2014 Eighth Joint National Committee Panel Recommendation for Blood Pressure Targets Revisited : Results From the INVEST Study

Background

The 2014 Eighth Joint National Committee panel recommendations for management of high blood pressure (BP) recommend a systolic BP threshold for initiation of drug therapy and a therapeutic target of <150 mm Hg in those ≥60 years of age, a departure from prior recommendations of <140 mm Hg. However, it is not known whether this is an optimal choice, especially for the large population with coronary artery disease (CAD).

Objectives

This study sought to evaluate optimal BP in patients ≥60 years of age.

Methods

Patients 60 years of age or older with CAD and baseline systolic BP >150 mm Hg randomized to a treatment strategy on the basis of either atenolol/hydrochlorothiazide or verapamil-SR (sustained release)/trandolapril in INVEST (INternational VErapamil SR Trandolapril STudy) were categorized into 3 groups on the basis of achieved on-treatment systolic BP: group 1, <140 mm Hg; group 2, 140 to <150 mm Hg; and group 3, ≥150 mm Hg. Primary outcome was first occurrence of all-cause death, nonfatal myocardial infarction (MI), or nonfatal stroke. Secondary outcomes were all-cause mortality, cardiovascular mortality, total MI, nonfatal MI, total stroke, nonfatal stroke, heart failure, or revascularization, tabulated separately. Outcomes for each group were compared in unadjusted and multiple propensity score–adjusted models.

Results

Among 8,354 patients included in this analysis with an accumulated 22,308 patient-years of follow-up, 4,787 (57%) achieved systolic BP of <140 mm Hg (group 1), 1,747 (21%) achieved systolic BP of 140 to <150 mm Hg (group 2), and 1,820 (22%) achieved systolic BP of ≥150 mm Hg (group 3). In unadjusted models, group 1 had the lowest rates of the primary outcome (9.36% vs. 12.71% vs. 21.32%; p < 0.0001), all-cause mortality (7.92% vs. 10.07% vs. 16.81%; p < 0.0001), cardiovascular mortality (3.26% vs. 4.58% vs. 7.80%; p < 0.0001), MI (1.07% vs. 1.03% vs. 2.91%; p < 0.0001), total stroke (1.19% vs. 2.63% vs. 3.85%; p <0.0001), and nonfatal stroke (0.86% vs 1.89% vs 2.86%; p<0.0001) compared with groups 2 and 3, respectively. In multiple propensity score–adjusted models, compared with the reference group of <140 mm Hg (group 1), the risk of cardiovascular mortality (adjusted hazard ratio [HR]: 1.34; 95% confidence interval [CI]: 1.01 to 1.77; p = 0.04), total stroke (adjusted HR: 1.89; 95% CI: 1.26 to 2.82; p = 0.002) and nonfatal stroke (adjusted HR: 1.70; 95% CI: 1.06 to 2.72; p = 0.03) was increased in the group with BP of 140 to <150 mm Hg, whereas the risk of primary outcome, all-cause mortality, cardiovascular mortality, total MI, nonfatal MI, total stroke, and nonfatal stroke was increased in the group with BP ≥150 mm Hg.

Conclusions

In hypertensive patients with CAD who are ≥60 years of age, achieving a BP target of 140 to <150 mm Hg as recommended by the JNC-8 panel was associated with less benefit than the previously recommended target of <140 mm Hg.     

Post‐stroke hypertension control and receipt of health care services among veterans

