Is chronic inflammation a determinant of blood pressure in the elderly?

BACKGROUND: Previous studies have shown that a rise in blood pressure (BP) causes chronic inflammation of the endothelium which, in turn, may be responsible for further damage of endothelium and worsening of BP control. On the other hand, several metabolic abnormalities such as dyslipidemia, hyperinsulinemia/insulin-resistance, diabetes, and obesity causes inflammation followed by a later rise in arterial BP. We investigated the role of chronic inflammation in the modulation of BP independently of other traditional cardiovascular risk factors and atherosclerotic lesions. METHODS: A total of 537 aged subjects, selected from the whole population of the INCHIANTI cohort, were enrolled. All subjects underwent plasma insulin, glucose, interleukin-6 (IL-6), interleukin-10 (IL-10), interleukin-1 beta (IL-1 beta), interleukin-1 receptor antagonist (IL-1ra), C-reactive protein, and tumor necrosis factor-alpha (TNF-alpha) levels determination. The IL-6-174 C/G promoter polymorphism was also evaluated. RESULTS: After adjusting for age, sex, insulin resistance syndrome score, and severity of carotid atherosclerosis, serum IL-1 beta (P <.001), IL-1ra (P <.005) concentration and the insulin resistance syndrome score (P <.001) were the only predictors of diastolic BP. Indeed, age (P <.001), insulin resistance syndrome score (P =.05), IL-1 beta (P <.05), and severity of carotid atherosclerosis (P <.05) were the only significant predictor of systolic BP. CONCLUSION: These results suggest that chronic inflammation may play a role in the modulation of arterial BP.     

Bayesian estimates of the prevalence of β-thalassemia trait in voluntary blood donors of central India: a survey

Early detection of β-thalassemia (β-thal) trait is important. Voluntary blood donors represent an important group who are accessible and cooperative for this purpose. However, the usefulness of this population in β-thal trait detection programs has not been studied in India. We conducted a hematological survey of 5,045 blood donors who visited the Bhopal Memorial Hospital & Research Centre, Bhopal in central India. Using robust Bayesian methods, we estimated the prevalence of β-thal trait. The overall prevalence of β-thal trait in the study population was 9.59% [95% confidence interval (95% CI) 8.78-10.4%]. The prevalence of β-thal trait varied across the states of origin and within the state of Madhya Pradesh. We observed a cline effect for β-thal trait prevalence in relation to the latitude (p = 0.024). We conclude that blood donors offer an attractive adjunct to β-thal trait detection in national programs. Our study also offers insights into the β-thal trait gene flow and migration in India.     

High blood pressure in early acute stroke: a sign of a poor outcome?

OBJECTIVE: To evaluate the prognostic value of admission blood pressure in patients with acute ischemic stroke by determining whether it contributes to clinical outcome and vascular death. METHODS: We studied 230 consecutive patients admitted within the first 24 h after the onset of ischemic stroke. We used the first systolic and diastolic blood pressure measurements recorded on admission. The functional outcome was assessed on the basis of mortality or dependency (Rankin Scale > 3) at the 10-day and 6-month visits. RESULTS: High systolic blood pressure on admission was associated with poor outcome at the 10-day and 6-month visits, independent of the baseline risk factors but not of the severity of the initial stroke (odds ratio, 1.39; 95% confidence interval, 0.50-3.87). The spontaneous decrease in systolic blood pressure within the first 10 days was higher in patients with functional improvement. The admission blood pressure was not significantly associated with total and vascular deaths, except for a threshold effect of diastolic blood pressure. CONCLUSIONS: After an acute stroke, the relationship between blood pressure and clinical outcome depended on the severity of the stroke on presentation, and on the level and trend of the systolic blood pressure during the first 24 h.     

Rheumatologists’ practice during the Coronavirus disease 2019 (COVID-19) pandemic: a survey in Egypt

Rheumatology International - The aim of this work is to trace how rheumatologists all over Egypt are approaching the COVID-19 pandemic and what changes it has brought about in the patients’...     

