Efficacy of various antihypertensive agents as evaluated by indices of vascular stiffness in elderly hypertensive patients.

When observed in elderly hypertensive patients, increased pulse pressure (PP) and arterial stiffness are known to be independent risk factors for cardiovascular diseases. Increased systolic blood pressure (SBP) leads to left ventricular hypertrophy, while decreased diastolic blood pressure (DBP) results in decreased coronary circulation. It is known that increased arterial stiffness is the major cause of increased PP. Thus basic morbid states of cardiac failure or ischemic heart diseases are more likely to develop in elderly hypertensive patients with increased PP and arterial stiffness, and there is need of antihypertensive drugs that decrease these effects in elderly hypertensives. In this study, we compared the effects of an angiotensin-receptor blocker (ARB: valsartan), an angiotensin-converting enzyme inhibitor (ACE-I: temocapril), and long-acting Ca antagonists (L- and N-type Ca channel blocker: cilnidipine; and L-type Ca channel blocker: nifedipine CR) on PP and arterial stiffness measured by pulse wave velocity in elderly hypertensive patients for 3 months. The ARB yielded the largest reductions in PP and brachial-ankle pulse wave velocity (baPWV), followed by the ACE-I and L- and N-type Ca channel blocker, while the L-type Ca channel blocker yielded no improvement. The effects on arterial stiffness and PP thus varied among the drug characteristics. Although ARB achieved the largest reduction in baPWV, this decrease was not associated with any reductions in PP, SBP, DBP, or mean blood pressure, as were the baPWV-decreases achieved by the other drugs, suggesting that ARB may further reduce the risk of arteriosclerosis in elderly hypertensive patients by decreasing arterial stiffness in addition to its antihypertensive effect.     

Pulse pressure,heart rate,and drug treatment of hypertension

Peak-systolic blood pressure (SBP) and end-diastolic blood pressure (DBP) have been considered the exclusive mechanical factors predicting cardiovascular (CV) risk in populations of normotensive and hypertensive subjects. The purpose of this review is to show that in addition to SBP and DBP, other hemodynamic indices that have particular relevance for coronary complications and originate from pulse pressure (PP) should be taken into account, namely brachial PP and, potentially, heart rate (HR). In normotensive and hypertensive populations, increased PP is an independent predictor for myocardial infarction, more powerful than SBP, even in hypertensive subjects under successful antihypertensive drug therapy. Increased HR is an additional CV risk factor, acting particularly through the presence of an enhanced PP x HR product. Such findings, observed during a period in which standard antihypertensive agents are known to reduce SBP and PP to a much lesser extent than DBP, require the development of intervention trials using drugs acting specifically on SBP, PP, and arterial stiffness.     

Improvement in blood pressure, arterial stiffness and wave reflections with a very-low-dose perindopril/indapamide combination in hypertensive patient: a comparison with atenolol

International guidelines recommend that antihypertensive drug therapy should normalize not only diastolic (DBP) but also systolic blood pressure (SBP). Therapeutic trials based on cardiovascular mortality have recently shown that SBP reduction requires normalization of both large artery stiffness and wave reflections. The aim of the present study was to compare the antihypertensive effects of the very-low-dose combination indapamide (0.625 mg) and perindopril (2 mg) (Per/Ind) with the beta-blocking agent atenolol (50 mg) to determine whether Per/Ind decreases SBP and pulse pressure (PP) more than does atenolol and, if so, whether this decrease is predominantly due to reduction of aortic pulse wave velocity (PWV) (automatic measurements) and reduction of wave reflections (pulse wave analysis, applanation tonometry). In a double-blind randomized study, 471 patients with essential hypertension were followed for 12 months. For the same DBP reduction, Per/Ind decreased brachial SBP (-6.02 mm Hg; 95% confidence interval, -8.90 to -3.14) and PP (-5.57; 95% confidence interval, -7.70 to -3.44) significantly more than did atenolol. This difference was significantly more pronounced for the carotid artery than for the brachial artery. Whereas the 2 antihypertensive agents decreased PWV to a similar degree, only Per/Ind significantly attenuated carotid wave reflections, resulting in a selective decrease in SBP and PP. The very-low-dose combination Per/Ind normalizes SBP, PP, and arterial function to a significantly larger extent than does atenolol, a hemodynamic profile that is known to improve survival in hypertensive populations with high cardiovascular risk.     

