Legacy benefits of blood pressure treatment on cardiovascular events are primarily mediated by improved blood pressure variability: the ASCOT trial.

BACKGROUND AND AIMS: Visit-to-visit systolic blood pressure variability (BPV) is an important predictor of cardiovascular (CV) outcomes. The long-term effect of a period of blood pressure (BP) control, but with differential BPV, is uncertain. Morbidity and mortality follow-up of UK participants in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure-Lowering Arm has been extended for up to 21 years to determine the CV impact of mean systolic blood pressure (SBP) control and BPV during the trial, and amongst those allocated to amlodipine- and atenolol-based treatment. METHODS: Eight thousand five hundred and eighty hypertensive participants (4305 assigned to amlodipine ± perindopril-based and 4275 to atenolol ± diuretic-based treatment during the in-trial period (median 5.5 years) were followed for up to 21 years (median 17.4 years), using linked hospital and mortality records. A subgroup of participants (n = 2156) was followed up 6 years after the trial closure with a self-administered questionnaire and a clinic visit. In-trial mean SBP and standard deviation of visit-to-visit SBP as a measure of BPV, were measured using >100 000 BP measurements. Cox proportional hazard models were used to estimate the risk [hazard ratios (HRs)], associated with (i) mean with SBP and BPV during the in-trial period, for the CV endpoints occurring after the end of the trial and (ii) randomly assigned treatment to events following randomization, for the first occurrence of pre-specified CV outcomes. RESULTS: Using BP data from the in-trial period, in the post-trial period, although mean SBP was a predictor of CV outcomes {HR per 10 mmHg, 1.14 [95% confidence interval (CI) 1.10-1.17], P < .001}, systolic BPV independent of mean SBP was a strong predictor of CV events [HR per 5 mmHg 1.22 (95% CI 1.18-1.26), P < .001] and predicted events even in participants with well-controlled BP. During 21-year follow-up, those on amlodipine-based compared with atenolol-based in-trial treatment had significantly reduced risk of stroke [HR 0.82 (95% CI 0.72-0.93), P = .003], total CV events [HR 0.93 (95% CI 0.88-0.98), P = .008], total coronary events [HR 0.92 (95% CI 0.86-0.99), P = .024], and atrial fibrillation [HR 0.91 (95% CI 0.83-0.99), P = .030], with weaker evidence of a difference in CV mortality [HR 0.91 (95% CI 0.82-1.01), P = .073]. There was no significant difference in the incidence of non-fatal myocardial infarction and fatal coronary heart disease, heart failure, and all-cause mortality. CONCLUSIONS: Systolic BPV is a strong predictor of CV outcome, even in those with controlled SBP. The long-term benefits of amlodipine-based treatment compared with atenolol-based treatment in reducing CV events appear to be primarily mediated by an effect on systolic BPV during the trial period.

Cardiovascular outcomes in adults with hypertension with evening versus morning dosing of usual antihypertensives in the UK (TIME study): a prospective, randomised, open-label, blinded-endpoint clinical trial.

