Serum Growth Differentiation Factor 15 Levels Predict the Incidence of Frailty among Patients with Cardiometabolic Diseases.

INTRODUCTION: Frailty is a crucial health issue among older adults. Growth differentiation factor 15 (GDF15) is associated with inflammation, oxidative stress, insulin resistance, and mitochondrial dysfunction, which are possible pathogeneses of frailty. However, few longitudinal studies have investigated the association between GDF15 and the incidence of frailty. Therefore, we investigated whether high serum GDF15 levels are associated with the incidence of frailty. METHODS: A total of 175 older adults (mean age: 77 ± 6 years; 63% women) with cardiometabolic diseases and no frailty out of the two criteria at baseline participated. Individuals with severe renal impairment or severe cognitive impairment were excluded. Serum GDF15 levels were measured at baseline. Patients were asked to assess frailty status at baseline and annually during follow-up using the modified version of the Cardiovascular Health Study (mCHS) and the Kihon Checklist (KCL). We examined the association between GDF15 tertiles and each frailty measure during follow-up (median 38-39 months). In the multivariate Cox regression analysis, with the GDF15 tertile groups as the explanatory variables, hazard ratios (HRs) and 95% confidence intervals (CIs) for incident frailty were calculated after adjusting for covariates and using the lowest tertile group as the reference. RESULTS: During the follow-up period, 25.6% and 34.0% of patients developed frailty, as defined by the mCHS and KCL, respectively. The highest GDF15 tertile group had a significantly higher incidence of mCHS- or KCL-defined frailty than the lowest GDF15 tertile group. Multivariate Cox regression analysis revealed that the adjusted HRs for incident mCHS- and KCL-defined frailty in the highest GDF15 tertile group were 3.9 (95% CI: 1.3-12.0) and 2.7 (95% CI: 1.1-6.9), respectively. CONCLUSION: High serum GDF15 levels predicted the incidence of frailty among older adults with cardiometabolic diseases and could be an effective marker of the risk for frailty in interventions aimed at preventing frailty, such as exercise and nutrition.

Age and sex differences in the risk of cardiovascular diseases by chronic kidney disease in a general Japanese population.

The risk of cardiovascular diseases (CVD) by chronic kidney disease (CKD) stratified by age and sex has not been examined in detail in rural Japanese populations. Therefore, we herein investigated the long-term risk of CVD by CKD and performed an age- and sex-stratified risk analysis. We examined 5163 subjects who underwent health screening between 1992 and 1995 with calculated eGFR and follow-up information on CVD events. The mean follow-up period was 10 years. We analyzed the incidences of CVD events, including stroke and myocardial infarction (MI). We compared the risk of CVD between subjects with and without CKD using a Cox proportional hazards model adjusted for well-known CVD confounding factors. The total number of CVD events was 175. The hazard ratios (HRs) for all events, stroke, MI, and sudden death by CKD relative to non-CKD were 1.18 (95% C.I.:0.83-1.68), 0.96 (0.63-1.46), 3.02 (1.2-7.62), and 1.29 (0.43-3.87), respectively. HRs for MI were 7.24 in subjects < 65 years and 1.65 in those ≥ 65 years. HRs for MI by sex were 3.55 in men and 2.09 in women. A younger age and men sex were identified as independent risk factors for the risk of MI in the presence of CKD. These results suggest that among CKD patients, the management of a younger age group and men will effectively prevent MI.

Association between physical performance during sit-to-stand motion and frailty in older adults with cardiometabolic diseases: a cross-sectional, longitudinal study.

