No cardiovascular disease reduction with intensive blood pressure lowering treatment

Blood pressure lowering treatment does not reduce death or cardiovascular disease in healthy individuals with a systolic blood pressure below 140. This is shown in a systematic review and meta-analysis from Umeå University. The results, published in JAMA Internal Medicine, support current guidelines and contradict the findings from the Systolic Blood Pressure Intervention Trial (SPRINT).

19 nov 2017--Blood pressure treatment goals have been intensively debated since the publication of the SPRINT study in 2015. While current guidelines recommend a systolic blood pressure goal < 140 mm Hg, SPRINT found additional mortality and cardiovascular diseasereduction with a goal < 120 mm Hg.
A systematic review and meta-analysis from Umeå University, published today in JAMA Internal Medicine, contradicts these findings. The Umeå study shows that treatment does not affect mortality or cardiovascular events if systolic blood pressure is < 140 mm Hg. The beneficial effect of treatment at low blood pressure levels is limited to trials in people with coronary heart disease.
"Our findings are of great importance to the debate concerning blood pressure treatment goals," says Dr Mattias Brunström, researcher at the Department of Public Health and Clinical Medicine, Umeå University and lead author.
The study is a meta-analysis, combining data from 74 randomized clinical trials, including more than 300 000 patients. The researchers separated primary preventive studies from studies in people with coronary heart disease or previous stroke. The analysis found that the treatment effect was dependent on how high blood pressure was in previously healthy individuals. If systolic blood pressure was above 140 mm Hg, treatment reduced the risk of death and cardiovascular disease. Below 140 mm Hg, treatment did not affect mortality or the risk of first-ever cardiovascular events.
"Several previous meta-analyses have found that blood pressure lowering treatment is beneficial down to levels below 130 mm Hg. We show that the beneficial effect of treatment at low blood pressure levels is limited to trials in people with coronary heart disease. In primary preventive trials, treatment effect was neutral," says Mattias Brunström.

More information: JAMA Internal Medicine (2017). DOI: 10.1001/jamainternmed.2017.6015


Provided by Umea University

Extreme swings in blood pressure are just as deadly as having consistently high blood pressure

Extreme ups and downs in systolic blood pressure may be just as deadly as having consistently high blood pressure, according to a new study from the Intermountain Medical Center Heart Institute in Salt Lake City.

Extreme ups and downs in systolic blood pressure may be just as deadly as having consistently high blood pressure, according to a new study from the Intermountain Medical Center Heart Institute in Salt Lake City.

19 nov 2017--Following a review of electronic medical records, researchers from the Intermountain Medical Center Heart Institute discovered that patients with systolic blood pressure numbers that varied by as much as 30 or 40 between doctor visits over an extended period of time were more likely to die than those with less extreme variances in their blood pressure.
The systolic blood pressure reading (the upper number) indicates how much pressure blood is exerting against the artery walls when the heart beats. According to the American Heart Association, a normal systolic blood pressure is less than 120. High blood pressure is categorized as above 140.
"Blood pressure is one of those numbers we encourage people to keep track of, as it's one indicator of your health heart," said Brian Clements, DO, an internal medicine specialist with the Intermountain Medical Center Heart Institute, and lead invesigator of the study. "The takeaway from the study is, if you allow your blood pressure to be uncontrolled for any period of time, or notice big changes in your blood pressure between doctor visits, you increase your risk of stroke, heart attack, kidney or heart failure, or even death."
Results of the study of nearly 11,000 patients will be reported at the 2017 American Heart Association Scientific Sessions in Anaheim, CA, on Monday, November 13.
Researchers at the Intermountain Medical Center Heart Institute modeled their study after an analysis of the largest hypertension clinical trial ever conducted - the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).
They examined visit-to-visit variability of systolic blood pressure in 10,903 patient records from Intermountain Healthcare facilities. The patients were required to have had seven blood pressure measurements between 2007 and 2011. After the date of their seventh recorded systolic blood pressure measurement, the patients were followed for five years, with researchers looking at all causes of mortality.
"The call to action for patients as a result of this study is to do everything they can to control their blood pressure on a regular basis," said Dr. Clements. "Eat healthy foods, exercise regularly, and if your doctor has prescribed you medications for your blood pressure, be sure and take them consistently. Because any time your blood pressure is out of control, you're at higher risk of injury or death."
In most people, systolic blood pressure rises steadily with age due to increased stiffness of large arteries, long-term build-up of plaque, and increased incidence of cardiac and vascular disease, according to the the American Heart Association.
Dr. Clements also recommends that people control their environment when measuring their blood pressure to help reduce additional variables from influencing the measurement.

