scholarly journals Blood pressure in frail older adults: associations with cardiovascular outcomes and all-cause mortality

2020 ◽  
Vol 49 (5) ◽  
pp. 807-813 ◽  
Author(s):  
Jane A H Masoli ◽  
Joao Delgado ◽  
Luke Pilling ◽  
David Strain ◽  
David Melzer
Keyword(s):  
Blood Pressure ◽  
Primary Care ◽  
Older People ◽  
Excess Mortality ◽  
Cardiovascular Outcomes ◽  
Sensitivity Analyses ◽  
Clinical Practice Research Datalink ◽  
Frail Older People ◽  
Co Morbidity ◽  
All Cause Mortality

Abstract Background Blood pressure (BP) management in frail older people is challenging. An randomised controlled trial of largely non-frail older people found cardiovascular and mortality benefit with systolic (S) BP target <120 mmHg. However, all-cause mortality by attained BP in routine care in frail adults aged above 75 is unclear. Objectives To estimate observational associations between baseline BP and mortality/cardiovascular outcomes in a primary-care population aged above 75, stratified by frailty. Methods Prospective observational analysis using electronic health records (clinical practice research datalink, n = 415,980). We tested BP associations with cardiovascular events and mortality using competing and Cox proportional-hazards models respectively (follow-up ≤10 years), stratified by baseline electronic frailty index (eFI: fit (non-frail), mild, moderate, severe frailty), with sensitivity analyses on co-morbidity, cardiovascular risk and BP trajectory. Results Risks of cardiovascular outcomes increased with SBPs >150 mmHg. Associations with mortality varied between non-frail <85 and frail 75–84-year-olds and all above 85 years. SBPs above the 130–139-mmHg reference were associated with lower mortality risk, particularly in moderate to severe frailty or above 85 years (e.g. 75–84 years: 150–159 mmHg Hazard Ratio (HR) mortality compared to 130–139: non-frail HR = 0.94, 0.92–0.97; moderate/severe frailty HR = 0.84, 0.77–0.92). SBP <130 mmHg and Diastolic(D)BP <80 mmHg were consistently associated with excess mortality, independent of BP trajectory toward the end of life. Conclusions In representative primary-care patients aged ≥75, BP <130/80 was associated with excess mortality. Hypertension was not associated with increased mortality at ages above 85 or at ages 75–84 with moderate/severe frailty, perhaps due to complexities of co-existing morbidities. The priority given to aggressive BP reduction in frail older people requires further evaluation.

scholarly journals Factors associated with excess all-cause mortality in the first wave of the COVID-19 pandemic in the UK: A time series analysis using the Clinical Practice Research Datalink

PLoS Medicine ◽  
2022 ◽  
Vol 19 (1) ◽  
pp. e1003870
Author(s):  
Helen Strongman ◽  
Helena Carreira ◽  
Bianca L. De Stavola ◽  
Krishnan Bhaskaran ◽  
David A. Leon
Keyword(s):  
Time Series ◽  
Learning Disabilities ◽  
Clinical Practice ◽  
Excess Mortality ◽  
Negative Binomial ◽  
Sensitivity Analyses ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
All Cause Mortality ◽  
The Uk

Background Excess mortality captures the total effect of the Coronavirus Disease 2019 (COVID-19) pandemic on mortality and is not affected by misspecification of cause of death. We aimed to describe how health and demographic factors were associated with excess mortality during, compared to before, the pandemic. Methods and findings We analysed a time series dataset including 9,635,613 adults (≥40 years old) registered at United Kingdom general practices contributing to the Clinical Practice Research Datalink. We extracted weekly numbers of deaths and numbers at risk between March 2015 and July 2020, stratified by individual-level factors. Excess mortality during Wave 1 of the UK pandemic (5 March to 27 May 2020) compared to the prepandemic period was estimated using seasonally adjusted negative binomial regression models. Relative rates (RRs) of death for a range of factors were estimated before and during Wave 1 by including interaction terms. We found that all-cause mortality increased by 43% (95% CI 40% to 47%) during Wave 1 compared with prepandemic. Changes to the RR of death associated with most sociodemographic and clinical characteristics were small during Wave 1 compared with prepandemic. However, the mortality RR associated with dementia markedly increased (RR for dementia versus no dementia prepandemic: 3.5, 95% CI 3.4 to 3.5; RR during Wave 1: 5.1, 4.9 to 5.3); a similar pattern was seen for learning disabilities (RR prepandemic: 3.6, 3.4 to 3.5; during Wave 1: 4.8, 4.4 to 5.3), for black or South Asian ethnicity compared to white, and for London compared to other regions. Relative risks for morbidities were stable in multiple sensitivity analyses. However, a limitation of the study is that we cannot assume that the risks observed during Wave 1 would apply to other waves due to changes in population behaviour, virus transmission, and risk perception. Conclusions The first wave of the UK COVID-19 pandemic appeared to amplify baseline mortality risk to approximately the same relative degree for most population subgroups. However, disproportionate increases in mortality were seen for those with dementia, learning disabilities, non-white ethnicity, or living in London.

