Benefits for intensive BP lowering in older HTN patients

For older patients with hypertension, intensive blood pressure (BP) lowering strategies are associated with reduced risk of certain cardiovascular events, according to research published in the Feb. 7 issue of the Journal of the American College of Cardiology.

09 feb 2017--Chirag Bavishi, M.D., M.P.H., from Mount Sinai St. Luke's & Mount Sinai West Hospitals in New York City, and colleagues examined data from four high-quality trials involving 10,857 older hypertension patients (aged ≥65 years) with a mean follow-up of 3.1 years.
The researchers found that, compared with standard BP lowering, intensive BP lowering correlated with significant reductions in major adverse cardiovascular events (MACE), cardiovascular mortality, and heart failure (pooled relative risks [RR], 0.71 [95 percent confidence interval (CI), 0.60 to 0.84], 0.67 [95 percent CI, 0.45 to 0.98], and 0.63 [95 percent CI, 0.43 to 0.99], respectively). There were no between-group differences in the rates of myocardial infarction or stroke. No significant between-group difference was seen in the incidence of serious adverse events or renal failure (RRs, 1.02 [95 percent CI, 0.94 to 1.09] and 1.81 [95 percent CI, 0.86 to 3.80], respectively). In a fixed effects model, results were largely similar except the risk of renal failure was increased with intensive BP-lowering therapy (RR, 2.03 [95 percent CI, 1.30 to 3.18]).
"When considering intensive BP control, clinicians should carefully weigh benefits against potential risks," the authors write.
Several authors disclosed financial ties to the pharmaceutical and medical technology industries.

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Editorial

High incidence of cardiovascular risk factors in older adults

(HealthDay)—Older adults have high incidence of cardiovascular risk factors, with increased incidence of hypertension, diabetes mellitus, and dyslipidemia for blacks, according to a study published online Sept. 26 in the Journal of the American Geriatrics Society.

09 oct 2016--George Howard, Dr.P.H., from the University of Alabama at Birmingham, and colleagues measured the incidence of hypertension, diabetes mellitus, dyslipidemia, and atrial fibrillation over 10 years of follow-up in 10,801 community-dwelling adults.
The researchers found that for white men, black men, and black women, there was no evidence of an age-related difference in the incidence of hypertension (P ≥ 0.68), while for white women the incidence increased with age. For white men, black men, and white women the incidence of diabetes mellitus was lower at older ages, while there was no evidence of age-related changes for black women (P = 0.11). The incidence of dyslipidemia was about 20 percent for those aged 45 to 54 years; 30 percent for those aged 54 to 74 years; and 22 percent for those aged ≥75 years for all race-sex groups. The incidence of atrial fibrillation was low at age 45 to 54 years and was about 20 and 11 percent for white and blacks, respectively, for those aged ≥75 years. Across the age spectrum, the incidence of hypertension, diabetes mellitus, and dyslipidemia was higher in blacks, but the incidence of atrial fibrillation was lower.
"Incidence of risk factors remains high in older adults," the authors write.

More information: Abstract

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USPSTF recommends counseling for adults at risk for CVD 

29 aug 2014—The U.S. Preventive Services Task Force (USPSTF) recommends offering or referring overweight and obese adults with cardiovascular disease risk factors to intensive behavioral counseling. These findings are presented in a final recommendation statement published online Aug. 26 in the Annals of Internal Medicine.

Michael L. LeFevre, M.D., M.S.P.H., from the USPSTF in Rockville, Md., and colleagues updated recommendations on dietary counseling for adults with cardiovascular disease risk factors. Data were reviewed from 74 trials relating to the benefits and harms of primary care-relevant counseling interventions for a healthful diet and physical activity.

Based on the current evidence, the researchers recommend offering or referring overweight or obese adults with additional cardiovascular disease risk factors to intensive behavioral counseling interventions (Grade B recommendation). These interventions should promote a healthful diet and physical activity. These findings apply to adults aged 18 years or older in primary care settings who are overweight or obese and have additional cardiovascular disease risk factors, including hypertension, dyslipidemia, impaired fasting glucose, or metabolic syndrome.

"The most effective interventions vary, but typically involve a trained counselor who provides education, helps patients set goals, shares tools to help promote healthy behaviors, and regularly monitors and follows up with patients," Task Force member Su Curry, Ph.D., said in a statement.

