Intensive Pressure Research Articles

Effect of visit-to-visit blood pressure variability on mild cognitive impairment and probable dementia in hypertensive patients receiving standard and intensive blood pressure treatment.

High visit-to-visit blood pressure variability (BPV) and hypertension are risk factors for mild cognitive impairment (MCI) and probable dementia (PD). Few articles assessed the effect of BPV on the MCI and PD in intensive blood pressure treatment and the different functions of three types of visit-to-visit BPV: systolic blood pressure variability (SBPV), diastolic blood pressure variability (DBPV) and pulse pressure variability (PPV). We performed a post hoc analysis of the SPRINT MIND trial. The primary outcomes were MCI and PD. BPV was measured by average real variability (ARV). The Kaplan-Meier curves were used to clarify the difference in tertiles of BPV. We fit Cox proportional hazards models to our outcome. We also did an interaction analysis between the intensive and standard groups. We enrolled 8,346 patients in the SPRINT MIND trial. The incidence of MCI and PD in the intensive group was lower than that in the standard group. 353 patients had MCI and 101 patients had PD in the standard group while 285 patients had MCI and 75 patients had PD in the intensive group. Tertiles with higher SBPV, DBPV and PPV in the standard group had a higher risk of MCI and PD (all p < 0.05). Meanwhile, higher SBPV and PPV in the intensive group were associated with an increased risk of PD (SBPV: HR(95%) = 2.1 (1.1-3.9), p = 0.026; PPV: HR(95%) = 2.0 (1.1-3.8), p = 0.025 in model 3) and higher SBPV in the intensive group was associated with an increased risk of MCI(HR(95%) = 1.4 (1.2-1.8), p < 0.001 in model 3). The difference between intensive and standard blood pressure treatment was not statistically significant when we considered the effect of the higher BPV on the risk of MCI and PD (all p for interaction >0.05). In this post hoc analysis of the SPRINT MIND trial, we found that higher SBPV and PPV were associated with an increased risk of PD in the intensive group, and higher SBPV was associated with an increased risk of MCI in the intensive group. The effect of higher BPV on the risk of MCI and PD was not significantly different in intensive and standard blood pressure treatment. These findings emphasized the need for clinical work to monitor BPV in intensive blood pressure treatment.

Intensive Blood Pressure Control After Mechanical Thrombectomy for Acute Ischemic Stroke

Optimal blood pressure targets following successful mechanical thrombectomy remain uncertain. While some observational studies suggest that the relationship between blood pressure and outcomes follows a U-shaped curve, others suggest a linear relationship where lower is better. The recent BP-TARGET study (Blood Pressure Target in Acute Stroke to Reduce Hemorrhage After Endovascular Therapy) did not find a benefit to intensive blood pressure lowering regarding the risk of symptomatic intracranial hemorrhage, but it was not sufficiently powered to detect differences in functional outcomes. On its heels arrived the ENCHANTED2 (Enhanced Control of Hypertension and Thrombectomy Stroke Study)/mechanical thrombectomy trial, the first trial of intensive blood pressure lowering in patients with hypertension following successful mechanical thrombectomy powered to detect a difference in functional outcomes. The trial randomized patients to either a systolic blood pressure less than 120 or 140 to 180 mm Hg. The trial was terminated early due to safety concerns in the more intensive blood pressure-lowering group. In this emerging therapy critique, we explore concerns regarding the generalizability of ENCHANTED2/mechanical thrombectomy, including the high prevalence of intracranial atherosclerosis in the studied population. We survey mechanisms for poor outcomes in patients who receive overly aggressive blood pressure reduction following successful thrombectomy, such as poststroke autoregulatory compromise and persistent microcirculatory hypoperfusion. Finally, we advocate for a more moderate approach, pending further research.