• Sit or lay down for 15 minutes prior to taking your blood pressure. Don't do things that will cause you stress, as that may raise your blood pressure.
• Use a blood pressure cuff that fits. Make sure it's not too tight or too large.

"After the ALLHAT study, we were in a unique position because Intermountain Healthcare has such a rich database of records that are perfect for identifying trends and outcomes," said Dr. Clements. "In this case, we're working to identify the cause of the variances in systolic blood pressure and learn if it's an independent predictor of mortality, thus helping clinicians work with their patients to better manage their heart health."


Provided by Intermountain Medical Center

Seasonal variation in blood pressure

17 jan 2009--A French study reported in the 12th January issue of Archives of Internal Medicine has found a strong correlation between blood pressure and outdoor temperature in a large sample of the elderly.(1) As a result, the investigators advise that, during periods of extreme temperatures, careful monitoring of blood pressure and antihypertensive treatment "could contribute to reducing the consequences of blood pressure variations in the elderly".

The study, which monitored 8801 participants over the age of 65 in the French Three-City study, found that systolic and diastolic blood pressure values differed significantly across the four seasons of the year and according to the distribution of outdoor temperature. The higher the temperature, the greater the decrease in blood pressure. Systolic blood pressure, for example, decreased with increasing temperature, with an 8.0 mmHg decrease between the lowest ( <>

Participants' blood pressure was measured at the beginning of the study (starting in 1999) and again about two years later. Outdoor temperatures on the day of measurement were obtained from local meteorological offices. Participants in the Three-City study were from Bordeaux, Dijon and Montpellier.

"Although our study does not demonstrate a causal link between blood pressure and external temperature, the observed relationship nevertheless has potentially important consequences for blood pressure management in the elderly," the authors state. "Because the risk of stroke or aneurysmal rupture is highest in the elderly, improved protection against these diseases by close monitoring of blood pressure and antihypertensive medication when outdoor temperature is very low could be considered."

Speaking on behalf of the European Society of Cardiology (ESC), Professor Frank Ruschitzka from the University Hospital, Zurich, says that the study reaffirms the place of the elderly as a target group for blood pressure monitoring. "The elderly, especially the increasing number of octogenarians, should not be neglected. They need extra care, and will benefit from monitoring and appropriate treatment. This study emphasises the need for year-round vigilance."

One possible explanation for the study findings, adds Professor Ruschitzka, lies in the emerging link between vitamin D and blood pressure. The elderly, especially those in care homes, are subject to vitamin D deficiency, largely as a result of their limited exposure to sunlight, and vitamin D deficiency can predispose to hyptertension via activation of the renin-angiotensin-aldosterone system. "The benefit of sunlight on vitamin D levels in the elderly is under appreciated," says Professor Ruschitzka. "Fifteen minutes exposure to sunlight can produce the equivalent of 2000 international units vitamin D."

A report from the Framingham Heart Study published in 2008 found that moderate vitamin D deficiency nearly doubles the risk of myocardial infarction, stroke and heart failure over a mean of 5.4 years in patients with high blood pressure.(2) The Nurses Health Study, also reporting in 2008, found that lower blood levels of vitamin D are independently associated with an increased risk of hypertension; women with the lowest levels had a 66 per cent higher incidence of hypertension than those with the highest levels.(3)

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References:

1. Alpérovitch A, Lacombe J-M, Hanon O, et al. Relationship Between Blood Pressure and Outdoor Temperature in a Large Sample of Elderly Individuals: The Three-City Study. Arch Intern Med 2009; 169: 75-80.

