Blood pressure: the lower, the better: the con side

Long-term sleep irregularity is associated with elevated cumulative blood pressure in older adults: Evidence from a mobile health five-year longitudinal study

INTRODUCTION

Sleep irregularity is increasingly recognized as a modifiable factor for cardiovascular health. This study aims to investigate relationships between short- and long-term sleep irregularity with blood pressure (BP) dynamics among older adults.

METHODS

We used data from a prospective cohort involving community-dwelling older adults based on a mobile health (mHealth) app from 2018 to 2022. Short-term exposure was defined as sleep irregularity for one week. Cumulative sleep irregularity, calculated as the area under the curve over 12 months, was regarded as long-term exposure. Outcomes included short-term deviations in BP, longitudinal changes in BP, and cumulative BP over one year. Linear mixed models and generalized additive mixed models were conducted to investigate the associations between sleep irregularity and BP.

RESULTS

A total of 1611 participants with a median age of 73.0 years were included. Short-term and long-term cumulative sleep irregularities were associated with increased SBP, DBP, and global BP Z-score. For instance, each SD increment in cumulative sleep onset timing SD was associated with a 0.42 mmHg increase in SBP (95 % CI, 0.25 to 0.60), a 0.31 mmHg increase in DBP (95 % CI, 0.17 to 0.45), respectively. Subgroup analyses indicated stronger associations among males and those with normotension. Strong linear dose-response relationships were further observed between cumulative sleep irregularity and cumulative BP.

CONCLUSIONS

Sleep irregularity, in both short-term and long-term exposure, is a risk factor for poor blood pressure control among older adults, highlighting the importance of implementing interventions promoting healthy sleep habits to mitigate cardiovascular risks.

Salt Substitution and Recurrent Stroke and Death: A Randomized Clinical Trial

Importance

The direct effect of consumption of salt substitutes on recurrent stroke and mortality among patients with stroke remains unclear.

Objective

To evaluate the effects of salt substitutes vs regular salt on the incidence of recurrent stroke and mortality among patients with stroke.

Design, Setting, and Participants

The Salt Substitute and Stroke Study (SSaSS), an open-label, cluster randomized clinical trial, was conducted in 600 northern Chinese villages (clusters). Patients who self-reported a hospital diagnosis of stroke were included in this prespecified subgroup analysis. Data were analyzed from November 2023 to August 2024.

Interventions

Participants were assigned to use either a salt substitute, consisting of 75% sodium chloride and 25% potassium chloride by mass, or regular salt.

Main Outcomes and Measures

The primary outcome was recurrent stroke.

Results

After excluding 5746 persons without a baseline history of stroke, 15 249 patients with stroke (mean [SD] age, 64.1 [8.8] years; 6999 [45.9%] female; 8250 male [54.1%]) were included. Over a median (IQR) follow-up of 61.2 (60.9-61.6) months, the mean difference in systolic blood pressure was -2.05 mm Hg (95% CI, -3.03 to -1.08 mm Hg). A total of 2735 recurrent stroke events (691 fatal and 2044 nonfatal) and 3242 deaths were recorded. Recurrent stroke was significantly lower in the salt substitute vs regular salt group (rate ratio [RR], 0.86; 95% CI, 0.77-0.95; P = .005), with larger effects on hemorrhagic stroke (relative reduction, 30%; P = .002). Death rates were also significantly lower (RR, 0.88; 95% CI, 0.82-0.96; P = .003), with larger effects on stroke-related deaths (relative reduction 21%; P = .01). No significant difference was observed for hyperkalemia (RR, 1.01; 95% CI, 0.74-1.38; P = .96).

Conclusions and Relevance

Results of this cluster trial demonstrate that salt substitution was safe, along with reduced risks of stroke recurrence and death, which underscores large health gains from scaling up this low-cost intervention among patients with stroke.

Trial Registration

ClinicalTrials.gov Identifier: NCT02092090.

Association of Wearable Device-Measured Step Volume and Variability With Blood Pressure in Older Chinese Adults: Mobile-Based Longitudinal Observational Study

BACKGROUND

The paucity of evidence on longitudinal and consecutive recordings of physical activity (PA) and blood pressure (BP) under real-life conditions and their relationships is a vital research gap that needs to be addressed.

OBJECTIVE

This study aims to (1) investigate the short-term relationship between device-measured step volume and BP; (2) explore the joint effects of step volume and variability on BP; and (3) examine whether the association patterns between PA and BP varied across sex, hypertension status, and chronic condition status.

METHODS

This study used PA data of a prospective cohort of 3070 community-dwelling older adults derived from a mobile health app. Daily step counts, as a proxy of step volume, were derived from wearable devices between 2018 and 2022 and categorized into tertiles (low, medium, and high). Step variability was assessed using the SD of daily step counts. Consecutive daily step count recordings within 0 to 6 days preceding each BP measurement were analyzed. Generalized estimation equation models were used to estimate the individual and joint associations of daily step volume and variability with BP. Stratified analyses by sex, the presence of hypertension, and the number of morbidities were further conducted.