The study of aortic stiffness in different hypertension subtypes in dialysis patients.

The aim of this study was to validate whether differences in aortic stiffness are responsible for the differences in cardiovascular mortality among hypertension subtypes. Twenty hundred and fifty continuous ambulatory peritoneal dialysis patients were included in the present study. They were classified into four groups: normotensives (n=92) with systolic blood pressure (SBP) <140 mmHg and diastolic blood pressure (DBP) <90 mmHg; isolated systolic hypertensives (ISH, n=84) with SBP > or =140 mmHg and DBP <90 mmHg; isolated diastolic hypertensives (IDH, n=21) with SBP <140 mmHg and DBP > or =90 mmHg; and systolic-diastolic hypertensives (SDH, n=53) with SBP > or =140 mmHg and DBP > or =90 mmHg. Aortic stiffness was assessed by pulse pressure, central pressure parameters and pulse wave velocity. The IDH group had more male patients and a lower mean age than the other groups. The percentage of diabetes in the ISH group was higher than that in the other groups. The comparisons of aortic stiffness showed that the ISH and SDH groups had higher aortic stiffness than the normotension and IDH groups. The aortic stiffness in the ISH group was also higher than that in the SDH group, but there was no significant difference in aortic stiffness between the normotension and IDH groups. In conclusion, this study showed that aortic stiffness was significantly different among different hypertension subtypes, which might be an underlying cause of the differences in cardiovascular mortality among the hypertension subtypes.     

Systolic Blood Pressure Revisited

The clinical importance of systolic blood pressure (SBP) needs no emphasis. Its determinants are well known, but recent studies of one of these determinants, arterial distensibility, have led to results that now have clinical relevance. This review summarizes the role of arterial stiffness in ventricular-vascular coupling in the normal circulation and that disordered by aging and hypertension. The discussion defines the unfamiliar terms of compliance, distensibility and modulus and indicates how they are measured. Such measurements have increased our understanding of the parts played by the inhomogeneity of the arterial tree and reflected pressure waves in governing SBP. Elevated SBP is a recognized risk factor for cardiovascular complications among older patients, but when this elevation is due to a stiffened arterial tree, diastolic blood pressure (DBP) is necessarily reduced. Early epidemiologic studies in hypertension required a DBP ≥90 mm Hg for hospital admission. They therefore excluded persons with high SBP, low DBP and very wide pulse pressure (PP). More recent inclusion of such patients has shown that elevation of SBP and PP is a strong predictor of cardiovascular risk. These considerations point to a possible redefinition of hypertension to include patients with lower DBP and to the inaccuracy but indispensability of the brachial artery pressure as a surrogate for aortic pressure—the pressure the heart sees. Finally, we review the known effects of available antihypertensive drugs on the arterial wall and indicate possible future directions of research stemming from wider understanding of the role of arterial distensibility in hypertension.

(J Am Coll Cardiol 1997;29:1407–13)     

