HEALTH

Study: Aiming for new lower systolic blood pressure target can improve outcomes

BY Michael Johnsen

CLEVELAND — Jackson Wright, Jr. and researchers from University Hospitals Case Medical Center on Monday presented new results from the Systolic Blood Pressure Intervention Trial showing that in patients at high risk for cardiovascular events, targeting a systolic blood pressure of less than 120 mm Hg resulted in lower rates of fatal and non-fatal major events or death compared to targeting systolic blood pressure to the usually recommended target of less than 140 mm Hg.
 
The findings were presented at the American Heart Association Scientific Sessions in Orlando and published in the New England Journal of Medicine and add to the preliminary results from SPRINT announced two months ago. These findings demonstrated that intensive management of high blood pressure below a commonly recommended blood pressure target significantly reduces rates of cardiovascular disease, and lowers risk of death in a group of adults 50 years and older with high blood pressure.
 
The SPRINT study, sponsored by the National Institutes of Health, has evaluated the benefits of maintaining a new target for systolic blood pressure, the top number in a blood pressure reading, among a group of patients 50 years and older at increased risk for heart disease or who have kidney disease. University Hospitals Case Medical Center/Case Western Reserve University School of Medicine coordinated one of the five Clinical Center Networks across the country selected to conduct the trial that has recruited more than 9,300 participants.
 
This blood pressure intervention portion of the trial was stopped 3.26 years into a planned 5-year term as a result of the finding of a 25% reduction in the primary cardiovascular outcome and 27% reduction of all-cause mortality in those randomized to the lower 120 mm blood pressure target. Specifically, a 38% reduction in heart failure and 43% reduction in death from heart-related events was found and reported in NEJM.
 
“What is so groundbreaking about the findings from SPRINT is that we are beginning to determine the most appropriate targets for systolic blood pressure to reduce cardiovascular morbidity and death, especially in a diverse population of older patients without diabetes,” said Wright, lead author and co-principal investigator on the SPRINT trial. Wright is director of the Clinical Hypertension Program at UH Case Medical Center and Professor of Medicine at Case Western Reserve School of Medicine and first author on the article.
 
The study reported about 1%-2% higher rates of adverse events such as hypotension, syncope, electrolyte abnormalities and acute kidney injury/failures in the group of patients treated to the lower systolic blood pressure target. As a continuation of these findings, SPRINT researchers are proceeding to examine how the lower systolic blood pressure target may impact the incidence of dementia and long-term kidney disease.
 
In order to achieve the 120 mm Hg target, the findings also noted that an average of one additional medication was required for the lower target with no difference in tolerability even in patients over age 75.
 
“I cannot predict whether the information presented today will alter the guidelines,” Wright said. “I can however assure that it will certainly create a discussion on the merits of treating hypertensive patients to much lower blood pressure targets than previously recommended.”
 
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Study finds link between vitamin D deficiency and increased heart disease risk

BY Michael Johnsen

SALT LAKE CITY – Recent studies have found that vitamin D deficiency is linked to more serious health risks such as coronary artery disease, heart attacks and strokes, in addition to weakened bones.
 
Researchers at the Intermountain Medical Center Heart Institute here have found that patients are fine from a heart standpoint, and may need no further treatment, if their vitamin D level is anywhere above 15 nanograms per milliliter.
 
“Although vitamin D levels above 30 were traditionally considered to be normal, more recently, some researchers have proposed that anything above 15 was a safe level. But the numbers hadn’t been backed up with research until now,” said Brent Muhlestein, co-director of cardiovascular research at the Intermountain Medical Center Heart Institute, and lead researcher of the study.
 
“Even if any level above 15 is safe, one out of 10 people still have vitamin D levels lower than that. This equates to a very large percentage of our population,” he said.
 
Muhlestein and his team have studied the effects of vitamin D on the heart for several years, looking at smaller numbers of patients. In this study, thanks to Intermountain Healthcare’s vast clinical database, they were able to evaluate the impact of vitamin D levels on more than 230,000 patients.
 
The 230,000 patients were split up into four groups (those with vitamin D levels of less than  15 ng/ml, levels of between 15-29, levels of between 30-44 and levels greater than or equal to 45) and were followed for the next three years by researchers who looked for major adverse cardiac events, including death, coronary artery disease, heart attacks, stroke and incidents of heart or kidney failure.
 
