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Oude Griep LM, Bentham J, Mahadevan P. Worldwide associations of fruit and vegetable supply with blood pressure from 1975 to 2015: an ecological study. BMJ Nutr Prev Health 2023; 6:28-38. [PMID: 37559966 PMCID: PMC10407360 DOI: 10.1136/bmjnph-2022-000455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 10/10/2022] [Indexed: 02/03/2023] Open
Abstract
Low fruit and vegetable consumption is a major modifiable risk factor for raised blood pressure (BP), but it is unknown how heterogeneity in national supply has contributed to BP trends. To address this, we characterised supply trends from 1975 to 2015 and whether it met WHO recommendations. We then examined associations with three metrics: systolic, diastolic and raised BP. We used ecological data on fruit and vegetable supply and on BP for 159 countries. We examined trends in fruit and vegetable supply from 1975 to 2015 by country and World Bank income region. Multivariable linear regression was used to examine cross-sectional associations with BP. Global fruit and vegetable supply increased from 1975 to 2015, but with heterogeneous national and regional trends. While WHO recommendations were met globally, this target was not met in almost half the countries, of which many were low-income countries. Significant associations between combined fruit and vegetable supply and raised BP were observed. Over the past four decades, combined fruit and vegetable supply has been consistently and strongly associated with lower prevalence of raised BP globally. However, the heterogeneous regional trends in fruit and vegetable supply underpin the need for international organisations and individual governments to introduce or strengthen policies for increased fruit and vegetable supply to reduce the burden of non-communicable diseases at national and global levels.
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Affiliation(s)
- Linda M Oude Griep
- NIHR Biomedical Research Centre, Diet, Anthropometry, and Physical Activity Group, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - James Bentham
- School of Mathematics, Statistics and Actuarial Science, University of Kent, Canterbury, UK
| | - Preveina Mahadevan
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
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Unwin D, Delon C, Unwin J, Tobin S, Taylor R. What predicts drug-free type 2 diabetes remission? Insights from an 8-year general practice service evaluation of a lower carbohydrate diet with weight loss. BMJ Nutr Prev Health 2023; 6:46-55. [PMID: 37559961 PMCID: PMC10407412 DOI: 10.1136/bmjnph-2022-000544] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/15/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Type 2 diabetes (T2D) is often regarded as a progressive, lifelong disease requiring an increasing number of drugs. Sustained remission of T2D is now well established, but is not yet routinely practised. Norwood surgery has used a low-carbohydrate programme aiming to achieve remission since 2013. METHODS Advice on a lower carbohydrate diet and weight loss was offered routinely to people with T2D between 2013 and 2021, in a suburban practice with 9800 patients. Conventional 'one-to-one' GP consultations were used, supplemented by group consultations and personal phone calls as necessary. Those interested in participating were computer coded for ongoing audit to compare 'baseline' with 'latest follow-up' for relevant parameters. RESULTS The cohort who chose the low-carbohydrate approach (n=186) equalled 39% of the practice T2D register. After an average of 33 months median (IQR) weight fell from 97 (84-109) to 86 (76-99) kg, giving a mean (SD) weight loss of -10 (8.9)kg. Median (IQR) HbA1c fell from 63 (54-80) to 46 (42-53) mmol/mol. Remission of diabetes was achieved in 77% with T2D duration less than 1 year, falling to 20% for duration greater than 15 years. Overall, remission was achieved in 51% of the cohort. Mean LDL cholesterol decreased by 0.5 mmol/L, mean triglyceride by 0.9 mmol/L and mean systolic blood pressure by 12 mm Hg. There were major prescribing savings; average Norwood surgery spend was £4.94 per patient per year on drugs for diabetes compared with £11.30 for local practices. In the year ending January 2022, Norwood surgery spent £68 353 per year less than the area average. CONCLUSIONS A practical primary care-based method to achieve remission of T2D is described. A low-carbohydrate diet-based approach was able to achieve major weight loss with substantial health and financial benefit. It resulted in 20% of the entire practice T2D population achieving remission. It appears that T2D duration <1 year represents an important window of opportunity for achieving drug-free remission of diabetes. The approach can also give hope to those with poorly controlled T2D who may not achieve remission, this group had the greatest improvements in diabetic control as represented by HbA1c.