Estradiol-17β reduces blood pressure and restores the normal amplitude of the circadian blood pressure rhythm in postmenopausal hypertension

After menopause, both systolic (SBP) and diastolic (DBP) blood pressure (BP) become higher in women than in men of the same age, suggesting that estrogen deficiency may influence the age-related increase in BP. We studied 30 postmenopausal women (mean age, 55 ± 5.7 years; time from menopause, 2–5 years) affected by mild hypertension with no target-organ complications by means of 24-h BP monitoring. None of the group were undergoing estrogen replacement therapy or taking antihypertensive drugs. According to a randomized, double-blind protocol, subjects received patches of transdermal estradiol-17β (E₂) or a matched placebo, with crossover after a 7-day washout period. In 12 patients the 24-h peak-to-trough variation in SBP and DBP amounted to less than 10% (nondippers). Administration of E₂ significantly decreased 24-h SBP and DBP in the whole cohort (P < .05). Furthermore, E₂ restored the expected reduction in BP during nighttime in the nondipper subgroup. It is well known that estrogen replacement therapy protects against the development of both cardiovascular diseases and stroke. Our data suggest that this activity could be attributed, at least in part, to the activity of E₂ in preserving physiologic circadian fluctuation of BP.     

Development of leprosy in a patient with ankylosing spondylitis during the infliximab treatment: reactivation of a latent infection?

The use of tumor necrosis factor α as a treatment for chronic inflammatory conditions has been shown to be associated with an increased risk of developing infections, especially Mycobacterium tuberculosis, atypical mycobacteria, and other microorganisms. We report the case of a 58-year-old man with ankylosing spondylitis, receiving infliximab treatment, who presented with multiple plaques on the face, chest, and extremities, a thickened, tender ulnar nerve, and severe neuritis of the feet. The results of a biopsy of these lesions revealed histopathological features of lepromatous Hansen disease. The use of anti-tumor necrosis factor biologic agent on this patient may have resulted in either a new infection or reactivation of a latent infection of Mycobacterium leprae.     

Limitations of blood pressure target in non-dialysis chronic kidney disease: a question of method?

International guidelines recommend to reduce blood pressure (BP) levels below 130/80 mmHg in non-dialysis chronic kidney disease (CKD) patients. However, this BP target has not been validated by randomized controlled trials and is mainly driven by data obtained in observational and post-hoc analyses suggesting that it improves the renal and, to some extent, cardiovascular prognosis. The inconclusive results on the prognostic role of the BP target in patients with CKD might also relate to the limited ability of office BP readings to adequately stratify the global risk of this population. In fact, alterations of the pressure profile (such as white-coat hypertension) and nighttime hypertension are common in CKD patients. Recent studies have demonstrated that ambulatory blood pressure monitoring (ABPM) is superior to clinic BP measurements in predicting renal death and cardiovascular events. Therefore, while waiting for the results from the ongoing randomized Systolic Blood Pressure Intervention Trial (SPRINT) comparing the effect on cardiorenal prognosis of two BP target levels, the more widespread use of ABPM is desirable in CKD patients.     

Long-term changes in blood pressure prior to the development of cerebral infarction—The Hisayama study

Long-term changes in blood pressure were studied to determine the relationship to hypertensive clinical manifestations, and to cerebral infarction. In the prospective cohort study in Hisayama, Japan, the initial 4yr were assigned for assessment of changes in blood pressure. During the subsequent 9 yr from 1965, cerebral infarction developed in 71 (44 men, 27 women) among 1181 subjects, 44-years old or older and fatalities were verified by autopsy. Blood pressure elevation to the hypertensive range contributed to the complications manifested by changes in ocular fundi and/or ECG, and increased the risk of cerebral infarction. However, in the women, a systolic blood pressure decrease greater than the mean − 1 SD, cerebral infarction developed more frequently than in those whose systolic blood pressure remained within mean ± 1 SD. Results of the multiple regression analysis indicated that blood pressure in women prior to cerebral infarction may cover a range of variability.     

