Blood Pressure Treatment Targets Research Articles

Do the frail experience more adverse events from intensive blood pressure control? A 2-year prospective study in the Irish Longitudinal Study on Ageing (TILDA).

SummaryBackgroundThe 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines for management of hypertension in adults aged ≥65 years recommend a blood pressure (BP) treatment target of 130–139/70–79 mmHg if tolerated. Randomised controlled trials have advocated for lower BP, but this may have adverse outcomes in the frail. Yet, definitions of frailty vary.MethodsUsing a prospective, observational study design, we compared two frailty classifications in their ability to predict short-term adverse outcomes associated with intensive BP control (<130/70 mmHg) in The Irish Longitudinal Study on Ageing (TILDA). Data from participants aged ≥65 treated for hypertension in Wave 1 (W1) between October 2009 and June 2011 were analysed. Frailty was identified by Frailty Phenotype (FP) and the Clinical Frailty Scale (CFS). We formulated 8 participant groups based on frailty-BP combinations. Outcomes at wave 2 (W2) in 2012–2013 were analysed with adjusted binary logistic regression models.FindingsOf 1920 W1 participants aged ≥65 and treated for hypertension, 1229 had full BP/FP and 1282 BP/CFS data. While the FP only identified risk of hospitalisation associated with intensive BP treatment, intensively treated frail-by-CFS participants had no increased or decreased risk of adverse outcomes, but those treated above the target had a higher risk of falls/fractures. In the non-frail by FP, intensive blood pressure treatment was associated with reduced risk of falls/fractures.InterpretationDifferent frailty classifications may have different prognostic implications for the purpose of the application of hypertension management guidelines. Our study had limited power due to low frailty prevalences, so further research is needed. Guidelines should specify the recommended frailty identification method/s. In the frail, therapy personalisation is needed.

Home and ambulatory blood pressure levels below target range and clinical effort to detect this condition: a population-based study in older treated hypertensives.

With implementation of stricter blood pressure (BP) treatment targets, potential for excessive BP lowering becomes an important issue, especially in older patients. Assess the magnitude, indicators and detection effort of BP levels below-target-range (BTR-BP) recommended by the European hypertension guidelines in older treated hypertensive patients (130-139/70-79mmHg). Cross-sectional, retrospective study (Seniors-ENRICA-2 cohort). General population. 1,329 treated hypertensive patients aged ≥65, assessed with three home casual BP measurements and 24-hour ambulatory BP monitoring (ABPM). Based on the European hypertension guidelines and the literature, BTR-BPs were defined as mean BP <130/70, <125/65, <130/70 and <110/55mmHg, for casual BP, 24-hour BP, daytime BP and nighttime BP, respectively, and hypotension as <110/70, <105/65, <110/70 and <90/55mmHg, respectively. Participants' mean age was 72 ± 4.4 (50.3%, women). Based on casual BP, 7.2% of patients were in target range (130-139/70-79mmHg), 44.3% in BTR-BP (<130/70) and 20.8% hypotensive (<110/70). Some 44.9, 54.9 and 22.0% of patients were in BTR-BP for 24-hour BP, daytime BP and nighttime BP, respectively, and 11.0, 21.1 and 5.6%, respectively, were hypotensive. The number of patients needed for ABPM to detect one case of 24-hour-, daytime-, and nighttime-BTR-BP was 3, 2 and 5, respectively, and 10, 5 and 18, respectively, for detecting one hypotensive case. Cardiovascular disease and female sex were associated with both BTR-BP and hypotension, and the number of antihypertensive drugs was only associated with hypotension. BTR-BP levels were common in older treated patients at home and in everyday life, more frequent than many trials report, and daytime ABPM is highly size-efficient for detecting the low ambulatory BP conditions.

