Excessive Blood Pressure Reduction Research Articles

Effectiveness of the intelligent hypertension excellence centers (iHEC) therapy model in the blood pressure management of older hypertensive patients: a randomized controlled trial.

Intelligent hypertension excellence centers (iHEC) may improve blood pressure (BP) management in older hypertensive patients. However, this has not yet been rigorously evaluated, so we conducted a prospective randomized open-label clinical trial to verify this hypothesis. Older patients with hypertension were recruited between January and June 2022. The control group received conventional treatment and visited doctors in clinic. The intervention group received the iHEC therapy model, including remote BP management, online consultation, and follow-up services with support from the internet. Both groups received 12 months follow-up. Finally, 540 older patients with hypertension participated in the study; of these, 517 completed the follow-up. The average age was 71.4 ± 3.7years, 81 patients with frailty (15.7%). When follow-up was terminated, the SBP of the intervention group was 4.2 mmHg lower than that of the control group (95% CI, 2.0 to 6.4, P < 0.001), and the overall BP control rate in the intervention group was higher than that in the control group (60.2% vs. 48.1%, P < 0.05). During follow-up, the new-onset rate of excessive BP lowering in the intervention group was lower than that in the control group (3.8% vs. 9.0%, P < 0.05). Patients with a median age or above and high school education or above had higher numbers of online consultations and home BP measurements (P < 0.05).Our study confirmed those who received the iHEC therapy model achieved better BP reduction, higher rates of BP control, and alleviated the risk of excessive BP reduction.

Comparative Proteomic and Phosphoproteomic Analyses Reveal Molecular Signatures of Myocardial Infarction and Transverse Aortic Constriction in Aged Mouse Models.

In the elderly population, coronary heart disease (CHD) often coexists with hypertension. However, excessive blood pressure reduction can paradoxically increase the incidence of adverse events. Understanding the molecular mechanisms underlying hypertension and CHD in aged populations is crucial for developing targeted therapies and improving clinical outcomes. In this study, we constructed myocardial infarction (MI) and transverse aortic constriction (TAC) modelsY in aged mice to simulate the disease states of CHD and hypertension, respectively. Using integrated proteomic and phosphoproteomic analyses, we investigated the molecular signatures associated with MI and TAC in these models. Our aim was to identify key molecules involved in these conditions and to understand their unique and shared characteristics. Through our comprehensive proteomic and phosphoproteomic analysis, we identified a total of 1583 proteins and 232 phosphorylated proteins. We observed significant upregulation of heart disease markers such as Myh7, Xirp2, and Acta1, indicating the successful establishment of the MI and TAC models. The overlapped differentially expressed proteins (DEPs) and differentially phosphorylated proteins (DPPs) in MI and TAC were involved in heart failure-related processes including cardiac muscle contraction and hypertrophic cardiomyopathy, further supporting the validity of the models. Among the DEPs, Ppme1 was upregulated in the TAC model but downregulated in the MI model, while Sec31a and Gm56451 displayed the opposite expression patterns. Among the DPPs, Ablim1 and Atp2a2 were found to be significantly upregulated in the TAC model, whereas their expression was markedly reduced in the MI model. In addition, five other DPPs, including REV_Q3TAY5, Cbx3, PITPNB, Eif4b, and A0A1Y7VP73, were elevated in the MI model but decreased in the TAC model. In conclusion, these findings suggest that MI and TAC not only share certain molecular features but also retain their unique characteristics, providing potential biomarkers and therapeutic targets.

Two-Drug Combinations Therapy of Different Doses of Valsartan Existing Diverse Significance for Hypertensive Patients.