Validation of hospital frailty risk score to predict hospital use in older people: Evidence from the Australian Longitudinal Study on Women’s Health

BackgroundFrailty is among the most serious global public health challenges due to the rapid increase in the ageing population and age-associated declines in health. We aimed to validate hospital frailty risk score (HFRS) for its ability to predict prolonged hospital length of stay, 28-day unplanned readmission, repeated admission, and mortality in older people over a 15-year follow-up period.MethodsWe linked data from the Australian Longitudinal Study on Women’s Health (ALSWH) with hospital admission and National Death Index datasets to identify admitted patients and death dates. This study included patients with an index unplanned admission resulting in an overnight hospital stay in 2001–2016 and aged 75–95 years at the time of admission. HFRS and Charlson comorbidity index (CCI) were calculated from the hospital data using the International Statistical Classification of Diseases, Australia Modification (ICD-10-AM) diagnostic codes.ResultsOf 2740 older women aged 75 years and over with unplanned admission, the proportions of patients with low, intermediate, and high frailty risks were 77.15 % (n = 2114), 20.95 % (n = 574), and 1.90 % (n = 52), respectively. The 15-year follow-up revealed that high frailty risk patients increased 5-fold in 2015 (15.67 % patients, mean age = 92.26 years) compared to 2001 (2.56 % patients, mean age = 77.96 years). Prolonged hospital length of stay was higher in the intermediate (AOR = 2.86, 95 %CI: 2.26, 3.62) and high frailty risk group (AOR = 4.26, 95 %CI: 2.32, 7.63) compared to the low frailty risk group. Frailty risk was not associated with unplanned or repeated hospital admission. However, the intermediate frailty risk group (AHR = 1.78, 95 %CI: 1.47, 2.17) and the high frailty risk group (AHR = 4.17, 95 %CI: 2.00, 8.66) had a significant risk of mortality compared to the low frailty risk group.ConclusionsThis study confirms the ability of HFRS to identify older, frail people at higher risk of prolonged hospital length of stay and increased mortality risk. However, we did not observe a significant association between HFRS and 28-day unplanned readmission or repeated hospital admission.     

Effect of a fixed combination of Perindopril and Amlodipine on blood pressure control in 6256 patients with not-at-goal hypertension: the AVANT’AGE study

In clinical practice, general practitioners are likely to face hypertensives with uncontrolled blood pressure (BP), whose antihypertensive treatment need to be modified. In the present study, 710 general practitioners have each included the first 10 patients with not-at-goal hypertension, for whom they decided to modify their antihypertensive treatment with addition of a fixed combination of Perindopril and Amlodipine at either of its four dosages: 5/5, 5/10, 10/5, or 10/10 mg. In total, 6256 patients were included, with BP measured both at baseline and after 3 months. At the end of follow-up, a mean reduction of 20.3 ± 12.4 mm Hg in systolic BP and 11.3 ± 9.6 mm Hg in diastolic BP were observed, and 62.3% achieved successful BP control. Body mass index and waist circumference were significant determinants of both systolic and diastolic BP reductions (P ≤ .04). Moreover, in addition to baseline BP level, body mass index was the only significant determinant of BP control of systolic, diastolic BP, and of both (P ≤ .04). Addition of a fixed combination of Perindopril and Amlodipine to BP regimen was efficient, in terms of BP control, for 62.3% of those patients with not-at-goal hypertension. Furthermore, baseline BP level and obesity were important influential factors of BP control.     

Ambulatory diastolic blood pressure: a marker of comorbidity in elderly fit hypertensive individuals?