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Affiliation(s)
- David Unwin
- NNEdPro Global Centre for Nutrition and Health, St John’s Innovation Centre, Cambridge, UK
- Norwood surgery, Southport, UK
| | - Christine Delon
- NNEdPro Global Centre for Nutrition and Health, St John’s Innovation Centre, Cambridge, UK
- Data and Research Analyst, Independent Researcher, London, UK
| | | | | | - Roy Taylor
- Newcastle Magnetic Resonance Centre, Translational and Clinical Research Institute, Campus for Ageing and Vitality, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
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Kaboré M, Hien YE, Fassinou LC, Cissé K, Ngwasiri C, Coppieters Y, Samandoulougou FK. National levels, changes and correlates of ideal cardiovascular health among Beninese adults: evidence from the 2008 to 2015 STEPS surveys. BMJ Nutr Prev Health 2022; 5:297-305. [PMID: 36619317 PMCID: PMC9813615 DOI: 10.1136/bmjnph-2021-000417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 10/24/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction A higher number of ideal cardiovascular health (CVH) metrics is associated with a lower risk of cardiovascular-related and all-cause mortality. However, the change in CVH metrics has rarely been studied in sub-Saharan Africa. We investigated the level and changes of CVH metrics and their correlates among Beninese adults between 2008 and 2015. Methods Secondary analysis was performed on data obtained from Benin's 2008 and 2015 WHO Stepwise surveys (STEPS). In total, 3617 and 3768 participants aged 25-64 years were included from both surveys, respectively. CVH metrics were assessed using the American Heart Association definition, which categorised smoking, fruit and vegetable consumption, physical activity, body mass index (BMI), blood pressure (BP), total cholesterol (TC) and glycaemia into 'ideal', 'intermediate' and 'poor' CVH. The prevalence of ideal CVH metrics was standardised using the age and sex structure of the 2013 population census. Results Few participants met all seven ideal CVH metrics, and ideal CVH significantly declined between 2008 and 2015 (7.1% (95% CI 6.1% to 8.1%) and 1.2% (95% CI 0.8% to 1.5%), respectively). The level of poor smoking (8.0% (95% CI 7.1% to 8.9%) and 5.6% (95% CI 4.8% to 6.3%)) had decreased, whereas that of poor BP (25.9% (95% CI 24.5% to 27.4%) and 32.0% (95% CI 30.0% to 33.5%)), poor total cholesterol (1.5% (95% CI 1.0% to 1.9%) and 5.5% (95% CI 4.8% to 6.2%)) and poor fruit and vegetable consumption (34.2% (95% CI 32.4% to 35.9%) and 51.4% (95% CI 49.8% to 53.0%)) significantly increased. Rural residents and young adults (25-34 years) had better CVH metrics. Conclusion The proportion of adults with ideal CVH status was low and declined significantly between 2008 and 2015 in Benin, emphasising the need for primordial prevention targeting urban areas and older people to reduce the burden of cardiovascular disease risk factors.
