Subjective memory complaints and incident dementia in a high risk older adult hypertensive population.

BACKGROUND: there is a growing body of evidence demonstrating an association between subjective memory complaints (SMC) and an increased risk of incident cognitive decline or dementia. To date this has not been examined in hypertensive older adults, a prevalent and growing population group at high risk of cognitive decline. METHODS: using data from participants in the Hypertension in the Very Elderly Trial cohort the association between baseline SMC and incident cognitive decline and dementia was examined using Cox proportional hazard regression. Cognitive function was assessed using the Mini-Mental State Exam and diagnoses of dementia were made using standard diagnostic criteria. SMC was assessed by the question 'do you feel that you have more problems with memory than most?' Analyses were rerun to examine the associations by level of baseline cognitive function, to evaluate the role of SMC by dementia type and by sex. RESULTS: baseline SMC were associated with an increased risk of developing any dementia (hazard ratio (HR)1.63 (95% confidence intervals (CI): 1.18:2.25)), Alzheimer's disease (HR1.59 (95% CI: 1.08:2.34)) and vascular dementia (HR2.05 (95% CI: 1.19:3.54)). Similar patterns were seen across all levels of baseline MMSE but were strongest in those with scores of 25-27. There were no clear differences by sex. DISCUSSION: a positive report of SMC assessed by a single question in an older adult with hypertension raises the possibility of increased risk of incident dementia. As such its use may be a useful addition to the repertoire of the general practitioner and geriatrician when assessing older adults.

Arterial compliance may be reduced by ingestion of red wine.

The aim of this study was to assess the effect of alcohol on blood pressure and arterial compliance over 24 h in a group of volunteers, comparing the same group of subjects on two consecutive but separate days, one with alcohol intake (alcohol day) and one free of alcohol (control day). We studied 18 healthy subjects (mean age 34.2 years, range 25-53). The subjects received the two days in random order. On the alcohol day, the subjects were asked to drink two glasses of red wine (12% ethanol) between 1830 hours and 0430 hours. Measurements of heart rate, blood pressure and QKD interval (Q wave to Korotkoff (K) sound, diastolic phase (D) using Diasys Integra (Novacor, France)) were recorded (usually 1500 hours to 1500 hours). Three 'ingestion' periods were defined, from 1500 hours to 1830 hours ('before'), 1900 hours to 0430 hours ('during') and from 0430 hours to the following afternoon ('after') on both the alcohol day and on the control day. Red wine increased heart rate during alcohol ingestion and reduced arterial compliance after ingestion. The significant effect of interaction between day and ingestion period on heart rate, diastolic blood pressure and QKD were found, suggesting that the differences in response among the ingestion periods depended on whether alcohol has been consumed that day. For the first time our study indicates the effect of alcohol on 24 h arterial stiffness in a healthy group of volunteers.

Blood pressure control in the Hypertension in the Very Elderly Trial (HYVET).

To report blood pressure control in the Hypertension in the Very Elderly Trial, a placebo-controlled trial of hypertensive (systolic blood pressure (SBP) 160-199 mm Hg, diastolic blood pressure (DBP) <110 mm Hg) participants over the age of 80 years, given treatment in three steps: indapamide slow release 1.5 mg alone, indapamide plus 2 mg perindopril and indapamide plus 4 mg perindopril. The difference in control between participants with combined systolic and diastolic hypertension (SDH, DBP90 mm Hg) and those with isolated systolic hypertension (ISH, DBP<90 mm Hg) is determined together with the effects of increments in the treatment regimen. At 2 years, the active treatment lowered blood pressure by 16.5/6.9 mm Hg more than that on placebo in participants with SDH and by 19.3/4.8 mm Hg more in those with ISH. The 2-year falls in pressure on placebo alone were 13.2/8.5 mm Hg in SDH and 8.2/1.5 mm Hg in ISH participants. With full titration of active treatment, 62% of SDH participants achieved goal SBP (<150 mm Hg) by 2 years and 71% of those with ISH. The corresponding results for DBP control (<80 mm Hg) were 40 and 78%. The addition of active perindopril 2 mg roughly doubled the percentage controlled, as did increasing to 4 from 2 mg. Blood pressure control was good with ISH and better than with SDH. The fall in SBP accounted for the observed 30% reduction in strokes, but the 21% reduction in total mortality and 64% reduction in heart failure were greater than predicted.

