Diurnal blood pressure variations and silent cerebrovascular damage in elderly patients with hypertension.

OBJECTIVE: To examine the effect of diurnal blood pressure changes upon cerebrovascular damage in elderly patients with hypertension. DESIGN: Fifty-four asymptomatic hypertensive and 34 normotensive elderly subjects underwent both 24-h non-invasive ambulatory blood pressure monitoring and brain magnetic resonance imaging. METHODS. Diurnal variation was defined as a difference of greater than or equal to 10 mmHg between mean awake and asleep systolic blood pressure. Hypertensives were thus classified as dippers or non-dippers. Low intense foci (lacunae) and advanced periventricular hyperintensity were identified as silent cerebrovascular damage. RESULTS: In the hypertensive group, lacunae were correlated more closely with mean asleep systolic blood pressure than with mean awake systolic blood pressure. Age, awake blood pressure, predicted whole blood viscosity, lipid profiles or quantity of sleep did not differ between the hypertensive dippers or non-dippers. The non-dippers, however, showed significantly higher grades of cerebrovascular damage as well as cardiac hypertrophy by electrocardiography than the dippers, whose results were similar to those of normotensives in this regard. CONCLUSIONS: An absent or lower nocturnal blood pressure fall in elderly hypertensives is associated with silent cerebrovascular damage. In contrast, the presence of a nocturnal fall could prevent the development of hypertensive vascular damage.     

Systemic hypertension as a treatable risk factor for cerebrovascular disease

It has long been established that hypertension is the major risk factor for stroke. Three Italian studies have been reviewed in order to examine different aspects of the problem. In the first study, the role played by the systolic, diastolic and systodiastolic components of hypertension in causing atherosclerotic damage of extracerebral and intracerebral arteries was examined. At the extracranial level, a significant correlation between systolic hypertension and atherosclerotic lesions was evident. The second study evaluated the risk of major stroke, myocardial infarction and death in patients with transient ischemic attacks and reversible ischemic neurologic deficits. Possible prognostic predictors of these events were thoroughly considered: Cumulative survival with the multivariate Kaplan-Meier analysis was significantly lower in hypertensive than in normotensive subjects, particularly for cerebral deaths and for all deaths. The third study was aimed at assessing the risk factors for transient ischemic attacks and stroke in young adults. Again, hypertension emerged as a fundamental risk factor, significantly more frequent in the subgroup of older patients than in the younger subgroup.     

Elevated systolic blood pressure as a cardiovascular risk factor

This paper reviews the evolution of attitudes toward the treatment and diagnosis of hypertension. In particular, there is a growing realization that elevated systolic pressure may be a more valuable measurement in evaluating and controlling hypertension than is generally acknowledged. A large number of epidemiologic studies in a wide variety of populations have revealed that systolic blood pressure exerts a stronger influence than diastolic blood pressure. The largest of these, the Framingham Heart Study, showed that in subjects with systolic hypertension, diastolic blood pressure was only weakly related to the risk of cardiovascular events, but in those with diastolic hypertension, the risk of these events was strongly influenced by the level of systolic pressure. Furthermore, cardiovascular event rates were found to increase steeply with systolic pressure and were higher in cases of isolated systolic hypertension than diastolic hypertension. Clinical trials produced similar results, again suggesting that a greater reliance should be placed on systolic pressure in evaluating the risk of cardiovascular problems. This review concludes that the health community needs to be reeducated to consider the importance of systolic and diastolic blood pressure in assessing appropriate management strategies for hypertensive patients.     

The relationship between vitamin D and PTH levels and cardiovascular risk in the elderly hypertensives

Introduction and objective: In this study, we aimed to investigate the relationship between vitamin D, parathyroid hormone (PTH) and cardiovascular risk (CVR) in hypertensive patients aged 65 years and over.

Patients and methods: This study was performed with 84 hypertensive patients and 68 normotensive control group in Afyon Kocatepe University Faculty of Medicine Hospital. The determined cardiovascular risk degrees and the stages of blood pressure were compared with the levels of 25-(OH) vitamin D and PTH.

