Low blood pressure in the very old, a consequence of imminent heart failure: the Leiden 85-plus Study

Bemmel, Thomas van; Holman, Eduard R.; Gussekloo, Jacobijn; Blauw, Gerard J.; Bax, Jeroen J.; Westendorp, Rudi G. J.

doi:10.1038/jhh.2008.79

Cited by 28 publications

(25 citation statements)

References 26 publications

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“…Furthermore, low blood pressure-related risk of stroke in subjects with previous functional impairment can be attributed to the fact that structural heart disease and poor cardiac functioning are associated with both low blood pressure and risk of stroke. 19 This might partially explain different associations between blood pressure measures and stroke in subjects with different levels of cognitive function, because subjects with cognitive impairment had higher prevalence of myocardial infarction and heart failure. However, subjects with physical impairment did not have more cardiovascular pathologies at 85 years of age compared with the subjects with unimpaired physical function.…”

Section: Discussionmentioning

confidence: 99%

High Blood Pressure, Physical and Cognitive Function, and Risk of Stroke in the Oldest Old

Sabayan

Vliet

Ruijter

et al. 2013

Stroke

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The Leiden 85-Plus Study is a population-based prospective followup study of inhabitants of Leiden, the Netherlands. Between 1997 and 1999, all inhabitants of the1912-1914 birth cohort (n=705) were Background and Purpose-Epidemiological studies have shown mixed findings on the association between hypertension and stroke in the oldest old. Heterogeneity of the populations under study may underlie variation in outcomes. We examined whether the level of physical and cognitive function moderates the association between blood pressure and stroke. Methods-We included 513 subjects aged 85 years old from the population-based Leiden 85-plus Study. Systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pulse pressure were measured at baseline.

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Section: Discussionmentioning

confidence: 99%

High Blood Pressure, Physical and Cognitive Function, and Risk of Stroke in the Oldest Old

Sabayan

Vliet

Ruijter

et al. 2013

Stroke

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“…8,9 One possible explanation for the blood pressure decline in the oldest old might be the increasing prevalence of (subclinical) congestive heart failure. 10 Despite this dynamic correlation between blood pressure and cardiac function in relation to cognitive function in old age, previous studies have mainly focused on either the association of blood pressure or cardiac function with cognitive impairment.…”

Section: Discussionmentioning

confidence: 99%

NT-proBNP, blood pressure, and cognitive decline in the oldest old

et al. 2014

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Objective: To study the relation between N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, used as a marker of heart failure in clinical practice, blood pressure (BP), and cognitive decline in the oldest old.Methods: In 560 participants of the Leiden 85-plus Study, we measured NT-proBNP levels and BP at age 85 years, at baseline, and global cognitive function (Mini-Mental State Examination [MMSE]) annually during the follow-up of 5 years.Results: Subjects in the highest tertile of NT-proBNP levels scored 1.7 points lower on the MMSE at age 85 years than subjects in the lowest tertile (p 5 0.004), and had a 0.24-point-steeper decline in MMSE score per year (p 5 0.021). The longitudinal association disappeared after full adjustment for possible confounders (0.14-point-steeper decline, p 5 0.187). Subjects in the category "highest tertile of NT-proBNP and the lowest tertile of systolic BP" had a 3.7-point-lower MMSE score at baseline (p , 0.001) and a 0.49-point-steeper decline in MMSE score per year (p , 0.001) compared with subjects in the other categories. Conclusions:In the oldest old, high NT-proBNP levels are associated with lower MMSE scores. The combination of high NT-proBNP levels and low systolic BP is associated with worst global cognitive function and the steepest cognitive decline. Possibly, a failing pump function of the heart results in lower BP and lower brain perfusion with resultant brain dysfunction. Cardiovascular diseases, such as myocardial infarction, generalized atherosclerosis, and stroke have been associated with increased dementia risk and cognitive decline.1-4 Hypertension, however, is only a risk factor for dementia when present in middle age, whereas most studies show that dementia and cognitive decline in the oldest old associate with lower blood pressures. 5In the oldest old, blood pressures decrease over time, 6,7 and stronger declines are related to the presence of dementia and cognitive decline. 8,9 One possible explanation for the blood pressure decline in the oldest old might be the increasing prevalence of (subclinical) congestive heart failure.10 Despite this dynamic correlation between blood pressure and cardiac function in relation to cognitive function in old age, previous studies have mainly focused on either the association of blood pressure or cardiac function with cognitive impairment.Congestive heart failure has been associated with an increased risk of cognitive impairment. 11-13A frequently used serum marker of heart failure is the N-terminal pro-brain natriuretic peptide (NT-proBNP), the inactive fragment of the proBNP hormone. 14 NT-proBNP has proven to be a quantitative marker of acute heart failure in clinical practice, with high sensitivity and reasonable specificity, 15 although elevated NT-proBNP levels are not specific for heart failure in the general population. Several studies have shown that higher NT-proBNP levels associate with lower cognitive function. 16,17 However, the relation among NT-proBNP levels, blood pressure, and cognitive f...