217 DO THE FRAIL EXPERIENCE ADVERSE EVENTS FROM INTENSIVE BLOOD PRESSURE CONTROL? FINDINGS FROM THE IRISH LONGITUDINAL STUDY ON AGEING(TILDA)

Abstract Background The 2018 ESC/ESH guidelines for the management of arterial hypertension in adults aged ≥65 years recommend a blood pressure (BP) treatment target of 130–139/70–79 mmHg if tolerated. Randomised controlled trials have recommended lower BP. However, low BP may cause adverse outcomes, especially in the frail.We aimed to identify if older adults, frail and non-frail, in wave 1 of TILDA being treated intensely for hypertension experienced more adverse events by wave 2. Methods Data from participants aged ≥65 years treated for hypertension in Wave 1 was analysed.Frail/non-frail was identified by Frailty Phenotype (FP) and the Clinical Frailty Scale (CFS).Two blood pressure thresholds defined intensive control:&amp;lt;130/70 and &amp;lt; 110/70 mmHg.We formulated 16 baseline participant groups based on frailty-BP combinations.Outcomes at wave 2 were analysed with adjusted binary logistic regression models. Results 1,920 participants at Wave 1 were aged ≥65 years and treated for hypertension. 1,229 participants had full BP/FP data, while 1,288 had complete BP/CFS data.The frail by FP with treated BP &amp;gt;130/70 or &amp;gt; 110/70 had a statistically significant risk of new TIA or stroke by Wave 2.The frail by CFS with treated BP &amp;gt;130/70 or &amp;gt; 110/70 had a statistically increased risk of recurrent falls and/or fractures, as did the frail by FP with treated BP &amp;gt;110/70. FP with treated BP &amp;lt;130/70 was associated with new heart failure. None of the frail-BP groups was independently predictive of cognitive decline,myocardial infarction, syncope or hospitalization. For the non-frail-BP groups,there was no increased risk of any of the outcomes. Conclusion Frail older adults treated to higher BP thresholds seemed to have more adverse short-term health outcomes compared to the frail treated more intensely. Overall, a BP of &amp;lt;130/70 did not seem associated with more adverse outcomes. This 2-year prospective study’s results of a community-dwelling cohort may not be generalisable to clinical populations.

Hypertension Pharmacological Treatment in Adults: A World Health Organization Guideline Executive Summary.

Hypertension is a major cause of cardiovascular disease and deaths worldwide especially in low- and middle-income countries. Despite the availability of safe, well-tolerated, and cost-effective blood pressure (BP)-lowering therapies, <14% of adults with hypertension have BP controlled to a systolic/diastolic BP <140/90 mm Hg. We report new hypertension treatment guidelines, developed in accordance with the World Health Organization Handbook for Guideline Development. Overviews of reviews of the evidence were conducted and summary tables were developed according to the Grading of Recommendations, Assessment, Development, and Evaluations approach. In these guidelines, the World Health Organization provides the most current and relevant evidence-based guidance for the pharmacological treatment of nonpregnant adults with hypertension. The recommendations pertain to adults with an accurate diagnosis of hypertension who have already received lifestyle modification counseling. The guidelines recommend BP threshold to initiate pharmacological therapy, BP treatment targets, intervals for follow-up visits, and best use of health care workers in the management of hypertension. The guidelines provide guidance for choice of monotherapy or dual therapy, treatment with single pill combination medications, and use of treatment algorithms for hypertension management. Strength of the recommendations was guided by the quality of the underlying evidence; the tradeoffs between desirable and undesirable effects; patient’s values, resource considerations and cost-effectiveness; health equity; acceptability, and feasibility consideration of different treatment options. The goal of the guideline is to facilitate standard approaches to pharmacological treatment and management of hypertension which, if widely implemented, will increase the hypertension control rate world-wide.

