Arterial stiffness and age moderate the association between physical activity and global cognition in older adults.

BACKGROUND: Evidence supports that time spent on physical activity has beneficial effects on cognition in older adults. Nevertheless, whether these beneficial effects are still present at the intersection of different levels of arterial stiffness and age is uncertain. METHODS: One hundred and ten healthy older adults aged 60-75 years were examined for arterial stiffness [carotid-femoral pulse wave velocity (cf-PWV)], global cognition (composite score of Montreal Cognitive Assessment, and Mini-Mental State Examination), and self-reported physical activity (PACED diary). Using PROCESS macro for SPSS, we evaluated if cf-PWV (moderator 1), and age (moderator 2) moderate the relationship between physical activity (X) and global cognition (Y). The threshold for high stiffness was set at 8.5 m/s based on previous studies that reported this cut-off as more appropriate for classifying cerebrovascular risk groups. RESULTS: Physical activity had a positive effect on cognition in young-elderly adults (<68.5 years) with a cf-PWV of at least 8.5 m/s (ß = 0.48, SE = 0.193, P = 0.014, 95% CI = 0.100--0.868) and in elderly adults (≥68.5 years) with a cf-PWV of less than 8.5 m/s (ß = 0.56, SE = 0.230, P = 0.017, 95% CI = 0.104-1.018). This was not the case in elderly adults with a cf-PWV of at least 8.5 m/s (ß = 0.00, SE = 0.193, P = 0.998, 95% CI = -0.362 to 361), or in young-elderly adults with a cf-PWV of less than 8.5 m/s (ß = 0.16, SE = 0.247, P = 0.501, 95% CI = -0.326 to 656). CONCLUSION: The interaction between arterial stiffness and age moderated the effect of physical activity on global cognition. Time spent on physical activity alone might not be sufficient to achieve cognitive benefit over a specific threshold of arterial stiffness and age.

Associations Between Relative Morning Blood Pressure, Cerebral Blood Flow, and Memory in Older Adults Treated and Controlled for Hypertension.

[Figure: see text].

Performance of an automated blood pressure measurement device in a stroke rehabilitation unit.

CONTEXT: Valid blood pressure (BP) measurements are needed in post-stroke rehabilitation hospital units for the management of hypertension. Automated devices could be used to improve on usual care BP measurement. However, more information is needed about the performance of these devices in such a context. METHODS: This prospective nonrandomized study was performed in stroke patients with hypertension hospitalized in a stroke rehabilitation unit. Two in-hospital BP assessment strategies were compared: usual care BP and in-hospital automated office BP (AOBP) standardized measurements. In-office AOBP and ambulatory BP monitoring (ABPM) were also performed on these patients. The main outcome was SBP. Study follow-up was until discharge, up to a maximum of 4 weeks. RESULTS: Sixty-two patients with stroke hospitalized in a rehabilitation unit were included. Usual care BP was 130 ± 12/79 ± 9 mmHg and differed from an in-hospital AOBP of 117 ± 14/75 ± 12 mmHg (P < 0.001/P < 0.001). In-hospital and in-office AOBP measurements did not differ. Twenty percent of patients reached SBP therapeutic goals according to in-hospital AOBP but not according to usual care BP measurements. CONCLUSION: This study shows that in a post-stroke rehabilitation unit, standardized in-hospital AOBP estimates are on average much lower than the usual care BP correlates and similar to the in-office AOBP estimates. In-hospital AOBP devices in a stroke rehabilitation unit could add important information for the management of hypertension.

A Cross-Sectional Study on the Impact of Arterial Stiffness on the Corpus Callosum, a Key White Matter Tract Implicated in Alzheimer's Disease.

BACKGROUND: Vascular risk factors such as arterial stiffness play an important role in the etiology of Alzheimer's disease (AD), presumably due to the emergence of white matter lesions. However, the impact of arterial stiffness to white matter structure involved in the etiology of AD, including the corpus callosum remains poorly understood. OBJECTIVE: The aims of the study are to better understand the relationship between arterial stiffness, white matter microstructure, and perfusion of the corpus callosum in older adults. METHODS: Arterial stiffness was estimated using the gold standard measure of carotid-femoral pulse wave velocity (cfPWV). Cognitive performance was evaluated with the Trail Making Test part B-A. Neurite orientation dispersion and density imaging was used to obtain microstructural information such as neurite density and extracellular water diffusion. The cerebral blood flow was estimated using arterial spin labelling. RESULTS: cfPWV better predicts the microstructural integrity of the corpus callosum when compared with other index of vascular aging (the augmentation index, the systolic blood pressure, and the pulse pressure). In particular, significant associations were found between the cfPWV, an alteration of the extracellular water diffusion, and a neuronal density increase in the body of the corpus callosum which was also correlated with the performance in cognitive flexibility. CONCLUSION: Our results suggest that arterial stiffness is associated with an alteration of brain integrity which impacts cognitive function in older adults.