BACKGROUND: Studies have suggested that evening dosing with antihypertensive therapy might have better outcomes than morning dosing. The Treatment in Morning versus Evening (TIME) study aimed to investigate whether evening dosing of usual antihypertensive medication improves major cardiovascular outcomes compared with morning dosing in patients with hypertension. METHODS: The TIME study is a prospective, pragmatic, decentralised, parallel-group study in the UK, that recruited adults (aged ≥18 years) with hypertension and taking at least one antihypertensive medication. Eligible participants were randomly assigned (1:1), without restriction, stratification, or minimisation, to take all of their usual antihypertensive medications in either the morning (0600-1000 h) or in the evening (2000-0000 h). Participants were followed up for the composite primary endpoint of vascular death or hospitalisation for non-fatal myocardial infarction or non-fatal stroke. Endpoints were identified by participant report or record linkage to National Health Service datasets and were adjudicated by a committee masked to treatment allocation. The primary endpoint was assessed as the time to first occurrence of an event in the intention-to-treat population (ie, all participants randomly assigned to a treatment group). Safety was assessed in all participants who submitted at least one follow-up questionnaire. The study is registered with EudraCT (2011-001968-21) and ISRCTN (18157641), and is now complete. FINDINGS: Between Dec 17, 2011, and June 5, 2018, 24 610 individuals were screened and 21 104 were randomly assigned to evening (n=10 503) or morning (n=10 601) dosing groups. Mean age at study entry was 65·1 years (SD 9·3); 12 136 (57·5%) participants were men; 8968 (42·5%) were women; 19 101 (90·5%) were White; 98 (0·5%) were Black, African, Caribbean, or Black British (ethnicity was not reported by 1637 [7·8%] participants); and 2725 (13·0%) had a previous cardiovascular disease. By the end of study follow-up (March 31, 2021), median follow-up was 5·2 years (IQR 4·9-5·7), and 529 (5·0%) of 10 503 participants assigned to evening treatment and 318 (3·0%) of 10 601 assigned to morning treatment had withdrawn from all follow-up. A primary endpoint event occurred in 362 (3·4%) participants assigned to evening treatment (0·69 events [95% CI 0·62-0·76] per 100 patient-years) and 390 (3·7%) assigned to morning treatment (0·72 events [95% CI 0·65-0·79] per 100 patient-years; unadjusted hazard ratio 0·95 [95% CI 0·83-1·10]; p=0·53). No safety concerns were identified. INTERPRETATION: Evening dosing of usual antihypertensive medication was not different from morning dosing in terms of major cardiovascular outcomes. Patients can be advised that they can take their regular antihypertensive medications at a convenient time that minimises any undesirable effects. FUNDING: British Heart Foundation.

Effects of oral semaglutide on cardiovascular outcomes in individuals with type 2 diabetes and established atherosclerotic cardiovascular disease and/or chronic kidney disease: Design and baseline characteristics of SOUL, a randomized trial.

AIM: To describe the design of the SOUL trial (Semaglutide cardiOvascular oUtcomes triaL) and the baseline clinical data of its participants. MATERIALS AND METHODS: In SOUL, the effects of oral semaglutide, the first oral glucagon-like peptide-1 receptor agonist, on the risk of cardiovascular (CV) events in individuals with type 2 diabetes and established atherosclerotic CV disease (ASCVD) and/or chronic kidney disease (CKD) will be assessed. SOUL is a randomized, double-blind, parallel-group, placebo-controlled CV outcomes trial comparing oral semaglutide (14 mg once daily) with placebo, both in addition to standard of care, in individuals aged ≥50 years with type 2 diabetes and evidence of ASCVD (coronary artery disease [CAD], cerebrovascular disease, symptomatic peripheral arterial disease [PAD]) and/or CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2 ). The primary outcome is time from randomization to first occurrence of a major adverse CV event (MACE; a composite of CV death, nonfatal myocardial infarction or nonfatal stroke). This event-driven trial will continue until 1225 first adjudication-confirmed MACEs have occurred. Enrolment has been completed. RESULTS: Overall, 9650 participants were enrolled between June 17, 2019 and March 24, 2021 (men 71.1%, White ethnicity 68.9%, mean age 66.1 years, diabetes duration 15.4 years, body mass index 31.1 kg/m2 , glycated haemoglobin 63.5 mmol/mol [8.0%]). The most frequently used antihyperglycaemic medications at baseline were metformin (75.7%), insulin and insulin analogues (50.5%), sulphonylureas (29.1%), sodium-glucose cotransporter-2 inhibitors (26.7%) and dipeptidyl peptidase-4 inhibitors (23.0%). At randomization, 70.7% of participants had CAD, 42.3% had CKD, 21.1% had cerebrovascular disease and 15.7% had symptomatic PAD (categories not mutually exclusive). Prevalent heart failure was reported in 23.0% of participants. CONCLUSION: SOUL will provide evidence regarding the CV effects of oral semaglutide in individuals with type 2 diabetes and established ASCVD and/or CKD.

Ablation versus anti-arrhythmic therapy for reducing all hospital episodes from recurrent atrial fibrillation: a prospective, randomized, multi-centre, open label trial.

