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Antihypertensive treatment is equally beneficial for reducing cardiovascular risk in both men and women. Despite this, the drug treatment, prevalence and control of hypertension differ between men and women. Men and women respond differently, particularly with respect to the risk of adverse events, to many antihypertensive drugs. Certain antihypertensive drugs may also be especially beneficial in the setting of certain comorbidities – of both cardiovascular and extracardiac nature – which also differ between men and women. Furthermore, hypertension in pregnancy can pose a considerable therapeutic challenge for women and their physicians in primary care. In addition, data from population-based studies and from real-world data are inconsistent regarding whether men or women attain hypertension-related goals to a higher degree. In population-based studies, women with hypertension have higher rates of treatment and controlled blood pressure than men, whereas real-world, primary-care data instead show better blood pressure control in men. Men and women are also treated with different antihypertensive drugs: women use more thiazide diuretics and men use more angiotensin-enzyme inhibitors and calcium-channel blockers. This narrative review explores these sex-related differences with guidance from current literature. It also features original data from a large, Swedish primary-care register, which showed that blood pressure control was better in women than men until they reached their late sixties, after which the situation was reversed. This age-related decrease in blood pressure control in women was not, however, accompanied by a proportional increase in use of antihypertensive drugs and female sex was a significant predictor of less intensive antihypertensive treatment.

Objective To assess the relation between socioeconomic status and achievement of target blood pressure in hypertension. Design Retrospective longitudinal cohort study between 2001 and 2014. Setting Primary health care in Skaraborg, Sweden. Subjects 48,254 patients all older than 30 years, and 53.3% women, with diagnosed hypertension. Main outcome measures Proportion of patients who achieved a blood pressure target

Objective To assess the risk of haemorrhagic stroke at different baseline SBP levels in a primary care population with hypertension, atrial fibrillation and newly initiated oral anticoagulants (OACs). Methods We identified 3972 patients with hypertension, atrial fibrillation and newly initiated OAC in The Swedish Primary Care Cardiovascular Database of Skaraborg. Patients were followed from 1 January 2006 until a first event of haemorrhagic stroke, death, cessation of OAC or 31 December 2016. We analysed the association between continuous SBP and haemorrhagic stroke with a multivariable Cox regression model and plotted the hazard ratio as a function of SBP with a restricted cubic spline with 130 mmHg as reference. Results There were 40 cases of haemorrhagic stroke during follow-up. Baseline SBP in the 145-180 mmHg range was associated with a more than doubled risk of haemorrhagic stroke, compared with a SBP of 130 mmHg. Conclusion In this cohort of primary care patients with hypertension and atrial fibrillation, we found that baseline SBP in the 145-180 mmHg range, prior to initiation of OAC, was associated with a more than doubled risk of haemorrhagic stroke, as compared with an SBP of 130 mmHg. This suggests that lowering SBP to below 145 mmHg, prior to initiation of OAC, may decrease the risk of haemorrhagic stroke in patients with hypertension and atrial fibrillation.

Aims The aim of this study was to investigate the relation between body mass index (BMI) in young women, using weight early in pregnancy as a proxy for pre-pregnancy weight, and risk for early cardiovascular disease (CVD) and mortality. Methods and results In this prospective, registry-based study, we used weight data in early pregnancy from women, registered in the Swedish Medical Birth Registry, and who gave birth between 1982 and 2014 (n = 1,495,499; median age 28.3 years). Of the women, 118,212 (7.9%) were obese (BMI ≥ 30 kg/m2) and 29,630 (2.0%) severely obese (BMI ≥ 35 kg/m2). After a follow-up of median 16.3 years, we identified 3295 and 4375 cases of acute myocardial infarction (AMI) and ischemic stroke (IS) corresponding to 13.4 and 17.8 per 100,000 observation years, respectively, occurring at mean ages of 49.8 and 47.3 years. Compared to women with a BMI 20– Conclusion A significant increase in the risk for early AMI, IS and CVD death was noticeable in overweight young women, with a marked increase in obese women.

Summary In this prospective study in Swedish elderly men, PAD based on an ABI

Objective: Hypertension is a major cause of cardiovascular disease. Nevertheless, blood pressure (BP) is often inadequately treated. We studied visit patterns at primary health care centres (PHCCs) and their relation to individual BP control. Design and setting: Cross-sectional register-based study on all patients with hypertension who visited 188 PHCCs in a Swedish region. Patients: A total of 88,945 patients with uncomplicated hypertension age 40–79. Main outcome measures: Odds ratio (OR) for the individual patient to achieve the BP target of ≤140/90 mmHg. Results: Overall, 63% of patients had BP ≤ 140/90 mmHg (48% BP

Aims To describe 8-year trends in blood pressure (BP) control, blood lipid control, and smoking habits in patients with hypertension from QregPV, a primary care register in the Region of Västra Götaland, Sweden. Methods and results QregPV features clinical data on BP, low-density lipoprotein cholesterol (LDL-C), and smoking habits in 392 277 patients with hypertension or coronary heart disease or diabetes mellitus or any combination of the three diagnoses. Data from routine clinical practice have been automatically reported on a monthly basis to QregPV from all primary care centres in Västra Götaland (population 1.67 million) since 2010. Additional data on diagnoses, dispensed drugs and socioeconomic factors were acquired through linkage to regional and national registers. We identified 259 753 patients with hypertension, but without coronary heart disease and diabetes mellitus, in QregPV. From 2010 to 2017, the proportion of patients with BP Conclusions These regionwide data from eight consecutive years in 259 753 patients with hypertension demonstrate a large potential for risk factor improvement. An increased use of statins and antihypertensive drugs should, in addition to lifestyle modifications, decrease the risk of cardiovascular disease in these patients.