BACKGROUND: Although physical performance tests of the lower extremities are used to assess sarcopenia and frailty, little is known about the mechanisms by which the parameters of ground reaction force (GRF) measured during sit-to-stand motion affect the frailty status in older adults. We aimed to examine the association between GRF parameters during sit-to-stand motion and the incidence of frailty in older adults. METHODS: This longitudinal study evaluated 319 outpatients aged ≥ 65 years with cardiometabolic diseases. The GRF parameters were measured using a motor function analyzer, in which the power, speed, and balance scores were calculated. Frailty was diagnosed using the modified version of the Cardiovascular Health Study (mCHS) and the Kihon Checklist (KCL). The independent associations between scores and frailty indices were assessed using multivariate binomial logistic regression analyses. Cox regression analysis was used to examine whether power and speed scores were associated with the incidence of frailty after adjusting for covariates. RESULTS: Logistic regression analyses adjusted for covariates showed that the power and speed scores were associated with frailty according to the mCHS criteria (power: OR = 0.37, 95% CI = 0.22-0.63; speed: OR = 0.64, 95% CI = 0.52-0.79) and KCL criteria (power: OR = 0.40, 95% CI = 0.26-0.62; speed: OR = 0.81, 95% CI = 0.69-0.96) at baseline. Receiver operating characteristic analyses revealed that the area under the curve values of power and speed scores for discriminating mCHS-defined frailty were 0.72 and 0.73. The Cox regression analysis showed that the speed score predicted the incidence of mCHS-defined (HR = 0.45, 95% CI = 0.22-0.92, P = 0.029) and KCL-defined (HR = 0.77, 95% CI = 0.60-0.99, P = 0.039) frailty, whereas the power score was associated with the incidence of KCL-defined frailty (HR = 0.72, 95% CI = 0.55-0.95, P = 0.02) after adjusting for covariates. CONCLUSIONS: The speed and power scores measured during sit-to-stand motion are predictive of frailty in older adults with cardiometabolic disease. Therefore, the GRF parameters measured during sit-to-stand motion could be an important indicator of frailty. Further studies are necessary to examine whether the GRF parameters can be improved by exercise or whether the changes in these parameters are associated with the improvement of frailty status.

[A case of deep vein thrombosis in an elderly patient whose symptoms were exacerbated after applying catheter-based thrombolytic therapy].

We herein report a 99-year-old woman with hypertension and dyslipidemia. From the beginning of August 20XX, significant edema from the left thigh to the toes had been observed, so she had consulted her previous doctor. She had been suspected of having cellulitis and was given antibiotics, but no improvement in her symptoms was noted, so she was transferred to our hospital. The edema of the lower leg was localized to the left lower leg only, and the D-dimer level was as high as 16.6 µg/mL at her visit to the emergency room, so deep vein thrombosis (DVT) was suspected, and the patient received immediate hospitalization. Continuous administration of undifferentiated heparin was started, and lower extremity venous ultrasound was performed. As a result, central-type DVT extending from the left iliac vein to the common iliac vein bifurcation was observed. However, despite administering inferior vena cava (IVC) filter into under the renal vein, and changing heparin to edoxaban 30 mg, no improvement in the lower limb edema was observed. Therefore, catheter-based thrombolysis (CDT) was started on day 11 of illness, and continuous administration of urokinase was started via the catheter. Heparin and edoxaban were not used in combination in order to reduce the risk of bleeding. The edema gradually improved, and after confirming that the thrombus had completely disappeared on lower extremity venous ultrasound, the catheter was removed on day 14 (day 24 of illness) after starting CDT. The IVC filter was also removed, and prescription of edoxaban 30 mg was restarted. Since the patient had used a walking frame at home, she started rehabilitation from the initiation of CDT therapy and was discharged once she was able to use a self-sustaining portable toilet. The basic treatment for DVT is anticoagulant therapy; however, a large amount of thrombosis was observed in the present case, and no marked improvement was observed with conventional anticoagulant therapy. As the patient was particularly elderly, and considering that it was important to improve the edema promptly in order to maintain her activities of daily living, we performed CDT treatment and concluded that it was very effective in this case. However, the CDT procedure for DVT has yet to be standardized, and there are few cases of CDT treatment, especially for such super-elderly patients. In the current aging society, the incidence of DVT diseases is increasing, and in cases such as the present case, anticoagulation therapy alone and CDT therapy should be considered and implemented after careful consideration of the bleeding risk.

Dynapenic abdominal obesity is associated with mild cognitive impairment in patients with cardiometabolic disease: a cross-sectional study.

