The association between blood pressure, hypertension, and cerebral white matter lesions: cardiovascular determinants of dementia study

Cerebral white matter lesions are frequently observed on magnetic resonance imaging (MRI) scans in elderly people and are associated with stroke and dementia. Elevated blood pressure is presumed one of the main risk factors, although data are almost exclusively derived from cross-sectional studies. We assessed in 10 European cohorts the relation between concurrently and previously measured blood pressure levels, hypertension, its treatment, and severe cerebral white matter lesions. In total, 1805 nondemented subjects aged 65 to 75 years were sampled from ongoing community-based studies that were initiated 5 to 20 years before the MRI. White matter lesions in the periventricular and subcortical region were rated separately using semiquantitative measures. We performed logistic regression analyses adjusted for potential confounders in 1625 people with complete data. Concurrently and formerly assessed diastolic and systolic blood pressure levels were positively associated with severe white matter lesions. Both increases and decreases in diastolic blood pressure were associated with more severe periventricular white matter lesions. Increase in systolic blood pressure levels was associated with more severe periventricular and subcortical white matter lesions. People with poorly controlled hypertension had a higher risk of severe white matter lesions than those without hypertension, or those with controlled or untreated hypertension. Higher blood pressure was associated with an increased risk of severe white matter lesions. Successful treatment of hypertension may reduce this risk; however, a potential negative effect of decreasing diastolic blood pressure level on the occurrence of severe periventricular white matter lesions should be taken into account.     

Reducing cardiovascular risk in diabetes: beyond glycemic and blood pressure control

Patients with diabetes mellitus have a much higher rate of cardiovascular disease (CVD) than the general population, and, in addition to glycaemia and hypertension, dyslipidemia has emerged as an important modifiable cardiovascular risk factor in these patients. In most patients with type 2 diabetes, the major features of dyslipidemia are increased triglyceride levels, decreased high-density lipoprotein cholesterol (HDL-C) levels, and changes in the composition and level of low-density lipoprotein cholesterol (LDL-C). Clinical trials evaluating both primary and secondary prevention of CVD demonstrate that lipid-lowering therapy results in a substantial reduction of cardiovascular risk in patients with type 2 diabetes. Low-density lipoprotein cholesterol is the first priority for treatment, with a statin in adequate dosage as the first choice for pharmacological therapy. The first statin trial conducted solely in patients with type 2 diabetes and no prior CVD demonstrated a 37% reduction in cardiovascular events in patients randomized to atorvastatin 10 mg compared with placebo. Additional trials that further address the benefits of lipid-lowering therapy in patients with diabetes are near completion, or are underway, and should provide important information about further attenuating risk in patients with diabetes.     

Association between blood pressure, the treatment of hypertension, and cardiovascular risk factors in women

OBJECTIVE: To examine relationships of normal blood pressure (BP), hypertension and degree of BP control with cardiovascular disease (CVD) risk factors and predicted 10-year risks for coronary heart disease (CHD) and stroke. DESIGN: Cross-sectional survey. SETTING: 107 Marks and Spencer retail stores in the UK. PARTICIPANTS: 14,077 women, aged 30-64 years, screened for CVD risk factors between 1988 and 1991. MAIN OUTCOME MEASURES: Systolic (SBP) and diastolic (DBP) BP; total, high-(HDL) and low-density lipoprotein (LDL) cholesterol, ratio of total to HDL cholesterol (TC/HDL-C); triglycerides, apolipoprotein A1, apolipoprotein B, lipoprotein (a), glucose, body mass index, antihypertensive medication and predicted risks for CHD and stroke. Hypertension was defined as SBP > or = 140 mmHg and/or DBP > or = 90 mmHg and/or taking anti-hypertensive medication. Subjects were divided into normotensives with optimal (n = 6,599), normal (n = 3,170) and high normal (n = 2,184) BP levels, and hypertensives with adequate BP control (n = 228), untreated (n = 1,729) and inadequate BP control (n = 291). RESULTS: BP level was associated with other CVD risk factors among both normotensives and hypertensives. Women with inadequately controlled BP had the worst risk profile, followed by untreated hypertensives, those with adequately controlled BP and normotensives. Odds ratios for being in the top quintile of predicted 10-year CHD and stroke risks were 1, 2.7, 4.2, 8.5, 13.0, 18.9 for CHD; 1, 1.1, 5.8, 18.7, 20.6, 756 for stroke, for optimal, normal, high normal, adequate BP control, untreated and inadequate BP control groups respectively. CONCLUSIONS: Untreated hypertensives and women taking anti-hypertensive medication but with BP > or = 140/90 mmHg have the most atherogenic risk factor profiles. Effective management of BP and the associated CVD risk requires a multi-factorial approach, rather than addressing BP control in isolation.     

