RESUMO
The association between raised blood pressure and increased risk of subsequent cognitive decline is well known. Left ventricular hypertrophy (LVH), as a marker of hypertensive target organ damage, may help identify those at risk of cognitive decline. We assessed whether LVH was associated with subsequent cognitive decline or dementia in hypertensive participants aged ≥80 years in the randomized, placebo-controlled Hypertension in the Very Elderly Trial. LVH was assessed using 12-lead electrocardiography (ECG) based on the Cornell Product (CP-LVH), Sokolow-Lyon (SL-LVH), and Cornell Voltage (CV-LVH) criteria. The Mini-Mental State Examination (MMSE) was used to assess cognitive function at baseline and annually. A fall in MMSE to <24 or an annual fall of >3 points were defined as cognitive decline and triggered dementia screening (Diagnostic Statistical Manual IV). Death was defined as a competing event. Fine-Gray regression models were used to examine the relationship between baseline LVH and cognitive outcomes. There were 2645 in the analytical sample, including 201 (7.6%) with CP-LVH, 225 (8.5%) SL-LVH and 251 (9.5%) CV-LVH. CP-LVH was associated with increased risk of cognitive decline, subdistribution hazard ratio (sHR)1.3 (95% confidence interval (CI) 1.01-1.67) in multivariate analyses. SL-LVH and CV-LVH were not associated with cognitive decline (sHR1.06 (95% CI 0.82-1.37) and sHR1.13 (95% CI 0.89-1.43), respectively). LVH was not associated with dementia. LVH may be related to subsequent cognitive decline, but evidence was inconsistent depending on ECG criterion and there were no associations with incident dementia. Additional work is needed to understand the relationships between blood pressure, LVH assessment and cognition.
Assuntos
Disfunção Cognitiva , Demência , Hipertensão , Idoso , Humanos , Pressão Sanguínea , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/epidemiologia , Eletrocardiografia , Hipertensão/complicações , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipertrofia Ventricular Esquerda/diagnóstico , Hipertrofia Ventricular Esquerda/epidemiologia , Hipertrofia Ventricular Esquerda/complicaçõesRESUMO
OBJECTIVE: To assess the prognostic value of electrocardiographic atrial fibrillation in older hypertensive people in the randomized, placebo-controlled Hypertension in the Very Elderly Trial. METHODS: Hypertension in the Very Elderly Trial randomized 3845 hypertensive people aged 80 years and over, 3273 with electrographic data on the presence or absence of atrial fibrillation at baseline and without established cardiovascular disease. Multivariate Cox proportional hazard models were used to estimate hazard ratios with 95% confidence intervals (CIs) for all-cause mortality, incident fatal and nonfatal major cardiovascular events, all-stroke and all-heart failure. The mean follow-up time was 2.1 years. RESULTS: Baseline prevalence of atrial fibrillation was 5.8%. Compared with people without atrial fibrillation at baseline, after adjustments the presence of atrial fibrillation was associated with increased risk of mortality (hazard ratioâ=â2.49, 95% CIâ=â1.80-3.44, Pâ<â0.001), of nonfatal and fatal cardiovascular events (hazard ratioâ=â2.47, 95% CIâ=â1.71-3.55, Pâ<â0.001), all-stroke (hazard ratioâ=â2.47, 95% CIâ=â1.34-4.56, Pâ=â0.004) and all-heart failure (hazard ratio 2.33, 95% CIâ=â1.10-4.93, Pâ=â0.027). CONCLUSION: Atrial fibrillation is an important risk factor to consider when assessing older hypertensive adults as it is associated with increased risk of mortality, nonfatal and fatal cardiovascular events, stroke and heart failure.
