Intensive Blood Pressure Control Research Articles

NEJM at AHA — Intensive Blood-Pressure Control in Patients with Type 2 Diabetes

NEJM at AHA — Intensive Blood-Pressure Control in Patients with Type 2 Diabetes

Intensive Blood-Pressure Control in Patients with Type 2 Diabetes

Intensive Blood-Pressure Control in Patients with Type 2 Diabetes

Baseline Diastolic BP and BP-Lowering Effects on Cardiovascular Outcomes and All-Cause Mortality: A Meta Analysis.

Lowering blood pressure (BP) in persons with low diastolic BP could be harmful. Hence, we examined whether baseline diastolic BP modifies the effects of BP lowering on clinical outcomes in a meta-analysis of five large BP lowering trials. In a study-level meta-analysis based on individual participant data of the Systolic Blood Pressure Intervention Trial (N = 9361), the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (N = 2362), the Secondary Prevention of Small Subcortical Strokes (N = 3020), the African American Study of Kidney Disease and Hypertension (N = 1094) and the Modification of Diet in Renal Disease (N = 840) studies, we used DerSimonian-Laird random-effects models to examine the dependence of the effect of the BP lowering intervention on baseline diastolic BP for cardiovascular, all-cause mortality and kidney outcomes. Mean baseline age was 65 ± 10 years old. Mean baseline systolic and diastolic BP were 141 ± 17 and 79 ± 12 mm Hg, respectively. More intensive BP control resulted in lower risk of composite cardiovascular outcome (HR 0.79, 95% CI 0.72, 0.87) and all-cause mortality (HR 0.86, 95% CI 0.75, 0.99) without evidence that the BP intervention effects differed by level of baseline diastolic BP (interaction p = 0.76 for cardiovascular composite and 0.85 for all-cause mortality). The mean baseline diastolic BP in the lowest and the upper three quartiles of baseline diastolic BP were 65 ± 6 mm Hg and 84 ± 9 mm Hg, respectively but the effects of the BP interventions on the outcomes were similar in both groups. Furthermore, there was no evidence of interaction of the BP intervention and baseline diastolic BP for kidney outcomes. Within the included diastolic BP range, there was no evidence that baseline diastolic BP modified the beneficial effects of intensive BP lowering.

Influence of orthostatic blood pressure changes on the effects of intensive blood pressure control in patients with type 2 diabetes

Abstract Background Intensive blood pressure (BP) control has been proven to reduce the risks of major cardiovascular diseases (CVD) in patients with type 2 diabetes mellitus (T2DM) (1). Excessive orthostatic BP changes should be fully addressed, given its high prevalence and associations with adverse events among T2DM patients (2-5). However, the benefits of intensive BP control among T2DM patients with significant orthostatic BP changes have been equivocal. Purpose To examine whether orthostatic BP changes modify the efficacy of intensive BP control on CVD outcomes in patients with T2DM. Methods The Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial (ACCORD BP) is a 2×2 factorial designed trial that aimed to evaluate the effects of intensive glycemia and BP control on major CVD events among T2DM patients (6). We enrolled participants with at least one record of orthostatic BP values for analysis. The composite CVD outcome in this study comprised cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and hospitalized congestive heart failure. Associations between orthostatic BP changes and the composite CVD outcome and all-cause death, respectively, were presented by restricted cubic spline curves based on multivariable Cox models. We examined if the effects of intensive BP control varied across the orthostatic BP change for the composite CVD outcome and all-cause death. Results Among 4330 participants, 877 (20.3%) experienced episodes of orthostatic hypotension (OH) at baseline or during follow-up. There was no significant difference in the proportions of OH participants between the intensive and standard BP arms. U-shaped associations were observed between orthostatic systolic BP changes and the composite CVD outcome, as well as all-cause mortality (Figure 1). In the standard glycemia arm, intensive BP control was significantly associated with a lower risk of composite CVD outcome (HR 0.76, 95%CI 0.59-0.97). There was a beneficial association of intensive BP control with all-cause mortality without statistical significance (HR 0.85, 95%CI 0.56-1.30). The favorable effect of intensive BP control was not influenced by orthostatic BP changes (P for interaction 0.51 for the composite CVD outcome and 0.97 for all-cause mortality) (Figure 2). Beneficial effects of intensive BP control were not observed for participants in the intensive glycemia arm on the composite CVD outcome (HR 0.99, 95%CI 0.76-1.28) and all-cause mortality (HR 1.19, 0.79-1.80). Conclusion Orthostatic BP changes should not be a barrier to intensive BP control for T2DM patients treated with guideline-recommended standard glycemia control.