AIMS: There is rising healthcare utilization related to the increasing incidence and prevalence of atrial fibrillation (AF) worldwide. Simplifying therapy and reducing hospital episodes would be a valuable development. The efficacy of a streamlined AF ablation approach was compared to drug therapy and a conventional catheter ablation technique for symptom control in paroxysmal AF. METHODS AND RESULTS: We recruited 321 patients with symptomatic paroxysmal AF to a prospective randomized, multi-centre, open label trial at 13 UK hospitals. Patients were randomized 1:1:1 to cryo-balloon ablation without electrical mapping with patients discharged same day [Ablation Versus Anti-arrhythmic Therapy for Reducing All Hospital Episodes from Recurrent (AVATAR) protocol]; optimization of drug therapy; or cryo-balloon ablation with confirmation of pulmonary vein isolation and overnight hospitalization. The primary endpoint was time to any hospital episode related to treatment for atrial arrhythmia. Secondary endpoints included complications of treatment and quality-of-life measures. The hazard ratio (HR) for a primary endpoint event occurring when comparing AVATAR protocol arm to drug therapy was 0.156 (95% CI, 0.097-0.250; P < 0.0001 by Cox regression). Twenty-three patients (21%) recorded an endpoint event in the AVATAR arm compared to 76 patients (74%) within the drug therapy arm. Comparing AVATAR and conventional ablation arms resulted in a non-significant HR of 1.173 (95% CI, 0.639-2.154; P = 0.61 by Cox regression) with 23 patients (21%) and 19 patients (18%), respectively, recording primary endpoint events (P = 0.61 by log-rank test). CONCLUSION: The AVATAR protocol was superior to drug therapy for avoiding hospital episodes related to AF treatment, but conventional cryoablation was not superior to the AVATAR protocol. This could have wide-ranging implications on how demand for AF symptom control is met. TRIAL REGISTRATION: Clinical Trials Registration: NCT02459574.

Implications of ACC/AHA Versus ESC/EAS LDL-C Recommendations for Residual Risk Reduction in ASCVD: A Simulation Study From DA VINCI.

PURPOSE: Low-density lipoprotein cholesterol (LDL-C) recommendations differ between the 2018 American College of Cardiology/American Heart Association (ACC/AHA) and 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for patients with atherosclerotic cardiovascular disease (ASCVD) (< 70 vs. < 55 mg/dl, respectively). In the DA VINCI study, residual cardiovascular risk was predicted in ASCVD patients. The extent to which relative and absolute risk might be lowered by achieving ACC/AHA versus ESC/EAS LDL-C recommended approaches was simulated. METHODS: DA VINCI was a cross-sectional observational study of patients prescribed lipid-lowering therapy (LLT) across 18 European countries. Ten-year cardiovascular risk (CVR) was predicted among ASCVD patients receiving stabilized LLT. For patients with LDL-C ≥ 70 mg/dl, the absolute LDL-C reduction required to achieve an LDL-C of < 70 or < 55 mg/dl (LDL-C of 69 or 54 mg/dl, respectively) was calculated. Relative and absolute risk reductions (RRRs and ARRs) were simulated. RESULTS: Of the 2039 patients, 61% did not achieve LDL-C < 70 mg/dl. For patients with LDL-C ≥ 70 mg/dl, median (interquartile range) baseline LDL-C and 10-year CVR were 93 (81-115) mg/dl and 32% (25-43%), respectively. Median LDL-C reductions of 24 (12-46) and 39 (27-91) mg/dl were needed to achieve an LDL-C of 69 and 54 mg/dl, respectively. Attaining ACC/AHA or ESC/EAS goals resulted in simulated RRRs of 14% (7-25%) and 22% (15-32%), respectively, and ARRs of 4% (2-7%) and 6% (4-9%), respectively. CONCLUSION: In ASCVD patients, achieving ESC/EAS LDL-C goals could result in a 2% additional ARR over 10 years versus the ACC/AHA approach.

Comparison of Dual Therapies for Lowering Blood Pressure in Black Africans.