The incidence of hypertension and clinical complications (e.g., heart, cerebrovascular and kidney injury) is increasing worldwide. It is widely known that a relatively large dose of valsartan (320 mg) could alleviate clinical complications. The current network meta-analysis assessed which drug could be combined with a relatively large dose of valsartan to control blood pressure (BP) more effectively. And which combination therapy with different dosages of valsartan did not induce excessive BP reduction with increasing dosages of valsartan. The PubMed, Embase, Medline, Cochrane Library, CNKI, Wanfang, and CSTJ databases were searched from inception to October 2022 for relevant randomized controlled trials (RCTs). The search strategies included concepts related to hypertension and two-drug combination therapy of different doses of valsartan, and there were no language or data restrictions. The outcomes included adverse effects and changes in systolic BP and diastolic BP. Permanent discontinuations related to treatment were the most accurate and objective measure of adverse effects. The common adverse effects of most studies (i.e., dizziness, headache, nasopharyngitis, asthenia and urticaria) were also included. A Bayesian network meta-analysis was performed, and mean differences with 95% confidence intervals were calculated. ADDIS and STATA were used for Bayesian model network meta-calculation. Thirty-four RCTs were included involving 26,752 patients, and the interventions included different doses of valsartan combined with various types and doses of drugs. Among many combination therapies, the combination of valsartan 320 mg with amlodipine 10 mg (p 0.01) had the best antihypertensive effect without significant adverse effects. Compared with valsartan 80 mg and 160 mg, valsartan 320 mg combined with hydrochlorothiazide 25 mg (p 0.05) did not further reduce BP and was not shown to increase the incidence of adverse effects. Combination therapy with a relatively large dose of valsartan could control BP and improve clinical complications effectively. However, for hypertensive patients with different treatment requirements, specific choices should be made regarding whether to control BP, treat clinical complications, or both.

Left ventricular global function index and peculiarities of daily blood pressure profile in patients with arterial hypertension

BACKGROUND: The left ventricular global function index (LVGFI), determined using transthoracic echocardiography, is a simple clinical marker of left ventricular dysfunction and has superior prognostic value to the standard ejection fraction-based assessment of cardiac pump function. The methodology for calculating this index was proposed in 2019. Currently, the clinical factors that influence the state of left ventricular global functions are not examined.&#x0D; AIM: This study aimed to assess the association of LVGFI with the peculiarities of daily blood pressure (BP) profile in patients with arterial hypertension (AH).&#x0D; MATERIALS AND METHODS: A total of 104 patients [51 men (49%) and 53 (51%) women] with AH were examined. The mean age of the patients was 58.711.73 years, and disease duration was 6.0310.93 years. AH corresponded to grades 1, 2, and 3 in 47 (45.2%), 26 (25.0%), and 31 (29.8%) patients, respectively. Patients with myocardial infarction or stroke, cardiomyopathies, heart defects, diabetes mellitus, thyroid dysfunction, or chronic kidney disease were not included in the study. All patients underwent daily BP monitoring, echocardiography, carotid artery examination, and biochemical blood tests.&#x0D; RESULTS: A significant inverse weak correlation of LVGFI with age (r=0.215, p=0.028), body mass index (r=0.378, p=0.001), BP variability (r=0.307, p=0.002), and daily mean values of systolic (r=0.223, p=0.026) and diastolic (r=0.237, p=0.018) BP were observed. In the regression analysis, an increase in body mass index, abnormal diurnal BP with excessive BP reduction at night, and high BP variability demonstrated a significant and independent association with decreased LVGFI.&#x0D; CONCLUSIONS: The study revealed an independent association of decreased LVGFI with increased body mass index, excessive BP reduction at night, and high systolic BP variability. These factors should be considered in the possible development of a strategy to prevent target organ damage in AH.

Drug interactions with angiotensin-converting enzyme inhibitors

We reviewed potentially clinically significant drug–drug interactions (DDIs) with angiotensin-converting enzyme inhibitors (ACEIs) using Stockley’s Drug Interactions books and two online DDI databases. We identified &gt;10 such DDIs and described their mechanisms, clinical evidence and importance, as well as their management. Most DDIs with ACEIs were pharmacodynamic; only a few were pharmacokinetic. Most DDIs with ACEIs involved drugs that can lead to excessive reduction of blood pressure, hyperkalemia and impaired renal function. There is some evidence linking ACEIs with the induction of lithium toxicity. Severe hypersensitivity reactions may occur in patients treated with ACEIs with concomitant use of allopurinol or parenteral applications of iron. ACEIs should be combined carefully with hepatotoxic drugs due to their own potential hepatotoxic effects. The prevalence of adverse drug reactions due to DDIs might be high because they are prescribed frequently. Fortunately, most of such DDIs can be managed by clinical and laboratory monitoring of patients or by dosage adjustments of concomitantly used drugs.