Screening for hypertension in adults during emergency department consultation: a systematic review.

A large proportion of patients affected with hypertension go undetected. A systematic review was conducted to assess the performance of a screening strategy in adults using blood pressure measurement at the time of an emergency department consultation. A systematic literature search on Embase, CINHAL and Medline was carried out. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Diagnostic Test Accuracy. Intervention studies with adults including at least one blood pressure measurement for all participants were included. A repeat blood pressure assessment had to have been carried out to assess the validity of the elevated blood pressure value within the next few days after the emergency department initial visit. Out of 1030 articles identified, published between 1985 and 2018, 10 articles met the inclusion criteria. There were no randomized clinical trials. Mean age of participants was 51.6 years. A single study reports that blood pressure screening was measured according to hypertension guidelines referred to in the study. The average follow-up rate was 61.9% (95% confidence interval 45.5-78.3). For diagnostic confirmation, four studies used a blood pressure measurement method based on the reported guidelines. Half of the patients (50.2%) with elevated blood pressure during the emergency department visit had blood pressure corresponding to uncontrolled elevated blood pressure at follow-up measurement. The contribution of emergency department to the screening for hypertension, by recognizing the presence of elevated blood pressure and then making a referral for diagnostic confirmation, could provide an opportunity to detect a large number of people with hypertension.

Arterial stiffness cut-off value and white matter integrity in the elderly.

OBJECTIVE: Central artery stiffness is a confirmed predictor of cardiovascular health status that has been consistently associated with cognitive dysfunction and dementia. The European Society of Hypertension has established a threshold of arterial stiffness above which a cardiovascular event is likely to occur. However, the threshold at which arterial stiffness alters brain integrity has never been established. METHODS: The aim of this study is to determine the arterial stiffness cut-off value at which there is an impact on the white matter microstructure. This study has been conducted with 53 cognitively elderly without dementia. The integrity of the white matter was assessed using diffusion tensor metrics. Central artery stiffness was evaluated by measuring the carotid-femoral pulse wave velocity (cfPWV). The statistical analyses included 4 regions previously denoted vulnerable to increased central arterial stiffness (the corpus callosum, the internal capsule, the corona radiata and the superior longitudinal fasciculus). RESULTS: The results of this study call into question the threshold value of 10 m/s cfPWV established by the European Society of Hypertension to classify patients in neuro-cardiovascular risk groups. Our results suggest that the cfPWV threshold value would be approximately 8.5 m/s when the microstructure of the white matter is taken as a basis for comparison. CONCLUSIONS: Adjustment of the cfPWV value may be necessary for a more accurate distinction between lower and higher risk group of patients for white matter microstructural injury related to arterial stiffness. Targeting the highest risk group for prevention methods may, in turn, help preserve brain health and cognitive functions.

Diurnal blood pressure loads are associated with lower cognitive performances in controlled-hypertensive elderly individuals.

INTRODUCTION: Hypertension in midlife adults is associated with cognitive decline later in life. In individuals treated for hypertension, blood pressure (BP) loads have been associated with end organ damages. This study examines whether BP load inversely correlates with performance in cognitive tasks in normotensive or controlled hypertensive (CHT) individuals. METHODS: Participants between 60 and 75 years old were divided into normotensive participants who did not receive antihypertensive treatment (n = 49) and CHT patients (n = 28). They were evaluated for BP using ambulatory blood pressure monitoring and cognitive functions with tests assessing cognitive flexibility, working and episodic memory, and processing speed. RESULTS: Analysis of covariance between normotensive and CHT participants revealed lower cognitive performances on immediate and delayed recall and total number of words of the Rey Auditory Verbal Learning Test (P < 0.001). Spearman's correlations between BP loads and cognitive performances revealed inversed associations between diurnal systolic (SBP) loads and performances on the Trail Making Test Part B (TMTB) (P = 0.009), the TMTB-TMT Part A (P = 0.013), the Switching Cost of the color-word interference test (P = 0.020) and the Digit-Symbol Substitution Score tests (P = 0.018) in CHT. Diurnal diastolic (DBP) loads were inversely correlated to the TMTB (P = 0.014) and TMTB-TMT Part A (P = 0.006). In normotensive subjects, diurnal SBP loads were associated with the delayed recall of the Rey Auditory Verbal Learning Test (P = 0.031) and to the three components of the digit span (P < 0.05). CONCLUSION: Diurnal BP loads are associated with lower cognitive performances in CHT individuals. These results suggest a lowering of target levels of diurnal BPs and/or its variability.