BACKGROUNDMasked diastolic hypotension is a new blood pressure (BP) pattern detected by ambulatory blood pressure monitoring (ABPM) in elderly hypertensives. The aim of this study was to relate ABPM and comorbidity in a cohort of fit elderly subjects attending an outpatient hypertension clinic.METHODSComorbidity was assessed by Charlson comorbidity index (CCI) and CHA₂DS₂VASc score. All subjects evaluated with ABPM were aged ≥ 65 years. CCI and CHA₂DS₂VASc score were calculated. Diastolic hypotension was defined as mean ambulatory diastolic BP < 65 mmHg and logistic regression analysis was carried out in order to detect and independent relationship between comorbidity burden and night-time diastolic BP < 65 mmHg. RESULTSWe studied 174 hypertensive elderly patients aged 72.1 ± 5.2 years, men were 93 (53.4%). Mean CCI was 0.91 ± 1.14 and mean CHA₂DS₂VASc score of 2.68 ± 1.22. Subjects with night-time mean diastolic values < 65 mmHg were higher in females [54.7% vs. 45.3%, P = 0.048; odds ratio (OR) = 1.914, 95% CI: 1.047−3.500]. Logistic regression analysis showed that only CHA₂DS₂VASc score was independently associated with night-time mean diastolic values < 65 mmHg (OR = 1.518, 95% CI: 1.161−1.985; P = 0.002), but CCI was not. CONCLUSIONSABPM and comorbidity evaluation appear associated in elderly fit subjects with masked hypotension. Comorbid women appear to have higher risk for low ambulatory BP.

The global population is ageing, and the number of subjects with long-term disorders is increasing, with heavy consequences on medical commitment and health-care systems burden.^[1] Moreover, multimorbidity is associated with a higher mortality,^[2,3] and hypertension represents a frequent condition involving patients with multiple diseases.^[1] The relationship between multimorbidity and hypertension is bidirectional. Hypertension could cause organ damage and then development of comorbidity; on the other hand, comorbidity could worsen hypertension and its consequences. In elderly subjects, hypertension could cause brain damage that could be the cause of cognitive decline;^[4] moreover, systemic atheroembolic syndrome could worsen blood pressure (BP) variability leading to cardiovascular disease (CVD).^[5]Hypertension, both complicated or not complicated, is a variable taken into consideration in a series of risk scores applied to the general population to estimate the mortality risk, such as the Cumulative Illness Rating Scale,^[6] the Charlson comorbidity index (CCI),^[7] and the Elixhauser index.^[8] The CHA₂DS₂VASc score is widely used as predictor of the risk of stroke in patients with atrial fibrillation, it includes hypertension among the factors considered for score calculation and its importance is underlined by the same weight assigned to congestive heart failure (CHF), age > 75 years, and diabetes mellitus (1 point). ^[9] However, CHA₂DS₂VASc score has also been suggested to be able to stratify adverse clinical events in hypertensive patients.^[10]In patients with comorbidities, out-of-office monitoring of BP has been shown to be associated with reduced systolic BP (SBP) compared to usual care, representing a very useful tool in routine clinical practice.^[11] However, the discrepancy of measures between office and out-of-office BP measures, such as ambulatory blood pressure monitoring (ABPM), is known since two decades,^[12] and these two approaches have pros and cons depending also on type of patients. In untreated older patients with isolated systolic hypertension, for example, ambulatory SBP was a significant predictor of cardiovascular risk over and above conventional BP.^[13,14]It is widely accepted that ABPM is a crucial informative tool for the evaluation of BP behaviour in everyday clinical practice,^[15] and is recommended to identify white-coat hypertension and masked hypertension.^[15,16] However, its importance goes greatly beyond due to its capacity to provide information for clinical use.^[15] In fact, night-time evaluation of BP is crucial to detect abnormal patterns of night-time behaviour, such as non-dipping, inverse dipping, extreme dipping and the morning surge,^[17] and asleep SBP is a significant BP derived risk factor for CVD events.^[18,19]Recently, a novel BP pattern defined masked diastolic hypotension, frequently found in older patients under antihypertensive treatment, has raised attention.^[20] Knowledge related to clinical use of ABPM in elderly subjects is still a matter of debate, and information about BP components and circadian profiles in subjects with high comorbidity burden is scarce.^[21]The aim of this study was investigate the possible relationship between the BP components (recorded by ABPM) and the comorbidity burden (assessed by means of CCI and CHA₂DS₂VASc score) in a cohort of fit elderly subjects attending an outpatient hypertension clinic.