Relationships among intensive blood pressure control, morning blood pressure surge and 24-hour blood pressure variability

Abstract Objectives This study aimed to investigate the relationships between cardiovascular outcomes and blood pressure (BP) reduction, 24-hour BP variability (BPV), morning BP surge (MBPS), and visit-to-visit BPV. Methods This study involved 897 participants from the Systolic Blood Pressure International Trial (SPRINT), for whom biochemical and demographic data, medication history, and various blood profile information were collected. Univariate and multivariate linear regression models were used to assess the impact of intensive BP management on 24-hour BPV and the MBPS. Results Among the 897 participants (average age 71.48 ± 9.42 years; 640 males), 453 received intensive treatment. Those in the intensive group were more likely to be on ACE inhibitors, CCBs, or diuretics. This group showed significant reductions in 24-hour systolic and diastolic BP, as well as in both short-term and long-term BPVs, such as average real variability (ARV) and MBPS. The analysis demonstrated strong associations between intensive BP management and improvements in various BPV measures, including systolic ARV, diastolic BP ARV, and cumulative BP loads. A significant correlation was also found between intensive BP lowering and the primary composite outcome of the SPRINT study. Conclusions This study highlighted the significant associations between intensive BP management and reductions in the MBPS and 24-hour BPV, which affect both short-term and long-term health outcomes. The primary benefits of intensive BP control appear to stem from direct BP reduction rather than changes in BPV. However, further extensive randomized controlled trials are needed to confirm these findings.

Impact of appendicular skeletal muscle mass on effect of intensive blood pressure control

Abstract Background Appendicular skeletal muscle mass (ASM) is associated with cardiovascular diseases (CVDs) and chronic kidney diseases (CKDs). However, whether low ASM affects the efficacy of intensive systolic blood pressure control is currently uncertain. Purpose To examine the impact of low ASM on the effects of intensive SBP control on cardiovascular and kidney outcomes. Methods Data from the Systolic Blood Pressure Intervention Trial (SPRINT) and the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD-BP) trials was used. The primary outcome was a composite of myocardial infarction, acute coronary syndrome without myocardial infarction, stroke, heart failure, and cardiovascular death. The prespecified incident CKD was defined as a >30% decrease in estimated glomerular filtration rate to a value <60 mL/min/1.73 m2. Results A total of 14,017 patients were included in this study, 2203 (15.7%) of whom had low ASM. Over a median follow-up of 3.26 years, 1,032 primary outcomes and 460 incident CKD were observed. Patients with low ASM had a significantly higher risk of primary outcome and CKD. Intensive SBP control effects on cardiovascular outcomes were not significantly different on a relative scale or absolute scale. But low ASM significantly amplified the increased risk of CKD associated with intensive SBP control, on an absolute scale (P for interaction = 0.04). Conclusions Low ASM is one of the markers of increased risk of CVD and CKD, and it did not affect the cardiovascular benefits of intensive treatment, but significantly amplified the increased risk of CKD associated with intensive SBP control.

A novel digital twin strategy to enable the translation of evidence from randomized control trials to new populations

