Blood Pressure Targets In Patients Research Articles

Blood pressure levels and adverse cardiovascular outcomes in heart failure: A systematic review and meta-analysis.

Existing data on the association between blood pressure levels and adverse cardiovascular outcomes in patients with heart failure (HF) are inconsistent. The optimal blood pressure targets for patients with HF remain uncertain. This study sought to assess the associations between blood pressure (systolic and diastolic blood pressure, SBP and DBP) levels and adverse cardiovascular disease (CVD) outcomes in patients with HF. A systematic review and meta-analysis were conducted using MEDLINE, Embase, the Cochrane Library, and Web of Science databases up to 5 May 2023. The outcomes of interest included adverse cardiovascular events and all-cause mortality. Pooled relative risks (RRs) with corresponding 95% confidence intervals (CIs) were calculated. Forty-three unique observational cohort studies, comprising 120 643 participants with HF, were included. The pooled RRs (95% CIs) for SBP thresholds of ≥140 mmHg vs <140 mmHg were 0.92 (0.83-1.01) for all-cause mortality, 0.83 (0.67-1.04) for CVD death, and 0.98 (0.80-1.21) for HF hospitalization. The pooled RR (95% CI) for SBP thresholds of ≥160 mmHg vs <160 mmHg and all-cause mortality was 0.67 (0.62-0.74). SBP levels below <130, <120, and < 110 mmHg were each associated with an increased risk of various cardiovascular endpoints and all-cause mortality. The pooled RR (95% CI) for DBP thresholds of ≥80 mmHg vs <80 mmHg and all-cause mortality was 0.86 (0.67-1.10). A 10 mmHg increase in SBP or DBP was associated with a reduction in all-cause mortality and other cardiovascular endpoints. The findings suggest that lower and normal baseline SBP levels (<130, <120, and < 110 mmHg) may be associated with future risk of worse outcomes in patients with HF. Optimal baseline blood pressure levels for these patients may lie within the range of ≥140 mmHg for SBP. In the absence of observational studies with repeated blood pressure measurements or definitive trials evaluating optimal blood pressure targets, individualized blood pressure targets based on patients' unique circumstances are warranted in HF management.

Recent evidence on target blood pressure in patients with hypertension

Recent evidence on target blood pressure in patients with hypertension

Blood pressure targets in patients with chronic kidney disease: Comments and controversies.

Blood pressure targets in patients with chronic kidney disease: Comments and controversies.

Blood pressure control and treatment burden from comorbidities

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): the National Research Foundation of Korea grants funded by the Korea government (MEST) Background Achieving the optimal target blood pressure is important for patients with hypertension to prevent cardiovascular complications. Adhering to recommended therapeutic regimens is crucial to control the blood pressure. However, patients with non-cardiovascular comorbid conditions along with hypertension may experience difficulty performing adequate self-care of hypertension and achieving the optimal target blood pressure because they need to simultaneously manage hypertension and comorbidities. Treatment burden refers to workloads to manage chronic conditions and their impact. Thus, it is possible that the burden of treatment associated with managing multiple conditions adversely affects blood pressure control. Purpose To examine whether treatment burden was associated with achieving the optimal target blood pressure in patients with hypertension and non-cardiovascular comorbidities. Methods Patients with hypertension and non-cardiovascular comorbidities were recruited and asked to complete the questionnaires via online survey. Treatment burden was measured with the Multimorbidity Treatment Burden Questionnaire. Comorbid conditions that were diagnosed and/or treated were measured with the list developed to document self-reported chronic conditions in primary care. Patients were asked to report their blood pressure readings that were measured most recently within three months. Based on their blood pressure readings, patients were classified into two groups: controlled group with the blood pressure readings of &amp;lt; 140/90 mmHg and uncontrolled group with the blood pressure readings of 140/90 mmHg or above. To determine whether treatment burden was associated with blood pressure group assignment, multivariable logistic regression was used after adjusting for covariates (i.e., age, gender, education levels, employment status, periods since hypertension diagnosis, the number of non-cardiovascular comorbidities, and self-care maintenance of hypertension). Results A total of 280 patients with hypertension and non-cardiovascular comorbidities (52 years old, 33.2% female) were included in this study. Patients had an average of 3 comorbidities (SD 1.3). Of 280 patients, 153 (54.6%) had the blood pressure readings of &amp;lt;140/90 mmHg (i.e., controlled group). The multivariate logistic regression model shows that patients with greater levels of treatment burden were less likely to be in the controlled group after adjusting for covariates (adjusted odds ratio: 0.98, 95% confidence interval: 0.971-0.997). Conclusion We found that treatment burden was negatively associated with achieving the optimal target blood pressure in patients with hypertension and non-cardiovascular comorbidities. It is important for clinicians to assess patients’ burden of treatment associated with managing hypertension and comorbidities when discussing blood pressure management.