Assuntos
Fibrilação Atrial/complicações , Fibrilação Atrial/mortalidade , Hipertensão/complicações , Hipertensão/mortalidade , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/epidemiologia , Humanos , Masculino , Modelos de Riscos Proporcionais , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/epidemiologiaRESUMO
Aims: Systematically reviewing the literature found orthostatic hypotension (OH) to be associated with an increased risk of incident dementia but limited data were available in those at highest risk, the hypertensive oldest-old. Our aim was to analyse the relationship between OH and incident cognitive decline or dementia in this group and to synthesize the evidence base overall. Method and results: Participants aged ≥80 years, with hypertension, were from the Hypertension in the Very Elderly Trial (HYVET) cohort. Orthostatic hypotension was defined as a fall of ≥15 mmHg in systolic and or ≥7 mmHg in diastolic pressure after 2 min standing from a sitting position. Subclinical orthostatic hypotension with symptoms (SOH) was defined as a fall Assuntos
Disfunção Cognitiva/etiologia
, Hipertensão/psicologia
, Hipotensão Ortostática/psicologia
, Idoso de 80 Anos ou mais
, Pressão Sanguínea/fisiologia
, Disfunção Cognitiva/epidemiologia
, Disfunção Cognitiva/fisiopatologia
, Estudos de Coortes
, Demência/epidemiologia
, Demência/etiologia
, Demência/fisiopatologia
, Humanos
, Hipertensão/epidemiologia
, Hipertensão/fisiopatologia
, Hipotensão Ortostática/epidemiologia
, Hipotensão Ortostática/fisiopatologia
, Fatores de Risco
, Sensibilidade e Especificidade
RESUMO
The main Hypertension in the Very Elderly Trial (HYVET) demonstrated a very marked reduction in cardiovascular events by treating hypertensive participants 80 years or older with a low dose, sustained release prescription of indapamide (indapamide SR, 1.5 mg) to which was added a low dose of an angiotensin converting enzyme inhibitor in two-thirds of cases (perindopril 2-4 mg). This report from the ambulatory blood pressure sub-study investigates whether changes in arterial stiffness and ambulatory blood pressure (BP) could both explain the benefits observed in the main trial. A total of 139 participants were randomized to placebo [67] and to active treatment [72] and had both day and night observations of BP and arterial stiffness as determined from the Q wave Korotkoff diastolic (QKD) interval. The QKD interval was 5.6 ms longer (p = 0.017) in the actively treated group at night than in the placebo group. This was not true for the more numerous daytime readings so that 24-h results were similar in the two groups. The QKD interval remained longer at night in the actively treated group even when adjusted for systolic pressure, heart rate and height. The reduced arterial stiffness at night may partly explain the marked benefits observed in the main trial.
Assuntos
Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Anti-Hipertensivos/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Hipertensão , Indapamida/administração & dosagem , Rigidez Vascular/efeitos dos fármacos , Monitorização Ambulatorial da Pressão Arterial , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologiaRESUMO
OBJECTIVE: We assessed the prognostic value of ECG left ventricular hypertrophy (LVH) using Sokolow-Lyon (SL-LVH), Cornell voltage (CV-LVH) or Cornell product (CP-LVH) criteria in 3043 hypertensive people aged 80 years and over enrolled in the Hypertension in the Very Elderly Trial. METHODS: Multivariate Cox proportional hazard models were used to estimate hazard ratios with 95% confidence intervals (CIs) for all-cause mortality, cardiovascular diseases, stroke and heart failure in participants with and without LVH at baseline. The mean follow-up was 2.1 years. RESULTS: LVH identified by CV-LVH or CP-LVH criteria was associated with a 1.6-1.9-fold risk of cardiovascular disease and stroke. The presence of CP-LVH was associated with an increased risk of heart failure (hazard ratio 2.38, 95% CI 1.16-4.86). In sex-specific analyses, CV-LVH (hazard ratio 1.94, 95% CI 1.06-3.55) and CP-LVH (hazard ratio 2.36, 95% CI 1.25-4.45) were associated with an increased risk of stroke in women and of heart failure in men, CV-LVH (hazard ratio 6.47, 95% CI 1.41-29.79) and CP-LVH (10.63, 95% CI 3.58-31.57), respectively. There was no significant increase in the risk of any outcomes associated with Sokolow-Lyon-LVH. LVH identified by these three methods was not a significant predictor of all-cause mortality. CONCLUSION: Use of Cornell voltage and Cornell product criteria for LVH predicted the risk of cardiovascular disease and stroke. Only Cornell product was associated with an increased risk of heart failure. This was particularly the case in men. The identification of ECG LVH proved to be important in very elderly hypertensive people.
