Real-world characterization of clinical management and achievement of the recommended risk-based low-density lipoprotein cholesterol and blood pressure goals in patients with arterial hypertension and dyslipidemia. The SNAPSHOT study.

Optimal diabetes care and risk factor management are important to delay micro- and macrovascular complications in individuals with type 1 diabetes (T1D). Ongoing improvement of management strategies requires the evaluation of target achievement and identification of risk factors in individuals who do (or do not) achieve these targets. Cross-sectional data were collected from adults with T1D visiting six diabetes centers in the Netherlands in 2018. Targets were defined as glycated hemoglobin (HbA1c) <53 mmol/mol, low-density lipoprotein-cholesterol (LDL-c) <2.6 mmoL/L (no cardiovascular disease [CVD] present) or <1.8 mmoL/L (CVD present), or blood pressure (BP) <140/90 mm Hg. Target achievement was compared for individuals with and without CVD. Data from 1737 individuals were included. Mean HbA1c was 63 mmol/mol (7.9%), LDL-c was 2.67 mmoL/L, and BP 131/76 mm Hg. In individuals with CVD, 24%, 33%, and 46% achieved HbA1c, LDL-c, and BP targets respectively. In individuals without CVD these percentages were 29%, 54%, and 77%, respectively. Individuals with CVD did not have any significant risk factors for HbA1c, LDL-c, and BP target achievement. In comparison, individuals without CVD were more likely to achieve glycemic targets if they were men and insulin pump users. Smoking, microvascular complications, and the prescription of lipid-lowering and antihypertensive medication were negatively associated with glycemic target achievement. No characteristics were associated with LDL-c target achievement. Microvascular complications and antihypertensive medication prescription were negatively associated with BP target attainment. Opportunities for improvement of diabetes management exist for the achievement of glycemic, lipid, and BP targets but may differ between individuals with and without CVD.

Blood Pressure Goals: How Low Is Safe in CKD?

How Does SPRINT (Systolic Blood Pressure Intervention Trial) Direct Hypertension Treatment Targets for CKD?

Lowering Blood Pressure to Lower the Risk of Cardiovascular Events in CKD

Management of Hypertension in Patients With Diabetic Kidney Disease: Summary of the Joint Association of British Clinical Diabetologists and UK Kidney Association (ABCD-UKKA) Guideline 2021

A 70-year-old, right-handed African American woman with diabetes mellitus, treated with an oral hypoglycemic, and untreated mild hypertension developed right-sided face, arm, and leg weakness while at home preparing breakfast. She was able to reach the telephone and dial 911. An ambulance was summoned, and the Emergency Medical Service team, on arrival, noted a right facial droop, dysarthria, and right-sided weakness. She was transported to a local hospital, arriving within an hour of the onset of the event. The hospital stroke team was consulted and initiated an evaluation. The patient was afebrile, with a pulse of 72 and a blood pressure of 170/90 mm Hg. Neck was supple with no carotid bruits. Temporal arteries were nontender. Heart was regular with no murmurs or gallops. Peripheral pulses were 2+, and capillary refill was good. There were no peripheral bruits. She was awake, lucid, alert, and well oriented. She did not report headache. Speech was dysarthric, but comprehension was good and she spoke in fully formed sentences. There was no sensory neglect or extinction. Cranial nerve examination revealed equal, reactive pupils and full visual fields; funduscopic examination disclosed grade I hypertensive changes. She had a flattened nasolabial fold on the right, but was able to close her eyes and wrinkle her forehead. Motor examination revealed impaired fine motor movements in the right hand, pronator drift of the outstretched right arm, and mild proximal weakness of the right leg; sensory examination revealed decreased vibratory sensation in the distal feet bilaterally. Tendon reflexes were brisk in the right arm; ankle jerks could not be elicited. Plantar response was flexor bilaterally. Coordination in the arms and legs was normal, allowing for proximal weakness. Gait was not tested. A complete blood count, chemistry profile, coagulation studies, and cardiac enzymes and erythrocyte sedimentation rates were obtained, and …