Achievement rate of target blood pressure in patients with hypertension treated by hypertension specialists and non-specialists in a real-world setting.

Hypertension remains a major global healthcare issue. Considering that most Japanese patients with hypertension are managed by general practitioners, hypertension specialists should be involved in actual clinical practice. We investigated the blood pressure (BP), guidelines recommended for achievement rate of the target BP, and clinical variables of patients with hypertension treated by hypertension specialists and those treated by non-specialists in a real-world setting. Factors associated with the target BP achievement in this population were also investigated. Outpatients with hypertension from 12 medical facilities in Okinawa Prefecture were enrolled (n = 1469 [specialist group, 794; non-specialist group, 675]; mean age, 64.2 years; females, 45.8%). For all patients, BP and rate of the target BP achievement were 129.0 ± 15.5/74.6 ± 10.6 mmHg, and 51.8%, respectively. BP and the rate of target of BP achievement were 128.0 ± 15.1/73.4 ± 10.4 mmHg and 56.7% in the specialist group, and they were 130.1 ± 15.9/76.0 ± 10.8 mmHg and 46.1% in the non-specialist group. The urinary salt excretion and obesity rates were comparable between the specialist and non-specialist groups. Multivariable logistic analyses indicated that hypertension specialists and good medication adherence were positive factors, whereas obesity, chronic kidney disease, diabetes mellitus, and urinary salt excretion were inverse factors associated with target BP achievement in this population. Initiatives for salt reduction, medication adherence, and proper obesity management are crucial to improving BP management in patients with hypertension. Hypertension specialists are expected to play an essential role in them. For all patients, the target blood pressure (BP) achievement rate were 51.8%. Hypertension specialists and good medication adherence were positive factors in achieving target BP; conversely, obesity, diabetes mellitus, chronic kidney disease, and high urinary salt excretion were inverse factors in achieving target BP among patients with hypertension.

Вплив терапії постійним позитивним тиском у дихальних шляхах на артеріальну жорсткість у пацієнтів з артеріальною гіпертензією і синдромом обструктивного апное сну

Мета роботи – оцінити зміни жорсткості артерій у хворих з артеріальною гіпертензією (АГ) і синдромом обструктивного апное сну (CОАС) та можливості її корекції за допомогою терапії постійним позитивним тиском у дихальних шляхах (CPAP-терапії).Матеріали і методи. У дослідження було залучено 185 пацієнтів віком (49,8±0,8) року із АГ легкого та середнього ступеня тяжкості, які були розподілені на групи: 1-ша група – хворі з CОАС (n=148), 2-га група – пацієнти без CОАС (контрольна група, n=37). Їм проводили клінічне та спеціальне обстеження: полісомнографію на двоканальному портативному моніторі, оцінку добової сонливості за шкалою сонливості Епворта, офісне та амбулаторне моніторування артеріального тиску (АТ), ехокардіографію та апланаційну тонометрію. У 10-місячне спостереження для оцінки впливу CPAP-терапії було залучено 105 пацієнтів, яких розділили на 4 підгрупи: А – пацієнти із СОАС середнього та тяжкого ступеня, які отримували CPAP-терапію (n=23); B – пацієнти з помірним та тяжким СOAС без CPAP-терапії (n=29); С – пацієнти з легким СОАС (n=29); D – пацієнти без СОАС (контрольна група, n=24). Усі пацієнти отримували аналогічну антигіпертензивну терапію відповідно до рекомендацій ESH/ESC 2013 р.Результати та обговорення. Пацієнти з АГ та СОАС (середній індекс апное-гіпопное (AГI) (38,10±2,51) епізоду за годину) порівняно з пацієнтами без СОАС (середній AГI (3,02±0,25) епізоду за годину) мали значно вищий індекс маси тіла ((35,20±0,57) проти (30,60±0,79) кг/м2; p&lt;0,001), рівень глюкози в крові ((107,2±2,2) проти (98,0±2,5) мг/дцл; p=0,045), рівень сечової кислоти ((6,17±0,10) проти (5,5±0,3) мг/дцл; p=0,048) та індекс маси міокарда лівого шлуночка ((115,8±2,39) проти (104,60±4,56) г/м2; p=0,035). Також пацієнти з АГ та СОАС порівняно з пацієнтами з АГ без СОАС мали більшу швидкість поширення пульсової хвилі артеріями еластичного типу (ШППХел) ((11,19±0,20) проти (10,10±0,41) м/с, p=0,014) та вищий центральний систолічний АТ ((133,43±1,67) проти (125,22±3,41) мм рт. ст.; p=0,027). Протягом 10 міс у пацієнтів з АГ та СОАС, які отримували CPAP-терапію, спостерігалося статистично значуще зниження ШППХел (з (12,20±0,63) до (10,05±0,43) м/с; p=0,009) з досягненням нормального рівня (&lt; 10 м/с) у 60,9 % пацієнтів, зниження офісного систолічного АТ (з (143,8±132,7) до (132,70±2,33) мм рт. ст.; p=0,021) та діастолічного АТ (з (93,80±3,31) до (86,0±3,19) мм рт. ст.; p=0,012) з досягненням цільових рівнів. У пацієнтів знизився центральний систолічний АТ (з (130,30±3,97) до (119,70±2,97) мм рт. ст.; p=0,012) та знизився центральний діастолічний АТ (з (94,70±3,31) до (87,10±2,36) мм рт. ст.; p=0,013).Висновок. Комбінація терапії постійним позитивним тиском у дихальних шляхах і антигіпертензивної терапії поліпшує еластичність артерій і допомагає досягти цільового рівня АТ у пацієнтів із АГ та СОАС середнього і тяжкого ступеня.