36. Clinical Outcome of Intensive Blood Pressure Lowering in Diabetic Patients: A Systematic Review and Meta-analysis

Background: It remains controversial in defining the optimal blood pressure (BP) targets for diabetes mellitus (DM) patients. There were various data on intensive BP lowering management in DM population, particularly in reducing cardiovascular outcomes. Objective: This study was conducted to compare the clinical outcome of intensive and standard BP lowering management in DM patients. Methods: Randomized Controlled Trials (RCTs) from Pubmed, Proquest, Google Scholar and Cochrane Library databases which compare the clinical outcome between intensive and standard BP lowering therapy were analyzed. Meta-analysis was conducted with random effects and Mantel-Haenszel method. Results: 18723 patients with DM from 11 RCTs were included. Intensive BP lowering strategy gave less number of stroke events (RR: 0.55; 95%CI: 0.36 to 0.85; p: 0.007) compared with standard BP lowering management. Between the two groups, there was no significant difference in causing all-cause death (RR: 0.94; 95%CI: 0.83 to 1.08; p: 0.39), cardiovascular death (RR: 0.85; 95%CI: 0.52 to 1.39; p: 0.53), myocardial infarction (RR: 0.96; 95%CI: 0.85 to 1.09; p: 0.54), heart failure (RR: 0.96; 95%CI: 0.75 to 1.23; p: 0.73), microalbuminuria (RR: 0.96; 95%CI: 0.65 to 1.40; p: 0.82). In the subgroup analysis, SBP reduction to lower than 120 mmHg caused lower incidence of stroke events compared with BP target of lower than 130 mmHg (RR: 0.57; 95%CI: 0.35 to 0.93; p: 0.02). Conclusion: Intensive BP lowering strategy gave a better outcome in reducing stroke events in DM patients. Targeting SBP to below 120 mmHg showed more benefit compared with below 130 mmHg.

17. Intensive vs. Standard Blood Pressure Strategy in Elderly Patients: A Systematic Review and Meta-analysis

Background and Objectives: Currently, ESC and AHA have different blood pressure (BP) goals, particularly for elderly patients. This study compared efficacy and side effect of intensive BP-lowering strategies in elderly (age $60 years) hypertensive patients. Methods: We searched PubMed, ProQuest, Google Scholar, and Cochrane database for all Randomized Control Trials (RCTs). Studies that compare the outcome of intensive vs. standard BP strategy in the elderly hypertensive patient were included. All-cause death, Acute Myocardial Infarction (AMI), cardiovascular (CV) death, Heart Failure (HF), stroke, injurious fall/fracture, and syncope were evaluated. We did a subgroup analysis in elderly hypertensive patients (&gt;70 years old) with no comorbidities. Random effect analysis was used to calculate pooled relative risk (RRs) and 95% confidence intervals (Cis). Results: This study includes 7 RCTs with 19.650 patients. Intensive BP showed significant differences from standard BP to all-cause death (RR: 0.74; 95% CI: 0.58 - 0.93; P = 0.01), AMI (RR: 0.72; 95% CI: 0.57 - 0.92: P = 0.008), CV death (RR: 0.63; 95%CI: 0.47 - 0.84; P = 0.001), HF (RR: 0.61; 95% CI: 0.42 - 0.89; P = 0.01), and stroke (RR: 0.72; 95% CI: 0.55 - 0.95; P = 0.02). In the subgroup analysis of 3 RCTs with 6.439 patients, intensive BP significantly reduce all-cause death (RR: 0.66; 95% CI: 0.54 to 0.80; P = 0.0001), CV death (RR: 0.60; 95%CI: 0.43 to 0.84; P = 0.003), and stroke (RR: 0.62; 95% CI: 0.39 to 0.99; P = 0.04). Conclusions: Intensive BP strategy in older patients reduces all-cause death, AMI, CV death, HF, and stroke event.

Concordance between clinical outcomes in the Systolic Blood Pressure Intervention Trial and in the electronic health record

