Blood Pressure Treatment Targets Research Articles

First look at new 2018 joint ESH/ESC Guidelines on diagnosis and management of hypertension

Systemic hypertension (HTN) is the most prevalent non-communicable disease and the leading cause for major cardiovascular events, renal failure and cognitive decline. The World Health Organization showed that HTN is a key area of concern for healthcare and identified this condition as one of the primary targets for intervention to reduce global morbidity and mortality. The hard-hitting AHA/ACC Guidelines on management of High blood pressure in adults published in 2017 shocked medical community and enforced reconsidering overall significance HTN once again due to the large pool of newly diagnosed individuals and higher healthcare costs. Ensuing debates around Task Force committee opinions were fomenting at every scientific session related to cardiac diseases throughout first half-year 2018 and beyond the lecture halls as well. Thus all attendees at the 28th European Congress on Hypertension and Cardiovascular Protection held in Barcelona, Spain in June were captivated with the European expert’s presented preview of the new 2018 ESH/ESC joint clinical Guidelines on diagnosis and management of HTN. This short review highlights the bullet points presented before fulltext publication. The chapters on diagnosis, risk stratification, blood pressure treatment target ranges had undergone minor but crucial corrections. Key changes include medical treatment of uncomplicated HTN and drug therapy in special groups with major comorbidities, management of resistant HTN, device-based HTN therapy and adherence interventions.

Low diastolic blood pressure is associated with a high atherosclerotic burden in patients with obstructive coronary artery disease.

The optimal blood pressure (BP) treatment target is still being debated, specifically di-astolic BP (DBP) in patients with obstructive coronary artery disease (CAD); a DBP which is too low could compromise myocardial perfusion and is associated with adverse outcomes. This study examined the relationship between DBP levels and the severity and atheroscle-rotic burden of CAD in 231 consecutive stable patients with evidence of obstructive CAD as detected by elective coronary angiography. The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) Score and SYNTAX Score II were used to quantify the atherosclerotic burden. The patients were male (71%), median age 62, interquartile range [IQR] of 57 to 67, and 84% had hypertension. The median DBP was 71.0 mmHg (IQR: 61 to 80) and the median SYNTAX Score was 16.0 (IQR 9.0-23.0). DBP levels were inversely correlated with SYNTAX Score (r = -0.61) and SYNTAX Score II (r = -0.73). Adjusting for traditional risk factors, unprotected left main CAD, systolic BP, renal function, and medications, DBP levels remained independently inversely associated with a higher tertile of SYNTAX Score (adjusted odds ratio [OR] 0.89; 95% confidence interval [CI] 0.85-0.92, p < 0.001) and SYNTAX Score II (adjusted OR 0.75; 95% CI 0.69-0.80, p < 0.001). The frequency of high athero-sclerotic burden identified by the presence of intermediate or high SYNTAX Score and SYNTAX Score II was significantly higher among patients with a DBP < 60 mmHg. Low DBP levels are independently associated with high SYNTAX Score and SYNTAX Score II in stable patients with obstructive CAD.

Individual and Joint Effects of Pulse Pressure and Blood Pressure Treatment Intensity on Serious Adverse Events in the SPRINT Trial

PurposeThe objective of this study was to determine individual and joint effects of pulse pressure and blood pressure treatment intensity on serious adverse events in the Systolic Blood Pressure Intervention Trial. MethodsPulse pressure was calculated by subtracting diastolic blood pressure from systolic blood pressure. Blood pressure treatment intensity goal was ≤140mm Hg in the control arm and ≤120mm Hg in the intensive arm. The primary outcome was a 5-point composite of hypotension, syncope, electrolyte abnormalities, acute renal insufficiency, or injurious falls. ResultsIn 9361 trial participants, the incident rate for the primary outcome per 1000 person-years increased with higher pulse pressure category: ≤49 mmHg: 20.4 (17.2-24.1), 50-59 mmHg: 24.5 (21.3-28.2), 60-69 mmHg: 31.7 (27.7-36.2), ≥70 mmHg: 44.6 (39.8-49.9; Ptrend < .0001; hazard ratio [HR] of pulse pressure [every 10mm Hg] 1.23; 95% confidence interval [CI], 1.18-1.28). The intensive treatment arm had a higher incidence rate of serious adverse events than the control arm (34.2, 95% CI, 31.2-37.3, vs 26.0, 95% CI, 23.4-28.8, P = .0001; HR 1.32; 95% CI, 1.15-1.51). The combined effect was not significant in the relative risk scale (HR 0.97, Pinteraction = .48) but was significant in the risk difference scale (P = .027), contributing 2.5 additional serious adverse events per 1000 person-years for every 10mm Hg increase in pulse pressure in excess of the individual effects of pulse pressure and treatment intensity. ConclusionsWider pulse pressure and intensive blood pressure treatment were individually associated with the composite adverse event outcome. A modest effect modification of pulse pressure and treatment intensity led to additional adverse events when both were present. Clinicians should use caution when treating older patients with elevated pulse pressure to an intensive blood pressure treatment target.

