Intensive Blood Pressure Targets Research Articles

Effects of Achieving Rapid, Intensive, and Sustained Blood Pressure Reduction in Intracerebral Hemorrhage Expansion and Functional Outcome.

The time taken to achieve blood pressure (BP) control could be pivotal in the benefits of reducing BP in acute intracerebral hemorrhage (ICH). We aimed to assess the relationship between the rapid achievement and sustained maintenance of an intensive systolic BP (SBP) target with radiologic, clinical, and functional outcomes. Rapid, Intensive, and Sustained BP lowering in Acute ICH (RAINS) was a multicenter, prospective, observational cohort study of adult patients with ICH <6 hours and SBP ≥150 mm Hg at 4 Comprehensive Stroke Centers during a 4.5-year period. Patients underwent baseline and 24-hour CT scans and 24-hour noninvasive BP monitoring. BP was managed under a rapid (target achievement ≤60 minutes), intensive (target SBP <140 mm Hg), and sustained (target stability for 24 hours) BP protocol. SBP target achievement ≤60 minutes and 24-hour SBP variability were recorded. Outcomes included hematoma expansion (>6 mL or >33%) at 24 hours (primary outcome), early neurologic deterioration (END, 24-hour increase in NIH Stroke Scale score ≥4), and 90-day ordinal modified Rankin scale (mRS) score. Analyses were adjusted by age, sex, anticoagulation, onset-to-imaging time, ICH volume, and intraventricular extension. We included 312 patients (mean age 70.2 ± 13.3 years, 202 [64.7%] male). Hematoma expansion occurred in 70/274 (25.6%) patients, END in 58/291 (19.9%), and the median 90-day mRS score was 4 (interquartile range, 2-5). SBP target achievement ≤60 minutes (178/312 [57.1%]) associated with a lower risk of hematoma expansion (adjusted odds ratio [aOR] 0.43, 95% confidence interval [CI] 0.23-0.77), lower END rate (aOR 0.43, 95% CI 0.23-0.80), and lower 90-day mRS scores (aOR 0.48, 95% CI 0.32-0.74). The mean 24-hour SBP variability was 21.0 ± 7.6 mm Hg. Higher 24-hour SBP variability was not related to expansion (aOR 0.99, 95% CI 0.95-1.04) but associated with higher END rate (aOR 1.15, 95% CI 1.09-1.21) and 90-day mRS scores (aOR 1.06, 95% CI 1.04-1.10). Among patients with acute ICH, achieving an intensive SBP target within 60 minutes was associated with lower hematoma expansion risk. Rapid SBP reduction and stable sustention within 24 hours were related to improved clinical and functional outcomes. These findings warrant the design of randomized clinical trials examining the impact of effectively achieving rapid, intensive, and sustained BP control on hematoma expansion. This study provides Class III evidence that in adults with spontaneous ICH and initial SBP ≥150 mm Hg, lowering SBP to <140 mm Hg within the first hour and maintaining this for 24 hours is associated with decreased hematoma expansion.

Association of the Intensive Blood Pressure Target and Cardiovascular Outcomes in the Population With Chronic Kidney Disease: A Retrospective Study in Korea.

Recently, the target systolic blood pressure (BP) <120 mm Hg was suggested in the population with chronic kidney disease. We aimed to determine the applicability of intensified BP and to assess the incidence of cardiovascular disease (CVD) in the population with chronic kidney disease. Participants who were >20 years old and had estimated glomerular filtration rate 15 to 60 mL/min per 1.73 m2 during 2009 to 2011 were included from the database of Korean National Health Insurance Service and were followed up to 2018. Participants were categorized by BP as <120/80 mm Hg; 120 to 129/<80 mm Hg; 130 to 139/80 to 89 mm Hg; ≥140/90 mm Hg. The primary outcome was CVD risk and the secondary outcomes were all-cause mortality and progression to end-stage renal disease followed by subgroup analysis. Among the 45 263 adults with chronic kidney disease, 5196 CVD events were noted. In Cox regression analysis, higher BP was associated with a higher risk for CVD (hazard ratio [HR], 1.15 [95% CI, 1.12-1.19]; P for trend <0.001), end-stage renal disease (HR, 1.29 [95% CI, 1.22-1.37]; P for trend <0.001), and all-cause mortality (HR, 1.09 [95% CI, 1.06-1.13]; P for trend <0.001) than BP <120/80 mm Hg. In subgroup analysis, the association between BP and CVD showed a different trend in participants taking antihypertensives compared with those not using antihypertensive drugs. When comparing BP-treated individuals to untreated individuals, a significant interaction in the association between BP categories and end-stage renal disease was observed. The new intensive BP target proposed by 2021 Kidney Disease: Improving Global Outcomes should be applied to patients with chronic kidney disease in a personalized and advisory manner.

Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischemic Stroke: aSystematic Review and Meta-Analysis.

Optimal clinical outcome with successful recanalization from endovascular thrombectomy (EVT) requires optimal blood pressure (BP) management. We aimed to evaluate the efficacy and safety of the intensive BP target (< 140 mm Hg) versus the standard BP target (< 180 mm Hg) after EVT for acute ischemic stroke. We conducted asystematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) obtained from PubMed, Embase Cochrane, Scopus, and WOS until September 7th, 2023. We used the fixed-effect model to report dichotomous outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD), with a95% confidence interval (CI). CRD42023463206. We included four RCTs with 1559 patients. There was no difference between intensive BP and standard BP targets regarding the National Institutes of Health Stroke Scale (NIHSS) change after 24 h [MD: 0.44 with 95% CI (0.0, 0.87), P = 0.05]. However, the intensive BP target was significantly associated with adecreased risk of excellent neurological recovery (mRS ≤ 1) [RR: 0.87 with 95% CI (0.76, 0.99), P = 0.03], functional independence (mRS ≤ 2) [RR: 0.81 with 95% CI (0.73, 0.90), P = 0.0001] and independent ambulation (mRS ≤ 3) [RR: 0.85 with 95% CI (0.79, 0.92), P < 0.0001]. An intensive BP target after EVT is associated with worse neurological recovery and significantly decreased rates of functional independence and independent ambulation compared to the standard BP target. Therefore, the intensive BP target should be avoided after EVT for acute ischemic stroke.

Intensive blood pressure lowering in older people with hypertension: a systematic review and meta-analysis

Abstract Background Hypertension is a prevalent chronic disease associated with increased risk of ischaemic heart disease, stroke, and heart failure, especially in older people. Recommendations on blood pressure target in older patients are not consistent among guidelines. While most guidelines suggested the target of systolic blood pressure (SBP) &amp;lt;140 mmHg or a more relaxing target of 150 mmHg in older people, several guidelines suggested a more intensive target of &amp;lt;130 mmHg or &amp;lt;120 mmHg. Purpose The objective of this study is to evaluate the benefits and adverse side effects of intensive blood pressure targets, defined as SBP &amp;lt;130mmHg, compared to standard blood pressure targets, defined as SBP &amp;lt;140mmHg, in older people with hypertension. Methods We performed a systematic review and meta-analysis of randomised controlled trials comparing intensive blood pressure targets (SBP &amp;lt;130mmHg) with standard blood pressure targets in older people (aged≥60 years). Pooled odds ratios (ORs) and 95% Confidence Intervals (95%CI) were estimated using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. The study outcomes include all-cause mortality, cardiovascular mortality, major adverse cardiac events (MACE), acute coronary syndrome, stroke, heart failure, and adverse side effects including hypotension, syncope, falls and acute kidney injury. Results A total of 485 articles were identified, of these, 4 studies were included in this analysis. These 4 trials randomised 12,456 patients to either intensive blood pressure targets or standard blood pressure targets. Intensive blood target was defined as SBP &amp;lt;120 mmHg in 2 trials, and as SBP &amp;lt;130 mmHg in 2 trials. The meta-analysis showed that intensive blood pressure control was associated with reduced MACE (OR 0.69, 95%CI 0.58-0.83), acute coronary syndrome (OR 0.70, 95% CI 0.55-0.90), heart failure (OR 0.55, 95% CI 0.37-0.80), and stroke (OR 0.65, 95% CI 0.49-0.86). Similar trend was observed with all-cause mortality (OR 0.81, 95%CI 0.64-1.01) and cardiovascular mortality (OR 0.67, 95%CI 0.44-1.02), although not statistically significant. In terms of adverse effects, intensive blood pressure control was significantly associated with increased hypotension compared to standard blood pressure targets: OR 1.32 (95% CI 1.06-1.65, p=0.01). However, there was no significant difference in falls, syncope, or acute kidney injury between the two groups. Conclusion While the evidence base is limited, this analysis suggests that intensive blood pressure target may be a beneficial strategy in reducing the risk of cardiovascular events in the elderly population with hypertension. More studies are needed to evaluate the impact of this strategy on mortality and on the adverse side effects in older populations.Outcome: strokeOutcome: mortality

The HOPE Asia Network consensus on blood pressure measurements corresponding to office measurements: Automated office, home, and ambulatory blood pressures.