BACKGROUND: The prevalence of hypertension among black African patients is high, and these patients usually need two or more medications for blood-pressure control. However, the most effective two-drug combination that is currently available for blood-pressure control in these patients has not been established. METHODS: In this randomized, single-blind, three-group trial conducted in six countries in sub-Saharan Africa, we randomly assigned 728 black patients with uncontrolled hypertension (≥140/90 mm Hg while the patient was not being treated or was taking only one antihypertensive drug) to receive a daily regimen of 5 mg of amlodipine plus 12.5 mg of hydrochlorothiazide, 5 mg of amlodipine plus 4 mg of perindopril, or 4 mg of perindopril plus 12.5 mg of hydrochlorothiazide for 2 months. Doses were then doubled (10 and 25 mg, 10 and 8 mg, and 8 and 25 mg, respectively) for an additional 4 months. The primary end point was the change in the 24-hour ambulatory systolic blood pressure between baseline and 6 months. RESULTS: The mean age of the patients was 51 years, and 63% were women. Among the 621 patients who underwent 24-hour blood-pressure monitoring at baseline and at 6 months, those receiving amlodipine plus hydrochlorothiazide and those receiving amlodipine plus perindopril had a lower 24-hour ambulatory systolic blood pressure than those receiving perindopril plus hydrochlorothiazide (between-group difference in the change from baseline, -3.14 mm Hg; 95% confidence interval [CI], -5.90 to -0.38; P = 0.03; and -3.00 mm Hg; 95% CI, -5.8 to -0.20; P = 0.04, respectively). The difference between the group receiving amlodipine plus hydrochlorothiazide and the group receiving amlodipine plus perindopril was -0.14 mm Hg (95% CI, -2.90 to 2.61; P=0.92). Similar differential effects on office and ambulatory diastolic blood pressures, along with blood-pressure control and response rates, were apparent among the three groups. CONCLUSIONS: These findings suggest that in black patients in sub-Saharan Africa, amlodipine plus either hydrochlorothiazide or perindopril was more effective than perindopril plus hydrochlorothiazide at lowering blood pressure at 6 months. (Funded by GlaxoSmithKline Africa Noncommunicable Disease Open Lab; CREOLE ClinicalTrials.gov number, NCT02742467.).

May Measurement Month 2017: an analysis of blood pressure screening results from Mauritius.

Hypertension is a growing burden worldwide. According to the World Health Organization, ∼1.13 billion people worldwide suffer from hypertension. May Measurement Month (MMM) is a global initiative of the International Society of Hypertension aimed at raising awareness of high blood pressure (BP) and to act as a temporary solution to the lack of screening programmes worldwide. We provide the results of the 2017 MMM (MMM17) edition in Mauritius. This cross-sectional survey of participants aged 18 years and over was carried out in May 2017. Hypertension was defined as systolic BP of at least 140 mmHg or diastolic BP of at least 90mmHg or in those on antihypertensive medication. Blood pressure measurement and statistical analysis followed the standard MMM protocol. The screening was conducted by the Non-Communicable Diseases and Health Promotion Unit, which is under the aegis of the Ministry of Health and Wellness, mainly in workplaces and community centres, in both rural and urban areas across Mauritius. Of the 2302 individuals screened, after multiple imputations, 375 (16.3%) had untreated hypertension. May Measurement Month 2017 was the very first BP screening campaign initiated in Mauritius. These results suggest that MMM17 was useful in the identification of potential patients with raised BP.

May Measurement Month 2018: an analysis of blood pressure screening results from Pakistan.

The May Measurement Month (MMM) screening campaigns comprise an opportunistic assessment of the arterial blood pressure (BP) of Pakistani adults (≥18 years old) and evaluate the level of awareness and spectrum of the problem of hypertension and the associated risk factors. The prospective study was carried out in May 2018 in multiple medical screening camps at hospitals, pharmacies, and public areas with the help of local health care workers under ethical guidelines. The volunteers took BP measurements using OMRON digital BP devices, in a seated position, and three successive readings were noted after 5 min rest. The mean values of the second and third readings were attained. Data were analysed centrally by the MMM project management team and multiple imputations were performed, where BP readings were missing. Hypertension was defined as a systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, or in those taking antihypertensive medication. This study included 25 076 participants, of whom 14 726 (58.7%) were hypertensive. Among all hypertensives, only 11 681 were aware of their hypertension status. After imputation, age and gender standardization, mean systolic and diastolic BP were 129.8 mmHg and 82.9 mmHg, respectively. MMM17 data revealed that 55.2% of those screened were hypertensive in Pakistan, while in 2018 the proportion rose slightly to 58.7%. The prevalence of hypertension among those screened for MMM in Pakistan was high in both years. Although most patients with hypertension were treated, the majority remained uncontrolled. Further efforts to improve awareness and control are needed.