POTENTIAL IMPACT OF THE 2017 ACC/AHA HIGH BLOOD PRESSURE GUIDELINE IN NORMOTENSIVE PATIENTS WITH STABLE CORONARY ARTERY DISEASE

Objective: The 2017ACC/AHA high blood pressure (BP) guideline lowered the threshold defining hypertension and BP target in high-risk patients to 130/80 mmHg, Patients with coronary artery disease (CAD) and systolic BP 130–139 mmHg or diastolic BP 80–89 mmHg should now receive medication to achieve this target. We aimed to investigate the relationship between BP and cardiovascular events in “real-life” CAD patients considered as normotensive until the recent guideline. Design and method: Data from patients with stable CAD, with no history of hypertension and baseline BP < 140/90 mmHg, receiving > = 1 BP-lowering medication prescribed for angina, enrolled in the international CLARIFY registry from November 2009 to June 2010, were analyzed. Patients with heart failure were excluded. A Cox proportional hazards model was used to evaluate the relationship between average BP during follow-up and cardiovascular outcomes. SBP subgroups were defined as < 120 mmHg, 120–129 mmHg (reference), 130–139 mmHg, and > = 140 mmHg. DBP subgroups were defined as < 60, 60–69 mmHg, 70–79 mmHg (reference), 80–89 mmHg, and > = 90 mmHg. The primary endpoint was the composite of cardiovascular death, myocardial infarction and stroke, and secondary endpoints were each component of the primary endpoint. Results: In 5826 patients (median follow-up 5.0 years), diastolic BP 80–89 mmHg, but not systolic BP 130–139 mmHg, was associated with an increased risk of the primary endpoint (adjusted HRs 1.81, 95% CI 1.09–2.99, and 0.80, 95%CI 0.46–1.40, versus 70–79 mmHg and 120–129 mmHg, respectively). Similar results were observed for cardiovascular death and stroke. No significantly increased risk was observed for systolic BP < 120 mmHg for either endpoint (HR 1.26, 95% CI 0.76 - 2.07, for the primary endpoint). Diastolic BP < 70 mmHg was associated with an increased risk of the primary outcome, but the same was observed for stroke, suggesting a degree of reverse causality. Conclusions: In this population of stable CAD patients defined as normotensive according to the 140/90 mmHg threshold, and receiving antianginal BP-lowering medication, achieved diastolic BP 80–89 mmHg was associated with increased cardiovascular risk while achieved systolic BP 130–139 mmHg was not, supporting the lower diastolic but the not the lower systolic BP hypertension-defining threshold and treatment target.

Abdominal obesity in type 1 diabetes associated with gender, cardiovascular risk factors and complications, and difficulties achieving treatment targets: a cross sectional study at a secondary care diabetes clinic

