Association of diastolic blood pressure with cardiovascular events in older people varies upon cardiovascular history

Background: In older age, a low DBP has been associated with increased risk of cardiovascular events, especially in frail older people. We tested the hypothesis that low DBP is associated with a high risk of cardiovascular events in people with a previous history of cardiovascular disease, as a proxy of vascular impairment. Methods: We included 5804 participants (mean age 75 years) from the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) who as part of the trial were intensively monitored for an average period of 3.2 years. DBP was categorized in low (<70 mmHg), normal (70–90 mmHg) or high (>90 mmHg). Cox proportional hazards analyses were used to estimate hazard ratio with 95% confidence intervals (CI); analyses were stratified for cardiovascular history. Results: Participants with low DBP had a 1.24-fold (1.04; 1.49) increased risk of cardiovascular events compared with those with normal DBP. After further adjusting for cardiovascular factors, this association attenuated to 1.05 (0.86; 1.28). A previous history of cardiovascular disease significantly modified the relation between DBP and risk of cardiovascular events (P-interaction 0.042). In participants without a history of cardiovascular disease, DBP was marginally significantly associated with an increased event risk (hazard ratio (95% CI) per 10 mmHg increase in DBP 1.08 (0.99; 1.18), P value = 0.07), whereas in participants with a history of cardiovascular disease, higher DBP was associated with a decreased risk of cardiovascular events (hazard ratio (95% CI) per 10 mmHg increase in DBP 0.92 (0.85; 0.99, P value = 0.018). These risk estimates were independent of potential confounders, including classical cardiovascular risk factors. Conclusion: The association of DBP with cardiovascular events in older people varies upon their previous history, showing that in participants with preexisting cardiovascular diseases, a higher DBP associates with a decreased risk of future cardiovascular events.

[1]  A. Dominiczak,et al.  An Expert Opinion From the European Society of Hypertension-European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects. , 2016, Hypertension.

[2]  Justine E. F. Moonen,et al.  Effect of Discontinuation of Antihypertensive Treatment in Elderly People on Cognitive Functioning--the DANTE Study Leiden: A Randomized Clinical Trial. , 2015, JAMA internal medicine.

[3]  D. Deeg,et al.  Relation between blood pressure and mortality risk in an older population: role of chronological and biological age , 2015, Journal of internal medicine.

[4]  L. Wilkins.  Joint effect of mid- and late-life blood pressure on the brain: The AGES-Reykjavik Study , 2014, Neurology.

[5]  P. D. de Leeuw,et al.  Treatment of Hypertension in the Oldest Old: A Critical Role for Frailty? , 2014, Hypertension.

[6]  A. D. de Craen,et al.  High Blood Pressure, Physical and Cognitive Function, and Risk of Stroke in the Oldest Old: The Leiden 85-Plus Study , 2013, Stroke.

[7]  A. D. de Craen,et al.  Blood pressure trends and mortality: the Leiden 85-plus Study , 2013, Journal of hypertension.

[8]  W. Assendelft,et al.  Proximity to death is associated with frequency of GP contacts in the oldest old: the Leiden 85-plus study. , 2012, Age and ageing.

[9]  K. Covinsky,et al.  Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty. , 2012, Archives of internal medicine.

[10]  D. Grobbee,et al.  Relation Between Blood Pressure and Vascular Events and Mortality in Patients With Manifest Vascular Disease: J-Curve Revisited , 2012, Hypertension.

[11]  V. Gudnason,et al.  Arterial stiffness, pressure and flow pulsatility and brain structure and function: the Age, Gene/Environment Susceptibility--Reykjavik study. , 2011, Brain : a journal of neurology.

[12]  W. Mali,et al.  Blood pressure, cerebral blood flow, and brain volumes. The SMART-MR study , 2010, Journal of hypertension.

[13]  J. Filipovský,et al.  Diastolic Blood Pressure and Mortality in the Elderly With Cardiovascular Disease , 2007, Hypertension.

[14]  G. Mancia,et al.  Dogma Disputed: Can Aggressively Lowering Blood Pressure in Hypertensive Patients with Coronary Artery Disease Be Dangerous? , 2006, Annals of Internal Medicine.

[15]  R. Westendorp,et al.  In a population-based prospective study, no association between high blood pressure and mortality after age 85 years , 2006, Journal of hypertension.

[16]  R. Collins,et al.  Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies , 2002, The Lancet.

[17]  P. Macfarlane,et al.  Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial , 2002, The Lancet.

[18]  François Gueyffier,et al.  J-Shaped Relationship between Blood Pressure and Mortality in Hypertensive Patients: New Insights from a Meta-Analysis of Individual-Patient Data , 2002, Annals of Internal Medicine.

[19]  J. Goodwin,et al.  Clinical significance of falling blood pressure among older adults. , 2001, Journal of clinical epidemiology.

[20]  Z Vokó,et al.  J-shaped relation between blood pressure and stroke in treated hypertensives. , 1999, Hypertension.

[21]  P. Macfarlane,et al.  The design of a prospective study of Pravastatin in the Elderly at Risk (PROSPER). PROSPER Study Group. PROspective Study of Pravastatin in the Elderly at Risk. , 1999, The American journal of cardiology.

[22]  Hendriek C Boshuizen,et al.  Blood pressure and mortality in elderly people aged 85 and older: community based study , 1998, BMJ.

[23]  A. Hofman,et al.  Low diastolic blood pressure and atherosclerosis in elderly subjects. The Rotterdam study. , 1996, Archives of internal medicine.

[24]  D. E. Grobbee,et al.  J-shaped relation between change in diastolic blood pressure and progression of aortic atherosclerosis , 1994, The Lancet.

[25]  R. Langer,et al.  Blood pressure change and survival after age 75. , 1993, Hypertension.

[26]  Richard A. Kronmal,et al.  Distribution and Correlates of Sonographically Detected Carotid Artery Disease in the Cardiovascular Health Study , 1992, Stroke.

[27]  H. Ritzow,et al.  treatment of , 2004 .

[28]  M. Safar.  Relation of pulse pressure and blood pressure reduction to the incidence of myocardial infarction. , 1994, Hypertension.