Subclavian artery stenosis: prevalence, risk factors, and association with cardiovascular diseases

OBJECTIVES: The objective was to assess the prevalence of subclavian artery stenosis (SS) in four cohorts (two free-living and two clinical populations) and determine both risk factors for this condition and the association with other cardiovascular conditions. BACKGROUND: The prevalence of SS in the general population is unknown, and its association with risk factors and other cardiovascular diseases is not well-established. METHODS: A total of 4,223 subjects (2,975 from two free-living cohorts and 1,248 from two clinical cohorts) were included in this cross-sectional analysis. Subclavian artery stenosis was defined as > or =15 mm Hg interarm pressure difference. RESULTS: The prevalence of SS was 1.9% in the free-living cohorts and 7.1% in the clinical cohorts; SS was significantly (p < 0.05) associated with past smoking (odds ratio [OR] = 1.80), current smoking (OR = 2.61), and higher levels of systolic blood pressure (OR = 1.90 per 20 mm Hg). Higher levels of high-density lipoprotein (HDL) cholesterol were inversely and significantly associated with SS (OR = 0.87 per 10 mg/dl). In regression analyses relating SS to other cardiovascular diseases, the only significant finding was with peripheral arterial disease (PAD) (OR = 5.11, p < 0.001). CONCLUSIONS: Significant SS is present in approximately 2% of the free-living population and 7% of the clinical population. Additionally, SS is correlated with current and past smoking histories, systolic blood pressure, HDL levels (inversely), and the presence of PAD. These findings suggest that bilateral brachial blood pressure measurements should routinely be performed in patients with an elevated risk profile, both to screen for SS, and to avoid missing a hypertension or PAD diagnosis because of unilateral pressure measurement in an obstructed arm.     

Systolic blood pressure, diabetes and the risk of cardiovascular diseases in the Asia-Pacific region

OBJECTIVE: To assess the association between systolic blood pressure (SBP) and cardiovascular diseases (CVD) among participants with and without diabetes from cohorts in the Asia-Pacific region. RESEARCH DESIGN AND METHODS: Hazards ratios and 95% confidence intervals (CI) for CVD were calculated from Cox models, stratified by sex and region and adjusted for age using individual participant data from 36 cohort studies. Repeat measurements of SBP were used to adjust for regression dilution bias. RESULTS: During follow-up, 7387 fatal or non-fatal cardiovascular endpoints were recorded among 368 307 participants (6.4% with diabetes). SBP was associated with coronary heart disease (CHD), ischaemic stroke and haemorrhagic stroke in a continuous log-linear fashion among individuals with diabetes, as well as those without diabetes. Overall, each 10 mmHg higher usual SBP was associated with 18% (95% CI: 9-27%) and 23% (19-26%) greater risk for CHD among those with and without diabetes, respectively. The corresponding values for ischaemic stroke were 29% (14-45%) and 43% (37-50%), and for haemorrhagic stroke, 56% (32-83%) and 74% (66-82%). The test for heterogeneity by diabetes status in each of these associations was not significant (P >or= 0.10). CONCLUSIONS: Systolic blood pressure is an important marker of risk of CVD in people with and without diabetes. A given reduction in systolic blood pressure is likely to have a similar relative effect on reducing the risk of a cardiovascular event, regardless of diabetes status.     