Hypertension magnitude and management in the elderly population of Spain

OBJECTIVE: The present study assessed the prevalence, awareness, treatment and control of hypertension among the elderly population of Spain. DESIGN: Based on a nationally representative sample of 4009 individuals aged 60 years, two sets of six blood pressure measurements were obtained by trained observers at each subject's home, using standardized methods. In each set, three mercury-based measurements were alternated with three automated measurements. RESULTS: The mean systolic blood pressure (SBP)/diastolic blood pressure (DBP) was 143/79 mmHg, and the pulse pressure was 64 mmHg. The prevalence rate of hypertension (SBP 140 mmHg, DBP 90 mmHg, or current drug treatment) was 68.3%. No result obtained was sensitive to a particular measurement device. Of the hypertensives, 65% were aware of their condition, 55.3% were treated and 16.3% were controlled. Among treated hypertensives, SBP control (32.2%) was much lower than DBP control (82.3%). Control was lower in men than in women, in older than in younger subjects, and in those with lowest than in those with higher educational levels. About 57% of uncontrolled treated hypertensives were on monotherapy. Weight loss was among the least heeded items of advice (39% among overweight hypertensives). CONCLUSIONS: Hypertension is a major public health problem in elderly Spaniards. Most hypertensives had their hypertension uncontrolled. Greater emphasis should be laid on the most disadvantaged (the older, men, and those with lowest education) in terms of hypertension management, and on reinforcing weight loss and combining drugs for enhanced hypertension control.     

老老年人群动态血压参数与动脉僵硬度的相关性

目的探讨老老年人群动态血压参数与动脉僵硬度的相关性。方法筛选年龄≥80岁的老老年人238例,以血压≥160/95 mm Hg(1 mm Hg=0.133 kPa)为标准,分为高血压组(134例)和对照组(104例),并进行臂-踝脉搏传导速度(baPWV)和24 h动态血压监测。用Pearson分析动态血压各参数与动脉僵硬度的相关性。结果高血压组baPWV高于对照组(P<0.05)。高血压组偶测收缩压,24 h、昼间和夜间收缩压、舒张压、脉压,收缩压负荷及舒张压负荷均高于对照组.夜间收缩压下降率、舒张压下降率低于对照组,差异有统计学意义(P<0.05,P<0.01)。baPWV与偶测血压;24 h收缩压、舒张压、脉压;昼间收缩压、舒张压、脉压、心率;夜间收缩压、舒张压、脉压;收缩压负荷、舒张压负荷呈正相关(P<0.05,P<0.01),而与夜间收缩压下降率呈负相关(P<0.01)。结论高血压是老老年人群动脉僵硬度增加的一个重要因素,动脉僵硬度与动态血压、脉压、心率及血压负荷相关。     

Correlation of arterial blood pressure and compliance with left ventricular structure and function in the very elderly

There are very few data on the relationship between systolic blood pressure (SBP), diastolic blood pressure (DBP), arterial compliance, and left ventricular structure and function, particularly left ventricular hypertrophy (LVH), in the very elderly (>75 years). SBP and arterial stiffness increase with age, and the question is: which of the two is the main stimulus to LVH? This is a cross-sectional study to compare blood pressure and arterial stiffness measures with regard to their correlations with echocardiographic parameters of LV structure and function, controlling for age and cardiovascular risk factors, in a very elderly population. Arterial stiffness was determined by radial pulse waveform using pulse contour analysis. LV dimensions were measured by transthoracic M-mode echocardiography, and diastolic function by tissue Doppler measurements of diastolic mitral annular velocities. There were 179 subjects, all male, with a mean age of 81.8 years. Using age-adjusted partial correlations, SBP, DBP, and mean arterial pressure (MAP) were correlated with parameters of LV structure and function. Correlation coefficients were: SBP versus left ventricular mass index (LVMI), r = 0.246; SBP versus early diastolic mitral annular velocity (MAV), r = ?0.179; DBP versus LVMI, r = 0.199; DBP versus MAV, r = ?0.199; MAP versus LVMI, r = 0.276; and MAP versus MAV, r = ?0.206, all with P < .05. However, neither capacitative nor reflective arterial compliance was significantly correlated with any parameter of LV structure and function. After controlling for age and 10 cardiovascular and metabolic risk factors, the correlation between blood pressure and the measured LV parameters was substantially unchanged, as was the lack of correlation between indices of arterial compliance and the LV indices. Arterial blood pressure is correlated with LV structure and function in the very elderly, but arterial stiffness, as measured by diastolic pulse contour analysis, is not.     