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Affiliation(s)
- Michael Kaboré
- Département de biochimie et microbiologie, Université Joseph Ki-Zerbo, Ouagadougou, Centre, Burkina Faso,Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Bruxelles, Belgium
| | - Yéri Esther Hien
- Département de biochimie et microbiologie, Université Joseph Ki-Zerbo, Ouagadougou, Centre, Burkina Faso
| | - Lucresse Corine Fassinou
- Institut supérieur des sciences de la santé, Université Nazi Boni, Bobo-Dioulasso, Houet, Burkina Faso
| | - Kadari Cissé
- Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Bruxelles, Belgium,Biomedical et santé publique, Institut de Recherche en Sciences de la Santé, Ouagadougou, Centre, Burkina Faso
| | - Calypse Ngwasiri
- Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Bruxelles, Belgium
| | - Yves Coppieters
- Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Bruxelles, Belgium
| | - Fati Kirakoya Samandoulougou
- Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Bruxelles, Belgium
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Wilmsen N, Pijl H, Geerlings W, Navis G. Retrospective analysis on the effect of Reverse Diabetes2 Now on kidney function in patients with type 2 diabetes with impaired kidney function. BMJ Nutr Prev Health 2022; 5:271-276. [PMID: 36619323 PMCID: PMC9813621 DOI: 10.1136/bmjnph-2021-000397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 10/12/2022] [Indexed: 12/31/2022] Open
Abstract
Objective Type 2 diabetes is one of the main causes of kidney damage. Recent intervention studies suggest that the progression of type 2 diabetes can be halted, or even brought into remission by lifestyle interventions. In a pragmatic trial, the Reverse Diabetes2 Now programme (RD2N, NL: Keer Diabetes2 Om), a multicomponent lifestyle intervention, reduced the need for bloodglucose lowering medications up to 24 months. Research design and methods Here, we retrospectively investigate the effect of RD2N on markers of kidney function in patients selected for impaired kidney function at baseline (eGFR <70 mL/min/1.73 m2 (n=45). Baseline data were retrieved from the intervention database and follow-up data on renal markers were collected from routine medical records. Wilcoxon non-parametric tests were used to assess changes over 6 and 12 months. Results After 6 months median eGFR increased significantly from 62.0 (IQR 55.5-65.0) to 69.0 (IQR 55.0-76.5) mL/min/1.73 m2 (p=0.002). Median albumin/creatinine ratio (n=26) remained within the normal range (<3 mg/mmol). The effect on eGFR was similar after exclusion of patients in whom medication was changed (median eGFR 62.0 ((IQR 59.5-66.0) to 69.0 (IQR 60.0-77.0) mL/min/1.73 m2, p=0.006, n=29), suggesting that the effect on eGFR is not related to medication changes. At 12 months, eGFR was not significantly changed (n=22, median eGFR 63.5 mL/min/1.73 m2 (IQR 58.5-71.0), p=0.067). Conclusions The retrospective nature of this study and the despite guidelines limited availability of renal markers in routine type 2 diabetes care are limiting. Nevertheless, these data support a favourable effect of RD2N on renal function. Further research, with proper documentation of renal function, urinary protein excretion and dietary intake, is needed to substantiate these results, ideally in a large-scale prospective cohort study.
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Affiliation(s)
- Nathalie Wilmsen
- Research & Development, Voeding Leeft, Amsterdam, The Netherlands
| | - Hanno Pijl
- Division of Internal Medicine, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Willem Geerlings
- Research & Development, Voeding Leeft, Amsterdam, The Netherlands
| | - Gerjan Navis
- Division of Internal Medicine, Department of Nephrology, Academic Hospital Groningen, Groningen, The Netherlands
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Abstract
With a rapidly aging population, adequate blood pressure (BP) control is critical for hypertension management and prevention of cardiovascular events. Impressive cardiovascular benefits have been observed with intensive BP control (SBP target, <120 mmHg) in the SPRINT (Systolic Blood Pressure Intervention Trial) study, even in patients 75 years of age or older. A most recent meta-analysis including 51 randomized trials with over 350,000 participants from the BPLTTC (The Blood Pressure Lowering Treatment Trialists’ Collaboration) showed that BP lowering is effective in older people for reducing major cardiovascular events. The STEP (Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients) study—a multicenter, randomized, controlled trial conducted in China, provided important evidence that intensive BP treatment (SBP target, 110 mmHg to <130 mmHg) benefits older hypertensive patients (aged 60–80 years) and reduced the incidence of cardiovascular events than standard treatment (target 130 mmHg to <150 mmHg). Because Asian people have a higher burden of hypertension and stroke than Caucasian people, intensive BP treatment has more advantages in reducing the risk of cardiovascular events including stroke in Asian hypertensive patients than in Caucasian people. Home BP monitoring is helpful to facilitate hypertension management for older patients. It should also be noted that clinical decision-making should be on a patient basis, such as fragility, diabetes, stroke, and other comorbidities, with tailored BP targets. Here we review the important clinical trials of BP control in elderly hypertension, interpretate the main findings of STEP, and also discuss the perspectives of managing hypertension in Asia.