Results: Mean systolic and diastolic blood pressure (BP) levels of the patients with vitamin D deficiency (VDD) were significantly higher than those without VDD (p?p?=?0.012, p?=?0.036, respectively). CVR was reversely correlated with vitamin D but the correlation with hyperparathyroidism did not reach statistically significant level (r?=?–0.752, p?r?=?0.210, p?=?0.055), respectively.

Conclusion: These results indicate that the presence of hypertension is associated with VDD, as well as the stage of hypertension contributes to insufficiency, hyperparathyroidism and increased CVR. Clinicians should be aware and perhaps more aggressive for the treatment of HT and VDD in patients over 65 years of age.     

Correlating the relationship between interarm systolic blood pressure and cardiovascular disease risk factors

Interarm systolic blood pressure difference (IASBPD) can predict cardiovascular disease. To investigate the relationship between IASBPD and cardiovascular disease risk factors, a total of 1426 individuals were studied. Blood pressure was assessed simultaneously and IASBPD was expressed as the absolute difference value (|R−L|). Cardiovascular disease risk factors were compared between the high IASBPD group (IASBPD ≥10 mm Hg) and the normal IASBPD group (IASBPD <10 mm Hg). An increased prevalence of hypertension, body mass index, and systolic and diastolic blood pressure were observed in the high IASBPD group (P<.05), associated with the enhanced mean values of intima–media thickness and maximum intima–media thickness (P<.05). Brachial‐ankle pulse wave velocity was increased, while ankle‐brachial index was lower in the high IASBPD group (P<.05). Multivariate logistic regression analysis revealed that IASBPD ≥10 mm Hg was positively associated with body mass index (odds ratio, 1.077; P=.002) and systolic blood pressure (odds ratio, 1.032; P<.001), and negatively associated with ankle‐brachial index (odds ratio, 0.038; P<.001).     

老年原发性高血压患者卧立位血压改变与脑白质损害的相关性

目的探讨老年原发性高血压患者卧立位血压改变与脑白质损害的关系。方法自2012年5月~2013年7月于禹城市人民医院筛选住院的老年高血压患者287例,根据卧立位收缩压变化值(OC)三分位分为低OC组92例,中OC组102例和高OC组93例。所有受试者接受头颅MRI扫描,检测脑白质高信号体积及脑白质高信号分数。结果高OC组脑白质高信号体积和脑白质高信号分数显著高于低OC组及中OC组[(10.82±3.19)ml vs(6.48±2.83)ml和(7.58±3.65)ml,P0.05;(0.71±0.24)%vs(0.50±0.21)%和(0.53±0.25)%,P0.05]。OC及卧立位舒张压变化值均与脑白质高信号体积(r=0.499,r=0.328,P0.01)及脑白质高信号分数(r=0.358,r=0.220,P0.01)呈显著正相关。OC是脑白质高信号体积和脑白质高信号分数的独立影响因素(95%CI:0.098~0.149,95%CI:0.004~0.008,P0.01)。结论 OC与老年原发性高血压患者脑白质损害相关。     

Systolic blood pressure variability as a risk factor for stroke and cardiovascular mortality in the elderly hypertensive population