Arterial stiffness is related to augmented seasonal variation of blood pressure in hypertensive patients

BACKGROUND: Seasonal variation in blood pressure (BP), a usual tendency of both systolic (SBP) and diastolic BP (DBP) to rise during winter in hypertensive patients, may be related to the higher cardiovascular mortality in winter. However, it is not yet clear what factors are relevant to the seasonal BP changes. We hypothesized that arterial stiffness is related to the BP changes between summer and winter. METHODS AND RESULTS: Eighty-five elderly (>55 years) patients with essential hypertension (33 males, 64+/-6.0 years) were enrolled. Seasonal BP profiles over at least 2 years were studied along with arterial stiffness and clinical variables (age, gender, smoking, duration of hypertension, anti-hypertensive medications and body mass index). Both SBP and DBP were significantly higher during winter compared with three other seasons (spring 128+/-10.0/79+/-7.3 mmHg, summer 127+/-9.8/78+/-7.1 mmHg, autumn 127+/-10.3/78+/-8.0 mmHg, winter 136+/-12.5/81+/-7.6 mmHg; SBP changes; p<0.001, DBP changes; p<0.001). There were no significant seasonal differences among spring, summer and autumn. Pulse wave velocity (PWV), a widely used clinical indicator of arterial stiffness was correlated with winter-summer differences in SBP (r = 0.272, p = 0.012), but not in DBP (r = 0.188, p = 0.085). Age, which was correlated with PWV strongly (p<0.001), was not significantly related to the seasonal changes in BP (SBP changes; p = 0.114, DBP changes; p = 0.298). No other clinical variables had significant correlation with seasonal BP changes. Multivariate regression analysis revealed that PWV is the only significant predictor for winter-summer SBP changes. CONCLUSIONS: Our results established a feasible link between arterial stiffness and seasonal BP variation. These findings may partly explain higher cardiovascular risk in patients with increased arterial stiffness.     

Angiotensin receptor blockade in the challenging era of systolic hypertension

Systolic blood pressure is a major cardiovascular risk factor which is often associated with arterial stiffness. Markers of arterial stiffness, such as pulse pressure and carotid-femoral pulse wave velocity, have been proved independent predictors of cardiovascular risk. Recent evidence suggests that the renin-angiotensin system is involved in the pathogenesis of systolic hypertension and arterial stiffness. Outcome trials have shown impressive cardiovascular protection by reducing systolic blood pressure (BP) with drug treatment. However, in clinical practice systolic hypertension remains largely uncontrolled, first, because systolic BP goal is more difficult to be reached than diastolic and, second, because physicians are often reluctant to intensify treatment in patients with systolic BP close to 150 mmHg. Recent trials have focused on the effects of antihypertensive drugs not only on blood pressure, but also on pulse pressure and pulse-wave velocity. Blockade of the renin-angiotensin-aldosterone system, using angiotensin-converting enzyme inhibitors and more recently angiotensin receptor blockers, has been shown to provide beneficial effects on arterial stiffness that appear to be independent of their antihypertensive effects. Recent outcome trials have shown significant cardiovascular protection with angiotensin receptor blockers. These drugs have an excellent placebolike profile of adverse effects which is maintained when these drugs are combined with low-dose diuretics. Therefore, an angiotensin receptor blocker-based treatment strategy appears to be an attractive and evidence-based approach for the management of systolic hypertension, the reduction of arterial stiffness and the prevention of cardiovascular disease.     

Validation of the TONOPORT V ambulatory blood pressure monitor according to the European Society of Hypertension International Protocol for Validation of Blood Pressure Measuring Devices in Adults