Abstract Background Randomized clinical trials (RCTs) are essential to guide medical practice; however, their generalizability to a given population is often uncertain. Between the SPRINT and ACCORD trials, only SPRINT found a significant reduction in major cardiovascular events (MACE) with intensive blood pressure control, but ACCORD did not, without clear evidence of whether this reflected differences in enrolled patients. Purpose To use a novel RCT digital twin-based approach to demonstrate the translation of an RCT to a different population, leveraging the differences in populations and treatment effects in SPRINT and ACCORD. Methods We developed a statistically informed Generative Adversarial Network (GAN) model that leverages relationships between covariates and outcomes using Directed Acyclic Graphs (DAGs). This model can generate a digital twin of an RCT (RCT-Twin) conditioned on covariate distributions from a second patient population while maintaining these relationships (Fig A). Using this, we generated the (i) RCT-Twin of SPRINT, which was conditioned on the 10 most disparate covariates drawn from ACCORD, and (ii) an RCT-Twin of ACCORD conditioned on SPRINT. To demonstrate treatment effect estimates of each RCT conditioned on the other RCT’s patient population, we evaluated the cardiovascular event-free survival of 10 iterations of these cross-trained RCT-Twins against the original trials. Results Using 9361 SPRINT participants and conditioning on 4733 ACCORD participants, we generated 10 ACCORD-conditioned SPRINT-Twin datasets. We confirmed that the RCT-Twins were consistently balanced between treatment and controls across all measured covariates (mean absolute standardized mean difference (MASMD) 0.019, SD 0.018), as expected for real RCTs. We also confirmed that covariates of the ACCORD-conditioned SPRINT-Twins were closer to ACCORD than SPRINT (MASMD 0.0082 vs 0.46, SD 0.016 vs 0.20), suggestive of successful conditioning. Most importantly, across iterations, ACCORD-conditioned SPRINT-Twin datasets reproduced the overall non-significant effect size seen in ACCORD (5-year MACE hazard ratio (95% confidence interval) of 0.88 (0.73-1.06) in ACCORD vs median 0.87 (0.68-1.13) in the ACCORD-conditioned SPRINT-Twins, Fig B), while the SPRINT-conditioned ACCORD-Twin datasets reproduced the significant effect size seen in SPRINT (0.75 (0.64-0.89) vs median 0.79 (0.72-0.86) in the SPRINT-conditioned ACCORD-Twins, Fig C). Conclusions Our novel conditioned digital twin approach simulates RCT-derived effects in different patient populations by translating these effects to the covariate distributions of the patients. This key methodological advance may enable the direct translation of RCT-derived effects into disparate patient populations and may enable causal inference in real-world settings.

Differential impact of clinic BP target on the prevalence and predictors of the masked uncontrolled hypertension and white-coat uncontrolled hypertension

Abstract Background Although intensive blood pressure (BP) control have been advocated, major clinical practices guidelines still recommend clinic BP (cBP) < 149/90 mmHg as the target for antihypertensive therapy. But, cBP targets could influence the prevalence and predictors of any hypertension phenotype. We investigated how different cBP targets impacted on the prevalence and predictors of masked uncontrolled hypertension (MUCH) and white-coat uncontrolled hypertension (WUCH) using the Korean Ambulatory Blood Pressure (KorABP) registry. Methods A multicenter prospective longitudinal cohort study was performed in outpatients with hypertension. Among 5,965 patients enrolled in the KorABP registry, 1,601 patients on antihypertensive medications with a valid ambulatory BP monitoring record were included in this study. Two different cBP targets, <130/80mmHg (intensive) and <140/90 mmHg (conventional) were investigated. Results Controlled ambulatory BP (aBP; <130/80 mmHg) was observed in 472 patients (29.5%). Controlled cBP was shown in 348 patients (21.7%) with the intensive cBP target and in 697 patients (43.5%) with the conventional cBP target. Controlled hypertension, WUCH, MUCH and uncontrolled hypertension were found in 294, 174, 54, and 1,075 patients with the intensive target and in 378, 94, 319 and 810 patients with the conventional target, respectively. Among the patients with controlled cBP, the prevalence of MUCH markedly decreased with the intensive target (15.5%), compared to the conventional target (45.8%). In contrast, among the patients with uncontrolled cBP, the prevalence of WUCH had only 3.8% increase with the intensive target (10.4%), compared to the conventional target (14.2%) (Figure 1). With the conventional target, 75.9% of patients with MUCH had cBP between 130/80 mmHg and 139/89 mmHg. The concordance between the controlled aBP and controlled cBP was higher with the intensive target than with the conventional target (Cohen’s κ 0.62 [0.58-0.67] vs. 0.46 [0.41-0.50]). The logistic models for MUCH included the left ventricular mass index and underuse of antihypertensive drugs (<2 types of drugs) as the common predictors of the both targets. With the conventional target, clinic systolic BP and diastolic BP were the strongest predictors of MUCH, but the cBP was not a predictor of MUCH with the intensive target. The logistic models for WUCH included beta-blocker use, increased heart rate and lower waist circumference and clinic systolic BP as the common predictors of WUCH with the both target. The logistic model for MUCH performed better with the conventional target, whereas the logistic model for WUCH performed better with the intensive target (Figure 2). Conclusion The use of the intensive cBP target (<130/80 mmHg) could reduce the prevalence of MUCH with minimal increase in the prevalence of WUCH and would provide the better assessment for the BP control status than the use of the conventional cBP target (<140/90 mmHg).Figure 1Figure 2

