HR 0.81 [95% CI 0.69, 0.96]) but no difference for other patients, including patients ≥65 years, who achieved SBP <130 mmHg when compared with the group that achieved SBP <140 mmHg.

CONCLUSIONS

Our findings support a SBP treatment target of 140 mmHg and suspect no risk reduction attenuation on CVD for lower SBP targets (<120 or <130 mmHg) for most patients with uncomplicated T2DM. A randomized control trial is still needed to confirm these findings.

Aggressive systolic blood pressure control in older subjects: benefits and risks

Systolic hypertension, especially isolated systolic hypertension (ISH) is very common in older subjects aged ≥ 65 years and is a major risk factor for cardiovascular disease (CVD), strokes, heart failure (HF) and chronic kidney disease (CKD). It is also, directly and linearly related with these complications irrespective of sex, or ethnicity, but it is worse with the advancement of age. Effective control of systolic blood pressure (SBP), is associated with significant reduction in the incidence of these complications. Currently, there is a debate about the optimal SBP control in view of the Systolic Blood Pressure Intervention Trial (SPRINT) showing beneficial cardiovascular (CV) effects of intensive SBP of < 120 mmHg in older patients. Also, the recently released blood pressure (BP) guidelines by the American College of Cardiology, the American Heart Association and the American Society of Hypertension (ACC/AHA/ASH) recommend a SBP reduction of < 130 mmHg. These SBP treatment recommendations are in contrast with the current (JNC VIII) committee of BP treatment guidelines, which recommend a SBP reduction < 150 mmHg for the same age of patients. All these different recommendations have created a debate regarding the optimal treatment targets for the systolic hypertension of the elderly patients. To gain more information a focused Medline search was conducted from 2010 to 2017 using the terms, systolic blood pressure, aggressive control, older subjects, treatment guidelines, and 37 pertinent papers were retrieved. The findings from these studies suggest a SBP reduction of < 140 mm Hg for persons aged ≥ 60 years, with an attempt for SBP reduction to ≤130 mm Hg in healthier subjects and hose with CVD, DM, and CKD. Care should be taken not to further reduce the SBP in older subjects if their DBP is ≤60 mmHg for the fear of J-curve effect.

Blood Pressure Parameters and their Associations with Death in Patients with Chronic Kidney Disease

PURPOSE OF REVIEW

Optimal blood pressure (BP) parameters among patients with chronic kidney disease (CKD) have been a matter of debate. This review critically evaluates recent literature to better define the associations of BP parameters and death among individuals with non-dialysis-dependent CKD.

RECENT FINDINGS

Observational studies report a "U- or J-shaped" association between BP and all-cause mortality in CKD and caution-intensive BP lowering in the elderly. Causes of death have been evaluated in a recent report noting higher cardiovascular and non-cardiovascular/non-malignant-related mortality among CKD population with SBP < 110 and > 150 mmHg. Very few randomized control trials evaluated the impact of different BP targets on patient-centered outcomes in those with CKD. Recently published SPRINT trial results suggest that intensive SBP control (<120 mm Hg) reduces cardiovascular events and all-cause death among non-diabetic patients with and without CKD. Clinical trial evidence supports lower BP target in those with mild to moderate non-diabetic CKD. However, clinical trials are warranted to further determine the beneficial effects of intensive blood pressure control in diabetic CKD population. In elderly population with CKD, BP targets might need to be individualized based on their comorbidities, life expectancy, and other factors.

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

BACKGROUND

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 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

The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to February 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also searched the Latin American and Caribbean Health Science Literature Database (from 1982) and contacted authors of relevant papers regarding further published and unpublished work. There were no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) with more than 50 participants per group and at least six months follow-up. Trial reports needed to present data for at least one primary outcome (total mortality, serious adverse events, total cardiovascular events, cardiovascular mortality). Eligible interventions were lower target for systolic/diastolic blood pressure (≤ 135/85 mmHg) compared with standard target for blood pressure (≤ 140 to 160/90 to 100 mmHg).Participants were adults with documented hypertension or who were receiving treatment for hypertension and 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 The Cochrane Collaboration.

MAIN RESULTS

We included six RCTs that involved a total of 9795 participants. Mean follow-up was 3.7 years (range 1.0 to 4.7 years). Five RCTs provided individual patient data for 6775 participants.We found no change in total mortality (RR 1.05, 95% CI 0.90 to 1.22) or cardiovascular mortality (RR 0.96, 95% CI 0.77 to 1.21; moderate-quality evidence). Similarly, no differences were found in serious adverse events (RR 1.02, 95% CI 0.95 to 1.11; low-quality evidence). There was a reduction in fatal and non fatal cardiovascular events (including myocardial infarction, stroke, sudden death, hospitalization or death from congestive heart failure) with the lower target (RR 0.87, 95% CI 0.78 to 0.98; ARR 1.6% over 3.7 years; low-quality evidence). There were 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 9.5/4.9 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

No evidence of a difference in total mortality and serious adverse events was found between treating to a lower or to a standard blood pressure target in people with hypertension and cardiovascular disease. This suggests no net health benefit from a lower systolic blood pressure target despite the small absolute reduction in total cardiovascular serious adverse events. There was very limited evidence on adverse events, which lead to high uncertainty. At present there is insufficient evidence to justify lower blood pressure targets (≤ 135/85 mmHg) in people with hypertension and established cardiovascular disease. More trials are needed to answer this question.