Many ischemic stroke patients do not achieve goal blood pressure (BP < 140/90 mm Hg). To identify barriers to post‐stroke hypertension management, we examined healthcare utilization and BP control in the year after index ischemic stroke admission. This retrospective cohort study included patients admitted for acute ischemic stroke to a VA hospital in fiscal year 2011 and who were discharged with a BP ≥ 140/90 mm Hg. One‐year post‐discharge, BP trajectories, utilization of primary care, specialty and ancillary services were studied. Among 265 patients, 246 (92.8%) were seen by primary care (PC) during the 1‐year post‐discharge; a median time to the first PC visit was 32 days (interquartile range: 53). Among N = 245 patients with post‐discharge BP data, 103 (42.0%) achieved a mean BP < 140/90 mm Hg in the year post‐discharge. Provider follow‐ups were: neurology (51.7%), cardiology (14.0%), nephrology (7.2%), endocrinology (3.8%), and geriatrics (2.6%) and ancillary services (BP monitor [30.6%], pharmacy [20.0%], nutrition [8.3%], and telehealth [8%]). Non‐adherence to medications was documented in 21.9% of patients and was observed more commonly among patients with uncontrolled compared with controlled BP (28.7% vs 15.5%; P = .02). The recurrent stroke rate did not differ among patients with uncontrolled (4.2%) compared with controlled BP (3.8%; P = .89). Few patients achieved goal BP in the year post‐stroke. Visits to primary care were not timely. Underuse of specialty as well as ancillary services and provider perception of medication non‐adherence were common. Future intervention studies seeking to improve post‐stroke hypertension management should address these observed gaps in care.     

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.     

Contribution of metabolic risk factors and lifestyle behaviors to cardiovascular disease: A mendelian randomization study

Background and aimsEtiologic associations between some modifiable factors (metabolic risk factors and lifestyle behaviors) and cardiovascular disease (CVD) remain unclear. To identify targets for CVD prevention, we evaluated the causal associations of these factors with coronary artery disease (CAD) and ischemic stroke using a two-sample Mendelian randomization (MR) method.Methods and resultsPreviously published genome-wide association studies (GWASs) for blood pressure (BP), glucose, lipids, overweight, smoking, alcohol intake, sedentariness, and education were used to identify instruments for 15 modifiable factors. We extracted effects of the genetic variants used as instruments for the exposures on coronary artery disease (CAD) and ischemic stroke from large GWASs (N = 60 801 cases/123 504 controls for CAD and N = 40 585 cases/406 111 controls for ischemic stroke). Genetically predicted hypertension (CAD: OR, 5.19 [95% CI, 4.21–6.41]; ischemic stroke: OR, 4.92 [4.12–5.86]), systolic BP (CAD: OR, 1.03 [1.03–1.04]; ischemic stroke: OR, 1.03 [1.03–1.03]), diastolic BP (CAD: OR, 1.05 [1.05–1.06]; ischemic stroke: OR, 1.05 [1.04–1.05]), type 2 diabetes (CAD: OR, 1.11 [1.08–1.15]; ischemic stroke: OR, 1.07 [1.04-1.10]), smoking initiation (CAD: OR, 1.26 [1.18–1.35]; ischemic stroke: OR, 1.24 [1.16–1.33]), educational attainment (CAD: OR, 0.62 [0.58–0.66]; ischemic stroke: OR, 0.68 [0.63–0.72]), low-density lipoprotein cholesterol (CAD: OR, 1.55 [1.41–1.71]), high-density lipoprotein cholesterol (CAD: OR, 0.82 [0.74–0.91]), triglycerides (CAD: OR, 1.29 [1.14–1.45]), body mass index (CAD: OR, 1.25 [1.19–1.32]), and alcohol dependence (OR, 1.04 [1.03–1.06]) were causally related to CVD.ConclusionThis systematic MR study identified 11 modifiable factors as causal risk factors for CVD, indicating that these factors are important targets for preventing CVD.     

Low Blood Pressure Is Associated With Greater Risk for Cardiovascular Events in Treated Adults With and Without Apparent Treatment‐Resistant Hypertension