PRESERVE: Randomized Trial of Intensive Versus Standard Blood Pressure Control in Small Vessel Disease.

[Figure: see text].

HIGH PREVALENCE OF HIGH BLOOD PRESSURE AND EXCESSIVE BLOOD PRESSURE REDUCTION IN PATIENTS WITH “CONTROLLED” ARTERIAL HYPERTENSION AFTER MYOCARDIAL INFARCTION AND STROKE

Objective: Arterial hypertension (AH) is important risk factor and its control is a cornerstone of primary and secondary prevention. On the other hand, excessive blood pressure (BP) reduction may be harmful, especially in patients with the history of ischemic events. To assess AH control we performed 24-hours ambulatory blood pressure monitoring (ABPM) in patients with AH in remote period after myocardial infarction (MI) or ischemic stroke (IS) in whom AH was believed to be controlled accordingly BP office measurements. Design and method: 64 patients with AH and previous (at least 6 months after) MI (39 patients, 64.1% men) and IS (25 patients, 36.0% men) with normal office BP (120–139 mm Hg/60–89 mm Hg) during two consecutive visits were involved into the study. ABPM was performed and mean values of systolic BP (SBP) and diastolic BP (DBP) were assessed. Excessive BP reduction (EBPR) was considered as SBP below 100 mm Hg at daytime. Prolonged EBPR was considered as EBPR more than 1 hour of consecutive measurements. Results: Groups did not differ significantly in age, body mass index, glomerular filtration rate, number of antihypertensive drugs, prevalence of diabetes. Mean 24-hour SBP was higher in IS group (131.9/76.4 ± 11.7/7.3 mm Hg) comparing to 118.5/71.3 ± 11.0/9.0 mm Hg in MI group (p &lt; 0,00001 for both SBP and DBP). Mean 24-hour SBP higher than 140/90 mm Hg was found in 28.0% patients in IS and only in 2.6% patients in MI group (p = 0.002). Much more episodes of EBPR were detected in MI than in IS group (10.2 ± 10.8 vs 4.0 ± 3.9, p = 0.008) and number of patients with at least one prolonged EBPR was also higher in MI group (23.1% vs 8.0%). Patients with prolonged EBPR did not differ significantly in age, body mass index, glomerular filtration rate, prevalence of diabetes and number of antihypertensive drugs. Conclusions: Around a quarter of patients in remote period after IS had high BP levels whereas similar proportion of patients after MI had prolonged episodes of excessive hypotension during ABPM. Office BP measurements may be not sufficient to detect inadequacy of AH control in secondary prevention.

Effectiveness of arterial hypertension control using ambulatory blood pressure monitoring in patients in the remote period after myocardial infarction and ischemic stroke

Arterial hypertension is one of the most important modified risk factors and its adequate control is a cornerstone of primary and secondary prevention. On the other hand, excessive lowering of blood pressure can be harmful, especially in patients with a history of ischemic events. The aim: To evaluate daily blood pressure fluctuations with ambulatory blood pressure monitoring in patients with controlled hypertension according to office measurements in the remote period after myocardial infarction and ischemic stroke Materials and methods: The study involved 64 patients with hypertension in remote period (at least 6 months) after myocardial infarction (38 patients) and ischemic stroke (26 patients) with systolic blood pressure during the last three months and at least two visits. in the range of 120-139 mm Hg and diastolic blood pressure 70–89 mm Hg. Patients with valvular heart disease, severe arrhythmias, significant heart failure (NYHA III-IV) were not included in the study.All patients underwent daily blood pressure monitoring. According to the recommendations of ESC / ESH in 2018, the optimal blood pressure control was considered to be the average daily blood pressure after myocardial infarction 130–140 / 70–79 mm Hg. at the age of >65 years, 120–130 / 70–79 mm Hg at the age of ≤65 years; after ischemic stroke 120–130 / <80 mm Hg. All values below the optimal levels were considered to be low blood pressure, higher than optimal – high blood pressure. Particular attention was paid to excessive reduction of blood pressure with the calculation of the number of excessive reductions and their duration during the day. Results: The average daily blood pressure values corresponded to the definition of optimal in only 23.4 % of patients with ischemic events. In 63.2 % of patients after myocardial infarction, the mean daily values of systolic blood pressure and diastolic blood pressure were lower than recommended, and in patients after ischemic stroke, this number was significantly lower – 23.1 %. Conversely, in more than half of the patients after ischemic stroke (53.6 %) the average daily blood pressure levels exceeded the recommended ones. In patients after myocardial infarction, this number was only 13.2 %. Excessive reductions in blood pressure were recorded in 58 of 64 patients (90.6 %), in 54 persons such episodes were observed during the day (84.3 %). Persistent (over 1 hour) excessive decrease in blood pressure was registered in 16 people (25.0 %), 8 of whom had persistent excessive blood pressure reductions ≥2/day (12.5 %). Predictors of excessive blood pressure lowering were males, myocardial infarction, beta-blockers. Conclusions: Patients with hypertension after myocardial infarction or ischemic stroke require regular monitoring of blood pressure, even in cases where blood pressure is within the recommended range for some time. It is necessary to take into account the risk not only of increasing but also of excessive lowering of blood pressure