Screening for hypertension: an elevated office blood pressure measurement is valuable, adding an automated one is even better.

BACKGROUND: Previous studies have examined the relevance of hypertension (HTN) screening in walk-in clinics. So far, no valid algorithm has been proposed on how to integrate HTN screening in this context. The aim of our study was to assess, in a walk-in clinic setting, the HTN screening strategy for performing an automated office blood pressure (AOBP) measurement following an initially high office blood pressure (OBP) measurement. PATIENTS AND METHODS: Included participants were adults with nonemergent medical conditions and an initial walk-in clinic OBP between systolic 140 and/or diastolic 90 mmHg and systolic 180 and/or diastolic 110 mmHg. AOBP was performed with patients unattended. The 24-h ambulatory blood pressure measurement (ABPM) was used as the diagnostic threshold. RESULTS: Fifty participants were included in the study. The overall HTN prevalence as confirmed by the 24-h ABPM was 46% [95% confidence interval (CI): 32.19-59.81]. After an elevated OBP, AOBP over diagnostic thresholds occurred in 32 patients and were confirmed by ABPM in 20 participants, leading to a 62.5% positive predictive value (95% CI: 51.5-72.3%). Measurements under the AOBP diagnostic threshold occurred in 18 patients and were confirmed by ABPM in 15 participants, leading to a negative predictive value of 83.3% (95% CI: 62.3-93.8%). CONCLUSION: In a walk-in clinic, an elevated OBP is a useful screening tool due its ability to recognize nearly one in two patients as actually hypertensive. Adding an AOBP makes it possible to specify what course of action to take. This ultimately results in better targeting of patients for an ABPM referral.

Arterial stiffness and white matter integrity in the elderly: A diffusion tensor and magnetization transfer imaging study.

BACKGROUND AND PURPOSE: The stiffness of large arteries and increased pulsatility can have an impact on the brain white matter (WM) microstructure, however those mechanisms are still poorly understood. The aim of this study was to investigate the association between central artery stiffness, axonal and myelin integrity in 54 cognitively unimpaired elderly subjects (65-75 years old). METHODS: The neuronal fiber integrity of brain WM was assessed using diffusion tensor metrics and magnetization transfer imaging as measures of axonal organization (Fractional anisotropy, Radial diffusivity) and state of myelination (Myelin volume fraction). Central artery stiffness was measured by carotid-femoral pulse wave velocity (cfPWV). Statistical analyses included 4 regions (the corpus callosum, the internal capsule, the corona radiata and the superior longitudinal fasciculus) which have been previously denoted as vulnerable to increased central artery stiffness. RESULTS: cfPWV was significantly associated with fractional anisotropy and radial diffusivity (p < 0.05, corrected for multiple comparisons) but not with myelin volume fraction. Findings from this study also show that improved executive function performance correlates with Fractional anisotropy positively (p < 0.05 corrected) as well as with myelin volume fraction and radial diffusivity negatively (p < 0.05 corrected). CONCLUSIONS: These findings suggest that arterial stiffness is associated with axon degeneration rather than demyelination. Controlling arterial stiffness may play a role in maintaining the health of WM axons in the aging brain.

Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children.

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines are introduced, and 1 existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke is revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed.

The 2017 American College of Cardiology/American Heart Association vs Hypertension Canada High Blood Pressure Guidelines and Potential Implications.

In this report we examine the differences between the 2017 Hypertension Canada and 2017 American College of Cardiology and American Heart Association (ACC/AHA) blood pressure (BP) guidelines regarding the proportions of individuals with a diagnosis of hypertension, BP above thresholds for treatment initiation, and BP below targets using the CARTaGENE cohort. Compared with the 2017 Canadian guidelines, the 2017 ACC/AHA guidelines would result in increases of 8.7% in hypertension diagnosis and 3.4% of individuals needing treatment, with 17.2% having a different BP target. In conclusion, implementing the 2017 ACC/AHA hypertension guidelines in Canada could result in major effects for millions of Canadians.