BackgroundAbdominal obesity is linked to cardiovascular diseases in type 1 diabetes (T1D). The primary aim was to explore associations between abdominal obesity and cardiovascular complications, metabolic and inflammatory factors. The secondary aim was to explore whether achieved recommended treatment targets differed between the obese and non-obese participants.MethodsCross sectional study of 284 T1D patients (age 18–59 years, men 56%), consecutively recruited from one secondary care specialist diabetes clinic in Sweden. Anthropometrics, blood pressure, serum-lipids and high-sensitivity C-reactive protein (hs-CRP) were collected and supplemented with data from the patients’ medical records and from the Swedish National Diabetes Registry. Abdominal obesity was defined as waist circumference men/women (meters): ≥1.02/≥0.88. Hs-CRP was divided into low-, moderate-, and high-risk groups for future cardiovascular events (< 1, 1 to 3, and > 3 to ≤8.9 mg/l). Treatment targets were blood pressure ≤ 130/≤ 80, total cholesterol ≤4.5 mmol/l, LDL: ≤ 2.5 mmol/l, and HbA1c: ≤5 2 mmol/mol (≤ 6.9%). Different explanatory linear, logistic and ordinal regression models were elaborated for the associations, and calibrated and validated for goodness of fit with the data variables.ResultsThe prevalence of abdominal obesity was 49/284 (17%), men/women: 8%/29% (P < 0.001). Women (adjusted odds ratio (AOR) 6.5), cardiovascular complications (AOR 5.7), HbA1c > 70 mmol/mol (> 8.6%) (AOR 2.7), systolic blood pressure (per mm Hg) (AOR 1.05), and triglycerides (per mmol/l) (AOR 1.7), were associated with abdominal obesity. Sub analyses (n = 171), showed that abdominal obesity (AOR 5.3) and triglycerides (per mmol/l) (AOR 2.8) were associated with increasing risk levels of hs-CRP. Treatment targets were obtained for fewer patients with abdominal obesity for HbA1c (8% vs 21%, P = 0.044) and systolic blood pressure (51% vs 68%, P = 0.033). No patients with abdominal obesity reached all treatment targets compared to 8% in patients without abdominal obesity.ConclusionsSignificant associations between abdominal obesity and gender, cardiovascular disease, and the cardiovascular risk factors low-grade inflammation, systolic blood pressure, high HbA1c, and triglycerides, were found in 284 T1D patients. Fewer patients with abdominal obesity reached the treatment targets for HbA1c and systolic blood pressure compared to the non-obese.

Reevaluating the Evidence for Blood Pressure Targets in Type 2 Diabetes.

There is general consensus that treating adults with type 2 diabetes mellitus (T2DM) and hypertension to a target blood pressure (BP) of <140/90 mmHg helps prevent cardiovascular disease (CVD). Whether more intensive BP control should be routinely targeted remains a matter of debate. While the American Diabetes Association (ADA) BP guidelines recommend an individualized assessment to consider different treatment goals, the American College of Cardiology/American Heart Association BP guidelines recommend a BP target of <130/80 mmHg for most individuals with hypertension, including those with T2DM (1–3). In large part, these discrepant recommendations reflect the divergent results of the Action to Control Cardiovascular Risk in Diabetes-BP trial (ACCORD-BP) among people with T2DM and the Systolic Blood Pressure Intervention Trial (SPRINT), which excluded people with diabetes (4,5). Both trials evaluated the effect of intensive compared with standard BP treatment targets (<120 vs. <140 mmHg systolic) on a composite CVD end point of nonfatal myocardial infarction or stroke or death from cardiovascular causes. SPRINT also included unstable angina and acute heart failure in its composite end point. While ACCORD-BP did not show a significant benefit from the intervention (hazard ratio [HR] 0.88; 95% CI 0.73–1.06), SPRINT found a significant 25% relative risk reduction on the primary end point favoring intensive therapy (0.75; 0.64–0.89). Why did ACCORD-BP and SPRINT arrive at divergent conclusions? Recent secondary analyses provide new insights into potential reasons, including differences in trial design, populations studied, approach to BP lowering, trial end points, and statistical power or chance findings. While SPRINT used a parallel group study design, ACCORD-BP used …

Hypertension Guidelines in the United States and Canada: Are We Getting Closer?