BACKGROUND: It is now accepted that blood pressure measuring devices should be subjected to an independent evaluation of their accuracy before they are marketed for clinical use. The results of validation of the TONOPORT V blood pressure monitor for the measurement of ambulatory blood pressure according to the European Society of Hypertension International Protocol for Validation of Blood Pressure Measuring Devices in Adults are presented in this paper. POPULATION: Thirty-three subjects were recruited from among staff and patients at Beaumont Hospital, Dublin, Ireland. METHODS: The TONOPORT V monitor was connected to the Sphygmocorder, an audiovisual system for validation, which records blood pressure on tape and video for later analysis. Nine sequential same-arm measurements between the device and a standard mercury sphygmomanometer were recorded using the Sphygmocorder. RESULTS: In phase 1, the TONOPORT V monitor produced 28 measurements within 5 mmHg, 37 within 10 mmHg and 40 within 15 mmHg for systolic blood pressure (SBP), and 26 within 5 mmHg, 38 within 10 mmHg and 44 within 15 mmHg for diastolic blood pressure (DBP). The mean differences were -2.2 (8.6) [mean (SD)] mmHg for SBP and +0.5 (7.2) mmHg for DBP. The TONOPORT V monitor passed all the criteria for both SBP and DBP. In phase 2.1, the TONOPORT V monitor had 56 measurements within 5 mmHg, 78 within 10 mmHg and 88 within 15 mmHg for SBP, and 60 measurements within 5 mmHg, 83 within 10 mmHg and 97 within 15 mmHg for DBP. The mean differences were -1.4 (8.7) mmHg for SBP and -0.2 (6.8) mmHg for DBP. The TONOPORT V monitor passed the criteria for DBP but failed to meet any of the criteria for SBP. In phase 2.2, 19 subjects had at least two of the differences within 5 mmHg and six subjects had no differences within 5 mmHg for SBP, and 22 subjects had at least two of the differences within 5 mmHg and six subjects no differences within 5 mmHg for DBP. The TONOPORT V monitor failed to meet the criteria for SBP and for DBP. CONCLUSIONS: The TONOPORT V monitor cannot be recommended for clinical use in an adult population because it records SBP inaccurately and because it records DBP inaccurately in an unacceptably high proportion of people.     

Validation of the ROSSMAX blood pressure measuring monitor according to the European Society of Hypertension International Protocol for Validation of Blood Pressure Measuring Devices in Adults

BACKGROUND: It is now accepted that blood pressure measuring devices should be subjected to an independent evaluation of their accuracy before they are marketed for clinical use. The results of validation of the ROSSMAX Blood Pressure Measuring Monitor for self-measurement according to the European Society of Hypertension International Protocol for Validation of Blood Pressure Measuring Devices in Adults are presented in this paper. POPULATION: Thirty-three subjects were recruited from among staff and patients at Beaumont Hospital, Dublin, Ireland. METHODS: The ROSSMAX monitor was connected to the Sphygmocorder, an audiovisual system for validation, which records blood pressure on tape and video for later analysis. Nine sequential same-arm measurements between the device and a standard mercury sphygmomanometer were recorded using the Sphygmocorder. RESULTS: In phase 1, the ROSSMAX monitor produced 21 measurements within 5 mmHg, 31 within 10 mmHg and 38 within 15 mmHg for systolic blood pressure (SBP), and 36 within 5 mmHg, 43 within 10 mmHg and 45 within 15 mmHg for diastolic blood pressure (DBP). The mean differences were -5.6 (10.2) [mean (SD)] mmHg for SBP and -0.5 (4.5) mmHg for DBP. The ROSSMAX monitor failed to meet any of the criteria for SBP but comfortably passed all of the criteria for DBP. In phase 2.1, the ROSSMAX monitor had 51 measurements within 5 mmHg, 73 within 10 mmHg and 86 within 15 mmHg for SBP, and 71 measurements within 5 mmHg, 93 within 10 mmHg and 98 within 15 mmHg for DBP. The mean differences were -4.5. (9.5) mmHg for SBP and -1.8 (5.0) mmHg for DBP. The ROSSMAX monitor failed to meet any of the criteria for SBP but comfortably passed all of the criteria for DBP. In phase 2.2, 16 subjects had at least two of the differences lying within 5 mmHg and 10 subjects had no differences within 5 mmHg for SBP; 26 subjects had at least two of the differences falling within 5 mmHg and three subjects no differences within 5 mmHg for DBP. The ROSSMAX monitor failed to meet the criteria for SBP but passed the criteria for DBP. CONCLUSIONS: The ROSSMAX monitor cannot be recommended for clinical use in an adult population because it records SBP inaccurately.     

