Junho de 2010

Beta-Blockers May Reduce Mortality and Risk of Exacerbations in Patients With Chronic Obstructive Pulmonary Disease.
Arch Intern Med. 2010;170(10):880-887

Background: Physicians avoid the use of _-blockers in patients with chronic obstructive pulmonary disease (COPD) and concurrent cardiovascular disease because of concerns about adverse pulmonary effects. We assessed the long-term effect of _-blocker use on survival and exacerbations in patients with COPD. Methods: An observational cohort study using data from
the electronic medical records of 23 general practices in the Netherlands. The data included standardized information about daily patient contacts, diagnoses, and drug prescriptions. Results: In total, the study included 2230 patients 45 years and older with an incident or prevalent diagnosis of COPD between 1996 and 2006. The mean (SD) age of the patients with COPD was 64.8 (11.2) years at the start of the study, and 53% of the patients were male. During a mean (SD) follow-up of 7.2 (2.8) years, 686 patients (30.8%) died and 1055 (47.3%) had at least 1 exacerbation of COPD. The crude and adjusted hazard ratios with Cox regression analysis of _-blocker use for mortality were 0.70 (95% confidence interval [CI], 0.59- 0.84) and 0.68 (95% CI, 0.56-0.83), respectively. The crude and adjusted hazard ratios for exacerbation ofCOPD were 0.73 (95% CI, 0.63-0.83) and 0.71 (95% CI, 0.60- 0.83), respectively. The adjusted hazard ratios with the propensity score methods were even lower. Subgroup analyses revealed that patients with COPD but without overt cardiovascular disease had similar results. Conclusion: Treatment with _-blockers may reduce the risk of exacerbations and improve survival in patients with COPD, possibly as a result of dual cardiopulmonary protective properties.


Exercise Blood Pressure and Future Cardiovascular Death in Asymptomatic Individuals
Circulation. 2010;121:2109-2116

Background—Individuals with exaggerated exercise blood pressure (BP) tend to develop future hypertension. It is controversial whether they have higher risk of death from cardiovascular disease (CVD). Methods and Results—A total of 6578 asymptomatic Lipid Research Clinics Prevalence Study participants (45% women; mean age, 46 years; 74% with untreated baseline BP _140/90 mm Hg [nonhypertensive]) performing submaximal Bruce treadmill tests were followed for 20 years (385 CVD deaths occurred). Systolic and diastolic BP at rest, Bruce stage 2, and maximal BP during exercise were significantly associated with CVD death. When we compared multivariate hazard ratios and 95% confidence intervals per 10/5-mm Hg BP increments, the association was strongest for rest BP (systolic, 1.21 [1.14 to 1.27]; diastolic, 1.20 [1.14 to 1.26]), then Bruce stage 2 BP (systolic, 1.09 [1.04 to 1.14]; diastolic, 1.09 [1.05 to 1.13]), then maximal exercise BP (systolic, 1.06 [1.01 to 1.10]; diastolic, 1.04 [1.01 to 1.08]). Overall, exercise BP was not significant after adjustment for rest BP. However, hypertension status modified the risk associated with exercise BP (Pinteraction_0.03). Among nonhypertensives, whether they had normal BP (_120/80 mm Hg) or prehypertension, Bruce stage 2 BP _180/90 versus _180/90 mm Hg carried increased risk independent of rest BP and risk factors (adjusted hazard ratio for systolic, 1.96 [1.40 to 2.74], P_0.001; diastolic, 1.48 [1.06 to 2.06], P_0.02) and added predictive value (net reclassification improvement, systolic, 12.0% [_0.1% to 24.2%]; diastolic,9.9% [_0.3% to 20.0%]; relative integrated discrimination improvement, 14.3% and 12.0%, respectively). Conclusions—In asymptomatic individuals, elevated exercise BP carried higher risk of CVD death but became nonsignificant after accounting for rest BP. However, Bruce stage 2 BP _180/90 mm Hg identified nonhypertensive individuals at higher risk of CVD death.


