BP, cardiovascular disease, and death in the Folic Acid for Vascular Outcome Reduction in Transplantation trial.
ABSTRACT: The optimal BP level in kidney transplant recipients remains uncertain. This post hoc analysis of the Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) trial cohort assessed associations of BP with a pooled cardiovascular disease (CVD) outcome and with all-cause mortality. In 3474 prevalent kidney transplant patients, mean age was 52±9 years, 63% were men, 76% were white, 20% had a history of CVD, 40% had a history of diabetes mellitus, and the median time since transplant was 4.1 years (25th to 75th percentiles, 1.7-7.4); mean systolic BP was 136±20 mmHg and mean diastolic BP was 79±12 mmHg. There were 497 CVD events and 406 deaths. After adjustment for demographic and transplant characteristics and CVD risk factors, each 20-mmHg increase in baseline systolic BP associated with a 32% increase in subsequent CVD risk (hazard ratio [HR], 1.32; 95% confidence interval [95% CI], 1.19 to 1.46) and a 13% increase in mortality risk (HR, 1.13; 95% CI, 1.01 to 1.27). Similarly, after adjustment, at diastolic BP levels<70 mmHg, each 10-mmHg decrease in diastolic BP level associated with a 31% increase in CVD risk (HR, 1.31; 95% CI, 1.06 to 1.62) and a 31% increase in mortality risk (HR, 1.31; 95% CI, 1.03 to 1.66). However, at diastolic BP levels>70 mmHg, there was no significant relationship between diastolic BP and outcomes. Higher systolic BP strongly and independently associated with increased risk of CVD and all-cause mortality, without evidence of a J shape, whereas only lower levels of diastolic BP associated with increased risk of CVD and death in this trial.
Project description:Aims:To characterize the relationship between blood pressure (BP) or heart rate and mortality and morbidity in chronic obstructive pulmonary disease (COPD). Methods and results:We performed post hoc analysis of baseline BP or heart rate and all-cause mortality and cardiovascular events in the SUMMIT trial. SUMMIT was a randomized double-blind outcome trial of 16 485 participants (65?±?8?years, 75% male, and 47% active smokers) enrolled at 1368 sites in 43 countries. Participants with moderate COPD with or at risk for cardiovascular disease (CVD) were randomized to placebo, long-acting beta agonist, inhaled corticosteroid, or their combination. All-cause mortality increased in relation to high systolic [?140?mmHg; hazard ratio (HR) 1.27, 95% confidence interval (CI) 1.12-1.45] or diastolic (?90?mmHg; HR 1.35, 95% CI 1.14-1.59) BP and low systolic (<120?mmHg; HR 1.36, 95% CI 1.13-1.63) or diastolic (<80?mmHg; HR 1.15, 95% CI 1.00-1.32) BP. Higher heart rates (?80 per minute; HR 1.39, 95% CI 1.21-1.60) and pulse pressures (?80?mmHg; HR 1.39, 95% CI 1.07-1.80) were more linearly related to increases in all-cause mortality. The risks of cardiovascular events followed similar patterns to all-cause mortality. Similar findings were observed in subgroups of patients without established CVD. Conclusion:A 'U-shaped' relationship between BP and all-cause mortality and cardiovascular events exists in patients with COPD and heightened cardiovascular risk. A linear relationship exists between heart rate and all-cause mortality and cardiovascular events in this population. These findings extend the prognostic importance of BP to this growing group of patients and raise concerns that both high and low BP may pose health risks.
