ClinicSpeak & BrainHealth: what is your blood pressure?

When last have you had your blood pressure checked? #MSBlog #MSResearch #BrainHealth

"Prof Gold suggested to me that our 'Brain Health' campaign should have been named the 'Save Brain' campaign instead. He thinks as a term Brain Health is limp and that Saving Brain is more impactful from a public health perspective. What do you think?"

"Up until now we have tended to focus the campaign on the delays in diagnosis, getting referred to an MS expert promptly, starting a DMT early, having your disease activity monitored and having the option of rapid escalation to more effective treatments, or flipping the pyramid and accessing this treatment early. However, a large part of the Brain Health campaign related to lifestyle issues and co-morbidities. Today the focus is on hypertension."

"When last have you had your blood pressure checked? Are you hypertensive?"

"The following study published in the New England Journal of Medicine shows that people with hypertension with intensive blood pressure control (<120mmHg) do better than those with less intensive control of blood pressure (<140mmHg). We have to assume the same outcomes apply to pwMS and that the link between blood pressure control and MS progression is driven by the complications of high blood pressure. I say this knowing that there is some data supporting certain classes of antihypertensives as being disease-modifying independently of their effect on blood pressure. The downside of lowering your blood pressure too much is that the people in the intensive BP control arm had more serious adverse events that included light-headedness and fainting, altered renal function, including renal failure, but interestingly not injurious falls. The latter may not apply to pwMS who may be at higher risk of falls due to their MS, i.e. lower limb weakness and unsteadiness of gait due to damage to their balance and walking centres. Therefore this study should ideally be repeated in pwMS who have hypertension; this is unlikely to happen prospectively but may emerge from registry data."

"Do you need to see you doctor to have your blood pressure checked? No. A large number of pharmacies offer this as a free service. Many of you may have access to home BP machines that either work on your wrist or arms. The message here is to get your BP measured. Having a normal blood pressure will reduce the chance of vascular disease, small or mini-strokes, damaging your brain and speeding up your progression. Blood pressure control needs to be viewed as one of the components of MS management that contributes to the holistic management of the disease."

The SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373:2103-211.

BACKGROUND: The most appropriate targets for systolic blood pressure to reduce cardiovascular morbidity and mortality among persons without diabetes remain uncertain.

METHODS: We randomly assigned 9361 persons with a systolic blood pressure of 130 mm Hg or higher and an increased cardiovascular risk, but without diabetes, to a systolic blood-pressure target of less than 120 mm Hg (intensive treatment) or a target of less than 140 mm Hg (standard treatment). The primary composite outcome was myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes.

RESULTS: At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensive-treatment group and 136.2 mm Hg in the standard-treatment group. The intervention was stopped early after a median follow-up of 3.26 years owing to a significantly lower rate of the primary composite outcome in the intensive-treatment group than in the standard-treatment group (1.65% per year vs. 2.19% per year; hazard ratio with intensive treatment, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P<0.001). All-cause mortality was also significantly lower in the intensive-treatment group (hazard ratio, 0.73; 95% CI, 0.60 to 0.90; P=0.003). Rates of serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure, but not of injurious falls, were higher in the intensive-treatment group than in the standard-treatment group.

CONCLUSIONS: Among patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive-treatment group. (Funded by the National Institutes of Health; number,NCT01206062.)

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