For adopting recently introduced hypertension phenotypes categorized using office and out of office blood pressure (BP) for the diagnosis of hypertension and antihypertension drug therapy, it is mandatory to define the corresponding out of office BP with the specific target BP recommended by the major guidelines. Such conditions include white-coat hypertension (WCH), masked hypertension (MH), white-coat uncontrolled hypertension (WUCH), and masked uncontrolled hypertension (MUCH). Here, the authors review the relevant literature and discuss the related issue to facilitate the use of corresponding BPs for proper diagnosis of WCH, MH, WUCH, and MUCH in the setting of standard target BP as well as intensive target BP. The methodology of deriving the corresponding BP has evolved from statistical methods such as standard deviation, percentile value, and regression to an outcome-based approach using pooled international cohort study data and comparative analysis in randomized clinical trials for target BPs such as the SPRINT and STEP studies. Corresponding BPs to 140/90 and 130/80mm Hg in office BP is important for safe and strict achievement of intensive BP targets. The corresponding home, daytime, and 24-h BPs to 130/80mm Hg in office BP are 130/80, 130/80, and 125/75mm Hg, respectively. However, researchers have found some discrepancies among the home corresponding BPs. As tentative criterion for de-escalation of antihypertensive therapy as shown in European guidelines was 120mm Hg in office BP, corresponding home, daytime, and 24-h systolic BPs to 120mm Hg in office systolic BP are 120, 120, and 115mm Hg, respectively.

New Studies Show No Benefit for Intensive Blood Pressure Target for Stroke After Endovascular Therapy

New Studies Show No Benefit for Intensive Blood Pressure Target for Stroke After Endovascular Therapy

S-14-3: WHICH IS THE OPTIMAL BP TARGET TO ACHIEVE? SHOULD GUIDELINES BE UPDATED?

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.

Should we rethink the blood pressure targets in hypertension guidelines?

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 (i.e., 140 mmHg, 130 mmHg, etc.). The definition of rigid and precise BP targets overall and in different risk categories is not fully supported by evidence. Observational studies: A direct relation between BP and risk of cardiovascular disease emerged from observational studies, including a large meta-analysis (Lancet 2002:1903). The majority of the studies showed that after correction for several confounders (cancer, heart failure, etc.), the lowest cardiovascular risk occurred at low values of achieved BP (<120/80 mmHg, or even <100/60 mmHg). 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 in association 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 2016:642) when compared to a less intensive strategy. Notably, BP targets considerably differed across the studies. Evidence regarding tolerability of treatment: According to Guidelines, a more intensive BP target may be allowed at condition that the treatment is well tolerated. However, the concept of ‘good tolerability of treatment’ holds at any level of achieved BP, irrespective of the BP target. No evidence supports the concept of ‘safety thresholds’ in patients who tolerate treatment very well. Conclusion: The ‘lowest well tolerated BP’ looks like a simple, evidence-based and reasonable BP target regardless of the cardiovascular risk status of the patient.

Economic evaluation of new blood pressure target for hypertensive patients in Taiwan according to the 2022 hypertension clinical practice guidelines of the Taiwan society of cardiology: a simulation modeling study.

With the promising cardiovascular benefits in the STEP and SPRINT trials, the2022 Taiwan's hypertension guidelines redefined the hypertension threshold as 130/80 mmHg and a universal blood-pressure target of <130/80 mmHg. This study's objective was to examine the cost-effectiveness of the intensive blood-pressure target for hypertensive patients using estimated lifetime medical costs and quality-adjusted life years (QALY) from the Taiwan national payer's perspective. We developed a lifetime Markov model comparing the intensive and conservative blood-pressure targets. Incremental cost-effectiveness ratio (ICER) against the willing-to-pay thresholds at the one-time [US$34,000(NT$1,020,000)] and three-time [US$100,000(NT$3,000,000)] gross domestic product per capita were defined as very cost-effect and only cost-effective. The cost-effectiveness in different age stratifications and cardiovascular risks treated with a more intensive target (120 mmHg) were examined in the subgroup analyses. The new blood-pressure treatment target produced more lifetime medical costs [US$31,589(NT$947,670) versus US$26,788(NT$803,640)] and QALYs (12.54 versus 12.25), and the ICER was US$16,589(NT$497,670), which was 99.1% and 100% probability of a very cost-effective and cost-effective strategy. The ICERs in all age stratifications had more than a 90% probability of being very cost-effective, and ICERs decreased with age. More intensive control in patients with high cardiovascular risks produced a lower ICER [US$14,547(NT$436,410)]. In conclusion, Taiwan's new blood-pressure treatment target can prevent more cardiovascular events with acceptable costs per QALY below the willing-to-pay thresholds. The cost-effectiveness of intensive control is consistent across different ages and more pronounced with the increase in age and cardiovascular risk.

