Hypertension control and cardiovascular disease

On the basis of Omran's theory of epidemiological transition, Jacques Blacher and colleagues (July 30, p 530)1Blacher J Levy BI Mourad JJ Safar ME Bakris G From epidemiological transition to modern cardiovascular epidemiology: hypertension in the 21st century.Lancet. 2016; 388: 530-532Summary Full Text Full Text PDF PubMed Scopus (57) Google Scholar provocatively propose six strategies to reduce the burden of hypertensive cardiovascular disease. Notably, missing from their list are strategies to minimise blood pressure variability. In several large randomised trials, such as ALLHAT2ALLHAT Collaborative Research GroupMajor outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).JAMA. 2002; 288: 2981-2997Crossref PubMed Scopus (5112) Google Scholar and ASCOT,3Jamerson K Weber MA Bakris GL for the ACCOMPLISH Trial InvestigatorsBenazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients.N Engl J Med. 2008; 359: 2417-2428Crossref PubMed Scopus (1753) Google Scholar blood pressure variability has been identified as a powerful independent risk factor for stroke and cardiovascular events.4Webb AJ Fischer U Mehta Z Rothwell PM Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis.Lancet. 2010; 375: 906-915Summary Full Text Full Text PDF PubMed Scopus (580) Google Scholar, 5Muntner P Whittle J Lynch AI et al.Visit-to-visit variability of blood pressure and coronary heart disease, stroke, heart failure, and mortality: a cohort study.Ann Intern Med. 2015; 163: 329-338Crossref PubMed Scopus (199) Google Scholar, 6Rothwell PM Howard SC Dolan E et al.Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension.Lancet. 2010; 375: 895-905Summary Full Text Full Text PDF PubMed Scopus (1298) Google Scholar Of note, not all antihypertensive drugs are equally effective in reducing blood pressure variability. The ALLHAT trial5Muntner P Whittle J Lynch AI et al.Visit-to-visit variability of blood pressure and coronary heart disease, stroke, heart failure, and mortality: a cohort study.Ann Intern Med. 2015; 163: 329-338Crossref PubMed Scopus (199) Google Scholar documented blood pressure variability reduction to be best with amlodipine, followed by chlorthalidone, whereas lisinopril was much less efficacious than were the other two. Given the excessive variability, it is little surprise that stroke reduction is left to be desired in the lisinopril group. Adjustment for blood pressure variability explained the differences in stroke and coronary heart disease outcomes between amlodipine-based and atenolol-based treatment in the ASCOT trial.6Rothwell PM Howard SC Dolan E et al.Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension.Lancet. 2010; 375: 895-905Summary Full Text Full Text PDF PubMed Scopus (1298) Google Scholar Increased residual systolic blood pressure variability in treated hypertension causes a high risk of vascular events.7Rothwell PM Howard SC Dolan E et al.for the ASCOT-BPLA and MRC Trial InvestigatorsEffects of beta blockers and calcium-channel blockers on within-individual variability in blood pressure and risk of stroke.Lancet Neurol. 2010; 9: 469-480Summary Full Text Full Text PDF PubMed Scopus (558) Google Scholar Similar to blood pressure variability, LDL cholesterol variability has been identified as a powerful independent predictor of death and cardiovascular events.8Bangalore S Breazna A DeMicco DA Wun CC Messerli FH Visit-to-visit low-density lipoprotein cholesterol variability and risk of cardiovascular outcomes: insights from the TNT trial.J Am Coll Cardiol. 2015; 65: 1539-1548Summary Full Text Full Text PDF PubMed Scopus (118) Google Scholar Conceivably, the sixth strategy of Blacher and colleagues',1Blacher J Levy BI Mourad JJ Safar ME Bakris G From epidemiological transition to modern cardiovascular epidemiology: hypertension in the 21st century.Lancet. 2016; 388: 530-532Summary Full Text Full Text PDF PubMed Scopus (57) Google Scholar namely the temporality of antihypertensive therapy, might also relate to blood pressure variability. The fact that renin-angiotensin-aldosterone system (RAAS) blockers and β blockers are less effective with increasing age might not be due to only diminished RAAS activity, but also to increased vascular stiffness. Rigid stiff arteries enhance blood pressure variability and are less responsive to RAAS blockade than to other agents such as calcium channel blockers. We propose that reduction of blood pressure variability should be added as a seventh strategy to the list of Blacher and colleagues', which could change hypertension therapy. FHM has consultant or advisory relationships with Daiichi Sankyo, Pfizer, Abbott, Servier, Medtronic, WebMD, Ipca, American College of Cardiology, Menarini, Relypsa, and the University of Utah. SB has consultant or advisory relationships with Daiichi Sankyo, Pfizer, Abbott, and Merck. UF and SFR declare no competing interests. From epidemiological transition to modern cardiovascular epidemiology: hypertension in the 21st centuryIn 1971, Omran formulated the theory of epidemiological transition to explain the shift in mortality and disease patterns worldwide.1 The theory begins with the major premise that mortality is a fundamental factor in population dynamics. At the beginning of time was the age of so-called pestilence and famine. Mortality was high; life expectancy around 20–30 years; and famine, injuries, and infectious diseases were common causes of death. The first transition took place around 10 000 years ago which brought the world into the age of receding pandemics. Full-Text PDF Hypertension control and cardiovascular disease – Authors' replyAs pointed out by Franz Messerli and colleagues, we did not include blood pressure variability among our therapeutic objectives for optimisation of the management of hypertension and prevention of its complications in our Viewpoint.1 Numerous epidemiological studies2 have shown blood pressure variability to be correlated with prognosis in hypertension. However, many risk factors, including age, mean blood pressure, and diabetes, are significantly associated with blood pressure variability. The questions are whether this blood pressure variability is an independent cardiovascular risk factor, and whether the attributable risk could potentially be reversed. Full-Text PDF