mmHg In Participants Research Articles

The prevalence of glaucoma in a 70-year-old Swedish population in the city area of Gothenburg.

To determine the prevalence of and risk factors for open-angle glaucoma in a population of 70-year-olds in Gothenburg, Sweden and to compare the visual function between the glaucoma population and the non-glaucoma population. Of the entire cohort (n = 1203), 1182 participants responded a questionnaire on self-reported glaucoma and were tested for blood pressure (BP) and diabetes. In all, 560 participants underwent ophthalmic examination including best-corrected visual acuity (BCVA), intraocular pressure (IOP), central corneal thickness (CCT), contrast sensitivity (CS), perimetry and photos of the retina and lens. Glaucoma prevalence was 4.8% (95% confidence interval, 3.0%-6.6%), of which 56% was previously undiagnosed. The proportion of participants with diastolic BP >90 mmHg was higher in the non-glaucomatous group (8.3%) than the glaucoma group (0%), p < 0.001. A family history of glaucoma was present in a larger proportion of the glaucoma group (39%) than of the non-glaucomatous group (1.1%), p = 0.001. Mean IOP in individuals without glaucoma was 16 mmHg, versus 21 mmHg in participants with glaucoma detected at the examination. IOP was ≤21 mmHg in 67% among participants with previously unknown glaucoma. BCVA was lower in eyes with previously unknown glaucoma than in eyes without glaucoma (p = 0.017) but BCVA in the best eye did not differ. CCT and CS were similar in all cases. The prevalence of glaucoma was comparable to that reported previously. A family history of glaucoma and higher IOP were risk factors associated with glaucoma. BCVA in the best eye did not differ significantly between subjects with and without glaucoma.

IDF21-0652 Blood pressure-lowering for prevention of major cardiovascular diseases in persons with and without type 2 diabetes

Background: There is insufficient randomised evidence as to whether the effect of blood pressure (BP)-lowering treatment differs in people with type 2 diabetes versus those without this metabolic condition, particularly at a normal or high-normal BP level. Aim: To investigate the effects of BP-lowering treatment on the risk of major cardiovascular events in people with and without type 2 diabetes, and by baseline levels of systolic and diastolic BP. Method: We used the resource provided by the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC) to conduct a one-stage individual participant data meta-analysis of major randomised trials. The primary outcome was total major cardiovascular events, defined as the first occurrence of fatal or non-fatal stroke or cerebrovascular disease, fatal or non-fatal myocardial infarction, and heart failure causing death or requiring hospitalisation. The analysis was stratified for type 2 diabetes status at baseline, and baseline categories of systolic BP (in 10 mm Hg increments from <120 mm Hg to ≥170 mm Hg) and diastolic BP from <70 mm Hg to ≥110 mm Hg diastolic). Cox proportional hazard model stratified by the trial was used to estimate hazard ratio (HR). A Poisson regression model with an identity link was used to calculate the absolute risk reduction (ARR). Results: Data for 358,533 participants (58.4% men) from 51 randomised clinical trials were included in the analysis, in which 28.8% (n=103,325) of the participants had diagnosis of type 2 diabetes at baseline. Baseline mean systolic/diastolic BPs were 149/84 mm Hg in participants with type 2 diabetes (n=103,325) and 153/88 mm Hg in participants without type 2 diabetes (n=255,208). The incidence risks of primary events during the study follow-up time in participants with and without type 2 diabetes were 16.5% and 10.2%, respectively. Over 4.2 years of median follow-up, a fixed value of 5-mm Hg reduction in systolic BP was associated with a lower risk of major cardiovascular events both in participants with type 2 diabetes (HR 0.94 [95% CI 0.91 to 0.98]; ARR -0.015 [95% CI -0.020 to -0.010]) and in those without history of type 2 diabetes (HR 0.89 [95% CI 0.87 to 0.92]; ARR =-0.016 [95% CI -0.018 to -0.013]). In stratified analyses, we did not find reliable evidence for heterogeneity of treatment effects by baseline systolic or diastolic BP level in participants with or without type 2 diabetes (all P for interaction > 0.78). Discussion: The effect of BP reduction for primary and secondary prevention of major cardiovascular events was broadly comparable among people with and without type 2 diabetes, with no clinically important evidence that the level of systolic or diastolic BP at baseline is a determinant of treatment effect. Recommendations by guidelines on different BP reduction treatment in people with and without diabetes, or initiation of BP reduction therapy at a specific BP threshold, are not substantiated by these findings. This work will be presented on behalf of the Blood Pressure Lowering Treatment Trialists' Collaboration. Working group: Milad Nazarzadeh, Zeinab Bidel, Dexter Canoy, Emma Copland, Abbas Dehghan, Derrick A Bennett, George Davey Smith, Rury R. Holman, Mark Woodward, Ajay Gupta, Amanda Adler, Naveed Sattar, Richard J McManus, Koon Teo, Barry R Davis, John Chalmers, Carl J. Pepine, Kazem Rahimi.

