Right ventricular systolic pressure – Non-invasive bedside predictor of mortality and readmission in heart failure with reduced and preserved ejection fraction hospitalization

ObjectiveTo study the prognostic role of right ventricular systolic pressure (RVSP) in patients with heart failure (HF).BackgroundAlthough RVSP is a readily available echocardiographic parameter, it is often underused. Its prognostic role in patients with heart failure is not well established compared with pulmonary artery pressure measured by right heart catheterization.MethodsThis single-center retrospective cohort study included patients with acute heart failure hospitalization admitted to the hospital from January 2005 to December 2018. The primary predictor was right ventricular systolic pressure (RVSP) obtained from bedside transthoracic echocardiography at admission. We divided RVSP into two groups, RVSP <40 mm Hg (reference group) and RVSP ≥40 mm Hg. Primary outcome was all-cause mortality. Secondary outcomes were all-cause readmission and cardiac readmission. We conducted propensity-score matching and applied cox-proportional hazard model to compute hazard ratio (HR) with 95% confidence interval (CI).ResultsOut of 972 HF patients, 534 patients had RVSP <40 mm Hg and 438 patients had RVSP ≥40 mm Hg. Patients with RVSP ≥40 mm Hg compared with RVSP <40 mm Hg were associated with higher rates of death [HR: 1.60, 95% CI: 1.22–2.09, P-value = 0.001], all-cause readmissions [HR: 1.37, 95% CI: 1.09–1.73, P-value = 0.008] and cardiac readmissions [HR: 1.41, 95% CI: 1.07–1.85, P-value = 0.014].ConclusionHigher RVSP (≥40 mm Hg) in HF patients was associated with higher rates of death, all-cause readmissions, and cardiac readmissions. RVSP can be considered as a prognostic marker for mortality and readmission.     

Low systolic blood pressure at admission predicts long-term mortality in heart failure with preserved ejection fraction

Background

Systolic blood pressure (SBP) at hospital admission predicts in-hospital and postdischarge mortality in patients with left ventricular systolic dysfunction. The relationship between admission SBP and mortality in heart failure with preserved (≥50%) ejection fraction (HFPEF) is still unclear.

Methods and Results

We aimed to investigate the relationship between admission SBP and 5-year outcome in 368 consecutive patients hospitalized for new-onset HFPEF. Five-year all-cause mortality rates according to admission SBP categories (<120, 120–139, 140–159, 160–179, and ≥180 mm Hg) were 75 ± 7%, 53 ± 6%, 52 ± 7%, 55 ± 4%, and 60 ± 7%, respectively (P = .029). Survival analysis showed an inverse relation between admission SBP and mortality with increased risk of death for SBP <120 mm Hg. SBP <120 mm Hg independently predicted 5-year all-cause mortality (adjusted hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.08–2.63) and cardiovascular mortality (adjusted HR 1.89, 95% CI 1.21–2.97). In patients discharged alive, after adjustment for medical treatment at discharge, admission SBP <120 mm Hg remained predictive of all-cause mortality (adjusted HR 1.52, 95% CI 1.04–2.43) and cardiovascular mortality (adjusted HR 1.69, 95% CI 1.06–2.73). There was no interaction between any of the therapeutic classes and outcome prediction of SBP.

Conclusions

In HFPEF, low SBP (<120 mm Hg) at the time of hospital admission is associated with excess long-term mortality. Further studies are required to determine the mechanism of this association.     

Diastolic Blood Pressure and Heart Rate Are Independently Associated With Mortality in Chronic Aortic Regurgitation