PS-C36-7: FACTORS ASSOCIATED WITH NONACHIEVEMENT OF TARGET BLOOD PRESSURE IN PATIENTS WITH CHRONIC KIDNEY DISEASE ON ANTITHROMBOTIC THERAPY

Background: Patients with chronic kidney disease (CKD) can become at risk for thromboembolism and bleeding such as hemorrhagic stroke. The Japanese Society of Hypertension Guidelines for the Management of Hypertension 2019 (JSH2019) recommend that blood pressure (BP) should be cautiously controlled in patients on antithrombotic therapy, with a target value of &lt; 130/80 mmHg to prevent hemorrhagic complications during antithrombotic therapy. Objective: The current study aimed to investigate the achievement rate of target BP, and factors associated with nonachievement of target BP in patients with CKD on antithrombotic therapy. Methods: This cross-sectional study was conducted at an outpatient clinic in 2018. Of 2,427 outpatients who received antithrombotic therapy, patients without CKD, those with CKD stage 5 or on hemodialysis, and those with missing data on body mass index, urinalysis results, and estimated glomerular filtration rate were excluded from the study. Finally, 786 outpatients met the inclusion criteria. Clinical parameters were obtained from the center's electronic database. The office BP value was classified according to the JSH2019 guidelines. The target office BP was set at &lt; 130/80 mmHg in patients with CKD on antithrombotic therapy. The odds ratio (OR) for nonachievement of target BP was calculated via multivariable logistic regression analyses. Results: The majority of patients were on antihypertensive therapy. Calcium channel blockers were the most frequently prescribed drugs, followed by angiotensin II receptor blockers and then diuretics. Acetylsalicylic acid was the most commonly prescribed antithrombotic agent, followed by P2Y12 receptor inhibitors and warfarin. The distribution of BP in this population is 16.2%, 14.1%, 29.1%, 29.5%, 10.1%, and 1.0% had normal BP, high-normal BP, elevated BP, grade I hypertension, grade II hypertension, and grade III hypertension, respectively. Approximately 30% achieved the target BP of &lt; 130/80 mmHg. Multivariable logistic regression analyses indicated that obesity (OR = 1.849, P &lt; 0.001) and proteinuria (OR = 1.846, P &lt; 0.001) were significantly correlated with nonachievement of target BP. Moreover, heart failure and cerebrovascular disease were negatively associated with the nonachievement of target BP. Conclusions: Only a small proportion of patients with CKD on antithrombotic therapy achieved the target BP. Obesity and proteinuria were associated with nonachievement of the target BP in patients with CKD on antithrombotic therapy.

