Do you have mild hypertension? If you don't know get measuring.
In medicine we define a disease as a clinicopathological correlate, i.e. there are clinical findings associated with a specific pathology that is unique and separates the specific disease from other disorders, which may mimic it. When mild-to-moderate hypertension develops there are usually no specific symptoms and when diagnosed early there is little of no end-organ signs of damage. In other words, hypertension is part of the prodrome for diseases that manifest many years later. However, the medical profession treats hypertension as a disease in itself. Why? I think it is because the epidemiological evidence showing hypertension is associated with poor outcomes is so strong, i.e. if hypertension is left untreated it will result in disease in the future, for example, ischaemic heart disease, cerebrovascular disease, kidney damage, etc. However, is it hypertension itself that causes these downstream events or is it the metabolic syndrome (insulin resistance, obesity, sedentary lifestyle) that invariably accompanies hypertension that is the culprit? This is why interventional studies are so important. By treating hypertension and not the associated metabolic syndrome you can test whether or not hypertension itself is causal.
When hypertension is diagnosed and treated it is usually accompanied by advice about lifestyle interventions, i.e. weight reduction, dietary changes (less salt) and exercise. This is why randomised controlled trials are so important to test whether or not the intervention itself, i.e. antihypertensives, work. Another bit of evidence is to look for a dose-effect; does excellent control of hypertension outperform less good control? This is why studies such as the SPRINT (Systolic Blood Pressure Intervention Trial) trial are so important (see final report below). Among people who are at risk of vascular disease due to hypertension targeting a systolic blood pressure of less than 120 mm Hg results in lower rates of major adverse cardiovascular events and lower all-cause mortality than targeting a systolic blood pressure of less than 140 mm Hg. The one downside is that the more intensive control of blood pressure came at the cost of slightly higher rates of some adverse events.
The implications of these findings are not trivial and suggest that many of us, me included, who are over 50 years of age and have mild hypertension with systolic blood pressure consistently over 130mmHg with another cardiovascular risk factor should be aggressively controlling their blood pressure. I am not!
These results also have implications for the polypill concept i.e. fixed-dose combination pills to target hypertension and metabolic syndrome. We may need to adjust the dose of various constituents of the polypill to individualise dosing to achieve optimal control of hypertension (systolic BP < 120 mmHg). Just maybe the recent development of 3D printing of pills is a solution to this problem; by adjusting the doses of individual constituents, 3D printed pills could create bespoke even unique polypills for individuals based on their response or non-response to any one constituent.
The bottom line is that these results need to be incorporated into any all-cause dementia prevention strategy considering targeting hypertension and metabolic syndrome with a polypill. As an individual should you react to these results? Yes, you should be having your blood pressure checked on a regular basis.
SPRINT Research Group. Final Report of a Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2021 May 20;384(20):1921-1930
Background: In a previously reported randomized trial of standard and intensive systolic blood-pressure control, data on some outcome events had yet to be adjudicated and post-trial follow-up data had not yet been collected.
Methods: We randomly assigned 9361 participants who were at increased risk for cardiovascular disease but did not have diabetes or previous stroke to adhere to an intensive treatment target (systolic blood pressure, <120 mm Hg) or a standard treatment target (systolic blood pressure, <140 mm Hg). The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, acute decompensated heart failure, or death from cardiovascular causes. Additional primary outcome events occurring through the end of the intervention period (August 20, 2015) were adjudicated after data lock for the primary analysis. We also analyzed post-trial observational follow-up data through July 29, 2016.
Results: At a median of 3.33 years of follow-up, the rate of the primary outcome and all-cause mortality during the trial were significantly lower in the intensive-treatment group than in the standard-treatment group (rate of the primary outcome, 1.77% per year vs. 2.40% per year; hazard ratio, 0.73; 95% confidence interval [CI], 0.63 to 0.86; all-cause mortality, 1.06% per year vs. 1.41% per year; hazard ratio, 0.75; 95% CI, 0.61 to 0.92). Serious adverse events of hypotension, electrolyte abnormalities, acute kidney injury or failure, and syncope were significantly more frequent in the intensive-treatment group. When trial and post-trial follow-up data were combined (3.88 years in total), similar patterns were found for treatment benefit and adverse events; however, rates of heart failure no longer differed between the groups.
Conclusions: Among patients who were at increased cardiovascular risk, targeting a systolic blood pressure of less than 120 mm Hg resulted in lower rates of major adverse cardiovascular events and lower all-cause mortality than targeting a systolic blood pressure of less than 140 mm Hg, both during receipt of the randomly assigned therapy and after the trial. Rates of some adverse events were higher in the intensive-treatment group. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062.).
Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not reflect the position of the Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust.