BackgroundThe prognostic significance of diastolic blood pressure (DBP) and resting heart rate (RHR) in patients with hemodynamically significant aortic regurgitation (AR) is unknown.ObjectivesThis study sought to investigate the association of DBP and RHR with all-cause mortality in patients with AR.MethodsConsecutive patients with ≥ moderate to severe AR were retrospectively identified from 2006 to 2017. The association between all-cause mortality and routinely measured DBP and RHR was examined.ResultsOf 820 patients (age 59 ± 17 years; 82% men) followed for 5.5 ± 3.5 years, 104 died under medical management, and 400 underwent aortic valve surgery (AVS). Age, symptoms, left ventricular ejection fraction (LVEF), LV end-systolic diameter-index (LVESDi), DBP, and RHR were univariable predictors of all-cause mortality (all p ≤ 0.002). When adjusted for demographics, comorbidities, and surgical triggers (symptoms, LVEF, and LVESDi), baseline DBP (adjusted-hazard ratio [HR]: 0.79 [95% confidence interval: 0.66 to 0.94] per 10 mm Hg increase, p = 0.009) and baseline RHR (adjusted HR: 1.23 [95% confidence interval: 1.03 to 1.45] per 10 beat per min [bpm] increase, p = 0.01) were independently associated with all-cause mortality. These associations persisted after adjustment for presence of hypertension, medications, time-dependent AVS, and using average DBP and RHR (all p ≤ 0.02). Compared with the general population, patients with AR exhibited excess mortality (relative risk of death >1), which rose steeply in inverse proportion (p nonlinearity = 0.002) to DBP starting at 70 mm Hg and peaking at 55 mm Hg and in direct proportion to RHR starting at 60 bpm.ConclusionsIn patients with chronic hemodynamically significant AR, routinely measured DBP and RHR demonstrate a robust association with all-cause death, independent of demographics, comorbidities, guideline-based surgical triggers, presence of hypertension, and use of medications. Therefore, DBP and RHR should be integrated into comprehensive clinical decision-making for these patients.     

Optimal Systolic Blood Pressure Target in Resistant and Non-Resistant Hypertension: A Pooled Analysis of Patient-Level Data from SPRINT and ACCORD

Background

Prior studies suggest benefits of blood pressure lowering on cardiovascular risk may be attenuated in patients with resistant hypertension compared with the general hypertensive population, but prospective data are lacking.

Prevalence of uncontrolled hypertension in patients with Fabry disease

BACKGROUND: Fabry disease is a rare X-linked disease arising from deficiency of alpha-galactosidase A. It results in early death related to renal, cardiac, and cerebrovascular disease, which are also important outcomes in patients with elevated blood pressure (BP). The prevalence of uncontrolled hypertension, as well as the effect of enzyme replacement therapy on BP, in patients with Fabry disease is unknown. METHODS: We examined uncontrolled hypertension (systolic BP [SBP] >or=130 mm Hg or diastolic BP [DBP] >or=80 mm Hg) among 391 patients with Fabry disease who were participating in the Fabry Outcome Survey (FOS). RESULTS: Uncontrolled hypertension was present in 57% of men and 47% of women. In patients with chronic kidney disease (CKD) stage 1 (n100), median SBP was 120 mm Hg and median DBP was 74 mm Hg. In patients with CKD stage 2 (n172), median SBP was 125 mm Hg and median DBP was 75 mm Hg. In patients with CKD stage 3 (n63), median SBP was 130 mm Hg and median DBP was 75 mm Hg. There was a significant decrease in both SBP and DBP during a 2-year course of enzyme replacement therapy. CONCLUSIONS: This study revealed a high prevalence of uncontrolled hypertension among patients with Fabry disease. Thus there is a need to improve BP control and renoprotection in patients with Fabry disease.     

Mortality associated with diastolic hypertension and isolated systolic hypertension among men screened for the Multiple Risk Factor Intervention Trial

The large cohort of white men (317,871) 35 to 57 years old at initial screening for possible enrollment into the Multiple Risk Factor Intervention Trial (MRFIT) was examined with regard to initial blood pressure levels and subsequent coronary heart disease (CHD), stroke, and all-cause mortality. The overall prevalence of isolated systolic hypertension (ISH), defined as systolic blood pressure (SBP) greater than or equal to 160 mm Hg and diastolic blood pressure (DBP) less than 90 mm Hg, was 0.67% among white men screened for MRFIT and increased with age (0.31% among 35- to 39-year-olds to 1.7% among 55- to 57-year-olds). The 6 year CHD and all-cause mortality rates in men over 50 were highest in those with ISH compared with both subjects with diastolic hypertension and those with normal pressure. The relative risk of death from stroke in those with ISH, compared with that in those with SBP less than 160 mm Hg and those with DBP less than 90 mm Hg, was 3.0 (95% confidence interval 1.3 to 6.8). In addition, at any level of DBP, the level of SBP appeared to be the major determinant of all-cause and CHD mortality. The determinants of ISH in individuals under 60 years of age as well as the possible efficacy of its treatment should be evaluated further.     