Abstract 10240: Lower May Not Be Better: Systolic Blood Pressure and Risk of Major Adverse Limb Events in Patients With Symptomatic Peripheral Artery Disease After Revascularization: Insights From Voyager Pad

Introduction: Blood pressure (BP) trials have established optimal targets for major adverse cardiovascular event (MACE) prevention; however, less intensive BP control (also called permissive hypertension) is sometimes utilized to minimize end organ damage in specific settings such as acute stroke and acute kidney injury. An analysis from ALLHAT found that systolic blood pressure (SBP) &lt;120mmHg was associated with a 26% higher rate of major adverse limb events (MALE) in peripheral artery disease (PAD). Whether this association is present in patients with PAD after lower extremity revascularization (LER) is not well described. Methods: VOYAGER PAD randomized patients with symptomatic PAD after LER to rivaroxaban or placebo. The primary composite endpoint was time to first event of MACE or MALE. BP measurements were obtained at baseline, 1, 3, and every 6 months after enrollment. Associations between average SBP at 1 month after LER and incident MACE and MALE through follow up were evaluated. Splines were estimated in proportional hazard models with adjustment for treatment assignment. Results: SBP measurements at 1 month were available in 6,248 patients. Median (IQR) SBP in mmHg was (126, 114-139). The relationship between SBP after LER and future risk of MACE (Figure, Panel A) shows an apparent increased risk at SBP &lt;90mmHg. The relationship of SBP and MALE appeared linear (Figure, Panel B) with a lower risk at higher SBP and greater risk with SBP below ~120mmHg. For every 5mmHg decrease in SBP there was an associated 7% increase in risk of MALE (HR 1.07, 95% CI 1.05-1.10, p &lt;0.0001). The pattern appeared consistent regardless of index revascularization type (surgical vs endovascular). Conclusion: Patients with PAD are at heightened risk of MALE due to obstructive conduit artery disease. There is an inverse relationship between SBP and MALE after LER. Further investigation into optimal BP targets in patients with PAD are warranted.

Blood Pressure Target in Type 2 Diabetes Mellitus.

The prevalence of diabetes mellitus continues to increase worldwide, and it is a well-established cardiovascular risk factor. Hypertension is also an important cardiovascular risk factor to be controlled and is common among patients with diabetes mellitus. Optimal blood pressure (BP) goals have been the subject of great debate in the management of hypertension among patients with diabetes mellitus. This review provides detailed results from randomized controlled trials and meta-analyses of clinical outcomes according to the target BP in patients with type 2 diabetes mellitus. In addition, the target BP in patients with diabetes mellitus recommended by different guidelines was summarized and presented. A target BP of <140/90 mm Hg is recommended for patients with hypertension and diabetes mellitus, and BP should be controlled to <130/80 mm Hg in patients with diabetes mellitus who have high-risk clinical features. We hope that this review will be helpful to clinicians and patients by promoting the understanding and appropriate application of BP control in the comprehensive management of patients with diabetes mellitus.

Treatment of patients with arterial hypertension in clinical practice in 2010-2020 (according to the national register of hypertension)

To analyze therapy in patients with arterial hypertension (AH) in 20102020. Data of hypertensive patients observed in primary health care, entered into the base of hypertension registry for 20102020 years in the whole group (n=44 653) and in a separate subgroup of hypertensive patients in the absence of: ischemic heart disease, a history of myocardial infarction, chronic heart failure (n=20 569). About 80% of hypertensive patients are patients of high and very high risks (from 2010 to 2020, the proportion of very high cardiovascular risk (CVR) increased from 18.1 to 57.3%). The number of hypertensive patients with a history of myocardial infarction increased in 5 times, in 3 times with ischemic heart disease and with chronic heart failure. The number of prescribed drugs increased: mineralocorticoid receptor antagonist (in 5.8 times), loop diuretics (in 7.2) angiotensin receptor blockers (in 3 times), b-adrenoblockers, calcium channel blockers of the dihydropyridine series, thiazide-like diuretics in 2 times. Patients at high and very high risk are more likely reached target blood pressure values. Angiotensin-converting enzyme inhibitors were prescribed in more than 70% of patients with hypertension and the absence of coronary heart disease, chronic heart failure, history of myocardial infarction; the prescription of b-adrenoblockers, angiotension receptor blockers, thiazide-like and loop diuretics increased. The proportion of more severe and comorbid patients has increased in observed in primary health care patients with AH over a 10-year period (20102020). This was probably the main factor of increasing antihypertensive therapy and prescribing drugs with additional indications and improving the achievement of target blood pressure in patients with high and very high cardiovascular risk.