Impact of aggressive blood pressure reduction on kidney function after renal denervation: long-term outcome

Objective. To investigate the dynamics of renal function in patients with resistant arterial hypertension after renal denervation depending on the degree of central and peripheral blood pressure (BP) reduction and the baseline state of the kidneys.Design and methods. A total of 22 patients (mean age 56,1 ± 10,2 years, 9 males) with treated resistant hypertension undergoing bilateral renal denervation (RDN) (Symplicity RDN System, Medtronic, USA) were included. Office BP measuring, 24-hour ambulatory BP monitoring (ABPM) (SpaceLabs 90207, USA), applanation tonometry (SphygmoCor, AtCor Medical, Australia) with the calculation of central aortic blood pressure (CAP), Doppler ultrasonography (Vivid 7 dimension) were obtained at baseline and at 1, 3, 6, 12, 18 and 24 months after RDN. Urine levels of NGAL (neutrophil gelatinase-associated lipocalin), KIM-1 (kidney injury molecule 1), L-FABP (Liver-type fatty acid binding protein), albuminuria and serum levels of сystatin C (sCysC) and creatinine (sCr) were measured by quantitative enzyme immunoassay at baseline and at 1, 3, 6, 12, 18 and 24 months after RDN. Glomerular filtration rate was estimated by the level of sCr and sCysC by CKD-EPI formula.Results. All patients were divided into 3 groups according BP reduction: 1 — BP increase above 0 mm Hg; 2 — BP reduction from 0 to –30 mm Hg; 3 — BP reduction by &gt; 31 mm Hg. An increased sCysС was registered in a group with decreased 24-hour systolic BP (1,06 ± 0,41; 0,93 ± 0,18 and 1,22 ± 0,23 ng/mL; F = 2,882; р = 0,04) and increased urine KIM-1 level — in a group with decreased office diastolic BP (2,18 ± 1,94; 1,53 ± 1,02 and 4,41 ± 0,97 pg/mL; F = 3,663; р = 0,03) at 3-month follow-up. An increased sCr level was registered in a group with decreased 24-hour systolic BP (78,3 ± 3,7; 88,2 ± 6,8 and 142,00 ± 8,8 μmol/L; F = 61,987; p = 0,004) and diastolic CAP (83,4 ± 8,2; 82,0 ± 8,0 and 142,0 ± 9,4 μmol/L; F = 23,476; p = 0,01), also an increased urine L-FABP level — in a group with decreased office diastolic BP (3531,3 ± 1795,0; 997,5 ± 1096,8 and 7351,7 ± 3297,0 pg/mL; F = 12,103; p = 0,002) at 6-month follow up.Conclusions. Renal function worsening in patients during the period of maximum BP lowering may be associated with an excessive BP reduction. Therefore, we can suggest the occurrence of the J-curve phenomenon in relation to the kidneys.