The impact of oral phenylpropanolamine on blood pressure: a meta-analysis and review of the literature

Oral phenylpropanolamine is commonly used to treat congestion and obesity. Clinicians often wonder what effect it has on blood pressure and whether they are safe in hypertensive patients. The purpose of our systematic review was to assess whether these drugs cause clinically meaningful elevations in pulse or blood pressure. English-language, randomized, placebo-controlled trials of oral phenylpropanolamine in adults with extractable data on pulse or blood pressure were studied. MEDLINE (1966-2003), Embase, the Cochrane library and reviewed article references were used as sources. Systolic (SBP) and diastolic blood pressure (DBP) and heart rate data were extracted. Additional extracted data included demographics, year, study design, study duration, drug dose and frequency, duration of washout and country. Study quality was assessed using the methods of Jadad and data were synthesized using a random effects model using weighted mean differences. In all, 33 trials reporting 48 treatment arms with 2165 patients were included. Phenylpropanolamine increased SBP 5.5 mmHg (95% CI: 3.1-8.0) and DBP 4.1 mmHg (95% CI: 2.2-6.0) with no effect on pulse. Patients with controlled hypertension were not at greater risk of blood pressure elevation. Immediate release preparations had greater effects on blood pressure than sustained release ones. Higher doses and shorter duration use also caused greater increases. Eighteen studies contained at least one treated subjects having blood pressure elevations > or =140/90 mmHg, an increase in SBP > or =15 mmHg or an increase in DBP > or =10 mmHg. In conclusion, phenylpropanolamine caused a small, but significant increase in systolic blood pressure. The effect was more pronounced with shorter-term administration, higher doses of medication and immediate release formulations.     

Effect of acute and long-term aerobic exercise on arterial stiffness in the elderly.

Arterial stiffness is an important factor for cardiovascular performance and a predictor of cardiovascular risk. We evaluated the effects of both acute and long-term aerobic exercise on arterial stiffness in community-dwelling healthy elderly subjects. In addition, we evaluated the relationship between the effects of long-term exercise and those of acute exercise. The study subjects were participants in the Shimanami Health Promoting Program study (J-SHIPP), which was designed to investigate factors relating to cardiovascular disease, dementia, and death (67+/-6 years). They performed mild-to-moderate aerobic exercise lasting for 30 min twice a week for 6 months. Arterial stiffness was assessed before and after the first 30-min acute exercise (n=99) and long-term 6-month aerobic training (n=40). The radial arterial augmentation index (AI) obtained from the radial pulse waveform by the tonometry method was used as a parameter of arterial stiffness. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly decreased after 30-min of aerobic exercise, however no significant change in AI was observed. On the other hand, there were significant decreases in AI (from 87 to 84%, p<0.01), SBP (from 136 to 129 mmHg, p<0.01), and DBP (from 75 to 70 mmHg, p<0.01) after the 6-month exercise period. Long-term exercise-induced changes in AI were significantly and inversely correlated with the pre-exercise AI (r=-0.40, p<0.01). In addition, AI changes after the 6-month exercise period were significantly related to those observed after first 30-min exercise (r=0.48, p<0.01). These findings indicate that apparently healthy and sedentary elderly subjects with higher AI may benefit from mild-to-moderate aerobic exercise to improve arterial stiffness.     

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.     

Altered aortic properties in elderly orthostatic hypertension.