RESULTS

A total of 3070 participants, with a median age of 72 (IQR 67-77) years and 71.37% (2191/3070) women, were included. Participants walked a median of 7580 (IQR 4972-10,653) steps and 5523 (IQR 3590-7820) meters per day for a total of 592,597 person-days of PA monitoring. Our results showed that higher levels of daily step volume were associated with lower BP (systolic BP, diastolic BP, mean arterial pressure, and pulse pressure). Compared with participants with low step volume (daily step counts <6000/d) and irregular steps, participants with high step volume (≥9500/d) and regular steps showed the strongest decrease in systolic BP (-1.69 mm Hg, 95% CI -2.2 to -1.18), while participants with medium step volume (6000/d to <9500/d) and regular steps were associated with the lowest diastolic BP (-1.067 mm Hg, 95% CI -1.379 to -0.755). Subgroup analyses indicated generally greater effects on women, individuals with normal BP, and those with only 1 chronic disease, but the effect pattern was varied and heterogeneous between participants with different characteristics.

CONCLUSIONS

Increased step volume demonstrated a substantial protective effect on BP among older adults with chronic conditions. Furthermore, the beneficial association between step volume and BP was enhanced by regular steps, suggesting potential synergistic protective effects of both increased step volume and step regularity. Targeting both step volume and variability through PA interventions may yield greater benefits in BP control, particularly among participants with hypertension and a higher chronic disease burden.

Influence of hypertension duration and blood pressure levels on cardiovascular disease and all-cause mortality: A large prospective cohort study

Background and objects

A longer duration of hypertension (HTN) has been suggested to be associated with a greater risk of cardiovascular disease (CVD). Whether such an association is similar for mortality risk, and whether HTN duration is associated with CVD/mortality beyond blood pressure (BP) control levels are yet to be assessed. We aimed to examine the associations of HTN duration and the combination of HTN duration and systolic blood pressure (SBP)/diastolic blood pressure (DBP) with risks of CVD and all-cause mortality.

Methods

We used data on ∼450,000 UK residents. Participants were categorized by HTN status and HTN duration. The primary outcome was a composite of non-fatal myocardial infarction, non-fatal stroke and CVD death. We also explored the results for the above-mentioned CVD outcomes separately. All-cause mortality was also used as a secondary outcome. The age at HTN diagnosis was obtained by self-report. HTN duration was calculated as baseline age minus age at diagnosis.

Results

Among all participants, compared with non-hypertensive participants, those with a longer HTN duration had increased risks of CVD and all-cause mortality. These associations persisted among hypertensive patients. Specifically, compared with patients with HTN durations of < 5 y, patients with a HTN duration of 5 to < 10 y, 10 to < 15 y, and ≥ 15 y had adjusted HRs (95% CI) of 1.09 (1.03, 1.17), 1.21 (1.13, 1.31), and 1.38 (1.29, 1.48) for composite CVD (P-trend < 0.001); and 1.03 (0.97, 1.08), 1.09 (1.02, 1.16), and 1.17 (1.11, 1.24) for all-cause mortality (P-trend < 0.001). When compared with hypertensive patients with BP < 140/90 mmHg and a HTN duration of < 5 y, adjusted HRs of CVD and all-cause mortality were 1.35 (1.15, 1.57) and 1.26 (1.11, 1.42) for those with BP < 140/90 mmHg and a duration of ≥ 15 y, and 1.43 (1.26, 1.60) and 1.13 (1.03, 1.25) for those with BP ≥ 140/90 mmHg and durations of ≥ 15 y, respectively.

Conclusion

A longer HTN duration was associated with increased risks of CVD and overall death in a linear fashion, and these associations were independent of BP control levels.