May Measurement Month 2017-2019: an analysis of blood pressure screening results from Lithuania.

In 2017, Lithuania joined the global May Measurement Month (MMM) campaign which aims at raising awareness of raised blood pressure worldwide. Presented here are the data arising from the 2017, 2018, and 2019 campaigns. An opportunistic cross-sectional survey of individuals aged ≥18 years was carried out in Lithuania in 2017, 2018, and 2019. Two thousand nine hundred and nineteen participants were recruited in the MMM campaigns in response to the media engagement and interactions with the study team. The mean age of participants was 46.1 years (SD 16.3) years, 58.9% were females. Blood pressures were measured using electronic devices provided by Omron according to the MMM protocol. Of the 2919 screened participants, 1308 (44.8%) had hypertension. Of all hypertensive participants, the awareness rate, the treatment rate, and the control rates (<140/90 mmHg) were 79.5%, 41.0%, and 14.2%, respectively. Of those on antihypertensive medication, the control rate was 34.8%. The high percentage of participants with hypertension was either untreated (59.0%) or treated but uncontrolled (65.2%) suggests the usefulness of such screening programmes to improve awareness of hypertension control in Lithuania.

May Measurement Month 2017-19: an analysis of blood pressure screening results from Paraguay.

The aim of this study was to highlight the importance of measuring blood pressure (BP) and to identify and reduce the BPs of those people who require intervention to lower their BP according to current guidelines. A total of 7782 individuals aged ≥18 years were recruited during the 3 years of the May Measurement Month (MMM) campaign (2017: 1196, 2018: 2285, 2019: 4301). Recruitment was through opportunistic sampling at a variety of screening sites distributed throughout the country. Each participant underwent a pre-specified questionnaire with questions on risk factors concluding with three BP measurements at 1 min intervals and measurement of weight and height. Hypertension was defined as a systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg or those receiving antihypertensive therapy. Of all 7782 participants, 3323 had hypertension (42.7%) of whom 61.8% were aware and 50.4% were not receiving antihypertensive medication. Of those treated (49.6%), 43.8% had controlled BP (<140/90 mmHg). Among all hypertensive patients (with and without medication), 21.7% had controlled BP. In relation to previous surveys carried out in the country, awareness of hypertension increased two-fold, with no change in the proportion of hypertensive patients on treatment and the proportion of hypertensive patients with controlled BP which remained low.

May Measurement Month 2017-2019: an analysis of blood pressure screening results from Guatemala.

In 2018, the Ministry of Public Health and Social Assistance of Guatemala published the last update of the prevalence of noncommunicable diseases (NCDs), and as in other low-income countries, the prevalence of NCD morbidity and mortality had risen. The prevalence of hypertension in Guatemala has been reported in a range from 18.7 to 22.7% which could be underestimated, because the country does not have an adequate statistical surveillance system. May Measurement Month (MMM) 2017, 2018, and 2019 in Guatemala was an opportunistic survey, which followed the methodology previously published. Blood pressure (BP) measurements were carried out in various locations, mainly hospitals and clinics (48.9%) or pharmacies (34.2%) in Guatemala City. In all patients, three BP measurements were taken after 5 min of rest and sitting in the correct recommended position. The mean of the second and third BP measurements was used for the analyses. Multiple imputation was used to impute the missing readings, based on the global MMM data. After multiple imputation, of all 3265 participants, 43.4% had hypertension. Of all participants with hypertension, 74.7% were aware of their diagnosis, 69.2% were on antihypertensive medication, and 63.1% had controlled BP (<140/90 mmHg). Of all those with hypertension, 43.6% had controlled BP. MMM is the largest hypertension survey ever carried out globally. The MMM results from Guatemala reported here provide complementary and strong data on the impact of hypertension in the country and help to make hypertension visible as a priority health problem, which requires urgent solutions.

May Measurement Month 2017-2019: an analysis of blood pressure screening results from Ukraine.