Diagnostic precision of mentally estimated home blood pressure means.

CONTEXT: Paper home blood pressure (HBP) charts are commonly brought to physicians at office visits. The precision and accuracy of mental calculations of blood pressure (BP) means are not known. METHODS: A total of 109 hypertensive patients were instructed to measure and record their HBP for 1 week and to bring their paper charts to their office visit. Study section 1: HBP means were calculated electronically and compared to corresponding in-office BP estimates made by physicians. Study section 2: 100 randomly ordered HBP charts were re-examined repetitively by 11 evaluators. Each evaluator estimated BP means four times in 5, 15, 30, and 60 s (random order) allocated for the task. BP means and diagnostic performance (determination of therapeutic systolic and diastolic BP goals attained or not) were compared between physician estimates and electronically calculated results. RESULTS: Overall, electronically and mentally calculated BP means were not different. Individual analysis showed that 83% of in-office physician estimates were within a 5-mmHg systolic BP range. There was diagnostic disagreement in 15% of cases. Performance improved consistently when the time allocated for BP estimation was increased from 5 to 15 s and from 15 to 30 s, but not when it exceeded 30 s. CONCLUSION: Mentally calculating HBP means from paper charts can cause a number of diagnostic errors. Chart evaluation exceeding 30 s does not significantly improve accuracy. BP-measuring devices with modern analytical capacities could be useful to physicians.

Hypertension in Adults With Type 2 Diabetes: A Review of Blood Pressure Measurement Methods, Targets and Therapy.

Hypertension occurs in more than two-thirds of patients with type 2 diabetes. In a retrospective analysis of a Framingham cohort, high blood pressure was associated with a 72% increase in the risk for all-cause death and a 57% increment in the risk for any cardiovascular disease event, making hypertension the strongest driver of cardiovascular outcomes in individuals with diabetes. One of the key aspects of hypertension management is the correct measurement of blood pressure; various types of monitoring in both clinic and ambulatory settings are reviewed here. Their benefits and challenges are presented along with the resources available to support clinicians and patients in better understanding and using the monitors. Specific phenotypes, such as white-coat hypertension and masked hypertension, are also addressed. This review outlines major trials that set systolic and diastolic blood pressure thresholds for patients with diabetes and hypertension. Optimal antihypertensive therapies are described in studies supporting these recommendations.

The impact of unrecorded readings on the precision and diagnostic performance of home blood pressure monitoring: a statistical study.

Hypertension is a major cardiovascular risk factor. To address the disease adequately, most clinicians rely on home blood pressure monitoring (HBPM). However, the impact of unrecorded BP values on the precision and diagnostic performance of BP schedules is unknown. We obtained 103 HBP patients schedules from a previous study. Then, readings were randomly removed from each schedule in order to create new incomplete schedules using a resampling technique. We obtained 10,000 new incomplete schedules. For each number of randomly removed readings, the percentages of incomplete schedules outside a systolic/diastolic blood pressure (SBP/DBP) range of 5/3 mmHg were calculated from the same complete patient's schedule. The sensitivity and specificity of incomplete HBPM schedules regarding BP control were also assessed. One hundred three HBPM schedules were analyzed. Mean patients' age was 67.9 ± 9.9 years. In non-diabetic patients, the mean BP of complete schedules' means was 131.9 ± 12.4/75.5 ± 10.5. In diabetic patients, the mean BP of complete schedules' means was 135.5 ± 14.0/73.4 ± 8.2 mmHg. When schedules were composed of 14 and 21 random measures, differences over 5 mmHg were seen in 2.6% and 0.1% of non-diabetic patients' schedule and 3.7% and 0.1% of diabetic patients' schedule, respectively. At 21 measurements, sensitivity and specificity were approximately 95% and 98% in non-diabetic patients and 90% and 99% in non-diabetic patients, respectively. HBPM precision and diagnostic performance improve rapidly with accumulation of readings. Incomplete schedules composed of 21 readings can provide an almost perfect diagnostic tool compared with the complete schedule reference.

Comparison of Different Automated Office Blood Pressure Measurement Devices: Evidence of Nonequivalence and Clinical Implications.