Considerations for Optimal Blood Pressure Target of Hypertension

Hypertension is a major risk factor for cardiovascular morbidity and mortality that has led to a huge public health burden. The optimal target of blood pressure (BP) to prevent cardiovascular complications remains unclear. Based on the results of the Systolic BP Intervention Trial (SPRINT) in 2015, the 2017 American College of Cardiology/American Heart Association guidelines for diagnosis and management of high BP in adults has changed the diagnostic threshold from 140/90 to 130/80 mmHg, and the target BP to 130/80 mmHg for nearly all hypertensive patients diagnosed using the new criteria. However, the findings from the SPRINT trial were to an extent contrasting with the results of previous large randomized controlled trials, namely Action to Control Cardiovascular Risk in Diabetes (ACCORD) and Secondary Prevention of Small Subcortical Strokes (SPS3). Besides, the 2018 European Society of Cardiology/European Society of Hypertension guidelines and the 2018 Chinese guidelines have maintained the conventional threshold and recommended target of 140/90 mmHg for most hypertensive patients. Given the special measurement of BP in the SPRINT trial and using an automated measurement system, the intensive systolic BP target of 120 mmHg provided by the SPRINT trial was not widely adopted. Most recently, the Strategy of BP Intervention in the Elderly Hypertensive Patients (STEP) trial, with a higher systolic BP target of 110 to 130 mmHg in the intensive group, confirmed the benefit and safety of intensive BP control in patients with hypertension, in accordance with the SPRINT trial. Here, the results from randomized controlled trials, meta-analyses, and other observational research studies, have been reviewed to evaluate the optimal target of BP treatment and the threshold of diagnostic criteria for hypertension.

Associations Between the Prevalence, Treatment, Control of Hypertension and Cognitive Trajectories Among Chinese Middle-Aged and Older Adults

ObjectiveTo investigate the associations between the prevalence, treatment, control of hypertension, and trajectories of cognitive performance among Chinese middle-aged and older adults. DesignAn 8-year longitudinal study. SettingChina. ParticipantsChinese middle-aged and older adults. MeasurementsData from the China Health and Retirement Longitudinal Study were utilized. Group-based trajectory modeling was performed to identify heterogeneous trajectories of episodic memory and executive function. Multinomial logistic regression models were established to examine the relationships between hypertension status and cognitive trajectories, stratified by sex. ResultsThree episodic memory trajectories and four executive function trajectories were identified in males and females. Hypertension prevalence was associated with worse episodic memory and executive function trajectories in females. Compared with treated hypertensives, untreated hypertensives were more likely to have worse executive function trajectories, both in males and females. Among male treated hypertensives, those with uncontrolled blood pressure (BP) had worse episodic memory trajectories compared with their counterparts with controlled at standard targets, while females with uncontrolled BP demonstrated worse executive function trajectories compared with females controlled at standard targets. There was basically no significant difference in cognitive trajectory memberships between individuals with controlled hypertension corresponding to intensive or standard BP targets. ConclusionsThe prevalence of hypertension was associated with worse cognitive trajectories, and the treatment and control of hypertension were related to more favorable cognitive trajectories. Intensive BP control target was not associated with additional benefit beyond the recognized protective effect of standard BP targets on cognitive trajectories.

