Tomasz Grodzicki

Pulsatile blood pressure component as predictor of mortality in hypertension: a meta-analysis of clinical trial control groups

Objective Although current guidelines rest exclusively on the measurement of systolic and diastolic blood pressures, the arterial pressure wave is more precisely described as consisting of a pulsatile (pulse pressure) and a steady (mean pressure) component. This study explored the independent roles of pulse pressure and mean pressure as predictors of mortality in a wide range of patients with hypertension. Design and methods This meta-analysis, based on individual patient data, has combined results from the control groups of seven randomized clinical trials conducted in patients with systolo-diastolic or isolated systolic hypertension. The relative hazard rates associated with pulse pressure and mean pressure were calculated using Coxs proportional hazard regression models with stratification for the seven trials and with adjustment for sex, age, smoking and the other pressure. Results A 10 mmHg wider pulse pressure at baseline, which corresponds to approximately one-half of its standard deviation, was independently associated with an increase in risk by 6% for total mortality (P = 0.001), 7% for cardiovascular mortality (P = 0.01), and 7% for fatal coronary accidents (P = 0.03).The corresponding increase in risk of fatal stroke was similar (+6%, P = 0.27) but there were too few strokes to reach statistical significance. In similar analyses, mean pressure was not identified as an independent predictor of these outcomes. Significant interactions of pulse pressure or mean pressure with age suggested that the prognostic power of pulse pressure for fatal stroke was more important at higher age (P = 0.04), whereas the prognostic power of mean pressure for coronary mortality was greatest in the young (P = 0.01). Conclusions In hypertensive patients pulse pressure, not mean pressure, is associated with an increased risk of fatal events. This appears to be true in a broad range of patients with hypertension.

Salt and Hypertension: Is Salt Dietary Reduction Worth the Effort?

In numerous epidemiologic, clinical, and experimental studies, dietary sodium intake has been linked to blood pressure, and a reduction in dietary salt intake has been documented to lower blood pressure. In young subjects, salt intake has a programming effect in that blood pressure remains elevated even after a high salt intake has been reduced. Elderly subjects, African Americans, and obese patients are more sensitive to the blood pressure-lowering effects of a decreased salt intake. Depending on the baseline blood pressure and degree of salt intake reduction, systolic blood pressure can be lowered by 4 to 8 mm Hg. A greater decrease in blood pressure is achieved when a reduced salt intake is combined with other lifestyle interventions, such as adherence to Dietary Approaches to Stop Hypertension. A high salt intake has been shown to increase not only blood pressure but also the risk of stroke, left ventricular hypertrophy, and proteinuria. Adverse effects associated with salt intake reduction, unless excessive, seem to be minimal. However, data linking a decreased salt intake to a decrease in morbidity and mortality in hypertensive patients are not unanimous. Dietary salt intake reduction can delay or prevent the incidence of antihypertensive therapy, can facilitate blood pressure reduction in hypertensive patients receiving medical therapy, and may represent a simple cost-saving mediator to reduce cardiovascular morbidity and mortality.

Medical, psychological and socioeconomic aspects of aging in Poland Assumptions and objectives of the PolSenior project

Both descriptive and longitudinal studies of aging are nowadays a subject of growing interest in different countries worldwide. However, in Poland and other Central-Eastern European countries, such comprehensive, nationally representative, multidimensional studies were never performed in the past in elderly population. The present paper describes the PolSenior project including its objectives, sample selection and structure, methods, fieldwork procedures and study flow. The aim of the project was to examine medical, psychological and socioeconomic aspects of aging in Poland. The research sample included 5695 respondents (2899 males and 2796 females) split into six equally sized age groups of elderly individuals (65-69 years, 70-74 years, 75-79 years, 80-84 years, 85-89 years, 90+years) and one group of subjects just about to enter old age (55-59 years). Subjects were recruited using three stage stratified, proportional draw. The response rate was 42% and ranged from 32% to 61% between provinces. The study consisted of three visits performed by trained nurses including questionnaire survey, comprehensive geriatric assessment and blood and urine sampling. The questionnaire consisted of medical and specific socioeconomic questions. The comprehensive geriatric assessment included blood pressure and anthropometric measurements, as well as selected scales and tests routinely used in the examination of elderly subjects. Blood and urine samples were collected from 4737 and 4526 individuals, respectively. More than 50 biochemical parameters were measured, and DNA was isolated and banked. In a selected group of 1018 subjects, a medical examination by a physician was performed. The self-rated health was lower in females than in males in age groups 70-84, but similar in individuals of both sexes aged 65-69 and 85 years. Besides providing data on health and functioning of elderly population, the PolSenior project aims to analyze interrelationships between different elements of health and social status, and between genetics and health status in advanced age. The results of the PolSenior project will facilitate prioritizing the states public health and social policies in elderly population. Such a program provides also an excellent starting point for longitudinal studies and a basis for comparative analysis between Poland and other European countries or regions.