BACKGROUND: Dementia is an important health issue for older people and requires early intervention in the mild cognitive impairment (MCI) stage to manage risk factors. Both dynapenia (DP) and abdominal obesity (AO) are associated with inflammation and oxidative stress, which may be involved in the pathogenesis of cognitive impairment. Therefore, in this cross-sectional study, we aimed to evaluate the association between MCI and dynapenic abdominal obesity (DAO), a combination of DP and AO. METHODS: A total of 417 older outpatients with cardiometabolic diseases without severe cognitive impairment were studied to compare cognitive function in four groups: control, DP, AO, and DAO groups. DAO was defined as the combination of DP (handgrip strength of < 28 kg and < 18 kg in men and women, respectively) and AO (waist circumference of ≥ 85 cm and ≥ 90 cm in men and women, respectively). MCI was defined as a score of ≤ 25 in the Japanese version of the Montreal Cognitive Assessment. Multiple regression analyses were performed to examine if MCI was independently associated with DAO, low handgrip strength, or high waist circumference. RESULTS: The DAO group obtained the lowest cognitive test scores and had the highest prevalence of MCI. Furthermore, after adjusting for covariates, the logistic regression analysis showed that patients in the DAO group were at an increased risk of MCI (odds ratio [OR] = 3.98, 95% confidence interval [CI]: 1.15-13.77). Further logistic regression analyses revealed that both low handgrip strength (OR = 2.19, 95% CI: 1.11-4.29) and high waist circumference (OR = 2.03, 95% CI: 1.03-3.99) were associated with MCI. CONCLUSIONS: DAO, which can be easily diagnosed by a combination of handgrip strength and waist circumference, was associated with MCI in patents with cardiometabolic metabolic disease. This study suggests that screening for MCI in DAO patients could be important for early intervention of dementia prevention.

Increased blood pressure variability is associated with probable rapid eye movement sleep behaviour disorder in elderly hypertensive patients.

PURPOSE: An increased blood pressure variability (BPV) has been reported to be associated with older age and cognitive dysfunction; however, associations between increased BPV and rapid eye movement sleep behaviour disorder (RBD) has not been thoroughly investigated in patients without clinical Lewy body diseases. MATERIALS AND METHODS: In frailty outpatient clinic, we evaluated ambulatory BP, RBD screening questionnaire (RBDSQ), and beat-to-beat heart rate variability during positional change from sitting to standing in 112 elderly hypertensive patients. RESULTS: The mean age was 81.2 ± 6.3 years (68% male). There were 15 patients who had probable RBD (RBDSQ scores ≥ 5). Patients with RBD had a greater body mass index, coefficient of variation (CV) in 24-h diastolic BP (23.5 ± 6.1 versus 18.7 ± 5.8, p = 0.005), awake diastolic BP (23.0 ± 7.7 versus 18.6 ± 6.2, p = 0.017), and nocturnal systolic BP (14.9 ± 5.5 versus 12.0 ± 4.4, p = 0.025) compared with those without RBD, while systolic BP, diastolic BP, and cognitive function did not differ significantly between patients with and without RBD. Patients with RBD exhibited larger orthostatic BP fall compared with patients without RBD (-4.9 ± 11.0 versus 7.5 ± 11.8, p = 0.009) and lower CV of R-R intervals while standing (1.3 ± 0.6 versus 2.4 ± 1.5, p = 0.039). Multiple regression analysis revealed that patients with RBD had significantly greater CV of nocturnal systolic BP independent of age, sex, BMI, history of diabetes and dyslipidaemia, and use of antihypertensive drugs (p = 0.008). CONCLUSION: An increased BPV in ambulatory BP, associated with autonomic dysfunction, can be observed in patients with probable RBD even in elderly patients without clinical presentation of Lewy body diseases.

[Posture-dependent left ventricular outflow tract obstruction in a case of Lewy body dementia that presented with transient loss of consciousness].

An 80-year-old woman with a history of hypertrophic obstructive cardiomyopathy and Lewy body dementia was admitted to our hospital with a first episode of syncope while walking. The pressure gradient of left ventricular outflow tract (LVOT) had been stable at nearly 10 mmHg for 3 years before the admission. We evaluated the cause of syncope. Echocardiography showed that the pressure gradient of LVOT was unchanged, even in the supine position ergometer exercise test. Although the head-up tilt test revealed a drop in blood pressure of 44 mmHg systolic and 23 mmHg diastolic, she was asymptomatic during the test. The orthostatic hypotension was considered to be a manifestation of autonomic failure due to Lewy body dementia; however, it was insufficient to explain the syncope on exertion. Echocardiography in a sitting-up position showed that the pressure gradient of LVOT was exacerbated to 41 mmHg, which might be the cause of syncope while walking. Orthostatic hypotension, especially in patients with Lewy body dementia, is a common cause of syncope in the elderly. However, we should keep in mind that the exacerbation of LVOT obstruction due to posture-dependent fluid shift can be a cause of syncope in patients with hypertrophic cardiomyopathy or sigmoid-shaped interventricular septum. In such patients, echocardiography in a sitting-up position can be an effective tool to diagnose the cause of syncope.