OBJECTIVES: Hypertension and diabetes are common and are both associated with high cardiovascular morbidity and mortality. We aimed to investigate associations between mortality risk and country of birth among hypertensive individuals in primary care with and without concomitant diabetes, which has not been studied previously. In addition, we aimed to study the corresponding risks of myocardial infarction and ischemic stroke. METHODS: This observational cohort study of 62 557 individuals with hypertension diagnosed 2001-2008 in the Swedish Primary Care Cardiovascular Database assessed mortality by the Swedish Cause of Death Register, and myocardial infarction and ischemic stroke by the National Patient Register. Cox regression models were used to estimate study outcome hazard ratios by country of birth and time updated diabetes status, with adjustments for multiple confounders. RESULTS: During follow-up time without diabetes using Swedish-born as reference, adjusted mortality hazard ratios per country of birth category were Finland: 1.26 (95% confidence interval 1.15-1.38), high-income European countries: 0.84 (0.74-0.95), low-income European countries: 0.84 (0.71-1.00) and non-European countries: 0.65 (0.56-0.76). The corresponding adjusted mortality hazard ratios during follow-up time with diabetes were high-income European countries: 0.78 (0.63-0.98), low-income European countries: 0.74 (0.57-0.96) and non-European countries: 0.56 (0.44-0.71). During follow-up without diabetes, the corresponding adjusted hazard ratio of myocardial infarction was increased for Finland: 1.16 (1.01-1.34), whereas the results for ischemic stroke were inconclusive. CONCLUSION: In Sweden, hypertensive immigrants (with the exception for Finnish-born) with and without diabetes have a mortality advantage, as compared to Swedish-born. (Less)

Background Haemorrhagic stroke (HS) is a serious condition that kills and debilitates many of those afflicted by it. Hypertension and oral anticoagulation (OAC) are independent risk factors for HS. Many patients with atrial fibrillation (AF) have hypertension and OAC. The concomitance of hypertension and OAC confers an even higher risk of haemorrhagic stroke, but less is known about the association between specific blood pressure levels and the risk of HS in patients with AF and OAC. Purpose To assess the risk of haemorrhagic stroke at different systolic blood pressure (SBP) levels in a primary care population with hypertension, AF and OAC. Methods We identified 3972 patients with hypertension, AF and OAC in a primary care database in southern Sweden. We followed patients from Jan 1, 2006 until a first event of HS, death, cessation of OAC or Dec 31, 2016. HS was defined as ICD-10 diagnosis codes: I60, I61, and I62. We analysed the association between SBP levels and HS by dividing SBP into five categories: Results We identified 51 cases of HS during follow-up. In the categorical analysis of SBP, point estimates of HRs for HS increased gradually from the lowest SBP category to the 160–179 category. Only the 160–179 category had a significantly different HR (3.76, CI 1.56–9.04) than the reference 130–139 category, however. See Table 1. No other co-variates were significantly associated with HS. The spline curve, Figure 1, illustrates a significantly increased HR for HS in the 140–175 SBP range. Conclusions In this real-world primary care cohort with hypertension, AF and OAC, we found that SBP in the 160–179 mmHg range was significantly associated with an increased risk of haemorrhagic stroke. Our findings emphasise the importance of blood pressure control in this patient category. Figure 1. Continuous and categorical SBP & HS risk Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The study was financed by grants from the Swedish state under the agreement between the Swedish government and the country councils, the ALF-agreement.

ObjectiveIn this study we aimed to estimate the effect of diabetes, educational level and income on the risk of mortality and cardiovascular events in primary care patients with hypertension.MethodsWe followed 62,557 individuals with hypertension diagnosed 2001-2008, in the Swedish Primary Care Cardiovascular Database. Study outcomes were death, myocardial infarction, and ischemic stroke, assessed using national registers until 2012. Cox regression models were used to estimate adjusted hazard ratios of outcomes according to diabetes status, educational level, and income.ResultsDuring follow-up, 13,231 individuals died, 9981 were diagnosed with diabetes, 4431 with myocardial infarction, and 4433 with ischemic stroke. Hazard ratios (95% confidence intervals) for diabetes versus no diabetes: mortality 1.57 (1.50-1.65), myocardial infarction 1.24 (1.14-1.34), and ischemic stroke 1.17 (1.07-1.27). Hazard ratios for diabetes and ≤9 years of school versus no diabetes and >12 years of school: mortality 1.56 (1.41-1.73), myocardial infarction 1.36 (1.17-1.59), and ischemic stroke 1.27 (1.08-1.50). Hazard ratios for diabetes and income in the lowest fifth group versus no diabetes and income in the highest fifth group: mortality 3.82 (3.36-4.34), myocardial infarction 2.00 (1.66-2.42), and ischemic stroke 1.91 (1.58-2.31).ConclusionsDiabetes combined with low income was associated with substantial excess risk of mortality, myocardial infarction and ischemic stroke among primary care patients with hypertension.

Our aim was to assess causes of death and temporal changes in excess mortality among patients with new-onset type 2 diabetes in Skaraborg, Sweden.Patients from the Skaraborg Diabetes Register with prospectively registered new-onset type 2 diabetes 1991-2004 were included. Five individual controls matched for sex, age, geographical area and calendar year of study entry were selected using population records. Causes of deaths until 31 December 2014 were retrieved from the Cause of Death Register. Adjusted excess mortality among patients and temporal changes of excess mortality were calculated using Poisson models. Cumulative incidences of cause-specific mortality were calculated by competing risk regression.During 24 years of follow-up 4364 deaths occurred among 7461 patients in 90,529 person-years (48.2/1000 person-years, 95% CI 46.8-49.7), and 18,541 deaths in 479,428 person-years among 37,271 controls (38.7/1000 person-years, 38.1-39.2). The overall adjusted mortality hazard ratio was 1.47 (p .0001) among patients diagnosed at study start 1991 and decreased by 2% (p .0001) per increase in calendar year of diagnosis until 2004. Excess mortality was mainly attributed to endocrine and cardiovascular cause of death with crude subdistributional hazard ratios of 5.06 (p .001) and 1.22 (p .001).Excess mortality for patients with new-onset type 2 diabetes was mainly attributed to deaths related to diabetes and the cardiovascular system, and decreased with increasing year of diagnosis 1991-2004. Possible explanations could be temporal trends of earlier diagnosis due to lowered diagnostic thresholds and intensified diagnostic activities, as well as improved treatment.