Self management and patient understanding of diabetes in the older person.

AIM: To examine knowledge and management of diabetes by older people. METHODS: A representative sample of 1047 people with Type 2 diabetes, aged 75 years and over, were asked a series of questions relating to their diabetes management and their understanding of self management. The impact of cognitive impairment and socio-economic status were assessed. RESULTS: The majority of people, 1015 (96.9%), were under the care of a health professional and 1018 (97.2%) were taking insulin, tablets, controlling their diet or a combination. Cognitive impairment (Mini-Mental State Examination ≤ 23) was found in 235 (22.5%) people. Recent eye, foot and dietician assessment was reported by 813 (77.7%), 836 (79.7%) and 326 (31.1%) people, respectively. A quarter overall and 70% of those taking insulin tested their blood glucose. In the insulin group, 78 (54.2%) reported hypoglycaemia and those with cognitive impairment gave more incorrect responses when asked about diabetes management. Socio-economic status made very little difference to any of these outcomes. CONCLUSIONS: Most older people with diabetes, regardless of their socio-economic status, are under the care of a healthcare professional and use medication or diet to manage their disease. Large numbers also attend foot and eye examinations. However, over one fifth of older people with diabetes have cognitive impairment. Older people had a reasonable understanding of their diabetes management but this was worse in those people with cognitive impairment.

Immediate and late benefits of treating very elderly people with hypertension: results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial.

OBJECTIVE: To assess if very elderly people with hypertension obtain early benefit from antihypertensive treatment. DESIGN: One year open label active treatment extension of randomised controlled trial (Hypertension in the Very Elderly Trial (HYVET)). SETTING: Hospital and general practice based centres mainly in eastern and western Europe, China, and Tunisia. PARTICIPANTS: People on double blind treatment at the end of HYVET were eligible to enter the extension. INTERVENTIONS: Participants on active blood pressure lowering treatment continued taking active drug; those on placebo were given active blood pressure lowering treatment. The treatment regimen was as used in the main trial-indapamide SR 1.5 mg (plus perindopril 2-4 mg if required)-with the same target blood pressure of less than 150/80 mm Hg. MAIN OUTCOME MEASURES: The primary outcome was all stroke; other outcomes included total mortality, cardiovascular mortality, and cardiovascular events. RESULTS: Of 1882 people eligible for entry to the extension, 1712 (91%) agreed to participate. During the extension period, 1682 patient years were accrued. By six months, the difference in blood pressure between the two groups was 1.2/0.7 mm Hg. Comparing people previously treated with active drug and those previously on placebo, no significant differences were seen for stroke (n = 13; hazard ratio 1.92, 95% confidence interval 0.59 to 6.22) or cardiovascular events (n = 25; 0.78, 0.36 to 1.72). Differences were seen for total mortality (47 deaths; hazard ratio 0.48, 0.26 to 0.87; P = 0.02) and cardiovascular mortality (11 deaths; 0.19, 0.04 to 0.87; P = 0.03). CONCLUSION: Very elderly patients with hypertension may gain immediate benefit from treatment. Sustained differences in reductions of total mortality and cardiovascular mortality reinforce the benefits and support the need for early and long term treatment. Trial registration Clinical trials NCT00122811.

The prevalence of Type 2 diabetes and its associated health problems in a community-dwelling elderly population.

AIMS: Prevalence estimates of Type 2 diabetes and its associated health problems in elderly populations are rare, especially in the very elderly. METHODS: A sample of 15 095 community-dwelling older people aged > or = 75 years were assessed. Type 2 diabetes and associated health problems were identified using self-reporting, general practitioner records, drug histories, and blood and urine measurements. RESULTS: There were 1177 people identified as having Type 2 diabetes mellitus, giving an overall prevalence of 7.8% (95% confidence interval 7.1, 8.5), 9.4% (8.4, 10.5) for men and 6.8% (6.1, 7.6) for women. The age, sex and smoking adjusted odds ratios for various health problems, comparing people with and without diabetes were: low vision 1.6 (1.3, 1.9), proteinuria 1.7 (1.4, 2.1), chronic kidney disease stage 4 or 5 1.5 (1.0, 2.1), angina 1.3 (1.1, 1.6), myocardial infarction 1.5 (1.2, 1.8), cerebrovascular event 2.0 (1.8, 2.1) and foot ulceration 1.7 (1.2, 2.4). CONCLUSIONS: The prevalence of Type 2 diabetes is not high in community-dwelling older people, but diabetes was a contributory factor to a number of health problems.