OBJECTIVE: To investigate whether baseline systolic blood pressure variability was a risk factor for stroke, cardiovascular mortality or cardiac events during the Syst-Eur trial. DESIGN: The Syst-Eur study was a randomized, double-blind, placebo-controlled trial, powered to detect differences in stroke rate between participants on active antihypertensive treatment and placebo. Systolic blood pressure variability measurements were made on 744 participants at the start of the trial. Systolic blood pressure variability was calculated over three time frames: 24 h, daytime and night-time. The placebo and active treatment subgroups were analysed separately using an intention-to-treat principle, adjusting for confounding factors using a multiple Cox regression model. PARTICIPANTS: An elderly hypertensive European population. MAIN OUTCOME MEASURES: Stroke, cardiac events (fatal and non-fatal heart failure, fatal and non-fatal myocardial infarction and sudden death) and cardiovascular mortality (death attributed to stroke, heart failure, myocardial infarction, sudden death, pulmonary embolus, peripheral vascular disease and aortic dissection). RESULTS: The risk of stroke increased by 80% (95% confidence interval: 17-176%) for every 5 mmHg increase in night-time systolic blood pressure variability in the placebo group. Risk of cardiovascular mortality and cardiac events was not significantly altered. Daytime variability readings did not predict outcome. Antihypertensive treatment did not affect systolic blood pressure variability over the median 4.4-year follow-up. CONCLUSION: In the placebo group, but not the active treatment group, increased night-time systolic blood pressure variability on admission to the Syst-Eur trial was an independent risk factor for stroke during the trial.     

Sympathetic overactivity in hypertension: a risk factor for cardiovascular disease

Numerous prospective studies have shown that high heart rate is related to the development of hypertension, atherosclerosis, and incidence of cardiovascular events. Experimental studies in monkeys have shown that high heart rate has direct atherogenic effects on the arteries as a result of increased wall stress. However, clustering of several risk factors for coronary artery disease in persons with high heart rate suggests that sympathetic overactivity also accounts for part of the increased cardiovascular morbidity that is observed in persons with tachycardia. Indeed, experimental studies have shown that heightened sympathetic tone can cause obesity, hyperinsulinemia, and insulin resistance, which in the long term can promote the development of atherosclerosis. Through its interaction with plasma insulin, sympathetic overactivity can promote the development of left ventricular hypertrophy. Sympathetic activation can also increase hematocrit and precipitate a procoagulant state. Angiotensin II has an effect both on the central nervous system, enhancing sympathetic outflow, and on the peripheral sympathetic nerves. Among the angiotensin II receptor antagonists, eprosartan showed a particular ability to block presynaptic angiotensin II receptor 1 (AT(1)) receptors at neuro-effector junctions in the sympathetic nervous system, as well as AT(1) receptors in blood vessels. This dual action may represent an important advance in treatment of elevated blood pressure.     

Epidemiological aspects of isolated systolic hypertension in the elderly population as cerebrovascular risk factor

A large number of studies indicate that isolated systolic hypertension (ISH) is an important cerebrovascular risk factor. This clinical state is very common in elderly people who are the most exposed to stroke risk. Therefore, it is important to know the real prevalence of ISH, in order to predict the possible incidence of cerebrovascular disease in the elderly population. In the Camerano study on hypertension, we have verified the prevalence of ISH in the elderly. ISH has been considered clinically when the systolic arterial pressure (SAP) was higher than 160 mmHg, and the diastolic arterial pressure (DAP) was lower than 90 mmHg. In our study population, an ISH prevalence of 11.9% was found in the elderly (above 60 years of age); whereas in the adult population (between 30 and 60 years), it amounted only to 4.5%.     

老年体位性血压变化与焦虑抑郁状态的相关性

中国正逐渐进入老龄化社会,老年人的心理问题对健康的影响引起越来越多的社会重视。在老年群体中,血压的波动易导致心源性猝死、心肌梗死等疾病,而焦虑、抑郁等负面情绪是导致患者血压波动的独立危险因素。老年人体位性血压变化与焦虑抑郁共存,使得老年人的病情更复杂,预后更差。但目前关于二者之间相关性及其主要机制尚未完全明确,相关的研究也较少,进一步研究并阐明潜在的可改变因素在这种复杂疾病发展中的作用是必要的。本文综述了老年体位性血压变化与焦虑抑郁事件的相关性及其可能机制,为老年人体位性血压变化以及焦虑抑郁的相关诊断和治疗提供研究方向。     

Beyond blood pressure: Arterial stiffness as a new biomarker of cardiovascular disease