Association of Intensive vs Standard Blood Pressure Control With Cerebral Blood Flow

Antihypertensive treatments benefit cerebrovascular health and cognitive function in patients with hypertension, but it is uncertain whether an intensive blood pressure target leads to potentially harmful cerebral hypoperfusion. To investigate the association of intensive systolic blood pressure (SBP) control vs standard control with whole-brain cerebral blood flow (CBF). This substudy of the Systolic Blood Pressure Intervention Trial (SPRINT) randomized clinical trial compared the efficacy of 2 different blood pressure-lowering strategies with longitudinal brain magnetic resonance imaging (MRI) including arterial spin labeled perfusion imaging to quantify CBF. A total of 1267 adults 50 years or older with hypertension and increased cardiovascular risk but free of diabetes or dementia were screened for the SPRINT substudy from 6 sites in the US. Randomization began in November 2010 with final follow-up MRI in July 2016. Analyses were performed from September 2020 through December 2021. Study participants with baseline CBF measures were randomized to an intensive SBP target less than 120 mm Hg or standard SBP target less than 140 mm Hg. The primary outcome was change in whole-brain CBF from baseline. Secondary outcomes were change in gray matter, white matter, and periventricular white matter CBF. Among 547 participants with CBF measured at baseline, the mean (SD) age was 67.5 (8.1) years and 219 (40.0%) were women; 315 completed follow-up MRI at a median (IQR) of 4.0 (3.7-4.1) years after randomization. Mean whole-brain CBF increased from 38.90 to 40.36 (difference, 1.46 [95% CI, 0.08-2.83]) mL/100 g/min in the intensive treatment group, with no mean increase in the standard treatment group (37.96 to 37.12; difference, -0.84 [95% CI, -2.30 to 0.61] mL/100 g/min; between-group difference, 2.30 [95% CI, 0.30-4.30; P = .02]). Gray, white, and periventricular white matter CBF showed similar changes. The association of intensive vs standard treatment with CBF was generally similar across subgroups defined by age, sex, race, chronic kidney disease, SBP, orthostatic hypotension, and frailty, with the exception of an indication of larger mean increases in CBF associated with intensive treatment among participants with a history of cardiovascular disease (interaction P = .05). Intensive vs standard antihypertensive treatment was associated with increased, rather than decreased, cerebral perfusion, most notably in participants with a history of cardiovascular disease. ClinicalTrials.gov Identifier: NCT01206062.

Associations between diabetic retinopathy and modifiable risk factors: An umbrella review of meta-analyses.

Several modifiable risk factors have been meta-analysed for diabetic retinopathy (DR), such as physical activity and vitamin D status. To date, these factors have not been systematically aggregated and the credibility of evidence assessed. Therefore, the aim of this umbrella review was to aggregate all modifiable risks of DR and assess the credibility of the evidence. An umbrella review of meta-analyses was undertaken. For each meta-analytic association, random-effects effect size, 95% confidence intervals (CIs), heterogeneity, small-study effects, excess significance bias and 95% prediction intervals were calculated. The credibility of significant evidence (p<0.05) was graded from I to IV, using pre-defined criteria. After initial searches, 13studies were included covering 34 independent outcomes (total participants=824,372). Positive associations were found between insulin usage and diabetic macular oedema (RR=4.5; 95% CI 3.1-6.6), and DR risk (RR=2.3; 95% CI 1.4-3.9) in people with type 2 diabetes. Vitamin D deficiency was associated with DR risk (OR=2.8; 95% CI 1.1-7.1), as was obesity (RR=1.34; 95% CI 1.06-1.68) and sedentary behaviour (RR=1.22; 95%CI 1.03-1.44). Intensive blood pressure targets (RR=0.8 95%CI 0.8-1.0), and moderate physical activity (RR=0.69; 95%CI 0.53-0.91) yielded significant protective associations with DR. People with type 2 diabetes on insulin have a high risk of macular oedema and DR. Vitamin D deficiency yielded almost three times greater odds of DR, while intensive blood pressure control reduces DR risk by 20% and moderate physical activity by 31%. Healthcare professionals should use this evidence to identify those people most at risk to ensure that proper treatment and healthy lifestyles are recommended.