Relationship between blood pressure levels and ischemic stroke, myocardial infarction, and mortality in very elderly patients taking antihypertensives: a nationwide population-based cohort study

BackgroundIn the very elderly, “the lower the better” hypothesis has constantly been contradicted by randomized control trials and various cohort studies, but inconsistency in results led to unclear blood pressure treatment targets. This study aimed to assess the relationship between baseline blood pressure (BP) and ischemic stroke, myocardial infarction, and all-cause mortality in very elderly people treated for hypertension.MethodsThis large population-based retrospective cohort study was based on the national claims database of the Korean National Health Insurance System, which covers the entire Korean population. 374,250 participants aged ≥ 75 years taking antihypertensive agents were recruited, excluding patients with a history of previous ischemic stroke or myocardial infarction.ResultsSystolic BP (SBP) followed a J curve for ischemic stroke and a U curve for all-cause mortality, with nadir ranges of 120 to 129 mmHg and 140 to 149 mmHg, respectively. While increasing diastolic BP (DBP) generally resulted in higher HRs for ischemic stroke, HRs for myocardial infarction and all-cause mortality significantly increased only when DBP was ≥ 80 mmHg and ≥ 90 mmHg, respectively. The SBP/DBP combination analysis showed that even with SBP < 130 mmHg, higher DBP ≥ 90 mmHg had higher HRs for all three outcomes compared to the reference group (130 to 149 / < 80 mmHg).ConclusionsThere were no further benefits or even harm below certain BP levels for ischemic stroke, myocardial infarction, and all-cause mortality in very elderly hypertensive patients.

November 2021 Stroke Highlights

November 2021 <i>Stroke</i> Highlights

Organizational and patient-level predictors for reaching key risk factor targets in cardiac rehabilitation after myocardial infarction – the perfect-CR study

Abstract Background The benefits of specific cardiac rehabilitation (CR) programme components on patient outcomes after myocardial infarction (MI) remain unclear, as does their relative predictive strength compared to patient-level predictors. Purpose To identify CR organizational and patient-level predictors for reaching risk factor targets at one-year post-MI. Methods This was an observational survey- and registry-based study. Data on CR organization at all 78 CR centres in Sweden was collected in 2016 and merged with individual patient data from nationwide registries (n=7549, median age 64 years, 24% females). Cross-validation resampled orthogonal partial least squares discriminant analysis identified predictors for reaching treatment targets for low-density lipoprotein-cholesterol (LDL-C&amp;lt;1.8 mmol/L), blood pressure (BP&amp;lt;140/90 mmHg) and smoking abstinence (yes/no). Predictors with Variables of Importance for the Projection (VIP) value &amp;gt;0.8 and 95% confidence intervals (CI) excluding zero, were considered meaningful. Results Of the 71 analysed organizational variables, 36 were identified as meaningful predictors for reaching LDL-C and 35 for BP targets (Figure 1). The strongest predictors (VIP [95% CI]) for LDL-C and BP were: offering psychosocial management at initial CR assessment 2.09 [1.70–2.49]; 2.34 [1.90–2.78], having a CR team psychologist 1.59 [1.28–1.91]; 2.00 [1.46–2.55], having extended CR centre opening hours 2.17 [1.95–2.40]; 1.51 [1.03–2.00], staff reporting satisfaction with CR centre facilities 1.55 [1.07–2.04]; 1.96 [1.64–2.28], having a medical director 1.71 [1.45–1.97]; 1.47 [1.07–1.87], nurses using protocols for antihypertensive and/or lipid lowering medication adjustment 1.58 [1.35–1.81]; 1.56 [1.03–2.08], having operational team meetings 1.36 [1.08–1.64]; 1.34 [0.99–1.70], and using audit data for quality improvement 1.00 [0.79–1.20]; 1.27 [0.99–1.56]. Offering pre-exercise-based CR (exCR) assessment and different modes of exCR were predictors for reaching both targets. The strongest patient-level predictor of reaching LDL-C target was low baseline LDL-C 3.90 [3.25–4.56], and for BP it was having no history of hypertension 2.93 [2.74–3.12]. Second, participation in exCR was the strongest predictor for both outcomes 1.60 [0.83–2.37]; 1.50 [1.15–1.86]. For smoking abstinence, 5 organizational variables were identified as meaningful predictors, the strongest being prescription of varenicline by the centre physicians 1.98 [0.13–3.84] (Figure 2). The strongest patient-level predictors were exCR participation 2.51 [2.24–2.79] and socioeconomic status variables e.g., income 1.67 [1.28–2.06], living with partner 1.47 [0.84–2.09] and education 0.80 [0.48–1.12]. Conclusion The study identified multiple CR organizational and patient-level predictors for reaching key risk factor targets one-year post-MI. The results might contribute to defining the optimal composition of comprehensive CR programmes. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1) The Swedish Research Council for Health, Working Life and Welfare (FORTE)2) The Swedish Heart and Lung Foundation (Hjärt Lung Fonden)

