Supine and exercise systolic blood pressure predict cardiovascular death in middle-aged men

AIM AND METHODS: The outcome of 1999 apparently healthy men, aged 40-59 years, initially investigated in the period 1972-1975, has previously been ascertained at 7 and 16 year follow-ups. This has now been repeated after 21 years, to determine whether seated systolic blood pressure (BP) during a bicycle ergometer exercise test adds prognostic information on cardiovascular (CV) mortality beyond that of systolic BP measured after 5 min of supine rest. RESULTS: After 21 years, 41 979 years of observation, 470 patients had died, 255 from CV causes. Supine systolic BP [2 SD increase: relative risk (RR) 1.6, 95% confidence interval (CI) 1.3-2.0, P < 0.0001], 6 min exercise systolic BP (2 SD increase: RR 1.6, 95% CI 1.3-2.0, P < 0.0001) on the starting workload of 600 kpm/min (approximately 100 W, 5880 J/min) and maximal systolic BP (2 SD increase: RR 1.5, 95% CI 1.2-1.9, P = 0.0005) during work were all related to CV mortality when adjusting for a large number of variables measured in the present study including age, exercise capacity, heart rates, smoking habits, glucose tolerance and serum cholesterol. When including other systolic BPs in the continuous multivariate analysis, supine systolic BP (2 SD increase: RR 1.4, 95% CI 1.04-1.9, P = 0.029) and 6 min systolic BP at 600 kpm/min (2 SD increase: RR 1.4, 95% CI 1.06-1.9, P = 0.017) were independent predictors of CV death but not maximal systolic BP during exercise (2 SD increase: RR 1.0, 95% CI 0.7-1.2, P = 0.95). CONCLUSION: These results are different from the mortality data at 16 years, when the independent predictive effect of supine systolic BP was cancelled out by 6 min exercise systolic BP at 600 kpm/min. Twenty-one years of follow-up of 1999 apparently healthy men disclose independently predictive information on CV death, of both supine systolic BP and 6 min exercise systolic BP taken at an early moderate workload. The influence of maximal exercise systolic BP on CV death is however cancelled out by the two other systolic BPs.     

Two-year changes in blood pressure and subsequent risk of cardiovascular disease in men

BACKGROUND-It is unclear whether, given a current blood pressure level, the previous 2-year change in blood pressure adds important predictive information for cardiovascular disease (CVD). METHODS AND RESULTS-We conducted a prospective cohort study of 11 150 middle-aged and older men reporting blood pressure in the Physicians' Health Study. These men had no history of CVD or antihypertensive medication use through the time of the 2-year follow-up questionnaire; after this time, follow-up for the current study began. A total of 905 incident cases of CVD (705 cases of coronary heart disease and 200 cases of stroke) occurred during a median follow-up of 10.8 years. After controlling for current blood pressure and other coronary risk factors, we found that previous 2-year changes in systolic blood pressure were not associated with the risk of CVD. A similar lack of association was found for individual end points of coronary heart disease and stroke. However, previous 2-year changes in diastolic blood pressure (DBP) may be inversely associated with the risk of CVD (linear trend, P=0.049) independent of coronary risk factors and current DBP. In subgroup analyses, previous 2-year blood pressure changes only added information in leaner men (body mass index <24.39 kg/m(2)). CONCLUSIONS-In this normotensive population of men, the prior 2-year change in DBP, but not systolic blood pressure, may add information to current levels in relation to the risk of CVD. Clinicians may need to consider the previous pattern of DBP change when considering the risk associated with the current DBP level. These data require confirmation in other studies in which blood pressure is measured.     

Relationship of blood pressure and cardiovascular disease risk factors in normotensive middle-aged men

We conducted this study to investigate whether subjects with high-normal systolic blood pressure (SBP) have an increased risk of cardiovascular disease (CVD) and/or diabetes compared to subjects with low-normal SBP, using metabolic syndrome (MetS) as a risk factor for future CVD/diabetes.The study included 6133 apparently healthy Taiwanese men aged 40-65 years. All subjects were normotensive, and none took medication for any abnormal MetS component. To avoid the effect of age on blood pressure, we stratified patients first by age then by SBP (that is, low, middle, and high SBP). We pooled all the low, middle, and high SBP groups from the different age strata to create 3 larger groups (Group 1, Group 2, and Group 3, respectively). The MetS components in subjects with the lowest SBP (Group 1) were compared with those in the other 2 groups. All of the MetS components, except for high-density lipoprotein cholesterol (HDL-C), were significantly lower in Group 1. Thus, it was not surprising that Group 2 and Group 3 had significantly higher odds ratios for abnormal body mass index, fasting plasma glucose, low-density lipoprotein-cholesterol (LDL-C), and triglycerides than Group 1 (but not for HDL-C). Specifically, Group 3 had a 1.7-fold higher odds ratio (p < 0.001) for having MetS than Group 1. Age, body mass index, fasting plasma glucose, LDL-C, and log triglycerides correlated significantly with SBP. In multivariate linear regression analysis, we found that only body mass index, fasting plasma glucose, and log triglycerides remained significantly related to SBP. Among them, body mass index had the highest β value.In conclusion, the level of SBP was highly correlated with body mass index, fasting plasma glucose, and triglycerides in subjects with normotension. Although there is not a cause-and-effect relationship, the risk of CVD and diabetes was significantly associated with an elevation of SBP, even when the SBP remained within the normal range. Further studies are needed to determine whether normotensive subjects would benefit from medical management.     