Beyond salt: lifestyle modifications and blood pressure

Lifestyle changes have been shown to effect significant blood pressure (BP) reductions. Although there are several proposed neurohormonal links between weight loss and BP, body mass index itself appears to be the most powerful mediator of the weight-BP relationship. There appears to be a mostly linear relationship between weight and BP; as weight is regained, the BP benefit is mostly lost. Physical activity, but more so physical fitness (the physiological benefit obtained from physical activity), has a dose-dependent BP benefit but reaches a plateau at which there is no further benefit. However, even just a modest physical activity can have a meaningful BP effect. A diet rich in fruits and vegetables with low-fat dairy products and low in saturated and total fat (DASH) is independently effective in reducing BP. Of the dietary mineral nutrients, the strongest data exist for increased potassium intake, which reduces BP and stroke risk. Vitamin D is associated with BP benefit, but no causal relationship has been established. Flavonoids such as those found in cocoa and berries may have a modest BP benefit. Neither caffeine nor nicotine has any significant, lasting BP effect. Biofeedback therapies such as those obtained with device-guided breathing have a modest and safe BP benefit; more research is needed before such therapies move beyond those having an adjunctive treatment role. There is a strong, linear relationship between alcohol intake and BP; however, the alcohol effects on BP and coronary heart disease are divergent. The greatest BP benefit seems to be obtained with one drink per day for women and with two per day for men. This benefit is lost or attenuated if the drinking occurs in a binge form or without food. Overall, the greatest and most sustained BP benefit is obtained when multiple lifestyle interventions are incorporated simultaneously.

Polypharmacy in the Aging Patient: Management of Hypertension in Octogenarians

IMPORTANCE Hypertension treatment is beneficial for most hypertensive patients. The benefits for patients who are very old and frail, especially those taking numerous medications, are less certain. OBJECTIVE To provide recommendations for the evaluation and treatment of hypertension among patients aged 80 years and older. EVIDENCE ACQUISITION MEDLINE, PubMed Central, and the Cochrane Database of Systematic Reviews were searched from inception through April 2015, with an emphasis on 2010-2015. Manual cross-referencing of review articles and meta-analyses was also performed to identify randomized controlled trials (RCTs) examining antihypertensive use in octogenarians. The search strategy included the following Medical Subject Headings: hypertension or high blood pressure and trials and oldest old or very old or very elderly. FINDINGS Six post hoc analyses of the previously published Hypertension in the Very Elderly Trial (HYVET) met the inclusion criteria. In the only placebo-controlled RCT on hypertension management in patients older than 80 years (HYVET; N = 3845), the treatment was associated with lower total mortality and key cardiovascular end points but the effect on stroke (fatal and nonfatal), which was the primary outcome, failed to reach the significance level (P = .06). Post hoc analyses of HYVET suggested that active hypertension treatment in very elderly patients was beneficial by reducing blood pressure in individuals with white coat hypertension, showed moderate benefits of the active treatment for cognition, a possible effect for fractures prevention, and sustained differences in reductions of total mortality and cardiovascular mortality in those receiving active treatment. However, patients were community dwelling and less disabled than individuals of the same age in general. CONCLUSIONS AND RELEVANCE Hypertensive patients who are healthy, functionally independent, and aged 80 years and older should be treated according to current recommendations for people older than 65 years. There is insufficient evidence regarding the benefits of hypertension treatment for frail polymedicated octogenarians, for whom treatment should be individualized.