Background Atrial fibrillation is associated with increased cardiovascular morbidity and mortality. Hypertension is an important risk factor for the development of atrial fibrillation. Aim This study assessed the relationship between blood pressure control and new-onset atrial fibrillation in hypertensive patients. Methods and results We followed 45,530 hypertensive patients with no previously documented atrial fibrillation, attending primary healthcare in Sweden during 2001-2008. After a mean follow-up of 3.5 years 2057 patients (4.5%) developed atrial fibrillation. Compared to patients with no atrial fibrillation, the new-onset atrial fibrillation group (after adjustment for age, sex, diabetes mellitus, heart failure, ischaemic heart disease, cerebrovascular disease and number of visits) had higher mean in-treatment systolic blood pressure (SBP) and diastolic blood pressure of 3.8 mmHg (95% confidence interval (CI) 3.0-4.6; P 0.0001) and 1.6 mmHg (95% CI 1.2-2.0; P 0.0001), respectively. Similarly, mean in-treatment pulse pressure in the new-onset atrial fibrillation group was 2.2 mmHg (95% CI 1.6-2.9; P 0.001) higher. In a logistic regression analysis, achieved SBP ≥ 140 mmHg was associated with a higher risk of new-onset atrial fibrillation, compared to SBP 130-139 mmHg (odds ratio (OR) 1.5; 95% CI 1.3-1.7) and to SBP 130 mmHg (OR 1.3; 95% CI 1.1-1.5). There was no difference in risk for new-onset AF between SBP 130-139 and130 mmHg (OR 0.9; 95% CI 0.7-1.1). Conclusion The present findings indicate that blood pressure control in hypertension is associated with a lower risk of new-onset atrial fibrillation.

Objective:The objective is to investigate if treatment with thiazides reduces the risk of osteoporotic fractures in hypertensive patients in primary healthcare. Further we aimed to examine the impact of duration of thiazide use, the consequences of discontinuation of treatment, and the possible diff

Introduction The preventive effect of lipid lowering treatment in secondary prevention after coronary heart disease (CHD) is well documented. In 2015, regional guidelines recommend an LDL cholesterol of ≤1.8 mmol/L for patients with established CHD but the adherence to these guidelines is low. Purpose Our aim was to predict potential reductions in cardiovascular disease (CVD) events defined as acute myocardial infarction or stroke if patients: 1) with low-dose/less potent or no statin were treated with Atorvastatin 80 mg, or 2) all reached LDL ≤1.8 mmol/L. Methods In total, 37 120 patients with established CHD in a primary care regional register 2015 were studied. Predicted number of CVD events were calculated with actual treatment, with improved treatment and with lowered LDL. For risk estimation we used data from a Cox Proportional Hazards risk estimation model based on patients from 2010 (n=52 042) in combination with data from the literature on effect of statin treatment and LDL reduction. A risk reduction of 22% for CVD events per 1 mmol/L reduction in LDL was used in our model. The risk prediction model included age, sex, diabetes mellitus, a history of heart failure and/or atrial fibrillations, treatment with acetylic salicylic acid and stroke or AMI past year. Smoking and BMI were excluded due to missing data but sensitivity analysis has shown only small differences in results. Results In total, 18% of included patients reached LDL ≤1.8 mmol/L and 32% had no statin treatment. Based on actual LDL levels and treatments, the predicted number of CVD events over 5 years was 9209/37120. If all patients with no statin or less potent statin treatment had been given atorvastatin 80 mg this would lead to a reduction of CVD events by 14% (7901 vs 9209). The largest gain, 33% reduction, occurred when adding statins to patients without previous treatment (1970 vs 2937). Furthermore, if all patients were to reach LDL ≤1.8 mmol/L the predicted number of events would be reduced by 18% (7577 vs 9209). Conclusion There is a substantial potential to reduce the number of CVD events in the large population of patients with established CHD in primary care by improved adherence to lipid treatment guidelines. Acknowledgement/Funding Närhälsan R&D Health Care, R&D Centre Gothenburg and Södra Bohuslän. the Swedish state under the Agreement concerning research and education of doctor

Hypertension and fractures related to osteoporosis are major public health problems that often coexist. This study examined the associations between exposure to different antihypertensive drug classes and the risk of hip fracture in hypertensive patients.We included 59 246 individuals, 50 years and older, diagnosed with hypertension during 2001-2008 in the Swedish Primary Care Cardiovascular Database. Patients were followed from 1 January 2006 (or the date of diagnosis of hypertension) until they had their first hip fracture, died, or reached the end of the study on 31 December 2012. Cox proportional hazards models were used to calculate the risk of hip fracture across types of antihypertensive medications, adjusted for age, sex, comorbidity, medications, and socioeconomic factors.In total, 2593 hip fractures occurred. Compared to nonusers, current use of bendroflumethiazide or hydrochlorothiazide was associated with a reduced risk of hip fracture (hazard ratio 0.86; 95% CI 0.75-0.98 and hazard ratio 0.84; 95% CI 0.74-0.96, respectively), as was use of fixed drug combinations containing a thiazide (hazard ratio 0.69; 95% CI 0.57-0.83). Current use of loop diuretics was associated with an increased risk of hip fracture (hazard ratio 1.23; 95% CI 1.11-1.35). No significant associations were found between the risk of hip fracture and current exposure to beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone-receptor blockers or calcium channel blockers.In this large observational study of hypertensive patients, the risk of hip fracture differed across users of different antihypertensive drugs, results that could have practical implications when choosing antihypertensive drug therapy.