Factors Associated with Nonachievement of Target Blood Pressure in Patients on Antithrombotic Therapy: A Real-World Study.

Introduction: The current guidelines for managing hypertension recommend strict blood pressure (BP) control to prevent bleeding complications in patients with hypertension on antithrombotic therapy. However, the target BP value of <130/80 mmHg is achieved in a small proportion of these patients. This study aimed to examine the factors associated with nonachievement of target BP value (≥130/80 mmHg) in patients on antithrombotic therapy. Methods: This retrospective study was conducted at an outpatient clinic in 2018. Clinical parameters were obtained from the center’s electronic medical database. Office BP was measured once in the sitting position. A target BP value of <130/80 mmHg was defined according to the Japanese Society of Hypertension Guidelines for the Management of Hypertension 2019. Results: Of the 26,803 outpatients who had scheduled visits during this time, 2,427 received antithrombotic therapy. Patients with chronic kidney disease stage 5 or on hemodialysis and those with missing data on body mass index were excluded from the study; eventually, 2,201 outpatients met the inclusion criteria. BP values of <140/90 mmHg were observed in 59.2% of these outpatients; however, only 30.6% displayed the target BP value of <130/80 mmHg. Univariate and multivariate logistic regression analyses indicated that male gender and obesity significantly correlated with nonachievement of the target BP (≥130/80 mmHg). However, heart failure and ischemic heart disease were negatively but significantly related to nonachievement of the target BP. Conclusions: The target BP value was achieved in only a small proportion of the patients treated with antithrombotic drugs. In patients on antithrombotic therapy, obesity appeared to be a modifiable risk factor, whereas cardiovascular comorbidities, such as heart failure, were negative factors contributing to nonachievement of the target BP.

Choosing the optimal antihypertensive therapy

The article considers approaches to the selection of optimal antihypertensive therapy in order to achieve the target blood pressure in patients with hypertension in accordance with the latest Recommendations on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology; ESC), as well as the circadian rhythm of blood pressure. Fixed combinations of renin-angiotensin-aldosterone system blockers, which include angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors, with calcium antagonists should be preferred. Taking such a fixed combination at night can prevent the morning rise in blood pressure, when patients with hypertension usually have cardiovascular accidents.

Структура пацієнтів із резистентною артеріальною гіпертензією

Актуальність. Неконтрольований артеріальний тиск в осіб (АТ) пов’язаний із чотириразовим збільшенням ризику розвитку серцево-судинних подій порівняно з пацієнтами з АГ, які досягли цільового рівня АТ. Мета: оцінити загальну характеристику пацієнтів із резистентною АГ, які проходили стаціонарне лікування у відділенні симптоматичних гіпертензій ДУ «ННЦ «Інститут кардіології імені академіка М.Д. Стражеска» НАМН України», та визначити досягнення цільового рівня артеріального тиску в пацієнтів із резистентною АГ, які приймають 3 антигіпертензивні препарати та більше. Матеріали та методи. У дослідження було включено 1146 пацієнтів із резистентною АГ, які приймали 3 антигіпертензивні препарати та більше і лікувалися у відділенні симптоматичних гіпертензій ДУ «ННЦ «Інститут кардіології ім. акад. М.Д. Стражеска» НАМН України». Рівень офісного АТ при надходженні хворих у відділення при прийомі 3 антигіпертензивних препаратів і більше становив ≥ 140/90 мм рт.ст.: середній рівень систолічного (САТ)/діастолічного АТ (ДАТ) був 174,60 ± 0,64/100,50 ± 0,38 мм рт.ст. Пацієнтам проводили такі обстеження: вимірювання зросту та маси тіла, офісного АТ, добове моніторування артеріального тиску, ехокардіографічне дослідження, вимірювання швидкості поширення пульсової хвилі та центрального артеріального тиску, визначення нічного апное сну, загальний аналіз крові, біохімічний аналіз крові, визначення рівнів тиреотропного гормона, Т3, Т4, реніну крові, альдостерону крові та їх співвідношення, визначення метанефринів сечі, кортизолу. Результати. Серед пацієнтів із резистентною артеріальною гіпертензією жінок було більше, ніж чоловіків, — 62,7 проти 36,7 % відповідно. Серед них у 5 % була виявлена вторинна АГ, де в структурі переважну частку становили ренопаренхімна артеріальна гіпертензія, аденома наднирників із гіперальдостеронізмом та порушення функції щитоподібної залози з гіпотиреозом. У 16,6 % пацієнтів із резистентною АГ відмічався цукровий діабет 2-го типу, 15,8 % пацієнтів перенесли порушення мозкового кровообігу в анамнезі, де переважав ішемічний інсульт — 12,8 %. У пацієнтів, у яких не було досягнуто цільового САТ (31 %), спостерігались достовірно вищі показники АТ при надходженні в стаціонар. У них відмічались достовірно вищий рівень кортизолу крові (155,0 ± 44,0 нг/л проти 35,9 ± 20,8 нг/л), вищий індекс маси міокарда лівого шлуночка (147,50 ± 3,46 г/м2 проти 135,30 ± 1,74 г/м2), частіше спостерігались ожиріння (42,9 проти 37,5 %), аномалії розвитку нирок (2,7 проти 0,8 %), облітеруючий атеросклероз нижніх кінцівок (2,0 проти 0,2 %), структурні зміни наднирників (3,0 проти 1,2 %), нефропатія (1,3 проти 0,2 %), вищий ступінь серцевої недостатності (СН 2А стадії; 16,9 проти 8,5 %). Ступінь зниження офісного АТ серед пацієнтів, які приймали 3 антигіпертензивні препарати та більше, загалом становив для САТ 43,47 ± ± 0,65 мм рт.ст., для ДАТ — 20,33 ± 0,74 мм рт.ст., р &lt; 0,001 для обох значень. ДАТ між пацієнтами, які приймали 3 препарати та 4 препарати і більше, достовірно не відрізнявся та становив 19,88 і 20,81 мм рт.ст. відповідно, а офісний САТ достовірно більше знизився в пацієнтів, які приймали 4 препарати та більше, — на 45,78 мм рт.ст. порівняно з групою, яка приймала 3 препарати, — 41,3 мм рт.ст., р &lt; 0,001. Висновки. Вторинна артеріальна гіпертензія була виявлена в 5 % хворих із резистентною гіпертензією, в структурі найбільшу частку становили ренопаренхімна гіпертензія, аденома наднирників із гіперальдостеронізмом та порушення функції щитоподібної залози з гіпотиреозом.