Intensive postpartum antihypertensive treatment (IPAT) and healthy lifestyle education: Study protocol for a pilot randomized controlled trial for patients with hypertensive disorders of pregnancy

BackgroundHypertensive disorders of pregnancy (HDP) complicate about 10 % of pregnancies and lead to postpartum hospital readmissions and cardiovascular complications. Following HDP, vascular dysfunction could persist and accelerate the trajectory of cardiovascular disease risk. The benefits of intensive blood pressure (BP) control following HDP have not been adequately investigated. Therefore, no standard guidelines exist to guide the management of mild-to-moderate hypertension in the postpartum period, leading to a wide variation in clinical practice. The present study will investigate the effect of intensive BP control and healthy lifestyle education on maternal cardiovascular health (CVH) and vascular function following HDP. MethodsThe Intensive Postpartum Antihypertensive Treatment (IPAT) study is a randomized controlled, two-arm, single-site, pilot trial where 60 postpartum HDP patients will be randomized 1:1 to one of two groups: 1) Intensive postpartum BP control – nifedipine initiation at BP ≥140/90 mmHg to maintain BP <140/90 mmHg; or 2) Less intensive postpartum BP control – nifedipine initiation at BP ≥150/100 mmHg to maintain BP <150/100 mmHg. All participants will also undergo vascular function assessments and receive healthy lifestyle education. The study will primarily test feasibility of all study procedures. It will secondarily examine changes in BP and CVH scores from baseline to 12 months postpartum. ConclusionThis pilot trial will study whether the BP threshold of 140/90 is superior to 150/100 for initiation of pharmacotherapy and evaluate feasibility to ultimately conduct a trial capable of generating robust evidence to standardize clinical practice and guidelines in postpartum HDP management.Trial registration number: NCT05687344

Intensive Home Blood Pressure Lowering in Patients with Advanced CKD

Optimal blood pressure (BP) targets in advanced CKD are controversial. More intensive BP lowering in the setting of advanced CKD is thought to be associated with risk of acute kidney injury, hyperkalemia, and ESKD. We aimed to conduct a pilot trial of intensive BP control to determine if lower SBP targets can be safely achieved for patients with CKD through titration of BP medications using in-home measured BP. Non-blinded randomized controlled trial. 108 patients with advanced CKD (eGFR ≤30 mL/min/1.73 m2) and hypertension. Participants were randomized either to a target home SBP goal of <120 mmHg (N=66) or a less intensive SBP goal (N=42). Antihypertensive medications were titrated to achieve the target home SBP range in the first 4 months of the study and maintained until the end of the study. Home BP was measured using a wireless Bluetooth-enabled monitor that transmitted readings to providers in real-time. The primary efficacy outcome was the difference in achieved clinic SBP between the two study arms from months 4-12. Safety outcomes included hyperkalemia, a composite outcome of falls or syncope, and onset of need for dialysis or kidney transplantation. The mean clinic SBP at month 12 was 124.7 mmHg in the intensive SBP group vs. 138.2 mmHg in the less intensive SBP group. Averaged over months 4-12, the achieved mean clinic SBP in the intensive SBP arm was 11.7 mmHg (95% CI 7.5 to 16 mmHg, p<0.001) lower than the mean SBP achieved in the less intensive SBP arm. Primary safety outcomes were not statistically significantly different between the two arms (all p>0.05). Small sample size which may limit our ability to detect clinically significant differences in rates of adverse outcomes; single-center design. A clinic SBP goal of <120 mmHg is feasible to achieve with the help of real-time home BP monitoring and appears to be safe in this study population with advanced CKD. Larger trials to determine optimal BP targets in advanced CKD and the risks and benefits associated with more intensive BP control are warranted.