Objective The aim of this study was to compare the risk of cardiovascular disease (CVD) - nonfatal acute myocardial infarction (AMI) or stroke - at blood pressure levels that meet current recommendations with risk at lower levels, particularly in older patients. Methods We identified patients with hypertension aged 40-90 years from a primary care register. Patients with a history of cancer, diabetes mellitus or CVD were excluded. Patients were divided into age groups (40-75 and 76-90), and four groups of SBP 110-129, 130-139 (reference), 140-149 and ≥150 mmHg. We used the Kaplan-Meier estimator to study incidence of AMI, stroke and a composite of the two. Cox proportional-hazards regression was used to estimate hazard ratios for outcomes. Results We included 31 704 patients: 26 663 were 40-75 years old and 5041 were 76-90 years old. Mean follow-up was 2 years. Although no significant differences in risk of any outcome were found in the younger group, low blood pressure was associated with the lowest risk in the older group. Older patients in the 110-129 mmHg group had a lower incidence of CVD (15.9/1000 vs. 25.3/1000 person-years) than the reference group. After adjustment for covariates, the hazard ratio of CVD in older patients in the 110-129 mmHg group compared with the reference group was 0.60 (95% confidence interval 0.40-0.92). Conclusion Blood pressure levels lower than those currently recommended are not harmful among older patients. The association between lower SBP and lesser risk of CVD may instead suggest a beneficial effect of lower SBP.

We aimed to describe the prevalence, treatment, and associated comorbidity of treatment-resistant hypertension (TRH). This registry-based cohort study from The Swedish Primary Care Cardiovascular Database assessed 53,090 hypertensive patients attending primary care. Patients adherent to antihypertensive treatment measured by pharmacy fills and with proportion of days covered ≥80% were included. The prevalence of TRH was 17% when considering all current TRH definitions. Adherence to mineralocorticoid receptor antagonists differed between TRH- and non-TRH patients (8 vs. 4%). Higher frequencies (prevalence ratio and 95% confidence intervals) of diabetes mellitus (1.59, 1.53-1.66), heart failure (1.55, 1.48-1.64), atrial fibrillation (1.33, 1.27-1.40), ischemic heart disease (1.25, 1.20-1.30), and chronic kidney disease (1.38, 1.23-1.54) were seen in patients with TRH compared to patients without TRH. These findings, in a population with valid data on medication adherence, emphasize a broad preventive approach for these high-risk patients.

Obstructive sleep apnea (OSA) is common in people with hypertension, particularly resistant hypertension. Treatment with an antihypertensive agent alone is often insufficient to control hypertension in patients with OSA.To determine whether continuous positive airway pressure (CPAP) added to treatment with an antihypertensive agent has an impact on blood pressure (BP) levels.During the initial 6-week, two-center, open, prospective, case-control, parallel-design study (2:1; OSA/no-OSA), all patients began treatment with an angiotensin II receptor antagonist, losartan, 50 mg daily. In the second 6-week, sex-stratified, open, randomized, parallel-design study of the OSA group, all subjects continued to receive losartan and were randomly assigned to either nightly CPAP as add-on therapy or no CPAP.Twenty-four-hour BP monitoring included assessment every 15 minutes during daytime hours and every 20 minutes during the night. Ninety-one patients with untreated hypertension underwent a home sleep study (55 were found to have OSA; 36 were not). Losartan significantly reduced systolic, diastolic, and mean arterial BP in both groups (without OSA: 12.6, 7.2, and 9.0 mm Hg; with OSA: 9.8, 5.7, and 6.1 mm Hg). Add-on CPAP treatment had no significant changes in 24-hour BP values but did reduce nighttime systolic BP by 4.7 mm Hg. All 24-hour BP values were reduced significantly in the 13 patients with OSA who used CPAP at least 4 hours per night.Losartan reduced BP in OSA, but the reductions were less than in no-OSA. Add-on CPAP therapy resulted in no significant changes in 24-hour BP measures except in patients using CPAP efficiently. Clinical trial registered with www.clinicaltrials.gov (NCT00701428).​

Objectives To explore relationships between patients’ self-monitoring of blood pressure (BP) and their concurrent self-reports of medication intake, well-being, stress, physical activity and symptoms. Design This study is a secondary analysis of a prospective study exploring the 8-week effectiveness of a mobile phone-based self-management support system for patients with hypertension. Setting Four primary healthcare centres situated in urban and suburban communities in Sweden. Participants 50 patients undergoing treatment for hypertension. Primary and secondary outcome measures Associations between systolic (SBP) and diastolic blood pressure (DBP) and 10 self-report lifestyle-related variables were analysed using linear mixed effects modelling. Results Medication intake, better well-being, less stress and greater physical activity were associated variously with lower same-day SBP and DBP. The single strongest association was found between medication intake and SBP, where failure to take medications was associated with an estimated 7.44 mm Hg higher SBP. To a lesser degree, medication intake was also associated with DBP, where DBP was 4.70 mm Hg higher in cases where medications were not taken. Well-being and stress were consistently associated with SBP and DBP, whereas physical activity was associated with only SBP. None of the symptoms—dizziness, headache, restlessness, fatigue or palpitations—were significantly associated with BP. Conclusions Our findings that BP was associated with patients’ BP management behaviours and experiences of well-being and stress, but not symptoms suggest that enabling persons with hypertension to monitor and track their BP in relation to medication intake, physical activity, well-being, stress and symptoms may be a fruitful way to help them gain first-hand understanding of the importance of adherence and persistence to treatment recommendations. Trial registration number NCT01510301; Pre-results.

Background Atrial fibrillation is associated with hyperthyroidism. Patients with primary aldosteronism have an increased prevalence of atrial fibrillation. However, the prevalence of primary aldosteronism in the atrial fibrillation population is unknown. Aim This nationwide case–control study aimed to compare the prevalence of primary aldosteronism and thyroid disorders in patients with atrial fibrillation with that of age- and sex-matched controls. Methods We identified all atrial fibrillation cases in Sweden between 1987 and 2013 ( n = 713,569) by using the Swedish National Patient Register. A control cohort without atrial fibrillation was randomly selected from the Swedish Total Population Register with a case to control ratio of 1:2. This control cohort was matched for age, sex and place of birth ( n = 1,393,953). Results The prevalence of primary aldosteronism in December 2013 was 0.056% in the atrial fibrillation cohort and 0.024% in controls. At the same time, the prevalence of hypothyroidism was 5.9% in the atrial fibrillation cohort and 3.7% in controls. The prevalence of hyperthyroidism was 2.3% in the atrial fibrillation cohort and 0.8% in controls. Conclusion This study shows, for the first time, a doubled prevalence of primary aldosteronism in a large cohort of patients with atrial fibrillation compared with the general population. There is also an increased prevalence of hypo- and hyper-thyroidism in patients with atrial fibrillation compared with the general population.