Apparent treatment‐resistant hypertension (aTRH) may confound the reported relationship between low blood pressure (BP) and increased cardiovascular disease (CVD) in treated hypertensive patients. Incident CVD was assessed in treated hypertensive patients with and without aTRH (BP ≥140 and/or ≥90 mm Hg on ≥3 medications or <140/<90 mm Hg on ≥4 BP medications) at three BP levels: 1: <120 and/or <70 mm Hg and <140/<90 mm Hg; 2: 120–139/70–89 mm Hg; and 3: ≥140 and/or ≥90 mm Hg. Electronic health data were matched to emergency and hospital claims for incident CVD in 118 356 treated hypertensive patients. In adults with and without aTRH, respectively, CVD was greater in level 1 versus level 2 (multivariable hazard ratio, 1.88 [95% confidence interval [CI], 1.70–2.07]; 1.71 [95% CI, 1.59–1.84]), intermediate in level 1 versus level 3 (hazard ratio, 1.32 [95% CI, 1.21–1.44]; 0.99, [95% CI, 0.92–1.07]), and lowest in level 2 versus level 3 (hazard ratio, 0.70 [95% CI, 0.65–0.76]; 0.58, [95% CI, 0.54–0.62]). Low treated BP was associated with more CVD than less stringent BP control irrespective of aTRH.     

Predictors of Recurrent Events in Patients With Cryptogenic Stroke and Patent Foramen Ovale Within the CLOSURE I (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke and/or Transient Ischemic Attack Due to Presumed Paradoxical Embolism Through a Patent Foramen Ovale) Trial

ObjectivesThis study sought to identify predictors of recurrent ischemic neurologic events within the CLOSURE I (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke and/or Transient Ischemic Attack Due to Presumed Paradoxical Embolism Through a Patent Foramen Ovale) trial.BackgroundThe CLOSURE I trial found that transcatheter patent foramen ovale (PFO) closure using the STARFlex device was not superior to medical therapy in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO.MethodsThe CLOSURE I trial is a multicenter, randomized trial of transcatheter PFO closure compared with medical therapy in patients who presented with cryptogenic stroke or TIA and had a PFO. We identified clinical predictors of recurrent ischemic stroke or TIA during 2 years of follow-up using Cox proportional hazards regression within the pooled intention-to-treat cohort.ResultsIn 909 patients, the incidence of recurrent events was 5.7% with 25 patients suffering a recurrent stroke and 30 a TIA. Patients who had a recurrent event had higher body mass index (30.2 ± 6.2 vs. 28.3 ± 5.8%; p = 0.03) and more frequently had diabetes (19.2% vs. 7.1%; p = 0.0016), hypertension (46.2% vs. 30.1%; p = 0.015), and ischemic heart disease (3.8% vs. 0.9%; p = 0.05). Diabetes (hazard ratio [HR]: 3.39; 95% confidence interval [CI]: 1.69 to 6.84; p = 0.0007), index TIA (HR vs. stroke: 2.13; 95% CI: 1.20 to 3.80; p = 0.01), and the detection of atrial fibrillation after study enrollment (HR: 4.85; 95% CI: 2.05 to 11.47; p = 0.0003) independently predicted recurrent ischemic neurologic events. Recurrent neurologic events were more frequent in subjects with RoPE (Risk of Paradoxical Embolism) score ≤5 than those with >5 (14.5% vs. 4.2%; p < 0.0001).ConclusionsThese findings suggest an alternative etiology to paradoxical embolism was frequently responsible for recurrent events within the CLOSURE I trial. (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke or TIA Due to the Possible Passage of a Clot of Unknown Origin Through a Patent Foramen Ovale (PFO) [CLOSURE I]; NCT00201461)     

Prevalence and clinical outcomes of white‐coat and masked hypertension: Analysis of a large ambulatory blood pressure database