More information: Recommendation
Evidence Review

New tests needed to predict cardiovascular problems in older people more accurately

Research paper: Use of Framingham risk score or new biomarkers to predict cardiovascular mortality in older people: Population-based observational cohort study

10 jan 2009--A long-standing system for assessing the risk of cardiovascular disease amongst older people should be replaced with something more accurate, according to a study published today on bmj.com.

The Dutch study looked at several hundred people with no history of cardiovascular disease aged 85 over a five year period to see which of them died of cardiovascular disease (such as stroke and heart disease), and whether different ways of assessing their risk of such disease at the start proved to be more accurate.

The Framingham Risk Score system has been used for decades to predict the 10-year risk of developing coronary heart disease in people with no history of such disease. It uses classic risk factors including sex, systolic blood pressure, cholesterol, diabetes, and smoking.

The ability of these classic risk factors to identify a person at high risk of heart disease diminishes as the person gets older.

In recent times, several new biomarkers for cardiovascular disease have been shown to be effective at indicating high risk of such disease, including C-reactive protein and homocysteine.

The researchers studied 302 people aged 85 years old (215 men and 87 women) who had no history of cardiovascular disease. The people were taking part in the existing Leiden 85-plus Study and were followed up for five years.

As well as using the Framingham Risk Score, the researchers also measured plasma levels of the new biomarkers homocysteine, folic acid, C-reactive protein and interleukin-6 in the people.

During the follow-up period, 108 of the 302 participants died and 32% of the deaths were from cardiovascular disease.

The researchers found that classic risk factors were unable to predict cardiovascular deaths accurately, neither by using the Framingham Risk Score nor by using the classic risk factors in a newly calibrated model.

From the new biomarkers used, homocysteine had the best ability to predict deaths.

Of the 35 people who died from cardiovascular disease during the five years studied, the Framingham Risk Score had classified just 12 people as being at high risk. However, the homocysteine-based model had classified 20 people as being high risk—nearly a quarter more of all individuals who died from cardiovascular disease.

The authors conclude that a single homocysteine measurement can accurately identify very elderly people who are at high risk of dying from cardiovascular disease. They call for a larger study to be carried out as their findings could lead to a change to current guidelines.

The researchers say: "Possibly, plasma homocysteine, and not classic risk factors, could be used to select very elderly people for primary preventive interventions."

Intense diabetes therapy didn't cut heart problems

By STEPHANIE NANO
06 june 2008--Aggressively treating diabetes doesn't prevent heart problems and deaths any better than standard treatment for lowering blood sugar, Australian researchers reported Friday.
It's the second large study, involving thousands of patients, to show no heart benefit from drastically lowering diabetics' blood sugar levels. Experts said doctors should stick to the recommended target levels.
Heart disease is the cause of death for two-thirds of diabetics. Researchers tried pushing blood sugar down to near-normal levels to see if that would protect the hearts of high-risk patients with Type 2 diabetes.
But the Australian study showed no difference in the number of heart attacks, strokes and heart-related deaths between groups who got intensive or standard care. A U.S. study that was stopped earlier this year also showed no benefit and in addition reported an unexplained higher number of deaths among those who were aggressively treated.
The Australian study showed one positive result — a one-fifth reduction in kidney problems, a common complication of diabetes, compared to normal care.
"Both studies are important contributions to the field but do not provide a definitive answer," Dr. William T. Cefalu, of Louisiana State University, wrote in an editorial in the New England Journal of Medicine. He said other ongoing studies should provide clarification.
Both studies were released Friday in the journal and are being presented at an American Diabetes Association meeting in San Francisco. Partial results of the U.S. research were released in February when it was halted.
An estimated 21 million Americans and 250 million people worldwide have diabetes, meaning their bodies can't properly regulate their blood sugar, or glucose. Most have Type 2 diabetes. High levels of blood sugar can cause damage to the heart, blood vessels, kidneys and eyes.
Instead of trying aggressive measures, experts say there should be more focus on other strategies known to lower heart risks — diet, exercise and medications such as aspirin, cholesterol-lowering statins and blood pressure drugs.
In the two studies, researchers used a test that tracks average glucose levels over two to three months. For diabetics in the U.S., the recommended level is below 7. People without diabetes have levels around 5.
Both studies targeted diabetes patients middle-aged or older who had a heart problem or other heart risk factors. Doctors used a variety of diabetes drugs and insulin to try to get blood sugar levels down — to less than 6 in the U.S. study and 6.5 or lower in the international study.
The Australian study had more than 11,000 participants from Asia, Australia, Europe and Canada; the U.S. study had 10,000.
The U.S study was stopped after 3 1/2 years because of more deaths in the aggressively treated group: 257 deaths compared to 203 for standard care. The researchers said they haven't found a reason for the difference. Everyone was switched to standard treatment, and the researchers are continuing to follow them.
In a statement, Dr. Elizabeth G. Nabel, director of the National Heart, Lung, and Blood Institute, said that severely lowering blood sugar appears to be too risky for diabetes patients at higher risk for heart problems. Her institute helped pay for the study.
Dr. Alvin Powers of Vanderbilt University said the Australian study was reassuring because it showed blood sugar levels could be safely lowered below the current targets, in contrast to the U.S. results. He said reducing kidney complications is significant because it would might mean fewer people needing dialysis or a kidney transplant.
"I think this affirms that 7 (blood sugar level) should remain our goal — but most people don't reach that goal," he said.
The Australian study was funded by the government and diabetes drugmaker Servier. The U.S. study was paid for by National Institutes of Health, and various companies provided diabetes drugs. A number of researchers in both studies report receiving grant support or frees from drugmakers.