BackgroundRandomized trials are the gold standard for generating clinical practice evidence, but follow-up and outcome ascertainment are resource-intensive. Electronic health record (EHR) data from routine care can be a cost-effective means of follow-up, but concordance with trial-ascertained outcomes is less well-studied. MethodsWe linked EHR and trial data for participants of the Systolic Blood Pressure Intervention Trial (SPRINT), a randomized trial comparing intensive and standard blood pressure targets. Among participants with available EHR data concurrent to trial-ascertained outcomes, we calculated sensitivity, specificity, positive predictive value, and negative predictive value for EHR-recorded cardiovascular disease (CVD) events, using the gold standard of SPRINT-adjudicated outcomes (myocardial infarction (MI)/acute coronary syndrome (ACS), heart failure, stroke, and composite CVD events). We additionally compared the incidence of non-CVD adverse events (hyponatremia, hypernatremia, hypokalemia, hyperkalemia, bradycardia, and hypotension) in trial versus EHR data. Results2468 SPRINT participants were included (mean age 68 (SD 9) years; 26% female). EHR data demonstrated ≥80% sensitivity and specificity, and ≥ 99% negative predictive value for MI/ACS, heart failure, stroke, and composite CVD events. Positive predictive value ranged from 26% (95% CI; 16%, 38%) for heart failure to 52% (95% CI; 37%, 67%) for MI/ACS. EHR data uniformly identified more non-CVD adverse events and higher incidence rates compared with trial ascertainment. ConclusionsThese results support a role for EHR data collection in clinical trials, particularly for capturing laboratory-based adverse events. EHR data may be an efficient source for CVD outcome ascertainment, though there is clear benefit from adjudication to avoid false positives.

The impact of uncontrolled hypertension on the CNS.

The brain is a target of organ damage due to hypertension. In addition to acute damage in the form of hypertensive encephalopathy, ischaemic stroke, and intracerebral haemorrhage, hypertension causes chronic changes in the brain tissue that, over the course of years, will be manifested by impaired brain functions including cognitive deficit. Hypertension is also a risk factor for progression of cognitive disorder to overt dementia. It is commonly accepted that the earlier in life hypertension occurs, the greater the risk of developing dementia in old age. The pathophysiological mechanism underlying this effect of hypertension is microvascular damage which causes changes in the brain tissue and brain atrophy. A favourable fact is that the treatment with antihypertensive drugs demonstrably reduces the risk of developing dementia in individuals with hypertension. A more profound preventive effect was found in intensive blood pressure control and in RAAS system inhibitors. Therefore, hypertension has to be controlled since its onset, even in younger patients.

Association Between the Frailty and Cognitive Impairment Among Patients WithHypertension-A Post Hoc Analysis ofthe SPRINT Trial.

Background Frailty and cognitive impairment are common in the elderly, with various shared risk factors like hypertension. Frailty is a marker for future cognitive function. Moreover, whether intensive blood pressure interacted with frailty and cognitive impairment is unknown. Methods and Results We performed a post hoc analysis of data from SPRINT (Systolic Blood Pressure Intervention Trial). The relationship between frailty and a composite of probable dementia (PD) and mild cognitive impairment (MCI) was analyzed. Also, we evaluated the interaction of intensive blood pressure lowering in the relationship between frailty and cognitive impairment. A total of 8537 patients were included in our study, and 35.1% were women. The mean age of these participants was 67.9±9.3 years. According to the baseline frailty index, 1670, 4637, and 2230 patients were in fit, less fit, and frail statuses, respectively. During a mean follow-up of 4.61 years, 871 cases of PD or MCI occurred. Compared with those in fit status, those with less fit (hazard ratio [HR], 2.14 [95% CI, 1.65-2.77]) and frailty (HR, 4.28 [95% CI, 3.26-5.61]) status had a higher incidence of a composite of PD and MCI. Blood pressure control strategy interacted with the correlation between frailty and cognitive impairment. Intensive blood pressure control (HR, 2.4 [95% CI, 2.0-2.8]) accelerated the relationship between frailty and incidence of PD and MCI compared with the standard treatment group (HR, 1.8 [95% CI, 1.5-2.1]; P for interaction=0.009). Conclusions This study found that the baseline frailty status was a possible marker for the incidence of a composite of PD and MCI. Intensive blood pressure control may strengthen this correlation. Registration URL: https://clinicaltrials.gov/; Unique identifier: NCT01206062.

Additive effects of intensive BP control and ACE inhibition on suppression of proteinuria in patients with CKD

The synergistic effects of RAAS inhibition and intensive blood pressure lowering in reducing proteinuria have not been well studied. We aimed to study this effect using data from the AASK Trial where our data suggest there is an additive and synergistic effect between RAAS inhibition and intensive blood pressure inhibition in reducing proteinuria.