The aim of this study was to analyze prevalence and clinical outcomes of the following clinical conditions: normotension (NT; clinic BP < 140/90 mm Hg; 24‐hour BP < 130/80 mm Hg), white‐coat hypertension (WCHT; clinic BP ≥ 140 and/or ≥90 mm Hg; 24‐hour BP < 130/80 mm Hg), masked hypertension (MHT; clinic BP < 140/90 mm Hg; 24‐hour BP ≥ 130 and/or ≥80 mm Hg), and sustained hypertension (SHT; clinic BP ≥ 140 and/or ≥90 mm Hg; 24‐hour BP ≥ 130 and/or ≥80 mm Hg) in a large cohort of adult untreated individuals. Systematic research throughout the medical database of Regione Lazio (Italy) was performed to estimate incidence of myocardial infarction (MI), stroke, and hospitalizations for HT and heart failure (HF). Among a total study sample of 2209 outpatients, 377 (17.1%) had NT, 351 (15.9%) had WCHT, 149 (6.7%) had MHT, and 1332 had (60.3%) SHT. During an average follow‐up of 120.1 ± 73.9 months, WCHT was associated with increased risk of hospitalization for HT (OR 95% CI: 1.927 [1.233‐3.013]; P = .04) and HF (OR 95% CI: 3.449 [1.321‐9.007]; P = .011). MHT was associated with an increased risk of MI (OR 95% CI: 5.062 [2.218‐11.550]; P < .001), hospitalization for HT (OR 95% CI: 2.553 [1.446‐4.508]; P = .001), and for HF (OR 95% CI: 4.214 [1.449‐12.249]; P = .008). These effects remained statistically significant event after corrections for confounding factors including age, BMI, gender, smoking, dyslipidaemia, diabetes, and presence of antihypertensive therapies.     

Effects of antihypertensive treatment in Asian populations: A meta-analysis of prospective randomized controlled studies (CARdiovascular protectioN group in Asia: CARNA)

To examine the effects of antihypertensive treatment on cardiovascular disease (CVD) in Asian populations, we systematically evaluated prospective randomized studies carried out in Asia (1991–2013). We identified 18 trials with 23,215 and 21,986 hypertensive patients in the intervention (ie, strict blood pressure [BP] lowering or add-on treatment) and reference groups, respectively (mean age, 65 years; follow-up duration, 3.2 years). Analysis was performed through 1) first subgroup: eight trials that compared active antihypertensive treatment with placebo or intensive with less intensive BP control and 2) second subgroup: 10 trials that compared different antihypertensive treatments. In the first subgroup analysis, BP was reduced from 160.3/87.3 mm Hg to 140.2/78.4 mm Hg in the intervention group with a −6.7/−2.2 mm Hg (P < .001) greater BP reduction than the reference group. Compared with the reference group, the intervention group had a lower risk of composite CVD events (odd ratio [OR], 0.73; 95% confidence interval [CI], 0.66–0.81), myocardial infarction (OR, 0.79; 95% CI, 0.63–1.0), stroke (OR, 0.71; 95% CI, 0.63–0.80), and CVD mortality (OR, 0.81; 95% CI, 0.68–0.97; all P ≤ .05). In the second subgroup analysis, no difference was found for any outcome between renin-angiotensin blockers and calcium-channel blockers or diuretics. The meta-regression line among the 18 trials indicated that a 10 mm Hg reduction in systolic BP was associated with a reduced risk for composite CVD events (−39.5%) and stroke (−30.0%). Our meta-analysis shows a benefit when a BP target of less than 140/80 mm Hg is achieved in Asian hypertensives. BP reduction itself, regardless of BP lowering agents, is important for achieving CVD risk reduction.     

Effects of Intensive Antihypertensive Treatment on Chinese Hypertensive Patients Older Than 70 Years

This study was performed to investigate whether intensive antihypertensive treatment with achieved blood pressure (BP) ≤140/90 mm Hg, as compared with standard treatment with achieved BP ≤150/90 mm Hg, could further improve cardiovascular outcomes in Chinese hypertensive patients older than 70 years. A total of 724 participants were randomly assigned to intensive or standard antihypertensive treatment. After a mean follow‐up of 4 years, the mean achieved BP was 135.7/76.2 mm Hg in the intensive treatment group and 149.7/82.1 mm Hg in the standard treatment group. The visit‐to‐visit variability in systolic BP and diastolic BP was lower in the intensive group than that in the standard group. Intensive antihypertensive treatment, compared with the standard treatment, decreased total and cardiovascular mortality by 41.7% and 50.3%, respectively, and reduced fatal/nonfatal stroke by 42.0% and heart failure death by 62.7%. Cox regression analysis indicated that the mean systolic BP (P=.020; 95% confidence interval, 1.006–1.069) and the standard deviation of systolic BP (P=.033; 95% confidence interval, 1.006–1.151) were risk factors for cardiovascular endpoint events. Intensive antihypertensive treatment with achieved 136/76 mm Hg was beneficial for Chinese hypertensive patients older than 70 years. Long‐term visit‐to‐visit variability in systolic BP was positively associated with the incidence of cardiovascular events.     