Blood pressure goal for the elderly Chinese: the findings from the Northern Shanghai Study

BACKGROUND

The Eighth Joint National Committee Panel (JNC8) recommended a novel blood pressure (BP) goal for individuals with hypertension, which was less stringent than the Seventh Joint National Committee (JNC7) guideline and is still under debate. In our study, we aimed at finding a better BP goal for the elderly Chinese.

METHODS

About 1599 community-based elderly participants were recruited in the northern Shanghai and were classified by chronic kidney disease or diabetes mellitus to investigate their BP control conditions based on both the JNC7 and JNC8. Then, participants were categorized into four groups: normotensive individuals (Group 1), individuals at BP goal by JNC7 (Group 2), individuals at BP goal by JNC8 but not by JNC7 (Group 3), and individuals not at-goal by both guidelines (Group 4). Patients' hypertensive target organ damages as left ventricular mass index (LVMI), peak transmitral pulsed Doppler velocity/early diastolic tissue Doppler velocity (E/Ea), pulse wave velocity (PWV), etc. were evaluated.

RESULTS

According to the JNC8, 19.0% of the population were reclassified as at-goal. Group 4 had significantly greater LVMI than Group 2 (96.5 vs 91.5 g/m², p < 0.05) and also had significantly greater E/Ea (10.3 vs 9.7 and 10.3 vs 9.7, p < 0.05) and PWV (10.3 vs 9.3 m/s and 10.3 vs 9.7 m/s, p < 0.05) than both Group 2 and Group 3; however, there were no significant differences of these variables between Group 2 and Group 3.

CONCLUSION

In the community-based elderly Chinese, the JNC8 hypertension guideline may set a better BP goal than the JNC7 in identifying patients' left ventricular diastolic dysfunction and arterial stiffening.

Decreased systolic blood pressure is associated with increased risk of all-cause mortality in patients with type 2 diabetes and renal impairment: A nationwide longitudinal observational study of 27,732 patients based on the Swedish National Diabetes Register

BACKGROUND

Previous studies have shown a U-shaped relationship between systolic blood pressure and risk of all-cause of mortality in patients with type 2 diabetes and renal impairment.

AIMS

To evaluate the associations between time-updated systolic blood pressure and time-updated change in systolic blood pressure during the follow-up period and risk of all-cause mortality in patients with type 2 diabetes and renal impairment.

PATIENTS AND METHODS

A total of 27,732 patients with type 2 diabetes and renal impairment in the Swedish National Diabetes Register were followed for 4.7 years. Time-dependent Cox models were used to estimate risk of all-cause mortality. Time-updated mean systolic blood pressure is the average of the baseline and the reported post-baseline systolic blood pressures.

RESULTS

A time-updated systolic blood pressure < 130 mmHg was associated with a higher risk of all-cause mortality in patients both with and without a history of chronic heart failure (hazard ratio: 1.25, 95% confidence interval: 1.13-1.40 and hazard ratio: 1.26, 1.17-1.36, respectively). A time-updated decrease in systolic blood pressure > 10 mmHg between the last two observations was associated with higher risk of all-cause mortality (-10 to -25 mmHg; hazard ratio: 1.24, 95% confidence interval: 1.17-1.32).

CONCLUSION

Both low systolic blood pressure and a decrease in systolic blood pressure during the follow-up are associated with a higher risk of all-cause mortality in patients with type 2 diabetes and renal impairment.

Low Blood Pressure Is Associated With Greater Risk for Cardiovascular Events in Treated Adults With and Without Apparent Treatment-Resistant Hypertension

Apparent treatment-resistant hypertension (aTRH) may confound the reported relationship between low blood pressure (BP) and increased cardiovascular disease (CVD) in treated hypertensive patients. Incident CVD was assessed in treated hypertensive patients with and without aTRH (BP ≥140 and/or ≥90 mm Hg on ≥3 medications or <140/<90 mm Hg on ≥4 BP medications) at three BP levels: 1: <120 and/or <70 mm Hg and <140/<90 mm Hg; 2: 120-139/70-89 mm Hg; and 3: ≥140 and/or ≥90 mm Hg. Electronic health data were matched to emergency and hospital claims for incident CVD in 118 356 treated hypertensive patients. In adults with and without aTRH, respectively, CVD was greater in level 1 versus level 2 (multivariable hazard ratio, 1.88 [95% confidence interval [CI], 1.70-2.07]; 1.71 [95% CI, 1.59-1.84]), intermediate in level 1 versus level 3 (hazard ratio, 1.32 [95% CI, 1.21-1.44]; 0.99, [95% CI, 0.92-1.07]), and lowest in level 2 versus level 3 (hazard ratio, 0.70 [95% CI, 0.65-0.76]; 0.58, [95% CI, 0.54-0.62]). Low treated BP was associated with more CVD than less stringent BP control irrespective of aTRH.

