Cerebral hemodynamic effects of early blood pressure lowering after TIA and stroke in patients with carotid stenosis

Background: Effects of early blood pressure (BP) lowering on cerebral perfusion in patients with moderate/severe occlusive carotid disease after transient ischemic attack (TIA) and non-disabling stroke are uncertain. Aims: We aimed to evaluate the changes in transcranial Doppler (TCD) indices in patients undergoing blood pressure lowering soon after TIA/non-disabling stroke. Methods: Consecutive eligible patients (1 November 2011 to 30 October 2018) attending a rapid-access clinic with TIA/non-disabling stroke underwent telemetric home blood pressure monitoring (HBPM) for 1 month and middle cerebral artery velocities measurements ipsilateral to carotid stenosis on TCD ultrasound in the acute setting and at 1 month. Hypertensive patients (HBPM ⩾ 135/85) underwent intensive BP-lowering guided by HBPM unless they had bilateral severe occlusive disease (⩾ 70%). Changes in BP and TCD parameters were compared in patients with extracranial moderate/severe carotid stenosis (between 50% and occlusion) versus those with no or mild (< 50%) stenosis. Results: Of 764 patients with repeated TCD measures, 42 had moderate/severe extracranial carotid stenosis without bilateral severe occlusive disease. HBPM was reduced from baseline to 1 month in hypertensive patients both with versus without moderate/severe carotid stenosis (−12.44/15.99 vs −13.2/12.2 mmHg, respectively, p-difference = 0.82), and changes in TCD velocities (4.69/14.94 vs 2.69/13.86 cm/s, respectively, p-difference = 0.52 for peak systolic velocity and 0.33/7.06 vs 1.75/6.84 cm/s, p-difference = 0.34 for end-diastolic velocity) were also similar, with no evidence of greater hemodynamic compromise in patients with stenosis/occlusion. Conclusion: There was no evidence of worsening of TCD hemodynamic indices in patients with moderate/severe occlusive carotid disease treated with BP-lowering soon after TIA/non-disabling stroke, suggesting that antihypertensive treatment in this group of patients is safe in the acute setting of TIA clinics.

Edukasi Tanggap Hipertensi di Desa Lemukutan Kecamatan Sungai Raya Kepulauan Kabupaten Bengkayang Provinsi Kalimantan Barat