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| Photo by Mufid Majnun on Unsplash |
Defining mild-to-moderate hypertension as a disease when it is largely asymptomatic and is really only a risk factor for diseases as a result of end-organ damage caused by hypertension is a triumph of preventive medicine.
In medicine we define a disease as a clinicopathological correlate, i.e. there are clinical findings associated with a specific pathology that is unique and separates the specific disease from other disorders, which may mimic it. When mild-to-moderate hypertension develops there are usually no specific symptoms and when diagnosed early there is little of no end-organ signs of damage. In other words, hypertension is part of the prodrome for diseases that manifest many years later. However, the medical profession treats hypertension as a disease in itself. Why? I think it is because the epidemiological evidence showing hypertension is associated with poor outcomes is so strong, i.e. if hypertension is left untreated it will result in disease in the future, for example, ischaemic heart disease, cerebrovascular disease, kidney damage, etc. However, is it hypertension itself that causes these downstream events or is it the metabolic syndrome (insulin resistance, obesity, sedentary lifestyle) that invariably accompanies hypertension that is the culprit? This is why interventional studies are so important. By treating hypertension and not the associated metabolic syndrome you can test whether or not hypertension itself is causal.
When hypertension is diagnosed and treated it is usually accompanied by advice about lifestyle interventions, i.e. weight reduction, dietary changes (less salt) and exercise. This is why randomised controlled trials are so important to test whether or not the intervention itself, i.e. antihypertensives, work. Another bit of evidence is to look for a dose-effect; does excellent control of hypertension outperform less good control? This is why studies such as the SPRINT (Systolic Blood Pressure Intervention Trial) trial are so important (see final report below). Among people who are at risk of vascular disease due to hypertension targeting a systolic blood pressure of less than 120 mm Hg results in lower rates of major adverse cardiovascular events and lower all-cause mortality than targeting a systolic blood pressure of less than 140 mm Hg. The one downside is that the more intensive control of blood pressure came at the cost of slightly higher rates of some adverse events.
The implications of these findings are not trivial and suggest that many of us, me included, who are over 50 years of age and have mild hypertension with systolic blood pressure consistently over 130mmHg with another cardiovascular risk factor should be aggressively controlling their blood pressure. I am not!
These results also have implications for the polypill concept i.e. fixed-dose combination pills to target hypertension and metabolic syndrome. We may need to adjust the dose of various constituents of the polypill to individualise dosing to achieve optimal control of hypertension (systolic BP < 120 mmHg). Just maybe the recent development of 3D printing of pills is a solution to this problem; by adjusting the doses of individual constituents, 3D printed pills could create bespoke even unique polypills for individuals based on their response or non-response to any one constituent.
The bottom line is that these results need to be incorporated into any all-cause dementia prevention strategy considering targeting hypertension and metabolic syndrome with a polypill. As an individual should you react to these results? Yes, you should be having your blood pressure checked on a regular basis.
SPRINT Research Group. Final Report of a Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2021 May 20;384(20):1921-1930
Background: In a previously reported randomized trial of standard and intensive systolic blood-pressure control, data on some outcome events had yet to be adjudicated and post-trial follow-up data had not yet been collected.
Methods: We randomly assigned 9361 participants who were at increased risk for cardiovascular disease but did not have diabetes or previous stroke to adhere to an intensive treatment target (systolic blood pressure, <120 mm Hg) or a standard treatment target (systolic blood pressure, <140 mm Hg). The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, acute decompensated heart failure, or death from cardiovascular causes. Additional primary outcome events occurring through the end of the intervention period (August 20, 2015) were adjudicated after data lock for the primary analysis. We also analyzed post-trial observational follow-up data through July 29, 2016.
Results: At a median of 3.33 years of follow-up, the rate of the primary outcome and all-cause mortality during the trial were significantly lower in the intensive-treatment group than in the standard-treatment group (rate of the primary outcome, 1.77% per year vs. 2.40% per year; hazard ratio, 0.73; 95% confidence interval [CI], 0.63 to 0.86; all-cause mortality, 1.06% per year vs. 1.41% per year; hazard ratio, 0.75; 95% CI, 0.61 to 0.92). Serious adverse events of hypotension, electrolyte abnormalities, acute kidney injury or failure, and syncope were significantly more frequent in the intensive-treatment group. When trial and post-trial follow-up data were combined (3.88 years in total), similar patterns were found for treatment benefit and adverse events; however, rates of heart failure no longer differed between the groups.
Conclusions: Among patients who were at increased cardiovascular risk, targeting a systolic blood pressure of less than 120 mm Hg resulted in lower rates of major adverse cardiovascular events and lower all-cause mortality than targeting a systolic blood pressure of less than 140 mm Hg, both during receipt of the randomly assigned therapy and after the trial. Rates of some adverse events were higher in the intensive-treatment group. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062.).
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