The Clinical Utility of Ambulatory Blood Pressure and Heart Rate Monitoring in Psychiatric Inpatients

Alterations in heart rate and blood pressure (BP) may occur in patients receiving psychiatric medication. Twenty-four–hour ambulatory blood pressure (ABP) monitoring was compared with nurses’ conventional vital signs (CVS) for systolic (SBP) and diastolic (DBP) and heart rate (HR) measurements in psychiatric inpatients receiving multidrug treatments. Twelve consecutive subjects were enrolled. ABP monitoring and CVS measurements were concurrent but independent in each subject. Ambulatory BP monitoring recorded SBP, DBP, and HR thrice hourly from 6:00 am to 10:00 pm and once hourly between 10:00 pm and 6:00 am; CVS were obtained an average of 3.6 times/24 h. The frequency with which each BP and HR measurement method detected Level-1 (SBP 90 to 100 or 180 to 209 mm Hg; DBP 40 to 60 or 110 to 119 mm Hg; HR 50 to 60 or 110 to 119 beats/min) or Level-2 (SBP < 90 or ≥ 210 mm Hg; DBP < 40 or ≥ 120 mm Hg; HR < 50 or ≥ 120 beats/min) events was determined, and disagreements between the two measurement systems were analyzed using the McNemar test for paired sample data. Ambulatory BP monitoring detected significantly more Level-1 and Level-2 events than CVS. A significant number of mostly low BP were documented by ABP monitoring and were undetected by the CVS obtained by the nursing staff. This finding may be of clinical relevance in view of the potential hemodynamic consequences of hypotension, especially in older patients receiving psychotropic multidrug treatment.     

Is systolic blood pressure below 150 mm Hg an appropriate goal for primary prevention of cardiovascular events among elderly population?

Recently, Joint National Committee has changed the optimal therapeutic goal of systolic blood pressure (SBP) up to 150 mm Hg for elderly population. We aimed to investigate impact of different blood pressure (BP) categories on risk of developing cardiovascular disease (CVD) and mortality among elderly. The present study included 1845 participants, aged ≥60 years (mean age = 65 years), free of CVD at baseline, who had undergone health examinations between January 1999 and 2001, and were followed up until March 2010. Cox proportional hazard regression was performed to assess the hazard ratios (HRs) of BP categories for CVD and mortality events, considering those with optimal BP (SBP <120 mm Hg and diastolic BP [DBP] <80 mm Hg) as reference. During a median of 10 years follow-up, 380 cases of first CVD and 260 cases of mortality events occurred. In multivariable adjusted model, prehypertensive group (SBP between 120–129 mm Hg or DBP between 80–85 mm Hg) could not predict CVD (HR, 0.87 [0.61–1.24]) nor mortality events (HR, 0.86 [0.58–1.34]). Those with SBP between 140 mm Hg and 150 mm Hg (group 3) were at higher risk for developing CVD (HR, 1.79 [1.17–2.74]), but there were no significant risk for total mortality (HR, 1.13 [0.65–1.97]). Hypertensive group (SBP ≥150 mm Hg or DBP ≥90 mm Hg or taking antihypertensive drugs) was associated with increased risk of both CVD (HR, 1.73 [1.24–2.42]) and mortality events (HR, 1.49 [1.00–2.23]).However, Joint National Committee 8 suggested no more benefit with lowering SBP <150 mm Hg, but the results of this study imply that those with SBP between 150 mm Hg and 140 mm Hg are still at elevated risk for CVD/coronary heart disease events.     

Diastolic Hypotension May Attenuate Benefits from Intensive Systolic Targets: Secondary Analysis of a Randomized Controlled Trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) was a randomized controlled trial that studied 9361 adults ≥50 years of age with systolic blood pressure >130 mm Hg and ≥1 cardiovascular risk factors. Patients were randomized to intensive (≤120 mm Hg) or standard (≤140 mm Hg) systolic targets. In August 2016, a limited dataset was released for secondary analysis. We hypothesized that excessive lowering of diastolic blood pressure could cause harm. Using the data from SPRINT, we sought to determine whether the development of diastolic hypotension during treatment was associated with adverse outcomes.