See related article, pp e13–e115 The American College of Cardiology/American Heart Association (ACC/AHA) with 9 other organizations recently released new guidelines for the prevention, detection, evaluation, and management of hypertension in adults, including new blood pressure (BP) treatment thresholds and targets.1 The previous US guidelines released in 2014 caused some controversy by recommending relaxed treatment goals for several high-risk subgroups, including patients aged ≥60 years and those with diabetes mellitus or kidney disease.2 Instead, the new ACC/AHA guidelines provide a single, more intensive BP target for BP management, regardless of age or comorbid conditions. Overall, these new guidelines are more aligned with the 2017 Hypertension Canada guidelines3 and share similar key messages given that both sets of guidelines were derived from the same clinical evidence. However, some differences between ACC/AHA and Hypertension Canada are notable and warrant further discussion. First, diagnosis of hypertension. In the ACC/AHA guidelines, hypertension diagnosis is set as BP ≥130/801 versus ≥140/90 mm Hg in Hypertension Canada and other international guidelines.3,4 However, most people in the BP bracket of 130 to 139/80 to 89 mm Hg (stage 1 hypertension according to the new ACC/AHA guidelines) will have low cardiovascular risk, and both guidelines encourage health behavior modification for low-risk patients. Although observational studies demonstrate a doubling in cardiovascular risk in patients with pressures of 130 to 139/80 to 89 mm Hg compared with optimal readings, the absolute 10-year cardiovascular risk increase is relatively small. In a recent meta-analysis of 74 trials (n=306 273 participants),5 BP lowering for primary prevention was associated with decreased risk for cardiovascular disease and mortality only if baseline systolic BP was ≥140 mm Hg. The benefits for BP lowering when systolic BP was below a threshold of 140 mm Hg were only experienced in …

Correction: Evaluation of a multi-faceted diabetes care program including community-based peer educators in Takeo province, Cambodia, 2007-2013.

[This corrects the article DOI: 10.1371/journal.pone.0181582.].

Abstract P173: Hypertension Clusters Across Time and Differential Risk of Mortality: National Health and Nutrition Examination Survey 1999 - 2012

Background: Blood pressure treatment strategies and targets are generally similar for most patients with hypertension, apart from individuals with certain specific comorbidities such as diabetes. We hypothesize that there is latent heterogeneity in the population of adults with hypertension and that this may be associated with differential risk of mortality and might suggest opportunities for more tailored treatment strategies. Our study of adults with hypertension in the US explores whether clusters of social and health-related characteristics exist, how trends in clusters have varied between 1999 and 2012, and how risk of mortality varies between clusters. Methods: In a nationally representative sample of adults (&amp;gt 18 years) with hypertension (physician diagnosed, systolic &amp;ge 140 mmHg or diastolic &amp;ge 90 mmHg, or taking hypertension -related medication) from the National Health and Nutrition Examination Survey from 1999 to 2012 (Total N=16,855), we used a hierarchical cluster analysis approach to identify hypertension sub-groups according to chronic diseases, social factors, and health behaviors. Results: We found significant heterogeneity among hypertensive participants across time, according to 7 distinct clusters: Young Mexican-Americans with good health (55% of sample); Low-income non-White elderly with good health behaviors (7%); Elderly obese who smoke (18%); Men with poor health who drink and smoke (1%); Normal weight individuals with high prevalence of cancer (16%); Low-income and fit individuals with poor health (1%); and Obese and morbidly obese with high prevalence of chronic conditions (2%). The prevalence of each of these clusters remained relatively constant throughout the last decade, although there was an increase in the “Elderly obese who smoke” cluster from 14% to 18%. Mortality risk varied by subgroup. For example, the odds of dying for “Obese and morbidly obese with high prevalence of chronic conditions” were 1.73 times higher compared to “Young Mexican-Americans with good health” (p-value&lt;0.001), adjusting for confounders over a 12 year follow-up interval. Conclusions: Sociodemographic and clinical clusters among hypertensive individuals in the U.S. remained stable over a decade, with higher risk of mortality associated with specific clusters. Recognizing these clinically-identifiable phenotypes may highlight opportunities to develop and evaluate targeted interventions that account for complex and inter-related clinical and social factors. Further, there is an opportunity through clinical trials to determine whether these clusters merit different blood pressure treatment strategies.

Impact of the SPRINT Trial on Hypertension Management.