Impact of astaxanthin supplementation on blood pressure: A systematic review and meta-analysis of randomized controlled trials

• Astaxanthin supplementation had beneficial effects on diastolic blood pressure (DBP). • Reduction in DBP was stronger in non-healthy participants compared to healthy ones. • Astaxanthin supplementation reduced DBP in Asian populations more than non-Asians. • Astaxanthin supplementation did not considerably affect systolic blood pressure. This systematic review and meta-analysis on randomized controlled trials (RCTs) evaluated the impact of astaxanthin (AST) supplementation on blood pressure in adults. We conducted a comprehensive search using different electronic databases. Ten RCTs with 493 participants that reported the effect of AST supplementation on blood pressure in adults were included. AST supplementation led to a marginally decline in diastolic blood pressure (DBP) (mean difference (MD) = −1.21; 95 %CI: −2.51, 0.09), but not systolic blood pressure. In patients, AST supplementation reduced DBP by 2.77 mmHg (95 %CI: −4.34, −1.19). Also, assigning ≥ 12 mg of AST to adults resulted in a slight decrease in DBP (MD = −0.89; 95 %CI: −1.82, 0.04). AST supplementation significantly reduced DBP by 2.27 mmHg in participants from Asian countries (95 %CI: −3.71, −0.83). This meta -analysis of RCTs disclosed that AST supplementation could reduce DBP, especially with a dose of ≥ 12 mg/d supplementation, in patient individuals and in participants from Asian countries.

Abstract 20: Association Of Systolic Blood Pressure Time-in-target Range With Adverse Kidney And Cardiovascular Outcomes In Adults With And Without Diabetes

Introduction: Hypertension associates with both kidney and cardiovascular (CV) disease risk. Time-in-target range (TTR) associates with CV risk independent of mean SBP and SBP variability. We hypothesized that SBP TTR predicts both adverse kidney and CV outcomes. Methods: ACCORD BP and SPRINT trial participants with &gt;=2 SBP measurements were eligible, except ACCORD standard BP lowering participants due fewer SBP measurements. SBP TTR for months 0-3 was calculated using Rosendaal linear interpolation with target ranges of 110-130 mm Hg and 120-140 mm Hg for participants in the intensive or standard arms, respectively. Adverse kidney outcomes included dialysis, kidney transplant, serum creatinine &gt; 3.3 mg/dL, sustained eGFR of &lt; 15 mL/min per 1.73 m 2 or sustained eGFR decline &gt;40% after month 3. Adverse CV outcomes included myocardial infarction, stroke, heart failure and CV death. Cox proportional hazards regression models were used to estimate the association between TTR and adverse outcomes after demographics, clinical risk factors and baseline SBP adjustment Results: Participants with higher TTR were younger, less likely to have preexisting CV disease and had less albuminuria, higher eGFR and lower baseline SBP. In fully adjusted models accounting for baseline SBP, higher TTR independently associated with a lower risk of adverse kidney and CV outcomes (P-trend &lt; .001 for each). Whereas the relationship between TTR and CV risk increased monotonically with higher TTR, the TTR association with kidney risk was greatest at the extremes of TTR ( Figure ). Conclusions: Further reductions in adverse kidney and CV outcomes may be achievable through sustained SBP control.

Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis

SummaryBackgroundThe effects of pharmacological blood pressure lowering at normal or high-normal blood pressure ranges in people with or without pre-existing cardiovascular disease remains uncertain. We analysed individual participant data from randomised trials to investigate the effects of blood pressure lowering treatment on the risk of major cardiovascular events by baseline levels of systolic blood pressure.MethodsWe did a meta-analysis of individual participant-level data from 48 randomised trials of pharmacological blood pressure lowering medications versus placebo or other classes of blood pressure-lowering medications, or between more versus less intensive treatment regimens, which had at least 1000 persons-years of follow-up in each group. Trials exclusively done with participants with heart failure or short-term interventions in participants with acute myocardial infarction or other acute settings were excluded. Data from 51 studies published between 1972 and 2013 were obtained by the Blood Pressure Lowering Treatment Trialists' Collaboration (Oxford University, Oxford, UK). We pooled the data to investigate the stratified effects of blood pressure-lowering treatment in participants with and without prevalent cardiovascular disease (ie, any reports of stroke, myocardial infarction, or ischaemic heart disease before randomisation), overall and across seven systolic blood pressure categories (ranging from <120 to ≥170 mm Hg). The primary outcome was a major cardiovascular event (defined as a composite of fatal and non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring admission to hospital), analysed as per intention to treat.FindingsData for 344 716 participants from 48 randomised clinical trials were available for this analysis. Pre-randomisation mean systolic/diastolic blood pressures were 146/84 mm Hg in participants with previous cardiovascular disease (n=157 728) and 157/89 mm Hg in participants without previous cardiovascular disease (n=186 988). There was substantial spread in participants' blood pressure at baseline, with 31 239 (19·8%) of participants with previous cardiovascular disease and 14 928 (8·0%) of individuals without previous cardiovascular disease having a systolic blood pressure of less than 130 mm Hg. The relative effects of blood pressure-lowering treatment were proportional to the intensity of systolic blood pressure reduction. After a median 4·15 years' follow-up (Q1–Q3 2·97–4·96), 42 324 participants (12·3%) had at least one major cardiovascular event. In participants without previous cardiovascular disease at baseline, the incidence rate for developing a major cardiovascular event per 1000 person-years was 31·9 (95% CI 31·3–32·5) in the comparator group and 25·9 (25·4–26·4) in the intervention group. In participants with previous cardiovascular disease at baseline, the corresponding rates were 39·7 (95% CI 39·0–40·5) and 36·0 (95% CI 35·3–36·7), in the comparator and intervention groups, respectively. Hazard ratios (HR) associated with a reduction of systolic blood pressure by 5 mm Hg for a major cardiovascular event were 0·91, 95% CI 0·89–0·94 for partipants without previous cardiovascular disease and 0·89, 0·86–0·92, for those with previous cardiovascular disease. In stratified analyses, there was no reliable evidence of heterogeneity of treatment effects on major cardiovascular events by baseline cardiovascular disease status or systolic blood pressure categories.InterpretationIn this large-scale analysis of randomised trials, a 5 mm Hg reduction of systolic blood pressure reduced the risk of major cardiovascular events by about 10%, irrespective of previous diagnoses of cardiovascular disease, and even at normal or high–normal blood pressure values. These findings suggest that a fixed degree of pharmacological blood pressure lowering is similarly effective for primary and secondary prevention of major cardiovascular disease, even at blood pressure levels currently not considered for treatment. Physicians communicating the indication for blood pressure lowering treatment to their patients should emphasise its importance on reducing cardiovascular risk rather than focusing on blood pressure reduction itself.FundingBritish Heart Foundation, UK National Institute for Health Research, and Oxford Martin School.

Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride.

Recent cohort studies show that salt intake below 6 g is associated with increased mortality. These findings have not changed public recommendations to lower salt intake below 6 g, which are based on assumed blood pressure (BP) effects and no side-effects. To assess the effects of sodium reduction on BP, and on potential side-effects (hormones and lipids) SEARCH METHODS: The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials up to April 2018 and a top-up search in March 2020: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. The top-up search articles are recorded under "awaiting assessment." Studies randomizing persons to low-sodium and high-sodium diets were included if they evaluated at least one of the outcome parameters (BP, renin, aldosterone, noradrenalin, adrenalin, cholesterol, high-density lipoprotein, low-density lipoprotein and triglyceride,. Two review authors independently collected data, which were analysed with Review Manager 5.3. Certainty of evidence was assessed using GRADE. Since the first review in 2003 the number of included references has increased from 96 to 195 (174 were in white participants). As a previous study found different BP outcomes in black and white study populations, we stratified the BP outcomes by race. The effect of sodium reduction (from 203 to 65 mmol/day) on BP in white participants was as follows: Normal blood pressure: SBP: mean difference (MD) -1.14 mmHg (95% confidence interval (CI): -1.65 to -0.63), 5982 participants, 95 trials; DBP: MD + 0.01 mmHg (95% CI: -0.37 to 0.39), 6276 participants, 96 trials. Hypertension: SBP: MD -5.71 mmHg (95% CI: -6.67 to -4.74), 3998 participants,88 trials; DBP: MD -2.87 mmHg (95% CI: -3.41 to -2.32), 4032 participants, 89 trials (all high-quality evidence). The largest bias contrast across studies was recorded for the detection bias element. A comparison of detection bias low-risk studies versus high/unclear risk studies showed no differences. The effect of sodium reduction (from 195 to 66 mmol/day) on BP in black participants was as follows: Normal blood pressure: SBP: mean difference (MD) -4.02 mmHg (95% CI:-7.37 to -0.68); DBP: MD -2.01 mmHg (95% CI:-4.37, 0.35), 253 participants, 7 trials. Hypertension: SBP: MD -6.64 mmHg (95% CI:-9.00, -4.27); DBP: MD -2.91 mmHg (95% CI:-4.52, -1.30), 398 participants, 8 trials (low-quality evidence). The effect of sodium reduction (from 217 to 103 mmol/day) on BP in Asian participants was as follows: Normal blood pressure: SBP: mean difference (MD) -1.50 mmHg (95% CI: -3.09, 0.10); DBP: MD -1.06 mmHg (95% CI:-2.53 to 0.41), 950 participants, 5 trials. Hypertension: SBP: MD -7.75 mmHg (95% CI:-11.44, -4.07); DBP: MD -2.68 mmHg (95% CI: -4.21 to -1.15), 254 participants, 8 trials (moderate-low-quality evidence). During sodium reduction renin increased 1.56 ng/mL/hour (95%CI:1.39, 1.73) in 2904 participants (82 trials); aldosterone increased 104 pg/mL (95%CI:88.4,119.7) in 2506 participants (66 trials); noradrenalin increased 62.3 pg/mL: (95%CI: 41.9, 82.8) in 878 participants (35 trials); adrenalin increased 7.55 pg/mL (95%CI: 0.85, 14.26) in 331 participants (15 trials); cholesterol increased 5.19 mg/dL (95%CI:2.1, 8.3) in 917 participants (27 trials); triglyceride increased 7.10 mg/dL (95%CI: 3.1,11.1) in 712 participants (20 trials); LDL tended to increase 2.46 mg/dl (95%CI: -1, 5.9) in 696 participants (18 trials); HDL was unchanged -0.3 mg/dl (95%CI: -1.66,1.05) in 738 participants (20 trials) (All high-quality evidence except the evidence for adrenalin). In white participants, sodium reduction in accordance with the public recommendations resulted in mean arterial pressure (MAP) decrease of about 0.4 mmHg in participants with normal blood pressure and a MAP decrease of about 4 mmHg in participants with hypertension. Weak evidence indicated that these effects may be a little greater in black and Asian participants. The effects of sodium reduction on potential side effects (hormones and lipids) were more consistent than the effect on BP, especially in people with normal BP.

Abstract 14191: Effect of Intensive Blood Pressure Lowering on Incident Atrial Fibrillation: A Systemic Review and Meta-analysis