Is neurocardiovascular instability a risk factor for cognitive decline and/or dementia? The science to date

2007 ◽  
Vol 17 (3) ◽  
pp. 153-160 ◽  
Author(s):  
Orla Collins ◽  
Rose Anne Kenny
Keyword(s):  
Blood Pressure ◽  
Older People ◽  
Carotid Sinus ◽  
Vasovagal Syncope ◽  
Hypersensitivity Syndrome ◽  
Age Related ◽  
Co Morbidity ◽  
Criteria For Diagnosis ◽  
Rate Behaviour ◽  
Humoral Control

Neurocardiovascular instability (NCVI) is defined as ‘age-related changes in blood pressure and heart-rate behaviour, predominantly resulting in hypotension and bradyarrhythmia’ The four most common presentations of NCVI are orthostatic hypotension (OH), carotid sinus hypersensitivity/syndrome (CSH/CSS), vasovagal syncope (VVS) and post-prandial hypotension (PPH), although there is considerable overlap between these conditions. The criteria for diagnosis of these syndromes are given in Table 1. Clinically, these conditions manifest as dizziness, falls, pre-syncope and syncope. Older people are more susceptible to NCVI because of age-related physiological changes in the cardiovascular system, the autonomic nervous system, and humoral control of blood pressure. These neurocardiovascular changes are further complicated by co-morbidity and polypharmacy in older people.

P2524Extent and outcomes of frailty in older people with atrial fibrillation: a nationwide study using primary care data

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
C Wilkinson ◽  
O Todd ◽  
M Yadegarfar ◽  
A Clegg ◽  
C P Gale ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Primary Care ◽  
Older People ◽  
Proportional Hazards ◽  
Frailty Index ◽  
Community Setting ◽  
Cox Proportional Hazards ◽  
Adverse Outcomes ◽  
All Cause Mortality

Abstract Background The prevalence of atrial fibrillation (AF) in older people is increasing, as is frailty. Frailty describes an increased vulnerability to adverse outcomes, whereby the balance of risk and benefit associated with an intervention may be more nuanced. However, there are limited data from a community setting on the prevalence of AF and frailty in older people. It is important to understand the burden of AF and frailty, and the associated impact on mortality and stroke disease in order to inform shared decision making with patients, and also inform guidelines for this increasing group of older people. Purpose To estimate the prevalence of AF and the burden of frailty in patients with AF, in a large primary care dataset. To report stroke and mortality by frailty group. Methods We used electronic health records of 537,051 patients in England aged 65 years or older on 31/12/2015, with follow-up for all-cause mortality and ischaemic or unclassified stroke to 11/04/2017. Patients with a history of AF were identified using Clinical Terms Version 3 (CTV-3) codes. Frailty was identified up to the point of study entry using the electronic frailty index (eFI, the proportion of deficits out of 36 possible deficits), and categorised into robust (0–0.12), mild (>0.12–0.24), moderate (>0.24–0.36) or severe (>0.36) frailty. Median CHA2DS2-VASc and ATRIA scores for patients with frailty were compared with the robust group using Mann-Whitney. The association between frailty status, all-cause mortality and stroke was calculated using Cox proportional hazards models, adjusted for age and sex. Results Of the cohort, 61,177 patients (11.4%) had AF. Of those with AF, 27,987 (45.8%) were female, and 54,734 (89.5%) had frailty. 6,443 (10.5%) were classified as robust; 20,352 (33.3%) mildly frail; 20,315 (33.2%) moderately frail; and 14,067 (23.0%) severely frail. The median number of eFI-defined deficits among patients with AF was 9 (interquartile range [IQR] 6–12). Median stroke and bleeding scores were higher in those with frailty compared with the robust group (CHA2DS2-VASc 4 [IQR 3–5] v 2 [2–3], p≤0.001; ATRIA 4 [2–6] v 1 [0–2], p≤0.001). During 73,338 patient-years of follow-up, there were 6,805 (11.1%) deaths and 945 (1.54%) strokes. Compared with the robust group, all-cause mortality and stroke were higher with increasing frailty. Mortality: mild frailty hazard ratio 1.53 (95% confidence interval 1.29–1.80); moderate frailty 2.50 (2.13–2.94); severe frailty 4.26 (3.63–5.01). Stroke: mild frailty 1.36 (0.99–1.85); moderate frailty 1.67 (1.23–2.28); severe 1.99 (1.45–2.73). Kaplan-Meier survival curves by frailty Conclusion The prevalence of AF among those aged over 65 years in primary care in England is high, the majority of whom are frail. Increasing severity of frailty was associated with higher mortality and stroke rates. The extent to which the judicious use of oral anticoagulation may improve clinical outcomes for patients with AF and frailty is currently unknown. Acknowledgement/Funding CPG: Bayer, BMS, AstraZeneca, Novartis Vifor Pharma, Menerini

scholarly journals Long term clinical outcomes of patients with ischemic stroke in primary care – a 9-year retrospective study

