Watch out for the ibuprofen if you are older with high blood pressure or coronary artery disease

Older patients with hypertension and coronary artery disease who use NSAIDs for chronic pain are at significantly increased risk of cardiovascular events, a new analysis shows.

An observational study found in a cohort of more than 22,000 patients, with a mean age of 66.1, chronic NSAID use was associated with a 47% increased risk of cardiovascular events compared to non-users.  The trial was conducted with data from the hypertension trial INVEST, a trial comparing treatment with and without a calcium channel blocker in patients with hypertension and coronary artery disease.

Researchers asked each patient about their use if NSAIDs at every follow-up visit and patients who reported NSAID use at every visit were identified as chronic users, while all others were identified as non-chronic users.  After a mean follow-up of 2.7 years the researchers compared the 882 chronic NSAID users with the 14,408 non-users.

The primary outcome of all-cause death, non-fatal myocardial infarction or non-fatal stroke occurred at a rate of 4.4 events per 100 patient-years in chronic NSAID users and 3.7 events per 100 patient-years in non-chronic NSAID users, a 47% increased relative risk due largely to a 2.3-fold increase in the risk of cardiovascular mortality.  Lead author Dr Anthony Bavry, a cardiologist at the University of Florida, concluded: ‘Among hypertensive patients with coronary artery disease, chronic self-reported use of NSAIDs was associated with an increased risk of adverse events during long-term follow-up.'

Dr Barry said: ‘We found a significant increase in adverse cardiovascular outcomes, primarily driven by an increase in cardiovascular mortality. This is not the first study to show there is potential harm with these agents, but I think it further solidifies that concern.  ‘When I see patients like these… I try to get them to switch to an alternative agent, such as paracetamol, or if that's not possible I at least try to get them to reduce the dose of NSAID or the frequency of dosing. But ultimately it's up to them if this potential risk is worth taking.'

Am J Med. 2011 Jul;124(7):614-20.

Climbing the greasy class pole might be a healthy thing to do

Social climbing could be good for your blood pressure, a study has suggested.

Swedish researchers, writing in the Journal of Epidemiology and Community Health, looked at the blood pressure of 12,000 same sex twins and the social status of them and their parents.  Those born with lower socioeconomic status who then moved upwards had lower incidence of high blood pressure than those who remained in a poorer class.

One theory says moving into a different social bracket than that of your family and the people you grow up with causes added stress, while another argues that "social climbing" will in itself improve health chances.

In this study, researchers from the Karolinska Institute used data from the Swedish Twin Registry to track adult and parental socioeconomic status among 12,000 same sex twins born between 1926 and 1958.

A postal survey on health and lifestyle was carried out in 1973, and a phone interviews were conducted between 1998 and 2002 as part of the Screening Across the Lifespan Study (SALT).

Questions included any treatment for high blood pressure. Parental occupations were obtained from birth records, which routinely contain this type of information in Sweden.

Environment

Compared with those who stayed on the lower rungs of the social ladder, those who rose up were less likely to have high blood pressure - 12.5% of those who moved up compared to 15.4 who did not.  Overall, people with a low socioeconomic status were more likely to have high blood pressure (17.1%) than those of a high status (12.9%).  Writing in the journal, the team led by Dr Lovisa Hogberg, said: "These findings suggest that the risk of hypertension associated with low parental social status could be modified by social status later in life.

"This could possibly be targeted by early introduced public health or political interventions."  Cathy Ross, senior cardiac nurse at the British Heart Foundation, said: "This study adds further evidence that socioeconomic differences influence our health.  "Low socioeconomic status can increase the risk of poor health and in particular risk factors associated with heart disease such as high blood pressure.

"Furthermore, there is increasing evidence that improving people's socioeconomic status can help improve their health awareness and reduce the health risks associated with their environment."

"Action is needed at a national and local level to close the heart health gap between affluent and deprived groups, and to make sure people aren't left behind."

Where next for salt. Good or bad?

In an analysis that set off a fierce debate over the health effects of salt, researchers said on Wednesday they had found no evidence that small cuts to salt intake reduce the risk of developing heart disease or dying prematurely.  In a systematic review published by The Cochrane Library, British scientists found that while cutting salt consumption did appear to lead to slight reductions in blood pressure, that was not translated into lower death or heart disease risk.

The researchers said they suspected the trials conducted so far were not big enough to show any benefits to heart health, and called for large-scale studies to be carried out soon.  "With governments setting ever lower targets for salt intake and food manufacturers working to remove it from their products, it's really important that we do some large research trials to get a full understanding of the benefits and risks of reducing salt intake," said Rod Taylor of Exeter University, who led the review.

The Cochrane review attracted sharp criticism from nutrition experts. Francesco Cappuccio, head of the World Health Organisation's collaborating centre for nutrition at Warwick University, said it was "a surprisingly poor piece of work".  "This study does not change the priorities outlined worldwide for a population reduction in salt intake to prevent heart attacks and strokes, the greatest killers in the world," he said in an emailed comment.

Simon Capewell, a professor of Clinical Epidemiology at Liverpool University, said the review was "disappointing and inconclusive" and did not change public health consensus that dietary salt raises blood pressure.  Most experts are agreed that consuming too much salt is not good for you and that cutting salt intake can reduce hypertension in people with normal and high blood pressure.

Many developed nations have government-sanctioned guidelines calling on people to cut their salt or sodium intake for the sake of their longer-term health. The World Health Organisation (WHO) lists reducing salt intake among its top 10 "best buys" for reducing rates of chronic disease.

In Britain, the National Institute of Health and Clinical Guidance (NICE) has called for an acceleration of the reduction in salt in the general population from a maximum intake of 6 grams(g) a day for adults by 2015 to 3g by 2025.