Is Pulse Pressure a Predictor of New-Onset Diabetes in High-Risk Hypertensive Patients?
Diabetes Care 33:1122–1127, 2010

A subanalysis of the Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial
OBJECTIVE— Hypertensive patients have an increased risk of developing diabetes. Accumulating evidence suggests a close relation between metabolic disturbance and increased arterial stiffness. Here, we examined the association between pulse pressure and the risk of new-onset diabetes in high-risk Japanese hypertensive patients. RESEARCH DESIGN AND METHODS— The Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial examined the effects of candesartan and amlodipine on the incidence of cardiovascular events in 4,728 high-risk Japanese hypertensive patients. In the present study, we analyzed the relationship between pulse pressure at baseline and new-onset diabetes in 2,685 patients without diabetes at baseline (male 1,471; mean age 63.7 years; mean BMI 24.8 kg/m2) as a subanalysis of the CASE-J trial. RESULTS— During 3.3 _ 0.8 years of follow-up, 97 patients (3.6%) developed diabetes. In multiple Cox regression analysis, pulse pressure was an independent predictor for new-onset diabetes (hazard ratio [HR] per 1 SD increase 1.44 [95% CI 1.15–1.79]) as were male sex, BMI, and additional use of diuretics, whereas age and heart rate were not. Plots of HRs for new-onset diabetes considering both systolic and diastolic blood pressure (DBP) revealed that a higher pulse pressure with a lower DBP, indicating that the increased pulse pressure was largely due to increased arterial stiffness, was strongly associated with the risk of new-onset diabetes. CONCLUSIONS— Pulse pressure is an independent predictor of new-onset diabetes in high-risk Japanese hypertensive patients. Increased arterial stiffness may be involved in the development of diabetes. Diabetes Care 33:1122–1127, 2010


Home-Measured Blood Pressure Is a Stronger Predictor of Cardiovascular Risk Than Office Blood Pressure
The Finn-Home Study
Hypertension. 2010;55:1346-1351

Abstract—Previous studies with some limitations have provided equivocal results for the prognostic significance of home-measured blood pressure (BP). We investigated whether home-measured BP is more strongly associated with cardiovascular events and total mortality than is office BP. A prospective nationwide study was initiated in 2000 to 2001 on 2081 randomly selected subjects aged 45 to 74 years. Home and office BP were determined at baseline along with other cardiovascular risk factors. The primary end point was incidence of a cardiovascular event (cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, hospitalization for heart failure, percutaneous coronary intervention, or coronary artery bypass graft surgery). The secondary end point was total mortality. After a mean follow-up of 6.8 years, 162 subjects had experienced a cardiovascular event, and 118 subjects had died. In Cox proportional hazard models adjusted for other cardiovascular risk factors, office BP (systolic/diastolic hazard ratio [HR] per 10/5 mm Hg increase in BP, 1.13/1.13; systolic/diastolic 95% confidence interval [CI], 1.05 to 1.22/1.05 to 1.22) and home BP (HR, 1.23/1.18; 95% CI, 1.13 to 1.34/1.10 to 1.27) were predictive of cardiovascular events. However, when both BPs were simultaneously included in the models, only home BP (HR, 1.22/1.15; 95% CI, 1.09 to 1.37/1.05 to 1.26), not office BP (HR, 1.01/1.06; 95% CI, 0.92 to 1.12/0.97 to 1.16), was predictive of cardiovascular events. Systolic home BP was the sole predictor of total mortality (HR, 1.11; 95% CI, 1.01/1.23). Our findings suggest that home-measured BP is prognostically superior to office BP. On the basis of the results of this and previous studies, it can be concluded that home BP measurement offers specific advantages more than conventional office measurement.


Differing effects of aging on central and peripheral blood pressures and pulse wave velocity: a direct intraarterial study
J Hypertens 28:1252–1260; 2010

Objectives There have been a few noninvasive studies showing the effect of aging on blood pressure (BP) and pulse wave velocity (PWV) in different arterial segments. The aim of this study was to evaluate the effect of aging on arterial hemodynamics in central and peripheral arteries using an invasive method. Methods We observed 175 individuals undergoing coronary angiography. SBP and DBP were measured by pressure wave at the radial artery, abdominal aorta, and aortic arch. Aortic arch-abdominal aorta PWV (aoPWV) and aortic arch-radial artery PWV (arPWV) were also assessed by the foot-to-foot velocity method using a fluid-filled system. Results SBP and pulse pressure were significantly positively correlated and DBP was significantly negatively correlated with age through the arterial tree in a multivariate analysis after adjusting for sex, coronary artery disease, diabetes, dyslipidemia, smoking status, and the use of antihypertensive agents. Pulse pressure, SBP, and DBP were significantly associated with age (ranked in order of association strength) at all studied arterial segments. Each central BP showed a consistently higher correlation with age than radial BP. aoPWV and arPWV were also significantly correlated with age, and this relationship was much stronger for aoPWV (rU0.474, P<0.001) than for arPWV (rU0.224, PU0.003). Conclusion The present invasive study suggests that aging has a greater effect on central rather than peripheral arterial hemodynamics. The central pulse pressure was the predominant BP affected by aging, which could be caused by the stronger relationship of aging with central arterial stiffness.
 

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