The effect of a practice‐based multicomponent intervention that includes health coaching on medication adherence and blood pressure control in rural primary care

Low adherence to anti‐hypertensive medications contributes to worse outcomes. The authors conducted a secondary data analysis to examine the effects of a health‐coaching intervention on medication adherence and blood pressure (BP), and to explore whether changes in medication adherence over time were associated with changes in BP longitudinally in 477 patients with hypertension. Data regarding medication adherence and BP were collected at baseline, 6, 12, 18, and 24 months. The intervention resulted in increases in medication adherence (5.75→5.94, P = .04) and decreases in diastolic BP (81.6→76.1 mm Hg, P < .001) over time. The changes in medication adherence were associated with reductions in diastolic BP longitudinally (P = .047). Patients with low medication adherence at baseline had significantly greater improvement in medication adherence and BP over time than those with high medication adherence. The intervention demonstrated improvements in medication adherence and diastolic BP and offers promise as a clinically applicable intervention in rural primary care.     

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.     

Association between statin adherence and the risk of stroke among South Korean adults with hyperlipidemia

Background and aimsThe effectiveness of statins commonly used to prevent stroke may depend on adherence to treatment. We examined the association between statin adherence and stroke risk among South Korean adults with hyperlipidemia.Methods and resultsThe data of 128,052 and 129,390 participants with hyperlipidemia for the purpose of studying the risks of ischemic and hemorrhagic stroke, respectively, were collected from the Korean National Health Insurance Service-National Sample Cohort between 2002 and 2013. Participants were divided into groups according to statin adherence, calculated as the proportion of days covered (PDC; poor, moderate, good). The risk of ischemic and hemorrhagic stroke were analyzed using a Cox proportional hazards model. Individuals with poor PDC exhibited higher risks of ischemic and hemorrhagic stroke than those with good PDC (ischemic stroke: hazard ratio [HR] = 1.09, 95% confidence interval [CI] = 1.03–1.15, hemorrhagic stroke: HR = 1.37, 95% CI = 1.22–1.54). Women with poor PDC were at higher risk of ischemic stroke than those with good PDC (HR = 1.17, 95% CI = 1.09–1.26), while men with poor PDC exhibited a higher risk of hemorrhagic stroke than those with good PDC (HR = 1.55, 95% CI = 1.27–1.90). Individuals with disabilities who had poor PDC were at higher risk of ischemic stroke than those with good PDC (HR = 1.55, 95% CI = 1.24–1.93).ConclusionsWe detected a significant association between statin adherence and ischemic and hemorrhagic stroke risk. Therefore, hyperlipidemia patients should adhere to statin treatment; such interventions are required to reduce the stroke risk.     

A Hypertensive Response to Exercise Is Prominent in Patients With Obstructive Sleep Apnea and Hypertension: A Controlled Study

Blood pressure (BP) behavior during exercise is not clear in hypertensive patients with obstructive sleep apnea (OSA). The authors studied 57 men with newly diagnosed essential hypertension and untreated OSA (apnea‐hypopnea index [AHI] ≥5) but without daytime sleepiness (Epworth Sleepiness Scale score ≤10), and an equal number of hypertensive controls without OSA matched for age, body mass index, and office systolic BP. All patients underwent ambulatory BP measurements, transthoracic echocardiography, and exercise treadmill testing according to the Bruce protocol. A hypertensive response to exercise (HRE) was defined as peak systolic BP ≥210 mm Hg. Patients with OSA and control patients had similar ambulatory and resting BP, ejection fraction, and left ventricular mass. Peak systolic BP was significantly higher in patients with OSA (197.6±25.6 mm Hg vs 187.8±23.6 mm Hg; P=.03), while peak diastolic BP and heart rate did not differ between groups. Furthermore, an HRE was more prevalent in patients with OSA (44% vs 19%; P=.009). Multiple logistic regression revealed that an HRE is independently predicted by both the logAHI and minimum oxygen saturation during sleep (odds ratio, 3.94; confidence interval, 1.69–9.18; P=.001 and odds ratio, 0.94; confidence interval, 0.89–0.99; P=.02, respectively). Exaggerated BP response is more prevalent in nonsleepy hypertensives with OSA compared with their nonapneic counterparts. This finding may have distinct diagnostic and prognostic implications.     