U.S. guidelines recommend Americans consume less than 2.3g of salt daily, or 1.5g for certain people who are more at risk for high blood pressure or heart disease.  While previous trials have found there is a blood pressure benefit from cutting salt, research has yet to show if that translates into better overall heart health in the wider population. High blood pressure, or hypertension, is a major risk factor for cardiovascular diseases -- the leading causes of death worldwide.

Taylor said he thought it did not find any evidence of big benefits because the numbers of people studied and the salt intake reductions were relatively small.  "The people in the trials we analysed only reduced their salt intake by a moderate amount, so the effect on blood pressure and heart disease was not large," he said.

For this review, Taylor's team found seven studies that together included 6,489 participants. This gave the researchers enough data to be able to start drawing conclusions, they said. But even so, the scientists think they would need to have data from at least 18,000 people before they could expect to identify any clear health benefits.

Elaine Rush, a professor of nutrition at Auckland University of Technology in Australia, said that putting a spotlight on single trials and generalising dietary advice for a single nutrient such as salt was "not helpful".

"What is helpful is for the food industry to reformulate products to reduce sodium and increase the nutrient quality of foods by using real ingredients," she said in an emailed comment.

More than one blood pressure measurement is necessary for accuracy

Accurate blood pressure assessment requires multiple measures regardless of whether it is measured at home, in a clinic, or in a research setting, according to findings from a study of more than 400 veterans. In a secondary analysis of a randomized trial, within-patient variability in blood pressure readings decreased and certainty about the true reading was enhanced as the number of measurements increased, according to Benjamin Powers, MD, of the Durham VA Medical Center in North Carolina, and colleagues.  "In hypertension, simple changes in the setting and number of blood pressure measurements used for decision making could greatly enhance the personalization of care," they wrote in the June 21 issue of Annals of Internal Medicine. "If providers are supposed to rely more on averaged measurements, new ways of capturing and presenting these data at the point of care are needed," Powers and his colleagues added.  "Calculated averages from home monitors, blood pressure control charts that visually display the signal–noise relationship, or personalized algorithms that account for each patient's own variability may improve the interpretation of blood pressure and facilitate more informed and individual decisions." Clinicians often cite uncertainty about a patient's true blood pressure based on clinic measurements as a common reason for not changing therapy, according to the researchers. To look at the certainty with which a patient's blood pressure can be determined using various methods, Powers and his colleagues performed a secondary analysis of the Hypertension Intervention Nurse Telemedicine Study (HINTS), which was conducted in primary care clinics affiliated with the Durham VA Medical Center.  The current analysis included 444 veterans with hypertension. Their mean age was 64, most were men (92%), and three-quarters had hypertension for at least 10 years.  Blood pressure was measured repeatedly throughout the 18-months study in three ways -- standardized study blood pressure readings at six-month intervals, clinic readings during outpatient visits, and home readings using a monitor that transmitted measurements electronically. Rates of systolic blood pressure control (a mean of less than 140 mm Hg for clinic or research measurements and less than 135 mm Hg for home measurements) varied greatly between the strategies, with 28%, 47%, and 68% considered under control by clinic, home, and research measurements, respectively. Half of the patients had a mean clinic reading that was 10 mm Hg greater than their mean home reading. Within-patient variability was substantial as well, with a mean coefficient of variation of 10% across all three randomized groups.  A single systolic blood pressure reading from 120 to 157 mm Hg could not be used to classify blood pressure control with 80% certainty. However, within-patient variation decreased and certainty about the true blood pressure value improved as the number of measurements increased. The largest improvement occurred when a second reading was added, with little additional precision beyond four to six measurements. The findings show that hypertension quality metrics based on a single clinic measurements -- as practiced within the Healthcare Effectiveness Data and Information Set of the National Committee for Quality Assurance -- may misclassify a large proportion of patients in terms of blood pressure control. The study "highlights the benefits of recording and averaging high-quality blood pressure measurements across several visits," according to Lawrence Appel, MD, MPH, of Johns Hopkins University, and colleagues. Although the cost of getting repeated measurements across clinic visits is a concern, they wrote in an accompanying editorial, home blood pressure readings improve precision to a similar extent. "Hence, a benefit of home blood pressure measurement is frequent... readings that can be averaged and can potentially obviate the need for repeated clinic visits," they wrote. Appel and his colleagues advocated "a regulatory approach in which professional organizations include blood pressure measurement as a performance metric" and pointed out that health-information technologies could be used to automatically calculate average blood pressure from previous visits. "It is time to get serious about blood pressure measurement," they wrote.  Powers and his colleagues noted some limitations of the study, including the use of patients who were mostly male, had a long-standing history of hypertension, and had a history of poor blood pressure control.  The study was supported by a grant from the U.S. Department of Veterans Affairs Health Services Research and Development Service. Powers is supported by a U.S. Department of Veterans Affairs Career Development Award. One of his co-authors is supported by an Established Investigator Award from the American Heart Association and a U.S. Department of Veterans Affairs Health Services Research and Development Service Career Scientist Award.  Powers and two of his co-authors reported receiving grant money through their institution from the U.S. Department of Veterans Affairs Health Services Research and Development Service. One of the other study authors reported being employed by the Medical University of South Carolina and the University of Iowa.

Primary source: Annals of Internal Medicine Source reference: Powers B, et al "Measuring blood pressure for decision making and quality reporting: where and how many measures?" Ann Intern Med 2011; 154: 781-788. Additional source: Annals of Internal Medicine Source reference: Appel L, et al "Improving the measurement of blood pressure: Is it time for regulated standards?" Ann Intern Med 2011; 154: 838-839.