Blood Pressure Changes After a Health Promotion Program Among Mexican Workers

Background: Cardiovascular disease is becoming increasingly prevalent in low and middle-income countries (LMIC), and high blood pressure (BP) is one of the main risk factors. The efficacy and sustainability of worksite health promotion (WHP) programs for BP reduction in LMIC have yet to be determined. Methods: This non-randomized company-based trial evaluated 6- and 12-months effects of a WHP intervention on BP among 2,002 participating workers from seven Mexican companies. Intervention and control groups were assigned at the company level. The intervention included nutrition counseling, physical exercise, and stress management components. Mixed models assessed differences in BP change between intervention and control companies in intent-to-treat (ITT), per-protocol (PerP), and as-treated (AsTr) analyses, and also within-group changes stratified by company, intervention component, and baseline cardiovascular risk factor levels. All analyses were adjusted for potential confounders. We accounted for missing data and loss to follow-up using inverse probability of censoring weighting. Results: ITT analyses revealed mean BP change differences of -1.1 mmHg at 12 months (95% CI: -2.9; 0.6) in intervention companies relative to control companies. PerP and AsTr analyses confirmed this finding. Within-group analyses showed consistent BP reductions at both 6 and 12 months. Substantial differences in BP changes ranging from diastolic -6.1 mmHg, (95% CI: -11.2; -1.2) to systolic -13.0 mmHg (95% CI: -16.0; -10.1) were found among individuals with diabetes at baseline in intervention companies relative to control companies. Conclusion: After 1 year, WHP was associated with modest but uncertain BP reductions. Substantial reductions were mainly observed among diabetic workers.

Healthcare professional-led interventions on lifestyle modifications for hypertensive patients - a systematic review and meta-analysis

BACKGROUND

About 0.9 billion people in the world have hypertension. The mortality due to hypertension increased dramatically over the last decades. Healthcare professionals should support patients with hypertension to modify their lifestyle to decrease blood pressure, but an overview of effective lifestyle interventions is lacking. The aim of this study was to determine whether healthcare professional-led interventions on lifestyle modifications are effective in lowering blood pressure in patients with hypertension.

METHODS

A systematic literature review following the PRISMA guidelines was conducted. PubMed, EMBASE and CINAHL databases were searched for randomized control trials (RCTs) of interventions on lifestyle modifications of hypertensive patients which were performed by healthcare professionals (physician, nurse, pharmacist) and which reported blood pressure measurements. Papers were reviewed by two reviewers and analysed using Cochrane software Revman 5.4. In a meta-analysis difference in systolic blood pressure (SBP), diastolic blood pressure (DBP) and the percentage of patients with controlled blood pressure (BP) was analysed.

RESULTS

In total, 34 clinical trials reporting on 22,419 patients (mean age 58.4 years, 49.14% female, 69.9% used antihypertensive medications) were included. The mean difference SBP was - 4.41 mmHg (95% CI, - 5.52to - 3.30) and the mean difference DBP was - 1.66 mmHg (95% CI - 2.44 to - 0.88) in favor of the intervention group vs usual care. Fifty-six percent of patients achieved BP control in the intervention group vs 44% in usual care, OR = 1.87 (95% CI, 1.51 to 2.31).

CONCLUSION

Healthcare professional-led interventions were effective. Patients achieved almost 5 mmHg decrease of SBP and more patients achieved BP control. The results suggest that efforts are needed for widespread implementation.

Blood pressure targets in adults with hypertension

BACKGROUND

This is the first update of this review first published in 2009. When treating elevated blood pressure, doctors usually try to achieve a blood pressure target. That target is the blood pressure value below which the optimal clinical benefit is supposedly obtained. "The lower the better" approach that guided the treatment of elevated blood pressure for many years was challenged during the last decade due to lack of evidence from randomised trials supporting that strategy. For that reason, the standard blood pressure target in clinical practice during the last years has been less than 140/90 mm Hg for the general population of patients with elevated blood pressure. However, new trials published in recent years have reintroduced the idea of trying to achieve lower blood pressure targets. Therefore, it is important to know whether the benefits outweigh harms when attempting to achieve targets lower than the standard target.

OBJECTIVES

The primary objective was to determine if lower blood pressure targets (any target less than or equal to 135/85 mm Hg) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (less than or equal to 140/ 90 mm Hg) for the treatment of patients with chronic arterial hypertension. The secondary objectives were: to determine if there is a change in mean achieved systolic blood pressure (SBP) and diastolic blood pressure (DBP associated with "lower targets" as compared with "standard targets" in patients with chronic arterial hypertension; and to determine if there is a change in withdrawals due to adverse events with "lower targets" as compared with "standard targets", in patients with elevated blood pressure.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to May 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 4), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing patients allocated to lower or to standard blood pressure targets (see above).

