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Cumulative pressure and cardiovascular risk in diabetic patients

The patients Hypertension Blood pressure control is assessed based on isolated blood pressure (BP) measurements, which are measured at a single moment and considered adequate when it is below a pre-determined cut-off value. This approach may not be appropriate, as blood pressure measurements vary over time and the latter measurement does not always reflect actual blood pressure control.

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The time a patient remains below target pressure is known as time on target, abbreviated TITER. time on targetIt is a new marker of cardiovascular disease risk. This marker includes the time the pressure is on target, but does not assess the magnitude of the hypertension. Pressure load, the time a patient is above the target in 24 hours, can provide interesting information, but it also does not assess the magnitude of the pressure. high BP.

Based on this, the concept of cumulative pressure load emerged, which is a measure that relates the magnitude of the increase in blood pressure over time that appears to be related to target organ damage. This measurement is defined as the area under the curve expressed in units of mmHg over time. However, there are few studies on this topic.

Then a study was conducted to estimate the relationship between pregnancy cumulative systolic pressure over 24 months and Major cardiovascular events. Another objective is also to determine if this scale is a better predictor of events than the mean systolic blood pressure (SBP), SBP TITRE and the variance of isolated SBP measurements in consultations (standard deviation).


The study was controlled and randomized, in 2×2 format. It evaluated the effects of hypertension and diabetes treatment on vascular outcomes in patients with diabetes. Type 2 diabetes.

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11,140 patients with type 2 diabetes and high risk of cardiovascular disease were selected from 215 centers in 20 countries. Half of the participants received a fixed dose of perindopril 4mg associated with indapamide 1.25mg or placebo and glicazide, with the goal of either intensive diabetes control (glycated hemoglobin target less than 6.5%) or diabetes control with standard local therapy. distancethat itAt the end of the study, 8,494 patients were continued long-term.

For this analysis, 9338 participants were included, who performed SBP measurements on 6 occasions: 3, 4, 6, 12, 18 and 24 months. The SBP cutoff was set at 130 mmHg, based on the most recent guidelines. The TITER measurement of SBP was calculated as the percentage of time below target BP over the course of the follow-up period.

Mean SBP was calculated by the mean of the measurements on each occasion and the standard deviation SBP, calculated from the same six measurements. The measurement of longitudinal SBP was estimated based on linear interpolation, which made it possible to calculate the cumulative load of systolic pressure.

Follow-up was performed for 24 months or until the occurrence of the first cardiovascular event comprising the primary study outcome: cardiovascular death, acute myocardial infarction (AMI) non-fatal and Cerebrovascular accident (stroke) Not fatal. The secondary endpoint was the components of the primary endpoint and all-cause mortality.


As for the characteristics of the patients, the mean age was 65 years and 42% were women. When evaluating patients with cumulative systolic hypertension, they were older (67 x 65 years) with a higher prevalence of conventional cardiovascular risk factors, except for a history of coronary heart disease and smoking, which are more common in people with cardiovascular disease bloody; Decreased cumulative systolic pressure burden.

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Measurement of cumulative systolic pressure load was closely associated with mean SBP and SBP TITRE, but not correlated with standard deviation of SBP.

Of the 9,338 patients, 217 had cardiovascular disease at the age of 2 years. At a median follow-up of 7.6 years, 1649 patients developed cardiovascular disease and 1615 patients died, 660 from cardiovascular death, 491 from AMI and 674 from stroke. The risk of a major cardiovascular event increased linearly with increasing cumulative systolic pressure load (p < 0.001), with the highest quartile associated with a 24% risk of a major cardiovascular event compared to the lowest quartile.

peel offAnd theSimilar evidence was observed for all-cause mortality (p = 0.001), cardiovascular mortality (p < 0.001) and AMI (p < 0.001), but not for stroke (p = 0.492).

Each increase in cumulative systolic pressure load was associated with a 14% increase in the risk of major cardiovascular events (HR 1.14; 95% CI 1.09-1.20), a 13% increase in the risk of all-cause death (HR 1.14; 95% CI 1.09-1.20) 1.13; 95% CI 1.13–1.18) and 19% risk of AMI (HR 1.19; 95% CI 1.10–1.29) and 10% risk of stroke (HR 1.10; 95% CI 1.02–1.18).

Higher levels of other measures of SBP were also associated with higher risks of primary and secondary outcomes, with the exception of TITER of SBP for all mortality and stroke and standard deviation of SBP for stroke.

Cumulative systolic pressure remained an independent predictor of risk, even after adjusting for conventional risk factors.


In this study, the cumulative systolic pressure burden was associated with the incidence of cardiovascular events and mortality in diabetic patients, independent of other risk factors.

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This metric integrates both the duration and magnitude of BP’s exposure into a single metric and has been shown to be a higher risk indicator than other measures evaluating BP, showing its importance and potential future contribution to risk prediction algorithms.

Practical message

These data also reinforce the need to treat hypertension early, in order to reduce prolonged exposure to elevated levels of blood pressure, whether using non-pharmacological or drug-related measures, if necessary.

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