ABSTRAK Banyak dari penderita hipertensi yang tidak menyadari atau menganggap remeh akibat belum dirasakannya keluhan berarti meskipun tekanan darah sudah mencapai level berbahaya. Kondisi tersebut akan semakin berbahaya apabila masyarakat memiliki keterbatasan akses ke pelayanan kesehatan yang memadai seperti daerah-daerah pesisir pantai atau pulau-pulau kecil yang memerlukan transportasi air apabila ingin menuju ke pekayanan kesehatan yang memadai. Tujuan pengabdian kepada masyarakat untuk meningkatkan pengetahuan dan keterampilan masyarakat tentang tanggap hipertensi di Desa Lemukutan Kecamatan Sungai Raya Kepulauan. Metode palaksanaan pengabdian kepada masyarakat adalah penyuluhan tentang tanggap hipertensi dan pelatihan pengolahan mentimun serta prosedur rendam kaki air hangat dan jahe kepada masyarakat Desa Lemukutan Kecamatan Sungai Raya Kepulauan. Hasil pengabdian kepada masyarakat didapatkan data terjadi peningkatan pengetahuan masyarakat sebelum dan setelah penyuluhan kesehatan tentang tanggap hipertensi dengan hasil sebelum diberikan edukasi dan demonstrasi pengolahan penurun tekanan darah non farmakologis dan terapi terkait penurunan hipertensi sebagian besar peserta memiliki pengetahuan dan kemampuan pada kategori sedang yaitu 66,7%, kategori rendah yaitu 30% dan kategori tinggi yaitu 3,33%. Sedangkan setelah diberikan edukasi dan pengolahan penurun tekanan darah non farmakologis dan terapi terkait penurunan hipertensi diperoleh pengetahuan dan kemampuan pada kategori sedang yaitu 76,7% dan kategori tinggi yaitu 23,33%.. Peningkatan pengatahuan masyarakat tentang hipertensi dan keterampilan dalam melakukan pengolahan mentimun serta prosedur rendam kaki air hangat jahe menjadi salah satu upaya pencegahan komplikasi hipertensi. Kata Kunci: Edukasi, Pelatihan, Hipertensi ABSTRACT Many people with hypertension do not realize or underestimate the consequences of not having any significant complaints even though their blood pressure has reached a dangerous level. This condition will be even more dangerous if the community has limited access to adequate health services, such as coastal areas or small islands that require water transportation if they want to go to adequate health services. The purpose of community service is to increase community knowledge and skills about hypertension response in Lemukutan Village, Sungai Raya Islands District. The method of implementing community service is counseling about hypertension response and training on cucumber processing as well as foot soaking procedures in warm water and ginger to the people of Lemukutan Village, Sungai Raya Islands District. The results of community service showed that there was an increase in community knowledge before and after health counseling about hypertension response with the results before being given education and demonstration of non-pharmacological blood pressure-lowering processing and therapy related to reducing hypertension, most of the participants had knowledge and abilities in the moderate category, namely 66.7 %, the low category is 30% and the high category is 3.33%. Meanwhile, after being given education and processing non-pharmacological blood pressure lowering and therapy related to reducing hypertension, knowledge, and abilities were obtained in the medium category, namely 76.7%, and the high category, namely 23.33%. Increasing public knowledge about hypertension and skills in processing cucumbers and The procedure of soaking feet in warm ginger water is an effort to prevent complications of hypertension. Keywords: Education, Training, Hypertension

Methodological Aspects of Meta-Analyses Assessing the Effect of Blood Pressure–Lowering Treatment on Clinical Outcomes

Systematic reviews and meta-analyses are often considered the highest level of evidence, with high impact on clinical practice guidelines. The methodological literature on systematic reviews and meta-analyses is extensive and covers most aspects relevant to the design and interpretation of meta-analysis findings in general. Analyzing the effect of blood pressure–lowering on clinical outcomes poses several challenges over and above what is covered in the general literature, including how to combine placebo-controlled trials, target-trials, and comparative studies depending on the research question, how to handle the potential interaction between baseline blood pressure level, common comorbidities, and the estimated treatment effect, and how to consider different magnitudes of blood pressure reduction across trials. This review aims to address the most important methodological considerations, to guide the general reader of systematic reviews and meta-analyses within our field, and to help inform the design of future studies. Furthermore, we highlight issues where published meta-analyses have applied different analytical strategies and discuss pros and cons with different strategies.

Is Blood Pressure Lowering in the Very Elderly With Previous Stroke Associated With a Higher Risk of Adverse Events?

Background We investigated whether blood pressure lowering for secondary prevention is associated with a reduction in recurrent stroke risk and/or a higher risk of adverse events in very elderly compared with younger trial participants. Methods and Results This is a random effects meta‐analysis of randomized controlled trials of blood pressure lowering for secondary stroke prevention to evaluate age‐stratified (<80, ≥80 years) risk of adverse events. Ovid‐MEDLINE was searched for trials between 1970 and 2020. Summary‐level data were acquired including outcomes of stroke, cardiovascular events, mortality, and adverse events. Seven trials were included comprising 38 596 participants, of whom 2336 (6.1%) were aged ≥80 years. There was an overall reduction in stroke risk in the intervention group compared with controls (risk ratio [RR], 0.90 [95% CI, 0.80, 0.98], I 2 =49%), and the magnitude of risk reduction did not differ by age subgroup (<80, ≥80 years). There was no increase in the risk of hypotensive symptoms in the intervention group for patients aged <80 years (RR, 1.19 [95% CI, 0.99], 1.44, I 2 =0%), but there was an increased risk in those ≥80 years (RR, 2.17 [95% CI, 1.22], 3.86, I 2 =0%). No increase was observed in the risk of falls, syncope, study withdrawal, or falls in either age subgroup. Conclusions Very elderly people in secondary prevention trials of blood pressure lowering have an increased risk of hypotensive symptoms, but with no statistical increase in the risk of falls, syncope, or mortality. However, evidence is lacking for frail elderly with multiple comorbidities who may be more vulnerable to adverse effects of blood pressure lowering.