Assuntos
Insuficiência Cardíaca/epidemiologia , Hipertensão , Hipertrofia Ventricular Esquerda , Acidente Vascular Cerebral/epidemiologia , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Hipertrofia Ventricular Esquerda/complicações , Hipertrofia Ventricular Esquerda/epidemiologia , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de RiscoAssuntos
Anti-Hipertensivos/administração & dosagem , Prova Pericial/normas , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Guias de Prática Clínica como Assunto , Idoso , Idoso de 80 Anos ou mais , Determinação da Pressão Arterial/métodos , Gerenciamento Clínico , União Europeia , Feminino , Idoso Fragilizado , Avaliação Geriátrica/métodos , Geriatria/normas , Humanos , Hipertensão/mortalidade , Masculino , Prognóstico , Medição de Risco , Índice de Gravidade de Doença , Sociedades Médicas/normas , Análise de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVE: To estimate the prevalence and covariates of electrocardiographic left ventricular hypertrophy (LVH) in the Hypertension in the Very Elderly Trial. METHODS: A total of 2993 hypertensive people aged at least 80 years with technically codable ECGs without pacing, bundle branch block, or ECG myocardial infarction were studied. LVH was assessed using Sokolow-Lyon (SL-LVH), Cornell voltage (CV-LVH), and Cornell product criterion (CP-LVH). RESULTS: The prevalence of LVH varied from 2.4 to 17.5% depending on sex, race, and ECG criterion. The highest prevalence of SL-LVH (12.0%) was in Chinese men and in white women for both CV-LVH (17.5%) and CP-LVH (12.9%). Increasing SBP was an independent covariate of the presence of LVH in Chinese women independently of the criterion used (ßâ=â0.052-0.069, Pâ<â0.001), of SL-LVH in Chinese men (ßâ=â0.047 Pâ=â0.006). In white women, CP-LVH was associated with increasing age (ßâ=â0.055, Pâ=â0.027) and SBP (ßâ=â0.023, Pâ=â0.040). Increasing BMI was associated inversely with SL-LVH; the association in white men only was not significant. In white men, a history of diabetes was directly and history of antihypertensive drug treatment inversely related to CV-LVH and CP-LVH. SL-ECG was associated inversely to serum uric acid concentration in Chinese women and to serum hemoglobin concentration in Chinese men. CONCLUSION: Prevalence and covariates of electrocardiographic LVH varied by sex, race, and ECG criterion. CP-LVH may prove to be the most useful measure of LVH in this study owing to its close relationship to SBP, at least in women, and independence from BMI.
Assuntos
Hipertensão/epidemiologia , Hipertrofia Ventricular Esquerda/epidemiologia , Idoso de 80 Anos ou mais , Método Duplo-Cego , Eletrocardiografia , Feminino , Humanos , Masculino , PrevalênciaRESUMO
White coat hypertension is considered to be a benign condition that does not require antihypertensive treatment. Ambulatory blood pressure (ABP) was measured in 284 participants in the Hypertension in the Very Elderly Trial (HYVET), a double-blind randomized trial of indapamide sustained release 1.5 mg±perindopril 2 to 4 mg versus matching placebo in hypertensive subjects (systolic blood pressure 160-199 mm Hg) aged >80 years. ABP recordings (Diasys Integra II) were obtained in 112 participants at baseline and 186 after an average follow-up of 13 months. At baseline, clinic blood pressure (CBP) exceeded the morning ABP by 32/10 mm Hg. Fifty percent of participants fulfilled the established criteria for white coat hypertension. The highest ABP readings were in the morning (average 140/80 mm Hg), the average night-time pressure was low at 124/72 mm Hg, and the average 24-hour blood pressure was 133/77 mm Hg. During follow-up, the systolic/diastolic blood pressure placebo-active differences averaged 6/5 mm Hg for morning ABP, 8/5 mm Hg for 24-hour ABP, and 13/5 mm Hg for CBP. The lowering of blood pressure over 24 hours supports the reduction in blood pressure with indapamide sustained release±perindopril as the explanation for the reduction in total mortality and cardiovascular events observed in the main HYVET study. Because we estimate that 50% had white coat hypertension in the main study, this condition may benefit from treatment in the very elderly.
Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Indapamida/uso terapêutico , Perindopril/uso terapêutico , Hipertensão do Jaleco Branco/tratamento farmacológico , Idoso de 80 Anos ou mais , Anti-Hipertensivos/farmacologia , Monitorização Ambulatorial da Pressão Arterial , Método Duplo-Cego , Feminino , Humanos , Indapamida/farmacologia , Masculino , Perindopril/farmacologia , Resultado do TratamentoRESUMO
BACKGROUND: We previously have shown that chronic kidney disease (CKD) is associated with cardiovascular and all-cause mortality in community-dwelling people 75 years and older. The present study addresses the hypothesis that CKD is associated with a higher rate of hospital admission at an older age. STUDY DESIGN: Cohort study. SETTING & PARTICIPANTS: 15,336 participants from 53 UK general practices underwent comprehensive health assessment between 1994 and 1999. PREDICTOR: Data for estimated glomerular filtration rate (eGFR, derived from creatinine levels using the CKD Epidemiology Collaboration [CKD-EPI] study equation) and dipstick proteinuria were available for 12,371 participants. OUTCOMES: Hospital admissions collected from hospital discharge letters for 2 years after assessment. MEASUREMENTS: Age, sex, cardiovascular risk factors, possible biochemical and health consequences of kidney disease (hemoglobin, phosphate, and albumin levels; physical and mental health problems). RESULTS: 2,310 (17%) participants had 1 hospital admission, and 981 (7%) had 2 or more. After adjusting for age, sex, and cardiovascular risk factors, HRs were 1.66 (95% CI, 1.21-2.27), 1.17 (95% CI, 0.95-1.43), 1.08 (95% CI, 0.90-1.30), and 1.11 (95% CI, 0.91-1.35) for eGFRs <30, 30-44, 45-59, and ≥75 mL/min/1.73 m(2), respectively, compared with eGFRs of 60-74 mL/min/1.73 m(2) for hospitalizations during <6 months of follow-up. HRs were weaker for follow-up of 6-18 months. Dipstick-positive proteinuria was associated with an increased HR throughout follow-up (HR, 1.29 [95% CI, 1.11-1.49], adjusting for cardiovascular risk factors). Dipstick-positive proteinuria and eGFR <30 mL/min/1.73 m(2) were independently associated with 2 or more hospital admissions during the 2-year follow-up. Adjustment for other health factors and laboratory measurements attenuated the effect of eGFR, but not the effect of proteinuria. LIMITATIONS: Follow-up limited to 2 years, selection bias due to nonparticipation in study, missing data for potential covariates, and single noncalibrated measurements from multiple laboratories. CONCLUSIONS: The study indicates that community-dwelling older people who have dipstick-positive proteinuria and/or eGFR <30 mL/min/1.73 m(2) are at increased risk of hospitalization.
Assuntos
Hospitalização/tendências , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/terapia , Características de Residência , Idoso , Idoso de 80 Anos ou mais , Análise por Conglomerados , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Reino Unido/epidemiologiaRESUMO
BACKGROUND: Up to 50% of patients with acute stroke are taking antihypertensive drugs on hospital admission. However, whether such treatment should be continued during the immediate post-stroke period is unclear. We therefore aimed to assess the efficacy and safety of continuing or stopping pre-existing antihypertensive drugs in patients who had recently had a stroke. METHODS: The Continue or Stop Post-Stroke Antihypertensives Collaborative Study (COSSACS) was a UK multicentre, prospective, randomised, open, blinded-endpoint trial. Patients were recruited at 49 UK National Institute for Health Research Stroke Research Network centres from January 1, 2003, to March 31, 2009. Patients aged over 18 years who were taking antihypertensive drugs were enrolled within 48 h of stroke and the last dose of antihypertensive drug. Patients were randomly assigned (1:1) by secure internet central randomisation to either continue or stop pre-existing antihypertensive drugs for 2 weeks. Patients and clinicians who randomly assigned patients were unmasked to group allocation. Clinicians who assessed 2-week outcomes and 6-month outcomes were masked to group allocation. The primary endpoint was death or dependency at 2 weeks, with dependency defined as a modified Rankin scale score greater than 3 points. Analysis was by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Register, number ISRCTN89712435. FINDINGS: 763 patients were assigned to continue (n=379) or stop (n=384) pre-existing antihypertensive drugs. 72 of 379 patients in the continue group and 82 of 384 patients in the stop group reached the primary endpoint (relative risk 0.86, 95% CI 0.65-1.14; p=0.3). The difference in systolic blood pressure at 2 weeks between the continue group and the stop group was 13 mm Hg (95% CI 10-17) and the difference in diastolic blood pressure was 8 mm Hg (6-10; difference between groups p<0.0001). No substantial differences were observed between groups in rates of serious adverse events, 6-month mortality, or major cardiovascular events. INTERPRETATION: Continuation of antihypertensive drugs did not reduce 2-week death or dependency, cardiovascular event rate, or mortality at 6 months. Lower blood pressure levels in those who continued antihypertensive treatment after acute mild stroke were not associated with an increase in adverse events. These neutral results might be because COSSACS was underpowered owing to early termination of the trial, and support the continuation of ongoing research trials. FUNDING: The Health Foundation and The Stroke Association.