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“…Also, it has been shown that BP gradually decreases in the 3 years before death in the oldest old, suggesting that lower BP levels are a risk indicator of underlying comorbidity. 80,81 Thus, high BP may be a compensatory mechanism to maintain organ perfusion, and therefore ultimately prevents morbidity and functional decline.…”

Section: Risk Of Functional Disabilitiesmentioning

confidence: 99%

Treatment of Hypertension in the Oldest Old

et al. 2014

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A n 88-year-old woman with chronic hypertension was seen in the internal/geriatric medicine outpatient clinic. She had been treated for high blood pressure (BP) for ≈20 years with a low-dose thiazide, to which an angiotensin-converting enzyme-inhibitor had been added 5 years ago. In addition, after a possible transient ischemic attack 10 years ago, aspirin, omeprazole, and simvastatin had been added. She is known with mild cognitive impairment, which is stable with a mini-mental state examination score of 25, and a mild depression for which fluoxetine has been prescribed. In addition, she experienced 2 falls in the past 2 years; calcium/vitamin D and alendronate were started for the management of osteoporosis. On physical examination, she appears vital with a normal fluent gait and no signs of hemiparesis. Her BP is 165/75 mm Hg in the sitting position. Immediately after standing up from her chair, she feels dizzy for ≈10 seconds, but after 1 and 3 minutes, no orthostatic hypotension is found. Estimated glomerular filtration rate is 50 mL/min per 1.73 m 2 . Should antihypertensive treatment be intensified, left unaltered, or reduced?The oldest old, that is, persons aged ≥80 years, will be the fastest growing segment of the population for the next 40 years. By 2050, more than one quarter of all men and women aged ≥65 years in the Western world will be in the oldest old group. 1Despite longer life expectancy, the prevalence of various chronic diseases and functional impairment increases with age. As a result, populations of older individuals are often highly heterogeneous and individuals with same chronological age vary widely in health and functional ability. In other words, there is substantial heterogeneity in their biological age, and those at the higher end of biological age are often referred to as vulnerable or frail.BP rises with age, and ≈80% of people in Western societies aged ≥80 years have hypertension.2 Their hypertension is commonly characterized by elevated systolic BP, with often normal or even low diastolic BP. The widened pulse pressure (PP) is a reflection of increased arterial stiffness. Despite the large body of evidence in middle-aged populations, the predictive value of high BP in this rapidly growing older population is still debated, as is the question of whether hypertension should be treated, and if so, how intensively. Importantly, the current paradigm of lower is better may not apply to (untreated or treated) BP in the oldest old.In this concise narrative review, we summarize evidence from observational studies and randomized clinical trials. We conclude that biological age/frailty is becoming an important criterion for treatment decisions. Finally, we address what we think are the most pressing research questions for the coming years. Pathophysiology of BP Regulation in the Oldest OldAlthough hypertension in the oldest old may reflect a longstanding condition, often it manifests itself as a de novo abnormality. Data from the Framingham Heart Study indicate that the majority of patient...

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Low blood pressure in the very old, a consequence of imminent heart failure: the Leiden 85-plus Study

Cited by 28 publications

References 26 publications

High Blood Pressure, Physical and Cognitive Function, and Risk of Stroke in the Oldest Old

High Blood Pressure, Physical and Cognitive Function, and Risk of Stroke in the Oldest Old

NT-proBNP, blood pressure, and cognitive decline in the oldest old

Treatment of Hypertension in the Oldest Old

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