The relationship between diastolic blood pressure and the risk of cardiovascular events in patients with atrial fibrillation whose systolic blood pressure was treated to less than 130 mmHg

Abstract Background Hypertension is one of the major risk factors of cardiovascular events in patients with atrial fibrillation (AF). Low diastolic blood pressure (DBP) has been reported to be associated with the incidence of cardiovascular events, but current guidelines recommend an intensive blood pressure target of less than 130/80 mmHg for AF patients taking oral anticoagulants without mentioning the lower limits of DBP. Methods The Fushimi AF Registry is a community-based prospective survey of AF patients in a city of Japan. Follow-up data were available in 4,472 patients, and hypertensive patients who received prescription of any antihypertensive agents and whose systolic blood pressure was treated to less than 130 mmHg were available were examined (n=1,319). We divided the patients into four groups according to their DBP at baseline; G1 (DBP&amp;lt;60 mmHg, n=349), G2 (60≤DBP&amp;lt;70, n=434), G3 (70≤DBP&amp;lt;80, n=386) and G4 (80≤DBP, n=150), and compared the clinical background and outcomes among groups. Results The proportion of female was grater in G1 group, and the patients in G1 group were older. During the median follow-up of 2,458 days, in Kaplan-Meier analysis, the incidence rates of cardiovascular events (composite of cardiac death, ischemic stroke, systemic embolism, non-fatal myocardial infarction and heart failure hospitalization during follow up) were the highest in G1 group and the lowest in G3 group (G1: 7.2% per person-year vs. G2: 4.9% vs. G3: 2.2% vs. G4: 4.4%; p&amp;lt;0.01). Multivariate Cox proportional hazards regression analysis revealed that DBP was an independent determinant of cardiovascular events (G1 vs. G3; hazard ratio (HR): 1.96, 95% confidence intervals (CI): 1.39–2.76, G2 vs. G3; HR: 1.79, 95% CI: 1.28–2.50, G4 vs. G3; HR: 1.56, 95% CI: 0.99–2.45) (Figure 1). When we examined the association of DBP according to 10 mmHg increment, patients with excessively low DBP (&amp;lt;50 mmHg) had significantly higher incidence of cardiovascular events than patients with DBP of 70–79 mmHg (HR: 2.80, 95% CI: 1.81–4.33), and DBP exhibited J curve association with higher incidence of cardiovascular events (Figure 2). Conclusion In Japanese AF patients whose systolic blood pressure was treated to less than 130 mmHg, patients with excessively low DBP had significantly higher incidence of cardiovascular events, and DBP exhibited J curve association with higher incidence of cardiovascular events. Funding Acknowledgement Type of funding sources: None.

Cardiovascular and Renal Outcomes of the New Intensive Blood Pressure Target in a CKD Population in Korea

Cardiovascular and Renal Outcomes of the New Intensive Blood Pressure Target in a CKD Population in Korea

SPRINT-A Kidney-Centric Narrative Review: Recent Advances in Hypertension.

Hypertension is a potent cardiovascular risk factor with deleterious end-organ effects and is especially prevalent among patients with chronic kidney disease. The SPRINT (Systolic Blood Pressure Intervention Trial) enrolled patients at an elevated cardiac risk including patients with mild to moderate chronic kidney disease and found that an intensive systolic blood pressure goal of <120 mm Hg significantly reduced the rates of adverse cardiovascular events and all-cause mortality and nonsignificantly reduced the rates of probable dementia; these results were consistent whether one had chronic kidney disease or not. However, results of intensive blood pressure therapy on chronic kidney disease progression were inconclusive, and there was an increased risk of incident chronic kidney disease and acute kidney injury, but the declines in kidney function appear to be hemodynamically driven and reversible. Overall, an intensive blood pressure target is effective in reducing cardiovascular disease and all-cause mortality and may reduce the risk of probable dementia in patients with mild to moderate chronic kidney disease. More studies are needed to determine its long-term effects on kidney function.

CARDIOVASCULAR OUTCOMES AT RECOMMENDED BLOOD PRESSURE TARGETS IN MIDDLE AGED AND ELDERLY PATIENTS WITH TYPE 2 DIABETES MELLITUS AND HYPERTENSION

