成田 圭佑

BACKGROUND: The Predicting Risk of Cardiovascular Disease Events (PREVENT) equations may provide more precise risk stratification than older calculators by incorporating estimated glomerular filtration rate, excluding race, and capturing total cardiovascular disease (CVD) events including heart failure. OBJECTIVES: The aim of this study was to quantify the relative and absolute benefits and harms of intensive vs standard systolic blood pressure (SBP) treatment by the new PREVENT risk levels. METHODS: A secondary analysis of SPRING (Systolic Blood Pressure Intervention Trial) was performed among participants without prevalent CVD and with complete data to calculate the baseline PREVENT 10-year risk for total CVD, which was categorized as low or borderline (<7.5%), intermediate (7.5% to <20%), and high (≥20%). Across these groups, the HRs and 4-year absolute risk differences were estimated for the effect of intensive (<120 mm Hg) vs standard (<140 mm Hg) SBP treatment on the primary composite outcome (myocardial infarction, acute coronary syndrome, stroke, heart failure, or CVD death) and treatment-related serious adverse events. RESULTS: Of 6,554 SPRINT participants analyzed (mean age 65 years, 37% women, 53% non-Hispanic White), the median PREVENTbase 10-year risk for total CVD was 13% (Q1-Q3: 9%-19%). Respectively, 16%, 62%, and 22% were categorized as low or borderline, intermediate, and high risk. Over a median follow-up period of 3.86 years, the HRs for CVD events comparing intensive vs standard treatment were 0.74 (95% CI: 0.33-1.66) for low or borderline risk, 0.70 (95% CI: 0.52-0.93) for intermediate risk, and 0.85 (95% CI: 0.60-1.20) for high risk (P for interaction = 0.68). The 4-year absolute risk difference was 0.002 for low or borderline, 0.015 for intermediate, and 0.024 for high risk. Similarly, there was no evidence of interaction on the relative risk scale across PREVENT strata for serious adverse events with intensive vs standard treatment (low or borderline: HR: 1.12 [95% CI: 0.53-2.38]; intermediate: HR: 1.66 [95% CI: 1.24-2.24]; high: HR: 1.28 [95% CI: 0.87-1.87]; P for interaction = 0.44). CONCLUSIONS: Among SPRINT participants without baseline CVD, the relative risk reduction with intensive vs standard SBP treatment was consistent across PREVENT risk strata. However, the absolute risks varied several-fold from the low- or borderline-risk group to the high-risk group. These findings underscore the utility of PREVENT to identify those most likely to derive substantial absolute benefit from intensive SBP control for primary prevention.

Heart failure (HF) guidelines recommend screening for non-symptomatic Stage B HF. Evidence on the utility of home blood pressure (BP) for risk stratification of Stage B HF is limited. We aimed to examine the association of home BP with the prevalence of Stage B HF and the risk of symptomatic HF. This study used cohort data with 14 days of morning and evening home BP measurements, biomarker sampling, and cardiovascular event follow-up among Japanese outpatients. Stage B HF was defined as N-terminal pro-B-type natriuretic peptide ≥125 pg/mL, and/or high-sensitivity cardiac troponin >22 ng/L in men and >14 ng/L in women. Among 3077 participants without prior cardiovascular disease including coronary artery disease, symptomatic HF, stroke, and others (mean age 64.5 years, 43.1% male), 548 participants had Stage B HF. In the multivariable logistic model, home systolic BP (SBP) was associated with Stage B HF (OR [95% CI] per 10 mmHg, 1.22 [1.13-1.33]). The area under the curve (AUC) was significantly improved by adding home SBP to the model including office SBP (AUC 0.757-0.763). During the median 5.0-year follow-up, Stage B HF was associated with a higher risk of HF hospitalization (adjusted HR [95% CI], 3.94 [1.45-10.70]). Home SBP tended to be associated with an increased risk of HF hospitalization (unadjusted HR [95% CI] per 10 mmHg, 1.29 [0.97-1.71], p = 0.081), but this association was not significant after adjustment. In conclusion, appropriate BP management using home BP monitoring before the progression of HF could help prevent symptomatic HF.

BACKGROUND: Noninvasive assessment of cardiac function is useful in the management of heart failure (HF). OBJECTIVES: We developed a novel pulse waveform index, 'Sf/Am', from cuff-oscillometric ambulatory blood pressure (BP) monitoring (ABPM), to estimate cardiac function. This study aimed to investigate the usefulness of square forward pulse wave/amplitude measure pulse wave (Sf/Am), which reflects cardiac systolic function in ambulatory settings, for estimating echocardiographic left ventricular ejection fraction (LVEF) in patients with HF. METHODS: A cuff volumetric waveform was obtained from the diastolic phase of each BP measurement with a multisensor-ABPM (TM-2441, A&D). The area of the ejection is the Sf. Sf is divided by the Am, that is, Sf/Am, to eliminate the effects of arterial and cuff compliance. This index was hypothesized to represent left ventricular systolic function. LVEF was determined using the modified Simpson's method. RESULTS: A total of 195 participants with HF completed ABPM and echocardiogram. After excluding 76 participants with atrial fibrillation, 119 participants (mean age, 70.0 ± 15.9 years; 58.8% male) were included in the analysis. Sf/Am was correlated with LVEF (r = 0.550, P < 0.001). This relationship remained significant in a multivariable linear regression model adjusted for BP level and other confounders (β = 0.603, P < 0.001). The area under the curve values 95% confidence interval (CI) for Sf/Am in predicting LVEF < 40% and <30% were 0.814 (0.738-0.890) and 0.897 (0.840-0.953), respectively. CONCLUSION: Pulse waveform analysis using ABPM has potential for noninvasive estimation of echocardiographic LVEF.