Muhlestein found that for the 9% of patients in the less than 15 group, their risk of cardiovascular events increased by 35% compared to the other three groups, and the risks faced by the other three groups weren’t very different from each other.
 
“This study sheds new light and direction on which patients might best benefit from taking vitamin D supplements,” Muhlestein said. “Even though there’s a possibility that patients may benefit in some way from achieving higher blood levels of vitamin D, this new information tells us the greatest benefit to the heart will likely occur among patients whose vitamin D level is below 15 ng/ml.”
 
Going forward, Muhlestein hopes to take these findings and perform a randomized trial with patients whose levels are below 15. The idea is to randomly separate them into groups and provide supplements for one but not the other to see what the long-term benefits for combatting heart problems really are.
 
“As we continue to study vitamin D and the heart, we hope to ultimately gain enough information so we can inform all patients specifically what they should do to reduce their cardiac risk as much as possible,” he said. 
 
 
 
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Pedometers and positive intervention produce tangible results in RA community

BY Michael Johnsen

SAN FRANCISCO — Using a pedometer to measure the number of steps one takes in a day has been linked to lower fatigue in persons with rheumatoid arthritis, according to research presented last week at the American College of Rheumatology Annual Meeting in San Francisco.
 
Fatigue is a problem for many people with RA, and this can often lead to them shying away from physical activity, which unfortunately contributes to a cycle of more fatigue and less physical activity. Researchers from the University of California in San Francisco recently looked at one way of breaking this cycle – the use of pedometers.
 
“With prior funding from the Rheumatology Research Foundation, I completed a study of the predictors of fatigue in RA. We found that, even after accounting for RA disease activity, obesity, depression and sleep disturbance were important predictors of RA fatigue, and that physical inactivity was associated with each of those predictors. So, physical inactivity seemed to be the most important target to address,” explained lead investigator, Patricia Katz, professor of medicine and health policy; Division of Rheumatology, Department of Medicine, University of California, San Francisco.
 
Katz’s team recruited 96 people from previous studies and rheumatology clinics to participate in a study — also funded by the Rheumatology Research Foundation — that looked at the effects of increased daily activity on RA-related fatigue. To participate in the study, a person had to be English or Spanish speaking, able to walk (even with a walking aid), able to return for follow up visits, experience at least a moderate level of fatigue and be sedentary. Of the 96 participants, 88% were women with an average age of 54 and who had been diagnosed with RA an average of 14 years. The majority were English speaking; and 59% and 60% were on glucocorticoids and biologics, respectively.
 
Each of the participants was randomly placed into one of three groups. The first group received education on physical activity and no other intervention. Group two received a pedometer and a diary to log their daily steps. Group three received a pedometer, step diary, and a goal of increasing their steps by 10 percent every two weeks.
 
Groups two and three received calls from study personnel every two weeks to check on progress and collect the number of steps walked. Additionally, during these calls, group three would receive their new step goal for the next two weeks. All of the groups received a follow-up call at 10 weeks and participated in an in-person follow up at 21 weeks.
 
At 21 weeks, groups two and three had significant increases in their daily steps when compared to group one (which had virtually no change in activity). Group two increased their steps by 87%, and group three by 159%. “Just having a pedometer and reporting steps seemed to be important,” Katz said. “Combined, both pedometer groups increased average daily steps by 125%, and both had significant decreases in fatigue. Of course, having goals seemed to create an even greater increase in steps and decrease in fatigue, but the important shift occurred just from having the pedometer and monitoring steps.” 
 
While all groups noted their fatigue decreased the more they moved, it was the participants who were the least active at the beginning of the study who noticed the biggest change in fatigue at the end, suggesting that people who were the least active gained the most from the intervention.
 
“From a purely logistical point of view, if someone’s baseline activity level is 2,000 steps per day, it may be less difficult in terms of time and effort for them to increase their steps per day by 100% to 4,000 steps per day over a five-month period,” Katz said. “This may also move them from being very sedentary to a healthier level of activity. On the other hand, if someone is already covering 5,000 steps per day, it will take more time during the day for them to increase by 100%. And, while this increase is likely to have health benefits, the change in health benefits may not be as great when compared to someone moving from sedentary to low activity," she said. 
 
“Overall, this study further confirms the importance of physical activity for people with RA,” Katz concluded. “Not only does it help to reduce fatigue — as shown in this study — it may improve mood, help a patient maintain a healthy weight, improve cardiovascular risk factors and improve overall functioning.”
 
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