Assuntos
Anti-Hipertensivos/uso terapêutico , Comportamento Cooperativo , Determinação de Ponto Final/tendências , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Método Simples-Cego , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: Microvascular dysfunction may be an early precursor of cardiovascular disease (CVD). Increased left ventricular mass (LVM), concentric left ventricular remodelling and increased left atrial size are the factors that could predict future CVD. We investigated whether microvascular dysfunction was associated with these cardiac measures. METHODS AND RESULTS: Laser Doppler fluximetry of skin vessels was used to study associations with risk factors and echocardiographic measurements of LVM, relative wall thickness (RWT), and left atrial size in 305 people (aged 40-65 years; 117 with type 2 diabetes). Flow in response to a 3-min arterial occlusion was measured. Postischaemic peak flow responses were categorized into three distinct groups: slow rise to peak (normal), nondominant early peak group (mildly abnormal) and a dominant early peak (abnormal). Those with a dominant early peak had higher blood pressure (P = 0.001), weight (P = 0.001), fasting glucose (P = 0.001) and prevalence of diabetes (P = 0.02). LVM (P = 0.01), RWT (P < 0.001) and left atrial size (P < 0.001) were greater with worsening postischaemic peak flow responses. Differences in LVM between postischaemic response groups were accounted for by blood pressure (BP). However, differences in BP and other CVD risk factors did not account for the greater RWT and left atrial size observed in the more adverse peak response groups [geometric mean of RWT [95% confidence interval (CI)] 0.40 (0.38-0.41) vs. 0.41 (0.40-0.42) vs. 0.43 (0.41-0.45), P = 0.007; left atrial size 36.1 (35.4-36.1) vs. 37.4 (36.8-38.0) vs. 38.7 (37.5-40.0), P = 0.002 for normal vs. mildly abnormal vs. abnormal respectively]. CONCLUSION: An abnormal microcirculatory cutaneous peak flow response following ischaemia is associated with adverse cardiac remodelling, independent of CVD risk factors including blood pressure.
Assuntos
Pressão Sanguínea/fisiologia , Diabetes Mellitus Tipo 2/fisiopatologia , Angiopatias Diabéticas/fisiopatologia , Microcirculação/fisiologia , Pele/irrigação sanguínea , Adulto , Idoso , Feminino , Humanos , Hipertensão/fisiopatologia , Hipertrofia Ventricular Esquerda/patologia , Hipertrofia Ventricular Esquerda/fisiopatologia , Isquemia/fisiopatologia , Fluxometria por Laser-Doppler , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Remodelação Ventricular/fisiologiaRESUMO
BACKGROUND: Measures of biological age have not been proven to predict mortality. This study examines whether measuring biological age improves the prediction of mortality. METHODS: Prospective study from 1981 to 2001 of 397 male London Civil Servants. Two indices of biological ageing were calculated. RESULTS: 60 men died and both indices of biological ageing were related to survival. In a model that mutually adjusted for both chronological and biological age, biological age using index one was statistically significant with a hazard ratio (HR) of 1.11 per year of age (95% confidence interval 1.01 - 1.21, P=0.03). The useful components of the measures of biological ageing were systolic blood pressure (HR 1.31 for 1SD), albumin, and, to a lesser degree, Erythrocyte Sedimentation Rate (ESR). Greying of the hair, skin inelasticity, arcus senilis, and baldness were not predictors of mortality as measured by our methods. Similarly serum cholesterol, creatinine, calcium and urate could be excluded. A modified index was developed including systolic pressure, ESR, urea, albumin, and bilirubin and had a sensitivity of 78% and specificity of 51% in predicting subjects who died. CONCLUSION: This study represents 'proof of principle' in demonstrating the utility and validity of measuring biological age. The modified index needs to be tested prospectively.