Carotid Bruit May Predict Cardiovascular Risk

By Charles Bankhead
WASHINGTON, 10 may 2008 -- Checking for carotid bruit can identify patients at high cardiovascular risk, a meta-analysis here suggested.Carotid bruit doubled the risk of myocardial infarction and almost tripled the risk of cardiovascular death, Christopher Pickett, M.D., of Walter Reed Army Medical Center, and colleagues reported in the May 10 issue of The Lancet.When the analysis was limited to studies that permitted direct comparison of patients with and without bruit, the risk of MI and cardiovascular death remained twice as high in those with bruit.
"Our findings accord with the notion that these atherosclerotic changes [that lead to bruit] might be indicative of system-wide vascular pathological change to include the coronary bed," the authors concluded. "Clinicians auscultating a carotid bruit should be concerned that atherosclerosis might not just reside solely in the carotid artery."
They added, "Since auscultation of the carotid is a swift and inexpensive test, it should be used in every patient who might be at risk for coronary heart disease to aid the clinician in assessment of cardiac risk."
The prognostic implications of carotid bruit have focused primarily on cerebrovascular events. However, carotid bruit has only weak predictive accuracy for cerebrovascular events in patients who are otherwise symptomatic, the authors noted.
As a result of the prognostic uncertainty of carotid bruit, screening recommendations vary. For example, the U.S. Preventive Services Task Force and the Canadian Task Force recommend against routine auscultation for carotid bruit, the authors continued. On the other hand, the American Academy of Family Physicians and other groups recommend screening auscultation in select patients.
"Carotid bruits are probably a better indicator of generalized atherosclerotic disease than of stroke risk, and several studies have suggested that patients with carotid artery disease are more likely to die from cardiovascular than from cerebrovascular disease," the authors said.
To examine bruits' predictive accuracy for cardiovascular death and MI, Dr. Pickett and colleagues analyzed data from 22 studies involving a total of 17,295 patients with 62,413.5 patient-years of follow-up. Median duration of follow-up was four years.
The analysis showed that patients with bruits had an MI rate of 3.69 per 100 patient-years versus 1.86 per 100 patient-years in those without bruits. The yearly rate of cardiovascular death was 2.85 versus 1.11 per 100 patient-years, respectively, for patients with and without bruits.
The design of four trials allowed direct comparisons of patients with and without bruits. In that analysis, patients with bruits had a two-fold greater risk of MI (OR 2.15, 95% CI 1.67 to 2.78) and cardiovascular death (OR 2.27, 95% CI 1.49 to 3.49).
In a commentary accompanying the article, Victor Aboyans, M.D., and Philippe Lacroix, M.D. of Dupuyten Hospital in Limoges, France, cited several limitations of the study and findings.
About a third of the study participants had existing cardiovascular disease. Bruit's influence on secondary prevention is unclear.
Bruit's prognostic value was not compared with cardiovascular risk scores, making the incremental value unknown.
Patients without bruit have other clinical signs that could have similar prognostic significance.
Despite those limitations, the editorialists suggested that evaluation of patients for bruit could be added to other simple tests for a simple office-based assessment capable of identifying high-risk patients.
"Prospective studies on asymptomatic patients are needed to study the prognostic value of a combination of simple clinical signs such as neck and groin auscultation and pulse palpation," said Drs. Aboyans and Lacroix. "Heart rate, pulse pressure, or blood-pressure difference between arms could also be considered."
They added, "These studies could narrow the indications of cardiovascular imaging techniques and make them more cost effective in developed countries. In developing countries, the same data could help make the best use of very limited resources dedicated to prevention of cardiovascular disease."
The authors and the editorialists declared no conflicts of interest.
Primary source: The LancetSource reference:Pickett CA, et al "Carotid bruits as a prognostic indicator of cardiovascular death and myocardial infarction: A meta-analysis" Lancet 2008.