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Jinghao Han ◽  
Yue Kwan Choi ◽  
Wing Kit Leung ◽  
Ming Tung Hui ◽  
Maria Kwan Wa Leung
Keyword(s):  
Blood Pressure ◽  
Primary Care ◽  
Risk Factor ◽  
Ischemic Stroke ◽  
Diastolic Blood Pressure ◽  
Recurrent Stroke ◽  
Stroke Patients ◽  
All Cause Mortality

Abstract Background We aim to document the long-term outcomes of ischemic stroke patients and explore the potential risk factors for recurrent cardiovascular events and all-cause mortality in primary care. Methods A retrospective cohort study performed at two general out-patient clinics (GOPCs) under Hospital Authority (HA) in Hong Kong (HK). Ischemic stroke patients with at least two consecutive follow-up visits during the recruitment period (1/1–30/6/2010) were included. Patients were followed up regularly till the date of recurrent stroke, cardiovascular event, death or 31/12/2018. The primary outcome was the occurrence of recurrent cerebrovascular event including transient ischemic stroke (TIA), ischemic stroke or hemorrhagic stroke. The secondary outcomes were all-cause mortality and coronary artery disease (CAD). We fit cox proportional hazard model adjusting death as competing risk factor to estimate the cause-specific hazard ratio (csHR). Results A total of 466 patients (mean age, 71.5 years) were included. During a median follow-up period of 8.7 years, 158 patients (33.9%) died. Eighty patients (17.2%) had recurrent stroke and 57 (12.2%) patients developed CAD. Age was an independent risk factor for recurrent stroke, CAD and death. Statin therapy at baseline had a protective effect for recurrent stroke (csHR = 0.476; 95% confidence interval [CI] 0.285–0.796, P = 0.005) after adjusting death as a competing risk factor and all-cause mortality (HR = 0.693, 95% CI 0.486–0.968, P = 0.043). In addition, female sex, antiplatelet and a higher diastolic blood pressure (DBP) at baseline were also independent predictors for survival. Conclusions Long term prognosis of ischemic stroke patients in primary care is favorable. Use of statin was associated with a significant decrease in stroke recurrence and mortality. Patients who died had a significant lower DBP at baseline, highlighted the need to consider both systolic and diastolic blood pressure in our daily practice.

scholarly journals Trends in end digit preference for blood pressure and associations with cardiovascular outcomes in Canadian and UK primary care: a retrospective observational study

BMJ Open ◽  
2019 ◽  
Vol 9 (1) ◽  
pp. e024970 ◽  
Author(s):  
Michelle Greiver ◽  
Sumeet Kalia ◽  
Teja Voruganti ◽  
Babak Aliarzadeh ◽  
Rahim Moineddin ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Primary Care ◽  
Observational Study ◽  
Diastolic Pressure ◽  
Cardiovascular Outcomes ◽  
Retrospective Observational Study ◽  
Digit Preference ◽  
The Mean ◽  
The Uk ◽  
Primary Care Practices

ObjectivesTo study systematic errors in recording blood pressure (BP) as measured by end digit preference (EDP); to determine associations between EDP, uptake of Automated Office BP (AOBP) machines and cardiovascular outcomes.DesignRetrospective observational study using routinely collected electronic medical record data from 2006 to 2015 and a survey on year of AOBP acquisition in Toronto, Canada in 2017.SettingPrimary care practices in Canada and the UK.ParticipantsAdults aged 18 years or more.Main outcome measuresMean rates of EDP and change in rates. Rates of EDP following acquisition of an AOBP machine. Associations between site EDP levels and mean BP. Associations between site EDP levels and frequency of cardiovascular outcomes.Results707 227 patients in Canada and 1 558 471 patients in the UK were included. From 2006 to 2015, the mean rate of BP readings with both systolic and diastolic pressure ending in zero decreased from 26.6% to 15.4% in Canada and from 24.2% to 17.3% in the UK. Systolic BP readings ending in zero decreased from 41.8% to 32.5% in the 3 years following the purchase of an AOBP machine. Sites with high EDP had a mean systolic BP of 2.0 mm Hg in Canada, and 1.7 mm Hg in the UK, lower than sites with no or low EDP. Patients in sites with high levels of EDP had a higher frequency of stroke (standardised morbidity ratio (SMR) 1.15, 95% CI 1.12 to 1.17), myocardial infarction (SMR 1.16, 95% CI 1.14 to 1.19) and angina (SMR 1.25, 95% CI 1.22 to 1.28) than patients in sites with no or low EDP.ConclusionsAcquisition of an AOBP machine was associated with a decrease in EDP levels. Sites with higher rates of EDP had lower mean BPs and a higher frequency of adverse cardiovascular outcomes. The routine use of manual office-based BP measurement should be reconsidered.

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