The Distance Monitoring of Blood Pressure as a Tool for Improving of the Quality of Follow-Up Observation of Patients with Arterial Hypertension

This article focuses on the distant blood pressure monitoring for patients with arterial hypertension. As numerous studies show, even slightly elevated blood pressure significantly raises the risk of cardiovascular complications. And, vice versa, a 5 mmHg decrease in blood pressure reduces the lethality risk. Therefore, it is not enough to prescribe the right medication but also it is of paramount importance to monitor patients’ compliance with the treatment. Clinical observation of patients with arterial hypertension is an effective tool for the prevention of cardiovascular complications. However, to date, the coverage of follow-up and the achievement of blood pressure targets in patients with arterial hypertension is one of the most problematic aspects. Distance monitoring of blood pressure opens more opportunities for the doctor’s involvement, timely assessment and adjustment of the medication. The results of domestic and foreign research show high efficacy of the distance blood pressure monitoring. Positive results regarding the achievement of target blood pressure after 3 months are shown when using the technology of blood pressure monitoring and distance counseling of patients with arterial hypertension. In particular, the article considers the technology of mobile health care (mHealth), which is a more flexible platform for a patient’s continuous self-care.

The J-Curve Association Between Blood Pressure and Mortality in Stroke Survivors.

PurposeThe optimal blood pressure (BP) targets in terms of mortality risk after stroke remain unclear. This study aimed to assess the relationship between BP and mortality in stroke survivors.Patients and MethodsWe included 1696 participants with self-reported history of stroke aged 18 years and older from the National Health and Nutrition Examination Survey (NHANES) 1999–2014 and NHANES III with public-use linked mortality files from 2015. Baseline systolic BP (SBP) and diastolic BP (DBP) levels were obtained by taking the average of 3 measures. Cox proportional hazard models and restricted cubic splines were conducted to explore the relationship between BP and all-cause mortality.ResultsDuring a median follow-up period of 5.6 years, 888 deaths occurred. After fully adjusting for confounding factors, SBP displayed a J-curve relationship (nadir 135 mm Hg), while DBP exhibited a reverse J-curve relationship (nadir 73 mm Hg) with the risk of all-cause mortality. However, the J-curve or reverse J-curve pattern between blood pressure and mortality appeared to be limited to individuals with an age >65 years, identifying a nadir of SBP/DBP of 142/73 mm Hg. The risk of mortality followed a linear relationship for SBP and DBP in stroke survivors aged ≤65 years, with risks increasing with higher SBP and lower DBP.ConclusionIn this cross-sectional study that used national survey data, these data suggest a strong J-curve or reverse J-curve relationship between blood pressure and risk of all-cause mortality, whereas the pattern appears to be limited to individuals with an age >65 years, with a nadir at 142/73 mmHg. However, missing data on stroke type and stroke treatment limits the generalizability. Future prospective studies are needed to determine preferential blood pressure target in patients after stroke.