Assuntos
Envelhecimento , Fenômenos Cronobiológicos , Indicadores Básicos de Saúde , Fatores Etários , Alopecia/mortalidade , Alopecia/fisiopatologia , Arco Senil/mortalidade , Arco Senil/fisiopatologia , Biomarcadores/sangue , Pressão Sanguínea , Cor de Cabelo , Humanos , Londres/epidemiologia , Masculino , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Prospectivos , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Envelhecimento da Pele , Fumar/mortalidadeRESUMO
OBJECTIVES: Several cardiovascular and biochemical factors including hypertension have been associated with cognitive decline and dementia, although both epidemiological and intervention evidence is mixed with the majority of studies examining those in midlife or younger elderly and the recent Hypertension in the Very Elderly Trial showing no significant association between blood pressure lowering and incident dementia. It has also been suggested that risk factors may differ in the very elderly. The aim of these analyses was to examine the impact of baseline cardiovascular and biochemical factors upon incident dementia and cognitive decline in a very elderly hypertensive group. METHODS: Participants of the Hypertension in the Very Elderly Trial were aged at least 80 years and hypertensive. Cognitive function was assessed at baseline and annually with diagnostic information collected for dementia and relationships between baseline total and high-density lipoprotein cholesterol, creatinine, glucose, haemoglobin, heart failure, atrial fibrillation, diabetes, previous stroke and later dementia/cognitive decline were examined. RESULTS: There were 3336 participants with longitudinal cognitive function data. In multivariate analyses higher creatinine was associated with a lower risk of incident dementia and cognitive decline. Higher total and lower high-density lipoprotein cholesterol were associated with lower risk of cognitive decline. Other variables were not significant. CONCLUSIONS: In very elderly hypertensive patients heart failure, diabetes, atrial fibrillation, prior stroke, glucose and haemoglobin levels did not demonstrate a relationship with cognitive decline or dementia. Higher creatinine (excluding moderate renal impairment) was associated with a lower risk of dementia and cognitive decline. The findings for total and high-density lipoprotein cholesterol add to the varied literature in this area and together these findings may add weight to the suggestion that risk factor profiles differ in the very elderly.
Assuntos
Demência/sangue , Demência/epidemiologia , Hipertensão/sangue , Hipertensão/epidemiologia , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Glicemia/metabolismo , Pressão Sanguínea , HDL-Colesterol/sangue , Transtornos Cognitivos/sangue , Transtornos Cognitivos/epidemiologia , Creatinina/sangue , Diabetes Mellitus/epidemiologia , Feminino , Insuficiência Cardíaca/epidemiologia , Hemoglobinas/metabolismo , Humanos , Incidência , Estudos Longitudinais , Masculino , Análise Multivariada , Fatores de Risco , Acidente Vascular Cerebral/epidemiologiaRESUMO
BACKGROUND: Antihypertensive agents can reduce arterial stiffness. We hypothesized that an angiotensin receptor blocker (ARB) irbesartan and an angiotensin converting enzyme inhibitor (ACEI) lisinopril improved arterial compliance. METHODS: A randomized, double-blind, double-dummy, controlled crossover trial. Fifteen hypertensive patients, mean age 65.5 +/- 8.9 years (mean +/- SD) were given irbesartan (150 to 300 mg/day) or lisinopril (10 to 20 mg/day) for 12 weeks and then crossed over for 12 weeks. Pulse wave velocity (PWV) in the carotid-femoral (CF), carotid-radial (CR), and femoral dorsalis-pedis (FD) were measured using a Complior((R)) PWV system. RESULTS: After 12 weeks, systolic blood pressure (SBP) decreased from 162.4 +/- 12.9 to 134.5 +/- 14.8 with irbesartan and to 145.2 +/- 25 mmHg with lisinopril. Irbesartan and lisinopril reduced PWV (CF) in the elastic arterial system from 15.1 +/- 5 to 13.3 +/- 2.6 (p < 0.005) and to 14 +/- 4.7 (p < 0.05) m/s respectively (p = 0.345). Irbesartan reduced PWV (CR) and PWV (FD), whereas lisinopril did not. The difference between treatments was significant after SBP adjustment (p = 0.037 for PWV (CR) and p < 0.001 for PWV (FD)). CONCLUSIONS: Irbesartan improved arterial compliance in elastic and muscular arteries, whereas lisinopril improved it only in elastic arteries.