Assessing the applicability of 2017 ACC/AHA hypertension guidelines for secondary stroke prevention in the BOSS study

Using data from the Blood Pressure and Clinical Outcome in TIA or Ischemic Stroke (BOSS) study, we aim to test the applicability and feasibility of stroke secondary prevention recommendations from the 2017 American College of Cardiology/American Heart Association guideline. Patients were categorized based on their blood pressure (BP) status at 3 months. The nonhypertension group was defined as those without a diagnosis of hypertension. The other patients were further divided into three subgroups according to office BP measured at 3‐month visit (BP <130/80, 130‐139/80‐89, and ≥140/90 mm Hg). The primary outcome was any stroke within one year. The associations between BP status and 1‐year prognosis (recurrent stroke, recurrent stroke/TIA, and poor functional outcome [modified Rankin scale score 3‐6]) were estimated. Among 2341 IS/TIA patients, additional 1056 patients were classified as uncontrolled hypertension at the 90‐day visit according to the new guidelines. Adjusted hazard/odds ratios (95% confidence intervals [CI]) for recurrent stroke in BP <130/80, 130‐139/80‐89, and ≥140/90 compared with nonhypertension group were 2.42 (95% CI: 0.87‐6.76), and 4.30 (95% CI: 1.73‐10.70), respectively. The prevalence of hypertension and uncontrolled BP among BOSS study population was substantially higher based on the new guidelines. BP of 130‐139/80‐89 did not show the worsened clinical outcomes compared with people without hypertension. Our study adds to the growing uncertainty about secondary prevention BP goal for IS/TIA patients.     

Hypertension in African Americans Aged 60 to 79 Years: Statement From the International Society of Hypertension in Blacks

A 2014 hypertension guideline raised goal systolic blood pressure (SBP) from <140 mm Hg to <150 mm Hg for adults 60 years and older without diabetes mellitus (DM) or chronic kidney disease (CKD). The authors aimed to define the status of hypertension in black adults 60 to 79 years from the National Health and Nutrition Examination Survey 2005–2012 and provide practical guidance. Black patients were more often aware and treated (P≤.005) for hypertension than whites and had higher rates of DM/CKD (P<.001), similar control to <140/<90 mm Hg with DM/CKD (P=.59), and lower control without DM/CKD (<140/<90 mm Hg and <150/<90 mm Hg, P≤.01). Limited awareness (<30%) and infrequent health care (>30% 0–1 health‐care visits per year) occurred in untreated black and white hypertensive patients without DM/CKD and BP ≥140/<90 mm Hg. The literature suggests benefits of treated SBP <140 mm Hg in adults 60 to 79 years without DM/CKD. The International Society of Hypertension in Blacks recommends: (1) continuing efforts to achieve BP <140/<90 mm Hg in those with DM/CK, and (2) identifying hypertensive patients without DM/CKD and BP ≥140/<90 mm Hg and treat to an SBP <140 mm Hg in black adults 60–79 years.     