A practical approach to the pharmacological management of hypertension in older people

Hypertension is the leading cause of cardiovascular (CV) morbidity and mortality in adults over the age of 65. The first part of this paper is an overview, summarizing the current guidelines on the pharmacological management of hypertension in older adults in Europe and the USA, and evidence from key trials that contributed to the guidelines. In the second part of the paper, we will discuss the major challenges of managing hypertension in the context of multimorbidity, including frailty, orthostatic hypotension (OH), falls and cognitive impairment that are associated with ageing. A novel 'BEGIN' algorithm is proposed for use by prescribers prior to initiating antihypertensive therapy to guide safe medication use in older adults. Practical suggestions are highlighted to aid practitioners in making rational decisions to treat and monitor hypertension, and for considering withdrawal of antihypertensive drugs in the complex older person.

Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: an international cohort study

BACKGROUND

The optimum blood pressure target in hypertension remains debated, especially in coronary artery disease, given concerns for reduced myocardial perfusion if diastolic blood pressure is too low. We aimed to study the association between achieved blood pressure and cardiovascular outcomes in patients with coronary artery disease and hypertension.

METHODS

We analysed data from 22 672 patients with stable coronary artery disease enrolled (from Nov 26, 2009, to June 30, 2010) in the CLARIFY registry (including patients from 45 countries) and treated for hypertension. Systolic and diastolic blood pressures before each event were averaged and categorised into 10 mm Hg increments. The primary outcome was the composite of cardiovascular death, myocardial infarction, or stroke. Hazard ratios (HRs) were estimated with multivariable adjusted Cox proportional hazards models, using the 120-129 mm Hg systolic blood pressure and 70-79 mm Hg diastolic blood pressure subgroups as reference.

FINDINGS

After a median follow-up of 5·0 years, increased systolic blood pressure of 140 mm Hg or more and diastolic blood pressure of 80 mm Hg or more were each associated with increased risk of cardiovascular events. Systolic blood pressure of less than 120 mm Hg was also associated with increased risk for the primary outcome (adjusted HR 1·56, 95% CI 1·36-1·81). Likewise, diastolic blood pressure of less than 70 mm Hg was associated with an increase in the primary outcome (adjusted HR 1·41 [1·24-1·61] for diastolic blood pressure of 60-69 mm Hg and 2·01 [1·50-2·70] for diastolic blood pressure of less than 60 mm Hg).

INTERPRETATION

In patients with hypertension and coronary artery disease from routine clinical practice, systolic blood pressure of less than 120 mm Hg and diastolic blood pressure of less than 70 mm Hg were each associated with adverse cardiovascular outcomes, including mortality, supporting the existence of a J-curve phenomenon. This finding suggests that caution should be taken in the use of blood pressure-lowering treatment in patients with coronary artery disease.

FUNDING

Servier.

Benefits and risks of antihypertensive medications in the elderly

Hypertension is highly prevalent in older age and accounts for a large proportion of cardiovascular (CV) morbidity and mortality worldwide. Isolated systolic hypertension is more common in the elderly than younger adults and associated with poor outcomes such as cerebrovascular disease and acute coronary events. International guidelines are inconsistent in providing recommendations on optimal blood pressure targets in hypertensive elderly patients as a result of the limited evidence in this population. Evidence from clinical trials supports the use of antihypertensive drugs in hypertensive elderly patients due to benefits in reducing CV disease and mortality. However, elderly participants in these trials may not be typical of elderly patients seen in routine clinical practice, and the potential risks associated with use of antihypertensive drugs in the elderly are not as well studied as younger participants. Therefore, the purpose of this review was to provide a comprehensive summary of the benefits and risks of the use of antihypertensive drugs in elderly patients (aged ≥65 years), highlighting landmark clinical trials and observational studies. We will focus on specific outcomes relating to the benefits and risks of these medications in hypertensive elderly patients, such as CV disease, cognitive decline, dementia, orthostatic hypotension, falls, fractures, cancer and diabetes, in order to provide an update of the most relevant and current evidence to help inform clinical decision-making.