Introduction: The effect of intensive versus standard blood pressure (BP) lowering on the risk of atrial fibrillation (AF) is uncertain. Hypothesis: Intensive BP lowering is associated with a lower risk of AF among patients with hypertension. Methods: We searched PubMed, EMBASE, and CENTRAL for trials published between inception and June 5, 2020 for randomized controlled trials evaluating the effect of intensive versus standard (target systolic BP &lt; 140 mmHg) BP lowering on incident AF. We assessed heterogeneity using the I 2 statistic then used fixed-effects meta-analysis models to report pooled treatment effects and 95% confidence intervals. We also tested for publication bias by three funnel plot-based methods. The quality of each study was assessed with the Cochrane Risk of Bias tool. Results: We assessed 16 candidate studies for eligibility from 2,312 published articles, but only three randomized clinical trials were eligible for inclusion and included a combined 12,219 participants with hypertension: Cardio-Sis (Studio Italiano Sugli Effetti Cardiovascolari del Controllo della Pressione Arteriosa Sistolica), ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial), and SPRINT (Systolic Blood Pressure Intervention Trial). The target systolic BP in the intensive BP arm was &lt;120 mmHg for participants in SPRINT and ACCORD-BP, but &lt;130 mmHg for participants in Cardio-Sis. Participants randomized to intensive BP lowering had significantly lower risk of incident AF compared with those randomized tostandard BP lowering (AF incidence 2.2% vs. 3.0%, respectively; pooled hazard ratio (95% confidence interval ): 0.74 (0.59 - 0.93)). Conclusions: Intensive BP lowering is associated with a significantly lower risk of incident AF in patients with hypertension. These findings add to the current evidence supporting the benefits of intensive BP control.

Social connections and hypertension in women and men: a population-based cross-sectional study of the Canadian Longitudinal Study on Aging.

Associations between social ties and hypertension are poorly understood in women and men. We investigated the association between marital status, living arrangement, social network size and social participation and hypertension by sex/gender. Cross-sectional analysis of 28 238 middle-age and old-age adults (45-85 years) was conducted using the baseline Canadian Longitudinal Study on Aging Comprehensive cohort data. Blood pressure (BP) was measured using the automated BpTRU device and hypertension was defined as BP more than 140/90 mmHg, or more than 130/80 mmHg in participants with diabetes, self-reported history or receiving antihypertensive therapy. Being nonpartnered, having limited social participation (≤2 social activities per month) or a small social network size was associated with higher odds of having hypertension in women. Odds of hypertension were higher among widowed women [odds ratio 1.33 (95% confidence interval (CI): 1.16, 1.51)] compared with married women. The largest difference in adjusted mean SBP in women was between widowed [3.06 mmHg (95% CI: 2.01, 4.11)], vs. married women. For men, lone-living (vs. coliving) was linked to a lower odds of hypertension [odds ratio 0.85 (95% CI: 0.75, 0.96)] When considering two social ties simultaneously, the adverse associations between nonpartnership (mainly for singles and divorced) and BP were mitigated with increased social participation, especially among women. Social ties appear to be more strongly associated with hypertension in middle and older aged women than men. Women who are nonpartnered or who engage in few social activities and men who are coliving represent at risk groups for having hypertension. Healthcare professionals may need to consider these social factors in addressing risk for hypertension and cardiovascular disease prevention.

Alcohol intake reduction for controlling hypertension.

High blood pressure constitutes one of the leading causes of mortality and morbidity all over the world. At the same time, heavy drinking increases the risk for developing cardiovascular diseases, including cardiomyopathy, hypertension, atrial arrhythmias, or stroke. Several studies have already assessed specifically the relationship between alcohol intake and hypertension. However, the potential effect on blood pressure of alcohol intake reduction interventions is largely unknown. To assess the effect of any intervention to reduce alcohol intake in terms of blood pressure decrease in hypertensive people with alcohol consumption compared to a control intervention or no intervention at all. To determine additional effects related to mortality, major cardiovascular events, serious adverse events, or quality of life. The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to June 2020:the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2020), MEDLINE Ovid (from 1946), MEDLINE Ovid Epub Ahead of Print, and MEDLINE Ovid In-Process, Embase Ovid (from 1974), ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. Trial authors were contacted when needed and no language restrictions were applied. We included randomised controlled trials with minimum 12 weeks duration and including 50 or more subjects per group with quantitative measurement of alcohol consumption and/or biological measurement of the outcomes of interest. Participants were adults (16 years of age or older) with systolic blood pressure (SBP) greater than 140 mmHg and diastolic blood pressure (DBP) greater than 90 mmHg, and SBP ≥ 130 or DBP ≥ 80 mmHg in participants with diabetes. We included any intervention implemented to reduce their alcohol intake. Two review authors independently assessed search results and extracted data using standard methodological procedures adopted by Cochrane. A total of 1210 studies were screened. We included one randomised controlled trial involving a total of 269 participants with a two-year follow-up. Individual patient data for all participants were provided and used in this review. No differences were found between the cognitive-behavioural intervention group and the control group for overall mortality (RR 0.72, 95% CI 0.16 to 3.17; low-certainty evidence), cardiovascular mortality (not estimable) and cardiovascular events (RR 0.80, 95% CI 0.36 to 1.79; very low-certainty evidence). There was no statistical difference in systolic blood pressure (SBP) reduction (Mean Difference (MD) -0.92 mmHg, 95% confidence interval (CI) -5.66 to 3.82 mmHg; very low-certainty evidence) or diastolic blood pressure (DBP) decrease (MD 0.98 mmHg, 95% CI -1.69 to 3.65 mmHg; low-certainty evidence) between the cognitive-behavioural intervention group and the control group. We also did not find any differences in the proportion of subjects with SBP < 140 mmHg and DBP < 90 mmHg (Risk Ratio (RR) 1.21, 95% CI 0.88 to 1.65; very low-certainty evidence). Concerning secondary outcomes, the alcohol intake was significantly reduced in the cognitive-behavioural intervention compared with the control group (MD 191.33 g, 95% CI 85.36 to 297.30 g). We found no differences between the active and control intervention in the proportion of subjects with lower-risk alcohol intake versus higher-risk and extreme drinkers at the end of the study (RR 1.04, 95% CI 0.68 to 1.60). There were no estimable results for the quality of life outcome. An intervention for decreasing alcohol intake consumption did not result in differences in systolic and diastolic blood pressure when compared with a control intervention, although there was a reduction in alcohol intake favouring the active intervention. No differences were found either for overall mortality, cardiovascular mortality or cardiovascular events. No data on serious adverse events or quality of life were available to assess. Adequate randomised controlled trials are needed to provide additional evidence on this specific question.