Reference Values in White Europeans for the Arterial Pulse Wave Recorded by Means of the SphygmoCor Device

Measurement of blood pressure together with applanation tonometry at the radial artery allows the reproducible assessment of various indexes of arterial stiffness, including the peripheral (PPp) and central pulse pressures (PPc) and the peripheral (AIp) and central augmentation indexes (AIc). We defined preliminary diagnostic thresholds, using the distributional characteristics of these hemodynamic measurements in a reference population. We randomly recruited 870 subjects from 3 European populations. PPp was the average difference between systolic and diastolic blood pressure measured five times at one home visit. For measurement of PPc, AIp and AIc, we used the SphygmoCor device. We selected subjects without hypertension, diabetes, dyslipidemia in need of medical treatment or previous or concomitant cardiovascular disease. The study population included 228 men and 306 women (mean age 34.9 years). All hemodynamic measurements were curvilinearly related to age, and AIp and AIc were lower in men than in women. In men at age 40, the upper 95% prediction bands of the relations of the hemodynamic measurements with age approximated 60 mmHg for PPp, 40 mmHg for PPc, 90% for AIp, and 30% for AIc. For PPc, AIp and AIc, these thresholds must be adjusted for age, leading to lower and higher thresholds at younger and older age, respectively. In addition, in women of any age, the AIp and AIc thresholds must be increased by 10% and 7%, respectively. Pending validation in prospective outcome studies, distributional characteristics of arterial stiffness indexes in a reference population can be used to generate operational thresholds for use in clinical practice.

An Expert Opinion From the European Society of Hypertension–European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects

Two years after the publication of the 2013 guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC),1 the ESH and the European Union Geriatric Medicine Society have created a common working group to examine the management of hypertensive subjects aged >80 years. The general term hypertension in the elderly is not sufficiently accurate because it mixes younger old patients (60–70 years) with the oldest old. Our group believes that the management of hypertension in individuals aged ≥80 years should be specifically addressed. Although arbitrary, this cutoff value identifies a population that is expanding faster than any other age group with a 50% increase of life expectancy during the past 50 years2,3; furthermore, the incidence and prevalence of comorbidities, frailty, and loss of autonomy greatly increases after the age of 80 years4; finally, although there is limited evidence on the management of hypertension in this age group, the latest clinical studies indicate that in these patients, treatment may not be the same as in patients in the lower age strata. The aim of this Working Group was to discuss more in-depth treatment aspects of hypertensive patients aged ≥80 years or older, with special focus on the difficulties and uncertainties posed by very old frail individuals. We focused, in particular, on the following points of the 2013 ESH/ESC guidelines: The 2013 ESH/ESC guidelines1 reported the results of the Hypertension in the Very Elderly Double Blind Trial (HYVET). This showed that in hypertensive patients aged ≥80 years, the administration of the thiazide-like diuretic indapamide supplemented, if necessary, by the angiotensin-converting enzyme inhibitor perindopril led to a significant reduction in the …

Short-term and long-term repeatability of the morning blood pressure in older patients with isolated systolic hypertension

Objective Using 24-h ambulatory blood pressure monitoring, we studied the repeatability of the morning blood pressure in older (≥60 years) patients with isolated systolic hypertension. Methods The sleep-through morning surge was the morning blood pressure minus the lowest nighttime blood pressure. The preawake morning surge was the morning blood pressure minus the preawake blood pressure. In addition, we determined the cusum plot height of blood pressure from 04:00 to 10:00 h from a plot of cumulative sums. Results In 173 patients with repeat recordings within 33 days (median), the short-term repeatability coefficients, expressed as percentages of maximal variation, ranged from 35 to 41% for the daytime and nighttime blood pressures and from 50 to 56% for the night-to-day blood pressure ratios. Short-term repeatability ranged from 52 to 75% for the sleep-through and the preawake morning surge, and from 51 to 62% for the cusum plot height. In 219 patients with repeat recordings within 10 months (median), the corresponding long-term estimates ranged from 45 to 64%, from 69 to 71%, from 76 to 83%, and from 50 to 78%, respectively. In categorical analyses of the short-term repeatability of the sleep-through morning surge and the preawake morning surge, using the 75th percentile as arbitrary cut-off, surging status changed in 28.0 and 26.8% of patients (κ-statistic ≤0.33). In the long-term interval, these proportions were 32.0 and 32.0%, respectively (κ-statistic ≤0.20). The κ-statistic threshold for moderate reproducibility is 0.4. Conclusion The morning surge of blood pressure is poorly reproducible, irrespective of whether it is analysed as continuous or categorical variable.