Factors contributing to energy loss in left ventricle during diastolic and systolic phases in elderly patients.

BACKGROUND: The change of left ventricular function deteriorated with age because of gradual increases of blood pressure may result in increased energy loss (EL) in left ventricle (LV). The present study investigated EL in LV among hypertensive elderly patients and examined factors contributing to EL. METHODS: A single-center retrospective study was performed on elderly hypertensive outpatients (≥65 years) who underwent echocardiography (N = 105). EL in the LV was measured using a vector flow mapping system, and factors affecting peak EL during the early-diastolic phase (ED-EL), late-diastolic phase (LD-EL), and systolic phase (Sys-EL) were evaluated. RESULT: Mean age was 79.9 ± 6.4 years (male 43%). Mean ED-EL, LD-EL, and Sys-EL were 42.1 ± 46.7, 75.6 ± 60.2, and 40.4 ± 40.2 mJ/N/s. In a stepwise regression analysis, the E/e'(lateral) (unstandardized B = 0.005, 95%CI -0.03 to 0.007, standardized ß = 0.434, P < .001) was identified as factors affecting ED-EL. The factors affecting LD-EL were E/A ratio (B = -0.122, 95%CI -0.176 to -0.068, ß = -0.470, P < .001) and time velocity integral (TVI) in LVOT (unstandardized B = 0.002, 95%CI 0.000 to 0.004, ß = 0.247, P = .021). The factors influencing Sys-EL were TVI in LVOT (B = 0.002, 95%CI 0.001 to 0.004, ß = 0.390, P < .001), E/A ratio (B = -0.054, 95%CI -0.093 to -0.015, ß = -0.258, P = .008), left ventricular outflow tract (LVOT) diameter (B = -0.006, 95%CI -0.010 to -0.002, ß = -0.307, P = .006), and left ventricular mass index (B = 0.000, 95%CI 0.000 to 0.001, ß = 0.208, P = .039). CONCLUSION: Peak EL in the LV was higher during diastolic phase than systolic phase among elderly hypertensive patients. Peak EL both during late-diastolic phase and systolic phase was affected by systolic blood flow in LVOT and LV transmitral flow pattern.

Minor Electrocardiographic ST-T Change and Risk of Stroke in the General Japanese Population.

BACKGROUND: Minor ST-T changes are frequently observed on the electrocardiogram (ECG), but the risk of stroke associated with such changes is unclear.Methods and Results:In 10,642 subjects from the Japanese general population, we evaluated minor and major ST-T changes (major ST depression ≥0.1 mV) on ECGs obtained at annual health examinations. At baseline, minor ST-T changes were found in 10.7% of the subjects and 0.5% had major ST-T changes. Minor ST-T changes were associated with older age, female gender, higher systolic blood pressure, presence of hyperlipidemia, and use of antihypertensive medication. There were 375 stroke events during the follow-up period (128.7±28.1 months). In all subjects, minor ST-T changes (HR, 2.10; 95% CI: 1.57-2.81) and major ST-T changes (HR, 8.64; 95% CI: 4.44-16.82) were associated with an increased risk of stroke, but the stroke risk associated with minor ST-T changes had borderline significance after adjustment for conventional risk factors (P=0.055). In subgroup analysis, the risk of stroke was significantly associated with minor ST-T changes in subjects who had hyperlipidemia (HR, 1.75; 95% CI: 1.15-2.67) compared to those without hyperlipidemia (HR, 1.01; 95% CI: 0.64-1.59; P for interaction=0.016), even after adjustment for ECG-diagnosed left ventricular hypertrophy. CONCLUSIONS: Minor ST-T changes were particularly associated with a higher risk of stroke in subjects with hyperlipidemia and this association was independent of electrocardiographic left ventricular hypertrophy.

Prevalence of frailty, cognitive impairment, and sarcopenia in outpatients with cardiometabolic disease in a frailty clinic.