Objective: The optimal blood pressure (BP) target for patients with type-2 diabetes mellitus (DM) and hypertension has been set at &lt; 130/80 mmHg in guidelines. However, available data of event-based clinical outcomes trials show that little evidence supports these guideline recommendations. Design and method: We addressed this issue by post-hoc analyzing the risk of cardiovascular (CV) events in mostly elderly high-risk hypertensive patients with type-2 DM participating in the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial. Patients (n = 5250) were divided into 4 groups according to the proportion of on-treatment visits before the occurrence of an event (&lt; 25%, 25%-49%, 50–74%, 75% -100%) in which BP was reduced to &lt; 140/90 or &lt; 130/80 mmHg. Results: After adjustment for baseline demographic differences between groups, a reduction in the proportion of visits in which BP achieved &lt; 140/90 mmHg accompanied a progressive increase in the risk of CV mortality and morbidity as well as of cause-specific events such as stroke, myocardial infarction and heart failure (Figure, upper panel). A progressive reduction in the proportion of visits in which BP was reduced &lt; 130/80 mmHg did not have any effect on CV risks (Figure, lower panel). Conclusions: In mostly elderly high-risk hypertensive patients with type-2 diabetes mellitus participating in the VALUE trial, achieving more frequently BP &lt; 140/90 mmHg showed a marked protective effect on overall and all cause specific cardiovascular outcomes. This was not the case for a more frequent achievement of the more intensive BP target, i.e. &lt; 130/80 mmHg.

Evaluation of Optimal Diastolic Blood Pressure Range Among Adults With Treated Systolic Blood Pressure Less Than 130 mm Hg

Extremely low diastolic blood pressure has been reported to be associated with increased adverse cardiovascular events (ie, the diastolic J-shape phenomenon); however, current US guidelines recommend an intensive blood pressure target of less than 130/80 mm Hg without mentioning the lower limits of diastolic blood pressure. To evaluate whether there is a diastolic J-shape phenomenon for patients with an treated systolic blood pressure of less than 130 mm Hg and to explore the safe and optimal diastolic blood pressure ranges for this patient population. This cohort study analyzed outcome data of patients at high cardiovascular risk who were randomized to intensive or standard blood pressure control and achieved treated systolic blood pressure of less than 130 mm Hg in the Systolic Blood Pressure Intervention Trial (SPRINT) and Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial. Data were collected from October 2010 to August 2015 (SPRINT) and from September 1999 to June 2009 (ACCORD-BP). Data were analyzed from January to May 2020. Treated diastolic blood pressure, divided in intervals of less than 60, 60 to less than 70, 70 to less than 80, and 80 mm Hg and greater. The primary outcome was a composite of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. A composite cardiovascular outcome, including cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke, was among the key secondary outcomes. A total of 7515 patients (mean [SD] age, 65.6 [8.7] years; 4553 [60.6%] men) were included in this analysis. The nominally lowest risk was observed at a diastolic blood pressure between 70 and 80 mm Hg for the primary outcome, the composite cardiovascular outcome, nonfatal myocardial infarction, and cardiovascular death. A mean diastolic blood pressure of less than 60 mm Hg was associated with significantly increased risk of the primary outcome (hazard ratio [HR], 1.46; 95% CI, 1.13-1.90; P = .004), the composite cardiovascular outcome (HR, 1.74; 95% CI, 1.26-2.41; P = .001), nonfatal myocardial infarction (HR, 1.73; 95% CI, 1.15-2.59; P = .008), and nonfatal stroke (HR, 2.67; 95% CI, 1.26-5.63; P = .01). This cohort study found that lowering diastolic blood pressure to less than 60 mm Hg was associated with increased risk of cardiovascular events in patients with high cardiovascular risk and an treated systolic blood pressure less than 130 mm Hg. The finding that a diastolic blood pressure value between 70 and 80 mm Hg was an optimum target for this patient population merits further study.

Effect of intensive blood pressure on the progression of non-diabetic chronic kidney disease at varying degrees of proteinuria

The ideal blood pressure (BP) target for renoprotection is uncertain in patients with non-diabetic chronic kidney disease (CKD), especially considering the influence exerted by pre-existing proteinuria. In this pooled analysis...

Treatment of Hypertension in Patients with Diabetes Mellitus: a Contemporary Approach.

Blood pressure guidelines worldwide have changed their recommended blood pressure goals multiple times over the past decade due to an evolving understanding of the treatment of hypertension in patients with diabetes mellitus. While it is evident through randomized trials that treatment of hypertension in diabetes mellitus prevents complications, the optimal blood pressure goal is not clear. Post hoc analyses of the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial, its long-term follow along study ACCORDION, and Systolic Blood Pressure Intervention Trial (SPRINT) suggest that patients with diabetes have a reduced risk of adverse cardiovascular events when aiming for more intensive blood pressure targets. High-quality data support guideline recommendations for more aggressive blood pressure targets in patients with diabetes mellitus. Reasoning for a return to more aggressive blood pressure goals in this at-risk population is discussed, and treatment strategies encompassing contemporary therapeutic options are recommended.