Project description:The relationship between various categories of blood pressure (BP), subtypes of hypertension, and development of cardiovascular disease (CVD) have not been extensively studied. Therefore, our study aimed to explore this relationship in a random population sample of men born in 1943, living in Sweden and followed over a 21-year period.Participants were examined for the first time in 1993 (age 50 years), where data on medical history, concomitant diseases, and general health were collected. The examination was repeated in 2003 and with additional echocardiography also in 2014. Classification of participants according to their BP at the age of 50 years was as follows: optimal-normal BP (systolic blood pressure [SBP] <130 and diastolic BP [DBP] <85?mmHg), high-normal BP (130???SBP?<?140, 85???DBP?<?90?mmHg), isolated systolic-diastolic hypertension (ISH-IDH) (SBP ?140 and DBP <90 or SBP <140 and DBP ?90?mmHg), and systolic-diastolic hypertension (SDH) (SBP ?140 and DBP ?90?mmHg).During the follow-up, the incidence of heart failure (HF), CVD, and coronary heart disease were all lowest for those with optimal-normal BP. Participants with high-normal BP showed greater wall thickness and left ventricular mass index, larger LV size and larger left atrial size when compared with the optimal-normal BP group. Furthermore, those with high-normal BP, ISH-IDH, and SDH had a higher risk of CVD than those with optimal-normal BP. The adjusted relative risk of CVD was highest for SDH (hazard ratio [HR] 1.95; 95% confidence interval [95% CI] 1.37-2.79), followed by ISH-IDH (HR 1.34; 95% CI 0.93-1.95) and high-normal BP (HR 1.31; 95% CI 0.91-1.89).Over a 21-year follow-up, the participants with high-normal BP or ISH-IDH had a higher relative risk of CVD than those with optimal-normal BP.
Project description:BACKGROUND:Differences between the arms in systolic blood pressure (SBP) of ?10?mmHg have been associated with an increased risk of mortality in patients with hypertensive and chronic renal disease. For the first time, we examined these relationships in a non-clinical population. DESIGN:Cohort study. METHODS:Participants were 4419 men (mean age 38.37 years) from the Vietnam Experience Study. Bilateral SBP and diastolic BP (DBP), serum lipids, fasting glucose, erythrocyte sedimentation rate, metabolic syndrome, and ankle brachial index were assessed in 1986. RESULTS:Ten per cent of men had an interarm difference of ?10 and 2.4% of ?15?mmHg. A 15-year follow-up period gave rise to 246 deaths (64 from cardiovascular disease, CVD). Interarm differences of ?10?mmHg were associated with an elevated risk of all-cause mortality (hazard ratio, HR, 1.49, 95% confidence interval, CI, 1.04-2.14) and CVD mortality (HR 1.93, 95% CI 1.01-3.69). After adjusting for SBP, DBP, lipids, fasting glucose, and erythrocyte sedimentation rate, associations between interarm differences of ?10?mmHg and all-cause mortality (HR 1.35, 95% CI 0.94-1.95) and CVD mortality (1.62, 95% CI 0.84-3.14) were significantly attenuated. CONCLUSIONS:In this non-clinical cohort study, interarm differences in SBP were not associated with mortality after accounting for traditional CVD risk factors. Interarm differences might not be valuable as an additional risk factor for mortality in populations with a low risk of CVD.
Project description:BACKGROUND AND AIM:Cardiovascular diseases (CVDs) are globally the leading cause of death and hypertension is a significant risk factor. Treatment with glucagon-like peptide-1 (GLP-1) receptor agonists has been associated with decreases in blood pressure and CVD risk. Our aim was to investigate the association between endogenous GLP-1 responses to oral glucose and peripheral and central haemodynamic measures in a population at risk of diabetes and CVD. METHODS:This cross-sectional study included 837 Danish individuals from the ADDITION-PRO cohort (52% men, median (interquartile range) age 65.5 (59.8 to 70.7) years, BMI 26.1 (23.4 to 28.5) kg/m2, without antihypertensive treatment and known diabetes). All participants received an oral glucose tolerance test with measurements of GLP-1 at 0, 30 and 120 min. Aortic stiffness was assessed by pulse wave velocity (PWV). The associations between GLP-1 response and central and brachial blood pressure (BP) and PWV were assessed in linear regression models adjusting for age and sex. RESULTS:A greater GLP-1 response was associated with lower central systolic and diastolic BP of -?1.17 mmHg (95% confidence interval (CI) -?2.07 to -?0.27 mmHg, P?=?0.011) and -?0.74 mmHg (95% CI -?1.29 to -?0.18 mmHg, P?=?0.009), respectively, as well as lower brachial systolic and diastolic BP of -?1.27 mmHg (95% CI -?2.20 to -?0.33 mmHg, P?=?0.008) and -?1.00 (95% CI -?1.56 to -?0.44 mmHg, P?=?0.001), respectively. PWV was not associated with GLP-1 release (P?=?0.3). Individuals with the greatest quartile of GLP-1 response had clinically relevant lower BP measures compared to individuals with the lowest quartile of GLP-1 response (central systolic BP: -?4.94 (95% CI -?8.56 to -?1.31) mmHg, central diastolic BP: -?3.05 (95% CI -?5.29 to -?0.80) mmHg, brachial systolic BP: -?5.18 (95% CI -?8.94 to -?1.42) mmHg, and brachial diastolic BP: -?2.96 (95% CI -?5.26 to -?0.67) mmHg). CONCLUSION:Greater glucose-stimulated GLP-1 responses were associated with clinically relevant lower central and peripheral blood pressures, consistent with beneficial effects on the cardiovascular system and reduced risk of CVD and mortality. Trial registration ClinicalTrials.gov Identifier: NCT00237549. Retrospectively registered 10 October 2005.