Abstract WMP100: Excessive Blood Pressure Reduction Increases the Risk of Acute Kidney Injury After Intracerebral Hemorrhage

Background: Elevated blood pressure (BP) in the first 24 hours of admission of acute intracerebral hemorrhage (ICH) has been the focus of intensive therapeutic investigation, although early intensive BP lowering addresses a concern about development of acute kidney injury (AKI). However, it is unclear as to the effect of BP measure including the absolute BP reduction and increased BP variability on AKI in patients with acute ICH. Methods: We retrieved data of consecutive patients with acute ICH from our prospective stroke registry between July 2015 and August 2017. We excluded patients with preexisting end-stage renal disease or in-hospital death within 24 hours. The primary outcome was AKI within 7days after admission defined using the AKI Network criteria. We recorded BP on emergency department arrival and for every 1 hour from 1 to 24 hours after admission (25 measurements). We measured mean systolic BP (SBP) and maximum minus minimum SBP within both 12 hours and 24 hours, and also quantified SBP variabilities (SBPV) including standard deviation, coefficient of variation, successive variation, and average real variability. Results: Among 361 patients with ICH (age 72.7±12.8, male 55%, non-lobar 76%), 31 (9%) developed AKI. For all SBP measure, the 12-hour SBP reduction was associated with the increased risk of AKI in multivariable analysis (odds ratio [per10 mmHg increase] 1.30; 95% CI 1.10-1.35). There was no significant association between the SBP variability and risk of AKI. The area under the receiver operating characteristic curve of the 12-hour SBP reduction for predicting AKI was 0.75. The association between the 12-hour SBP reduction and AKI was not modified by preexisting chronic kidney disease (interaction P=0.40). Conclusion: Early BP reduction in the first 12 hours of admission contributed to the risk of AKI in acute ICH. This may have clinical implication to avoid excess absolute BP reduction in patients with acute ICH.

More accurate systolic blood pressure measurement is required for improved hypertension management: a perspective.

The commonly used techniques for systolic blood pressure (SBP) and diastolic blood pressure (DBP) measurement are the auscultatory Korotkoff-based sphygmomanometry and oscillometry. The former technique is relatively accurate but is limited to a physician’s office because its automatic variant is subject to noise artifacts. Consequently, the Korotkoff-based measurement overestimates the blood pressure in some patients due to white coat effect, and because it is a single measurement, it cannot properly represent the variable blood pressure. Automatic oscillometry can be used at home by the patient and is preferred even in clinics. However, the technique’s accuracy is low and errors of 10–15 mmHg are common. Recently, we have developed an automatic technique for SBP measurement, based on an arm pressure cuff and a finger photoplethysmographic probe. The technique was found to be significantly more accurate than oscillometry, and comparable to the Korotkoff-based technique, the reference-standard for non-invasive blood pressure measurements. The measurement of SBP is a mainstay for the diagnosis and follow-up of hypertension, which is a major risk factor for several adverse events, mainly cardiovascular. Lowering blood pressure evidently reduces the risk, but excessive lowering can result in hypotension and consequently hypoperfusion to vital organs, since blood pressure is the driving force for blood flow. Erroneous measurement by 10 mmHg can lead to a similar unintended reduction of SBP and may adversely affect patients treated to an SBP of 120–130 mmHg. In particular, in elderly patients, unintended excessive reduction of blood pressure due to inaccurate SBP measurement can result in cerebral hypoperfusion and consequent cognitive decline. By using a more accurate technique for automatic SBP measurement (such as the photoplethysmographic-based technique), the optimal blood pressure target can be achieved with lower risk for hypotension and its adverse events.

PS 06-25 THE ASSOCIATION OF THE BLOOD PRESSURE WITH FRAILTY INDICATORS AMONG COMMUNITY-DWELLING OLDER MEN WITH OR WITHOUT ANTIHYPERTENSIVE TREATMENT

Objective: The elderly population represents several medical challenges, particularly in the management of hypertension. However, the ideal blood pressure (BP) goal for very old people is still unclear. Especially, benefit of strict BP control for very old people is controversial. This is a serious issue in frail older people considering the adverse outcome. The purpose of this study is to investigate the association of BP level with frailty indicators among 70 and 80-year-old community dwelling Japanese. Design and Method: Community-dwelling older men aged 70 ± 1 (n = 457) and 80 ± 1 (n = 479) years participated in the invitation survey at the community centers; Septuagenarians, Octogenarians and Nonagenarians Investigation with Centenarians (SONIC) study. We interviewed medical histories and medications. BP, grip strength and 8-feet gait speed was examined on site. Mean differences of the grip strength and gait speed based on the BP level were evaluated using one-way ANOVA. Results: Among the participants with antihypertensive treatment, there was the significant difference of the grip strength between low level of diastolic BP (DBP): < 70 mmHg (24.7 kg) and other levels of DBP (70–80 mmHg: 27 kg, 80–90 mmHg: 27.4 kg, 90–100 mmHg: 29 kg) in men age around 80 by the multiple pairwise comparisons. The difference of the grip strength was not significant among participants without antihypertensive treatment nor among participants age around 70 regardless of the antihypertensive treatment. About systolic BP, the tendency of result was similar to DBP. No significant difference among any BP levels was observed for the gait speed. Conclusions: We found that the low DBP (< 70 mmHg) men participants age around 80 with antihypertensive treatment had significantly weak grip strength. The causal relationship should be clarified whether the weak grip strength is caused by excessive reduction of BP.