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 difference in blood pressure reduction and risk of cardiovascular events in a type 2 diabetes population: A meta-regression analysis

AimRecent US recommendations indicate a target blood pressure (BP) of 130/80 mmHg for patients with type 2 diabetes (T2D). Our aim was to characterize the association between risk of cardiovascular events and differences in BP decreases in randomized trials of a T2D population.MethodsA systematic search was made for randomized clinical trials assessing the effects of antihypertensive treatments in T2D patients on mortality, and fatal and non-fatal cardiovascular events, using a meta-regression technique to explore the influence of BP decreases on treatment effects.ResultsA total of 88,503 patients from 44 randomized trials were included. There was no significant association between BP decreases and risk of all-cause or cardiovascular mortality, cardiovascular events or myocardial infarction. However, stroke risk was influenced by BP decreases: compared with no reduction, a 10-mmHg reduction in systolic BP was associated with a relative odds ratio (OR) decrease of 33% (OR: 0.67, 95% CI: 0.54–0.82), and a 5-mmHg diastolic BP reduction was associated with a relative OR decrease of 38% (OR: 0.62, 95% CI: 0.50–0.76). Restricting the analysis to double-blind studies did not change the results for diastolic BP.ConclusionA reduction in BP lowers the risk of stroke, but does not appear to affect the risk of other cardiovascular events in a T2D population.     

VALUE trial: Long-term blood pressure trends in 13,449 patients with hypertension and high cardiovascular risk

BACKGROUND: The Valsartan Antihypertensive Long-term Use Evaluation (VALUE) study compares cardiovascular outcomes in 15,314 eligible patients from 31 countries randomized to valsartan or amlodipine-based treatment. METHODS: The blood pressure (BP) trends are analyzed in 13,449 of VALUE study patients who had baseline BP and 24 months BP and treatment data. RESULTS: In a cohort of 12,570 patients, baseline 24 and 30 months BP, but not 30 months treatment data, were available. Of 13,449 patients, 92% (N = 12,398) received antihypertensive therapy at baseline. The baseline BP was 153.5/86.9 mm Hg in treated compared to 168.1.8/95.3 mm Hg in 1051 untreated patients. After 6 months both groups had indistinguishable BP values. At 12 months the BP decreased to 141.2/82.9 mm Hg (P <.0001 for systolic BP and diastolic BP versus baseline), at 24 months to 139.1/80 mm Hg (P <.0001 v 12 months), and to 138/79 mm Hg at 30 months (P <.0001 v 24 months). The systolic BP control (<140 mm Hg) at 30 months increased from 21.9% at baseline to 62.2%, the diastolic BP (< 90 mm Hg) from 54.2% to 90.2% and the combined control (<140 and <90 mm Hg) from 18.9% to 60.5%. At 24 months 85.8% of patients were on protocol drugs: monotherapy = 39.7%, added hydrochlorothiazide = 26.6%, add-on drugs = 15.1%, and protocol drugs in nonstandard doses = 4.3%. CONCLUSIONS: The achieved BP control exceeds values reported in most published large-scale trials. The VALUE study is executed in regular clinical settings and 92% of the patients received antihypertensive drugs at baseline. When an explicit BP goal is set, and a treatment algorithm is provided, the physicians can achieve better control rates than in their regular practice.     

Microalbuminuria in diabetes: focus on cardiovascular and renal risk reduction

Albuminuria has long been recognized as a harbinger for the progression of diabetic nephropathy. Recently, it has become increasingly recognized that albuminuria is a powerful risk factor for cardiovascular disease and stroke. In this article we explore evidence for albuminuria being an integral component of the cardiometabolic syndrome and a risk factor for cardiovascular disease and stroke.     

Glycemic and blood pressure control in older patients with hypertension and diabetes: association with carotid atherosclerosis