Hypertension is a key cardiovascular disease risk factor leading to premature mortality worldwide. The purpose of the May Measurement Month (MMM) campaign in Ukraine is to improve awareness of hypertension at the individual and population level. Adults (≥18 years) were screened at sites in Ukraine. Data from the MMM17 (19 sites), MMM18 (1 site), and MMM19 (5 sites) campaigns are included in the present analysis. Ideally, three blood pressure (BP) measurements were taken for each participant, and data on lifestyle factors and comorbidities were collected. Hypertension was defined as systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mm Hg (based on the mean of the second and third readings) or being on antihypertension medication. Multiple imputation was used to estimate participants' mean BP where readings were missing. Linear regression models were used to evaluate associations between BP and participant characteristics. Of all 46 549 screenees, 33 307 (71.6%) had hypertension, and 82.6% of whom were on antihypertensive medication. Of all those on medication, 31.4% were controlled to BP < 140/90 mmHg, and of all 33 307 participants with hypertension, 25.9% had controlled BP. Of all participants, 6.6% took statins and 11.2% took aspirin. The analysis of the MMM 2017, 2018, and 2019 campaigns has shown a high proportion of hypertension, insufficient level of awareness, and critically low level of effective BP control in Ukraine. Further MMM screening is needed to increase awareness of high BP and to help improve diagnosis, management, and treatment of hypertension.

May Measurement Month 2017-2019: an analysis of blood pressure screening results from Dominican Republic.

Arterial hypertension is the main risk factor that contributes to cardiovascular disease and represents a leading cause of morbidity and mortality globally. May Measurement Month (MMM) is a global screening campaign with the aim of improving awareness of hypertension at the individual and population level, an initiative that has been supported in the Dominican Republic (DR) since 2017. Adults (≥18 years) were recruited by sampling in different places in the DR, three blood pressure (BP) readings were performed per participant, and data on risk factors and comorbidities were collected. Hypertension was defined as systolic BP ≥140 mm Hg, diastolic BP ≥ 90 mm Hg (mean of second and third readings), and/or taking antihypertensive medication. Multiple imputation was used to estimate participants' mean BP when three readings were not available. Of 3693 participants, 2134 (57.8%) had hypertension, of whom 1646 (77.1%) were taking medication, but only 38.6% of those on treatment had their BP under control(<140/90 mmHg). The remaining 61.4% of the participants received inadequate treatment. A total of 66% of treated patients were taking a single antihypertensive drug. MMM provides an important platform for the standardized compilation of BP data and the creation of awareness of hypertension in the DR and other nations of the world. The data generated from the 2017-2019 MMM campaigns highlight the importance of adequate detection, knowledge, and control of BP.

May Measurement Month 2018-2019: an analysis of blood pressure screening results from Austria.

Arterial hypertension is a global burden leading to over 10.8 million deaths per year worldwide. May Measurement Month (MMM) is a global project initiated by the International Society of Hypertension to raise the awareness of high blood pressure (BP) in the population. Following the MMM protocol 2508 participants ≥18 years had their BP measured in Austria in MMM18 and MMM19. Of those screened, 54.6% were found to be hypertensive, defined as a BP ≥140/90 mmHg and/or being on treatment for hypertension. Among those individuals with hypertension, 56.1% were on medication but only 42.0% of those treated had controlled BP (<140/90 mmHg). Lower BPs were found in those with previous myocardial infarction (MI), probably explained by a medical monitoring system of patients with MI in Austria. Those with hypertension were referred for further medical investigations and were provided lifestyle advice. Among a high number of individuals receiving antihypertensive treatment, BP is still not controlled. Further screening and monitoring of therapeutic effects is urgently required.

May Measurement Month 2019: analysis of blood pressure screening in Bishkek, Kyrgyzstan.

High blood pressure (BP) is one of the leading causes of death in Kyrgyzstan. The world's largest event in the field of increasing awareness of raised BP is the May Measurement Month (MMM) campaign. Kyrgyzstan joined MMM in 2019. The inclusion criteria for participants in the study were: age ≥18 years and providing informed consent. Hypertension was defined as the presence of systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg based on the mean of the second and third of three sitting BP measurements or on treatment for hypertension. Most of the participants (96.9%) were surveyed inside two large shopping malls of Bishkek. The total number of people who took part in the screening was 2013. The mean age was 38.8 (± 12.6) years, and 1006 were women (50.0%) and 1007 men (50.0%). One-hundred eighty-four participants had hypertension (9.1%), of whom 59 (32.0%) were aware of their diagnosis, and hypertension was controlled in 25 participants (13.7%). The mean BMI was 24.0 (± 4.1) kg/m2, 34 (1.7%) participants had diabetes mellitus, 12 (0.6%) had a history of myocardial infarction, 4 (0.2%) had a history of stroke, 314 (15.6%) were smokers. 41 (2.0%) drank alcohol 1-3 times a month, 46 (2.3%)-once per week. MMM screening allows us to gather up-to-date data on the prevalence, awareness and control of hypertension among volunteer screenees in Bishkek, Kyrgyzstan.

