Abstract-Isolated systolic hypertension is predominantly observed in the elderly because of increased arterial stiffness.Aggressive treatment leads to excessive lowering of diastolic blood pressure and favors the presence of a J-shaped curve association with mortality. We investigated whether, in the elderly, this pattern of association is a simple epiphenomenon of increased arterial stiffness and impaired cardiac function. In a cohort of 331 hospitalized subjects Ͼ70 years old (mean ageϮSD: 85Ϯ7 years), aortic pulse wave velocity and pressure wave reflections, by pulse wave analysis, and cardiac function, by ultrasound, were assessed. During a 2-year follow-up period, 110 subjects died. No association of prognosis with systolic pressure, pulse pressure, or pulse wave velocity was observed. A J-shaped association between diastolic pressure and overall and cardiovascular mortality was observed. Unadjusted Cox regression analysis showed that patients in the first tertile of diastolic pressure (Յ60 mm Hg) had higher mortality.In Cox regression analysis, diastolic pressure Յ60 mm Hg was a predictor of mortality independently from cardiac-vascular properties, cardiovascular risk factors, and drug treatment. Multivariate regression analysis showed that increased age and low total peripheral resistance, but not left ventricular function, were the cardinal determinants of low diastolic pressure. An "optimal" diastolic pressure of 70 mm Hg in subjects with isolated systolic hypertension was found. We showed that, in the frail elderly, a value of diastolic blood pressure Յ60 mm Hg is associated with reduced survival, independent from large artery stiffness and left ventricular function, suggesting that more rational antihypertensive therapy, not only based on systolic pressure level, is needed. Key Words: diastolic blood pressure Ⅲ mortality Ⅲ elderly Ⅲ arterial stiffness Ⅲ pressure wave reflections Ⅲ total peripheral resistance T he goal of antihypertensive treatment is to prevent cardiovascular (CV) complications through the reduction of systolic (SBP) and diastolic blood pressure (DBP). However, since the primary work of Cruickshank et al, 1 several reports, but not all, have shown that, in hypertensive subjects treated with drugs, low DBP is frequently associated with increased mortality (reviewed in Reference 2 ). This finding was constantly difficult to evaluate. First, it is difficult in epidemiological studies to assess a J-or U-shaped association with mortality, and it is often easier, using a semilogarithmic scale, to show a linear relation between DBP and mortality. Second, in humans, the decrease of DBP is the consequence of both the aging process 3 and the result of drug treatment, making the net drug effect quite difficult to define. Finally it should be noted that isolated systolic hypertension is difficult to treat and, therefore, aggressive treatment may lead to excessive lowering of diastolic blood pressure and that, in the oldest old, treating high SBP is not always related to reduced overall mortality....

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Summary Heart failure and liver disease often coexist because of systemic disorders and diseases that affect both organs as well as complex cardio-hepatic interactions. Heart failure can cause acute or chronic liver injury due to ischaemia and passive venous congestion, respectively. Congestive hepatopathy is frequently observed in patients with congenital heart disease and after the Fontan procedure, but also in older patients with chronic heart failure. As congestive hepatopathy can evolve into cirrhosis and hepatocellular carcinoma, screening for liver injury should be performed in patients with chronic cardiac diseases and after Fontan surgery. Fibrosis starts in the centro-lobular zone and will extend progressively to the portal area. Chronic liver injury can be reversible if heart function improves. However, in the case of terminal heart failure, uncontrolled by medical resources or by assistive device support, the combination of heart and liver transplants must be discussed in patients with chronic advanced liver fibrosis. In this review of the literature, we will focus on congestive hepatopathy and its complications, such as liver fibrosis and hepatocellular carcinoma, with the aim of improving the management and surveillance of patients experiencing these complications.

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Observational studies have shown that some of the classic CV risk factors, namely hypertension or hypercholesterolemia, become nebulous, or even act in the reverse direction, in the oldest people. We investigated whether in the elderly, increased aortic stiffness was associated with higher mortality risk, before and after adjustments on common geriatric confounders. In a cohort of 331 (86 men) subjects aged 470 years (mean age ( ± s.d.): 85 ± 7 years), aortic stiffness was assessed by carotid-femoral pulse wave velocity (PWV). Classical CV risk factors were determined simultaneously, in association with inflammation and denutrition parameters. One hundred and ten subjects died during a 2-year follow-up period. In crude analysis, a positive non-significant trend was observed between PWV and mortality risk. Multivariate Cox regression analysis showed that five parameters entered the prediction model: two were positively related to mortality risk, PWV (P ¼ 0.008) and orosomucoide (P ¼ 0.045), and three were related negatively, total cholesterol (P ¼ 0.006), albumin (P ¼ 0.026) and body weight (P ¼ 0.035). Interaction analysis revealed that the effect of PWV on mortality was increased in the presence of renal dysfunction and increased inflammation. In conclusion, although marginally significant in crude analysis, PWV is a powerful determinant of prognosis in the oldest people taking into account inflammation and denutrition.