Backgroud Numerous studies have confirmed the effectiveness of slowing the progression of atherosclerosis by blood pressure (Bp) control in patients with hypertension and several studies also showed the efficacy of intensive glycemic control in decreasing progression of carotid intima-media thickness (CIMT) in patients with type 1 and type 2 diabetes. However, few studies have compared the relative importance of glycemic vs. Bp control in patients with diabetes and hypertension. We aimed to investigate the association between Bp and glycemic control and subclinical carotid atherosclerosis in older patients with hypertension and type 2 diabetes. Methods In a cross-sectional study, B-mode high-resolution ultrasonography of the carotid artery was performed in 670 subjects (508 males and 162 females) aged 60 years or over who had self-reported hypertension and diabetes but no history of coronary heart disease or stroke. Subjects were categorized by their systolic blood pressure: tight control, < 130 mmHg; usual control, 130–139 mmHg; or uncontrolled, ≥ 140 mmHg, and by their hemoglobin A1c (HbA1c) level: tight control, < 6.5%; usual control, 6.5%–7.5%; or uncontrolled, ≥ 7.5%, respectively. Results The mean CIMT was 8.20 ± 0.11 mm, and carotid plaque was found in 52.5% (352/670) subjects. Overall, 62.1% of the subjects had subclinical carotid atherosclerosis, defined as having either carotid plaque or elevated CIMT (≥ 1.1 mm). The mean CIMT was significantly different between Bp control categories (7.60 ± 0.09 mm, 7.90 ± 0.08 mm, and 8.60 ± 0.12 mm, respectively, P = 0.03) but not between glycemic control categories (8.20 ± 0.10 mm, 8.1 ± 0.08 mm, and 8.40 ± 0.14 mm, respectively, P = 0.13) using ANCOVA analysis. Multivariable logistic regression adjusting for potential confounding factors showed that usual or uncontrolled Bp control were associated with having carotid plaque (OR = 1.08 and OR = 1.42, respectively), or elevated CIMT [Odd ratio (OR) = 1.17, 95% confidence interval (CI) 1.04–2.24, and OR = 1.54, 95% CI 1.36–2.96, respectively compared to tight Bp control; but did not show glycemic control as independent predictor of either having carotid plaque or elevated CIMT. Conclusions In older patients with hypertension and diabetes, blood pressure control, but not glycemic control is associated with subclinical carotid atherosclerosis.     

The association between exercise blood pressure and the prevalence of ECG abnormalities

The relationship between atrial and ventricular electrocardiographic abnormalities and exercise systolic blood pressure was studied in 246 male and 183 female subjects, of whom 199 males and 158 females were normotensive (resting blood pressure below 140/90 mmHg) and 47 males and 25 females were borderline hypertensive (resting systolic blood pressure 140 to 159 and/or diastolic blood pressure 90 to 99 mmHg). Subjects were classified into three groups according to systolic blood pressure during treadmill exercise (less than or equal to 180 mmHg, 180 to 199 mmHg and greater than or equal to 200 mmHg). With respect to atrial electrocardiographic abnormalities, the prevalence of abnormal values of the P-terminal force in lead V1 increased significantly with increased levels of resting exercise systolic blood pressure in males and females. The prevalence of electrocardiographic left ventricular hypertrophy, as reflected in abnormal values of one or more RS voltage indices, increased significantly with exercise systolic blood pressure in males but not in females. Males did not show a trend of increasing electrocardiographic left ventricular hypertrophy with increased resting systolic blood pressure means. In females, the significant difference between resting systolic blood pressure means and electrocardiographic left ventricular hypertrophy did not reflect a linear progression across resting systolic blood pressure categories. The significant association of the P-terminal force in lead V1 with exercise systolic blood pressure has not previously been reported. Although an association between left ventricular hypertrophy and exercise systolic blood pressure in hypertensives has been reported by others, the association seen in normotensive and borderline hypertensive males has not been reported previously.(ABSTRACT TRUNCATED AT 250 WORDS)     

The association between ambulatory systolic blood pressure and cardiovascular events in a selected population with intensive control of cardiovascular risk factors

Recent guidelines recommend a target clinic systolic blood pressure (BP) of <140 mm Hg. These recommendations are based on the relationship of office BP measurements and cardiovascular (CV) events. We evaluated the association between 24-hour ambulatory BP measurements (24H ABPM) and CV events in a selected population with intensive control of CV risk factors. We retrospectively followed all patients who had undergone 24H ABPM during 2005 at the Institute of Periodic Medical Examinations, Chaim Sheba Medical Center, Tel-Hashomer, Israel, to monitor the development of CV events. These patients were followed closely and treated meticulously in order to control CV risk factors. The study population consisted of 317 patients (81% males; mean age, 59.2 ± 9.8 years) followed for a mean period of 6.4 ± 2.1 years (median, 6 years). During follow-up, 22 patients had their first CV event. Patients who experienced CV events were significantly older, more likely diabetic, and had a history of previous CV disease. Twenty-four-hour ABPM systolic BP ≥140 mm Hg was not associated with increased CV events, whereas 24H ABPM systolic BP ≥150 mm Hg was. Logistic regression analysis showed that 24H ABPM systolic BP ≥150 mm Hg, a former smoker, old age, and a history of CV disease were associated with CV events during follow-up. We found that, in a population aggressively managed for CV risk factors, 24H ABPM systolic BP ≥150 mm Hg is associated with increased CV events.