Left ventricular hypertrophy by Sokolow-Lyon voltage criterion predicts mortality in overweight hypertensive subjects.

In view of the low sensitivity of Sokolow-Lyon voltage criteria in the assessment of electrocardiographic left ventricular hypertrophy (ECG LVH) in overweight subjects, we determined its clinical utility in 1840 lean and 3555 overweight subjects with hypertension. They were followed prospectively over an average of 11 years by the Department of Health and Social Security Hypertension Care Computer Project. LVH was determined at baseline using the Sokolow-Lyon criterion that is, the amplitude voltage SV1+(max RV5 or RV6) > or =3.5 mV. Overweight status was defined as body mass index (BMI) > or =25 kg m(-2). Prevalence of ECG LVH was 16% in lean and 12% in overweight women, 35 and 20% in lean and overweight men. For each 0.1 mV increase in ECG voltage as a continuous variable, the age and sex adjusted risk of stroke, coronary heart disease and cardiovascular disease (CVD) mortality increased significantly by 3.0, 1.5 and 1.8% in overweight subjects and by 2.8, 1.8 and 2.4% in lean subjects. After additional adjustments for smoking, blood glucose and serum cholesterol concentration in a subgroup of 654 lean and 1281 overweight subjects with complete information on these variables, an increasing voltage still significantly predicted stroke and CVD mortality in overweight subjects. The excess high risk of dying was evident especially in women with LVH in the highest BMI quartiles. When ECG detects LVH in overweight subjects, it is a good predictor of mortality despite the lower sensitivity in this group.

Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials.

OBJECTIVE: To quantify the relative risk reductions achieved with different regimens to lower blood pressure in younger and older adults. DESIGN: Meta-analyses and meta-regression analyses used to compare the effects on the primary outcome between two age groups (<65 v > or =65 years). Evidence for an interaction between age and the effects of treatment sought by fitting age as a continuous variable and estimating overall effects across trials. PRIMARY OUTCOME: total major cardiovascular events. RESULTS: 31 trials, with 190 606 participants, were included. The meta-analyses showed no clear difference between age groups in the effects of lowering blood pressure or any difference between the effects of the drug classes on major cardiovascular events (all P> or =0.24). Neither was there any significant interaction between age and treatment when age was fitted as a continuous variable (all P>0.09). The meta-regressions also showed no difference in effects between the two age groups for the outcome of major cardiovascular events (<65 v > or =65; P=0.38). CONCLUSIONS: Reduction of blood pressure produces benefits in younger (<65 years) and older (> or =65 years) adults, with no strong evidence that protection against major vascular events afforded by different drug classes varies substantially with age.

Left ventricular hypertrophy determined by Sokolow-Lyon criteria: a different predictor in women than in men?

The clinical usefulness of the Sokolow-Lyon voltage criteria in the assessment of electrocardiographic left ventricular hypertrophy (ECG LVH) is addressed. We prospectively studied 3,338 women and 3,330 men referred with hypertension, with an average follow-up of 11.2 years. The voltage amplitude sum SV1+max (RV5 or RV6) was calculated and ECG LVH was defined as a sum >or=3.5 mV. We adjusted survival for age, treatment status before presentation and a previous myocardial infarction or cerebrovascular accident. The risk of stroke, coronary heart disease (CHD) and cardiovascular disease (CVD) mortality increased significantly for each quantitative 0.1 mV increase in baseline electrocardiogram (ECG) voltage, in women within the range of 1.6-3.9% and in men 1.4-3.0%. After further adjustments for race, body mass index, smoking and systolic blood pressure, increasing voltage independently predicted CVD mortality in both men and women. In women, both increasing voltage and the presence of left ventricular hypertrophy (LVH) were predictors of stroke mortality, whereas in men this risk was attenuated. In men, the adjusted association between increasing voltage and CHD mortality tended to be stronger than in women. The use of different thresholds for the two genders made little difference. For stroke and CHD mortality, the population attributable fractions associated with LVH were 15.2 and 5.4% in women and 12.8 and 8.5% in men, respectively. In conclusion, the greater the baseline ECG voltage sum, the greater the associated CVD mortality risk. Women tended to have a high risk of stroke mortality owing to LVH despite adjustments.