Robotic pancreaticoduodenectomy decreases the risk of clinically relevant post-operative pancreatic fistula: a propensity score matched NSQIP analysis

BackgroundA single-institution study demonstrated robotic pancreaticoduodenectomy (RPD) was protective against clinically-relevant postoperative pancreatic fistula (CR-POPF) compared to open pancreaticoduodenectomy (OPD). We sought to compare the national rate of CR-POPF by approach.MethodsProcedure-targeted pancreatectomy Participant User Data File was queried from 2014 to 2017 for all patients undergoing pancreaticoduodenectomy. A modified fistula risk score was calculated and patients were stratified into risk categories. Multivariate logistic regression and propensity score matching was used.ResultsThe rate of CR-POPF (15.6% vs. 11.9%; p = 0.026) was higher in OPD compared to RPD. On subgroup analysis, OPD had higher CR-POPF in high risk patients (32.9% vs. 19.4%; p = 0.007). On multivariable analysis OPD was a predictor of increased CR-POPF (Odds Ratio [OR] = 1.61 [1.15–2.25]; p = 0.005). Other operative factors associated with increased CR-POPF included soft pancreatic texture (OR = 2.65 [2.27–3.09]; p < 0.001) and concomitant visceral resection (OR = 1.41 [1.03–1.93]; p = 0.031). Increased duct size (reference <3 mm) was predictive of decreased CR-POPF: 3–6 mm (OR = 0.70 [0.61–0.81]; p < 0.001) and ≥6 mm (OR = 0.47 [0.37–0.60]; p < 0.001). Following propensity score matching, RPD continued to be protective against the occurrence of CR-POPF (OR = 1.54 [1.09–2.17]; p = 0.013).ConclusionsThis is the largest multicenter study to evaluate the impact of RPD on POPF. It suggests that RPD can be protective against POPF, especially for high risk patients.     

Control of hypertension 5 years after stroke in the North East Melbourne Stroke Incidence Study

Control of blood pressure after stroke is important for reducing the risk of recurrent stroke. We examined the control of hypertension in a community-based population of 5-year stroke survivors. Cases of first-ever stroke from the North East Melbourne Stroke Incidence Study were interviewed at 5 years poststroke. Blood pressure, history of hypertension, and antihypertensive medications were recorded. Individuals were classified as normotensive (blood pressure < 140/90 mm Hg, no history of hypertension, and no antihypertensive medications), controlled hypertensive (blood pressure < 140/90 mm Hg, history of hypertension, and/or taking antihypertensive medications), uncontrolled hypertensive (blood pressure > or = 140/90 mm Hg, history of hypertension, and/or taking antihypertensive medications), or uninformed hypertensive (blood pressure > or = 140/90 mm Hg, no known history of hypertension, and no antihypertensive medications). At 5 years poststroke, 441 (45%) of 978 first-ever stroke cases were alive. Of these, 305 (69%) had complete data on blood pressure, antihypertensive medication use, and history of hypertension. No statistical differences existed between those with or without these data. Eight-two percent were hypertensive; 63% had controlled hypertension, 30% had uncontrolled hypertension, and 7% were unaware that they were hypertensive. Overall, 67% of individuals classified as uncontrolled or uninformed hypertensive subjects were receiving treatment that was insufficient to achieve target blood pressure levels. Uncontrolled hypertensive subjects were more likely to recall receiving advice to manage their hypertension with medication (P < 0.02) and diet (P < 0.09). Although the majority of hypertensive individuals had controlled hypertension at 5 years poststroke, considerable improvement can be made in the control of hypertension after stroke.     

Relationship between health‐related quality of life and blood pressure control in patients with uncontrolled hypertension

We sought to investigate the psychosocial characteristics of patients with uncontrolled hypertension and examine factors that influence blood pressure (BP) control. A total of 1011 patients with uncontrolled hypertension were enrolled in 13 tertiary hospitals. Uncontrolled hypertension was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg despite on antihypertensive therapy. Socio‐demographics, anthropometrics, behavioral risk factors, medication pattern, adherence, and measures of health‐related quality of life (HRQoL; EuroQol 5D visual analog scale [EQ‐5D VAS]) were assessed at baseline and during follow‐up visits (3 and 6 months). Patients were divided into 2 groups based on BP control status at 6 months (controlled group [n = 532] vs uncontrolled group [n = 367]). There were no differences in clinical characteristics except the proportion of smokers and baseline BP between patients with controlled BP and uncontrolled BP. At 6 months, the adherence of antihypertensive medication did not differ between the groups but the proportion of combination therapy with ≥3 antihypertensives was significantly higher in patients with uncontrolled BP. EQ‐5D VAS at follow‐up was significantly lower in patients with uncontrolled BP despite similar baseline values. Multivariate logistic regression analysis revealed that EQ‐5D VAS at follow‐up significantly correlated with BP control. Patients with worse HRQoL had higher Charlson Comorbidity Index and higher proportion of taking ≥3 antihypertensives, but medication adherence was similar to those with better HRQoL. These findings suggest that along with pharmacologic intervention of hypertension, management of comorbid conditions or psychological support might be helpful for optimizing BP control in patients with uncontrolled hypertension.     