Attainment of Targets of the 20-Year Infancy-Onset Dietary Intervention and Blood Pressure Across Childhood and Young Adulthood: The Special Turku Coronary Risk Factor Intervention Project (STRIP).

We examined whether success in achieving the key targets of an infancy-onset 20-year dietary intervention was associated with blood pressure (BP) from infancy to young adulthood. In the prospective randomized STRIP (Special Turku Coronary Risk Factor Intervention Project; n=877 children), dietary counseling was provided biannually based on the Nordic Nutrition Recommendations primarily to improve the quality of dietary fat in children's diets and secondarily to promote intake of vegetables, fruits, and whole grains. Dietary data and BP were accrued annually from the age of 13 months to 20 years. The dietary targets for fat quality were defined as the ratio of saturated fatty acids to monounsaturated and polyunsaturated fatty acids <1:2 and intake of saturated fatty acids <10 E%, dietary fiber intake in the top age-specific quintile, and dietary sucrose intake as being in the lowest age-specific quintile. Attaining a higher number of the dietary targets was associated with lower systolic BP (mean [SE] systolic BP, 107.3 [0.3], 107.6 [0.3], 106.8 [0.3], and 106.7 [0.5] mm Hg in participants meeting 0, 1, 2, and 3 to 4 targets, respectively; P=0.03) and diastolic BP (mean [SE] diastolic BP, 60.4 [0.2], 60.5 [0.2], 59.9 [0.2], and 59.9 [0.3] mm Hg; P=0.02). When the lowest age-specific quintile of dietary cholesterol was added as an additional target, the association with systolic BP remained significant (P=0.047), but the association with diastolic BP attenuated (P=0.13). Achieving the key targets of an infancy-onset 20-year dietary intervention, reflecting dietary guidelines, was favorably albeit modestly associated with systolic and diastolic BP from infancy to young adulthood. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00223600.

Differences between home blood pressure and strictly measured office blood pressure and their determinants in Japanese men.

Conventional office blood pressure (OBP) and home blood pressure (HBP) measurements are often inconsistent. The purpose of this research was (1) to test whether strictly measured OBP values with sufficient rest time before measurement (st-OBP) is comparable to HBP at the population level and (2) to ascertain whether there are particular determinants for the difference between HBP and st-OBP at the individual level. Data from a population-based group of 1056 men aged 40-79 years were analyzed. After a five-min rest, st-OBP was measured twice. HBP was measured after a 2-min rest every morning for seven consecutive days. To determine factors related to ΔSBP (HBP minus st-OBP measurements), multiple linear regression analyses and analyses of covariance were performed. While st-OBP and HBP were comparable (136.5 vs. 137.2 mmHg) at the population level, ΔSBP varied with a standard deviation of 13.5 mmHg. Smoking was associated with a larger ΔSBP regardless of antihypertensive usage, and BMI was associated with a larger ΔSBP in participants using antihypertensive drugs. The adjusted mean ΔSBP in the highest BMI tertile category was 4.6 mmHg in participants taking antihypertensive drugs. st-OBP and HBP measurements were comparable at the population level, although the distribution of ΔSBP was considerably broad. Smokers and obese men taking antihypertensive drugs had higher HBP than st-OBP, indicating that their blood pressure levels are at risk of being underestimated. Therefore, this group would benefit from the addition of HBP measurements.

Evaluating a large-scale roll out of blood pressure telemonitoring using routinely acquired data

Background1.2 million appointments in Scottish primary care annually are used solely for checking blood pressure (BP). While evidence from randomised controlled trials (RCTs) shows that telemonitoring of BP produces significant reductions, it has not been mainstreamed because of difficulties in integrating telemonitoring with routine medical care. With NHS Lothian a system was developed which extracted data from a telemonitoring provider website, and delivered it as a routine DOCMAN report to GP practices without need for logons.AimTo determine the feasibility of implementing telemonitoring of high blood pressure (HBP) at scale in primary care and the potential of using routinely acquired data for exploring clinical and resource-use impacts.MethodPractice recorded BP, prescribing, and appointments data were transferred for all people with HBP to a safe-haven. We compared before and after BPs at 1 year from participants and non-participants. Patient and clinician interviews.ResultsOver 2400 people were recruited to telemonitoring overall. Over a year, BP control improved in both telemonitoring participants and non-participants. Mean systolic BP (SBP) fell by 6.6 mmHg in participants and 3.5 mmHg in non-participants. In uncontrolled participants (SBP &gt;135 mmHg home-monitored) average fall was 15 mmHg. Proportion with very poor control BP (SBP &gt;150 mmHg) fell from 13.6% to 3.4%. Appointment data were challenging to interpret, but there was little change from the previous year in face-to-face appointment time and total appointments. Patients and clinicians were positive about the implementationConclusionThe study demonstrated an improvement in BP control similar to effects in RCTs in routine general practice with little impact on workload using routinely acquired data providing strong support for mainstreaming low-cost telemonitoring for HBP.

Technologies for Innovative Monitoring to Reduce Blood Pressure and Change Lifestyle Using Mobile Phones in Adult and Elderly Populations (TIM Study): Protocol for a Randomized Controlled Trial.