Achievement of treatment targets predicts progression of vascular complications in type 1 diabetes

Background and aimTo study the association between achievement of guideline-defined treatment targets on HbA1c, low-density lipoproteins (LDL-C), and blood pressure with the progression of diabetic complications in patients with type 1 diabetes (T1D). MethodsThe study included 355 patients at baseline and 114 patients with follow-up data after 3–5 years. Outcome variables were the progression of diabetic kidney disease, retinopathy, or cardiovascular disease (CVD). We used logistic regression and other machine learning algorithms (MLA) to model the association of achievement of treatment targets and probability of progression of complications. ResultsAchievement of the target blood pressure was associated with 96% lower odds of a new CVD event (0.04 (95% CI 0.00, 0.53), p = 0.016), and 72% lower odds of progression of any complication (0.28 (95% CI 0.09, 0.89), p = 0.027. Achievement of HbA1c target was associated with lower odds of composite complication progression by 82% (0.18 (95% CI 0.04, 0.88), p = 0.034.) None of the patients who achieved HbA1c target progressed in CVD. MLA demonstrated good accuracy for the prediction of progression of CVD (AUC 0.824), and lower accuracy for other complications. ConclusionThe achievement of blood pressure and HbA1c treatment targets is associated with lower odds of vascular complication of T1D in a real life study.

Gestational Hypertension and Preeclampsia: An Overview of National and International Guidelines.

Gestational hypertension and preeclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. Τhe lack of effective screening and management policies appears to be one of the main reasons. The aim of this study was to review and compare recommendations from published guidelines on these common pregnancy complications. A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the World Health Organization, and the US Preventive Services Task Force on gestational hypertension and preeclampsia was carried out. There is an overall agreement that, in case of suspected preeclampsia or new-onset hypertension, blood and urine tests should be carried out, including dipstick test for proteinuria, whereas placental growth factor-based testing is only recommended by the National Institute for Health and Care Excellence and the European Society of Cardiology. In addition, there is a consensus on the recommendations for the medical treatment of severe and nonsevere hypertension, the management of preeclampsia, the appropriate timing of delivery, the optimal method of anesthesia and the mode of delivery, the administration of antenatal corticosteroids and the use of magnesium sulfate for the treatment of eclamptic seizures, the prevention of eclampsia in cases of severe preeclampsia, and the neuroprotection of preterm neonates. The reviewed guidelines also state that, based on maternal risk factors, pregnant women identified to be at high risk for preeclampsia should receive low-dose aspirin starting ideally in the first trimester until labor or 36 to 37 weeks of gestation, although the recommended dose varies between 75 and 162 mg/d. Moreover, most guidelines recommend calcium supplementation for the prevention of preeclampsia and discourage the use of other agents. However, controversy exists regarding the definition and the optimal screening method for preeclampsia, the need for treating mild hypertension, the blood pressure treatment targets, and the postnatal blood pressure monitoring. The development and implementation of consistent international protocols will allow clinicians to adopt effective universal screening, as well as preventive and management strategies with the intention of improving maternal and neonatal outcomes.