The relation between dyslipidemia and atrial fibrillation (AF) development is still controversial. To assess the impact of lipid profile on new-onset AF, we followed 51,020 primary-care hypertensive patients without AF at baseline. After a mean follow-up time of 3.5 years, AF occurred in 2,389 participants (4.7%). We evaluated the association between total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, and new-onset AF. In a Poisson regression model fully adjusted for common risk factors of AF, we found that 1.0 mmol/l (39 mg/dl) increase in total cholesterol was associated with 19% lower risk of new-onset AF (95% confidence interval [CI] 9% to 28%), and 1.0 mmol/l (39 mg/dl) increase in low-density lipoprotein cholesterol was associated with 16% lower risk of new-onset AF (95% CI 3% to 27%). Gender-specific Poisson regression analyses revealed that increase in total cholesterol by 1.0 mmol/l (39 mg/dl) was found to be associated with lower risk of new-onset AF with 21% in men (95% CI 8% to 32%), and 18% in women (95% CI 1% to 31%). There was no association between high-density lipoprotein cholesterol or triglycerides and new-onset AF, neither in the whole population with respect to separate gender. In conclusion, in a large hypertensive population we found an inverse association between total cholesterol and new-onset AF for both men and women. Our results confirm previous reports of a dyslipidemia paradox, and extend these observations to the hypertensive population.

Objective:To study how regular control of systolic blood pressure (BP), assessed as time in therapeutic range (TTR), is associated to mortality in treated hypertensive patients attending primary care.Design and method:Electronic health record data from SPCCD on treated hypertensive patients in a Swe

To assess cardiovascular outcome in patients with treatment-resistant hypertension (TRH) compared with patients with nontreatment-resistant hypertension (HTN).Cohort study with data from 2006 to 2012 derived from the Swedish Primary Care Cardiovascular Database with hypertensive patients aged at least 30 years. TRH was defined as blood pressure at least 140/90 mmHg despite medication adherence to three or more dispensed antihypertensive drug classes. Patients with cardiovascular comorbidity were excluded. The association between TRH and cardiovascular events with adjustment for important confounders was analyzed.We included 4317 TRH patients and 32 282 HTN patients. TRH patients (61% women) were older (70 vs. 66 years), had higher SBP (152 vs. 141 mmHg) and more diabetes (30 vs. 20%) (P 0.001 for all) compared with HTN patients. Mean follow-up time was 4.3 years. In the adjusted analysis, TRH patients had an increased risk for total mortality [hazard ratio 1.12; 95% confidence interval (CI), 1.03-1.23], cardiovascular mortality (hazard ratio 1.20; 95% CI, 1.03-1.40) and incident heart failure (hazard ratio 1.34; 95% CI, 1.17-1.54) but not for incident stroke (hazard ratio 1.03; 95% CI, 0.90-1.19) or transitoric ischemic attack (hazard ratio 1.12; 95% CI, 0.86-1.46) compared with HTN patients.Patients with TRH have a poor prognosis beyond blood pressure level, compared with hypertensive patients without TRH. In particular, the high risk for heart failure is of clinical importance and merits further investigation.

Atrial fibrillation seems to be overrepresented among patients with primary aldosteronism. The aim of this study was to determine the usefulness of aldosterone to renin ratio as a screening instrument for primary aldosteronism in an atrial fibrillation population with relatively low cardiovascular risk profile. A total of 149 patients 65 pmol/mIU) was found in 15 participants (10.1%). Further investigation of the positive screened participants and confirmatory saline infusion test resulted in a diagnosis of primary aldosteronism in four individuals out of 149 (2.6%). Three out of the four individuals with primary aldosteronism had previously been diagnosed with hypertension, but only one out of the four had uncontrolled blood pressure, that is, >140/90 mmHg. All participants had normal potassium levels. Individuals with increased aldosterone to renin ratio had significantly higher mean systolic and diastolic blood pressure in comparison to participants with normal aldosterone to renin ratio (136 vs. 126 mmHg, p=0.02 and 84 vs. 78 mmHg, p=0.02). These findings suggest that assessment of aldosterone to renin ratio can be useful for identification of underlying primary aldosteronism in patients with diagnosed atrial fibrillation and hypertension in spite of well controlled blood pressure and normokalemia.

OBJECTIVE To study temporal trends in hypertension treatment and control in Swedish primary care, in relation to clinical characteristics, comorbidity, and drug treatment. MATERIALS AND METHODS Repeated cross-sectional analysis of 43 239 hypertensive patients attending primary care in 2001-2002 and of 62 407 patients in 2007-2008. RESULTS Mean blood pressure (BP) 2007-2008 was 143/79 mmHg in women and 142/81 mmHg in men. Cardiovascular comorbidity and diabetes were present in 13 and 15% of women, and in 18 and 20% of men. Overall BP reductions from 2001-2002 to 2007-2008 were 9.0/3.1 mmHg; greater in women than men, with advancing age, and in patients with comorbidity (all P

The aim of this observational cohort study was to investigate blood pressure level and the possibility to reach target blood pressure during concomitant use of NSAID in hypertensive patients.From the Swedish primary care cardiovascular database (SPCCD) a cohort of 5463 patients (2007 to 2008) with at least one prescription of NSAID dispensed 6 months prior to the last blood pressure measurement were included. Clinical data were extracted from computerized medical records and linked to the Prescribed Drug Register. Multivariable logistic regression models were used for analysis.Patients with NSAID usage were younger, more often female, with lower creatinine concentrations, more musculoskeletal diagnosis and less cardiovascular comorbidity compared to patients without dispensed NSAID (p .0001 for all). Regular dose of NSAID was not associated with a decreased possibility to reach target blood pressure. A correlation between the dose of naproxen and an increase in SBP of 7 mm Hg was found. Impairment in renal function did not influence the association between blood pressure control and NSAID (p = .27).In hypertensive patients with concomitant use of NSAID the chance to reach target blood pressure was not impaired. In intermediate and frequent users of NSAID there was a dose response relation with naproxen and SBP which was not found in diclofenac and ibuprofen.