Does low diastolic blood pressure contribute to the risk of recurrent hypertensive cardiovascular disease events? The Framingham Heart Study

Whether low diastolic blood pressure (DBP) is a risk factor for recurrent cardiovascular disease (CVD) events in persons with isolated systolic hypertension is controversial. We studied 791 individuals (mean age 75 years, 47% female, mean follow-up time: 8±6 years) with DBP <70 (n=225) versus 70 to 89 mm Hg (n=566) after initial CVD events in the original and offspring cohorts of the Framingham Heart Study. Recurrent CVD events occurred in 153 (68%) participants with lower DBP and 271 (48%) with higher DBP (P<0.0001). Risk of recurrent CVD events in risk factor-adjusted Cox regression was higher in those with DBP <70 mm Hg versus DBP 70 to 89 mm Hg in both treated (hazard ratio, 5.1 [95% confidence interval: 3.8-6.9] P<0.0001) and untreated individuals (hazard ratio, 11.7 [95% confidence interval: 6.5-21.1] P<0.0001; treatment interaction: P=0.71). Individually, coronary heart disease, heart failure, and stroke recurrent events were more likely with DBP <70 mm Hg versus 70 to 89 mm Hg (P<0.0001). To examine for an effect of wide pulse pressure on excess risk associated with low DBP, we defined 4 binary groupings of pulse pressure (≥68 versus <68 mm Hg) and DBP (<70 versus 70-89 mm Hg). CVD incidence rates were higher only in the group with pulse pressure ≥68 and DBP <70 mm Hg (76% versus 46%-54%; P<0.001). Persons with isolated systolic hypertension and prior CVD events have increased risk for recurrent CVD events in the presence of DBP <70 mm Hg versus DBP 70 to 89 mm Hg, whether treated or untreated, supporting wide pulse pressure as an important risk modifier for the adverse effect of low DBP.

Systolic and diastolic blood pressure changes in relation with myocardial infarction and stroke in patients with coronary artery disease

Excessively high and low achieved blood pressure (BP) may be associated with a bad outcome in patients with coronary artery disease, the J curve phenomenon. The effect of BP changes from baseline in relation with the subsequent risk of stroke and myocardial infarction (MI) is unknown. Of the 25 620 patients randomized in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) study, we selected 19 102 patients with coronary artery disease at baseline. BP at entry was 141/82 mm Hg, and its average decrease during follow-up was 7/6 mm Hg. BP entered the analysis as time-varying variable modeled with restricted cubic splines. After adjustment for several potential determinants of reverse causality, a change in BP from baseline by -34/-21 mm Hg (10th percentile) was associated with a lesser risk of stroke without any significant increase in the risk of MI. A rise in systolic/diastolic BP from baseline by 20/10 mm Hg (90th percentile) was associated with an increased risk of stroke, whereas the risk of MI increased with systolic BP and not with diastolic BP. In conclusion, in patients with coronary artery disease and initially free from congestive heart failure, a BP reduction from baseline over the examined BP range had little effect on the risk of MI and predicted a lower risk of stroke. An increase in systolic BP from baseline increased the risk of stroke and MI. The relationships of BP with risk were much steeper for stroke than for MI. A treatment-induced BP reduction over the explored range seems to be safe in patients with coronary artery disease.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00153101.

Amino-terminal-pro-B-type natriuretic peptide levels and low diastolic blood pressure: potential relevance to the diastolic J-curve

BACKGROUND

There is debate whether the J-curve relationship between cardiac event risk and DBP is because of inherent cardiac risk or is a consequence of blood pressure (BP) lowering therapy.

METHODS

We examined the association between the cardiovascular risk marker amino-terminal-pro-B-type natriuretic peptide (NT-proBNP) and DBP in 1781 women and 2211 men aged at least 60 years with one or more cardiovascular risk factors; exclusion criteria were known heart failure or cardiac abnormality on a cardiac imaging study.

RESULTS

The lowest median serum NT-proBNP levels were for DBP 85-89 mmHg for both women and men. DBP less than 70 mmHg in women and less than 80 mmHg in men was associated with higher NT-proBNP levels than the levels at DBP 85-89 mmHg, and this relationship was present for those with SBP equal to or less than 140 and SBP greater than 140 mmHg. In conditional logistic regression models, the association of elevated NT-proBNP levels with low DBP in women was no longer statistically significant after adjustment for age, ischaemic heart disease (IHD), pulse rate, atrial fibrillation, haemoglobin and glomerular filtration rate, whereas the association in men was no longer statistically significant after adjustment for age and IHD. By contrast, the association between elevated NT-proBNP levels and low DBP remained statistically significant after adjustment for the number of antihypertensive drug classes alone or together with all antihypertensive drugs, including β-blocker therapy.

CONCLUSION

There was a J-curve relationship between the cardiovascular risk marker NT-proBNP and DBP that was explained by the clinical variables and not by the BP-lowering therapy.