Severe frailty and cognitive impairment are related to higher mortality in 12-month follow-up of nursing home residents.

Frailty syndrome (FS) and cognitive impairment are associated with an increased risk of falls, disability, hospitalization and death. We investigated prognostic meaning of FS and cognitive impairment in persons ≥ 65 years, living in 2 nursing homes. Information about the health status of patients was gathered from history, medical documentation, test assessing FS, according to the Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) and the Mini-Mental State Examination (MMSE). The study group included 66 women and 20 men, between 66 and 101 years of age (mean ± S.D.=83.8 ± 8.3 years). The frequency of severe frailty (CSHA-CFS=7) among the elderly living in nursing homes was 34.9%, while severe cognitive impairment (MMSE<18) was present in 55.8%. Residents with severe FS and MMSE<18 consisted 33.7% of examined and 50.0% of those who died during 12-month follow-up, p<0.05. Individuals with severe FS and severe cognitive impairment (n=29) as compared to all other patients, were significantly less probable (59% vs. 79%, p=0.03) to survive one year. Neither frailty, nor dementia, nor severe FS or cognitive impairment when considered separately was associated with higher mortality rate. The risk assessment in severely disabled geriatric patients is best performed with measures of functional and cognitive function considered jointly, but not separately.

Isolated systolic hypertension: pathophysiology, consequences and therapeutic benefits

During recent decades the importance of perceiving isolated systolic hypertension (ISH) in cardiovascular pathophysiology has been changed from a benign condition to the major cardiovascular risk factor. Aging is per se associated with the deterioration in arterial compliance through both structural and functional changes in large arteries which mainly involves the intima and media. The observed changes result in a decrease of the lumen-to-wall ratio, the overall lumen cross-sectional area and an increase of arterial stiffness which especially involve the aorta and other elastic arteries. In addition to the structural changes in vessel walls, aging is associated with certain functional changes such as an increase in sympathetic system activity probably due to the age-related decreased sensitivity of beta-receptors. While the function of arterial wall alpha-receptors remains intact, in elderly subjects a shift towards arterial vasoconstriction can be observed.In many of the published studies the definition of ISH was based on the criterion 160/95 mm Hg or 160/90 mm Hg while in recognition of the high risk associated with systolic blood pressure (SBP) the WHO/ISH guidelines and Report of the Sixth Joint National Committee on Hypertension indicated that ISH should be diagnosed with SBP as ⩾140 mm Hg and diastolic BP (DBP) as <90 mm Hg. Thus the setting down of normal values of SBP will lead to an earlier diagnosis and treatment of ISH.Several prospective studies, such as the US Hypertension Detection and Follow-up Programme, confirmed this and the Multiple Risk Factor Intervention Trial demonstrated that for any given level of DBP, higher SBP was associated with an increase in cardiovascular risk. Moreover, data from the Framingham Study show that ISH was associated not only with increased mortality but also cardiovascular morbidity. Risk of non-fatal stroke and myocardial infarction was increased three and two-times respectively in the presence of ISH.Three major up-to-date studies that included patients with ISH have been published. In concordance to the previously published SHEP and MCR trials, the most recent, the Systolic Hypertension in the Elderly Trial (SYST-EUR), demonstrated that active treatment significantly reduces the risk of stroke and all fatal and non-fatal cardiac end-points, including sudden death. Of note, these benefits were demonstrated with new anti-hypertensive classes such as dihydropiridyne calcium channel blocker (nitrendipine) and the angiotensin- converting enzyme inhibitor (enalapril).The necessity to carefully balance the benefits and risks of anti-hypertensive therapy in the elderly indicates that patients with suspected ISH should undergo careful BP measurements on at least three different occasions before the diagnosis is established and an orthostatic reaction should be evaluated.If non-pharmacological procedures fail, drug therapy should be considered, especially in elderly patients with a SBP over 160 mm Hg, since their risk of complications is markedly higher. Pharmacological treatment should also be strongly considered in patients with a SBP between 140 and 160 mm Hg with such concomitant cardiovascular risk factors as diabetes, angina pectoris, and left ventricular hypertrophy. The drug regimen should be simple, starting with a low dose of a single drug that is titrated slowly. The selection of the first-line anti-hypertensive agent should be based on a careful assessment of pathophysiological and clinical parameters in each individual geriatric patient.