European guidelines on cardiovascular disease prevention in clinical practice<SBT>Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of eight societies and by invited experts)

Analysis of Recent Papers in Hypertension Jan Basile, MD, Senior Editor

Hypertension Guidelines disagree on the definition of the more appropriate blood pressure (BP) target to achieve. A shared feature of Guidelines was the definition of precise (albeit differing across Guidelines) BP targets in different patient categories (Table). Does the evidence support the definition of precise BP targets overall and in different patient categories? Evidence from observational studies. A direct relation between BP and risk of cardiovascular disease emerged from observational studies including a large meta-analysis (Lancet 2002). Most studies showed that after correction for several confounders (cancer; heart failure etc) the lowest cardiovascular risk occurred at low values of achieved BP (&lt;120/80 or even &lt; 100/60 mmHg). Evidence from intervention studies. Meta-analyses of randomized studies between different drugs or BP targets showed two main findings: (a) The larger the BP difference between randomized groups in the achieved BP the greater the benefit (particularly on stroke and heart failure) in the group with the lower achieved BP. (b) When comparing a more intensive with a less intensive BP target (i.e. 120 vs 140 mmHg) the risk of major cardiovascular disease was lower with the more intensive strategy. In a meta-analysis a more intensive strategy reduced stroke by 20%; myocardial infarction by 15%; heart failure by 25%; cardiovascular death by 18% and all-cause death by 11% (Hypertension 2016) when compared to a less intensive strategy. BP targets considerably differed across the studies. Evidence regarding tolerability of treatment. Some Guidelines suggest that a more intensive BP target could be achieved at condition that the treatment is well tolerated. However the concept of good treatment tolerability holds at any level of achieved BP (not only below 140/90 mmHg) irrespective of the BP target. There is no evidence supporting safety thresholds not to be exceeded when the treatment is well tolerated. Conclusion: The lowest well tolerated BP is a reasonable and evidence-based BP target irrespective of the cardiovascular risk status of the patient. Table: BP targets according to major hypertension Guidelines.

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): The following companies have supported the EORP programme: Amgen, Eli Lilly, Pfizer, Sanofi, Ferrer and Novo Nordisk. The sponsors had no role in the design, data collection, data analysis, data interpretation, decision to publish, or writing the manuscript. Background Hypertension is a highly prevalent cardiovascular risk factor, and yet a large proportion of patients with coronary heart disease (CHD) have uncontrolled hypertension. Awareness has been proposed as a factor that can influence hypertension management. Understanding factors that may improve hypertension control in CHD patients is essential due to their high cardiovascular risk. Goal: We aim to explore the distribution and association of hypertension control and awareness in hypertensive patients with established CHD. Methods We analysed data from ESC-EORP EUROASPIRE V, a cross-sectional study including 9018 CHD patients in 27 countries, with data collected through medical records, interview and physical examination. Hypertension was defined by blood pressure (BP) level at physical examination, antihypertensive medication use, and hypertension history. Controlled hypertension was defined as BP &amp;lt;140/90mmHg (140/85mmHg in diabetics). Awareness was studied as awareness of the patient’s BP level, and of the patient’s BP target. Patients were considered aware if they reported to be aware of their latest BP level and their target, and if they indicated their actual and target BP levels correctly (±10mmHg). We used logistic regression with hypertension control as outcome and awareness as determinant. Separate models were fit for actual BP level and BP target level awareness as determinants. We additionally performed a subgroup analysis by middle-income (MIC) and high-income (HIC) countries. Results 5896 subjects were considered hypertensive, from which 39.6% were controlled. 79.2% of patients were aware of their BP level, and 84.5% were aware of their BP target. Hypertension control was more common in HICs (41.3%) than in MICs (35.2%). Patients aware of their BP level (OR 0.47, 95%CI 0.39-0.57) and of their target (0.36, 0.28-0.46) were less likely to have controlled hypertension, compared to unaware patients. Furthermore, hypertension control was associated with age &amp;lt;65 years (0.43, 0.37-0.51 own BP awareness model; 0.43, 0.35-0.52 BP target awareness model), BMI &amp;lt;25 kg/m2 (0.46, 0.37-0.56 own BP awareness model 0.5 0.39-0.64, BP target awareness model) and male sex (1.31,1.09-1.58, own BP awareness model; 1.39, 1.1-1.74 BP target awareness model). Higher education was associated with hypertension control in HICs (1.41, 1.01-1.97 own BP awareness model). Conclusion Control was low in the hypertensive study participants, and it was lower in MICs. Awareness levels were generally high, although it is concerning that 20.7% and 15.5%% of hypertensive patients were not aware of their BP level and their target respectively. Patients with uncontrolled hypertension were more likely to be aware of their own BP level and target. Controlled patients may have a lower risk perception. It is important that prevention efforts work on improving the awareness to prevent development uncontrolled hypertension in the future.