The reasons why women and men are treated with different antihypertensive drugs are not clear. Whether socioeconomic factors influence prescription patterns and blood pressure control differently in women and men has not been investigated. This cross-sectional study performed in a cohort of hypertensive patients from the Swedish Primary Care Cardiovascular Database (SPCCD) examined the influence of educational level, country of birth, gender and concomitant psychiatric disorder on prescription pattern and blood pressure control in 40,825 hypertensive patients. Men were more often than women treated with calcium channel blocker and angiotensin-converting enzyme inhibitor (ACEI), irrespective of education, country of birth and psychiatric disorder. Educational level influenced the prescription pattern to some extent, where the gender differences were reduced in patients with a higher educational level. In women, but not in men, high educational level and concomitant psychiatric disorder were associated with a higher proportion reaching target blood pressure. The predominant use of ACEI and calcium channel blockers in men is not influenced by educational level, country of birth or psychiatric disorder. Thus other explanations must be considered such as gender differences in side effects. Educational level seems to have a greater impact on reaching target blood pressure in women compared with men.

To describe the Swedish Primary Care Cardiovascular Database, SPCCD. Design. Longitudinal data from electronic medical records, linked to national registers. Setting. 48 primary healthcare centres in urban (south-western Stockholm) and rural (Skaraborg) regions in Sweden. Subjects. Patients diagnosed with hypertension 2001-2008.Blood pressure (BP) and impact of retrieval of data on BP levels, clinical characteristics, co-morbidity and pharmacological treatment.The SPCCD contains 74 751 individuals, 56% women. Completeness of data ranged from99% for drug prescriptions to 34% for smoking habits. BP was recorded in 98% of patients during 2001-2008 and in 63% in 2008. Mean BP based on the last recorded value in 2008 was 142 ± 17/80 ± 13 mmHg. Digit preference in BP measurements differed between the two regions, p0.001. Antihypertensive drugs were prescribed in primary healthcare to 88% of the patients in 2008; however, when all prescribers were included 96% purchased their drugs. Cardiovascular co-morbidity and diabetes mellitus were present in 28% and 22%, respectively.This large and representative database shows that there is room for improvement of BP control in Sweden. The SPCCD will provide a rich source for further research of hypertension and its complications.

Background Cerebrovascular lesions are often associated with electrocardiographic (ECG) abnormalities. The main purpose of this work was to investigate the prognostic value of ECG abnormalities and/or elevated cardiac troponin (cTNT) on admission in patients with nontraumatic intracerebral hemorrhage (ICH). Methods Ninety-seven consecutive patients with ICH were included. The predictive value of ECG abnormalities and increased TNT on survival were evaluated using Cox proportional hazard model. Results The most frequently observed ECG abnormalities were the presence of a Q wave (39.6%), followed by prolonged QTc (>0.44 s; 35.4%), which was an independent predictor for long-term mortality (P = 0.019). No difference in QTc was observed between patients with right versus left ICH. Increased cTNT levels at admission had no prognostic value. Conclusion Various ECG changes were common in patients presenting with an ICH, but only prolonged QTc was found to be an independent predictor of poor survival during follow-up after ICH.

Maternal cardiovascular morbidity is increased after hypertensive pregnancies (HTP). The pathways from complicated pregnancies to future cardiovascular disease are complex. The aim of the present study was to test the hypothesis that different cardiovascular mechanisms are changed in women who experienced HTP four decades earlier in comparison to women with normotensive pregnancies.One hundred and five women (50 with hypertensive and 55 with normal pregnancies) were examined with anthropometric measurements; office blood pressure, ambulatory blood pressure and central blood pressure, pulse wave velocity, augmentation index, intimal-media thickness, echocardiography and laboratory measurements. In addition another 204 women were followed-up by a questionnaire regarding their pregnancy 40 years ago, as well as their present health status and medications.Women with HTP had more often diagnosed hypertension when compared with women with normal pregnancies (50 vs. 31%, respectively; P = 0.046), but the groups did not differ in any blood pressure levels. HTP were associated with higher pulse wave velocity (8.8 m/s vs. 7.8 m/s, P = 0.021), and higher levels of P-glucose (5.7 mmol/l vs. 5.2 mmol/l, P = 0.022), P-HbA1c (4.4% vs. 4.2%, P = 0.010) and noradrenaline (2.45 mmol/l vs. 2.11 mmol/l, P = 0.040) when compared with normotensive pregnancies. Women followed up with a questionnaire reported deteriorated cardiovascular health compared to women attending the clinical investigations of the study.HTP are associated with impairment in vascular function and metabolic status 40 years postpartum despite well controlled blood pressure levels.

Blood pressure reduction in response to antihypertensive agents is less for patients with obstructive sleep apnea (OSA). Increased sympathetic and inflammatory activity, as well as alterations in the renin-angiotensin-aldosterone system, may play a role in this context.To address the cardiovascular mechanisms involved in response to an angiotensin II receptor antagonist, losartan, and continuous positive airway pressure (CPAP) as add-on treatment for hypertension and OSA.Newly diagnosed hypertensive patients with or without OSA (allocated in a 2:1 ratio for OSA vs. no OSA) were treated with losartan 50 mg daily during a 6-week two-center, open-label, prospective, case-control, parallel-design study. In the second 6-week, sex-stratified, open-label, randomized, parallel-design study, all subjects with OSA continued to receive losartan and were randomly assigned to either CPAP as add-on therapy or to no CPAP (1:1 ratio for CPAP vs. no CPAP). Study subjects without OSA were followed in parallel while they continued to take losartan. Blood samples were collected at baseline, after 6 weeks, and after 12 weeks for analysis of renin, aldosterone, noradrenaline, adrenaline, and inflammatory markers.Fifty-four patients with OSA and 35 without OSA were included in the first 6-week study. Losartan significantly increased renin levels and reduced aldosterone levels in the group without OSA. There was no significant decrease in aldosterone levels among patients with OSA. Add-on CPAP treatment tended to lower aldosterone levels, but reductions were more pronounced in measures of sympathetic activity. No significant changes in inflammatory markers were observed following treatment with losartan and CPAP.Hypertensive patients with OSA responded to losartan treatment with smaller reductions in aldosterone compared with hypertensive patients without OSA. Sympathetic system activity seemed to respond primarily to add-on CPAP treatment in patients with newly discovered hypertension and OSA. Clinical trial registered with www.clinicaltrials.gov (NCT00701428).

