Less Atherosclerosis and Lower Blood Pressure for a Meaningful Life Perspective With More Brain

Abstract

T raditional teaching subdivides the dementia syndrome into neurodegenerative Alzheimer's disease (AD), vascular dementia (VaD), and mixed variants. In spite of the vast and continuing literature on the dichotomy between AD and VaD, new emerging concepts highlight the role of cardiovascular risk factors in the pathogenesis of AD, especially in older patients. 1,2 Hypertension is the major player in the pathogenesis of stroke, poststroke dementia, and VaD. AD is the most common cause of dementia, contributing from 45% to Ͼ75% of the cases in Asians and whites, respectively. 3 This review will focus on the role of hypertension as a reversible risk factor in the development of dementia, in particular AD. To set the stage, we will first summarize current insights in the epidemiology of AD, the pathogenesis of VaD and AD, and the association between neurodegeneration and atherosclerosis. Epidemiology of DementiaAcross 36 cross-sectional studies, the prevalence of dementia increased exponentially from 0.3% to 1.0% in subjects aged 60 to 64 years to 10% to 20% in octogenarians and to Ͼ40% in the ninth decade of life. 3 In 15 longitudinal studies, the incidence of dementia showed a similar age-related dependency with rates expressed in new cases per 1000 personyears ranging from 0.4 to 4 at 60 to 64 years to 20 to Ͼ40 at 80 to 85 years. 3 Currently, 24.3 million people have dementia with an annual worldwide incidence of 4.6 million new cases. 4

Vascular risk factors and dementia

“…The identification of this group of patients is more complicated than identifying subjects with vascular risk factorsthis could be done by recruiting patients with cognitive complaints and a confirmed deficit on validated neuropsychological tests. As vascular pathologies may have greater impact on non-memory cognitive domains such as executive dysfunction and processing speed, 56 inclusion criteria should not be restricted to only those with memory impairment but be broadened to individuals with deficits in any defined cognitive domain. The possibility of selecting subjects at high vascular risk within this group (patients with clinical risk factors or lesions due to small-vessel disease on neuroimaging) also becomes an important consideration.…”

Placebo-Controlled Trials of Blood Pressure–Lowering Therapies for Primary Prevention of Dementia

“…1 Because populations are aging, the number of demented patients will grow 2-fold every 20 years, from 24.3 million people in 2000 to 81.1 million by 2040, with Ͼ60% living in developing countries. 2 The question of whether hypertension is a modifiable risk factor for dementia is therefore of great clinical importance.…”

“…The pooled odds ratios were 0.75 (CI, 0.60 to 0.94; Pϭ0.01) for Systolic Hypertension in the Elderly Program (SHEP), 3 SystEur, 5 and the combination therapy arm of PROGRESS, 4 and 1.08 (CI, 0.84 to 1.38; Pϭ0.54) for SCOPE 6 and the perindopril-only subgroup of the PROGRESS trial. 4 Since our 2007 review, 1 4 additional placebo-controlled trials reported on the prevention of dementia by blood pressurelowering therapies, including ADVANCE, 7 HYVET-COG, 8 PRoFESS, 9 and, most recently, TRANSCEND. 10 We therefore updated our meta-analysis ( Figure).…”

Guías de práctica clínica para el tratamiento de la hipertensión arterial 2007

“…Hay escaso número de ensayos aleatorizados sobre el tratamiento antihipertensivo que han utilizado las lesiones cerebrales y la disfunción cognitiva como variables de valoración 404 . Un pequeño subestudio del ensayo PROGRESS ha explorado el efecto de la reducción de la presión arterial en la progresión de la afección de la sustancia blanca (imágenes de resonancia magnéti-ca), y ha observado una reducción significativa del volumen total medio de nuevas lesiones en el grupo en el que perindopril junto con indapamida redujo la presión arterial en 11/4 mmHg más que placebo 405 .…”