The Systolic Blood Pressure Intervention Trial is the first large prospective randomized controlled trial to demonstrate the benefit of an intensive systolic blood pressure (SBP) treatment target (<120 mm Hg) compared to a standard target (<140 mm Hg) in reducing cardiovascular morbidity and mortality and all-cause mortality in high-risk hypertensive patients. The impact of SPRINT on hypertension treatment has been large, but major questions remain about the feasibility of achieving the SPRINT intensive SBP target in routine practice, the generalizability of the SPRINT findings to hypertensive populations that were excluded from the trial, and the cost effectiveness of adopting the SPRINT intensive treatment goal. In this review, we discuss the generalizability of SPRINT data to the general population of adults with hypertension and with various comorbidities, the cost effectiveness of intensive SBP-lowering therapy, and the implications of SPRINT for future hypertension guideline development and clinical practice.

Hypertension Control in Adults With Diabetes Mellitus and Recurrent Cardiovascular Events: Global Results From the Trial Evaluating Cardiovascular Outcomes With Sitagliptin.

Systolic blood pressure (SBP) treatment targets for adults with diabetes mellitus remain unclear. SBP levels among 12 275 adults with diabetes mellitus, prior cardiovascular disease, and treated hypertension were evaluated in the TECOS (Trial Evaluating Cardiovascular Outcomes With Sitagliptin) randomized trial of sitagliptin versus placebo. The association between baseline SBP and recurrent cardiovascular disease was evaluated using multivariable Cox proportional hazards modeling with restricted cubic splines, adjusting for clinical characteristics. Kaplan-Meier curves by baseline SBP were created to assess time to cardiovascular disease and 2 potential hypotension-related adverse events: worsening kidney function and fractures. The association between time-updated SBP and outcomes was examined using multivariable Cox proportional hazards models. Overall, 42.2% of adults with diabetes mellitus, cardiovascular disease, and hypertension had an SBP ≥140 mm Hg. The association between SBP and cardiovascular disease risk was U shaped, with a nadir ≈130 mm Hg. When the analysis was restricted to those with baseline SBP of 110 to 150 mm Hg, the adjusted association between SBP and cardiovascular disease risk was flat (hazard ratio per 10-mm Hg increase, 0.96; 95% confidence interval, 0.91-1.02). There was no association between SBP and risk of fracture. Above 150 mm Hg, higher SBP was associated with increasing risk of worsening kidney function (hazard ratio per 10-mm Hg increase, 1.10; 95% confidence interval, 1.02-1.18). Many patients with diabetes mellitus have uncontrolled hypertension. The U-shaped association between SBP and cardiovascular disease events was largely driven by those with very high or low SBP, with no difference in cardiovascular disease risk between 110 and 150 mm Hg. Lower SBP was not associated with higher risks of fractures or worsening kidney function.

Blood pressure target in 2017

The issue of how far blood pressure (BP) should be lowered under antihypertensive treatment is still an important matter of scientific debate. The aim of the present review is to consider the clinical relevance of individualized BP goal under treatment in hypertensive patients according to their age, comorbidities or established cardio-vascular (CV) disease. The French and European recommendations propose a systolic BP target between 130 and 139mmHg (<150mmHg after 80 years) and diastolic BP target <90mmHg in hypertensive patients whatever their level of risk. The results of the recent SPRINT study suggest that a more ambitious systolic BP target, <120mmHg, significantly reduces CV morbidity and mortality, but with an increased iatrogenic risk. Several questions in everyday practice have to be considered. An important issue concerns BP measurement methods in this clinical trial (Dinamap) versus in routine clinical practice and the implications on BP treatment targets. In addition, close monitoring of participants in clinical trials and active orthostatic hypotension research limit the incidence of adverse events related to intensive treatement. Finally, in the presence of an established CV disease, an intensive therapeutic approach could be associated with a J-curve relationship between BP level and CV events. An early and strict BP control in young or middle-aged hypertensive patients in primary prevention should be a priority. In this hypertensive population with low to moderate CV risk, without established CV or renal diseases, more stringent than recommended BP-lowering treatment could potentially prevent hypertensive arterial damage and thus correct the increased residual CV risk later in life. The tolerance of an intensive therapeutic approach should remain a concern in elderly patients and in patients with established CV disease.

Evaluation of a multi-faceted diabetes care program including community-based peer educators in Takeo province, Cambodia, 2007-2013.