2. Wang TJ, Pencina MJ, Booth SL, et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation 2008; 117: 503-511.

3. Forman JP, Curhan JC, Taylor EN. Plasma 25-hydroxyvitamin D levels and risk of incident hypertension among young women. Hypertension 2008; 52: 828-832.

New AHA Statement Sets Lower BP Targets for High-Risk and Established CAD Patients

June 22, 2007 — Blood pressure (BP) targets in men and women with established coronary artery disease (CAD), or who are at high risk of developing CAD should be 130/80 mm Hg: lower than those specified in the Joint National Committee (JNC) 7th report of 140/90 mm Hg, a new American Heart Association Scientific Statement specifies. The BP target of 140/90 remains appropriate for general CAD prevention, the writing group, led by Dr Clive Rosendorff (Mount Sinai School of Medicine, New York, NY), says.
The JNC 7th report currently recommends that the lower target of 130/80 mm Hg be used in patients with diabetes or chronic kidney disease (CKD); the new statement suggests this group should be broadened. "When people walk into their doctors' offices with systolic pressures between 130 and 140, most primary care doctors and many cardiologists would believe that patient had normal blood pressure and wouldn't require additional treatment," Rosendorff told heartwire. "We have tried to show that in fact there is a great deal to be gained by treating those patients to lower levels."
The statement deals both with primary prevention patients — divided into "general" prevention or high CAD risk — as well as patients with pre-existing CAD in different forms: stable angina; unstable angina/non-ST elevation MI; ST-elevation MI; heart failure secondary to CAD. Patients in the high-risk category are defined as patients who also have diabetes, CKD, known CAD, a CAD-risk equivalent (carotid disease, peripheral artery disease, or abdominal aortic aneurysm), or a ten-year Framingham risk score ≥ 10%; these patients should all have their BP lowed to < 130/80 mm Hg, as would patients with pre-existing CAD. In patients with heart failure, physicians should consider a target even lower, the authors suggest, < 120/80 mm Hg, although blood pressure lowering should be slow, they caution.
Drug Therapy Recommendations
Authors of the statement also provide recommendations for drug therapy, according to CAD status. In keeping with recent European guidelines, beta-blockers are no longer recommended for blood pressure control in the primary prevention group.
"There have been lots of comparative clinical trails to show that for preventing both stroke and CAD complications, beta-blockers are inferior to newer classes of drugs like ACE inhibitors, angiotensin-receptor blockers, or calcium channel blockers, so we have dropped beta-blockers right out of the picture for prevention," Rosendorff explained. "However, once there is established, occlusive CAD, with symptoms like angina or acute MI, then beta-blockers come right back to center stage."
To heartwire, Rosendorff emphasized that this is the first time an AHA writing group has specifically tackled the topic of BP targets in the CAD population, despite the fact that the two conditions are pathophysiologically linked and constitute an "enormous public health issue." The new guidelines first appeared online last month; Rosendorff said he has already received some mixed feedback. "Some people think that 130/80 mm Hg is too low, and some think it's not low enough," he said. Overall, however, Rosendorff thinks many physicians are not yet aware of the recommendations, or do not appreciate the magnitude of the change.
"It doesn't sound like a lot — just 10 mm Hg — but in terms of the number of patients who are going to now require treatment if these guidelines are followed, it is huge," he said. "The impact is going to be that there will be many, many more people who will require antihypertensive medication, and of those already on antihypertensive medication, the management will need to be much more intensive or aggressive. But that's also going to translate into much better outcomes, much fewer heart attacks, and probably fewer strokes and fewer patients going into kidney failure."
Circulation. 2007;115;2761-2788.