Romanian subjects entered in the hypertension in the very elderly trial (HYVET).

The baseline characteristics, possibly related to cardiovascular outcome, in 94 Romanian hypertensive men and 168 women over the age of 80 entered into the Hypertension in the Very Elderly Trial (HYVET) were compared with those in 725 men and 1128 women entered into the trial in the rest of Western and Eastern Europe (mainly Russia and Bulgaria). There was a tendency for more women in the Romanian subjects (66.7% versus 60.9% (P = 0.08)) and therefore all comparisons were adjusted for this non significant difference. The Romanian subjects were slightly younger, had more previous hypertension, but more previous strokes than the rest of Europe, and consumed a similar amount of alcohol. The Romanian subjects were, on average, lighter and shorter. Romanians had higher mean concentrations of blood urea and glucose and higher concentrations of HDL cholesterol. Total cholesterol was, on average, lower in Romanian subjects than was serum creatinine. Serum sodium, blood hematocrit and hemoglobin were all, on average, lower in Romanian subjects. The Romanian subjects were recruited from predominantly rural areas and it is hypothesised that their diet may have contained less salt, iron and other haematinics. Calorie restriction, compared to the rest of Europe, may have resulted in lower stature and weight but recent increases in calorie intake may have resulted in the increasing average blood glucose in both sexes. DDT is known to block the uptake of HDL cholesterol by the liver and may explain the increased HDL concentrations in Romania. Some of these biochemical differences may reflect different methodologies employed in Romanian laboratories, but we could not confirm this possibility.

Differences in the association between type 2 diabetes and impaired microvascular function among Europeans and African Caribbeans.

AIMS/HYPOTHESIS: Diabetes is associated with microvascular damage in all populations, but diabetic patients of Black African descent (African Caribbeans) have a greater risk of vascular target organ damage than would be anticipated for any given blood pressure level. We investigated whether this may be due to differences in the microvasculature. MATERIALS AND METHODS: To assess the maximum hyperaemic response to heating and the post-ischaemic response, Laser Doppler fluximetry was performed on 51 and 100 Europeans, and on 66 and 88 African Caribbeans with and without diabetes, respectively. Subjects were aged between 40 and 65 years and recruited from the general population. Echocardiographic interventricular septal thickness (IVST) was measured as a proxy for vascular target organ damage. RESULTS: In diabetic subjects of both ethnic groups, the maximum hyperaemic response and peak response to ischaemia were attenuated as compared to the corresponding non-diabetic subjects (p=0.08 for diabetic and 0.03 for non-diabetic Europeans; p=0.03 and 0.1 for African Caribbeans). Adjustment for cardiovascular risk factors, in particular insulin and blood pressure, abolished these differences in Europeans (p=0.8 for diabetic and 0.2 for non-diabetic Europeans), but not in African Caribbeans (p=0.03 and 0.05). CONCLUSIONS/INTERPRETATION: Persisting microvascular dysfunction in African Caribbeans may contribute to the increased risk of target organ damage observed in diabetes in this population. The weak contribution of conventional cardiovascular risk factors to these disturbances indicates that conventional therapeutic interventions may be less beneficial in these patients. There was a risk-factor-independent, inverse association between IVST and maximal hyperaemia. These ethnic differences in microvascular responses to temperature and arterial occlusion could account for increased target organ damage in African Caribbeans.

Transiently elevated diastolic blood pressure is associated with a gender-dependent effect on cardiovascular risk.