Project description:Although orthostatic hypotension (OH) is often considered a contraindication to blood pressure (BP) treatment, evidence is lacking. We examined the effect of BP goal or initial medication choice on OH in AASK (African American Study of Kidney Disease and Hypertension), a 2×3 factorial trial. Blacks with chronic kidney disease attributed to hypertension were randomly assigned 1 of 2 BP goals: intensive (mean arterial pressure, ?92 mm?Hg) or standard (mean arterial pressure, 102-107 mm?Hg) and 1 of 3 initial medications (ramipril, metoprolol, and amlodipine). Postural changes in systolic BP, diastolic BP, or heart rate (HR) were determined after 2 minutes and 45 seconds of standing. OH was assessed each visit and defined using the consensus definition (drop in systolic BP ?20 mm?Hg or diastolic BP ?10 mm?Hg). Median follow-up was 4 years. Outcomes were congestive heart failure, stroke, nonfatal cardiovascular disease (CVD), fatal CVD, any CVD (composite of preceding events), and all-cause mortality. There were 1094 participants (mean age, 54.5±10.7 years; 38.8% female; OH was assessed at 52?864 visits). Mean seated systolic BP, diastolic BP, and HR were 150.3±23.9 mm?Hg, 95.5±14.2 mm?Hg, and 72.0±12.6 bpm, respectively. A more intensive BP goal did not alter the distributions of standing BP and was not associated with OH, but metoprolol was associated with systolic OH compared with ramipril (odds ratio, 1.68; 95% CI, 1.15-2.46) and amlodipine (odds ratio, 1.94; 95% CI, 1.09-3.44). Although consensus OH was associated with stroke (HR, 5.01; 95% CI, 1.80-13.92), nonfatal CVD (HR, 2.28; 95% CI, 1.21-4.30), and any CVD event (HR, 2.12; 95% CI, 1.12-3.98), neither BP goal or medication altered this risk. Concerns about causing OH or its CVD consequences should not deter a lower BP goal among adults with chronic kidney disease attributed to hypertension.
Project description:Aims:To examine associations of diastolic and systolic blood pressure (SBP) at age 50, 60, and 70?years with incidence of dementia, and whether cardiovascular disease (CVD) over the follow-up mediates this association. Methods and results:Systolic and diastolic blood pressure were measured on 8639 persons (32.5% women) from the Whitehall II cohort study in 1985, 1991, 1997, and 2003. Incidence of dementia (n dementia/n total?=?385/8639) was ascertained from electronic health records followed-up until 2017. Cubic splines using continuous blood pressure measures suggested SBP ?130?mmHg at age 50 but not at age 60 or 70 was associated with increased risk of dementia, confirmed in Cox regression analyses adjusted for sociodemographic factors, health behaviours, and time varying chronic conditions [hazard ratio (HR) 1.38; 95% confidence interval (95% CI) 1.11, 1.70]. Diastolic blood pressure was not associated with dementia. Participants with longer exposure to hypertension (SBP???130?mmHg) between mean ages of 45 and 61?years had an increased risk of dementia compared to those with no or low exposure to hypertension (HR 1.29, 95% CI 1.00, 1.66). In multi-state models, SBP ??130?mmHg at 50?years of age was associated with greater risk of dementia in those free of CVD over the follow-up (HR 1.47, 95% CI 1.15, 1.87). Conclusion:Systolic blood pressure ?130?mmHg at age 50, below the conventional ?140?mmHg threshold used to define hypertension, is associated with increased risk of dementia; in these persons this excess risk is independent of CVD.