Kidney Disease, Hypertension Treatment, and Cerebral Perfusion and Structure

The safety of intensive blood pressure (BP) targets is controversial for persons with chronic kidney disease (CKD). We studied the effects of hypertension treatment on cerebral perfusion and structure in individuals with and without CKD. Neuroimaging substudy of a randomized trial. A subset of participants in the Systolic Blood Pressure Intervention Trial (SPRINT) who underwent brain magnetic resonance imaging studies. Presence of baseline CKD was assessed by estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (UACR). Participants were randomly assigned to intensive (systolic BP<120 mm Hg) versus standard (systolic BP<140 mm Hg) BP lowering. The magnetic resonance imaging outcome measures were the 4-year change in global cerebral blood flow (CBF), white matter lesion (WML) volume, and total brain volume (TBV). A total of 716 randomized participants with a mean age of 68 years were enrolled; follow-up imaging occurred after a median 3.9 years. Among participants with eGFR<60 mL/min/1.73 m2 (n= 234), the effects of intensive versus standard BP treatment on change in global CBF, WMLs, and TBV were 3.38 (95% CI, 0.32 to 6.44) mL/100 g/min,-0.06 (95% CI,-0.16 to 0.04) cm3 (inverse hyperbolic sine-transformed), and-3.8 (95% CI,-8.3 to 0.7) cm3, respectively. Among participants with UACR >30 mg/g (n= 151), the effects of intensive versus standard BP treatment on change in global CBF, WMLs, and TBV were 1.91 (95% CI,-3.01 to 6.82) mL/100 g/min, 0.003 (95% CI,-0.13 to 0.13) cm3 (inverse hyperbolic sine-transformed), and-7.0 (95% CI,-13.3 to-0.3) cm3, respectively. The overall treatment effects on CBF and TBV were not modified by baseline eGFR or UACR; however, the effect on WMLs was attenuated in participants with albuminuria (P= 0.04 for interaction). Measurement variability due to multisite design. Among adults with hypertension who have primarily early kidney disease, intensive versus standard BP treatment did not appear to have a detrimental effect on brain perfusion or structure. The findings support the safety of intensive BP treatment targets on brain health in persons with early kidney disease. SPRINT was funded by the National Institutes of Health (including the National Heart, Lung, and Blood Institute; the National Institute of Diabetes and Digestive and Kidney Diseases; the National Institute on Aging; and the National Institute of Neurological Disorders and Stroke), and this substudy was funded by the National Institutes of Diabetes and Digestive and Kidney Diseases. SPRINT was registered at ClinicalTrials.gov with study number NCT01206062.

Should Blood Pressure Be Lowered in All Patients at High Risk for Adverse Cardiac Events

Patient selection and treatment targets for blood pressure (BP) reduction remain controversial, particularly among patients with high-normal BP and

Pharmacist Impact on Physician Practices Related to Diabetes Management

To examine the impact of a pharmacist’s physical presence on (1) the achievement of individual and combined targets for hemoglobin A1c (A1C), blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C) (composite target), and (2) physician practices in relation to the American Diabetes Association (ADA) standards of medical care.&#x0D; &#x0D; Methods&#x0D; A retrospective, comparative study of randomly selected diabetic patients seen within an underserved primary care setting at least twice annually between June 1, 2018- December 31, 2019. Patients were allocated by whether they had received care in one of the physician-pharmacist clinics (Group A) or the physician-only clinic (Group B). Study outcomes included the proportion of patients achieving the composite and individual treatment targets for A1C, BP, and LDL-C.&#x0D; &#x0D; Results&#x0D; A total of 394 patients were included; Majority were underserved African Americans. The composite target was attained by 20% of participants in Group A and 13% in Group B (p=0.09). There were no statistically significant differences in achievement of individual targets between groups. A significantly higher proportion of participants in Group A achieved better control of diastolic blood pressure control (85% vs. 74%), had microalbuminuria tested (50% vs. 12%), were prescribed aspirin (43% vs. 32%), and had lower utilization of non-insulin glucose-lowering agents relative to those in Group B.&#x0D; &#x0D; Conclusion&#x0D; The impact of a pharmacist’s physical presence on physician practice demonstrated a general trend towards improvement in clinical outcomes related to diabetes management. Future studies are needed to further characterize the impact provided by the physician-pharmacist relationship.

Impact of Guidelines on Hypertension Control in the Elderly.