Treatment of hypertension to specific blood pressure (BP) goals is controversial, and the exact goal BP for different clinical populations at high risk for cardiovascular disease (CVD) is hotly debated. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) specifically recommended a goal BP of 130 ⁄80 mm Hg for patients with chronic kidney disease (CKD) or diabetes mellitus (DM). The national kidney foundation (Kidney Disease Outcomes Quality Initiative [KDOQI]) guidelines also recommend a goal BP of 130 ⁄80 mm Hg in patients with CKD and DM and a goal BP of 125 ⁄75 mm Hg in CKD patients with proteinuria >1000 mg ⁄d. More recent, the American Heart Association (AHA) and the European Society of Hypertension ⁄European Society of Cardiology recommended a goal BP of 130 ⁄80 mm Hg in all patients with coronary artery disease (CAD) or CAD risk equivalents, including patients with carotid artery disease, peripheral arterial disease, abdominal aortic aneurysm, and patients with high risk for CVD with a Framingham 10-year risk score >10%. In addition, the AHA also recommended a BP 120 ⁄80 mm Hg in patients with CAD and left ventricular dysfunction. The rationale behind these recommendations in patients with CKD is that these patients are considered to be the ‘‘highest-risk’’ group for CVD. Although patients with CKD have a many-fold increased risk of CVD, there has not been a controlled trial demonstrating superior CVD prevention by lowering BP to the recommended 130 ⁄80 mm Hg goal. So where does this recommendation come from? A recent meta-analysis was conducted to assess whether lower BP targets ( 135 ⁄85) are associated with reduction in mortality and morbidity as compared with standard BP targets of 140–160 ⁄ 90–100 mm Hg. Interestingly, no trials comparing different systolic BP (SBP) targets were found. Seven trials (22,089 patients) comparing different diastolic BP (DBP) targets were included. Primary outcomes were myocardial infarction, stroke, congestive heart failure, major cardiovascular (CV) events, and endstage renal disease. Secondary outcomes were achieved mean SBP and DBP and withdrawals due to adverse effects. Despite a greater achieved reduction in SBP and DBP, the ‘‘lower targets’’ did not improve mortality, myocardial infarction, stroke, congestive heart failure, or end-stage renal disease. Specifically a sensitivity analysis in diabetic patients and in patients with CKD also did not show a reduction in any of the mortality and morbidity outcomes with lower targets as compared with standard targets. Treating patients to lower BP targets does not reduce mortality or morbidity. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study of 4733 diabetics with hypertension echoes the findings of this meta-analysis. Despite a difference of 14 mm Hg in SBP, the primary end points (non-fatal myocardial infarction, nonfatal stroke, or CV death) were not improved by more aggressive BP reduction after nearly 5 years of follow-up. Stroke risk was, however, significantly lower in the intensive BP group (P=.01). Critics of this study have pointed out that although From the Department of Medicine, Hypertension Program, University of Pennsylvania School of Medicine, Philadelphia, PA Address for correspondence: Debbie L. Cohen, MD, Renal Division, University of Pennsylvania School of Medicine, 210 White Building, Philadelphia, PA 19104 E-mail: cohendl@mail.med.upenn.edu