May Measurement Month 2018: an analysis of blood pressure screening results from Benin.

Hypertension is the strongest cardiovascular risk factor worldwide. May Measurement Month (MMM) is an international campaign for blood pressure (BP) screening initiated by the International Society of Hypertension. This work aims to estimate the proportion and the levels of awareness, treatment, and control of hypertension in participants of the MMM survey in Benin in 2018. A cross-sectional survey focused on people aged ≥18 years was conducted in May 2018 in nine rural and urban areas in Benin. A sampling of volunteers was done. BP was measured following the MMM protocol. Hypertension was defined as a systolic BP ≥140 mm Hg and/or a diastolic BP ≥90 mm Hg (mean of the second and third readings) and/or taking antihypertensive medication. Linear regression was used to identify BP associations. A total of 2035 people were screened, including 55.9% women. The mean age was 44.2 ± 15.9 years. The percentage with hypertension was 35.4%. Of 721 participants with hypertension, 56.2% were aware of their diagnosis, 39.7% were on antihypertensive medication, and 13.6% were controlled (<140/90 mmHg). The results confirm the significant proportion of hypertension in Benin. Education programs on risk factors, early detection, and better management strategies should be developed.

May Measurement Month 2017-19: an analysis of blood pressure screening results from Niger.

The aim of this study was to screen for cardiovascular risk factors with particular focus on high blood pressure (BP) in Niger and thereby to raise awareness among the population of Niger about raised BP and the associated risk to health. The city of Niamey served as our study location during the month of May in 2017, 2018, and 2019. We screened volunteer adults aged ≥18 years, who completed a pre-established questionnaire and had three sitting BP measurements taken. Hypertension was defined as a systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg (based on the mean of the second and third BP readings) or being on antihypertensive medication. We screened 2297 adults of which 42.9% were women and 57.1% men. Of the 2297 screened, 33.2% were found to be hypertensive of whom only 26 (3.4%) were recorded as being on treatment. Approximately 30% of those screened were found to be obese or overweight. High BP is a real public health danger, and this study finds alarming figures that highlight the need for improved policies for screening and management of hypertension. Raising awareness and improving detection of hypertension remain essential to reduce the burden of cardiovascular disease.

Polygenic risk scores predict diabetes complications and their response to intensive blood pressure and glucose control.

AIMS/HYPOTHESIS: Type 2 diabetes increases the risk of cardiovascular and renal complications, but early risk prediction could lead to timely intervention and better outcomes. Genetic information can be used to enable early detection of risk. METHODS: We developed a multi-polygenic risk score (multiPRS) that combines ten weighted PRSs (10 wPRS) composed of 598 SNPs associated with main risk factors and outcomes of type 2 diabetes, derived from summary statistics data of genome-wide association studies. The 10 wPRS, first principal component of ethnicity, sex, age at onset and diabetes duration were included into one logistic regression model to predict micro- and macrovascular outcomes in 4098 participants in the ADVANCE study and 17,604 individuals with type 2 diabetes in the UK Biobank study. RESULTS: The model showed a similar predictive performance for cardiovascular and renal complications in different cohorts. It identified the top 30% of ADVANCE participants with a mean of 3.1-fold increased risk of major micro- and macrovascular events (p = 6.3 × 10-21 and p = 9.6 × 10-31, respectively) and a 4.4-fold (p = 6.8 × 10-33) higher risk of cardiovascular death. While in ADVANCE overall, combined intensive blood pressure and glucose control decreased cardiovascular death by 24%, the model identified a high-risk group in whom it decreased the mortality rate by 47%, and a low-risk group in whom it had no discernible effect. High-risk individuals had the greatest absolute risk reduction with a number needed to treat of 12 to prevent one cardiovascular death over 5 years. CONCLUSIONS/INTERPRETATION: This novel multiPRS model stratified individuals with type 2 diabetes according to risk of complications and helped to target earlier those who would receive greater benefit from intensive therapy.