Association Between Magnitude of Differential Blood Pressure Reduction and Secondary Stroke Prevention

The degree to which more intensive blood pressure reduction is better than less intensive for secondary stroke prevention has not been delineated. To perform a standard meta-analysis and a meta-regression of randomized clinical trials to evaluate the association of magnitude of differential blood pressure reduction and recurrent stroke in patients with stroke or transient ischemic attack (TIA). PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1, 1980, to June 30, 2022. Randomized clinical trials that compared more intensive vs less intensive blood pressure lowering and recorded the outcome of recurrent stroke in patients with stroke or TIA. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was used for abstracting data and assessing data quality and validity. Risk ratio (RR) with 95% CI was used as a measure of the association of more intensive vs less intensive blood pressure lowering with primary and secondary outcomes. The univariate meta-regression analyses were conducted to evaluate a possible moderating effect of magnitude of differential systolic blood pressure (SBP) and diastolic blood pressure (DBP) reduction on the recurrent stroke and major cardiovascular events. The primary outcome was recurrent stroke and the lead secondary outcome was major cardiovascular events. Ten randomized clinical trials comprising 40 710 patients (13 752 women [34%]; mean age, 65 years) with stroke or TIA were included for analysis. The mean duration of follow-up was 2.8 years (range, 1-4 years). Pooled results showed that more intensive treatment compared with less intensive was associated with a reduced risk of recurrent stroke in patients with stroke or TIA (absolute risk, 8.4% vs 10.1%; RR, 0.83; 95% CI, 0.78-0.88). Meta-regression showed that the magnitude of differential SBP and DBP reduction was associated with a lower risk of recurrent stroke in patients with stroke or TIA in a log-linear fashion (SBP: regression slope, -0.06; 95% CI, -0.08 to -0.03; DBP: regression slope, -0.17; 95% CI, -0.26 to -0.08). Similar results were found in the association between differential blood pressure lowering and major cardiovascular events. More intensive blood pressure-lowering therapy might be associated with a reduced risk of recurrent stroke and major cardiovascular events. These results might support the use of more intensive blood pressure reduction for secondary prevention in patients with stroke or TIA.

Intensive Blood Pressure Control and Diabetes Mellitus Incidence for Patients with Impaired Fasting Glucose: A Secondary Analysis of SPRINT.

Previous studies indicated that intensive blood pressure (BP) control (systolic BP < 120 mm·Hg) compared with standard BP control (<140 mm·Hg) was associated with an increased risk of type 2 diabetes (T2D) and impaired fasting glucose (IFG) among hypertensive patients with normoglycemia. However, the impact of intensive BP control on the incidence of T2D for those with IFG is still unknown. This was a secondary analysis of the SPRINT (Systolic Blood Pressure Intervention Trial) of the study. We included participants with IFG at randomization, which was defined as fasting blood glucose (FBG) between 100 and 125 mg/dL. The primary outcome was incident T2D, defined as events of reaching FBG ≥ 126 mg/dL, participant self-report T2D at annual examination, or a record of hypoglycemic medications at follow-up. The secondary outcome was incident IFG reversion (IFGR), defined as the time to first FBG back to normoglycemia (<100 mg/dl) among participants without incident T2D. Cox proportional hazards models were used to compare the cumulative incidence of outcomes between the two BP control groups. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. A total of 3310 participants were included in our primary outcome analysis (median age 67 years, 29% female). There were 293 participants who developed T2D among the intensive BP control group and 256 participants who developed T2D among the standard BP control group, resulting in 56.87 (50.36-63.39) versus 49.33 (43.29-55.37) events per 1000 person-years of treatment (HR 1.18 [95% CI, 1.00-1.40], P=0.052). After excluding 549 participants who developed T2D, 2761 participants were included in our secondary outcome analysis with 559 participants who developed IFGR among the intensive BP control group and 632 participants who developed IFGR among the standard BP control group, resulting in 141.20 (129.50-152.91) versus 158.20 (145.86,170.53) events per 1000 person-years of treatment (HR 0.9 [95% CI, 0.8-1.01], P=0.067). Our study found that in comparison to the standard BP control for hypertensive patients with IFG, intensive BP control was associated with a small increased risk of new-onset T2D, though it did not reach statistical significance. This kind of impact should be considered when implementing the strategy, especially for those with high risks of developing T2D. This trial is registered with NCT01206062.

Effect of small vessel disease severity on blood pressure management after endovascular therapy in the BP TARGET trial.