Antihypertensive medication adherence and blood pressure control among central Alabama veterans

Medication nonadherence is associated with adverse outcomes. To evaluate antihypertensive medication adherence and its association with blood pressure (BP) control, the authors described population adherence to prescribed antihypertensive medication (proportion of days covered ≥80%) and BP control (mean BP <140/90 mm Hg) among central Alabama veterans during the fiscal year 2015. Overall, 75.1% of patients receiving antihypertensive medication were considered adherent, and 66.1% had adequate BP control. Patients adherent to antihypertensive medication were more likely to have adequate BP control compared with patients classified as nonadherent (67.4% vs 62.0%; adjusted odds ratio 1.33; 95% confidence interval, 1.22–1.44 [P<.0001]). Among patients who had uncontrolled BP, 73.6% were considered adherent to medication. Adherence to antihypertensive medication was associated with adequate BP control; however, a substantial proportion of patients with inadequate BP control were also considered adherent. Interventions to increase BP control could address more aggressive medication management to achieve BP goals.     

Treatment of Resistant Hypertension With Endovascular Baroreflex Amplification: 3-Year Results From the CALM-FIM Study

ObjectivesThe aim of this study was to evaluate the long-term (3-year) safety and effectiveness of endovascular baroreflex amplification (EVBA) from both the European and American CALM-FIM cohorts.BackgroundThe CALM-FIM study demonstrated that EVBA in patients with resistant hypertension significantly lowered blood pressure (BP) with an acceptable safety profile during 6-month follow-up.MethodsThe CALM-FIM studies were prospective, nonrandomized, first-in-human studies that enrolled patients with resistant hypertension (office systolic BP ≥160 mm Hg and mean 24-hour ambulatory BP ≥130/80 mm Hg despite a stable regimen of ≥3 antihypertensive medications, including a diuretic agent). The incidence of (serious) adverse events and changes in BP, heart rate, and prescribed antihypertensive medication up to 3 years after implantation were determined.ResultsThe Mobius device was implanted in 47 patients (30 in Europe, 17 in the United States; mean age 54 years, 23 women). Five serious adverse events (hypotension, n = 2; hypertension, n = 1; vascular access complications, n = 2) and 2 transient ischemic attacks occurred within 30 days postprocedure. Two strokes and 1 transient ischemic attack occurred more than 2 years postimplantation. Mean office BP at baseline was 181 ± 17/107 ± 16 mm Hg and decreased by 25/12 mm Hg (95% CI: 17-33/8-17 mm Hg) at 6 months and 30/12 mm Hg (95% CI: 21-38/8-17 mm Hg) at 3 years. Mean 24-hour ambulatory BP at baseline was 166 ± 16/98 ± 15 mm Hg and decreased by 20/11 mm Hg (95% CI: 14-25/8-15 mm Hg) at 6 months.ConclusionsEVBA with the MobiusHD was effective in reducing BP at 3-year follow-up and appears to have an acceptable safety profile in patients with uncomplicated implantation, although data from randomized sham-controlled trials are needed to further evaluate the risk-benefit profile. (Controlling and Lowering Blood Pressure With the MobiusHD? [CALM-FIM_EUR], NCT01911897; Controlling and Lowering Blood Pressure With the MobiusHD? [CALM-FIM_US], NCT01831895)