Early and Late Surgery-Free Rates of Conservative Management Strategy for Thrombosed Type A Acute Aortic Dissection and Acute Intramural Hematoma.

Background: We have employed a conservative management approach, including intensive control of both blood pressure and heart rate, in patients with aortic intramural hematoma (AIMH) and retrograde thrombosed type A acute aortic dissection (RT-TAAAD), sharing common clinical and imaging characteristics. Methods: To evaluate the outcomes of our conservative management approach, we retrospectively reviewed the clinical records of 98 patients diagnosed with AIMH or RT-TAAAD from January 2008 to March 2023. A conservative management approach was applied, except for those patients with an aortic diameter ≥ 55 mm, false lumen expansion, or cardiac tamponade, who underwent emergency aortic repair. Results: Besides 2 patients, who declined surgery and subsequently died from aortic rupture, 18 patients underwent urgent aortic surgery, while 78 did not. Multivariable logistic regression analysis identified the extrusion type of ulcer-like projections (ULPs) on admission and a maximum aortic diameter ≥ 45 mm on Day 1 as risk factors for acute aortic surgery. Among the 78 patients who were discharged, 9 (12%) underwent aortic surgery, while 69 (88%) did not, with a median follow-up of 44 months. The overall actuarial aortic surgery-free rates were 78% at 1 year and 72% at 5 years, respectively. A Cox proportional hazards analysis identified ULPs and an aortic diameter ≥ 45 mm at discharge as risk factors for late aortic surgery. Conclusions: The early and late outcomes of our conservative strategy for AIMH and RT-TAAAD demonstrate favorable surgery-free rates. The extrusion type of ULPs on admission and an aortic diameter ≥ 45 mm on Day 1 are predictors of acute aortic surgery, while ULPs and an aortic diameter ≥ 45 mm at discharge are predictors of late surgery.

Glomerular Hematuria as a Predictor of Renal Prognosis in Malignant Hypertension Patients with Thrombotic Microangiopathy: A Propensity Score-Matched Analysis of a Biopsy-Based Cohort Study

Introduction: Malignant hypertension (mHTN) is a hypertensive emergency. Thrombotic microangiopathy (TMA) is a widespread complication of mHTN. Few studies have evaluated whether glomerular hematuria provides prognostic information for renal dysfunction in patients with mHTN-associated TMA. Methods: This observational cohort study included 292 patients with mHTN-associated TMA based on renal biopsy. Propensity-score matching (PSM) analysis was conducted to adjust for clinical characteristics in a comparison between with and without glomerular hematuria. Cox regression was employed to identify risk factors for renal prognosis. Results: A total of 70 patients with glomerular hematuria were compared to 222 patients with non-glomerular hematuria. After PSM, 67 pairs of patients with mHTN-associated TMA were matched. Patients with glomerular hematuria exhibited lower serum albumin levels, higher 24-h proteinuria, and a higher prevalence of glomerular sclerosis than those with non-glomerular hematuria. Glomerular hematuria was independently associated with deteriorated renal function compared with non-glomerular hematuria (HR: 0.51; 95% CI: 0.29–0.89, p = 0.019). This association remained significant after PSM (HR: 0.51; 95% CI: 0.28–0.91, p = 0.022). Additionally, glomerular hematuria was independently associated with renal replacement therapy (RRT) (HR: 3.14; 95% CI: 2.06–5.66, p < 0.001). This difference remained significant after PSM comparison (HR: 2.41; 95% CI: 1.34–4.33, p = 0.003). Furthermore, despite intensive blood pressure control, patients with glomerular hematuria experienced a higher incidence of RRT and a poorer recovery in renal function, specifically a 25% reduction of creatinine levels, compared to patients with non-glomerular hematuria. Conclusion: Glomerular hematuria is significantly associated with an increased risk of adverse renal outcomes in patients with mHTN-associated TMA.