Acute ischaemic stroke patients with cerebral small vessel disease (CSVD), including cerebral microbleeds (CMBs) and white matter hyperintensities (WMHs), have worse outcomes. The effect was investigated of two blood pressure strategies (intensive vs. standard) and blood pressure variability (BPV) after reperfusion according to CSVD burden in the BP TARGET trial. Patients with available magnetic resonance imaging at baseline were included. CMBs were described as absent or present and WMH severity was described according to the Fazekas classification (0-1, absent-mild; 2-3, moderate to severe). Outcomes consisted of any intracerebral hemorrhage (ICH) at 24 h and favorable outcome at 90 days (modified Rankin Scale score between 0 and 2). In all, 246 patients were included. The intensive systolic blood pressure target was not associated with lower rates of ICH or favorable outcome according to CSVD subgroups (all p values >0.35). Several BPV parameters were associated with increased odds of ICH in patients with CMBs but not in patients without CMBs (diastolic blood pressure coefficient of variation, odds ratio 2.06, 95% confidence interval [CI] 1.13-3.77, in patients with ≥1 CMB vs. 0.94, 95% CI 0.68-1.31, in patients without CMBs, phet =0.026). Several diastolic BPV parameters were associated with worse outcomes in patients with severe WMHs but not in patients without WMHs (diastolic blood pressure coefficient of variation, odds ratio 0.32, 95% CI 0.17-0.61, in patients with severe WMHs vs. 1.09, 95% CI 0.67-1.79, in patients without WMHs; phet =0.003). No effect of the intensive systolic blood pressure management strategy was found on ICH occurrence or functional outcome according to CSVD burden. BPV was associated with higher odds of ICH in patients with CMBs and worse outcome in patients with moderate-to-severe WMHs.

Change in Smoking Behavior and Outcome After Ischemic Stroke: Post-Hoc Analysis of the SPS3 Trial.

Cigarette smoking is a known risk factor for cardiovascular disease, including ischemic stroke. The literature regarding the rate of persistent smoking after acute ischemic stroke and its effect on subsequent cardiovascular events is scarce. With this study, we aimed to report the rate of persistent smoking after ischemic stroke and the association between smoking status and major cardiovascular outcomes. This is a post-hoc analysis of the SPS3 trial (Secondary Prevention of Small Subcortical Strokes). Patients were divided into 4 groups based on smoking status at trial enrollment: (1) never smokers, (2) former smokers, (3) smokers who quit at 3 months, and (4) persistent smokers. The primary outcome is a major adverse cardiovascular events composite of stroke (ischemic and hemorrhagic), myocardial infarction, and mortality. Outcomes were adjudicated after month 3 of enrollment until an outcome event or the end of study follow-up. A total of 2874 patients were included in the study. Of the total cohort, 570 patients (20%) were smokers at enrollment, of whom 408 (71.5%) patients continued to smoke and 162 (28.4%) quit smoking by 3 months. The major adverse cardiovascular events outcome occurred in 18.4%, 12.4%, 16.2%, and 14.4%, respectively, in persistent smokers, smokers who quit, prior smokers, and never smokers. In a model adjusted for age, sex, race, ethnicity, education, employment status, history of hypertension, diabetes, hyperlipidemia, myocardial infarction, and intensive blood pressure randomization arm, the risk of major adverse cardiovascular events, and death were higher in the persistent smokers compared with never smokers (HR for major adverse cardiovascular events: 1.56 [95% CI, 1.16-2.09]; HR for death: 2.0 [95% CI, 2.18-3.12]). The risk of stroke, and MI did not differ according to smoking status Conclusions: Compared with never smoking, persistent smoking after acute ischemic stroke was associated with an increased risk of cardiovascular events and death. URL: https://www. gov; Unique identifier: NCT00059306.

Cardiac structure and function in resistant hypertension: The beneficial role of blood pressure control.

Cardiac structure and function in resistant hypertension: The beneficial role of blood pressure control.

Association of low diastolic blood pressure with all-cause death among US adults with normal systolic blood pressure.