Assuntos
Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anti-Hipertensivos/uso terapêutico , Artérias/efeitos dos fármacos , Compostos de Bifenilo/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Hipertensão/tratamento farmacológico , Lisinopril/uso terapêutico , Tetrazóis/uso terapêutico , Idoso , Artérias/fisiopatologia , Artérias Carótidas/efeitos dos fármacos , Artérias Carótidas/fisiopatologia , Complacência (Medida de Distensibilidade) , Estudos Cross-Over , Método Duplo-Cego , Feminino , Artéria Femoral/efeitos dos fármacos , Artéria Femoral/fisiopatologia , Humanos , Hipertensão/fisiopatologia , Irbesartana , Masculino , Pessoa de Meia-Idade , Artéria Radial/efeitos dos fármacos , Artéria Radial/fisiopatologia , Resultado do TratamentoRESUMO
OBJECTIVES: To examine the association and interaction between cognitive impairment and social support and mortality. DESIGN: Prospective cohort study. SETTING: Fifty-three family practices in the United Kingdom. PARTICIPANTS: Community-dwelling people (aged > or =75) participating in the Medical Research Council Trial of the Assessment and Management of Older People in the Community (10,720 individual subjects analyzed). MEASUREMENTS: Cognition was measured using the Mini-Mental State Examination. Social engagement was assessed using categorical data on marital status, living situation, availability of assistance, availability of a confidant, and frequency of social contact. The primary outcome was all-cause mortality. RESULTS: The prevalence of cognitive impairment was 13.0% (mild) and 2.0% (moderate to severe). In Cox survival models (fully adjusted for physical health, lifestyle, daily function, and depression), there was a consistent association between greater cognitive impairment and mortality risk (mild cognitive impairment, hazard ratio (HR)=1.31, 95% confidence interval (CI)=1.21-1.40; moderate to severe cognitive impairment, HR=1.64, 95% CI=1.41-1.93. Mortality risk was greater in the medium (HR=1.09, 95% CI=1.02-1.16) and low social engagement groups (HR=1.17, 95% CI=1.05-1.29) than in those with the highest level of social engagement. Lower social engagement did not increase mortality risk in those who were more cognitively impaired. CONCLUSION: Cognitive impairment and social support are independent risk factors for mortality. Interventions that promote early identification and management of cognitive impairment and enhance social support for older people may decrease mortality and produce public health benefits.
Assuntos
Transtornos Cognitivos/psicologia , Apoio Social , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Relações Interpessoais , Masculino , Estado Civil , Entrevista Psiquiátrica Padronizada , Mortalidade , Reino UnidoRESUMO
BACKGROUND: The prevalence of chronic kidney disease (CKD) increases with age; however, the prognostic significance in older people is uncertain. This study aims to determine the association of CKD with all-cause and cardiovascular mortality in community-dwelling older people 75 years and older. STUDY DESIGN: Cohort study of people 75 years and older recruited in 1994 to 1999 to 1 arm of a trial of multidimensional health assessment with mortality follow-up. SETTING & PARTICIPANTS: 53 general practices in Great Britain. 15,336 (73%) of those eligible participated. 13,177 (86%) had serum creatinine measured at baseline. MAIN FACTOR: Estimated glomerular filtration rate (eGFR). OUTCOMES: All-cause and cardiovascular mortality. MEASUREMENTS: eGFR derived from serum creatinine level using the 4-variable Modification of Diet in Renal Disease (MDRD) Study equation in milliliters per minute per 1.73 m(2); dipstick proteinuria. Mortality by linkage to national death registration and death certification. RESULTS: After a median follow-up of 7.3 years (interquartile range, 5.0), 7,633 (58%) had died, 42% of cardiovascular causes. In the first 2 years of follow-up, adjusted hazard ratios for all-cause mortality in eGFR bands of 45 to 59, 30 to 44, and less than 30 compared with eGFR greater than 60 mL/min/1.73 m(2) were 1.13 (95% confidence interval, 0.93 to 1.37), 1.69 (95% confidence interval, 1.26 to 2.28), and 3.87 (95% confidence interval, 2.78 to 5.38) in men and 1.14 (95% confidence interval, 0.93 to 1.40), 1.33 (95% confidence interval, 1.06 to 1.68), and 2.44 (95% confidence interval, 1.68 to 3.56) in women, respectively. Hazard ratios were greater for cardiovascular mortality and lower after 2 years. Dipstick proteinuria was independently associated with all-cause, but not cardiovascular, mortality risk in both sexes. LIMITATIONS: Single serum creatinine measurement, no calibration of serum creatinine, MDRD Study equation not validated in older people. CONCLUSION: As kidney function decreases, there is a graded and independent increase in all-cause and cardiovascular mortality risk in older people 75 years and older, especially in men and those with eGFR less than 45 mL/min/1.73 m(2). Dipstick proteinuria did not add to cardiovascular mortality risk in this elderly population. In older people, identification and management of CKD should prioritize the smaller numbers with more severe CKD.