IntroductionEarly detection and treatment for diabetes are essential for reducing disability and death from the disease. Finding effective screening and treatment for individuals living with diabetes in resource-limited countries is a challenge. MoPoTsyo, a Cambodian non-governmental organization, addressed this gap by utilizing a multi-pronged approach with community-based peer educators, access to laboratory procedures, local outpatient medical consultation, and a revolving drug fund. This study evaluated outcomes of MoPoTsyo’s diabetes program in Takeo Province by assessing glycemic and blood pressure outcomes for individuals diagnosed with diabetes over a 24-month follow-up period between 2007–2013.MethodsThis is a retrospective cohort analysis of records without a comparison group. We calculated the mean fasting blood glucose (FBG) and blood pressure (BP) at regular intervals of follow-up. The proportion of patients reaching recommended treatment targets for FBG and BP was assessed.ResultsOf the 3411 patients enrolled in the program, 2230 were included in the study. The cohort was predominantly female (68.9%) with a median age of 54 years. Median follow-up time in the program was 16 months (4.9–38.4 months). Mean FBG decreased 63.9 mg/dl in mean FBG (95% CI 58.5 to 69.3) at one year of follow-up (p<0.001). After one year, 45% (321/708) of patients achieved goal FBG < 126. Of the 41.6% (927/2230) with elevated BP at enrollment, systolic and diastolic BP levels significantly decreased (p<0.001) by 16.9 mmHg (95% CI 1.2 to 22.9) and 10 mm Hg (95% CI 0.7 to 12.9) respectively between enrollment and one year of follow-up. At one year of follow-up, 51.1%% (183/355) of these patients reached the BP goal < 140/90.ConclusionThe improved outcome indicators of diabetes care for MoPoTsyo’s Takeo program evaluation showed promise. The program demonstrated a reasonable and practical approach to delivering effective diabetes care in a rural area and may serve as a model for other low-income communities. Future prospective evaluations with more complete data are necessary for longer-term outcomes.

SPRINT trial: It's not just the blood pressure!

Background The SPRINT trial showed a beneficial effect of systolic blood pressure treatment targets of 120 mmHg on cardiovascular risk compared to targets of 140 mmHg. However, differences in medication use, most importantly diuretics, are suggested as an alternative explanation. This post-hoc analysis aimed to determine whether the reduced event rate can be attributed to changes in systolic blood pressure (ΔSBP) . Methods Analyses were based on all 9361 participants of the SPRINT trial. ΔSBP was defined as the change between baseline and 6-month follow-up systolic blood pressure. Major cardiovascular events were myocardial infarction, other acute coronary syndromes, stroke, heart failure, or cardiovascular death. Cox regression was used to describe the relation between ΔSBP and major cardiovascular events. Analyses were performed separately for patients in the lowest tertile of baseline systolic blood pressure, as the SPRINT trial reported the highest treatment effect in this subgroup. Results The relation between ΔSBP and major cardiovascular events was a hazard ratio per 10 mmHg decrease of 0.93 (95% confidence interval 0.89-0.98). Similar results were found within the lowest tertile of baseline systolic blood pressure: hazard ratio per 10 mmHg decrease 0.91 (95% confidence interval 0.82-1.01). Conclusion Our results show that lowering blood pressure prevents cardiovascular disease. However, not all the positive effects in the SPRINT trial could be explained by ΔSBP. Alternative explanations, such as differences in medication use, should be considered for the positive findings of the SPRINT trial.

Abstract 031: Diastolic Blood Pressure, Coronary Artery Calcium, and Cardiac Outcomes in the Multi-ethnic Study of Atherosclerosis

Diastolic blood pressure (BP) has a J-curve relationship with coronary heart disease and death. Because this association is thought to reflect reduced coronary perfusion at low diastolic BP, our objective was to test whether the J-curve is most pronounced among persons with coronary artery calcium. Among 6,811 participants from the Multi-Ethnic Study of Atherosclerosis, we used Cox models to examine if diastolic BP category is associated with coronary heart disease events, stroke, and mortality. Analyses were conducted in the sample overall and after stratification by coronary artery calcium score. In multivariable-adjusted analyses, compared with diastolic BP of 80 to 89 mmHg (reference), persons with diastolic BP &lt;60 mmHg had increased risk of coronary heart disease events (HR 1.69 [95% confidence interval 1.02-2.79]) and all-cause mortality (HR 1.48 [95% confidence interval 1.10-2.00]), but not stroke. After stratification, associations of diastolic BP &lt;60 mmHg with events were present only among participants with coronary artery calcium &gt;0. Diastolic BP &lt;60 mmHg was not associated with events when coronary artery calcium was zero. We also found no interaction in the association between low diastolic BP and events based on race. In conclusion, diastolic blood pressure &lt;60 mmHg was associated with increased risk of coronary heart disease events and all-cause mortality in the sample overall, but this association appeared strongest among individuals with elevated CAC; suggesting that added caution may be needed when pursuing intensive BP treatment targets among persons with subclinical atherosclerosis.