BackgroundHypertension is a growing problem worldwide, markedly in low- and middle-income countries, where the rate of control slightly decreased. The overall prevalence of hypertension in Brazil is 28.7% among adult individuals and 68.9% in the population aged 60 years and older, and less than a third of patients have controlled blood pressure (BP). The use of technologies—mobile phones and the internet—to implement interventions to reduce blood pressure can minimize costs and diminish cardiovascular risk. Interventions through text messaging and electronic BP monitoring present divergent results.ObjectiveThis trial evaluates the effectiveness of interventions—personalized messages and telemonitoring of BP—to reduce systolic BP and improve lifestyle compared to the usual care of patients with hypertension (control group).MethodsThis factorial randomized controlled trial enrolls individuals aged 30 to 75 years who have a mobile phone and internet access with the diagnosis of hypertension under drug treatment with up to 2 medications and uncontrolled BP. Eligible participants should have both increased office BP and 24-hour BP with ambulatory BP monitoring. Participants with severe hypertension (systolic BP ≥180 or diastolic BP ≥110 mm Hg), life threatening conditions, low life expectancy, recent major cardiovascular event (last 6 months), other indications for the use of antihypertensive medication, diagnosis of secondary hypertension, pregnant or lactating women, or those unable to understand the interventions are excluded. Participants are randomly allocate to 1 of 4 experimental arms: (1) Telemonitoring of blood pressure (TELEM) group: receives an automatic oscillometric device to measure BP, (2) telemonitoring by text message (TELEMEV) group: receives personalized, standardized text messages to stimulate lifestyle changes and adhere with BP-lowering medication, (3) TELEM-TELEMEV group: receives both interventions, and (4) control group: receives usual clinical treatment (UCT). Data collection is performed in a clinical research center located in a referent hospital. The primary outcomes are reduction of systolic BP assessed by 24-hour ambulatory BP monitoring (primary outcome) and change of lifestyle (based on dietary approaches to stop hypertension (DASH)-type diet, sodium restriction, weight loss or control, increase of physical activity).ResultsThis study was funded by two Brazilian agencies: the National Council for Scientific and Technological Development and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul. Enrollment was completed at the end of 2017 (N=231), the follow-up is ongoing, and data analysis is expected to begin in early 2019. A reduction of 24-hour systolic BP of approximately 8.8 [SD 13.1] mm Hg for participants in the BP monitoring group versus 3.4 [SD 11.6] mm Hg in the UCT group is expected. A similar reduction in the text messaging group is expected.ConclusionsThe use of mobile technologies connected to the internet through mobile phones promotes time optimization, cost reduction, and better use of public health resources. However, it has not been established whether simple interventions such as text messaging are superior to electronic BP monitoring and whether both outperform conventional counseling.Trial RegistrationClinicalTrials.gov NCT03005470; https://clinicaltrials.gov/ct2/show/NCT03005470 (Archived by WebCite at http://www.webcitation.org/70AoANESu). Plataforma Brasil CAAE 31423214.0.0000.5327.Registered Report IdentifierRR1-10.2196/9619

Interaction between antihypertensive therapy and exercise training therapy requires drug regulation in hypertensive patients

Exercise training could interact with the pharmacological therapy of hypertension, increasing the effects of these medications. To assess the effects of 12 weeks of physical training on blood pressure of hypertensive or diabetic patients, already receiving pharmacological therapy. Twelve participants with diabetes and hypertension, 16 participants with hypertension and 18 healthy participants were studied. During six weeks no intervention was carried out, except the treatment for their underlying conditions. During the ensuing six weeks, participants were subjected 12 sessions of physical training. Blood pressure was measured at baseline and after six and twelve weeks of intervention. During the period without physical training, no changes in blood pressure were observed. After the physical training intervention systolic blood pressure decreased by 16, 17 and 20 mm Hg in participants with diabetes and hypertension, participants with hypertension and healthy participants, respectively. Diastolic blood pressure decreased by 9 and 6 mmHg in participants with diabetes and hypertension and hypertension alone, respectively. There is a decrease in blood pressure among hypertensive participants receiving pharmacological therapy, after a period of physical training.

Can Antihypertensive Treatment Restore the Risk of Cardiovascular Disease to Ideal Levels?: The Coronary Artery Risk Development in Young Adults (CARDIA) Study and the Multi-Ethnic Study of Atherosclerosis (MESA).

BackgroundIt is unclear whether antihypertensive treatment can restore cardiovascular disease risk to the risk level of persons with ideal blood pressure (BP) levels.Methods and ResultsData from the Multi-Ethnic Study of Atherosclerosis (MESA) and the Coronary Artery Risk Development in Young Adults (CARDIA) study were analyzed. Outcomes were compared among participants without or with antihypertensive treatment at 3 BP levels: <120/<80 mm Hg, systolic BP 120 to 139 mm Hg or diastolic BP 80 to 89 mm Hg (120 to 129/≤80 mm Hg for participants with diabetes), and systolic BP ≥140 or diastolic BP ≥90 mm Hg (systolic BP ≥130 or diastolic BP ≥80 mm Hg for participants with diabetes). Among MESA participants aged ≥50 years at baseline, those with BP <120/<80 mm Hg on treatment had higher left ventricular mass index, prevalence of estimated glomerular filtration rate <60 mL/min per 1.73 m2, prevalence of coronary calcium score >100, and twice the incident cardiovascular disease rate over 9.5 years of follow-up than those with BP <120/<80 mm Hg without treatment. In CARDIA at year 25, persons with BP <120/<80 mm Hg with treatment had much longer exposure to higher BP and higher risk of end-organ damage and subclinical atherosclerosis than those with BP <120/<80 mm Hg without treatment. An exploratory analysis suggested that when cumulative systolic BP was high (eg, >3000 mm Hg–years in 25 years), the increase in left ventricular mass index accelerated.ConclusionsThe data suggest that based on the current approach, antihypertensive treatment cannot restore cardiovascular disease risk to ideal levels. Emphasis should be placed on primordial prevention of BP increases to further reduce cardiovascular disease morbidity and mortality.