Assuntos
Serviços de Saúde Comunitária/estatística & dados numéricos , Falência Renal Crônica/mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/fisiopatologia , Estudos de Coortes , Intervalos de Confiança , Feminino , Seguimentos , Taxa de Filtração Glomerular/fisiologia , Humanos , Falência Renal Crônica/fisiopatologia , Masculino , Fatores de Risco , Taxa de Sobrevida/tendências , Reino Unido/epidemiologiaRESUMO
Endogenous testosterone and estradiol are thought to be cardio-protective in men. We wanted to determine the effects of 2 different anti-androgen therapies on arterial stiffness as one suppresses (goserelin--a gonadotrophin-releasing hormone analog) while the other increases (bicalutamide--an androgen receptor blocker) both testosterone and estradiol. We conducted a randomized trial on 43 men (mean age, 71.2 +/- 6.2 years) with localized prostate cancer. They received either goserelin or bicalutamide for 24 weeks. Carotid-femoral (C-F) and carotid-radial (C-R) pulse wave velocities (PWVs) were measured. Twenty age- and disease-matched men with prostate cancer on no active treatment were studied in a similar manner. After 12 weeks of goserelin, radial artery PWV increased significantly from baseline and a nonsignificant increase was observed in femoral PWV (change from baseline radial: +1.4 m/s, P = .002, femoral: +0.9 m/s, P = .127) Both PWV measures increased significantly with bicalutamide (change from baseline radial: +0.8, femoral: +0.9 m/s, P
Assuntos
Antagonistas de Receptores de Andrógenos , Anilidas/uso terapêutico , Gosserrelina/uso terapêutico , Nitrilas/uso terapêutico , Neoplasias da Próstata/tratamento farmacológico , Fluxo Pulsátil/efeitos dos fármacos , Compostos de Tosil/uso terapêutico , Resistência Vascular/efeitos dos fármacos , Artérias Carótidas , Humanos , Masculino , Receptores AndrogênicosRESUMO
OBJECTIVE: design and evaluate a document to enable older inpatients in an NHS hospital to discuss and record end-of-life healthcare preferences. DESIGN: user and professional collaboration to design the Expression of Healthcare Preferences (EHP). Prospective questionnaire survey and outcome evaluation. SETTING AND PARTICIPANTS: inpatients on wards for older adults in a London NHS Hospital Trust. RESULTS: the EHP consists of a form and explanatory booklet. 95 patients (mean age 81, median MMSE 28) received the EHP. 61 (64% (54-74%)) read the EHP and 29 (48% (35-61%)) of these recorded their healthcare preferences in the EHP form. The form prompted end-of-life care discussions between 43% (30-57%) of these patients and medical staff and between 52 (38-65) of these patients and "those close to them". The EHP was highly rated: on a score of 1 to 10 it was thought to be helpful (median score 8), interesting (8), informative (8) and reassuring (7) but not upsetting (1). CONCLUSION: the EHP is an end-of-life advance healthcare planning tool that we have shown can be used to prompt older inpatients to discuss and record their end-of-life healthcare preferences.
Assuntos
Diretivas Antecipadas , Serviços de Saúde para Idosos/organização & administração , Planejamento de Assistência ao Paciente/organização & administração , Satisfação do Paciente , Medicina Estatal , Inquéritos e Questionários , Diretivas Antecipadas/psicologia , Idoso , Idoso de 80 Anos ou mais , Intervalos de Confiança , Coleta de Dados , Atenção à Saúde/métodos , Feminino , Hospitais Especializados , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Terminal , Reino UnidoRESUMO
BACKGROUND: The baseline characteristics of patients in a multinational trial are possibly related to cardiovascular outcome. This study compared the baseline characteristics of patients recruited in China with those recruited in other countries. METHODS: A total of 508 Chinese hypertensive men and 728 women over the age of 80 years who entered the Hypertension in the Very Elderly Trial (HYVET) were compared with those in 860 men and 1348 women who entered the trial in other countries. RESULTS: The Chinese subjects were slightly younger, had less previous hypertension but more previous strokes than the subjects from other countries. The Chinese subjects smoked more than those from other countries, but drank less alcohol. They had less previous episodes of myocardial infarction and were, on average, lighter and shorter. The Chinese had lower mean concentrations of blood urea, uric acid and creatinine as well as higher concentrations of high density lipoprotein (HDL) cholesterol. The concentration of total cholesterol was, on average, lower in the Chinese subjects as was blood glucose. The levels of serum sodium and potassium, blood hematocrit and hemoglobin were all, on average, lower in the Chinese subjects. CONCLUSIONS: Calorie restriction, compared with the rest of the world, may have resulted in lower stature and weight, and recent increases in calorie intake have not changed the metabolic profile of the very elderly hypertensive patients in China. Some of these biochemical differences may reflect different dietary lifestyle in the Chinese.