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Affiliation(s)
- Wei-Li Zhang
- State Key Laboratory of Cardiovascular Disease, Hypertension Center, FuWai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beilishi Road 167, Xicheng District, 100037, Beijing, China.
| | - Jun Cai
- State Key Laboratory of Cardiovascular Disease, Hypertension Center, FuWai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beilishi Road 167, Xicheng District, 100037, Beijing, China
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Kitagawa K, Arima H, Yamamoto Y, Ueda S, Rakugi H, Kohro T, Yonemoto K, Matsumoto M, Saruta T, Shimada K. Intensive or standard blood pressure control in patients with a history of ischemic stroke: RESPECT post hoc analysis. Hypertens Res 2022; 45:591-601. [PMID: 35241817 DOI: 10.1038/s41440-022-00862-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 11/09/2022]
Abstract
The Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study and its pooled analysis showed that intensive blood pressure (BP) lowering reduced recurrent stroke risk by 22% in patients with a history of stroke. Here, we report the effect of intensive BP lowering on the risk of recurrent stroke subtypes in patients with a history of ischemic stroke. RESPECT was a randomized clinical trial among 1280 people with a history of cerebral infarction or intracerebral hemorrhage. Participants were assigned to the intensive blood pressure control group (blood pressure < 120/80 mmHg) or standard blood pressure control group (blood pressure < 140/90 mmHg). In this post hoc analysis, we analyzed 1074 patients with a history of cerebral infarction. The mean BP at baseline was 140.7/81.4 mmHg. Throughout the follow-up period, the mean BP was 133.4/77.5 (95% CI, 132.7-134.1/76.9-78.2) mmHg in the standard group and 126.7/74.1 (95% CI, 126.0-127.4/73.5-74.8) mmHg in the intensive group. During a mean follow-up of 3.9 years, 78 first recurrent strokes occurred. Intensive treatment tended to reduce overall annual stroke recurrence (1.74% in intensive vs. 2.17% in standard; P = 0.351 by log-rank test) and did not change the risk of ischemic stroke (1.74% vs. 1.75%, P = 0.999) but markedly reduced the risk of hemorrhagic stroke (0.00% vs. 0.39%, P = 0.005). Beneficial effects of intensive BP control were observed for the risk of hemorrhagic stroke in patients with a history of ischemic stroke. The findings of this study indicate the benefit of intensive BP control for patients with a history of ischemic stroke at high risk of hemorrhagic stroke.
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Affiliation(s)
- Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan.
| | - Hisatomi Arima
- Department of Prevented Medicine and Public Health, Faculty of Medicine, Fukuoka University, Jonan, Fukuoka, Japan
| | - Yasumasa Yamamoto
- Department of Stroke Center, Kyoto Katsura Hospital, Nishikyo, Kyoto, Japan
| | - Shinichiro Ueda
- Department of Clinical Pharmacology & Therapeutics, Faculty of Medicine, University of the Ryukyus, Nakagamigunn, Okinawa, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takahide Kohro
- Department of Cardiovascular Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Koji Yonemoto
- Division of Biostatistics, School of Health Sciences, Faculty of Medicine, University of the Ryukyus, Nakagamigunn, Okinawa, Japan
| | | | - Takao Saruta
- Department of Internal Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Kazuyuki Shimada
- Cardiovascular Medicine, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
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Chalmers J, MacMahon S. PROGRESS in Blood Pressure Control for the Prevention of Secondary Stroke. Cerebrovasc Dis 2021; 50:617-621. [PMID: 34515080 DOI: 10.1159/000518181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/28/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen MacMahon
- Department of Epidemiology and Biostatistics, Imperial College, London, United Kingdom
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Wang X, Song L, Yang J, Sun L, Moullaali TJ, Sandset EC, Delcourt C, Lindley RI, Robinson TG, Minhas JS, Arima H, Chalmers J, Kim JS, Sharma V, Wang JG, Pontes-Neto O, Lavados PM, Olavarría VV, Lee TH, Levi C, Martins SO, Thang NH, Anderson CS. Interaction of Blood Pressure Lowering and Alteplase Dose in Acute Ischemic Stroke: Results of the Enhanced Control of Hypertension and Thrombolysis Stroke Study. Cerebrovasc Dis 2019; 48:207-216. [PMID: 31812956 DOI: 10.1159/000504745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 11/13/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the extent to which the effects of intensive blood pressure (BP) lowering are modified by doses of alteplase in thrombolysis-eligible acute ischemic stroke (AIS) patients. METHODS Prespecified analyses of the Enhanced Control of Hypertension and Thrombolysis Stroke Study for patients enrolled in both arms: (i) low-dose (0.6 mg/kg body weight) or standard-dose (0.9 mg/kg) alteplase and (ii) intensive (target systolic BP [SBP] 130-140 mm Hg) or guideline-recommended (target SBP <180 mm Hg) BP management. The primary outcome was functional recovery, measured by a shift in scores on modified Rankin scale at 90 days. The safety outcome was any intracranial hemorrhage (ICH). RESULTS