Blood Pressure Trajectories and Outcomes for Veterans Presenting at VA Medical Centers with a Stroke or Transient Ischemic Attack

BackgroundBlood pressure control has been shown to reduce risk of vascular events and mortality after an ischemic stroke or transient ischemic attack (TIA). Yet, questions remain about effectiveness, timing, and targeted blood pressure reduction.MethodsWe analyzed data from a retrospective cohort of 18,837 veterans cared for 12 months prior and up to 12 months after an emergency department visit or inpatient admission for stroke or TIA. Latent class growth analysis was used to classify patients into systolic blood pressure trajectories. With Cox proportional hazard models, we examined relationships between blood pressure trajectories, intensification of antihypertensive medication, and stroke (fatal or non-fatal) and all-cause mortality in 12 months following the index event.ResultsThe cohort was classified into 4 systolic blood pressure trajectories: 19% with a low systolic blood pressure trajectory (mean systolic blood pressure = 116 mm Hg); 65% with a medium systolic blood pressure trajectory (mean systolic blood pressure = 136 mm Hg); 15% with a high systolic blood pressure trajectory (mean systolic blood pressure = 158 mm Hg), and 1% with a very high trajectory (mean systolic blood pressure = 183 mm Hg). After the stroke or TIA, individuals in the high and very high systolic blood pressure trajectories experienced a substantial decrease in systolic blood pressure that coincided with intensification of antihypertensive medication. Patients with very low and very high systolic blood pressure trajectories had a significantly greater (P < .05) hazard of mortality, while medication intensification was related significantly (P < .05) to lower hazard of mortality.ConclusionsThese findings point to the importance of monitoring blood pressure over multiple time points and of instituting enhanced hypertension management after stroke or TIA, particularly for individuals with high or very high blood pressure trajectories.     

缺血性脑卒中急性期的血压及其预后价值

目的探讨缺血性脑卒中患者急性期血压变化规律及其对预后的影响。方法选择发病24 h内且无严重颈动脉狭窄的急性缺血性脑卒中患者127例,动态监测入院后7天内的血压。采用改良Rankin评分、Barthel指数和美国国立卫生研究院脑卒中评分,联合分析评估患者近期、远期的预后。结果发病24 h内血压增高患者91例(71.7%),患者平均动脉压在发病5天内呈明显的自发性下降,并趋于平稳。入院24 h收缩压140～159 mm Hg(1 mm Hg=0.133 kPa)或舒张压80～89 mm Hg时,发病近期、远期预后良好比率最高。以收缩压140～159mm Hg为界,患者血压每升高或降低20 mm Hg,远期预后不良增加38.2%或34.5%。以舒张压80～89 mm Hg为界,患者血压每升高或降低10 mm Hg,远期预后不良增加29.1%(P=0.014)或24.0%(P=0.021)。结论急性缺血性脑卒中患者入院24 h收缩压140～159 mm Hg或舒张压80～89 mm Hg时可能伴有较好的预后。     

The relationship between systolic blood pressure and cardiovascular risk--results of the Brisighella Heart Study

We examined the relationship of systolic (SBP) and diastolic (DBP) blood pressure, and pulse pressure to coronary heart disease and cerebrovascular disease risk in a prospective population-based European cohort. The Brisighella Heart Study included 2939 men and women between the ages of 14–84 without prior coronary heart disease or cerebrovascular disease and not taking antihypertensive therapy at baseline. Cox regression was used to obtain hazard ratios (HRs) for coronary heart disease and cerebrovascular disease as a function of baseline blood pressure parameters over a 23-year follow-up. Higher combined coronary heart disease and cerebrovascular disease risk was evident in comparison to the referent of <120 mm Hg, with a 44% increased risk at SBP 120–139 mm Hg (HR, 1.44; 95% confidence interval [CI], 1.00–2.09; p =0.052), 76% increased risk at SBP 140–159 mm Hg (HR, 1.76; 95% CI, 1.16–2.69; p =0.009), and 109% increased risk at SBP ≥160 mm Hg (HR, 2.09; 95% CI, 1.31–3.35; p =0.0021). Trends of increasing risk with increasing levels of blood pressure were significant for SBP and pulse pressure, ( p <0.0001) but not for DBP ( p =0.058). In this European cohort, SBP was a stronger predictor of coronary heart disease and cerebrovascular disease events than DBP, and an increase in risk was already evident with highnormal SBP (120–139 mm Hg). The prognostic significance of pulse pressure was also demonstrated. The importance of SBP as seen in the Framingham Heart Study may be generalized to a European population with differences in diet and other risk factors.     