BACKGROUND: Although frailty and cognitive impairment are critical risk factors for disability and mortality in the general population of older inhabitants, the prevalence and incidence of these factors in individuals treated in the specialty outpatient clinics are unknown. METHODS: We recently established a frailty clinic for comprehensive assessments of conditions such as frailty, sarcopenia, and cognition, and planned 3-year prospective observational study to identify the risk factors for progression of these aging-related statuses. To date, we recruited 323 patients who revealed symptoms suggestive of frailty mainly from a specialty outpatient clinic of cardiology and diabetes. Frailty status was diagnosed by the modified Cardiovascular Health Study (mCHS) criteria and some other scales. Cognitive function was assessed by Mini-Mental State Examination (MMSE), Japanese version of the Montreal Cognitive Assessment (MoCA-J), and some other modalities. Sarcopenia was defined by the criteria of the Asian Working Group for Sarcopenia (AWGS). In this report, we outlined our frailty clinic and analyzed the background characteristics of the subjects. RESULTS: Most patients reported hypertension (78%), diabetes mellitus (57%), or dyslipidemia (63%), and cardiovascular disease and probable heart failure also had a higher prevalence. The prevalence of frailty diagnosed according to the mCHS criteria, cognitive impairment defined by MMSE (≤27) and MoCA-J (≤25), and of AWGS-defined sarcopenia were 24, 41, and 84, and 31%, respectively. The prevalence of frailty and cognitive impairment increased with aging, whereas the increase in sarcopenia prevalence plateaued after the age of 80 years. No significant differences were observed in the prevalence of frailty, cognitive impairment, and sarcopenia between the groups with and without diabetes mellitus, hypertension, or dyslipidemia with a few exceptions, presumably due to the high-risk subjects who had multiple cardiovascular comorbidities. A majority of the frail and sarcopenic patients revealed cognitive impairment, whereas the frequency of suspected dementia among these patients were both approximately 20%. CONCLUSIONS: We found a high prevalence of frailty, cognitive impairment, and sarcopenia in patients with cardiometabolic disease in our frailty clinic. Comprehensive assessment of the high-risk patients could be useful to identify the risk factors for progression of frailty and cognitive decline.

Clinic Blood Pressure Underestimates Ambulatory Blood Pressure in an Untreated Employer-Based US Population: Results From the Masked Hypertension Study.

BACKGROUND: Ambulatory blood pressure (ABP) is consistently superior to clinic blood pressure (CBP) as a predictor of cardiovascular morbidity and mortality risk. A common perception is that ABP is usually lower than CBP. The relationship of the CBP minus ABP difference to age has not been examined in the United States. METHODS: Between 2005 and 2012, 888 healthy, employed, middle-aged (mean±SD age, 45±10.4 years) individuals (59% female, 7.4% black, 12% Hispanic) with screening BP <160/105 mm Hg and not taking antihypertensive medication completed 3 separate clinic BP assessments and a 24-hour ABP recording for the Masked Hypertension Study. The distributions of CBP, mean awake ABP (aABP), and the CBP-aABP difference in the full sample and by demographic characteristics were compared. Locally weighted scatterplot smoothing was used to model the relationship of the BP measures to age and body mass index. The prevalence of discrepancies in ABP- versus CBP-defined hypertension status-white-coat hypertension and masked hypertension-were also examined. RESULTS: Average systolic/diastolic aABP (123.0/77.4±10.3/7.4 mm Hg) was significantly higher than the average of 9 CBP readings over 3 visits (116.0/75.4±11.6/7.7 mm Hg). aABP exceeded CBP by >10 mm Hg much more frequently than CBP exceeded aABP. The difference (aABP>CBP) was most pronounced in young adults and those with normal body mass index. The systolic difference progressively diminished, but did not disappear, at older ages and higher body mass indexes. The diastolic difference vanished around age 65 and reversed (CBP>aABP) for body mass index >32.5 kg/m2. Whereas 5.3% of participants were hypertensive by CBP, 19.2% were hypertensive by aABP; 15.7% of those with nonelevated CBP had masked hypertension. CONCLUSIONS: Contrary to a widely held belief, based primarily on cohort studies of patients with elevated CBP, ABP is not usually lower than CBP, at least not among healthy, employed individuals. Furthermore, a substantial proportion of otherwise healthy individuals with nonelevated CBP have masked hypertension. Demonstrated CBP-aABP gradients, if confirmed in representative samples (eg, NHANES [National Health and Nutrition Examination Survey]), could provide guidance for primary care physicians as to when, for a given CBP, 24-hour ABP would be useful to identify or rule out masked hypertension.

Progression from prehypertension to hypertension and risk of cardiovascular disease.