There were 925 participants (mean age 67 years, 39% female, 77% Asian) randomized to both arms: 242 randomly assigned to guideline/standard-dose (GS); 234 to guideline/low-dose (GL); 227 to intensive/standard-dose (IS); and 222 to intensive/low-dose (IL). Overall, average SBP levels within 24 h were lower in the low-dose compared to standard-dose alteplase group (146 and 144 vs. 151 and 150 mm Hg, for GS and GL vs. IS and IL, respectively, p < 0.0001). There was no heterogeneity of the effects of BP lowering (intensive vs. guideline) on functional recovery between standard-dose (OR 0.81, 95% CI 0.59-1.12) and low-dose alteplase (1.06, 0.77-1.47; p = 0.25 for interaction). Similar results were observed for ICH (p = 0.50 for interaction). CONCLUSIONS In thrombolysis-treated patients with predominantly mild-to-moderate severity AIS, intensive BP lowering neither improve functional recovery, either with low- or standard-dose intravenous alteplase, nor beneficially interact with low-dose alteplase in reducing ICH. TRIAL REGISTRATION The trial is registered with ClinicalTrials.gov (NCT01422616).
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Lili Song
- The George Institute China at Peking University Health Science Centre, Beijing, China
| | - Jie Yang
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Lingli Sun
- The George Institute China at Peking University Health Science Centre, Beijing, China
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,The University of Sydney, Sydney, New South Wales, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Richard I Lindley
- Sydney Medical School, Westmead Hospital, Discipline of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Jatinder S Minhas
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Hisatomi Arima
- Department of Public Health, Fukuoka University, Fukuoka, Japan
| | - John Chalmers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Jong S Kim
- Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, Republic of Korea
| | - Vijay Sharma
- Division of Neurology, National University Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ji-Guang Wang
- Shanghai Institute for Hypertension, Rui Jin Hospital and Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Octávio Pontes-Neto
- Stroke Service, Division of Neurology, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Pablo M Lavados
- Departamento de Neurologia y Psiquiateria, Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile.,Departamento de Ciencias Neurológicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Verónica V Olavarría
- Departamento de Neurologia y Psiquiateria, Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Christopher Levi
- University of Newcastle, School of Medicine and Public Health, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia.,The Sydney Partnership for Health, Education, Research and Enterprise, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Sheila O Martins
- Stroke Division of Neurology Service, Hospital de Clinicas de Porto Alegre, University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Nguyen H Thang
- Department of Cerebrovascular Disease, The People 115 Hospital, Ho Chi Min City, Vietnam
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia, .,The George Institute China at Peking University Health Science Centre, Beijing, China, .,Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia, .,Heart Health Research Centre, Beijing, China,
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Zhong XL, Dong Y, Xu W, Sun L, Wang HF, Li HQ, Huang YY, Tan L, Dong Q, Yu JT. Blood pressure lowering and stroke prevention: a systematic review and network meta-analysis protocol. Ann Transl Med 2019; 7:489. [PMID: 31700925 DOI: 10.21037/atm.2019.08.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Hypertension is a leading cause of stroke and the significance of blood pressure lowering treatment strategies for prevention of stroke has been well established. Despite the established and widespread use of BP lowering drugs, which one is better for stroke prevention is still debated. This study aimed to determine the most effective and safest blood pressure lowering treatments for stroke prevention among various single and combined therapies. Methods A systematic search will be performed in PubMed and the Cochrane Library to identify RCTs and meta analyses of different pharmacological interventions for stroke prevention from January 01, 1966 to December 01, 2018. Primary efficacy outcome will be reduction of stroke incidence and safety outcome will be drug-related side effects withdraw. Study quality will be critically appraised based on the seven-point tool for assessing risk of bias by Cochrane collaboration. Pairwise meta-analyses and Bayesian network meta-analyses will be performed for all related outcome measures. We will conduct subgroup analyses and sensitivity analyses to assess the robustness of our findings. Discussion This network meta-analysis will summarize the direct and indirect evidence aiming to provide a ranking of various blood pressure lowering strategies for prevention of stroke. The results of this meta-analysis may help the physicians in determining the best treatments for their patients in stroke prevention. Trial registration CRD42018118454.