DATA COLLECTION AND ANALYSIS

Two review authors (JAA, VL) independently assessed the included trials and extracted data. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure, end stage renal disease, and other serious adverse events. Secondary outcomes were achieved mean SBP and DBP, withdrawals due to adverse effects, and mean number of antihypertensive drugs used. We assessed the risk of bias of each trial using the Cochrane risk of bias tool and the certainty of the evidence using the GRADE approach.  MAIN RESULTS: This update includes 11 RCTs involving 38,688 participants with a mean follow-up of 3.7 years. This represents 7 new RCTs compared with the original version. At baseline the mean weighted age was 63.1 years and the mean weighted blood pressure was 155/91 mm Hg. Lower targets do not reduce total mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.86 to 1.05; 11 trials, 38,688 participants; high-certainty evidence) and do not reduce total serious adverse events (RR 1.04, 95% CI 0.99 to 1.08; 6 trials, 18,165 participants; moderate-certainty evidence). This means that the benefits of lower targets do not outweigh the harms as compared to standard blood pressure targets. Lower targets may reduce myocardial infarction (RR 0.84, 95% CI 0.73 to 0.96; 6 trials, 18,938 participants, absolute risk reduction (ARR) 0.4%, number needed to treat to benefit (NNTB) 250 over 3.7 years) and congestive heart failure (RR 0.75, 95% CI 0.60 to 0.92; 5 trials, 15,859 participants, ARR 0.6%, NNTB  167 over 3.7 years) (low-certainty for both outcomes). Reduction in myocardial infarction and congestive heart failure was not reflected in total serious adverse events. This may be due to an increase in other serious adverse events (RR 1.44, 95% CI 1.32 to 1.59; 6 trials. 18,938 participants, absolute risk increase (ARI) 3%,  number needed to treat to harm (NNTH) 33 over four years) (low-certainty evidence). Participants assigned to a "lower" target received one additional antihypertensive medication and achieved a significantly lower mean SBP (122.8 mm Hg versus 135.0 mm Hg, and a lower mean DBP (82.0 mm Hg versus 85.2 mm Hg, than those assigned to "standard target".

AUTHORS' CONCLUSIONS

For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets. The results of this review are primarily applicable to older people with moderate to high cardiovascular risk. They may not be applicable to other populations.

Hypertension Drug Therapy

Hypertension is still the number one global killer. No matter what causes are, lowering blood pressure can significantly reduce cardiovascular complications, cardiovascular death, and total death. Unfortunately, some hypertensive individuals simply do not know having hypertension. Some knew it but either not being treated or treated but blood pressure does not achieve goal. The reasons for inadequate control of blood pressure are many. One important reason is that we are not very familiar with antihypertensive agents and less attention has been paid to comorbidities, complications as well as the hypertension-modified target organ damage in patients with hypertension. The right antihypertensive drug was not given to the right hypertensive patients at right time. This reviewer studied comprehensively the literature, hopefully that the review will help improve antihypertensive drug selection and antihypertensive therapy.

Effect of the Mediterranean diet in combination with exercise on metabolic syndrome parameters: 1-year randomized controlled trial

Abstract. This work aimed to evaluate and compare the benefits of the energy restricted Mediterranean diet (MD) and Standard hypolipemic diet (SHD) accompanied by exercise on metabolic syndrome parameters. A 12-month, randomized, single-blinded, diet-controlled study was conducted on 124 obese participants in the University Hospital Dubrava. Participants were assigned to the MD (n = 63) or the SHD (n = 61) and received the same amount of nutritional education and guidance on physical activity. The completion rate was 67.7 %. Both diets produced significant beneficial changes in body weight and waist circumference (P < 0.001 for MD and SHD). Compared with the SHD, HDL cholesterol increased (P = 0.031) and systolic blood pressure (SBP) decreased (P = 0.020) in the MD group. Fasting plasma glucose decreased significantly in both diet groups (P < 0.001 for MD; P = 0.026 for SHD). Although both diets accompanied by physical activity yielded similar weight reduction results, adherence to the MD was associated with more prominent reduction of the MetS components, namely HDL level elevation and SBP reduction.

Dietary intake of inorganic nitrate in vegetarians and omnivores and its impact on blood pressure, resting metabolic rate and the oral microbiome

Vegetarian diets are commonly associated with lower blood pressure levels. This has been related to greater consumption of inorganic nitrate, since vegetables are the main source of this anion. Dietary nitrate is reduced to nitrite by commensal bacteria in the mouth, which in turn leads to increased circulatory nitrite availability. Nitrite can form nitric oxide by several pathways promoting a reduction in the vascular tone and lower blood pressure. This study tested whether vegetarians have higher concentrations of nitrite in saliva and plasma, and lower blood pressure and resting metabolic rate (RMR), due to higher intakes of nitrate, compared to omnivores. Following a non-randomized, cross-over and single-blinded design we measured dietary nitrate intake, blood pressure and RMR in young and healthy vegetarians (n = 22) and omnivores (n = 19) with similar characteristics after using placebo or antibacterial mouthwash for a week to inhibit oral bacteria. Additionally, we analyzed salivary and plasma nitrate and nitrite concentrations, as well as the oral nitrate-reduction rate and oral microbiome in both groups. Dietary nitrate intake in vegetarians (97 ± 79 mg/day) was not statistically different (P > 0.05) to omnivores (78 ± 47 mg/day). Salivary and plasma nitrate and nitrite concentrations were similar after placebo mouthwash in both groups (P > 0.05). The oral nitrate-reducing capacity, abundance of oral bacterial species, blood pressure and RMR were also similar between vegetarians and omnivores (P > 0.05). Antibacterial mouthwash significantly decreased abundance of oral nitrate-reducing bacterial species in vegetarians (^_16.9%; P < 0.001) and omnivores (^_17.4%; P < 0.001), which in turn led to a significant reduction of the oral nitrate-reducing capacity in vegetarians (-78%; P < 0.001) and omnivores (-85%; P < 0.001). However, this did not lead to a significant increase in blood pressure and RMR in either groups (P > 0.05). These findings suggest that vegetarian diets may not alter nitrate and nitrite homeostasis, or the oral microbiome, compared to an omnivore diet. Additionally, inhibition of oral nitrite synthesis for a week with antibacterial mouthwash did not cause a significant raise in blood pressure and RMR in healthy, young individuals independent of diet.