We assessed the morbidity and mortality of subjects with transiently elevated diastolic pressure in the General Practice Hypertension Study Group (GPHSG) population. A total of 23 578 patients (aged 18-65 years) from seven UK general practices were screened in 1974 for a diastolic blood pressure (DBP4) of > or = 90 mmHg. Two further readings of DBP4 determined hypertensive (either DBP4 > or = 90 mmHg) or transient hypertensive (both DBP4 < 90 mmHg) status. Transients (n = 850) were matched with normotensive controls (n = 824) and risk ratios calculated over a mean follow-up of 18.7 years. Rescreening was conducted in six of the practices (n = 20 942) after 7.7 years. Male transients had a higher relative hazard for cardiovascular mortality than controls (11.8%, 8.6%, adjusted relative hazard 1.59, P = 0.056). Female transients had a lower relative hazard for cardiovascular mortality than controls (3.6%, 5.4%, adjusted relative hazard 0.39, P = 0.018). In all, 422 patients with transient hypertension were rescreened along with 367 matched controls. Significantly more transients were on antihypertensive treatment compared with their controls (odds ratio (OR) [95% CI]) for both male (4.2 [1.6-11.1]) and female patients (2.4 [1.0-5.56]) and more untreated female transients developed hypertension. Male transients had a higher rates of diabetes mellitus (adj OR = 5.1, P = 0.04) and stroke (adj OR 15.9, P = 0.03). This study has shown that transiently elevated DBP in GPHSG is associated with a significantly higher risk of later hypertension in men and women and of diabetes, stroke and cardiovascular mortality in men. Women with this condition have a significantly lower cardiovascular mortality.

Respiratory symptoms in older people and their association with mortality.

BACKGROUND: A study was undertaken to assess the prevalence of reported respiratory symptoms in a population aged over 75 years and their association with mortality. METHODS: A total of 14 458 people aged 75 years and over participating in a trial of health screening of older people in general practice answered questions on three respiratory symptoms: cough, sputum production, and wheeze. The association of symptoms with mortality was examined for all cause and respiratory causes of death taking account of potential confounders. RESULTS: Coughing up phlegm in winter mornings had a prevalence of 27.0% (95% confidence interval (CI) 26.8 to 27.2). Those with this symptom had an adjusted hazard ratio for all cause mortality of 1.35 (95% CI 1.21 to 1.50), p<0.001 and for respiratory specific mortality of 2.01 (95% CI 1.66 to 2.41), p<0.001. Phlegm at any time of the day in winter had a prevalence of 16.5% (95% CI 16.3 to 16.7) with hazard ratios for all cause and respiratory specific mortality of 1.28 (95% CI 1.15 to 1.42) and 2.28 (95% CI 1.92 to 2.70), p<0.001. Wheeze or whistling from the chest had a prevalence of 14.3% (95% CI 14.1 to 14.5) with hazard ratios of 1.45 (95% CI 1.31 to 1.61) and 2.86 (95% CI 2.45 to 3.35), p<0.001. CONCLUSIONS: The prevalence of respiratory symptoms is widespread among elderly people and their presence is a strong predictor of mortality.

CHHIPS (Controlling Hypertension and Hypotension Immediately Post-Stroke) Pilot Trial: rationale and design.

RATIONALE: High and low blood pressure (BP) levels are common following acute stroke, with up to 60% of patients being hypertensive (SBP > 160 mmHg) and nearly 20% having relative hypotension (SBP < or = 140 mmHg), within the first few hours of ictus, both conditions being associated with an adverse prognosis. At present, the optimum management of blood pressure in the immediate post-stroke period is unclear. OBJECTIVE: The primary aim of the Controlling Hypertension and Hypotension Immediately Post-Stroke (CHHIPS) Pilot Trial is to assess whether hypertension and relative hypotension, manipulated therapeutically in the first 24 h following acute stroke, affects short-term outcome measures. DESIGN: The CHHIPS Pilot Trial is a UK based multi-centre, randomized, double-blind, placebo-controlled, titrated dose trial. SETTING: Acute stroke and medical units in teaching and district general hospitals, in the UK. PATIENTS: The CHHIPS Pilot Study aims to recruit 2050 patients, with clinically suspected stroke, confirmed by brain imaging, who have no compelling indication or contraindication for BP manipulation. STUDY OUTCOMES: The primary outcome measure will be the effects of acute pressor therapy (initiated < or = 12 h from stroke onset) or depressor therapy (started < or = 24 h post-ictus) on death and dependency at 14 days post-stroke. Secondary outcome measures will include the influence of therapy on early neurological deterioration, the effectiveness of treatment in manipulating BP levels, the influence of time to treatment and stroke type on response and a cost-effectiveness analysis.

Area deprivation, social class, and quality of life among people aged 75 years and over in Britain.