BACKGROUND: Subjects with prehypertension (pre-HT; 120/80 to 139/89 mm Hg) have an increased risk of cardiovascular disease (CVD); however, whether the risk of pre-HT can be seen at the pre-HT status or only after progression to a hypertensive (HT; ≥140/90 mm Hg) state during the follow-up period is unknown. METHODS: The Jichi Medical Cohort study enrolled 12,490 subjects recruited from a Japanese general population. Of those, 2227 subjects whose BP data at baseline and at the middle of follow-up and tracking of CVD events were available (median follow-up period: 11.8 years). We evaluated the risk of HT in those with normal BP or pre-HT at baseline whose BP progressed to HT at the middle of follow-up compared with those whose BP remained at normal or pre-HT levels. RESULTS: Among the 707 normotensive patients at baseline, 34.1% and 6.6% of subjects progressed to pre-HT and HT, respectively, by the middle of follow-up. Among 702 subjects with pre-HT at baseline, 26.1% progressed to HT. During the follow-up period, there were 11 CVD events in normotensive patients and 16 CVD events in pre-HT patients at baseline. The subjects who progressed from pre-HT to HT had 2.95 times higher risk of CVD than those who remained at normal BP or pre-HT in a multivariable-adjusted Cox hazard model. CONCLUSION: This relatively long-term prospective cohort study indicated that the CVD risk with pre-HT might increase after progression to HT; however, the number of CVD events was small. Therefore, the results need to be confirmed in a larger cohort.

Gender-Adjustment and Cutoff Values of Cornell Product in Hypertensive Japanese Patients.

In the Japanese population, the electrocardiographic (ECG) Cornell voltage and product predict cardiovascular events at lower values (Cornell voltage of 2.04 mV in males and 1.71 mV in females, and Cornell product of 158.7 mV× msec) than in the guidelines (2.8 mV, 2.0 mV, and 244 mV× msec, respectively). We evaluated the ECG criteria for left ventricular hypertrophy (LVH) corresponding to echocardiographic LVH (Echo-LVH) in Japanese patients.We reviewed data on 345 consecutive hypertensive patients who underwent echocardiography, and evaluated the Cornell voltage (S in leads V3 + R in leads aVL), Cornell product [ (Cornell voltage + 0.6 mV for females) × QRS duration], and left ventricular mass index (LVMI) (Echo-LVH: LVMI ≥ 116 g/m2 in males and ≥ 96 g/m2 in females).The mean age was 63.8 ± 12.5 years (174 males/172 females). Echo-LVH was found in 22.7% of males and 37.2% of females. The equations for estimating LVMI from the Cornell voltage were (1) LVMI = 14.5 × Cornell voltage + 78.9 for males and (2) LVMI = 21.5 × Cornell voltage + 61.5 for females. The Cornell voltage corresponding to Echo-LVH was 2.6 mV in males and 1.6 mV in females, which were below the guideline levels and close to the values indicating cardiovascular risk. The equation for estimating LVMI from the Cornell product was LVMI = 0.15 × Cornell product + 68.8. The Cornell product corresponding to Echo-LVH was 170 mV× msec (sensitivity: 0.730, specificity: 0.601), which was also close to the cardiovascular risk level.Cornell voltage and product values indicating Echo-LVH are lower than those in the current guidelines and closer to the cardiovascular risk levels.

Levels of cornell voltage and cornell product for predicting cardiovascular and stroke mortality and morbidity in the general Japanese population.

BACKGROUND: ECG-diagnosed left ventricular hypertrophy (LVH), the Cornell voltage (CV: ≥2.8mV in males and ≥2.0mV in females) or Cornell product (CP: ≥244.0mV×ms), were selected in Western countries for their ability to diagnose anatomical LVH. METHODS AND RESULTS: We aimed to elucidate the CV and CP values that were associated with a significantly increased risk of cardiovascular or stroke mortality and morbidity in a Japanese general population (n=10,172). In the receiver-operating curves analysis of CV and CP for predicting the risks, the area under the curve in females was greater than in males. In a quintile-based multivariate analysis that was performed separately for females and males, the mortality and morbidity risks of CV were significantly increased at the highest quintile of CV (>1.71mV) in females. In males, the mortality risk was significantly increased at the highest quintile of CV (>2.04mV). Additionally, in the parallel analysis of CP that included both males and females, the morbidity risk was significantly elevated in subjects with CP belonging to the 4th (158.7-193.4mV×ms; hazard ratio=1.387) or 5th quintiles (≥193.5mV×ms; hazard ratio=1.507), compared with those with CP values within the lowest quintile (<101.9mV×ms). CONCLUSIONS: Cardiovascular and stroke risks may be elevated at lower levels of CV and CP in Japanese subjects, especially females.