Objectives To compare the risk associated with systolic blood pressure that meets current recommendations (that is, below 140 mm Hg) with the risk associated with lower levels in patients who have type 2 diabetes and no previous cardiovascular disease. Design Population based cohort study with nationwide clinical registries, 2006-12. The mean follow-up was 5.0 years. Setting 861 Swedish primary care units and hospital outpatient clinics. Participants 187 106 patients registered in the Swedish national diabetes register who had had type 2 diabetes for at least a year, age 75 or younger, and with no previous cardiovascular or other major disease. Main outcome measures Clinical events were obtained from the hospital discharge and death registers with respect to acute myocardial infarction, stroke, a composite of acute myocardial infarction and stroke (cardiovascular disease), coronary heart disease, heart failure, and total mortality. Hazard ratios were estimated for different levels of baseline systolic blood pressure with clinical characteristics and drug prescription data as covariates. Results The group with the lowest systolic blood pressure (110-119 mm Hg) had a significantly lower risk of non-fatal acute myocardial infarction (adjusted hazard ratio 0.76, 95% confidence interval 0.64 to 0.91; P=0.003), total acute myocardial infarction (0.85, 0.72 to 0.99; P=0.04), non-fatal cardiovascular disease (0.82, 0.72 to 0.93; P=0.002), total cardiovascular disease (0.88, 0.79 to 0.99; P=0.04), and non-fatal coronary heart disease (0.88, 0.78 to 0.99; P=0.03) compared with the reference group (130-139 mm Hg). There was no indication of a J shaped relation between systolic blood pressure and the endpoints, with the exception of heart failure and total mortality. Conclusions Lower systolic blood pressure than currently recommended is associated with significantly lower risk of cardiovascular events in patients with type 2 diabetes. The association between low blood pressure and increased mortality could be due to concomitant disease rather than antihypertensive treatment.

The aim was to study persistence to, and switching between, antihypertensive drug classes and to determine factors associated with poor persistence.This was an observational cohort study. The Swedish Primary Care Cardiovascular Database includes data from medical records, socioeconomic data, filled prescriptions, and hospitalizations from national registries for 75,000 patients with hypertension. Patients included in the study were initiated on antihypertensive drug treatment in primary healthcare in 2006 to 2007. We defined class persistence as the proportion remaining on the initial drug class, including 30 days of gap. Patients with a filled prescription of another antihypertensive drug class after discontinuation of the initial drug, including 30 days of gap, were classified as switchers. Persistence to the various drug classes were compared with that for diuretics.We identified 4997 patients (mean age 60 ± 12 years in men and 63 ± 13 years in women). Out of these, 95 (2%) filled their first prescription for fixed combination therapy and 4902 (98%) for monotherapy, including angiotensin converting enzyme inhibitors (37%), angiotensin receptor blockers (4%), beta blockers (21%), calcium channel blockers (8%), and diuretics (28%). Persistence to the initial drug class was 57% after 1 year and 43% after 2 years. There were no differences in persistence between diuretics and any of the other antihypertensive drug classes, after adjustment for confounders. Discontinuation (all adjusted) was more common in men (P = 0.004), younger patients (P

Although treatment with statins has produced beneficial effects when used as secondary prevention, its primary protective role is still somewhat controversial. Moreover, few studies have evaluated the effect of statins in older patients with stroke.The aim was to investigate whether treatment with statins decreases stroke severity and/or improves survival and outcome after stroke in an older population.We investigated the association between previous statin use and stroke severity (National Institutes of Health Stroke Scale [NIHSS]), as well as the effect of poststroke statin treatment on 12-month functional outcome (modified Rankin Scale [mRS] score) in 799 patients (mean age, 78 years), with acute ischemic stroke. The effect of statin treatment on survival was examined using the Cox proportional hazard model, after adjusting for relevant covariates.Statins did not decrease stroke severity and did not improve 30-day survival. However, both the 12-month survival (hazard ratio = 0.33; 95% CI, 0.20-to 0.54; P0.001) and the 12-month functional outcome (odds ratio = 2.09; 95% CI, 1.25-3.52; P = 0.005) were significantly better in the group treated with statins.Significantly better survival and functional outcome were noted with poststroke statins at the end of the 12-month follow-up period. Statins seem to provide beneficial effects for the long-term functional outcome and survival in the elderly.

Epidemiological studies show that women with pregnancies complicated by hypertension have an increased risk of cardiovascular morbidity later in life. The underlying mechanisms to the risk increase remain largely unknown. This study evaluated sympathetic nerve activity in women with hypertensive pregnancies 40 years earlier compared to women with normotensive pregnancies. We hypothesized that sympathetic outflow would be increased in women with previous hypertensive pregnancies and that this partly may explain the increased cardiovascular risk.Sympathetic nerve activity to the muscle vascular bed [muscle sympathetic nerve activity (MSNA)] was recorded in 28 women, 18 with and 10 without a hypertensive manifestation during pregnancy. Women were also examined with ambulatory blood pressure measurements, pulse wave velocity, blood pressure response during Stroop test and laboratory analysis.Women with previous hypertensive pregnancies did not show an increased sympathetic outflow compared to women with normotensive pregnancies. In eight women with treated hypertension sympathetic outflow was increased compared to normotensive women despite similar ambulatory blood pressure values (P 0.05). During Stroop test the hypertensive women showed increased systolic blood pressure and also displayed the highest augmentation index compared to normotensive women (P 0.05).Hypertensive pregnancies per se were not associated with increased sympathetic outflow 40 years later. The increased cardiovascular risk in women with previous hypertensive pregnancies cannot be explained by chronic activation of the sympathetic nervous system.In women with previous hypertensive pregnancies, still hypertensive though well controlled, sympathetic outflow and arterial stiffness were, however, increased compared to normotensive counterparts.