The SPRINT (Systolic Blood Pressure Intervention Trial) findings,1 together with the publication of other major studies within the last year addressing how low blood pressure should be targeted to prevent cardiovascular events in patients with hypertension,2–4 support what we have known for a long time that: (1) blood pressure >115/75 mm Hg is associated with increased risk of cardiovascular disease and stroke, (2) blood pressure lowering is associated with reduced morbidity and mortality, (3) antihypertensive drugs reduce the incidence of hypertension-associated events, and (4) prevention of cardiovascular morbidity is largely related to blood pressure lowering per se, although other effects of the drugs used contribute to this benefit. The questions that are now posed, particularly in response to an editorial commentary by the Editors of this Journal,5 are the following: What is the threshold at which antihypertensive treatment should be initiated? and what target blood pressure should we strive for to achieve maximum benefit in patients with hypertension? SPRINT and other recent meta-analyses and trials provide new data that allow us to sharpen and refine recommendations for blood pressure targets in people with hypertension.1–4 Here, we will briefly address the questions in the worldwide context of hypertension. In hypertensive patients without diabetes mellitus, previous stroke or polycystic kidney disease, SPRINT has provided strong evidence that targeting systolic blood pressure of <120 mm Hg (as measured by an automated measurement protocol in the office)1 provides significantly stronger protection from cardiovascular events and death than the traditionally accepted target of <140 mm Hg. This study was conducted in a hypertensive patient cohort of intermediate-to-high cardiovascular risk. It should be highlighted that the target of 120 mm Hg in SPRINT was based on blood pressure readings using a defined protocol with an office automated device, where blood pressure …

DA VINCI study: Change in approach to cholesterol management will be needed to reduce the implementation gap between guidelines and clinical practice in Europe

Epidemiological studies have established a strong association between hypertension and coronary artery disease (CAD). Hypertension is a major independent risk factor for the development of CAD, stroke, and renal failure. The optimal choice of antihypertensive agents remains controversial, and there are only partial answers to important questions in the treatment of hypertension in the prevention and management of ischemic heart disease (IHD), such as: ● What are the appropriate systolic blood pressure (SBP) and diastolic blood pressure (DBP) targets in patients at high risk of developing CAD or in those with established CAD? ● Are the beneficial effects of treatment simply a function of blood pressure (BP) lowering, or do particular classes of drugs have uniquely protective actions in addition to lowering BP? ● Are there antihypertensive drugs that have shown particular efficacy in the primary and secondary prevention of IHD? ● Which antihypertensive drugs should be used in patients who have established CAD with stable or unstable angina pectoris, in those with non–ST-elevation myocardial infarction (NSTEMI), and in those with ST-elevation myocardial infarction (STEMI)?

Epidemiological studies have established a strong association between hypertension and coronary artery disease (CAD). Hypertension is a major independent risk factor for the development of CAD, stroke, and renal failure. The optimal choice of antihypertensive agents remains controversial, and there are only partial answers to important questions in the treatment of hypertension in the prevention and management of ischemic heart disease (IHD), such as: This scientific statement summarizes the published data relating to the treatment of hypertension in the context of CAD prevention and management and attempts, on the basis of the best available evidence, to develop recommendations that will be appropriate for both BP reduction and the management of CAD in its various manifestations. Where data are meager or lacking, the writing group has proposed consensus recommendations, with all of the reservations that that term implies and with the hope that large gaps in our knowledge base will be filled in the near future by data from well-designed prospective clinical trials. All of the discussion and recommendations refer to adults. The writing committee has not addressed hypertension or IHD in the pediatric age group. Also, there is no discussion of the different …