Abstract
Midlife elevated blood pressure (BP) is an important risk factor associated with brain structure and function. Little is known about trajectories of BP that modulate this risk. To identify BP trajectory patterns from young adulthood to midlife that are associated with brain structure in midlife. This cohort study used data of US adults from Coronary Artery Risk Development in Young Adults (CARDIA), a prospective longitudinal study of Black and White men and women (baseline age 18 to 30 years) examined up to 8 times over 30 years (1985-1986 to 2015-2016). There were 885 participants who underwent brain magnetic resonance imaging (MRI) in the 25th or 30th year examinations. Analyses were conducted November 2019 to December 2020. Using group-based trajectory modeling, 5 25-year BP trajectories for 3 BP traits were identified in the total CARDIA cohort of participants with 3 or more BP measures, which were then applied to analyses of the subset of 853 participants in the Brain MRI substudy. Mean arterial pressure (MAP) was examined as an integrative measure of systolic and diastolic BP. With linear regression, the associations of the BP trajectories with brain structures were examined, adjusting sequentially for demographics, cardiovascular risk factors, and antihypertensive medication use. Brain MRI outcomes include total brain, total gray matter, normal-looking and abnormal white matter volumes, gray matter cerebral blood flow, and white matter fractional anisotropy. Brain MRI analyses were conducted on 853 participants (mean [SD] age, 50.3 [3.6] years; 399 [46.8%] men; 354 [41.5%] Black and 499 [58.5%] White individuals). The MAP trajectory distribution was 187 individuals (21.1%) with low-stable, 385 (43.5%) with moderate-gradual, 71 (8.0%) with moderate-increasing, 204 (23.1%) with elevated-stable, and 38 (4.3%) with elevated-increasing. Compared with the MAP low-stable trajectory group, individuals in the moderate-increasing and elevated-increasing groups were more likely to have higher abnormal white matter volume (moderate: β, 0.52; 95% CI, 0.23 to 0.82; elevated: β, 0.57; 95% CI, 0.19 to 0.95). Those in the MAP elevated-increasing group had lower gray matter cerebral blood flow (β, -0.42; 95% CI, -0.79 to -0.05) after adjusting for sociodemographics and cardiovascular risk factors. After adjustment for antihypertensive medication use, the difference was consistent for abnormal white matter volume, but results were no longer significant for gray matter cerebral blood flow. Among young adults with moderate to high levels of BP, a gradual increase in BP to middle-age may increase the risk in diffuse small vessel disease and lower brain perfusion.
Highlights
Clinical decisions about when to start treating elevated blood pressure (BP) are currently based on reducing the 10-year risk for atherosclerotic cardiovascular disease, including stroke
We examined the associations of early adulthood systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) trajectories with brain magnetic resonance imaging (MRI) outcomes in midlife
Five trajectory groups for each of Mean arterial pressure (MAP), SBP, and DBP were estimated and labeled as follows: (1) low-stable group, consisting of participants who maintained low BP levels throughout the study period (MAP, 917 individuals [19.6%]; SBP, 1071 individuals [22.9%]; DBP, 941 individuals [20.1%]); (2) moderate-gradual group, comprising individuals who started at moderate BP levels and experienced gradual increases
Summary
Clinical decisions about when to start treating elevated blood pressure (BP) are currently based on reducing the 10-year risk for atherosclerotic cardiovascular disease, including stroke. A recent randomized trial, the Systolic Blood Pressure Intervention Trial-Memory and Cognition in Decreased Hypertension,[1] showed that treating systolic BP intensively to a goal of below 120 mm Hg compared with treating to the standard goal of below 140 mm Hg reduced a combined outcome of probable dementia and mild cognitive impairment. Studies suggest knowing this history may improve clinical interpretations and decisions regarding treatment in mid- and late-life. Treatment of high BP could prevent known effects of elevated BP as a risk factor for cognitive impairment[2,3] and dementia.[2,4]. Evidence suggests that midlife measures may be more informative than concurrently measured BP about future risk for preventing late-life cognitive impairment,[5,6] dementia,[7,8] and brain pathology.[9,10] Treatment of high BP could prevent known effects of elevated BP as a risk factor for cognitive impairment[2,3] and dementia.[2,4] evidence suggests that midlife measures may be more informative than concurrently measured BP about future risk for preventing late-life cognitive impairment,[5,6] dementia,[7,8] and brain pathology.[9,10]
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