Associations of mortality with own blood pressure using son's blood pressure as an instrumental variable

High systolic blood pressure (SBP) causes cardiovascular disease (CVD) and is associated with mortality from other causes, but conventional multivariably-adjusted results may be confounded. Here we used a son’s SBP (>1 million Swedish men) as an instrumental variable for parental SBP and examined associations with parents’ cause-specific mortality, avoiding reverse causation. The hazard ratio for CVD mortality per SD (10.80 mmHg) of SBP was 1.49 (95% CI: 1.43, 1.56); SBP was positively associated with coronary heart disease and stroke. SBP was also associated positively with all-cause, diabetes and kidney cancer mortality, and negatively with external causes. Negative associations with respiratory-related mortality were probably confounded by smoking. Hazard ratios for other causes were imprecise or null. Diastolic blood pressure gave similar results to SBP. CVD hazard ratios were intermediate between those from conventional multivariable studies and Mendelian randomization and stronger than those from clinical trials, approximately consistent with an effect of exposure duration on effect sizes. Plots of parental mortality against offspring SBP were approximately linear, supporting calls for lower SBP targets. Results suggest that conventional multivariable analyses of mortality and SBP are not substantially confounded by reverse causation and confirm positive effects of SBP on all-cause, CVD and diabetes mortality.

Efficacy and Safety of S-Amlodipine 2.5 and 5 mg/d in Hypertensive Patients Who Were Treatment-Naive or Previously Received Antihypertensive Monotherapy

The aim of the present study was to evaluate the efficacy and safety of S-amlodipine 2.5 and 5 mg/d in patients with hypertension who were treatment-naive or previously received antihypertensive monotherapy. During the 8-week treatment period, all patients received S-amlodipine 2.5 mg/d for the first 4 weeks, followed by S-amlodipine 5 mg/d for the second 4 weeks. For efficacy assessments, ambulatory and office blood pressure (BP) measurements were performed during the baseline, fourth-week, and eighth-week visits. For safety assessments, all adverse events and abnormal laboratory findings were recorded. This study is registered with ClinicalTrials.gov (NCT03038451). Of 43 patients evaluated at the screening visit, 33 were enrolled. In the treatment-naive arm, significant reductions in both office and ambulatory systolic BP (SBP) and diastolic BP (DBP) were observed with S-amlodipine 2.5 mg/d and additional significant reductions were achieved with dose titration (S-amlodipine 5 mg/d). At the end of the study, the rate of the treatment-naive patients with BP under control (SBP/DBP <140/90 mm Hg) was 53% with S-amlodipine 2.5 mg and increased to 78% with S-amlodipine 5 mg. For the noninferiority evaluation, S-amlodipine 2.5 and 5 mg/d treatments were generally noninferior to both office and ambulatory BP levels achieved with the medications that the patients received before participating in the study. Five nonserious adverse events likely to be associated with the study drug were observed. No serious adverse event was encountered. Consequently, S-amlodipine can be suggested as an effective and safe treatment option for patients with hypertension.

Association between periodontitis and arterial hypertension: A systematic review and meta-analysis

BACKGROUND

Several studies have shown that periodontal diseases are associated with hypertension (HT). However, heterogeneity among populations, diagnosis criteria, and shared risk factors represent some difficulties in terms of interpretation. Therefore, the aim of this study was to determine the magnitude of the association between periodontal diseases and HT.

METHODS AND RESULTS

A systematic review and meta-analysis, including studies published up to June 2016, have been performed. Sixteen studies assessing the association between periodontal diseases and HT have been included. The meta-analysis considering all included studies (moderate to severe periodontitis) showed that the presence of HT was associated with the presence of periodontal diseases (OR, 1.50; 95% CI, 1.27-1.78). To reduce potential bias, a stratified analysis has been performed illustrating the impact of inclusion criteria and adjustments on the magnitude of the association. Interestingly, when only studies with secure diagnosis of severe periodontitis and HT were considered, an OR=1.64 (95% CI, 1.23-2.19) has been measured.