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Affiliation(s)
- Xiao-Ling Zhong
- Department of Neurology, Qingdao Central Hospital, Qingdao University, Qingdao 266031, China
| | - Yi Dong
- Department of Neurology and Institute of Neurology, WHO Collaborating Center for Research and Training in Neurosciences, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Wei Xu
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao 266071, China
| | - Li Sun
- Department of Neurology, Qingdao Central Hospital, Qingdao University, Qingdao 266031, China
| | - Hui-Fu Wang
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao 266071, China
| | - Hong-Qi Li
- Department of Neurology and Institute of Neurology, WHO Collaborating Center for Research and Training in Neurosciences, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yu-Yuan Huang
- Department of Neurology and Institute of Neurology, WHO Collaborating Center for Research and Training in Neurosciences, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Lan Tan
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao 266071, China
| | - Qiang Dong
- Department of Neurology and Institute of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai 200040, China
| | - Jin-Tai Yu
- Department of Neurology and Institute of Neurology, WHO Collaborating Center for Research and Training in Neurosciences, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
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Abstract
Although mineralocorticoid antagonists (MRAs) have been proposed as effective fourth-line blood pressure (BP) lowering agents in resistant hypertension, this effect in heart failure is undetermined. In this synthesis of heart failure randomized controlled trials (RCTs), we evaluated the extent of BP lowering following MRA treatment against placebo. We searched Medline and the Cochrane Collaboration Library databases from 1991 to September 2016 for RCTs, in which MRAs were compared with placebo. The quality of RCTs was assessed with Cochrane risk of bias tool. Outcomes were the extent of systolic and diastolic BP lowering. We included seven studies (13,354 patients, 65.8% males, mean age of 66.3 years, mean follow-up period of 9.4 months, mean baseline BP of 123.5/75.0 mmHg) of MRAs compared with placebo. MRAs were not significantly associated with systolic - 1.8 (95% CI: - 8.0, 4.4) mmHg or diastolic - 0.3 (95% CI: - 3.4, 2.7) mmHg, BP reduction. Although systolic BP was not lowered by spironolactone, diastolic BP was lowered by - 3.0 (95% CI: - 3.4, - 2.6) mmHg. Eplerenone treatment did not significantly lowered systolic [- 0.04 (95% CI: - 4.4, 4.3) mmHg], but it was associated with minimal diastolic BP increase [1.0 (95% CI: 0.5, 1.53) mmHg]. MRAs were not associated with systolic and diastolic BP reduction in heart failure patients. This finding suggests that MRAs should be used according to their indications in heart failure independently of initial BP levels.