Left ventricular diastolic function evaluated by the E/e' ratio is impaired in patients with masked uncontrolled hypertension.

BACKGROUND: Masked uncontrolled hypertension (MUH), defined as controlled office blood pressure (BP) but uncontrolled out-of-office BP in treated hypertensives, is a risk factor for cardiovascular disease. We tested the hypothesis that MUH is associated with a greater degree of diastolic dysfunction than controlled hypertension (CH) or uncontrolled hypertension (UH). METHODS AND RESULTS: We studied 299 treated patients who had at least one cardiovascular risk factor (age, 63 ± 10 years; male sex, 43%), consisting of 94 (31.4%) patients with UH, 46 (15.4%) with MUH, 56 (18.7%) with treated white-coat hypertension (WCH), and 103 (34.4%) with CH. We performed office and home BP monitoring, electrocardiography, echocardiography and blood tests. Diastolic dysfunction was defined as an E-wave to e'-wave (E/e') ratio ≥8 measured by Doppler echocardiography. The value of E/e' was higher in the MUH (8.3 ± 2.7) and UH (8.3 ± 2.7) groups than in the CH group (7.3 ± 2.3; p = 0.08, p = 0.02, respectively). In multivariable analysis, MUH was associated with a significantly higher likelihood of diastolic dysfunction than CH (odds ratio 2.90 versus CH, p < 0.01) after adjusting for significant covariates. CONCLUSIONS: MUH and UH were associated with a greater degree of diastolic dysfunction than CH. Even in treated patients, out-of-office BP is important to stratify the risk of cardiovascular disease.

[Alpha blocker x beta-blocker].

To control blood pressure for throughout a day, one of antihypertensive drugs will be administered at bedtime. Calcium channel blocker or angiotensin II receptor blocker will be the first line drug for bedtime administration. Alpha-blocker or beta-blocker will be the last choice.

Automated office blood pressure measurement with the assistance of an instructional video in patients with hypertension.

OBJECTIVES: Automated office blood pressure (AOBP) measurement often requires assistance. Accompanied by an instructional video, AOBP measurement could be performed independently by patients. DESIGN AND METHODS: Seventy-five patients with hypertension were enrolled. AOBP was measured three times at 1-min intervals after 5 min of rest by an automated BP measurement device with the assistance of an animated instructional video. The video was designed originally to instruct patients on the way to measure BP appropriately. Perceived stress was evaluated using a questionnaire after the AOBP measurement. Office BP was measured three times using the same device. Home BP measurement was performed on 5 consecutive days. RESULTS: The mean age of the patients was 74.5 ±â€…10.6 years, and 96% were taking antihypertensive drugs. Mean AOBP, office BP and home BP measurements were 135.2 ±â€…17.2/81.3 ±â€…11.1, 139.3 ±â€…16.3/78.6 ±â€…10.9 and 129.2 ±â€…16.7/72.7 ±â€…8.9 mmHg, respectively. Regarding SBP, the mean AOBP was significantly lower than office BP ( P  = 0.005) and higher than home BP ( P  = 0.004). The differences in SBP and DBP between AOBP and home BP measurements were significantly related to patients' perceived stress when performing AOBP measurements ( r  = 0.289; P  = 0.013 and r  = 0.328; P  = 0.004). In a multivariate analysis, patients' perceived stress was a significant predictor of the difference between AOBP and home BP ( P  = 0.013), even after adjusting for age, sex, BMI and mean of AOBP and home BP. CONCLUSION: AOBP values measured with the assistance of an instructional video were between conventional office and home BP measurements. Perceived stress during AOBP measurement was related to the difference in AOBP from home BP.

Relationship between blood pressure and cognitive impairment in elderly outpatients with cardiometabolic diseases.