Hypertension control is a crucial measure to reduce cardiovascular (CV) risk, and blood pressure (BP) treatment targets have been recently revised to address this issue. However, achieving the recommended goal may be challenging. We aimed to assess the prevalence of uncontrolled hypertension, according to the US hypertension guidelines, among elderly participants in an Italian nationwide epidemiological survey, the relevant clinical correlates, and the agreement with the application of the European guidelines. Elderly (≥65y) volunteers enrolled in an Italian nationwide survey underwent BP measurement using standard protocols. Uncontrolled hypertension was defined as BP≥130/80 mmHg. Agreement of this definition with those from European guidelines (≥140/90 mmHg; ≥140/80 mmHg) was tested using Cohen's kappa. Selfreported information on modifiable/non-modifiable CV risk factors was also collected. Of the 13,162 treated hypertensive elderly, 69.8% had uncontrolled hypertension. They tended to be overweight/obese men with diabetes. Overall agreement between US and European guidelines was poor to good (κ = 0.289, p<0.001 and κ = 0.691, p<0.001 based on the 140/90 and 140/80 mmHg threshold, respectively). Elderly participants with controlled hypertension were more likely to report a history of CV or chronic kidney disease. No difference in lifestyle habits was observed by BP control status. Real-world data identify limited concordance between guidelines in terms of BP target achievement among older hypertensive Italians and highlights the need to spread awareness of the CV risk, especially in the presence of diabetes and obesity.

Blood Pressure in Childhood and Adolescence.

Elevated blood pressure (BP) and hypertension commonly occur in children and adolescents and increase the risk of cardiovascular disease in adulthood. The purpose of this review is to summarize recent research in pediatric hypertension including changes in defining hypertension, BP measurement techniques, hypertension epidemiology, risk factors, treatment, and BP-related target organ damage. Defining pediatric hypertension using the 2017 American Academy of Pediatrics' updated Clinical Practice Guideline resulted in a larger proportion of children being classified as having elevated BP or hypertension compared with prior guidelines. Trends in the distribution of BP among US children and adolescents suggest that BP levels and the prevalence of hypertension may have increased from 2011-2014 to 2015-2018. Factors including a family history of hypertension, obesity, minority race/ethnicity, physical inactivity, high dietary intake of sodium, and poor sleep quality are associated with an increased prevalence of elevated BP and hypertension. Evidence of a linear relationship between systolic BP and target organ damage indicates that BP levels currently considered normal could increase the risk of target organ damage in childhood. Lifestyle changes, such as adhering to the Dietary Approaches to Stop Hypertension diet, are a central component of effectively reducing BP and have been shown to reduce target organ damage. Pharmacologic treatment using angiotensin-converting enzyme inhibitors and angiotensin receptor blockers is an effective and safe method for reducing BP among children with uncontrolled BP after implementing lifestyle changes. Research gaps in the prevention, detection, classification, and treatment of hypertension in children demonstrate opportunities for future study.

Management of Hypertension in Pregnancy

Abstract Hypertension in pregnancy is currently defined as a systolic blood pressure (BP) of 140 mmHg or more, or a diastolic BP of 90 mmHg or more. This level of BP warrants antihypertensive therapy. Treating to a target BP of 135/85 mmHg halves the risk of severe hypertension that is itself associated with adverse maternal and perinatal outcomes, similar in magnitude to preeclampsia. While based on the results of the Control of Hypertension in Pregnancy Study (CHIPS) trial, this finding is consistent with all antihypertensive trials to date. Also, in the CHIPS trial, “tight” BP control also halved the risk of progression to thrombocytopenia and elevated liver enzymes for the mother, without adverse effects for the fetus or newborn. This was true regardless of the gestational age at which BP control was instituted. While methyldopa, labetalol, and nifedipine are the most commonly-recommended oral antihypertensives, it is not clear that one antihypertensive agent has advantages over the others for treatment of non-severe hypertension in pregnancy. No antihypertensives, including renin-angiotensin-aldosterone system (RAAS) inhibitors, have been shown to be teratogenic, although there may be an increase in malformations associated with the underlying condition of chronic hypertension. Atenolol and RAAS inhibitors should not be used once pregnancy is diagnosed, based on fetotoxicity. At present, BP treatment targets used in clinic are the same as those used at home as the differences are quite variable among hypertensive women. For treatment of acute severe hypertension, the most commonly-recommended antihypertensives are oral nifedipine, IV labetalol, and IV hydralazine, although oral agents have also been shown to be effective in the majority of women; while concerns raised about IV hydralazine-induced maternal hypotension and its consequences have not been confirmed, this medication may be an inferior antihypertensive to oral nifedipine. While treatment recommendations are based on evidence, women should be engaged in decision-making, as their values may alter target BP and antihypertensive choice. Future work will clarify the optimal target BP based on home BP measurements; whether BP targets should be lowered further if the definition of hypertension is based on a lower BP; which, if any, antihypertensive medication for non-severe hypertension is better with regards to maternal and perinatal outcomes; and whether factors beyond BP level (such as variability, race, and other physiological variables) should inform antihypertensive therapy in pregnancy.