Project description:Objective:There is rising interest in digital health in preventive cardiology, particularly for blood pressure (BP) management. In a digital health study of early BP assessment following acute myocardial infarction (AMI), we sought to examine feasibility and the (1) proportion of post-AMI patients with controlled BP and hypotension, and (2) association between prior cardiovascular disease (CVD) and BP post-AMI. Methods:In this substudy of the parent Myocardial infarction, COmbined-device, Recovery Enhancement (MiCORE) study, type 1 AMI patients were enrolled between October 2017 and April 2019. Participants self-monitored their BP through 30 days after hospital discharge using an FDA-approved wireless BP monitor connected with a smartphone application. Linear mixed-effects models assessed the association between prior CVD and BP trajectory post-discharge, adjusting for antihypertensive medications and a propensity score inclusive of CVD risk factors. Results:Sixty-eight AMI patients (mean age 58 ?± ?10 years, 75% male, 68% white race, 68% history of hypertension, 24% prior CVD) provided 2638 measurements over 30 days. The percentage of BP control <130/80 ?mmHg was 59.6% (95% CI: 54.3-64.9%) and <140/90 ?mmHg was 83.7% (95% CI: 80.3-87.2%). The percentage of systolic BP ?<90 ?mmHg was 1.1% (95% CI: 0.17-2.0%) and the percentage of diastolic BP ?<60 ?mmHg was 3.9% (95% CI: 2.6-5.2%). Prior CVD was associated with 12.2 ?mmHg higher mean daily systolic BP during admission (95% CI: 3.5-20.9 ?mmHg), which persisted over follow-up. There was no association between prior CVD and diastolic BP. Conclusion:The digital health program was feasible and ~40% of post-AMI patients who engaged in it had uncontrolled BP according to recent guideline cutpoints, while hypotension occurred rarely. The gap in BP control was especially large in patients in whom AMI represented recurrent CVD. These data suggest an opportunity for more aggressive secondary prevention early after MI as care models integrate digital health.
Project description:Masked hypertension, defined as nonelevated clinic blood pressure (BP) with elevated out-of-clinic BP, has been associated with increased cardiovascular disease (CVD) risk in Europeans and Asians. Few data are available on masked hypertension and CVD and mortality risk among blacks. We analyzed data from the Jackson Heart Study, a prospective cohort study of blacks. Analyses included participants with clinic-measured systolic/diastolic BP <140/90 mm?Hg who completed ambulatory BP monitoring after the baseline examination in 2000 to 2004 (n=738). Masked daytime (10:00 am-8:00 pm) hypertension was defined as mean ambulatory systolic/diastolic BP ?135/85 mm?Hg. Masked nighttime (midnight to 6:00 am) hypertension was defined as mean ambulatory systolic/diastolic BP ?120/70 mm?Hg. Masked 24-hour hypertension was defined as mean systolic/diastolic BP ?130/80 mm?Hg. CVD events (nonfatal/fatal stroke, nonfatal myocardial infarction, or fatal coronary heart disease) and deaths identified through December 2010 were adjudicated. Any masked hypertension (masked daytime, nighttime, or 24-hour hypertension) was present in 52.2% of participants; 28.2%, 48.2% and 31.7% had masked daytime, nighttime, and 24-hour hypertension, respectively. There were 51 CVD events and 44 deaths during a median follow-up of 8.2 and 8.5 years, respectively. CVD rates per 1000 person-years (95% confidence interval) in participants with and without any masked hypertension were 13.5 (9.9-18.4) and 3.9 (2.2-7.1), respectively. The multivariable adjusted hazard ratio (95% confidence interval) for CVD was 2.49 (1.26-4.93) for any masked hypertension and 2.86 (1.59-5.13), 2.35 (1.23-4.50), and 2.52 (1.39-4.58) for masked daytime, nighttime, and 24-hour hypertension, respectively. Masked hypertension was not associated with all-cause mortality. Masked hypertension is common and associated with increased risk for CVD events in blacks.