Ankle-arm blood pressure index and cardiovascular risk factors in elderly Japanese men.

Low ankle-arm systolic blood pressure index (AAI) correlates with various cardiovascular risk factors and with risk of subsequent coronary heart disease and stroke in Western countries. However, few epidemiological data are available among Japanese, in whom the reported prevalence of peripheral artery disease is low. We examined the relationship between AAI and cardiovascular risk factors among 1,219 men aged 60 to 79 years in two Japanese communities in 1999 and 2000. The prevalence of AAI<0.90 was 5% in both communities. Hypertension, major ECG abnormality, current smoking, and history of stroke were associated with two- to four-fold higher prevalence of AAI<0.90. One-standard deviation increments of body mass index and high density lipoprotein-cholesterol levels were associated with 60% and 40% lower prevalence of AAI<0.90, respectively. Although the prevalence of low AAI in Japanese elderly men is lower than that reported in the Unites States and European studies, similar correlations of low AAI with cardiovascular risk factors were observed among different ethnic groups. Low AAI is suggested to be a predictor for stroke among Japanese men, which should be confirmed by a prospective study.     

Impact of blood pressure and blood pressure change during middle age on the remaining lifetime risk for cardiovascular disease: the cardiovascular lifetime risk pooling project

Background Prior estimates of lifetime risk (LTR) for cardiovascular disease (CVD) examined the impact of blood pressure (BP) at the index age and did not account for changes in BP over time. We examined how changes in BP during middle age affect LTR for CVD, coronary heart disease, and stroke. Methods and Results Data from 7 diverse US cohort studies were pooled. Remaining LTRs for CVD, coronary heart disease, and stroke were estimated for white and black men and women with death free of CVD as a competing event. LTRs for CVD by BP strata and by changes in BP over an average of 14 years were estimated. Starting at 55 years of age, we followed up 61 585 men and women for 700 000 person-years. LTR for CVD was 52.5% (95% confidence interval, 51.3-53.7) for men and 39.9% (95% confidence interval, 38.7-41.0) for women. LTR for CVD was higher for blacks and increased with increasing BP at index age. Individuals who maintained or decreased their BP to normal levels had the lowest remaining LTR for CVD, 22% to 41% , compared with individuals who had or developed hypertension by 55 years of age, 42% to 69%, suggesting a dose-response effect for the length of time at high BP levels. Conslusions Individuals who experience increases or decreases in BP in middle age have associated higher and lower remaining LTR for CVD. Prevention efforts should continue to emphasize the importance of lowering BP and avoiding or delaying the incidence of hypertension to reduce the LTR for CVD.     

Blood pressure parameters and cardiovascular risk in the elderly

The treatment decision must take into account the benefit and risks related to the intervention: the benefit demonstrated and quantified in many therapeutic trials in hypertension in the elderly, but also the patient's initial risk. It is now recognized that, in elderly hypertensive patients, systolic blood pressure is a better predictor of morbid and lethal events related to hypertension than diastolic blood pressure. Recent data in the medical literature attribute a predictive role to pulse pressure which is even greater than that of systolic blood pressure. From a pathophysiological point of view, the level of pulse pressure reflects the degree of rigidity of large arterial trunks. The arterial rigidity parameter could integrate the harmful effect of "cardiovascular risk factors" (hypertension, but also atherogenic dyslipidaemia, diabetes, smoking, homocysteine, genetic factors, etc.) on the years or decades of exposure, and pulsed pressure would therefore appear to be a better marker of cardiovascular risk than other blood pressure parameters. Pulse pressure should therefore be integrated into the benefit/risk ratio of antihypertensive treatment in the elderly.     