Evaluation of self-monitoring of blood pressure in the PERHIT study and the impact on glomerular function

Background Although intensive blood pressure (BP) control has not been shown to slow the progression of chronic kidney disease (CKD), intensive BP control has been shown to reduce the risk for adverse cardiovascular outcomes in the CKD population. The aim of this post-hoc study was to study the interplay between a self-monitoring BP system and glomerular function. Methods In all, 949 participants with hypertension underwent visits at baseline, after eight weeks and 12 months. Half of the participants received a BP monitor and installed a program on their mobile phone. During eight weeks, they measured daily and reported their BP values. Results Within the intervention group, BP and systolic BP (SBP) decreased from baseline to eight weeks and 12 months (p < .001). Pulse pressure (PP) and mean arterial blood pressure (MAP) decreased from baseline to eight weeks (p = .021 and p = .004) vs 12 months (p = .035 and p = .008). Within the control group, a decrease was observed from baseline to 12 months for SBP, diastolic BP (DBP) and PP (p = .025, p = .023 and p = .036). In the intervention group, we observed an association between a decrease in SBP, DBP, PP and MAP and a decrease in eGFR (estimated glomerular filtration rate), (p < .001, p < .001, p = .013 and p < .001). In the control group, similar results were observed for PP only (p = .027). Within the intervention group, eGFR decreased (p < .001) but within the control group, the decrease was non-significant (p = .051). Conclusion We observed an association between a decrease in all BP components and eGFR decline within the normal range in the intervention group but not in the controls. Trial registration The study was registered with ClinicalTrials.gov [NCT03554382].

Protocol for a randomized controlled trial of intensive blood pressure control on cardiovascular risk reduction in patients with atrial fibrillation: Rationale and design of the CRAFT trial

BackgroundCo-morbid hypertension is strong predictor of adverse cardiovascular (CV) outcomes in patients with atrial fibrillation (AF) but the optimal target for blood pressure (BP) control in this patient population has not been clearly defined. MethodsThe Cardiovascular Risk reduction in patients with Atrial Fibrillation Trial (CRAFT) is an investigator-initiated and conducted, international, multicenter, open-label, parallel-group, blinded outcome assessed, randomized controlled trial of intensive BP control in patients with AF. The aim is to determine whether intensive BP control (target home systolic blood pressure [SBP] <120 mmHg) is superior to standard BP control (home SBP <135 mmHg) on the hierarchical composite outcome of time to CV death, number of stroke events, time to the first stroke, number of myocardial infarction (MI) events, time to the first MI, number of heart failure hospitalization (HFH) events, and time to the first HFH. A sample size of 1,675 patients is estimated to provide 80% power to detect a win-ratio of 1.50 for intensive versus standard BP control on the primary composite outcome. Study visits are conducted at 1, 2, 3, and 6 months postrandomization, and every 6 months thereafter during the study. ConclusionsThis clinical trial aims to provide reliable evidence of the effects of intensive BP control in patients with AF. Trial registrationThe trial is registered at ClinicalTrials.gov (NCT04347330)

P007 HIGH PREVALENCE OF HYPOTENSION IN OLDER ADULTS ON AMBULATORY BLOOD PRESSURE MONITORING (ABPM)

Background: Hypertension, a prevalent public health concern, disproportionately affects older adults. Effective blood pressure (BP) control is crucial to preventing cardiovascular complications such as heart attack, stroke, and heart failure. In recent years, there has been a discussion about the optimal BP control strategies in older adults (1). While some studies advocate for intensive BP control, others emphasize the importance of considering individual patient characteristics, such as age and frailty (2,3). Objective: This study aims to describe the prevalence of hypotension in ambulatory blood pressure monitoring (ABPM) in older adult patients compared to younger patients. Methods: This cross-sectional descriptive study analyzed ABPM records from 2018 to 2024 at a cardiovascular institution in Colombia. The difference in systolic (SBP) and diastolic (DBP) blood pressure was evaluated according to the age group (younger or older than 80 years) to determine the presence of hypotension in older adults defined as pressure less than 90/60 mmHg. Normality was assessed using the Kolmogorov-Smirnov test. Comparisons of continuous variables across age categories were performed using the non-parametric Mann-Whitney U test. For categorical variables, the Chi-square test was employed. Results: Among the 653 participants, 57.3% (374) were women. The average age was 63 years, with 60 patients (9.18%) being over 80 years old. Table 1 shows a significant difference in systolic and diastolic blood pressure (SBP and DBP) between the age groups. Notably, 47.5% of patients over 80 had SBP less than 130 mmHg, and a high prevalence (84.7%) had DBP less than 90 mmHg. DBP below 60 mmHg was more common in this age group. Additionally, 20 older adults had SBP between 130-139 mmHg. Conclusions: This study demonstrates a high prevalence of hypotension, especially low DBP, in older adults. Considering these findings, re-evaluating current blood pressure control targets for older adults is crucial to avoid overtreatment and minimize the risk of complications like symptomatic hypotension and falls.