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11
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Schrader J, Schrader B. [Antihypertensive therapy in the elderly]. Herz 2017; 43:197-206. [PMID: 29188356 DOI: 10.1007/s00059-017-4642-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Arterial hypertension is the most common modifiable risk factor for cerebrovascular and cardiovascular morbidity and mortality in old age. The prevention of cognitive brain disorders is also a therapeutic goal of long-term treatment of hypertension. Older patients also have a higher risk of developing cardiovascular diseases and therefore benefit from a relatively moderate reduction in blood pressure. With respect to the high prevalence of hypertension in old age and the increasing incidence with time, the therapy of hypertension is becoming increasingly more important to achieve an improved prognosis for patients along with a reduction of costs. The accurate blood pressure measurement for elderly patients includes repeated measurements while standing and sitting. Additionally, the measurements should also be conducted by the patient or by a family member. The most accurate method for assessing the daily blood pressure level, e.g. practice hypertension, non-dipping and intermittent hypertension, is the 24-h blood pressure measurement by ambulatory blood pressure monitoring (ABPM). General measures and lifestyle interventions are effective for reducing blood pressure of elderly patients with hypertension and a low salt diet is scientifically proven to be superior. The same drugs used for young people are also recommended for older patients and most give preference to diuretics, renin-angiotensin-aldosterone system (RAAS) inhibitors and calcium antagonists. The target blood pressure in elderly patients is repeatedly the focus of scientific discussions. The current recommendations are presented in the text and the characteristics which must be particularly considered in the therapy of elderly patients are presented in detail.
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Affiliation(s)
- J Schrader
- Medizinische Klinik, St.-Josefs-Hospital Cloppenburg, Krankenhausstr. 13, 49661, Cloppenburg, Deutschland.
| | - B Schrader
- Medizinische Klinik, St.-Josefs-Hospital Cloppenburg, Krankenhausstr. 13, 49661, Cloppenburg, Deutschland
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12
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Gottsäter A. Pharmacological secondary prevention in patients with mesenterial artery atherosclerosis and arterial embolism. Best Pract Res Clin Gastroenterol 2017; 31:105-9. [PMID: 28395781 DOI: 10.1016/j.bpg.2016.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 07/20/2016] [Indexed: 01/31/2023]
Abstract
Visceral arteries such as the coeliac (CA), superior mesenteric (SMA), and the inferior mesenteric artery (IMA) might be affected by atherosclerotic occlusive lesions with or without thrombosis or embolization causing ischaemic symptoms from the gastrointestinal tract. After treatment of an acute event, these patients should be offered both non-pharmacological and pharmacological secondary prevention to reduce risk for future ischaemic arterial manifestations. Patients with mesenteric ischaemia caused by atherosclerosis should be evaluated concerning platelet antiaggregation with low dose aspirin or clopidogrel, and those with cardioembolic disease should be recommended anticoagulant treatment with either warfarin or one of the direct oral anticoagulants (DOAC; apixaban, dabigatran, edoxaban, or rivaroxaban). In all patients, blood pressure should be lowered to <140/90 mmHg with ACE-inhibitors, angiotensin receptor blockers, beta blockers, calcium channel blockers, or thiazide diuretics, and LDL-cholesterol should be kept at <1.8 mmol/l, preferably with statins. If present, diabetes should be treated aiming at good metabolic control, and all smokers should be recommended cessation.
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13
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Schernthaner G, Drexel H, Rosenkranz A, Schernthaner GH, Watschinger B. [Antihypertensive therapy in diabetes mellitus: Guidelines of the Austrian Diabetes Association 2016]. Wien Klin Wochenschr 2017; 128 Suppl 2:S62-7. [PMID: 27052224 DOI: 10.1007/s00508-015-0924-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Blood pressure lowering is one of the most important interventions for reducing the vascular complications and mortality in patients with diabetes mellitus. Recent studies indicate that the optimal blood pressure level might be in the range between 130-140 mmHg systolic and 80‒90 mmHg diastolic. Lower blood pressure levels (e.g. 120/80 mmHg) can further reduce the risk for stroke and diabetic nephropathy, but are associated with increased cardiovascular mortality. In particular, very low blood pressure levels (< 120 mmHg) should be avoided in patients with coronary heart disease or peripheral arterial disease. Most patients with diabetes mellitus need antihypertensive combination therapies, whereby ACE-inhibitors or Angiotensin-II receptor antagonists should be first line drugs.