Project description:To compare effects of combinations of standard and intensive treatment of glycemia and either blood pressure (BP) or lipids in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.ACCORD enrolled 10,251 type 2 diabetes patients aged 40-79 years at high risk for cardiovascular disease (CVD) events. Participants were randomly assigned to hemoglobin A1c goals of <6.0% (<42 mmol/mol; intensive glycemia) or 7.0-7.9% (53-63 mmol/mol; standard glycemia) and then randomized a second time to either 1) systolic BP goals of <120 mmHg (intensive BP) or <140 mmHg (standard BP) or 2) simvastatin plus fenofibrate (intensive lipid) or simvastatin plus placebo (standard lipid). Proportional hazards models were used to assess combinations of treatment assignments on the composite primary (deaths due to CVD, nonfatal myocardial infarction [MI], and nonfatal stroke) and secondary outcomes.In the BP trial, risk of the primary outcome was lower in the groups intensively treated for glycemia (hazard ratio [HR] 0.67; 95% CI 0.50-0.91), BP (HR 0.74; 95% CI 0.55-1.00), or both (HR 0.71; 95% CI 0.52-0.96) compared with combined standard BP and glycemia treatment. For secondary outcomes, MI was significantly reduced by intensive glycemia treatment and stroke by intensive BP treatment; most other HRs were neutral or favored intensive treatment groups. In the lipid trial, the general pattern of results showed no evidence of benefit of intensive regimens (whether single or combined) compared with combined standard lipid and glycemia treatment. The mortality HR was 1.33 (95% CI 1.02-1.74) in the standard lipid/intensive glycemia group compared with the standard lipid/standard glycemia group.In the ACCORD BP trial, compared with combined standard treatment, intensive BP or intensive glycemia treatment alone improved major CVD outcomes, without additional benefit from combining the two. In the ACCORD lipid trial, neither intensive lipid nor glycemia treatment produced an overall benefit, but intensive glycemia treatment increased mortality.
Project description:This study investigated whether a mean blood pressure (BP) of <130/80 mm Hg is associated with further reduction in cardiovascular outcomes in treated hypertensive subjects with previous stroke.Subjects from the Korea National Health Insurance Service health examinee cohort diagnosed as having stroke and hypertension from January 1st, 2003 and December 31st, 2006 (N=2320) were grouped according to mean systolic (<130, 130-<140, and ?140 mm Hg) and diastolic (<80, 80-<90, and ?90 mm Hg) BP recorded during follow-up health examinations. All-cause and cardiovascular mortality over 11 years were compared. Compared with subjects with a systolic BP of ?140 mm Hg (N=736), subjects with a systolic BP of 130 to <140 mm Hg (N=793) had a significantly lower risk of all-cause death (hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.47-0.79; P<0.001), cardiovascular mortality (HR, 0.39; 95% CI, 0.25-0.61; P<0.001), and fatal ischemic stroke (HR, 0.25; 95% CI, 0.10-0.63; P=0.003). Systolic BP of <130 mm Hg (N=791) was associated with lower risk of nonfatal hemorrhagic stroke. Subjects with a diastolic BP of 80 to <90 mm Hg (N=1100) had significantly lower risk of all-cause death (HR, 0.60, 95% CI, 0.45-0.80; P<0.001) and cardiovascular mortality (HR, 0.45; 95% CI, 0.30-0.70; P<0.001) than those with a diastolic BP of ?90 mm Hg (N=342). Diastolic BP of <80 mm Hg (N=878) was associated with reduced risk of nonfatal hemorrhagic stroke and further lowering of all-cause mortality and cardiovascular mortality.BP of <130/80 mm Hg was associated with improved outcomes in hypertensive subjects with previous stroke.