HYPERTENSION IN ELDERLY:OUR CURRENT TRENDS

Hypertension is a common disease in the elderly associated with signicant morbidity and mortality. Due to the complexity of this population, the optimal target of blood pressure (BP) control is still controversial. In this article, we conduct a literature review of trials published in English in the last 10 years which were specically designed to study the efcacy and safety of various BP targets in patients who are 70 years or older. Using these criteria, we found that the benets in the positive studies were demonstrated even with a minimal BPcontrol (systolic BP[SBP] &lt;150 mmHg) and continued to be reported for a SBP&lt;120 mmHg. On the other hand, keeping SBP&lt;140 mmHg seemed to be safely achieved in elderly patients. Although the safety of lowering SBP to &lt;120 mmHg is debated, Systolic Blood Pressure Intervention Trial study has shown no increased risk of falls, fractures, or kidney failure in elderly patients with SBP lower than this threshold. While the recent guidelines recommended to keep BP &lt;130/80 mmHg in the elderly, more individualized approach should be considered to achieve this goal in order to avoid undesirable complications. Furthermore, further studies are required to evaluate BPtarget in very old patients or those with multiple comorbidities.

Dynamics of resistant hypertension in the postoperative period of carotid endarterectomy with and without carotid body saving

Aim. To analyze the results of multicenter study on dynamics of resistant hypertension (RH) in patients after various types of carotid endarterectomy (CE) with and without carotid body savingMaterial and methods. During the period from January 2010 to December 2020, 1827 patients with hemodynamically significant stenosis of the internal carotid artery (ICA) and RH were operated on. Depending on CE type, the two groups were selected. Group 1 (n=1135; 62,2%) consisted of patients received glomus-saving surgery: 19,2% (n=351) -conventional CE with a patch repair of reconstitution point; 13,6% (n=248) — glomus-saving CE sensu R. A. Vinogradov; 7,3% (n=133) — glomus-saving CE sensu K. A. Antsupov; 11,7% (n=214) — glomus-saving CE sensu A. N. Kazantsev; 4,6% (n=84) — Chick-Chirik CE; 5,7% (n=105) — swallow tail type patch repair sensu R. I. Izhbuldin. Group 2 (n=692; 37,8%) consisted of patients received CE without glomus saving: 18,6% (n=341) — eversion CE with carotid body cutoff; 6,3% (n=115) — CE with new bifurcation plasty; 5,85% (n=107) — autoarterial reconstruction; 7,1% (n=129) ICA autotransplantation sensu E. V. Rosseikin.Results. The mortality rate, as well as the prevalence of myocardial infarction (MI) and ischemic strokes were comparable in groups. The incidence of hemorrhagic transformation (group 1: 0%; group 2: 0,6%; p=0,04; OR=0,06; 95% CI, 0,003-1,25) and composite endpoint (death+MI+ischemic stroke+hemorrhagic transformation) (group 1: 1,06%; group 2: 3,0%; p=0,004; odds ratio (OR)=0,34; 95% CI, 0,16-0,69) significantly differs between groups. After glomus-saving CE, the number of patients with the target blood pressure (BP) level reached 51,1% (p &lt;0,0001; OR=0,0009; 95% CI, 6,05-15,9). The number of patients with grade II (31,1%; p&lt;0,0001; OR=12,7; 95% CI, 10,4-15,52) and III (3,6%; p&lt;0,0001; OR=10,26; 95% CI, 6,71-15,67) hypertension significantly decreased. In the group 2, the prevalence grade III hypertension increased (48,0%; p&lt;0,0001; OR=0,23; 95% CI, 0,18-0,3), while the number of patients with grade I (0%; p&lt;0,0001; OR=77,0; 95% CI, 4,71-12,58) and II (52%; p&lt;0,0001; OR=3,06; 95% CI, 2,43-3,86) hypertension decreased.Conclusion. Glomus-saving CE contributes to achieving target BP in patients with RH. Its removal increases the risks of labile hypertension, postoperative hypertensive crisis, hyperperfusion syndrome and hemorrhagic transformation.