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Affiliation(s)
| | - Heinz Drexel
- Abteilung für Innere Medizin und Kardiologie, Landeskrankenhaus Feldkirch, Feldkirch, Österreich
| | - Alexander Rosenkranz
- Klinische Abteilung für Nephrologie, Medizinische Universitätsklinik Graz, Graz, Österreich
| | - Gerit-Holger Schernthaner
- Klinische Abteilung für Angiologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien, Wien, Österreich
| | - Bruno Watschinger
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
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14
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Bicknell CD, Kiru G, Falaschetti E, Powell JT, Poulter NR. An evaluation of the effect of an angiotensin-converting enzyme inhibitor on the growth rate of small abdominal aortic aneurysms: a randomized placebo-controlled trial (AARDVARK). Eur Heart J 2016; 37:3213-3221. [PMID: 27371719 PMCID: PMC5181384 DOI: 10.1093/eurheartj/ehw257] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/09/2016] [Accepted: 05/31/2016] [Indexed: 11/18/2022] Open
Abstract
Aims The AARDVARK (Aortic Aneurysmal Regression of Dilation: Value of ACE-Inhibition on RisK) trial investigated whether ACE-inhibition reduces small abdominal aortic aneurysms (AAA) growth rate, independent of blood pressure (BP) lowering. Methods and results A three-arm, multi-centre, single-blind, and randomized controlled trial (ISRCTN51383267) was conducted in 14 hospitals in England. Subjects aged ≥55 years with AAA diameter 3.0–5.4 cm were randomized 1:1:1 to receive perindopril arginine 10 mg, or amlodipine 5 mg, or placebo and followed 3–6 monthly over 2 years. The primary outcome was aneurysm growth rate (based on external antero-posterior ultrasound measurements in the longitudinal plane), determined by multi-level modelling to provide maximum likelihood estimates. Two hundred and twenty-four subjects were randomized (2011–2013) to placebo (n = 79), perindopril (n = 73), or amlodipine (n = 72). Mean (SD) changes in mid-trial systolic BP (12 months) were 0.5 (14.3) mmHg, P = 0.78 compared with baseline, −9.5 (13.1) mmHg (P < 0.001), and −6.7 (12.0) mmHg (P < 0.001), respectively. No significant differences in the modelled annual growth rates were apparent [1.68 mm (SE 0.2), 1.77 mm (0.2), and 1.81 mm (0.2), respectively]. The estimated difference in annual growth between the perindopril and placebo groups was 0.08 mm (CI −0.50, 0.65). Similar numbers of AAAs in each group reached 5.5 cm diameter and/or underwent elective surgery: 11 receiving placebo, 10 perindopril, and 11 amlodipine. Conclusion Small AAA growth rates were lower than anticipated, but there was no significant impact of perindopril compared with placebo or placebo and amlodipine, combined despite more effective BP lowering.
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Affiliation(s)
- Colin D Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Gaia Kiru
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Emanuela Falaschetti
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Janet T Powell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Neil R Poulter
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
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15
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Huge V. [Critical care management of intracerebral hemorrhage]. Med Klin Intensivmed Notfmed 2018; 113:164-73. [PMID: 27221095 DOI: 10.1007/s00063-016-0154-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 02/15/2016] [Accepted: 02/21/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Intracerebral hemorrhage accounts for up to 20 % percent of all ischemic strokes. In addition to a higher mortality, they are often associated with severe neurological impairment for those affected. OBJECTIVES Review of the current literature and guidelines addressing the critical care management of spontaneous intracerebral hemorrhage, including treatments to reduce primary and secondary neurological damage. RESULTS Acute blood pressure lowering to less than 140 mmHg should be aspired immediately after intensive care admission. During the following days blood pressure variability should be minimized. Preexisting oral anticoagulation should be immediately reversed, while hemostatic therapy not associated with reversal of antithrombotic therapy should not be applied. Surgery for patients with impaired consciousness should be discussed. Use of pneumatic compression in immobile patients is recommended. Developing intracranial hypertension should be treated with combined physical and pharmacological measures in a stepwise approach. Administration of glucocorticoids is currently not recommended. CONCLUSIONS Critical care management of spontaneous hemorrhage demands a multimodal, graded approach for reduction of both primary and secondary neurological damage.
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