BACKGROUND: Automated office blood pressure (AOBP) measuring devices are increasingly recommended as preferred blood pressure (BP) diagnostic tools, but it is unclear how they compare and how clinical environments impact their performance. METHODS: This prospective randomized factorial parallel 4-group study compared BP estimates by BpTRU (VSM MedTech, Vancouver, BC, Canada) and Omron HEM 907 (Omron Healthcare, Kyoto, Japan) devices in closed vs open areas. Patients diagnosed with hypertension were recruited during office visits. After baseline open-room AOBP measurement with the BpTRU, patients had a second BP measurement with either the BpTRU or HEM 907 in either open or closed areas. Absolute BP levels and differences between the first and second measurements were compared. Diagnostic performance was also assessed. RESULTS: Two hundred fifty-eight patients were studied. Their mean age was 66.2 ± 12.0 years, and 62% were men. The mean of first AOBP estimates was 127.4/73.3 mm Hg. Analyses of subsequent measurements revealed no influence of open or closed areas on BP means and diagnostic performance. Conversely, the Omron HEM 907 exceeded BpTRU systolic BP measurements by 4.6 mm Hg (< 0.01) in closed areas and by 3.9 mm Hg (< 0.01) in open areas. The discrepancy between devices was amplified at lower BP levels. CONCLUSIONS: Although different areas did not influence BP estimates, the Omron HEM 907 significantly exceeded BpTRU measurements on average and especially at lower BP levels. These differences should be considered when interchanging devices and could have clinical decision impacts in a population of patients treated for hypertension. Our results support the constant use of only 1 device type in a given clinic.

Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults.

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed.

The Gap Between Manual and Automated Office Blood Pressure Measurements Results at a Hypertension Clinic.

BACKGROUND: Blood pressure (BP) readings taken in clinics are often higher than BP readings taken in a research setting. Recent guidelines and clinical trials have highlighted the necessity of using automated office blood pressure (AOBP) devices and standardizing measurement procedures. The goal of the present study was to compare AOBP vs manual BP measurement in both research and clinical environments in which operators and devices were the same and measurement procedures were standardized and optimal. METHODS: Clinical manual BP and AOBP measurement estimates were gathered from a retrospective cohort of patients followed in a hypertension clinic. Research AOBP and manual BP measurement data were obtained from past research studies. Descriptive statistics and agreement analyses with Cohen kappa coefficients were developed. The AOBP/manual BP measurement gap between clinical and research follow-up was compared using an unpaired t test. RESULTS: Two hundred eighty-eight patients were included in the clinical cohort, and 195 patients contributed to research-grade BP data. All patients had hypertension. AOBP averages were lower than manual measurement averages in both clinical (-3.6 ± 14.9 mm Hg / -3.0 ± 8.8 mm Hg) and research (-2.7 ± 10.0 / -2.4 ± 6.3 mm Hg) environments. The gap between measurement methods did not differ between research and clinical data. Cohen kappa coefficient was lower in the clinical context because of greater variability and more time between BP measurements (5.5 ± 2.9 months). CONCLUSIONS: Manual BP readings were slightly higher than AOBP estimates. The difference was not influenced by the real-world context of clinical practice. Office nonautomated BP measurements may still be valuable if measurement procedures are well standardized and performed by trained nurses.

Hypertension Canada's 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension.

Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force provides annually updated, evidence-based recommendations to guide the diagnosis, assessment, prevention, and treatment of hypertension. This year, we present 4 new recommendations, as well as revisions to 2 previous recommendations. In the diagnosis and assessment of hypertension, automated office blood pressure, taken without patient-health provider interaction, is now recommended as the preferred method of measuring in-office blood pressure. Also, although a serum lipid panel remains part of the routine laboratory testing for patients with hypertension, fasting and nonfasting collections are now considered acceptable. For individuals with secondary hypertension arising from primary hyperaldosteronism, adrenal vein sampling is recommended for those who are candidates for potential adrenalectomy. With respect to the treatment of hypertension, a new recommendation that has been added is for increasing dietary potassium to reduce blood pressure in those who are not at high risk for hyperkalemia. Furthermore, in selected high-risk patients, intensive blood pressure reduction to a target systolic blood pressure ≤ 120 mm Hg should be considered to decrease the risk of cardiovascular events. Finally, in hypertensive individuals with uncomplicated, stable angina pectoris, either a ß-blocker or calcium channel blocker may be considered for initial therapy. The specific evidence and rationale underlying each of these recommendations are discussed. Hypertension Canada's Canadian Hypertension Education Program Guidelines Task Force will continue to provide annual updates.