BACKGROUND: There is a shortage of research studies that assess how selected characteristics of neighbourhood and personal social circumstances contribute towards health-related quality of life (QoL) among older people. METHODS: Analysis of baseline data for 5581 people aged > or =75 years and over from the Trial of Assessment and Management of Older People in the Community. The scores for four dimensions from the UK version of the Sickness Impact Profile and for the Philadelphia Geriatric Morale Scale were analysed in relation to individual social class and the Carstairs score of socioeconomic deprivation for the enumeration district of residence. RESULTS: In age and sex adjusted analyses, the proportion of participants of social class IV/V living in the most deprived areas who were in the quintile with worst QoL scores was more than double that among those from social class I/II living in the least deprived areas. Individual social class and area deprivation score contributed roughly equally to this doubling for home management, self-care and social interaction, whereas social class appeared a stronger determinant for mobility. Adjustment for living circumstances, health symptoms, and health behaviours substantially reduced the excess risk associated with social class and area deprivation. Being in a rural area was associated with lower risk of poor morale. CONCLUSION: Poor socioeconomic characteristics of both the area and the individual are associated with worse functioning (QoL) of older people in the community. This is not fully explained by health status. Policy should consider community-level interventions as well as those directed at individuals.

The Warfarin/Aspirin Study in Heart failure (WASH): a randomized trial comparing antithrombotic strategies for patients with heart failure.

BACKGROUND: Heart failure is commonly associated with vascular disease and a high rate of athero-thrombotic events, but the risks and benefits of antithrombotic therapy are unknown. METHODS: The current study was an open-label, randomized, controlled trial comparing no antithrombotic therapy, aspirin (300 mg/day), and warfarin (target international normalized ratio 2.5) in patients with heart failure and left ventricular systolic dysfunction requiring diuretic therapy. The primary objective was to demonstrate the feasibility and inform the design of a larger outcome study. The primary clinical outcome was death, nonfatal myocardial infarction, or nonfatal stroke. RESULTS: Two hundred seventy-nine patients were randomized and 627 patient-years exposure were accumulated over a mean follow-up time of 27 +/- 1 months. Twenty-six (26%), 29 (32%), and 23 (26%) patients randomized to no antithrombotic treatment, aspirin, and warfarin, respectively, reached the primary outcome (ns). There were trends to a worse outcome among those randomized to aspirin for a number of secondary outcomes. Significantly (P =.044) more patients randomized to aspirin were hospitalized for cardiovascular reasons, especially worsening heart failure. CONCLUSIONS: The Warfarin/Aspirin Study in Heart failure (WASH) provides no evidence that aspirin is effective or safe in patients with heart failure. The benefits of warfarin for patients with heart failure in sinus rhythm have not been established. Antithrombotic therapy in patients with heart failure is not evidence based but commonly contributes to polypharmacy.

The determinants of left ventricular hypertrophy defined by Sokolow-Lyon criteria in untreated hypertensive patients.

Left ventricular hypertrophy (LVH) measured by electrocardiography (ECG LVH) in hypertensive patients has been shown to be associated with an increased risk of cardiovascular sequelae. Analysis of the determinants predisposing to ECG LVH may be helpful in the prevention of LVH. The Department of Health and Social Security Hypertension Care Computer Project studied 2994 hypertensive patients in whom an electrocardiogram was recorded while not on treatment. LVH was determined as the voltage sum SV1+RV5 or RV6>or=35 mm using Sokolow-Lyon voltage criteria. The relations were determined between the presence of LVH or voltage sum and different variables. Untreated systolic (SBP) and diastolic (DBP) blood pressure and pulse pressure were positively related to the increasing ECG voltage, while body mass index (BMI) and serum cholesterol were inversely related. Blood glucose and age did not correlate significantly. Patients with the presence of ECG LVH were more often men, black people, smokers and users of alcohol. In multiple logistic regression analyses, SBP, DBP, male gender and black race were positively, whereas BMI was negatively related to the presence of LVH. The positive relation of smoking and negative relation of serum cholesterol concentration to the presence of ECG LVH were apparent in men but not in women. This study confirms the adverse association between ECG LVH and SBP and DBP, male gender, black race and decreased BMI. It also addresses the less well-known associations of blood glucose, cholesterol, smoking and alcohol consumption.