Single Tool Predicts Global and Specific Cardiovascular Risks

By Charles Bankhead
BOSTON, Jan. 23 -- A patient's global cardiovascular disease risk can be predicted accurately by an office-friendly algorithm, according to investigators here.
What's more, simple adjustments to the general algorithm allow accurate prediction of a patient's risk for each cardiovascular disease component -- coronary disease, cerebrovascular disease, peripheral arterial disease, and heart failure.
So said Ralph B. D'Agostino, Sr., Ph.D., of Boston University, and colleagues online in Circulation: Journal of the American Heart Association, in a Framingham study-based report slated for the Feb. 12 print issue.
Traditional cardiovascular disease risk factors proved to be highly significant predictors of cardiovascular disease risk (P<0.0001), and the general algorithm demonstrated good discrimination for men and women, they found.
"Individuals with a high overall cardiovascular disease risk require more aggressive risk factor modification," said Dr. D'Agostino and colleagues. "The goal of therapy for cholesterol disorders, diabetes, and hypertension should be linked to the global cardiovascular disease risk."
Use of validated cardiovascular disease risk prediction algorithms has lagged in primary care, in part because of the sheer number of algorithms, each targeted toward predicting a patient's risk for an individual cardiovascular disease event, the authors said.
So they set out to develop a single multivariable risk assessment tool that would allow physicians to identify patients with a high risk for any type of cardiovascular disease event, using measurements that are readily available in an office or clinic.
The resulting algorithm was derived from data on 8,491 Framingham study participants followed for 12 years. The patients were 30 to 74 years old at their initial examination and were free of cardiovascular disease.
Investigators developed sex-specific multivariable risk functions that incorporated several readily assessable cardiovascular disease risk factors:
Patient age
Total cholesterol and HDL
Systolic blood pressure
Treatment for hypertension
Smoking status
Diabetes status
During follow-up, 1,174 participants developed a first cardiovascular disease event, which translated into an occurrence rate of 10.08% for women and 18.09% for men. For predicting global cardiovascular disease risk, the algorithm demonstrated good accuracy for men and women, as reflected by c-statistics of 0.762 and 0.793, respectively. In contrast, an earlier Framingham risk algorithm yielded lower c-statistics of 0.756 for men and 0.778 for women.
Comparison of the two algorithms resulted in a "net reclassification improvement from using the new model that was statistically significant for men [P<0.001] and women [P=0.003]," the authors said.
To determine a patient's risk for individual cardiovascular disease events, the global risk score was calculated and then multiplied by the proportion of total cardiovascular disease events represented by the specific event. For example, a woman's risk for coronary heart disease events was determined by multiplying her global risk score by 0.61, the proportion of first cardiovascular disease events that were coronary heart disease events.
Discussing the clinical implications and potential utility of the algorithm, the authors noted that "a multivariable risk formulation for global cardiovascular disease made up of standard risk factors is particularly relevant for primary prevention of atherosclerotic cardiovascular disease because it is intuitive that measures taken to prevent any one cardiovascular disease outcome can be expected to also prevent risk of the other cardiovascular disease outcomes."
"Therefore, use of a general cardiovascular disease risk score is an attractive option in office-based primary care practices," they continued. "Serial assessment of global cardiovascular disease risk could be used to monitor progress of patients on treatment and improvement in their multivariable risk scores."
They also pointed out that "other risk factors not included in the general risk profile must be taken into account in evaluating risk and selecting the most efficacious treatment. These include abdominal obesity, ECG evidence of left ventricular hypertrophy, indications of insulin resistance, triglycerides, and a strong family history of premature cardiovascular disease. Obesity is not included because its influence is largely attributable to its promotion of insulin resistance and its attendant cardiovascular disease risk factors."
In acknowledging limitations of the study, the authors noted that the algorithm did not include all cardiovascular risk factors. They also acknowledged that the algorithm requires validation in other populations.
Dr. D'Agostino has served as a consultant or adviser for Sanofi and Pfizer.
Primary source: CirculationSource reference:D'Agostino RB, et al "General cardiovascular risk profile for use in primary care: the Framingham heart study" Circulation 2008; 117: DOI: 10.1161/CIRCULATIONAHA.107.699579.