Although the effect of intensive systolic blood pressure lowering is widely recognized, treatment-related low diastolic blood pressure still worrisome. This was a prospective cohort study based on the National Health and Nutrition Examination Survey. Adults (≥20 years old) with guideline-recommended blood pressure were included and pregnant women were excluded. Survey-weighted logistic regression and cox models were used for analysis. A total of 25 858 participants were included in this study. After weighted, the overall mean age of the participants was 43.17 (16.03) years, including 53.7% women and 68.1% non-Hispanic white. Numerous factors were associated with low DBP (<60 mmHg), including advanced age, heart failure, myocardial infarction, and diabetes. The use of antihypertensive drugs was also associated with lower DBP (OR, 1.52; 95% CI, 1.26-1.83). DBP of less than 60 mmHg were associated with a higher risk of all-cause death (HR, 1.30; 95% CI, 1.12-1.51) and cardiovascular death (HR, 1.34; 95% CI, 1.00-1.79) compared to those with DBP between 70 and 80 mmHg. After regrouping, DBP <60 mmHg (no antihypertensive drugs) was associated with a higher risk of all-cause death (HR, 1.46; 95% CI, 1.21-1.75). DBP <60 mmHg after taking antihypertensive drugs was not associated with a higher risk of all-cause death (HR, 0.99; 95% CI, 0.73-1.36). Antihypertensive drug is an important factor contributing to DBP below 60 mmHg. But the pre-existing risk does not increase further with an additional reduction of DBP after antihypertensive drugs treatment.

Effects of intensive blood pressure lowering on cerebral ischaemia in thrombolysed patients: insights from the ENCHANTED trial.

Intensive blood pressure lowering may adversely affect evolving cerebral ischaemia. We aimed to determine whether intensive blood pressure lowering altered the size of cerebral infarction in the 2196 patients who participated in the Enhanced Control of Hypertension and Thrombolysis Stroke Study, an international randomised controlled trial of intensive (systolic target 130-140mm Hg within 1h; maintained for 72h) or guideline-recommended (systolic target <180mm Hg) blood pressure management in patients with hypertension (systolic blood pressure >150mm Hg) after thrombolysis treatment for acute ischaemic stroke between March 3, 2012 and April 30,2018. All available brain imaging were analysed centrally by expert readers. Log-linear regression was used to determine the effects of intensive blood pressure lowering on the size of cerebral infarction, with adjustment for potential confounders. The primary analysis pertained to follow-up computerised tomography (CT) scans done between 24 and 36h. Sensitivity analysis were undertaken in patients with only a follow-up magnetic resonance imaging (MRI) and either MRI or CT at 24-36h, and in patients with any brain imaging done at any time during follow-up. This trial is registered with ClinicalTrials.gov, number NCT01422616. There were 1477 (67.3%) patients (mean age 67.7 [12.1] y; male 60%, Asian 65%) with available follow-up brain imaging for analysis, including 635 patients with a CT done at 24-36h. Mean achieved systolic blood pressures over 1-24h were 141mm Hg and 149mm Hg in the intensive group and guideline group, respectively. There was no effect of intensive blood pressure lowering on the median size (ml) of cerebral infarction on follow-up CT at 24-36h (0.3 [IQR 0.0-16.6] in the intensive group and 0.9 [0.0-12.5] in the guideline group; log Δmean-0.17, 95% CI-0.78 to 0.43). The results were consistent in sensitivity and subgroup analyses. Intensive blood pressure lowering treatment to a systolic target <140mm Hg within several hours after the onset of symptoms may not increase the size of cerebral infarction in patients who receive thrombolysis treatment for acute ischaemic stroke of mild to moderate neurological severity. National Health and Medical Research Council of Australia; UK Stroke Association; UK Dementia Research Institute; Ministry of Health and the National Council for Scientific and Technological Development of Brazil; Ministry for Health, Welfare, and Family Affairs of South Korea; Takeda.