Exercise blood pressure predicts cardiovascular death and myocardial infarction

OBJECTIVE: To investigate whether the exercise systolic blood pressure predicts cardiovascular morbidity and mortality and in particular myocardial infarction beyond that prediction provided by the casual blood pressure at rest and independently of other cardiovascular risk factors. METHODS: We performed an average 16-year follow-up of 1999 middle-aged healthy men. RESULTS: We found that the systolic blood pressure during 6 min on a moderate load during a bicycle ergometer exercise test was a stronger predictor of total cardiovascular mortality and of morbidity and mortality from myocardial infarction than was the blood pressure of the subjects at rest. Furthermore, an early rise in systolic blood pressure during exercise seems to add prognostic information only when the systolic blood pressure of the subject at rest is elevated mildly (>/= 140 mmHg). Subjects whose systolic blood pressure increased to >/= 200 mmHg had a more than twofold greater risk of dying from cardiovascular causes and from myocardial infarction in particular within 16 years than did normotensives and men whose systolic blood pressure was >/= 140 mmHg when they were at rest whose systolic blood pressure did not increase to a similar extent, after we had adjusted for differences in age and a rather large number of traditional risk factors for cardiovascular disease. CONCLUSION: We suggest that systolic blood pressures recorded during standardized ergometer exercise testing may help one to distinguish between severe and less severe cases of hypertension among middle-aged men.     

Serum copper and the risk of cardiovascular disease death in Finnish men

Background and aimsCopper (Cu) is a component of enzymes catalyzing oxidation-reduction reactions. With the persisting burden of cardiovascular disease (CVD), there is evident need to identify biomarkers and potential risk factors for CVD. We therefore examined the association between serum Cu levels and the risk of CVD death in Finnish men and across different body mass index (BMI) categories.Methods and resultsThis Finnish prospective study is based on 1911 men aged 42–60 years who were free of coronary heart disease at baseline. Cu concentrations (mg/l) were determined using atomic absorption spectrometer and categorized into quartiles (<1.0; 1 to <1.1; 1.1 to <1.21; ≥1.21). Participants were categorized into normal weight <25 kg/m², pre-obesity 25–29.9 kg/m², and obesity >30 kg/m². The association between Cu and CVD death was analyzed using multivariable Cox regression models. During a median follow-up of 25.8 years, 358 CVD deaths occurred. The risk of CVD death increased continuously with increasing Cu levels (for non-linearity, p = 0.64). Using the first quartile as reference after adjustment for covariates, the hazard ratios (HR) (95% confidence interval (CI)) for CVD death for Cu concentrations in second, third and fourth quartiles were 1.45(1.05–2.01), 1.69(1.25–2.27), and 1.68(1.23–2.29), respectively. Obese men in the third quartile of serum Cu concentrations had highest risk of CVD death (HR (95%CI) 2.71(1.27–5.78)).ConclusionElevated serum Cu level was associated with increased risk of CVD death across all BMI categories in middle-aged and older Finnish men. Serum Cu may have prognostic implication for CVD mortality risk; however, further studies are needed.     

Left atrium size and the risk of cardiovascular death in middle-aged men

BACKGROUND: The echocardiographic identification of subclinical risk markers may enhance risk stratification for the development of cardiovascular outcomes in the general population. Although echocardiography is widely used in the evaluation of cardiac structures and function, the prognostic value of echocardiographic assessment of left atrium (LA) size for risk stratification of cardiovascular death is unknown. METHODS: Left ventricular (LV) mass and LA size were measured by using M-mode echocardiography in a representative population-based sample of 830 men (age, 42-61 years) from eastern Finland. There were 54 deaths due to cardiovascular disease during an average follow-up of 13 years. RESULTS: The strongest risk factors for cardiovascular death were smoking, family history of coronary heart disease, low exercise capacity, elevated blood pressure, exercise-induced myocardial ischemia, and large LA diameter. Men in the highest tertile of LA diameter (>43 mm) had a 2.3-fold (95% confidence interval, 1.1-5.0) risk of cardiovascular death compared with men in the lowest tertile of LA diameter (<39 mm), after adjusting for other risk factors and the use of antihypertensive medications. The excess risk for cardiovascular mortality appeared to reside largely in the highest tertile of LA size. After additional adjustment for LV mass, the relation between LA size and mortality did not remain statistically significant (relative risk, 1.5; 95% confidence interval, 0.8-4.1; P = .15) in this group. CONCLUSIONS: This prospective population-based study shows that echocardiographically defined LA diameter was directly related to the risk of cardiovascular death. The association of LA enlargement to cardiovascular death appears to be partially related to LV hypertrophy.     