High triglyceride-glucose index is associated with adverse cardiovascular outcomes in patients with acute myocardial infarction

Background and aimsTriglyceride glucose (TyG) index is considered a new surrogate marker of insulin resistance that associated with the development of vascular disease. The aim of this study was to evaluate the prognostic value of TyG index in patients with acute myocardial infarction (AMI).Methods and resultsA total of 3181 patients with AMI were included in the analysis. Patients were stratified into 2 groups according to their TyG index levels: the TyG index <8.88 group and the TyG index ≥8.88 group. The incidence of major adverse cardiovascular events (MACEs) during a median of 33.3-month follow-up were recorded. Multivariable Cox regression models revealed that the TyG index was positively associated with all-cause death [HR (95% CI): 1.51 (1.10,2.06), p = 0.010], cardiac death [HR (95% CI): 1.68 (1.19,2.38), p = 0.004], revascularization [HR (95% CI): 1.50 (1.16,1.94), p = 0.002], cardiac rehospitalization [HR (95% CI): 1.25 (1.05,1.49), p = 0.012], and composite MACEs [HR (95% CI): 1.19 (1.01,1.41), p = 0.046] in patients with AMI. The independent predictive effect of TyG index on composite MACEs was mainly reflected in the subgroups of male gender and smoker. The area under the curve (AUC) of the TyG index predicting the occurrence of MACEs in AMI patients was 0.602 [95% CI 0.580,0.623; p < 0.001].ConclusionHigh TyG index levels appeared to be associated with an increased risk of MACEs in patients with AMI. The TyG index might be a valid predictor of cardiovascular outcomes of patients with AMI.Trial registrationRetrospectively registered.     

Metabolic syndrome and masked hypertension among African Americans: The Jackson Heart Study

The metabolic syndrome is associated with higher ambulatory blood pressure. The authors studied the association of metabolic syndrome and masked hypertension (MHT) among African Americans with clinic‐measured systolic/diastolic blood pressure (SBP/DBP) <140/90 mm Hg in the Jackson Heart Study. MHT was defined as daytime, nighttime, or 24‐hour hypertension on ambulatory blood pressure monitoring. Among 359 participants not taking antihypertensive medication, the metabolic syndrome was associated with MHT (prevalence ratio, 1.38; 95% confidence interval, 1.10–1.74]). When metabolic syndrome components (clinic SBP/DBP 130–139/85–89 mm Hg, abdominal obesity, impaired glucose, low high‐density lipoprotein cholesterol, high triglycerides) were analyzed separately, only clinic SBP/DBP 130–139/85–89 mm Hg was associated with MHT (prevalence ratio, 1.90; 95% confidence interval, 1.56–2.32]). The metabolic syndrome was not associated with MHT among participants not taking antihypertensive medication with SBP/DBP 130–139/85–89 and <130/85 mm Hg, separately, or among participants taking antihypertensive medication (n=393). Ambulatory blood pressure monitoring screening for MHT among African Americans should be considered based on clinic BP, not metabolic syndrome.     