Assessment of Anti-Hypertensive Drug Adherence by Serial Aldosterone-To-Renin Ratio Measurement.

Reduced or absent compliance to anti-hypertensive treatment is a major obstacle to the achievement of blood pressure target in patients with arterial hypertension. Current available methods for therapeutic adherence assessment display low accuracy, limited applicability in clinical practice and/or high costs. We designed a prospective study to evaluate the accuracy of serial measurement of ARR to assess the therapeutic compliance to RAAS inhibitors. We prospectively enrolled 80 subjects: 40 patients with arterial hypertension and 40 normotensive controls. The ARR was evaluated at baseline and 2 and 8 week after initiation of a RAAS inhibitor in patients with hypertension, and at baseline and 2 weeks for the control group. Adherence to the prescribed therapy was confirmed by therapeutic drug monitoring. We observed a significant increase of renin levels and reduction of aldosterone levels after RAAS inhibitors initiation, with consequent reduction of ARR. Delta ARR (ΔARR), defined as relative change in ARR before and after treatment initiation, provided high accuracy for determination of therapeutic compliance, with an AUC of 0.900 at 2 weeks and 0.886 at 8 weeks. A cut-off of −48% of ΔARR provided 90% sensitivity and 75% specificity, at 2 and 8 weeks. In conclusion, the measurement of ΔARR is a powerful test, cheap and widely available to accurately identify the non-adherence to RAAS inhibitors treatment. Herein we propose the implementation of ΔARR in clinical practice through a multi-step flow-chart for the management of patients with uncontrolled blood pressure, with identification of those suspected of non-adherence, reserving therapeutic drug monitoring for non-adherence confirmation.

Decisions about antihypertensive treatment should focus on reducing cardiovascular risk

Epidemiological studies 1 Lewington S Clarke R Qizilbash N Peto R Collins R Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002; 360: 1903-1913 Summary Full Text Full Text PDF PubMed Scopus (7223) Google Scholar , 2 Rapsomaniki E Timmis A George J et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people. Lancet. 2014; 383: 1899-1911 Summary Full Text Full Text PDF PubMed Scopus (819) Google Scholar provide strong evidence for an association between high blood pressure and fatal cardiovascular complications, and interventional studies have shown that antihypertensive treatments reduce cardiovascular events and all-cause mortality. 3 Thomopoulos C Parati G Zanchetti A Effects of blood pressure lowering on outcome incidence in hypertension. 1. Overview, meta-analyses, and meta-regression analyses of randomized trials. J Hypertens. 2014; 32: 2285-2295 Crossref PubMed Scopus (167) Google Scholar , 4 Ettehad D Emdin CA Kiran A et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016; 387: 957-967 Summary Full Text Full Text PDF PubMed Scopus (1541) Google Scholar Although the target blood pressure for patients with hypertension receiving treatment in the current US guidelines 5 Whelton PK Carey RM Aronow WS et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol. 2018; 71: e127-e248 Crossref PubMed Scopus (2007) Google Scholar is less than 130/80 mm Hg and European recommendations indicate achieving 120–129/70–79 mm Hg for people younger than 65 years (and 130–139/70–79 mm Hg for those ≥65 years), 6 Williams B Mancia G Dessormais E et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. The task force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). J Hypertens. 2018; 36: 1953-2041 Crossref PubMed Scopus (1073) Google Scholar other guidelines such as those from the UK 7 National Institute for Health and Care ExcellenceHypertension in adults: diagnosis and management. NICE Guideline 136. National Institute for Health and Care Excellence, London2019https://www.nice.org.uk/guidance/ng136Date accessed: April 4, 2021 Google Scholar recommend higher target values for treatment. Thus, threshold blood pressure levels for initiating therapy and target blood pressure levels with treatment remain controversial. Furthermore, the effect of initial blood pressure on outcome, and the benefit for patients treated in primary versus secondary prevention settings have not been settled. 4 Ettehad D Emdin CA Kiran A et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016; 387: 957-967 Summary Full Text Full Text PDF PubMed Scopus (1541) Google Scholar , 8 Brunström M Carlberg B Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis. JAMA Intern Med. 2018; 178: 28-36 Crossref PubMed Scopus (177) Google Scholar Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysisIn 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. Full-Text PDF Open Access

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.