Effectiveness of a non-physician community health-care provider-led intensive blood pressure intervention versus usual care on cardiovascular disease (CRHCP): an open-label, blinded-endpoint, cluster-randomised trial

Effectiveness of a non-physician community health-care provider-led intensive blood pressure intervention on cardiovascular disease has not been established. We aimed to test the effectiveness of such an intervention compared with usual care on risk of cardiovascular disease and all-cause death among individuals with hypertension. In this open-label, blinded-endpoint, cluster-randomised trial, we recruited individuals aged at least 40 years with an untreated systolic blood pressure of at least 140 mm Hg or a diastolic blood pressure of at least 90 mm Hg (≥130 mm Hg and ≥80 mm Hg for those at high risk for cardiovascular disease or if currently taking antihypertensive medication). We randomly assigned (1:1) 326 villages to a non-physician community health-care provider-led intervention or usual care, stratified by provinces, counties, and townships. In the intervention group, trained non-physician community health-care providers initiated and titrated antihypertensive medications according to a simple stepped-care protocol to achieve a systolic blood pressure goal of less than 130 mm Hg and diastolic blood pressure goal of less than 80 mm Hg with supervision from primary care physicians. They also delivered discounted or free antihypertensive medications and health coaching for patients. The primary effectiveness outcome was a composite outcome of myocardial infarction, stroke, heart failure requiring hospitalisation, and cardiovascular disease death during the 36-month follow-up in the study participants. Safety was assessed every 6 months. This trial is registered with ClinicalTrials.gov, NCT03527719. Between May 8 and Nov 28, 2018, we enrolled 163 villages per group with 33 995 participants. Over 36 months, the net group difference in systolic blood pressure reduction was -23·1 mm Hg (95% CI -24·4 to -21·9; p<0·0001) and in diastolic blood pressure reduction, it was -9·9 mm Hg (-10·6 to -9·3; p<0·0001). Fewer patients in the intervention group than the usual care group had a primary outcome (1·62% vs 2·40% per year; hazard ratio [HR] 0·67, 95% CI 0·61-0·73; p<0·0001). Secondary outcomes were also reduced in the intervention group: myocardial infarction (HR 0·77, 95% CI 0·60-0·98; p=0·037), stroke (0·66, 0·60-0·73; p<0·0001), heart failure (0·58, 0·42-0·81; p=0·0016), cardiovascular disease death (0·70, 0·58-0·83; p<0·0001), and all-cause death (0·85, 0·76-0·95; p=0·0037). The risk reduction of the primary outcome was consistent across subgroups of age, sex, education, antihypertensive medication use, and baseline cardiovascular disease risk. Hypotension was higher in the intervention than in the usual care group (1·75% vs 0·89%; p<0·0001). The non-physician community health-care provider-led intensive blood pressure intervention is effective in reducing cardiovascular disease and death. The Ministry of Science and Technology of China and the Science and Technology Program of Liaoning Province, China.

How Low Should We Go? Managing Hypertension in Older People.

This issue of The Senior Care Pharmacist includes the first of three articles related to hypertension management. These review key clinical trials regarding the evidence for treating hypertension, with a focus on older people. The first part of the series covers three key clinical trials that provide evidence related to intensive blood pressure control (below the systolic target of 140 mm Hg and closer to 120 mm Hg) in adults older than 75 years of age: HYVET, SPRINT, and STEP. These trials reiterate that older people can gain cardiovascular and mortality benefits from intensive blood pressure-lowering--but at what cost? Antihypertensive agents come with risks, most commonly hypotension, syncope, falls, electrolyte abnormalities, and acute kidney injury or failure. Pill burden is a concern, as many older people need multiple antihypertensive agents to control their blood pressure. Parts two and three of this series will explore some of the negative outcomes that can occur from going too low with intensive blood pressure control and will discuss aspects of deprescribing.