Impaired right ventricular hemodynamics indicate preclinical pulmonary hypertension in patients with metabolic syndrome.

BackgroundMetabolic disease can lead to intrinsic pulmonary hypertension in experimental models. The contributions of metabolic syndrome (MetS) and obesity to pulmonary hypertension and right ventricular dysfunction in humans remain unclear. We investigated the association of MetS and obesity with right ventricular structure and function in patients without cardiovascular disease.Methods and ResultsA total of 156 patients with MetS (mean age 44 years, 71% women, mean body mass index 40 kg/m2), 45 similarly obese persons without MetS, and 45 nonobese controls underwent echocardiography, including pulsed wave Doppler measurement of pulmonary artery acceleration time (PAAT) and ejection time. Pulmonary artery systolic pressure was estimated from PAAT using validated equations. MetS was associated with lower tricuspid valve e′ (right ventricular diastolic function parameter), shorter PAAT, shorter ejection time, and larger pulmonary artery diameter compared with controls (P<0.05 for all). Estimated pulmonary artery systolic pressure based on PAAT was 42±12 mm Hg in participants with MetS compared with 32±9 and 32±10 mm Hg in obese and nonobese controls (P for ANOVA <0.0001). After adjustment for age, sex, hypertension, diabetes, body mass index, and triglycerides, MetS remained associated with a 20‐ms–shorter PAAT (β=−20.4, SE=6.5, P=0.002 versus obese). This association persisted after accounting for left ventricular structure and function and after exclusion of participants with obstructive sleep apnea.ConclusionsMetS is associated with abnormal right ventricular and pulmonary artery hemodynamics, as shown by shorter PAAT and subclinical right ventricular diastolic dysfunction. Estimated pulmonary artery systolic pressures are higher in MetS and preclinical metabolic heart disease and raise the possibility that pulmonary hypertension contributes to the pathophysiology of metabolic heart disease.

Abstract P112: Changes in Lifestyle Behavior to Reduce Uncontrolled Blood Pressure in the Faith Trial

Introduction: Modifying lifestyle behaviors is a key method for controlling hypertension. This strategy is extremely important for hypertensive Black Americans, as they are more likely to have uncontrolled blood pressure (BP), have a higher risk of complications, and poorer outcomes. To address this need, we conducted a cluster-randomized controlled trial to reduce BP through lifestyle modification that was delivered by lay health advisors in Black churches. The Faith-based Approaches in the Treatment of Hypertension (FAITH) trial was designed to evaluate the effectiveness of a 12-week faith-based lifestyle intervention and subsequent 3-month motivational interviewing vs. health education control on BP reduction among hypertensive Black adults. This study examines the change in lifestyle behaviors during the trial from baseline to 6 months. Methods: We recruited 373 Black Americans with uncontrolled hypertension from 32 urban churches. BP was considered to be uncontrolled if systolic BP (SBP)≥140 mmHg or diastolic BP (DBP)≥90 mmHg, or DBP≥130 mmHg or DBP≥80 mmHg for participants with self-reported diabetes or kidney disease The primary outcome was within-participant change in BP from baseline to 6 months. Lifestyle data collected included the NCI fruit/vegetable intake screener and % calories from fat screener, the International Physical Activity Questionnaire (IPAQ), medication adherence, and measured height and weight. Results: Participants’ mean age was 63.4 y, 76.4% were female, and 96.1% reported being of African descent. The mean BMI was 32.1 kg/m2. At 6 months, the intervention was associated with significant reduction in SBP but not DBP compared with the control group (-16.0 mmHg vs -10.3 mmHg, p=0.017). There was no significant change in number of servings of fruits and vegetables consumed, minutes walked per day, or weight for either group. However, the intervention group had a slight but significantly greater decrease of 1.08 % calories from fat over time compared with the control (p=0.018), but that change was not related to change in SBP. Most notably, there was a significant months x treatment interaction on medication adherence the intervention group had a greater decrease in non-adherence score than the control (-0.84 vs -0.30, p=0.28). This improvement in adherence was related to decrease in SBP (p=0.019). Conclusion: Community-based lifestyle modification program led to significantly reduced systolic BP; and this intervention effect was mediated by improved medication adherence. However, the 12-week intervention resulted in little change in key diet and physical activity behaviors found in other trials to positively affect BP.

Systematic Review and Meta-Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation.

End-tidal carbon dioxide (ETCO(2)) measurements during cardiopulmonary resuscitation (CPR) reflect variable cardiac output over time, and low values have been associated with decreased survival. The goals of this review are to confirm and quantify this relationship and to determine the mean ETCO(2) value among patients with return of spontaneous circulation (ROSC) as an initial step toward determining an appropriate target for intervention during resuscitation in the absence of prospective data. The PubMed database was searched for the key words "end-tidal carbon dioxide" or "capnometry" or "capnography" and "resuscitation" or "return of spontaneous circulation." Randomized controlled trials, cohort studies, or case-control studies that reported ETCO(2) values for participants with and without ROSC were included. Twenty-seven studies met the inclusion criteria for qualitative synthesis. Twenty studies were included in determination of average ETCO(2) values. The mean ETCO(2) in participants with ROSC was 25.8 ± 9.8 mm Hg versus 13.1 ± 8.2 mm Hg (P = .001) in those without ROSC. Nineteen studies were included in a meta-analysis. The mean difference in ETCO(2) was 12.7 mm Hg (95% confidence interval: 10.3-15.1) between participants with and without ROSC (P < .001). The mean difference in ETCO(2) was not modified by the receipt of sodium bicarbonate, uncontrolled minute ventilation, or era of resuscitation guidelines. The overall quality of data by Grades of Recommendations, Assessment, Development and Evaluation criteria is very low, but no prospective data are currently available. Participants with ROSC after CPR have statistically higher levels of ETCO(2). The average ETCO(2) level of 25 mm Hg in participants with ROSC is notably higher than the threshold of 10 to 20 mm Hg to improve delivery of chest compressions. The ETCO(2) goals during resuscitation may be higher than previously suggested and further investigation into appropriate targets during resuscitation is needed to diminish morbidity and mortality after cardiorespiratory arrest.

