Clinical Implications of Blood Pressure Patterns Among Older Adults

75岁以上的成年人几乎100%都患有高血压，最近的血压监测显示， 干预试验（SPRINT）表明，针对较低的基于临床的血压（BP）测量 预防老年人的心血管疾病（CVD）事件。然而，与疾病有关的住院治疗 是强化BP治疗中最严重的并发症之一，尽管SPRINT仔细 执行BP测量方案。基于临床的BP无法预测膨胀性并发症， 导致许多人质疑仅基于门诊血压的较低血压治疗目标对老年人是否安全， 特别容易受到低血压的影响，比如福尔斯和痴呆。虽然准则 建议通过基于诊所的站立血压测量和24小时门诊血压测量来告知血压治疗。 门诊外血压监测（ABPM），（1）低血压的患病率和长期影响 站立时（即直立性低血压[OH]）和（2）诊所和家庭BP之间的巨大差异（“白色 “大衣效应”[WCE]）在老年人中特征不足。 在这项研究中，我们运用我们独特的专业知识与OH评估和24小时动态血压 监测（ABPM）的一个最长期和备受尊敬的美国同伙的社区居住 社区动脉粥样硬化风险研究（ARIC）我们的提案将在2345年评估OH和ABPM 80岁以上的黑人和白色成年人，建立了可能是最大的前瞻性研究， 美国老年人的WCE。我们的目标是量化OH和WCE的患病率， 不同的人口，并确定关联的OH和WCE与纵向变化（1）物理 功能（平衡、步态速度、步态模式），（2）认知功能（反应时间、视觉空间域），和（3） 亚临床心脏损伤和应变的高灵敏度标志物，高灵敏度心肌肌钙蛋白T和N末端 B型利钠肽原此外，我们将建立OH和WCE与临床事件的关联 与低血压相关--福尔斯、痴呆和心血管疾病--在近4年的随访中。 发现老年人的OH和WCE与福尔斯、痴呆和CVD无关， 目前建议在BP治疗开始或强化之前筛查这些BP模式， 减少治疗延迟。然而，发现OH和WCE普遍存在并与福尔斯有关， 痴呆症和心血管疾病通过我们全面的测量协议将告知这些最佳实践 在治疗开始和强化治疗前进行评估，以避免弱势成人发生不良事件。 该提案将填补与两个BP相关的知识空白，为BP管理提供指导方针。 这些模式通常被认为是推迟老年人强化治疗的原因。最终，我们的建议直接 回应了NHLBI 2017年BP测量专家小组对高影响力研究的呼吁，该研究确定： (1)“体位性降压的价值”和（2）“动态血压监测在高血压治疗中的作用”。

Hypertension affects nearly 100% of adults over 75 years of age, and the recent Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that targeting lower clinic-based blood pressure (BP) measurements prevented cardiovascular disease (CVD) events in older adults. However, hypotension-related hospitalizations were among the most significant complications from intensive BP treatment, despite SPRINT's carefully executed BP measurement protocols. The inability of clinic-based BP to predict hypotensive complications has led many to question whether lower BP treatment goals based on clinic BP alone are safe in older adults, who are especially vulnerable to perceived consequences of hypotension, like falls and dementia. While guidelines recommend that BP treatment be informed by standing clinic-based BP measurements and 24-hour ambulatory blood pressure monitoring (ABPM) outside of clinic, the prevalence and long-term implications of (1) low BP upon standing (i.e. orthostatic hypotension [OH]) and (2) large discrepancies between clinic and home BP (“white coat effects” [WCE]) are under-characterized among older adults. In this study, we apply our unique expertise with OH assessments and 24-hour ambulatory blood pressure monitoring (ABPM) to one of the most long-standing and well-respected American cohorts of community-dwelling adults, the Atherosclerosis Risk in Communities Study (ARIC). Our proposal will assess OH and ABPM in 2,345 black and white adults over age 80 years, establishing possibly the largest prospective study of both OH and WCE among older adults in the United States. Our aims are to quantify the prevalence of OH and WCE in this diverse population and determine the association of OH and WCE with longitudinal change in (1) physical function (balance, gait speed, gait pattern), (2) cognitive function (response time, visuospatial domains), and (3) highly sensitive markers of subclinical cardiac injury and strain, high sensitivity cardiac troponin T and N terminal b-type pro natriuretic peptide. Moreover, we will establish the association of OH and WCE with clinical events related to hypotension – falls, dementia, and CVD – over nearly four years of follow-up. Finding that OH and WCE in older adults are not associated with falls, dementia, and CVD would challenge current recommendations to screen for these BP patterns prior to BP treatment initiation or intensification, mitigating delays to treatment. However, finding that OH and WCE are prevalent and associated with falls, dementia, and CVD through our comprehensive measurement protocols would inform best practices for these assessments prior to treatment initiation and intensification to avoid adverse events among vulnerable adults. This proposal will inform guidelines for BP management by filling critical gaps in knowledge related to two BP patterns that are often cited as reasons to defer intensive therapy in older adults. Ultimately, our proposal directly answers the call by NHLBI's 2017 expert panel on BP measurement for high impact research that determines: (1) “the value of using orthostatic hypotension” and (2) “the role of ABPM…[in the] treatment of hypertension.”