Variation in hypertension clinical practice guidelines: a global comparison.

BACKGROUND: Hypertension is the largest single contributor to the global burden of disease, affecting an estimated 1.39 billion people worldwide. Clinical practice guidelines (CPGs) can aid in the effective management of this common condition, however, inconsistencies exist between CPGs, and the extent of this is unknown. Understanding the differences in CPG recommendations across income settings may provide an important means of understanding some of the global variations in clinical outcomes related to hypertension. AIMS: This study aims to analyse the variation between hypertension CPGs globally. It aims to assess the variation in three areas: diagnostic threshold and staging, treatment and target blood pressure (BP) recommendations in hypertension. METHODS: A search was conducted on the MEDLINE repository to identify national and international hypertension CPGs from 2010 to May 2020. An additional country-specific grey-literature search was conducted for all countries and territories of the world as identified by the World Bank. Data describing the diagnosis, staging, treatment and target blood pressure were extracted from CPGs, and variations between CPGs for these domains were analysed. RESULTS: Forty-eight CPGs from across all World Bank income settings were selected for analysis. Ninety-six per cent of guidelines defined hypertension as a clinic-based BP of ≥140/90 mmHg, and 87% of guidelines recommended a target BP of < 140/90 mmHg. In the pharmacological treatment of hypertension, eight different first-step, 17 different second-step and six different third-step drug recommendations were observed. Low-income countries preferentially recommended diuretics (63%) in the first-step treatment, whilst high-income countries offered more choice between antihypertensive classes. Forty-four per cent of guidelines, of which 71% were from higher-income contexts recommended initiating treatment with dual-drug therapy at BP 160/100 mmHg or higher. CONCLUSION: This study found that CPGs remained largely consistent in the definition, staging and target BP recommendations for hypertension. Extensive variation was observed in treatment recommendations, particularly for second-line therapy. Variation existed between income settings; low-income countries prescribed cheaper drugs, offered less clinician choice in medications and initiated dual therapy at later stages than higher-income countries. Future research exploring the underlying drivers of this variation may improve outcomes for hypertensive patients across clinical contexts.

History of lower-limb complications and risk of cancer death in people with type 2 diabetes.

BACKGROUND: Individuals with diabetes and lower-limb complications are at high risk for cardiovascular and all-cause mortality, but uncertainties remain in terms of cancer-related death in this population. We investigated this relationship in a large cohort of people with type 2 diabetes. METHODS: We used data from the Action in Diabetes and Vascular Disease: PreterAx and DiamicroN Modified-Release Controlled Evaluation (ADVANCE) study. The primary outcome was adjudicated cancer death; secondary outcomes were overall and site-specific incident cancers, determined according to the International Classification of Diseases Code (ICD-10). We compared outcomes in individuals with (versus without) a baseline history of lower-limb complications (peripheral artery disease (PAD) or sensory peripheral neuropathy) using Cox regression models. RESULTS: Among 11,140 participants (women 42%, mean age 66 years), lower-limb complications were reported at baseline in 4293 (38%) individuals: 2439 (22%) with PAD and 2973 (27%) with peripheral neuropathy. Cancer death occurred in 316 (2.8%) participants during a median of 5.0 (25th-75th percentile, 4.7-5.1) years of follow-up corresponding to 53,550 person-years and an incidence rate of 5.9 (95% CI 5.3-6.6) per 1000 person-years. The risk of cancer death was higher in individuals with (versus without) lower-limb complication [hazard ratio 1.53 (95% CI, 1.21-1.94), p = 0.0004], PAD [1.32 (1.02-1.70), p = 0.03] or neuropathy (1.41 (1.11-1.79), p = 0.004], adjusting for potential confounders and study allocations. PAD, but not neuropathy, was associated with excess risk of incident cancers. CONCLUSIONS: PAD and peripheral neuropathy were independently associated with increased 5-year risk of cancer death in individuals with type 2 diabetes. PAD was also associated with increased risk of incident cancers. Our findings provide new evidence on the non-cardiovascular prognostic burden of lower-limb complications in people with type 2 diabetes.