Hypertension is a major risk factor for vascular disease, yet blood pressure (BP) control is unsatisfactory low, partly due to side-effects. Transcutaneous electrical nerve stimulation (TENS) is well tolerated and studies have demonstrated BP reduction. In this study, we compared the BP lowering effect of 2.5 mg felodipin once daily with 30 min of bidaily low-frequency TENS in 32 adult hypertensive subjects (mean office BP 152.7/90.0 mmHg) in a randomized, crossover design. Office BP and 24-h ambulatory BP monitoring (ABPM) were performed at baseline and at the end of each 4-week treatment and washout period. Felodipin reduced office BP by 10/6 mmHg (p

The efficacy of antihypertensive drug therapy is undisputed, but observational studies show that few patients reach a target blood pressure

Objective: To explore relationships between patients’ self-monitoring of blood pressure and their concurrent self-reports of medication intake, wellbeing stress, physical activity and symptoms.Desi ...

Objectives Elevated blood pressure (BP) is common in acute ischemic stroke, but its effect on outcome is not fully understood. We aimed to investigate the association of baseline BP and BP change within the first day after stroke with stroke severity, functional outcome, and mortality. Methods Patients admitted to hospital with acute ischemic stroke (IS) from 15 February 2005 through 31 May 2009 were consecutively included. Acute stroke severity and functional outcome at three and twelve months were investigated using multivariate regression analysis; the association between BP and all-cause mortality at one, three, and twelve was investigated by Cox proportional hazard regression and Kaplan-Meier survival curves. Results A total of 799 patients (mean age 78.4 ± 8.0, 48% men) were included. Higher decreases in systolic and mean arterial blood pressure (ΔSBP and ΔMAP) were associated with decreased 1-month mortality (ΔSBP: hazard ratio, HR: 0.981; 95% CI: 0.968 - 0.994; p = .005), 3-month mortality (ΔSBP: HR 0.989; 95% CI 0.981 - 0.998; p-value .014), and twelve-month mortality (ΔSBP: HR 0.989; 95% CI 0.982 - 0.996; p-value .003). Stroke severity was associated with ΔMAP (B coefficient -.46, p-value .011). Higher SBP and MAP on admission were associated with better functional outcome at three (SBP: OR 0.987; 95% CI 0.978 - 0.997; p-value .008 - MAP: OR 0.985; 95% CI 0.971 - 1; p-value .046) and twelve (SBP: OR 0.988; 95% CI 0.979 - 0.998; p-value .015 - MAP: OR 0.983; 95% CI 0.968 - 0.997; p-value .02) months. Conclusion In this elderly population, higher BP on arrival to the emergency room (ER) and decrease in BP after the patients' arrival to the ward were associated with improved functional outcome and reduced mortality, respectively. These results may reflect a regulatory situation in which elevated initial blood pressure indicates adequate response to cerebral tissue ischemia while subsequent blood pressure decrease instead may be a consequence of partial, successful reperfusion.

Objective To study trends for 20 years in incidence and 1-year mortality in hospitalised patients who received a diagnosis of either angina or unexplained chest pain (UCP) in Sweden. Design and setting Register study of all patients aged 25–84 years identified from the Swedish National Hospital Discharge Register who were hospitalised with a first-time diagnosis of UCP or angina pectoris during 1987 to 2006. Participants A total of 378 454 patients, 235 855 with UCP and 142 599 with angina. Main outcome measures 1-Year mortality and standardised mortality ratios (SMRs). Results From the period 1987–1991 to 2002–2006, the observed 1-year mortality rate in men and women with UCP aged 25–74 years decreased from 2.19% to 1.45% and from 1.85% to 0.91%, respectively. SMRs decreased from 1.67 (95% CI 1.39 to 1.95) and 1.63 (1.27 to 2.00) to 1.09 (0.96 to 1.23) and 0.88 (0.75 to 1.00). Corresponding decreases in 1-year mortality for a discharge diagnosis of angina were from 6.50% to 2.49% in men and from 4.80% to 1.68% in women, with SMRs decreasing from 2.69 (2.33–3.05) and 2.59 (2.06–3.12) to 1.09 (0.93–1.25) and 1.05 (0.81–1.29), respectively. Similar changes occurred in patients aged 75–84 years. Only men with UCP aged 75–84 years still retained a slightly increased mortality (SMR 1.14 (1.01–1.28)). Conclusions The prognosis of patients admitted with chest pain in which acute myocardial infarction has been ruled out has improved for the past 20 years, such that the 1-year mortality of these patients is now similar to that in the general population.

The aim of this retrospective study in primary health care was to study gender differences in blood pressure levels in response to treatment of new onset hypertension. Gender difference in blood pressure control and pharmacological treatment was also recorded. A total of 334 women and 332 men aged ≥50 years and80 years at baseline, with blood pressure ≥140 mm Hg systolic and/or ≥90 mm Hg were included. Men were younger, had a higher frequency of type II diabetes mellitus and a higher body mass index compared with women at baseline. There was no difference between women and men in systolic blood pressure (SBP) before or after treatment. Women however had a lower diastolic blood pressure (DBP) before and after intervention and as a result a higher pulse pressure (PP). Approximately 50% of the patients reached target blood pressure (≤140/90 mm Hg) in both women and men. Beta blocker was the most commonly used antihypertensive treatment in both genders, whereas diuretics were predominately used in women. In conclusion; women and men reached target blood pressure to the same extent but with different antihypertensive treatment strategies. Differences at baseline in risk factor pattern may explain the finding.