SY 08-2 HYPERTENSION MANAGEMENT FOR SECONDARY PREVENTION OF STROKE

Stroke is known to frequently recur in patients with a history of cerebrovascular disease, and the control of hypertension is extremely important for the treatment of those patients. The robust relationship between the recurrent cerebrovascular disease and blood pressure control has been demonstrated in large-scale clinical studies. The antihypertensive drug therapy significantly reduces the recurrence rate of all types of cerebrovascular disease, incidences of myocardial infarction and all vascular events. Evidence suggests that any class of antihypertensive drugs including diuretics, Ca channel blockers, ARBs, and ACE inhibitors are shown to be similarly effective for the secondary prevention of stroke, except in some small study such as MOSES. Thus, most of the benefit obtained from drugs can be ascribed to a decrease in blood pressure. Then, how far should blood pressure be lowered? Target of blood pressure control has been somewhat controversial, since an excessive reduction of blood pressure might exacerbate cerebral ischemia in the area perfused by cerebral artery with a significant stenosis. In fact, some Japanese clinical study has shown that in patients with impaired perfusion demonstrated by PET-CT, the risk of recurrent stroke was high when the systolic blood pressure was There have been very few studies which have primarily investigated the optimum blood pressure level in the secondary prevention of stroke. The sub-analysis of the large clinical trial, PROGRESS, indicated that the incidences of cerebral hemorrhage and cerebral infarction were lower in patients in whom blood pressure was controlled at a lower level (a systolic blood pressure of about 120 mmHg). In the Bleeding with Antithrombotic Therapy (BAT) Study in Japan, 4,009 patients taking antithrombotic drugs for the prevention of recurrent cerebrovascular or heart disease were prospectively enrolled, and hemorrhagic events were investigated over 19 months. The results suggest that the incidence of cerebral hemorrhage is lower when the blood pressure immediately before/after onset is lower, suggesting that blood pressure should be reduced to In the Secondary Prevention of Small Subcortical Strokes (SPS3) Trial, a randomized comparative study was conducted in patients with chronic-phase lacunar infarction by dividing them into two groups: a group with a systolic blood pressure of We have been conducting a multicenter, randomized, open-label study (RESPECT study; Clinical Trials.gov Identifier: NCT01198496) since 2010, in which hypertensive patients with a history of strokes are randomly assigned to either a standard therapy group (£140/90 mmHg; if having current DM/CKD/MI, £130/80 mmHg) or a strict therapy group (BP lowering target: £120/80 mmHg). The patients were treated with stepwise multi-drug therapy using an angiotensin-receptor antagonist, diuretic, calcium channel blocker and additional other classes of drug if necessary. The recurrent stroke rates in both groups will be compared from various aspects, and whether strict BP management is useful for the prevention of recurrent strokes will be verified. The first interim analysis of this study has been recently performed. At present, in the JSH2014 Guidelines, the target of blood pressure control for patients with chronic-phase cerebral infarction is established as

Achieved Blood Pressure and Outcomes in the Secondary Prevention of Small Subcortical Strokes Trial.