Effect of recombinant human erythropoietin treatment on blood pressure and some haematological parameters in healthy men

The aim of this study was to evaluate the effect of treatment with subcutaneous injections of recombinant human erythropoietin (rhEpo), 20-40 IU kg-1 body weight, 3 times a week, on resting blood pressure, blood pressure response during submaximal exercise, some haematological parameters, and subjective side-effects in 15 healthy male subjects. RhEpo increased both haemoglobin (Hb) concentration and haematocrit (Hct) significantly, the values for Hb being 152 +/- 4.2 g l-1 before treatment and 169 +/- 9.3 g l-1 (mean values +/- SD) after 6 weeks of rhEpo treatment (P less than 0.001). The corresponding values for Hct were 44.5 +/- 1.5% and 49.7 +/- 1.9% (P less than 0.001), respectively. The systolic and diastolic blood pressure values at rest were unchanged after rhEpo treatment. A marked increase in systolic blood pressure was observed during submaximal exercise at 200 W, the initial and final values being 177 +/- 14.2 mmHg and 191 +/- 19.5 mmHg (P less than 0.01), respectively. Heart rate during exercise at 200 W was significantly lower after rhEpo treatment than before it: 144 +/- 15 beats min-1 compared to 136 +/- 8 beats min-1 (P less than 0.001). The leucocyte count remained unchanged after rhEpo treatment, but there was a significant decrease (P less than 0.05) in the number of lymphocytes. Reticulocyte and platelet counts were unchanged. Serum (S) ferritin decreased from 87.3 +/- 41.8 mmol l-1 to 59.3 +/- 27.8 mmol l-1 after rhEpo treatment (P less than 0.001). Serum-Na, S-K, S-Ca, S-creatinine, S-bilirubin, S-aspartate aminotransferase (ASAT), S-alanine aminotransferase (ALAT), and S-lactate dehydrogenase (LD) were unchanged after rhEpo treatment. No subjective side-effects were reported. In conclusion, low doses of rhEpo increased Hb levels and Hct by more than 10% after 6 weeks. Blood pressure at rest was unchanged, but rhEpo induced a markedly accentuated blood pressure reaction during exercise. A minor decrease in the lymphocyte count was observed, but electrolyte and creatinine levels remained unchanged after rhEpo treatment.     

Central aortic blood pressure assessment and cardiovascular risk

Peripheral brachial blood pressure measurements may not provide an accurate representation of degenerative changes that characterize cardiovascular disease. Evidence is mounting that antihypertensive treatment strategies with apparently similar effects on brachial blood pressure may have different effects on central aortic pressure, which in turn may lead to overestimation or underestimation of therapeutic efficacy. The relative importance of central and brachial blood pressure for predicting cardiovascular risk and clinical outcomes has been examined in several clinical studies. These studies have reported that a large proportion of individuals considered to have normal blood pressure values based on brachial systolic pressures had high-normal blood pressure based on central aortic pressure measurements. As additional evidence suggesting the superiority of central aortic pressure over peripheral assessments becomes more abundant, measurement of central aortic pressure may be the next important advancement in the management of hypertension.     

Blood pressure and risk of cardiovascular disease in Chinese men and women

BACKGROUND: We examined the relationship between systolic and diastolic blood pressure (BP) and the incidence of cardiovascular disease (CVD) in a nationally representative cohort of 169,871 men and women > or = 40 years of age in China. METHODS: Data on BP and other variables were obtained at a baseline examination in 1991 using standard protocols. Follow-up evaluation was conducted in 1999-2000, with a response rate of 93.4%. RESULTS: After adjustment for age, sex, cigarette smoking, alcohol consumption, physical activity, body mass index, education, geographic region, urbanization, and time-dependent history of diabetes, a strong and linear association between both systolic and diastolic BP and incidence of CVD, coronary heart disease and stroke were observed (all P < 0.0001). For example, the relative risks (95% confidence interval (CI)) of CVD incidence were 1.09 (1.00-1.18), 1.25 (1.16-1.35), 1.49 (1.38-1.62), 2.15 (1.99-2.31), 3.01 (2.78-3.27), and 4.16 (3.84-4.51) for those with systolic/diastolic BP of 110-119/75-79, 120-129/80-84, 130-139/85-89, 140-159/90-99, 160-179/100-109, and > or = 180/110 mm Hg compared to those with BP <110/75 mm Hg. Increases in systolic BP were associated with a greater risk of CVD compared to corresponding increases in diastolic BP. The linear trend for increased CVD risk being related to higher BP levels was observed in all subgroups of gender, age, body weight, and cigarette smoking. CONCLUSIONS: Our results indicate that there is a strong, linear, and independent relationship between BP levels and the risk of CVD in Chinese adults. Systolic BP is a stronger predictor of CVD risk compared to diastolic BP.