Clinical Implications of Blood Pressure Patterns Among Older Adults

高血压几乎100%影响75岁以上的成年人，最近的收缩压 干预试验(Sprint)表明，以较低的临床血压(BP)测量为目标 预防老年人的心血管疾病(CVD)事件。然而，与低血压相关的住院 是BP强化治疗最严重的并发症之一，尽管斯普林特小心地 执行BP测量方案。基于临床的血压不能预测低血压并发症 导致许多人质疑仅基于临床BP的较低BP治疗目标对老年人是否安全，他们 尤其容易受到感觉到的低血压后果的影响，如跌倒和痴呆症。虽然指导方针 建议通过基于诊所的常备血压测量和24小时动态血压测量来了解血压治疗情况 临床外血压监测(ABPM)：(1)低血压的患病率和长期意义 站立时(即直立性低血压[OH])和(2)临床血压和家庭血压之间的巨大差异(白色 衣物效应“[WCE])在老年人中的特征不足。 在这项研究中，我们将我们独特的专业知识应用于OH评估和24小时动态血压 对美国历史最悠久、最受尊敬的社区住宅群体之一的监测(ABPM) 成年人，社区动脉粥样硬化风险研究(ARIC)。我们的建议书将评估2,345年中的OH和ABPM 80岁以上的黑人和白人成年人，建立了可能是最大的关于OH和OHO的前瞻性研究 美国老年人中的WCE。我们的目标是量化OH和WCE在这一地区的流行程度 不同的种群，并确定OH和WCE与(1)物理上的纵向变化的关联 功能(平衡、步态速度、步态模式)，(2)认知功能(反应时间，视觉空间领域)，以及(3) 亚临床心脏损伤和应变的高敏标记物，高敏心肌肌钙蛋白T和N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 经过近四年的随访，发现了与低血压相关的疾病--跌倒、痴呆症和心血管疾病。 在老年人中发现OH和WCE与跌倒、痴呆症和心血管疾病无关将是一个挑战 当前建议在BP治疗开始或强化之前筛查这些BP模式， 减轻治疗的延误。然而，发现羟基和WCE普遍存在，并与跌倒有关， 痴呆症和心血管疾病通过我们的综合测量方案将提供这些方面的最佳实践 在治疗开始和强化之前进行评估，以避免易受伤害的成年人发生不良事件。 该提案将通过填补与两个BP相关的知识的关键空白，为BP管理提供指导方针 这些模式经常被认为是推迟老年人强化治疗的原因。最终，我们的提案直接 响应NHLBI 2017年BP测量专家小组的号召，进行高影响研究，确定： (1)“使用直立性低血压的价值”和(2)“动态血压监测…的作用”(在)高血压的治疗中。

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.”