Blood pressure targets for hypertension in older adults.

Eight out of 10 major antihypertensive trials in older adults attempted to achieve a target systolic blood pressure (BP) less than 160 mmHg. Collectively these trials demonstrated benefit for treatment, as compared to no treatment, for an older adult with BP greater than 160 mmHg. However an even lower BP target of less than 140 mmHg is commonly applied to all age groups. At the present time it is not known whether a lower or higher BP target is associated with better cardiovascular outcomes in older adults. To assess the effects of a higher (less than 150 to 160/95 to 105 mmHg) BP target compared to the lower BP target of less than 140/90 mmHg in hypertensive adults 65 years of age or older. The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to February 2017: the Cochrane Hypertension Specialised Register, MEDLINE, Embase, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We also contacted authors of relevant papers regarding further published and unpublished work. Randomised trials, of at least one year's duration, conducted on hypertensive adults aged 65 years or older, which report the effect on mortality and morbidity of a higher systolic or diastolic BP treatment target (whether ambulatory, home, or office measurements) in the range of systolic BP less than 150 to 160 mmHg or diastolic BP less than 95 to 105 mmHg as compared to a lower BP treatment target of less than 140/90 mmHg or lower. Two authors independently screened and selected trials for inclusion, assessed risk of bias, and extracted data. We combined data for dichotomous outcomes using the risk ratio (RR) with 95% confidence interval (CI) and for continuous outcomes we used mean difference (MD). Primary outcomes were all-cause mortality, stroke, institutionalisation, and cardiovascular serious adverse events. Secondary outcomes included cardiovascular mortality, non-cardiovascular mortality, unplanned hospitalisation, each component of cardiovascular serious adverse events separately (including cerebrovascular disease, cardiac disease, vascular disease, and renal failure), total serious adverse events, total minor adverse events, withdrawals due to adverse effects, systolic BP achieved, and diastolic BP achieved. We found and included three unblinded randomised trials in 8221 older adults (mean age 74.8 years), in which higher BP targets of less than 150/90 mmHg (two trials) and less than 160/90 mmHg (one trial) were compared to a lower target of less than 140/90 mmHg. Treatment to the two different BP targets over two to four years failed to produce a difference in any of our primary outcomes, including all-cause mortality (RR 1.24 95% CI 0.99 to 1.54), stroke (RR 1.25 95% CI 0.94 to 1.67) and total cardiovascular serious adverse events (RR 1.19 95% CI 0.98 to 1.45). However, the 95% confidence intervals of these outcomes suggest the lower BP target is probably not worse, and might offer a clinically important benefit. We judged all comparisons to be based on low-quality evidence. Data on adverse effects were not available from all trials and not different, including total serious adverse events, total minor adverse events, and withdrawals due to adverse effects. At the present time there is insufficient evidence to know whether a higher BP target (less than150 to 160/95 to 105 mmHg) or a lower BP target (less than 140/90 mmHg) is better for older adults with high BP. Additional good-quality trials assessing BP targets in this population are needed.

Reducing cardiovascular disease risk in diabetes: a randomised controlled trial of a quality improvement initiative.