Prognostic significance of left atrial size in patients with hypertrophic cardiomyopathy (from the Italian Registry for Hypertrophic Cardiomyopathy)

This study assessed left atrial (LA) dimension as a potential predictor of outcome in hypertrophic cardiomyopathy (HC). From the Italian Registry for Hypertrophic Cardiomyopathy, 1,491 patients (mean age 47 +/- 17 years; 61% men; 19% obstructive), followed for 9.4 +/- 7.4 years after the initial echocardiographic evaluation, constituted the study group. The mean LA transverse dimension was 43 +/- 9 mm and was larger in patients with severe symptoms (48 +/- 9 mm for New York Heart Association classes III and IV vs 42 +/- 9 mm for classes I and II, p <0.001), atrial fibrillation (47 +/- 9 vs 42 +/- 8 mm in sinus rhythm, p <0.001), and left ventricular outflow obstruction (46 +/- 9 mm for >or=30 mm Hg at rest vs 42 +/- 9 mm for <30 mm Hg at rest, p <0.001). On univariate analysis, each 5-mm increase in LA size was associated with a hazard ratio (HR) of 1.2 for all-cause mortality (p <0.0001). On multivariate analysis, a LA dimension >48 mm (the 75th percentile) had a HR of 1.9 for all-cause mortality (p = 0.008), 2.0 for cardiovascular death (p = 0.014), and 3.1 for death related to heart failure (p = 0.008) but was unassociated with sudden death (p = 0.81). Similar results were obtained after the exclusion of patients with atrial fibrillation (HR 1.7, p = 0.008) or outflow obstruction (HR 1.8, p = 0.003). The predictive power of LA dimension >48 mm was also validated in an independent HC cohort from the United States, with similar HRs (1.8 for all-cause mortality, p = 0.019). In conclusion, in a large cohort of patients with HC from a nationwide registry, a marked increase in LA dimension were predictive of long-term outcome, independent of co-existent atrial fibrillation or outflow obstruction. LA dimension is a novel and independent marker of prognosis in HC, particularly relevant to the identification of patients at risk for death related to heart failure.     

Systolic Blood Pressure and Outcomes in Older Patients with HFpEF and Hypertension

BackgroundNew hypertension and heart failure guidelines recommend that systolic blood pressure (SBP) in patients with heart failure with preserved ejection fraction (HFpEF) and hypertension be lowered to <130 mm Hg.MethodsOf the 6778 hospitalized patients with HFpEF and a history of hypertension in the Medicare-linked OPTIMIZE-HF registry, 3111 had a discharge SBP <130 mm Hg. Using propensity scores for SBP <130 mm Hg, we assembled a matched cohort of 1979 pairs with SBP <130 versus ≥130 mm Hg, balanced on 66 baseline characteristics (mean age, 79 years; 69% women; 12% African American). We then assembled a second matched cohort of 1326 pairs with SBP <120 versus ≥130 mm Hg. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with SBP <130 and <120 mm Hg were separately estimated in the matched cohorts using SBP ≥130 mm Hg as the reference.ResultsHRs (95% CIs) for 30-day, 12-month, and 6-year all-cause mortality associated with SBP <130 mm Hg were 1.20 (0.91–1.59; P = 0.200), 1.11 (0.99–1.26; P = 0.080), and 1.05 (0.98–1.14; P = 0.186), respectively. Respective HRs (95% CIs) associated with SBP <120 mm Hg were 1.68 (1.21–2.34; P = 0.002), 1.28 (1.11–1.48; P = 0.001), and 1.11 (1.02–1.22; P = 0.022). There was no association with readmission.ConclusionsAmong older patients with HFpEF and hypertension, compared with SBP ≥130 mm Hg, the new target SBP <130 mm Hg had no association with outcomes but SBP <120 mm Hg was associated with a higher risk of death but not of readmission. Future prospective studies need to evaluate optimal SBP treatment goals in these patients.     