Antihypertensive medications and dementia in older adults with hypertension.

Studies on middle-aged or individuals with cognitive or cardiovascular impairments, have established that intensive blood pressure (BP) control reduces cognitive decline risk. However, uncertainty exists on differential effects between antihypertensive medications (AHM) classes on this risk, independent of BP-lowering efficacy, particularly in community-dwelling hypertensive older adults. A post-hoc analysis of the ASPREE study, a randomized trial of low-dose aspirin in adults aged 70+ years (65+ if US minorities) without baseline dementia, and followed for two years post-trial. Cox proportional-hazards regression models were used to estimate associations between baseline and time-varying AHM exposure and incident dementia (an adjudicated primary trial endpoint), in participants with baseline hypertension. Subgroup analyses included prespecified factors, APO ε4 carrier status and monotherapy AHM use. Most hypertensive participants (9,843/13,916; 70.7%) used AHMs. Overall, 'any' AHM use was not associated with lower incident dementia risk, compared with untreated participants (HR 0.84, 95%CI 0.70-1.02, p=0.08), but risk was decreased when angiotensin receptor blockers (ARBs) were included (HR 0.73, 95%CI 0.59-0.92, p=0.007). ARBs and β-blockers decreased dementia risk, whereas angiotensin-converting enzyme inhibitors (ACEIs) and diuretics increased risk. There was no association with RAS modulating or blood-brain-barrier crossing AHMs on dementia risk. Overall, AHM exposure in hypertensive older adults was not associated with decreased dementia risk, however, specific AHM classes were with risk direction determined by class; ARBs and β-blockers were superior to ACEIs and other classes in decreasing risk. Our findings emphasize the importance of considering effects beyond BP-lowering efficacy when choosing AHM in older adults.

Surgical Management for Primary Intracerebral Hemorrhage.

The incidence of primary intracerebral hemorrhage (ICH) is increasing, particularly in younger patients, in part, because of increased prescription of anticoagulants. The ICH incidence rate from 2016 to 2018 in the United States was nearly 79 per 100,000 person-years and as high as 367 per 100,000 person-years among those 75 years or older. Worldwide, ICH comprises 28% of all new strokes, but a higher disease burden than ischemic stroke because of its higher morbidity and mortality. While mortality seems to be decreasing, functional outcomes are not improving. After negative trials of open surgical evacuation, recent trials of medical management strategies including intensive blood pressure control and prothrombotic agents intended to reduce hematoma expansion failed to demonstrate efficacy. Concomitantly, continued interest in minimally invasive surgical approaches arose from appreciation of secondary iatrogenic injury incurred to subcortical white matter tracts from open surgical techniques. A positive trial of minimally invasive surgery for lobar hemorrhage has recently been reported, bringing new optimism and demanding a reconsideration of surgical management of ICH. In this narrative review, we summarize the landmark studies, review recent literature, and consider the outstanding questions surrounding surgical management of ICH.

Design and rationale for a randomized, open-label, parallel clinical trial evaluating major adverse cardiovascular events (pharmacological treatment versus diet control) in patients with high-normal blood pressure: the PRINT-TAHA9 trial