To describe the management of cardiovascular disease (CVD) risk in Australian patients with diabetes; to compare the effectiveness of a quality improvement initiative for people with and without diabetes. Subgroup analyses of patients with and without diabetes participating in a cluster randomised trial. Indigenous people (≥ 35 years old) and non-Indigenous people (≥ 45 years old) who had attended one of 60 Australian primary health care services at least three times during the preceding 24 months and at least once during the past 6 months. Quality improvement initiative comprising point-of-care electronic decision support with audit and feedback tools. Adherence to CVD risk screening and prescribing guidelines. Baseline rates of guideline-recommended screening were higher for 8829 patients with diabetes than for 44 335 without diabetes (62.0% v 39.5%; P <0.001). Baseline rates of guideline-recommended prescribing were greater for patients with diabetes than for other patients at high risk of CVD (55.5% v 39.6%; P <0.001). The proportions of patients with diabetes not attaining recommended treatment targets for blood pressure, low-density lipoprotein-cholesterol or HbA1c levels who were not prescribed the corresponding therapy at baseline were 28%, 44% and 24% respectively. The intervention was associated with improved screening rates, but the effect was smaller for patients with diabetes than for those without diabetes (rate ratio [RR], 1.14 v 1.28; P = 0.01). It was associated with improved guideline-recommended prescribing only for undertreated individuals at high risk; the effect size was similar for those with and without diabetes (RR, 1.63 v 1.53; P = 0.28). Adherence to CVD risk management guidelines was better for people with diabetes, but there is room for improvement. The intervention was modestly effective in people with diabetes, but further strategies are needed to close evidence-practice gaps.Australian and New Zealand Clinical Trials Registry number: ACTRN12611000478910.

Social epidemiology of hypertension in Buffalo City Metropolitan Municipality (BCMM): cross-sectional study of determinants of prevalence, awareness, treatment and control among South African adults

ObjectivesThis study examined hypertension prevalence, awareness, treatment and control and their determinants among adults attending health facilities in Buffalo City Metropolitan Municipality (BCMM) in the Eastern Cape.DesignA cross-sectional analytical study.SettingsThe...

Does baseline hypotension predict incident depression in a cohort of community-dwelling older people? Data from The Irish Longitudinal Study on Ageing (TILDA).

hypotension is now recognised as a risk factor for syncope, cardiovascular events and mortality, but it may also represent a risk factor for late life depression (LLD). The aim of this study was to clarify the longitudinal relationship between hypotension and incident LLD. this is a longitudinal study involving community-dwelling participants aged ≥50 years, using data from The Irish Longitudinal Study on Ageing. The Centre for Epidemiological Studies Depression Scale (CES-D) was administered at baseline and at follow-up 2 years later. Blood pressure (BP) was measured at baseline. Participants with a CES-D score ≥16 at baseline and those taking antidepressants were excluded and considered to have a current diagnosis of depression. A score of ≥16 at follow-up was used to define incident depression. about 4,525 participants were included and 200 participants had diagnosis of incident LLD. The incident depression group had lower systolic BP at baseline than the non-depressed group (132.8 ± 1.43 mm Hg vs. 136.0 ± 0.30 mm HG, P = 0.025). Logistic regression showed those with systolic BP <130 mm HG had an unadjusted odds ratio of 1.31 (1.01-1.68) for incident depression. This persisted after adjustment for confounding factors. systolic BP <130 mm Hg increased the likelihood of incident depression in a cohort of community-dwelling older adults. These findings are important because systolic hypotension may represent a potentially modifiable risk factor for LLD. They are also relevant in the context of BP treatment targets for older people.

Optimal blood pressure target in stroke prevention.

A generalized single blood pressure (BP) goal may appear not suitable to achieve an optimal stroke prevention at the individual level. The aim of the present review is to consider the clinical relevance of individualized BP goal according to patient's age, comorbidities and established cerebrovascular disease. Observational and interventional data support heterogeneity in target organ prevention in that lower BP values than recommended by hypertension guidelines are associated with further stroke risk reduction. However, more ambitious BP treatment targets appear not broadly applicable to ageing hypertensive individuals or patients with established cerebrovascular disease. Strict BP control in early diagnosed hypertensive individuals, without established arterial disease, should be a priority in primary stroke prevention. In ageing hypertensive individuals, difficult to control SBP can be considered as a marker of increased systemic arterial disease in the brain, the heart and the kidneys. A delayed aggressive intervention to reduce BP in these high-risk patients may be associated with a J-shaped relationship between BP level and adverse events. Moreover, patients suffering from stroke frequently presented with a high burden of small cerebral vessel lesions that are associated with an increased risk of cognitive decline progression, particularly with stringent BP levels.