To investigate the impact of arterial properties on orthostatic blood pressure (BP) dysregulation in older hypertensives, orthostatic BP dysregulation, a common phenomenon in elderly hypertensives, is associated with target organ damage and falls. However, the mechanism of orthostatic BP dysregulation remains unclear. The pulse wave velocity (PWV), related arterial stiffness, and the augmentation index (AI), a measure of arterial wave reflection, were measured in 365 older hypertensives. We classified the study patients into an orthostatic hypertension (OHT) group with orthostatic increase of systolic BP (SBP) of > or = 220 mmHg (n = 27) and an orthostatic normotension (ONT) group with an orthostatic increase of SBP of < 20 mmHg and orthostatic SBP decrease of < 20 mmHg (n = 338). Orthostatic AI was significantly greater in the OHT group than in the ONT group (OHT: 6.5 +/- 12% vs. ONT: -5.6 +/- 12%, p < 0.001), while supine AI and supine and orthostatic pulse rate were comparable between the two groups. There was no significant difference in the PWV between the OHT and ONT groups. Orthostatic hypertension was affected by altered aortic properties and associated with augmented wave reflection of arterial pressure.     

Prevalence and magnitude of classical risk factors for coronary heart disease in a cohort of 4400 Chinese steelworkers over 13.5 years follow-up.

BACKGROUND: The incidence and mortality of cardiovascular disease among Orientals are very different than among Caucasians. This study addresses the prevalence and magnitude of classic cardiovascular disease risk factors associated with coronary heart disease (CHD) in an Oriental cohort of at-risk men (blood pressure, total cholesterol, Body Mass Index [BMI] and smoking), compared to Caucasian populations. We also address which blood pressure index (SBP, DBP, mean arterial pressure [MAP] and pulse pressure [PP]) is the best predictor of CHD. METHODS AND RESULTS: A cohort of 5092 male steelworkers (18-74 years old) recruited between 1974-1980 was followed up for an average of 13.5 years. The prevalence of risk factors was lower in Orientals than in Caucasians, except for smoking. The relative risks (RRs) of CHD associated with classic risk factors in this Oriental population were similar to Caucasians, except for blood pressure. The RRs of CHD associated with both SBP and DBP in this Oriental group were higher than in Caucasians; RR of CHD was approximately 3 for each 40 mmHg rise of SBP versus approximately 2 in Caucasians. SBP was the single best predictor for CHD, followed by MAP, and DBP. The population attributable risk (PAR%) for hypertension (140/90 mmHg) was 42.4. CONCLUSION: Our results would indicate that the lower incidence of CHD in Orientals is at least partly due to the lower prevalence of hypertension, hypercholesterolemia, and obesity. The magnitude of the risk associated with these factors is similar to that in Caucasians, except perhaps for a greater risk associated with hypertension. The most predictive BP index for CHD is SBP. These results are based on indirect comparisons only and should be studied further in prospective multi-ethnic cohorts.     

Antihypertensive treatment in patients with type-2 diabetes mellitus: what guidance from recent controlled randomized trials?

BACKGROUND: Patients with type-2 diabetes have a high prevalence of hypertension and show an elevated incidence of cardiovascular events and nephropathy. OBJECTIVES: Recent randomized trials of antihypertensive therapy providing information about cardiovascular and renal risk in diabetes, blood pressure goals and best suitable drugs were reviewed. FINDINGS: Evidence that association of type-2 diabetes with hypertension markedly increases cardiovascular and renal risk is incontrovertible: even blood pressure values in the high-normal range represent a more relevant risk than in non-diabetics. More versus less intensive blood pressure lowering or active versus placebo treatment can significantly prevent cardiovascular and renal events, with a particularly consistent reduction of proteinuria and microalbuminuria. Although several of the trials showing significant reduction of cardiovascular or renal risk achieved diastolic blood pressure (DBP) between 75 and 82 mmHg, systolic blood pressure (SBP) 140 mmHg was never achieved in trials showing cardiovascular benefits and SBP 130 mmHg was only achieved in two trials in normotensive subjects showing proteinuria reduction. The recommendation given by all major guidelines to lower SBP 130 mmHg appears to be difficult to comply with. Evidence of the superiority or inferiority of different drug classes (angiotensin-converting enzyme inhibitors, calcium antagonists, diuretics and beta-blockers) is rather vague, especially for cardiovascular protection. As to angiotensin-receptor antagonists, losartan has shown significant cardiovascular protection over a beta-blocker, and irbesartan, although not showing cardiovascular benefits over a calcium antagonist, was significantly better in retarding renal dysfunction and failure. CONCLUSIONS: In most trials on hypertensive diabetics, the large majority of patients were on two, three and even four-drug therapy. Therefore, it appears reasonable that all effective and well tolerated antihypertensive agents can be used in association to achieve DBP 80 mmHg and, whenever possible, SBP 130 or 135 mmHg, with the regular inclusion of an angiotensin-receptor antagonist for its proven renoprotective action. Hopefully, better guidance will be provided by further trials.     