Systolic hypertension and cardiovascular risk reduction: A clinical review

Conclusion  In conclusion, SBP and pulse pressure are stronger predictors of cardiovascular risk than is DBP in older individuals, and reduction in events has been more impressive in SBP treatment trials. Because of older morbidity trials that primarily used DBP entry criteria, however, treatment decisions should still include DBP goals. Nevertheless, clinicians should be more attentive to treating SBP, especially in patients older than 60 years. Although guidelines recommend SBP goals of < 140 mm Hg for most hypertensive patients and < 130 mm Hg for those with diabetes, clinical trial data are consistent with systolic blood pressure goals of < 150 and 140 mm Hg, respectively. Achieving these latter goals should be the first priority in the management of hypertension; the lower goals recommended by guidelines may then be considered. Several classes of antihypertensive agents have reduced events in morbidity trials, but an a-blocker (doxazosin) was inferior to a diuretic as initial therapy. Other clinical trials comparing newer classes to older classes are ongoing, and should clarify how much it matters which class of drugs is used as initial therapy. These trials are making it clear, however, that several agents in combination are usually necessary to reach modern treatment goals. Thus, convenience and tolerance, as well as efficacy in lowering SBP, are likely to be important properties of agents that are selected for a multidrug regimen. The angiotensin II receptor blockers may have a particular advantage in such regimens because of their ability to lower blood pressure, including SBP, with almost no symptomatic adverse effects.     

Association between pulse pressure at discharge and clinical outcomes in patients with acute myocardial infarction: From the KAMIR‐Korean‐NIH registry

Pulse pressure (PP) is affected by arterial stiffness and is a predictor of cardiovascular events. However, value and utility of PP assessment in patients with acute myocardial infarction (AMI) remain less clear. We aimed to evaluate the association between PP and cardiovascular events in surviving patients with AMI at discharge. A total of 11 944 surviving patients with AMI at discharge from a Korean nationwide registry were included. Blood pressure was checked just before discharge. Noncardiac death and major adverse cardiovascular events (MACEs) including cardiac death, AMI, and stroke after discharge were analyzed. The median follow‐up duration was 368 (IQR 339, 388) days. The rate of MACEs and cardiac death was higher in groups with the lowest PP (PP < 20 mm Hg) and highest PP (PP ≥ 71 mm Hg) and lowest in the group with PP of 31‐40 mm Hg. With PP of 31‐40 mm Hg as reference, univariate analysis showed a U‐shaped association between the risk of MACEs (PP ≤ 20 mm Hg: hazard ratio [HR] 2.3; PP ≥ 71 mm Hg: HR 2.7) or cardiac death (PP ≤ 20 mm Hg: HR 2.6; PP ≥ 71 mm Hg: HR 3.1) and PP. In multivariate analysis, the curve changed from being U‐shaped to J‐shaped, and HR for PP ≥ 71 mm Hg (1.2 for MACEs and 1.4 cardiac death) decreased and HR for PP < 20 (2.1 for MACEs and 2.4 for cardiac death) did not significantly decrease after adjustment for cardiovascular risk factors. Our findings indicate that PP is a strong independent prognostic factor of MACEs and cardiac death in surviving patients with AMI. Low PP is a more significant independent predictor of MACEs and cardiac death than high PP in surviving patients after AMI.     

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

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

High Blood Pressure and All-Cause and Cardiovascular Disease Mortalities in Community-Dwelling Older Adults

Although hypertension is common among older adults, the optimal blood pressure (BP) for survival in older adults remains unclear. We attempt to use a large cohort to assess the relationship between BP and mortality and to gain insight into what level of BP is required for optimal survival in older adults.A total of 77,389 community-dwelling adults, aged ≥65 years, were followed between 2006 and 2010. Mortality was determined using matching cohort identifications with national death files. Cox proportional hazards regression models were used to evaluate the relationship of BP with all-cause, cardiovascular disease (CVD), and expanded-CVD mortalities.The mortality risks of the stage 2–3 hypertension group were substantial (all-cause mortality: hazard ratio [HR]: 1.23; 95% confidence interval [CI]: 1.10–1.37; CVDs mortality: HR: 1.31; 95% CI: 1.05–1.64; expanded-CVDs mortality: HR: 1.40; 95% CI: 1.15–1.71). The cardiovascular and expanded-cardiovascular mortality risks were lowest when systolic blood pressures were 120 to 129 mm Hg, and increased significantly when systolic blood pressures (SBPs) were ≥160 mm Hg or diastolic BPs were ≥90 mm Hg. A J-curve phenomenon for SBP on CVD and expanded-CVD mortality was observed. The impacts of stage 2–3 hypertension on mortality risks were significantly increased among women. The mortality risks of hypertension were not attenuated with older age.This study provides insight for identifying the optimal BP for survival in older adults, and extends the knowledge of the impacts of hypertension on mortality risks among women and the older adults.