Arterial stiffness of the large, elastic conduit arteries is considered a risk marker of vascular aging, as well as a new biomarker of cardiovascular (CV) disease. Arterial stiffness also plays an important role in the development of isolated systolic hypertension (ISH) in the middle-aged and elderly population. ISH is characterized by an increase in pulse pressure (PP) in association with a rise in systolic blood pressure (SBP) and a fall in diastolic blood pressure (DBP). Increased PP, however, is not always a good surrogate for arterial stiffening because of the frequent discrepancy between peripheral brachial and central aortic PP values due to varying pressure amplification. Therefore, noninvasive, easily performed methods for more direct measurement of arterial stiffness and wave reflection, such as aortic pulse wave velocity (PWV) and pulse wave analysis, have been developed for clinical use. The present review aims to provide an understanding of the pathophysiology of arterial stiffness and wave reflection, to review the various techniques for their measurement, and to explore their usefulness in predicting CV risk and therapeutic benefit in comparison with traditional brachial artery cuff blood pressure (BP) by sphygmomanometry.     

Triglycerides as a risk factor in extracranial atherosclerotic cerebrovascular disease

A retrospective study was carried out on a group of 138 patients undergoing carotid endarterectomy for extracranial vascular disease. Risk factors of cerebrovascular disease and routine laboratory evaluations were assessed. Of the laboratory evaluations of blood lipids, only mean triglycerides were found to be significantly different from laboratory normals. Stroke as a clinical event has been suggested not to be correlated with blood lipids in a number of large studies, but the present investigation supports the notion that extracranial vascular disease may be associated with blood lipid concentrations. Previous studies of stroke and lipids have not separated out the anatomical site responsible for the cerebral infarction, and thus probably have underestimated the effect of lipids as a risk factor in cervical extracranial atherosclerosis and brain infarction.     

Effect of change in systolic blood pressure between clinic visits on estimated 10-year cardiovascular disease risk

Systolic blood pressure (SBP) often varies between clinic visits within individuals, which can affect estimation of cardiovascular disease (CVD) risk. We analyzed data from participants with two clinic visits separated by a median of 17 days in the Third National Health and Nutrition Examination Survey (n = 808). Ten-year CVD risk was calculated with SBP obtained at each visit using the Pooled Cohort Equations. The mean age of participants was 46.1 years, and 47.3% were male. The median SBP difference between the two visits was −1 mm Hg (1st to 99th percentiles: −23 to 32 mm Hg). The median estimated 10-year CVD risk was 2.5% and 2.4% at the first and second visit, respectively (1st to 99th percentiles −5.2% to +7.1%). Meaningful risk reclassification (ie, across the guideline recommended 7.5% threshold for statin initiation) occurred in 12 (11.3%) of 106 participants whose estimated CVD risk was between 5% and 10%, but only in two (0.3%) of 702 participants who had a 10-year estimated CVD risk of <5% or >10%. SBP variability can affect CVD risk estimation, and can influence statin eligibility for individuals with an estimated 10-year CVD risk between 5% and 10%.     

Left ventricular hypertrophy: a potent cardiovascular risk factor and its relationship to office and ambulatory blood pressure

Left ventricular hypertrophy (LVH) is an important cardiovascular risk factor. The presence of LVH carries risk independent of hypertension. LVH can be detected non-invasively using electrocardiography or echocardiography. Clinical studies have consistently shown that ambulatory blood pressure is a stronger correlate of left ventricular mass than office blood pressure. Furthermore, treatment-induced decreases in left ventricular mass index are also more tightly related to reductions in ambulatory blood pressure than reductions in office blood pressure. The primary intervention for subjects with hypertension and LVH is optimal blood pressure control. Several small studies now suggest that therapeutic changes resulting in regression of left ventricular mass also confer a reduction in cardiovascular risk. Therefore, LVH is a serious negative risk factor that is more closely related ambulatory rather than office blood pressure. Fortunately, current evidence suggests that optimal antihypertensive therapy resulting in regression of hypertrophy will reduce at least short-term cardiovascular events. Physicians need to be more aware of LVH as a cardiovascular risk factor.