CONCLUSIONS

Periodontal diseases are associated with a higher risk of HT especially for severe periodontitis. However, no conclusions could be made regarding the causative involvement of periodontal diseases mainly due to the reduced number of available prospective studies and remaining questions regarding underlying biological mechanisms.

Effect of liraglutide 3.0 mg in individuals with obesity and moderate or severe obstructive sleep apnea: the SCALE Sleep Apnea randomized clinical trial

BACKGROUND

Obesity is strongly associated with prevalence of obstructive sleep apnea (OSA), and weight loss has been shown to reduce disease severity.

OBJECTIVE

To investigate whether liraglutide 3.0 mg reduces OSA severity compared with placebo using the primary end point of change in apnea-hypopnea index (AHI) after 32 weeks. Liraglutide's weight loss efficacy was also examined.

SUBJECTS/METHODS

In this randomized, double-blind trial, non-diabetic participants with obesity who had moderate (AHI 15-29.9 events h(-1)) or severe (AHI ⩾30 events h(-1)) OSA and were unwilling/unable to use continuous positive airway pressure therapy were randomized for 32 weeks to liraglutide 3.0 mg (n=180) or placebo (n=179), both as adjunct to diet (500 kcal day(-1) deficit) and exercise. Baseline characteristics were similar between groups (mean age 48.5 years, males 71.9%, AHI 49.2 events h(-1), severe OSA 67.1%, body weight 117.6 kg, body mass index 39.1 kg m(-2), prediabetes 63.2%, HbA1c 5.7%).

RESULTS

After 32 weeks, the mean reduction in AHI was greater with liraglutide than with placebo (-12.2 vs -6.1 events h(-1), estimated treatment difference: -6.1 events h(-1) (95% confidence interval (CI), -11.0 to -1.2), P=0.0150). Liraglutide produced greater mean percentage weight loss compared with placebo (-5.7% vs -1.6%, estimated treatment difference: -4.2% (95% CI, -5.2 to -3.1%), P<0.0001). A statistically significant association between the degree of weight loss and improvement in OSA end points (P<0.01, all) was demonstrated post hoc. Greater reductions in glycated hemoglobin (HbA1c) and systolic blood pressure (SBP) were seen with liraglutide versus placebo (both P<0.001). The safety profile of liraglutide 3.0 mg was similar to that seen with doses ⩽1.8 mg.

CONCLUSIONS

As an adjunct to diet and exercise, liraglutide 3.0 mg was generally well tolerated and produced significantly greater reductions than placebo in AHI, body weight, SBP and HbA1c in participants with obesity and moderate/severe OSA. The results confirm that weight loss improves OSA-related parameters.

The effect of an e-health intervention designed to reduce prolonged occupational sitting on mean arterial pressure

OBJECTIVE

To evaluate the effect of a workplace health intervention designed to reduce prolonged occupational sitting on the mean arterial pressure (MAP) of desk-based employees.

METHODS

This randomized controlled trial involved an experimental group who received an e-health intervention and a control group who did not. The 13-week intervention passively prompted participants to stand and engage in short bouts of office-based physical activity by interrupting prolonged occupational sitting time periodically throughout the workday. Mean arterial pressure was measured at pretest and posttest.

RESULTS

Between pretest and posttest the experimental group significantly reduced their MAP, whereas MAP in the control group did not.

CONCLUSIONS

A workplace e-health intervention designed to reduce prolonged occupational sitting was effective in decreasing MAP in desk-based employees.

Probing genetic overlap in the regulation of systolic and diastolic blood pressure in Danish and Chinese twins

Although the phenotypic correlation between systolic blood pressure (SBP) and diastolic blood pressure (DBP) is well known, the genetic basis for the correlation has rarely been investigated. The aim of this paper is to examine the genetic overlap between SBP and DBP by fitting bivariate models to Danish and Chinese twins and comparing ethnic differences between the two samples. Our estimates revealed a high proportion of additive genetic components shared by both SBP and DBP in Danish (0.71, 95% confidence interval (CI): 0.65-0.75) and Chinese (0.62, 95% CI: 0.50-0.71) twins with no statistically significant ethnic differences. The estimated genetic component in phenotypic correlation could serve to guide molecular genetic studies searching for genetic variants that affect both SBP and DBP. The bivariate model also estimated genetic and environmental contributions to SBP and DBP separately, with an overall pattern of higher genetic regulation or heritability in Danish (0.72, 95% CI: 0.67-0.76 for SBP; 0.70, 95% CI: 0.65-0.75 for DBP) than in Chinese (0.54, 95% CI: 0.44-0.63 for SBP; 0.57, 95% CI: 0.47-0.65 for DBP) twins and a higher contribution from unique environmental factors in Chinese compared with Danish twins. The estimated contribution from unique environmental factors suggests that promoting healthy lifestyles may provide an efficient way of controlling high blood pressure, particularly in the Chinese population.