BackgroundThe distinction between normal and high blood pressure remains a debated topic, with varying guidelines on when to start medication. Contemporary guidelines advocate for the initiation of antihypertensive therapy in individuals who present with high-normal blood pressure, particularly those exhibiting elevated 10-year atherosclerotic cardiovascular disease (ASCVD) risk scores. Despite these recommendations, there is a notable lack of direct evidence supporting the efficacy of treating high-normal blood pressure to prevent major adverse cardiovascular events (MACE).MethodsThe PRINT-TAHA9 trial, a unicentric, randomized, open-label, controlled, parallel clinical study, seeks to explore the effects of intensive blood pressure control on MACE in participants with high-normal blood pressure. We will enroll 1620 adults aged 18 years and above with a systolic blood pressure range of 130–140 mmHg, diastolic blood pressure under 90 mmHg, and atherosclerotic cardiovascular disease (ASCVD) risk score exceeding 7.5%. The study will be executed in five distinct phases, with each phase enrolling between 300 and 400 participants. Participants will be randomly assigned to either the treatment group receiving antihypertensive medication (amlodipine/valsartan) and a low-salt/low-fat diet or to the control group receiving a similar diet. Follow-up visits are scheduled every 6 months over a 3-year period to monitor blood pressure, evaluate medication adherence, document any adverse events, and adjust the intervention as necessary. Cox proportional hazards regression analysis will be employed to examine the disparities between the two arms.DiscussionDespite guidelines promoting early treatment of elevated blood pressure, the debate continues due to insufficient evidence that such interventions significantly reduce the occurrence of MACE. This trial seeks to address this critical evidence gap.Trial registrationThe PRINT-TAHA9 trial was registered in October 2019 with the Iranian Registry of Clinical Trials (IRCT.ir) under the registration number IRCT20191002044961N1. https://irct.behdasht.gov.ir/trial/43092.

Relationship Between Sarcopenia and Intensive Blood Pressure Control Efficacy and Safety: A Secondary Analysis of SPRINT.

Sarcopenia and hypertension are independently associated with worse cardiovascular disease (CVD) risk and survival. While individuals with sarcopenia may benefit from intensive blood pressure (BP) control, the increased vulnerability of this population raises concerns for potential harm. This study aimed to evaluate clinical and safety outcomes with intensive (target <120 mm Hg) versus standard (<140 mm Hg) systolic BP targets in older hypertensive adults with sarcopenia compared with nonsarcopenic counterparts in the SPRINT (Systolic Blood Pressure Intervention Trial). Sarcopenia was defined using surrogates of the lowest sex-stratified median of the sarcopenia index (serum creatinine/cystatin C×100) for muscle wasting and gait speed ≤0.8 m/s for muscle weakness. Outcomes included CVD events, all-cause mortality, and serious adverse events. Of 2571 SPRINT participants with sarcopenia index and gait speed data available (aged ≥75 years), 502 (19.5%) met the criteria for sarcopenia, which was associated with higher risks of CVD events (adjusted hazard ratio, 1.49 [95% CI, 1.15-1.94]; P=0.003) and all-cause mortality (adjusted hazard ratio, 1.46 [95% CI, 1.09-1.94]; P=0.010). In participants with sarcopenia, intensive (versus standard) BP control nearly halved the risk of CVD events (adjusted hazard ratio, 0.57 [95% CI, 0.36-0.88]; P=0.012) without increasing serious adverse events. Similar risk reduction was seen for all-cause mortality in participants with sarcopenia (adjusted hazard ratio, 0.66 [95% CI, 0.41-1.08]; P=0.102), but the effect was only significant in those without chronic kidney disease. Older hypertensive adults with sarcopenia randomized to intensive BP control experienced a lower risk of CVD without increased adverse events compared with standard BP control. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01206062.

Blood pressure management after endovascular thrombectomy: Insights of recent randomized controlled trials.

The ideal blood pressure (BP) target in patients who undergo endovascular thrombectomy (EVT) with successful reperfusion is uncertain. Observational studies show that elevated BP during this period is associated with a higher risk of intracranial hemorrhage (ICH) and worse clinical outcomes. Several randomized controlled trials (RCTs) have explored whether intensive BP lowering improves clinical outcomes in these patients. This review aims to summarize the recent RCTs that compare intensive and conventional BP management strategies following EVT and discuss the innovative directions to improve. The recently published RCTs failed to demonstrate the benefit of intensive BP control on the functional outcome and decreasing the risk of ICH. The complex mechanism in cerebral blood flow regulation and the inappropriate BP range chosen in RCTs may be the reasons behind the inconsistent results between observational studies and RCTs. Individualized BP management, reducing BP variability, and multi-stage BP management should be paid more attention in future exploration. Intensive BP target did not improve clinical outcomes after successful EVT as compared with a conventional BP target. Further research is required to identify the optimal BP management strategy after reperfusion.