Risk evaluation and therapeutical implications of pulse pressure in primary arterial hypertension

SUMMARY: Analysis of the results raised in the Framingham and the MRFIT study have clearly shown that increased pulse pressure is an independent cardiovascular risk factor. This is valid for all age groups and both sexes. The risk increases with pulse pressures over 60 - 65 mmHg for office blood pressure and 53 mmHg for 24-h-mean of ambulatory blood pressure. Pulse pressure is strongly correlated with systolic blood pressure and will be highest in case of isolated systolic hypertension. Urinary albumin excretion and left ventricular hypertrophy are closely associated with pulse pressure. With elevated pulse pressure cardiovascular risk is increased 2- to 4-fold in relation to age and endpoint. The risk of myocardial infarction is raised more if pulse pressure is associated with low mean arterial blood pressure while risk of stroke is increased with wide pulse pressure and high mean arterial pressure. The risk of pulse pressure can be seen in normotensives and in early pregnancy. Therapeutic management of pulse pressure will be similar to that of systolic blood pressure, since normalization of systolic blood pressure will also lower or normalize pulse pressure. Results of preliminary studies suggest that diuretics are superior to other drugs in decreasing pulse pressure. An increase of pulse pressure during therapy should be avoided since each 10 mmHg increase in pulse pressure will raise the risk of stroke and myocardial infarction about 24 % and 32 %.     

Association between blood pressure level and the risk of myocardial infarction, stroke, and total mortality: the cardiovascular health study

BACKGROUND: Recent reports have drawn attention to the importance of pulse pressure as a predictor of cardiovascular events. Pulse pressure is used neither by clinicians nor by guidelines to define treatable levels of blood pressure. METHODS: In the Cardiovascular Health Study, 5888 adults 65 years and older were recruited from 4 US centers. At baseline in 1989-1990, participants underwent an extensive examination, and all subsequent cardiovascular events were ascertained and classified. RESULTS: At baseline, 1961 men and 2941 women were at risk for an incident myocardial infarction or stroke. During follow-up that averaged 6.7 years, 572 subjects had a coronary event, 385 had a stroke, and 896 died. After adjustment for potential confounders, systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure were directly associated with the risk of incident myocardial infarction and stroke. Only SBP was associated with total mortality. Importantly, SBP was a better predictor of cardiovascular events than DBP or pulse pressure. In the adjusted model for myocardial infarction, a 1-SD change in SBP, DBP, and pulse pressure was associated with hazard ratios (95% confidence intervals) of 1.24 (1.15-1.35), 1.13 (1.04-1.22), and 1.21 (1.12-1.31), respectively; and adding pulse pressure or DBP to the model did not improve the fit. For stroke, the hazard ratios (95% confidence intervals) were 1.34 (1.21-1.47) with SBP, 1.29 (1.17-1.42) with DBP, and 1.21 (1.10-1.34) with pulse pressure. The association between blood pressure level and cardiovascular disease risk was generally linear; specifically, there was no evidence of a J-shaped relationship. In those with treated hypertension, the hazard ratios for the association of SBP with the risks for myocardial infarction and stroke were less pronounced than in those without treated hypertension. CONCLUSION: In this population-based study of older adults, although all measures of blood pressure were strongly and directly related to the risk of coronary and cerebrovascular events, SBP was the best single predictor of cardiovascular events.