Studies suggest a J-shaped association between blood pressure and cardiovascular events in the setting of intensive systolic blood pressure control; whether there is a similar association with stroke remains less well established. The Secondary Prevention of Small Subcortical Strokes was a randomized trial to evaluate higher (130-149 mm Hg) versus lower (<130 mm Hg) systolic blood pressure targets in participants with recent lacunar infarcts. We evaluated the association of mean achieved blood pressure, 6 months after randomization, and recurrent stroke, major vascular events, and all-cause mortality. After a mean follow up of 3.7 years, there was a J-shaped association between achieved blood pressure and outcomes; the lowest risk was at ≈124 and 67 mm Hg systolic and diastolic blood pressure, respectively. For example, above a systolic blood pressure of 124 mm Hg, 1 standard deviation higher (11.1 mm Hg) was associated with increased mortality (adjusted hazard ratio: 1.9; 95% confidence interval: 1.4, 2.7), whereas below this level, this relationship was inverted (0.29; 0.10, 0.79), P<0.001 for interaction. Above a diastolic blood pressure of 67 mm Hg, a 1 standard deviation higher (8.2 mm Hg) was associated with an increased risk of stroke (2.2; 1.4, 3.6), whereas below this level, the association was in the opposite direction (0.34; 0.13, 0.89), P=0.02 for interaction. The lowest risk of all events occurred at a nadir of ≈120 to 128 mm Hg systolic blood pressure and 65 to 70 mm Hg diastolic blood pressure. Future studies should evaluate the impact of excessive blood pressure reduction, especially in older populations with preexisting vascular disease. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059306.

Intravenous Hydralazine in Hospitalized Children and Adolescents with Hypertension

To explore the efficacy and safety of intravenous (IV) hydralazine in hospitalized children with hypertension. Data were retrospectively collected on hospitalized children treated with IV hydralazine. Percent changes in blood pressure (BP) were calculated, and linear regression was used to investigate associations between BP change and pertinent clinical and demographic variables. Bivariate logistic regression was used to investigate associations between the same covariates and the outcomes of ideal clinical response (ICR), a 10%-25% reduction in mean arterial pressure (MAP), and excess response (ER), a 25% reduction in MAP. A total of 141 initial doses of IV hydralazine (median dose, 0.10mg/kg [IQR, 0.09-0.11; range, 0.02-0.37]) were analyzed. Median age was 8 years (IQR, 2-15; range, 0-24); most patients had renal disease, malignancy, or were organ transplant recipients. The mean MAP reduction was 19%±12%. An ICR occurred in 66 patients (47%). Higher initial MAP and increased hydralazine dose were associated with greater percentage decrease in MAP. No association was found between ICR and the covariates of interest; higher initial MAP was associated with greater odds of ICR. ER occurred in 44 children (31%). Among this group, higher initial MAP and higher hydralazine dose were associated with increased odds of ER, and administration of other antihypertensive drugs was associated with decreased odds of ER. Four adverse effects possibly related to IV hydralazine, including 2 episodes of hypotension, were recorded. IV hydralazine reduced BP in the majority of children. However, a substantial proportion of children experienced potentially excessive BP reduction.

Blood pressure limits--the lower, the better?

Arterial hypertension is a widespread risk factor for cardiovascular disease. The benefit of a consistent drug therapy is proportionally associated with the degree of blood pressure reduction. By extrapolating the data, the assumption arose “the lower the better” and was widely accepted. However, several studies found an increase in morbidity and mortality with an excessive reduction of blood pressure (J-curve). This seems to affect mainly cardiac risk, and only at lower blood pressures<60 mmHg also the cerebral risk. An important factor here is the diastolic blood pressure. Others found a linear correlation. Overall, a j-shaped connection remains controversial and is not considered equally for all organ systems. At the same time cardiovascular risk seems not to increase with additional reduction in blood pressure of <140 mm Hg to <120 mmHg. This has led to the latest guidelines of all societies recommending higher target values. Reasons for higher targets in drug therapy of arterial hypertension, are increased adverse drug reactions or increased healthcare costs with few additional benefit. The current recommendations of the ESH/ESC, AHA/ACC/ASH and the JNC 8 set a higher target value for some subgroups, but remain inconsistent among themselves.