Should lower income countries use higher blood pressure treatment targets?

Should lower income countries use higher blood pressure treatment targets?

Linear and Nonlinear Mendelian Randomization Analyses of the Association Between Diastolic Blood Pressure and Cardiovascular Events: The J-Curve Revisited.

Recent clinical guidelines support intensive blood pressure treatment targets. However, observational data suggest that excessive diastolic blood pressure (DBP) lowering might increase the risk of myocardial infarction (MI), reflecting a J- or U-shaped relationship. We analyzed 47 407 participants from 5 cohorts (median age, 60 years). First, to corroborate previous observational analyses, we used traditional statistical methods to test the shape of association between DBP and cardiovascular disease (CVD). Second, we created polygenic risk scores of DBP and systolic blood pressure and generated linear Mendelian randomization (MR) estimates for the effect of DBP on CVD. Third, using novel nonlinear MR approaches, we evaluated for nonlinearity in the genetic relationship between DBP and CVD events. Comprehensive MR interrogation of DBP required us to also model systolic blood pressure, given that the 2 are strongly correlated. Traditional observational analysis of our cohorts suggested a J-shaped association between DBP and MI. By contrast, linear MR analyses demonstrated an adverse effect of increasing DBP increments on CVD outcomes, including MI (MI hazard ratio, 1.07 per unit mm Hg increase in DBP; P<0.001). Furthermore, nonlinear MR analyses found no evidence for a J-shaped relationship; instead confirming that MI risk decreases consistently per unit decrease in DBP, even among individuals with low values of baseline DBP. In this analysis of the genetic effect of DBP, we found no evidence for a nonlinear J- or U-shaped relationship between DBP and adverse CVD outcomes; including MI.

What Is the Ideal Blood Pressure Treatment Target for Primary Prevention and Management of Atrial Fibrillation?

What Is the Ideal Blood Pressure Treatment Target for Primary Prevention and Management of Atrial Fibrillation?

Blood Pressure Target Achievement Under Monotheraphy: A Real-Life Appraisal

IntroductionDespite hypertension guidelines suggest that the most effective treatment strategy to improve blood pressure (BP) target achievement is to implement the use of combination treatment, monotherapy is still widely used in the clinical practice of hypertension.AimTo investigate BP control under monotherapy in the setting of real-life.MethodsWe extracted data from a medical database of adult outpatients who were referred to the Hypertension Unit, Sant’Andrea Hospital, Rome (IT), including anthropometric data, CV risk factors and comorbidities, presence or absence of antihypertensive therapy and concomitant medications. Among treated hypertensive patients, we identified only those under single antihypertensive agent (monotherapy). Office BP treatment targets were defined according to 2018 ESC/ESH guidelines as: (a) < 130/80 mmHg in individuals aged 18–65 years; (b) < 140/80 mmHg in those aged > 65 years.ResultsFrom an overall sample of 7797 records we selected 1578 (20.2%) hypertensive outpatients (47.3% female, age 59.5 ± 13.6 years, BMI 26.6 ± 4.4 kg/m2) treated with monotherapies, among whom 30.5% received ACE inhibitors, 37.7% ARBs, 15.8% beta-blockers, 10.6% CCBs, 3.0% diuretics, and 2.0% alpha-blockers. 36.6% of these patients reached the conventional clinic BP goal of < 140/90 mmHg, whilst the 2018 European guidelines BP treatment targets were fulfilled only in 14.0%. In particular, 10.2% patients aged 18–65 years and 20.4% of those aged > 65 years achieved the recommended BP goals. All these proportions results significantly lower than those achieved with dual (18.2%) or triple (22.2%) combination therapy, though higher than those obtained with life-style changes (10.8%). Proportions of patients on monotherapies with normal home and 24-h BP levels were 22.0% and 30.2%, respectively, though only 5.2% and 7.3% of these patients achieved sustained BP control, respectively. Ageing and dyslipidaemia showed significant and independent positive predictive value for the achievement of the recommended BP treatment targets, whereas European SCORE resulted a negative and independent predictor in outpatients treated with monotherapies.ConclusionsOur data showed a persistent use of monotherapy in the clinical practice, though with unsatisfactory BP control, especially in light of the BP treatment targets suggested by the last hypertension guidelines.Electronic supplementary materialThe online version of this article (10.1007/s40292-020-00420-y) contains supplementary material, which is available to authorized users.