Catheter-Based Renal Denervation Therapy: Evolution of Evidence and Future Directions

Motivated by the persistence of uncontrolled blood pressure and its public health impact, the development and evaluation of device-based therapies for hypertension has advanced at an accelerated pace to complement pharmaceutical and lifestyle intervention strategies. Countering widespread interest from early studies, the lack of demonstrable efficacy for renal denervation (RDN) in a large, sham-controlled randomized trial motivated revision of trial design and conduct to account for confounding variables of procedural technique, medication variability, and selection of both patients and end points. Now amidst varied trial design and methods, several sham-controlled, randomized trials have demonstrated clinically meaningful reductions in blood pressure with RDN. With this momentum, additional studies are underway to position RDN as a potential part of standard therapy for the world’s leading cause of death and disability. In parallel, further studies will address unresolved issues including durability of blood pressure lowering and reduction in antihypertensive medications, late-term safety, and impact on clinical outcomes. Identifying predictors of treatment effect and surveys of patient-reported outcomes and treatment preferences are also evolving areas of investigation. Aside from confirmatory studies of safety and effectiveness, these additional studies will further inform patient selection, expand experience with RDN in broader populations with hypertension, and provide guidance to how RDN may be incorporated into treatment pathways.

BP lowering and cardiovascular risk reduction

Overview of: The Blood Pressure Lowering Treatment Triallists’ Collaboration. Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis. Lancet 2021;397:1625–36.

Long-term trends in blood pressure and hypertension in Russia: an analysis of data from 14 health surveys conducted in 1975–2017

Background Hypertension is recognized as an important contributor to high cardiovascular mortality in Russia. A comprehensive analysis of data from Russian studies that measured blood pressure in population-based samples has not been previously undertaken. This study aims to identify trends and patterns in mean blood pressure and the prevalence of hypertension in Russia over the most recent 40 years. Methods We obtained anonymized individual records of blood pressure measurements from 14 surveys conducted in Russia in 1975–2017 relating to a total of 137,687 individuals. For comparative purposes we obtained equivalent data from 4 surveys in the USA and England for 23,864 individuals. A meta-regression on aggregated data adjusted for education was undertaken to estimate time trends in mean systolic and diastolic blood pressure, the prevalence of elevated blood pressure (> 140/90 mmHg), and hypertension (defined as elevated blood pressure and/or the use of blood pressure-lowering) medication. A meta-analysis of pooled individual-level data was used to assess male-female differences in blood pressure and hypertension. Results During the period 1975–2017 mean blood pressure, the prevalence of elevated blood pressure and hypertension remained stable among Russian men. Among Russian women, mean systolic blood pressure decreased at an annual rate of 0.25 mmHg (p < 0.1) at age 35–54 years and by 0.8 mmHg (p < 0.01) at ages 55 and over. The prevalence of elevated blood pressure also decreased by 0.8% per year (p < 0.01), but the prevalence of hypertension remained stable. Mean blood pressure and prevalence of hypertension were higher in Russia compared to the USA and England at all ages and for both sexes. Conclusions In contrast to the generally observed downward trend in elevated blood pressure in many other countries, levels in Russia have changed little over the past 40 years, although there are some positive trends among women. Improved strategies to bring down the high levels of mean blood pressure and hypertension in Russia compared to countries such as England and the USA are important to further reduce the high burden of CVD in Russia.