Tratamiento Médico de la Hipertensión Arterial

El 95% de los pacientes hipertensos tienen hipertensión esencial. Dentro del 5% que resta puede encontrarse casos en quienes el diagnóstico de feocromocitoma, o lesión unilateral renal puede resultar en la cura definitiva de la hipertensión. Existe una variedad de hipertensión esencial llamada maligna cuya rápida evolución hace imperioso el tratamiento. Debe ser separada del grupo de la nefritis crónica en bajar la presión arterial, que no sólo alivia al enfermo, sino que rompe un círculo vicioso que daña los vasos sanguíneos. Deben ser tratados todos los pacientes con hipertensión arterial maligna y todos los que teniendo hipertensión arterial esencial presentan una diastólica muy elevada más de 120 mmHg, o rápida evolución de la enfermedad. En el resto de hipertensos basta la psicoterapia y la terapéutica sedante. Es preciso tener especiales precauciones con pacientes arterioesclerósicos o urémicos, en quienes una excesiva reducción de la presión arterial o su caída brusca puede producir trombosis cerebral, o aumento de la uremia respectivamente. El procedimiento, o droga a escoger, será bueno si es que se logra una baja razonable de la presión arterial sin daño mayor para el paciente, o sin causarle excesivas molestias. Se hace una somera descripción de los principales procedimientos o drogas actualmente en uso.

Association between blood pressure and disability-free survival among community-dwelling elderly patients receiving antihypertensive treatment

A reduction of elevated blood pressure (BP) is an important treatment goal in elderly hypertensive patients. However, excessive reduction of systolic BP (SBP) and/or diastolic BP (DBP) might be harmful in such patients. We investigated whether this was the case with regard to risk of incident disability or death in community-dwelling elderly subjects. We analyzed 570 patients receiving antihypertensive treatment aged 65-94 years. The endpoint was the composite outcome of incident disability, defined as first certification of a support/care need or death. Relationships among each of the four classes of SBP or DBP and the risk of incident disability or death were estimated using the Cox proportional hazards model. Over four years, 77 (13.5%) incident disabilities or deaths occurred. After adjustment for age, sex and variables selected according to their univariate analysis P-value <0.20, the risk of events was significantly higher in subjects with baseline SBP<120 mm Hg (hazard ratio (HR)=2.81, P=0.023) and ⩾160 mm Hg (HR=4.32, P<0.001), compared with subjects with baseline SBP of 140-159 mm Hg, who showed the lowest incidence of events. This J-curve relationship was observed in very elderly patients (⩾75 years) but not in younger patients. Patients with SBP<120 mm Hg tended to have a higher risk of incident disability caused by cerebral events, and those with SBP⩾160 mm Hg had a higher risk of incident disability caused by falls/bone fractures. These observations indicate that excessive BP reduction could cause discontinuance of disability-free survival in community-dwelling elderly patients.

The Importance of 24-Hour Ambulatory Blood Pressure Monitoring in Patients at Risk of Cardiovascular Events

The accuracy of clinic blood pressure (BP) measurements is limited due to the presence of 24-hour BP variability and white-coat or masked hypertension. In contrast, 24-hour ambulatory BP monitoring (ABPM) has evolved into an accurate and reproducible tool for the assessment and management of hypertension. Various out-of-office measurements can be obtained using ABPM data, including morning, daytime, night-time and average 24-hour BP. Thus, in clinical practice, ABPM can be used to identify masked hypertension or excessive BP reduction. Furthermore, ABPM data can identify early-morning hypertension and excessive BP variability, both of which correlate with target-organ damage and cardiovascular outcomes. In large outcomes trials, ABPM sub-studies are increasingly performed to help further understand patient outcomes. However, it is evident that control of BP over the full 24-hour period, particularly during the risky early morning period, is not being achieved in general practice. In clinical trials of antihypertensive efficacy, a useful calculation is the smoothness index. This measure assesses the degree of 24-hour BP reduction, as well as its distribution pattern, throughout the 24-hour period. Importantly, the index correlates with hypertension-associated target organ damage, unlike the commonly used trough to peak ratio. Smooth BP control according to this index is achieved with long-acting drugs, such as telmisartan or amlodipine, which provide smooth 24-hour BP control, even during the early morning period. In summary, the use of ABPM is expanding, both in clinical practice and in trials, as it provides a closer correlation to prognosis than clinic BP measures. When choosing an antihypertensive agent for patients with hypertension, it is important to consider reducing BP variability by using longer acting antihypertensives, which may help to prevent cardiovascular morbidity and mortality.

Targeting albuminuria in arterial hypertension and diabetes

Targeting albuminuria in arterial hypertension and diabetes