Blood pressure targets for hypertension in people with diabetes mellitus

BACKGROUND

When treating elevated blood pressure (BP), doctors often want to know what blood pressure target they should try to achieve. The standard blood pressure target in clinical practice for some time has been less than 140 - 160/90 - 100 mmHg for the general population of people with elevated blood pressure. Several clinical guidelines published in recent years have recommended lower targets (less than 130/80 mmHg) for people with diabetes mellitus. It is not known whether attempting to achieve targets lower than the standard target reduces mortality and morbidity in those with elevated blood pressure and diabetes.

OBJECTIVES

To determine if 'lower' BP targets (any target less than 130/85 mmHg) are associated with reduction in mortality and morbidity compared with 'standard' BP targets (less than 140 - 160/90 - 100 mmHg) in people with diabetes.

SEARCH METHODS

We searched the Database of Abstracts of Reviews of Effectiveness (DARE) and the Cochrane Database of Systematic Reviews for related reviews. We conducted electronic searches of the Hypertension Group Specialised Register (January 1946 - October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 9), MEDLINE (January 1946 - October 2013), EMBASE (January 1974 - October 2013) and ClinicalTrials.gov. The most recent search was performed on October 4, 2013.Other search sources were the International Clinical Trials Registry Platform (WHO ICTRP), and reference lists of all papers and relevant reviews.

SELECTION CRITERIA

Randomized controlled trials comparing people with diabetes randomized to lower or to standard BP targets as previously defined, and providing data on any of the primary outcomes below.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and established the included trials and data entry. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure and end-stage renal disease. Secondary outcomes were achieved mean systolic and diastolic BP, and withdrawals due to adverse effects.

MAIN RESULTS

We found five randomized trials, recruiting a total of 7314 participants and with a mean follow-up of 4.5 years. Only one trial (ACCORD) compared outcomes associated with 'lower' (< 120 mmHg) or 'standard' (< 140 mmHg) systolic blood pressure targets in 4734 participants. Despite achieving a significantly lower BP (119.3/64.4 mmHg vs 133.5/70.5 mmHg, P < 0.0001), and using more antihypertensive medications, the only significant benefit in the group assigned to 'lower' systolic blood pressure (SBP) was a reduction in the incidence of stroke: risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.88, P = 0.009, absolute risk reduction 1.1%. The effect of SBP targets on mortality was compatible with both a reduction and increase in risk: RR 1.05 CI 0.84 to 1.30, low quality evidence. Trying to achieve the 'lower' SBP target was associated with a significant increase in the number of other serious adverse events: RR 2.58, 95% CI 1.70 to 3.91, P < 0.00001, absolute risk increase 2.0%.Four trials (ABCD-H, ABCD-N, ABCD-2V, and a subgroup of HOT) specifically compared clinical outcomes associated with 'lower' versus 'standard' targets for diastolic blood pressure (DBP) in people with diabetes. The total number of participants included in the DBP target analysis was 2580. Participants assigned to 'lower' DBP had a significantly lower achieved BP: 128/76 mmHg vs 135/83 mmHg, P < 0.0001. There was a trend towards reduction in total mortality in the group assigned to the 'lower' DBP target (RR 0.73, 95% CI 0.53 to 1.01), mainly due to a trend to lower non-cardiovascular mortality. There was no difference in stroke (RR 0.67, 95% CI 0.42 to 1.05), in myocardial infarction (RR 0.95, 95% CI 0.64 to 1.40) or in congestive heart failure (RR 1.06, 95% CI 0.58 to 1.92), low quality evidence. End-stage renal failure and total serious adverse events were not reported in any of the trials. A sensitivity analysis of trials comparing DBP targets < 80 mmHg (as suggested in clinical guidelines) versus < 90 mmHg showed similar results. There was a high risk of selection bias for every outcome analyzed in favor of the 'lower' target in the trials included for the analysis of DBP targets.

AUTHORS' CONCLUSIONS

At the present time, evidence from randomized trials does not support blood pressure targets lower than the standard targets in people with elevated blood pressure and diabetes. More randomized controlled trials are needed, with future trials reporting total mortality, total serious adverse events as well as cardiovascular and renal events.

Hypertension management algorithm for type 2 diabetic patients applied in primary care

BACKGROUND

Hypertension frequently coexists with type 2 diabetes (DM), and increases the risk of cardiovascular outcomes. The aim of the study was to obtain/maintain blood pressure (BP) goals (ADA/JNC 7) according to a stepwise algorithm using the medication supplied by the Brazilian government.