AIM: The aim of this study was to clarify the relationship between high or low blood pressure (BP) and cognitive function in elderly outpatients with cardiometabolic diseases. METHODS: We evaluated the association between BP and the Dementia Assessment Sheet for Community-based Integrated Care System-21 items (DASC-21), Mini Mental State Examination (MMSE), and Montreal Cognitive Assessment Tool (MoCA) (N = 677). RESULTS: The patients' mean age was 79.2 ± 6.3 years (male 35.3%), and BP was 132.1 ± 18.1/73.5 ± 12.2 mmHg. Systolic BP (SBP) was linearly related to the DASC-21 score (r = -0.122, P = 0.004), but not to the MMSE score (P = 0.101) or MoCA score (P = 0.802). Multiple linear regression analysis showed that lower SBP was significantly related to the DASC-21 score, even after controlling for confounding factors (B = -0.411 per 10 mmHg; 95% confidence interval [CI], -0.673 to -0.149; P = 0.002). Moreover, logistic regression analysis showed that lower SBP was associated with DASC-21 ≥ 31 (odds ratio = 0.838 per 10 mmHg, P = 0.048). An MMSE score ≤23 was significantly associated with higher SBP in patients without a history of hypertension but with lower SBP in those with hypertension, those on hypertensive medication, and those with dyslipidemia. CONCLUSION: Higher BP was associated with a higher prevalence of probable dementia in those without a history of hypertension, even in late life. In those with hypertension and those taking antihypertensives with comorbidities of stroke or heart failure, lower BP was associated with probable dementia, which was largely dependent on reduced activities of daily living, as measured by the DASC-21 score. Geriatr Gerontol Int 2024; 24: 110-117.

Association between Cognitive Impairment Severity and Polypharmacy in Older Patients with Atrial Fibrillation: A Retrospective Study Using Inpatient Data from a Specialised Geriatric Hospital.

This study aimed to investigate the association between cognitive impairment and polypharmacy in patients with atrial fibrillation prone to cognitive decline, and to elucidate if the Dementia Assessment Sheet for Community-based Integrated Care System 21-Items (DASC-21) severity classification indicates drug adjustment. This retrospective cohort study used the DASC-21 and Diagnosis Procedure Combination data at a specialised geriatric hospital with patients hospitalised between April 2019 and March 2022. The association between cognitive severity evaluated using the DASC-21 and polypharmacy was investigated using a multivariate logistic regression model. Data of 1191 inpatients (44.3% aged ≥85 years, 49.0% male) were analysed. Compared with severe cognitive impairment, mild (odds ratio [OR]: 3.33, 95% confidence interval [CI]: 1.29-8.57) and moderate (OR: 2.46, 95% CI: 1.06-5.72) impairments were associated with concurrent use of ≥6 medications. Antithrombotics were related to polypharmacy. The ORs did not change with 6, 8, or 10 medications (2.11 [95% CI: 1.51-2.95, p < 0.001], 2.42 [95% CI: 1.79-3.27, p < 0.001], and 2.01 [95% CI: 1.46-2.77, p < 0.001], respectively). DASC-21 severity was associated with polypharmacy in patients with atrial fibrillation, with a trend toward decreased polypharmacy from moderate to severe. The DASC-21 may serve as an indicator for drug adjustment in clinical practice.

Association of pulse pressure and mean blood pressure to frailty, sarcopenia, and cognitive dysfunction in elderly outpatients with history of hypertension.

This study aimed to evaluate the relationship between pulse pressure (PP) and sarcopenia, frailty, and cognitive function in elderly patients with hypertension. We evaluated 435 elderly patients with a history of hypertension who visited the frail outpatient clinic between July 2015 and October 2021. Data at the 1-, 2-, and 3-year follow-ups were available for 222, 177, and 164 patients, respectively. Sarcopenia, frailty, and cognitive function, including Mini-Mental State Examination (MMSE) scores, were evaluated. The patients' mean age was 79.2 ± 6.3 years (male, 34.9%). PP and mean blood pressure (BP) were 60.1 ± 13.6 mmHg and 94.1 ± 13.0 mmHg, respectively. At baseline, lower PP was associated with probable dementia (MMSE score ≤23 points) (OR = 0.960 per 1 mmHg increase; 95% CI, 0.933-0.989; P = 0.006) in the model adjusted for conventional confounding factors and comorbidities, whereas higher PP was associated with low handgrip strength (OR = 1.018 per 1 mmHg increase; 95% CI, 1.001-1.036; P = 0.041). In multivariate-adjusted logistic regression analysis of patients with preserved handgrip strength at baseline, reductions in PP (OR = 0.844; 95% CI, 0.731-0.974; P = 0.020) and mean BP (OR = 0.861; 95% CI, 0.758-0.979; P = 0.022) were significantly associated with the incidence of low handgrip strength at 3 years. In conclusion, a higher PP induced by increased arterial stiffness was associated with lower handgrip strength, whereas a lower PP was associated with probable dementia. Reduced PP was associated with decreased handgrip strength after three years.