Improving cardiovascular health in rural China and beyond

In 2021, high blood pressure claimed 11·3 million lives globally. 1 Vaduganathan M Mensah GA Turco JV Fuster V Roth GA The global burden of cardiovascular diseases and risk: a compass for future health. J Am Coll Cardiol. 2022; 80: 2361-2371 Crossref PubMed Scopus (4) Google Scholar High blood pressure has ranked consistently as the top modifiable risk factor globally for over 20 years. Although its prevalence is universally high, awareness, management, and control of high blood pressure are particularly poor in low-income and middle-income countries. 2 Geldsetzer P Manne-Goehler J Marcus ME et al. The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults. Lancet. 2019; 394: 652-662 Summary Full Text Full Text PDF PubMed Scopus (199) Google Scholar Several cluster randomised controlled trials have shown that community health worker-led interventions were effective in significantly reducing blood pressure in Argentina (the HCPIA trial), 3 He J Irazola V Mills KT et al. Effect of a community health worker-led multicomponent intervention on blood pressure control in low-income patients in Argentina: a randomized clinical trial. JAMA. 2017; 318: 1016-1025 Crossref PubMed Scopus (98) Google Scholar Malaysia and Colombia (the HOPE 4 trial), 4 Schwalm JD McCready T Lopez-Jaramillo P et al. A community-based comprehensive intervention to reduce cardiovascular risk in hypertension (HOPE 4): a cluster randomised controlled trial. Lancet. 2019; 394: 1231-1242 Summary Full Text Full Text PDF PubMed Scopus (92) Google Scholar and Bangladesh, Pakistan, and Sri Lanka (the COBRA-BPS trial). 5 Jafar TH Gandhi M de Silva HA et al. A community-based intervention for managing hypertension in rural South Asia. N Engl J Med. 2020; 382: 717-726 Crossref PubMed Scopus (68) Google Scholar More recently, in 2022, Sun and colleagues 6 Sun Y Mu J Wang DW et al. A village doctor-led multifaceted intervention for blood pressure control in rural China: an open, cluster randomised trial. Lancet. 2022; 399: 1964-1975 Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar showed that in the China Rural Hypertension Control Project (the CRHCP trial), a village doctor-led intensive hypertension intervention increased hypertension control by 37% compared with usual care. The 18-month net reduction in systolic blood pressure was as large as 14·5 mm Hg. Effectiveness of a non-physician community health-care provider-led intensive blood pressure intervention versus usual care on cardiovascular disease (CRHCP): an open-label, blinded-endpoint, cluster-randomised trialThe non-physician community health-care provider-led intensive blood pressure intervention is effective in reducing cardiovascular disease and death. Full-Text PDF

Spatial-temporal distributions, probable health risks, and source identification of organic pollutants in surface waters of an extremely hypoxic river basin in Türkiye.

This study was carried out to determine the spatiotemporal distributions of organic pollution parameters in the Meriç-Ergene River Basin subjected to intensive agricultural and industrial pressure. A total of 5 basin components, including Anadere (A), Çorlu (Ç), Tunca (T), Meriç (M), and Ergene (E) rivers, and 9 stations (A1, Ç1, T1, M1-M2, and E1-E4) were identified in the watershed, and surface water samples were collected in the dry (end of summer) and wet (end of winter) seasons of 2021-2022. The Water Quality Index (WQI) and Nutrient Pollution Index (NPI) were applied to the data to evaluate the overall water quality characteristics. The Chronic Daily Index (CDI), Hazard Quotient (HQ), and Hazard Index (HI) were applied to the data to reveal the probable noncarcinogenic health risks of organic contaminants. Cluster Analysis (CA) and Principal Component Analysis (PCA) were applied to the data to classify the sampling sites and identify the source apportionment of organic pollution parameters. The recorded spatiotemporal averages of the investigated parameters in the basin are as follows: 6.26mg/L for DO, 9 for pH, 1626 μS/cm for EC, 985mg/L for TDS, 1 ‰ for salinity, 6.88mg/L for nitrate, 0.1mg/L for nitrite, 1.8mg/L for phosphate, 81mg/L for sulfate, and 473mg/L for chloride. The results indicate that the most contaminated components of the basin are Çorlu Stream and Ergene River, and in addition to their quite high salt and nutrient content, they have extreme hypoxic conditions to the extent that it is impossible for many aquatic organisms to live. The contamination degrees of the investigated basin components were determined using the organic pollution risk assessment indices as follows: Çorlu Stream > Ergene River > Anadere Stream > Tunca River > Meriç River.

Incidentally Detected Chronic Left Ventricular Pseudoaneurysm After Subacute Inferior–Posterior Myocardial Infarction

We describe a 69-year-old man with subacute inferior myocardial infarction who had surgical repair for a left ventricular (LV) pseudoaneurysm incidentally detected by routine 6-month follow-up echocardiography. Although LV pseudoaneurysm is a rare complication after myocardial infarction, the delayed diagnosis and management can cause adverse patient outcomes. The present case suggests that patients with multiple risk factors for LV pseudoaneurysms, including advanced age, late presentation, and delayed revascularization, should receive intensive blood pressure control and closer examination using a multimodal imaging approach for early detection of aneurysmal formation and complications.