METHODS

A one-year, single-arm interventional study conducted with type 2 diabetes patients. Intervention consisted of intensification of lifestyle changes and sequential prescription of drugs: diuretic; ACE inhibitors; β-adrenergic blocking agent and calcium channel blocking agent if BP >130/80 mmHg.

RESULTS

Seventy-eight patients completed the trial. During intervention, the number of antihypertensive tablets rose (3.6 ± 3.5 vs. 5.9 ± 3.5 pills/patient; p <0.001), as the number of antihypertensive classes increased (1.8 ± 1.0 vs. 2.70 ± 1.2; p < 0.01) and the overall drop of BP was 11 mmHg for SBP (145.0 ± 22.8 vs. 133.7 ± 20.9 mmHg; p < 0.01) and 5 mmHg for DBP (78.7 ± 11.5 vs. 73.7 ± 10.5 mmHg; p = 0.001). Although the number of patients with BP in target almost doubled [14 (18.7%) vs. 30 (38.5%) p = 0.008], less than 40% of the patients achieved the proposed goals.

CONCLUSIONS

A BP algorithm applied to type 2 diabetic and hypertensive patients is able to lower BP, however more than half of the patients did not achieve the ADA/JNC 7 targets demonstrating the complexity of BP control in this population.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06260.

Social networks help control hypertension

Cardiovascular health disparities continue to pose a major public health problem. The authors evaluated the effect of education administered within social networks on the improvement of hypertension in 248 African Americans compared with historical controls. Patients formed clusters with peers and attended monthly hypertension education sessions. The authors assessed the likelihood of reaching goal below predefined systolic blood pressure (SBP) and diastolic blood pressure (DBP) thresholds as well as the absolute reduction in SBP and DBP, controlling for diabetes, smoking, baseline hypertension, and demographics. The intervention group was more likely to have ever reached treatment goal at 12-month follow-up (odds ratio, 1.72; P=.11). At 18-month follow-up, the Maryland Cardiovascular Disease Promotion Program group had a statistically significant larger drop in SBP (-4.82 mm Hg, P<.0001) and DBP (-3.37 mm Hg, P=.01) than the control group. The clustering of patients in social networks around hypertension education has a positive impact on the management of hypertension in minority populations and may help address cardiovascular health disparities.

Should we change the target blood pressure in diabetic patients?

Hypertension is a major modifiable risk factor for cardiovascular morbidity and mortality in diabetic patients. Guidelines recommend lowering blood pressure (BP) to less than 130/80 mmHg in diabetic patients. These recommendations are based on several studies in diabetic patients that showed the benefit of intensive BP control. However in all the studies the achieved BP was higher than 130/80 mmHg. Re-evaluation of earlier studies, as well as more recently accumulated data suggest that intensive BP control is associated with a significant reduction in all-cause mortality and stroke rate, but with no benefit for other microvascular or macrovascular (cardiac, renal and retinal) outcomes. Intensive BP control is associated with an increased risk of serious adverse effects, particularly for systolic BPs levels lower than 130 mmHg. When determining the target BP in diabetic patients one should balance the potential cerebrovascular protection against the increased risk of serious side effects, and the absence of benefit for other circulatory system. It seems therefore, that lowering BP to levels close to 130/80 mmHg should be the main goal of treatment in diabetic patients.

The occurrence rate of cerebrovascular and cardiac events in patients receiving antihypertensive therapy from the post-marketing surveillance data for valsartan in Japan (J-VALID)

It is well known that blood pressure (BP) management reduces the incidence of cerebrovascular and cardiovascular events. However, it is unclear how many of these events occur in hypertensive patients who receive pharmacological treatment. The aim of this survey was to evaluate the occurrence rate of both types of events in patients receiving valsartan-based treatment. Of 30 366 patients treated with valsartan, 28 356 patients were observed for 2.93 years. Antihypertensive drugs other than valsartan were used in 56.8% of patients. After the administration of valsartan, the systolic and diastolic BP significantly decreased from 161.1±19.1/90.4±13.1 to 139.9±18.1/79.6±11.9 mm Hg. Cerebrovascular events were observed in 550 patients (1.94%, 9.29/1000 patient-years), and cardiac events were observed in 576 patients (2.03%, 9.73/1000 patient-years). A comparative analysis of the hazard ratios for cerebrovascular and cardiac events according to the BP level at the endpoint showed a BP-dependent reduction of risk for cerebrovascular events, and the change in risk exhibited a J-curve phenomenon in the relationship between cardiac events and systolic BP. The J-curve phenomenon was not observed in patients aged <75 years, but it was observed for the systolic BP in patients aged 75 years. Adverse drug reactions were observed in 1925 of 28 420 patients (6.77%). This post-marketing surveillance data for valsartan showed the outcomes for treated hypertensive patients in a large population in Japan who were followed for up to 3 years. These data will add important knowledge regarding the treatment of hypertension in Japan.