Exercise-induced exaggerated blood pressure response in men with the metabolic syndrome

Abnormalities in the autonomic nervous system in the presence of insulin resistance may be involved in the pathophysiology of obesity-associated hypertension. We evaluated the association between exercise-induced exaggerated blood pressure (BP) response [exercise-induced hypertension (EIH)] and heart rate variability (HRV) and insulin resistance in men with metabolic syndrome (MetS). Ninety-eight resting normotensive men with MetS underwent a maximal symptom-limited treadmill test. BP was measured after a 5-min rest (anticipatory BP) every 3 min during exercise and during the recovery period. EIH was defined as maximum systolic BP of 220 mmHg or higher and/or maximum diastolic BP of 100 mmHg or higher. Insulin resistance was estimated using HOMA-IR. Each participant underwent a 3-h oral glucose tolerance test (OGTT). HRV was derived from a 24-h Holter. About half of the participants (52%) presented EIH. Resting BPs at baseline were 125 ± 10/83 ± 7 mmHg in participants with EIH and 120 ± 9/80 ± 6 mmHg (P = 0.01) in the group with normal BP response to exercise. OGTT glucose levels were higher in the group with EIH (all P < 0.04) as well as HOMA-IR compared with participants with normal BP response to exercise (P = 0.03). In terms of HRV, 24-h standard deviation of the RR intervals (SDNN) was lower in participants with EIH (P = 0.04) as well as 24-h daytime and night-time high frequency and low frequency (P < 0.05). Normotensive men with MetS but with EIH have greater insulin resistance as well as lower HRV parasympathetic and sympathetic indices. These features may be involved in the pathophysiology of EIH.

Combined Olmesartan, Amlodipine, and Hydrochlorothiazide Therapy in Randomized Patients with Hypertension: A Subgroup Analysis of the TRINITY Study by Age

BackgroundHypertension is often inadequately controlled in older people.ObjectiveThis prespecified subgroup analysis assessed the efficacy and safety of an olmesartan medoxomil (OM) 40 mg/amlodipine besylate (AML) 10 mg/hydrochlorothiazide (HCTZ) 25 mg triple-combination treatment compared with the 3 components as dual-combination treatments in participants with hypertension who were <65 and ≥65 years of age. Within the ≥65 years of age subgroup, efficacy and safety were also summarized for participants ≥75 years of age.Study design12-week, multicenter, double-blind, randomized, parallel-group study.Setting317 ambulatory care sites in the US and Puerto Rico.ParticipantsIndividuals ≥18 years of age with mean seated blood pressure (SeBP) ≥140/100 or ≥160/90 mmHg off antihypertensive medication on 2 consecutive clinic visits with no recent history of significant cerebrovascular disease, coronary artery disease, heart failure (New York Heart Association class III or IV), severe renal insufficiency, or uncontrolled diabetes (HbA1c >9 %).InterventionParticipants were randomized, stratified by age, diabetes status, and race to one of four treatment assignments: OM 40/AML 10/HCTZ 25 mg, OM 40/AML 10 mg, OM 40/HCTZ 25 mg, or AML 10/HCTZ 25 mg.Main Outcome MeasureLeast squares (LS) mean change from baseline in seated diastolic blood pressure (SeDBP) at week 12 (last observation carried forward) in each age subgroup (prespecified analysis).ResultsOf the 2492 randomized participants in the study (total cohort), 2021 (81.1 %) were <65 and 471 (18.9 %) were ≥65 years of age, including 79 (3.2 %) who were ≥75 years of age. OM 40/AML 10/HCTZ 25 mg triple-combination treatment resulted in a significantly greater reduction in LS mean SeDBP at week 12 than dual-combination component treatments in participants in both cohorts: <65 years (21.0 vs. 14.2–17.2 mmHg; p < 0.0001) and ≥65 years (23.7 vs. 17.3–20.0 mmHg; p ≤ 0.002). Similarly, triple-combination treatment resulted in a greater reduction in LS mean seated systolic blood pressure (SeSBP) at week 12 than dual-combination component treatments: <65 years (38.2 vs. 28.3–31.4 mmHg; p < 0.0001) and ≥65 years (39.2 vs. 29.3–31.1 mmHg; p < 0.0001). Triple-combination treatment was more effective than dual-combination treatments in enabling participants to reach SeBP goal (<140/90 mmHg [<130/80 mmHg in participants with diabetes, chronic kidney disease, or chronic cardiovascular disease]) in both age subgroups (<65 years: 65 vs. 34–50 %, respectively, p < 0.0001 and ≥65 years: 63 vs. 32–39 %; p ≤ 0.0004). All 4 treatments were safe and well tolerated with low discontinuation rates in both age subgroups. There were no clinically relevant differences in the incidence of treatment-emergent adverse events between participants <65 and ≥65 years of age receiving triple-combination treatment.ConclusionTriple-combination treatment with OM 40/AML 10/HCTZ 25 mg was well tolerated and more effective in lowering BP than the component dual-combination treatments in elderly and non-elderly subgroups.