Diabetes mellitus and cardiovascular risk management in patients with rheumatoid arthritis in a large international audit

Abstract Background The cardiovascular disease (CVD) risk in patients with rheumatoid arthritis (RA) is comparable to that of patients with diabetes mellitus (DM). Although several studies have indicated high prevalence's of DM in RA patients, little is known about how this affects their CVD risk. Objectives To examine indications for, and use of antihypertensive treatment (a-HT) and lipid-lowering therapy (LLT) in RA patients with DM (RA-DM) and RA patients without DM (RAwoDM). Further, to compare the prevalence of various types of CVD across RA-DM and RAwoDM. Methods The cohort was derived from the SUrvey of cardiovascular disease Risk Factor in patients with Rheumatoid Arthritis (SURF-RA), which was performed in 53 centres/17 countries in 5 world regions (West and East Europe; North and Latin America; and Asia) from 2014 - 2019. Indication for a-HT was defined as: 1) systolic/diastolic blood pressure (BP) ≥140/90 mm Hg, 2) self-reported hypertension, and/or 3) current use of a-HT. Indication for LLT was defined according to ESC guidelines. CVD risk estimates (by SCORE) were multiplied by 1.5 according to EULAR recommendations. Target treatment targets for BP and lipids were defined according to ESC guidelines applicable at the time data were recorded. Results Presence of comorbid DM was available in 10 602 (73.1%) of the 14 503 RA patients included in SURF-RA, of whom 75 and 1262 patients reported DM type 1 and type 2, respectively (total 1337 patients, 12.6%). Although less often current smokers, RA-DM patients were more often previous smokers, male sex and had higher body mass index compared to RAwoDM (p&amp;lt;0.0001 for all). a-HT (84.7% vs 62.3%) and LLT (100% vs 47.2%) were more frequently indicated in RA-DM than in RAwoDM patients (p&amp;lt;0.0001 for both). RA-DM were more likely than RAwoDM to receive a-HT on indication (60.4% vs 57.6%, p&amp;lt;0.0001), while the difference in LLT use on indication was not significantly different (45.7% vs 42.5%, p=0.06). Moreover, RA-DM compared to RAwoDM patients had more often reached treatment goals when on a-HT (60.7% vs 54.1%, p&amp;lt;0.0001) and LLT (62.8% vs 48.9%, p&amp;lt;0.0001). Finally, the risk of all recorded established CVD (coronary heart disease, stroke, peripheral artery disease and atrial fibrillation) was increased by a factor of 2 to 3 in RA-DM compared to RAwoDM (Figure). Conclusion The effect of RA and comorbid DM on CVD risk appears to be additive. While CVD preventive medications are more often indicated in RA-DM than in RAwoDM patients, they are also more likely to receive such therapy and to reach CVD preventive treatment goals. The latter finding may be due to more developed CVD preventive care in DM compared to RA patients. Improved CVD preventive systems for patients with RA are warranted. CVD in RA patients with and without DM Funding Acknowledgement Type of funding source: Other. Main funding source(s): Lilly