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Blood Pressure Control and Cardiovascular Outcomes in Patients With Atrial Fibrillation (From the ORBIT-AF Registry)

Published:February 23, 2019DOI:https://doi.org/10.1016/j.amjcard.2019.02.010
      Systolic blood pressure (SBP) and its association with clinical outcomes in atrial fibrillation (AF) patients in community practice are poorly characterized. In patients with AF, we sought to (1) examine the prevalence of baseline uncontrolled hypertension and the overall change in SBP control, (2) identify predictors of uncontrolled SBP over 2 years of follow-up, and (3) determine the relation between SBP and clinical outcomes. We analyzed 10,132 patients with AF at 176 clinics in the ORBIT-AF registry between 2010 and 2014, classified as: (1) no history of hypertension; (2) controlled hypertension (baseline SBP <140 mm Hg); (3) and uncontrolled hypertension (baseline SBP >140 mm Hg). Predictors of SBP >140 mm Hg at baseline or in follow-up were identified with pooled logistic regression. Random effects Cox regression models were used to compare cardiovascular outcomes and major bleeding as a function of continuous, time-dependent SBP. Overall 8,383 (83%) of patients with AF had hypertension. Of these, 24.2% (n = 2032) had uncontrolled baseline SBP, with little change over 2 years. Predictors of elevated follow-up SBP included uncontrolled baseline SBP, females, previous percutaneous coronary intervention, and diabetes. For every 5 mm Hg increase in follow-up SBP, the adjusted risk of stroke or systemic embolism or transient ischemic attack (adjusted hazard ratio [aHR] 1.05, 95% confidence interval [CI] 1.01 to 1.08, p = 0.01), myocardial infarction (aHR 1.05, 95% CI 1.00 to 1.11, p = 0.04), and major bleeding (aHR 1.03, 95% CI 1.00 to 1.06, p = 0.04) increased modestly. In conclusion, in patients with AF, higher SBP was associated with increasing adverse events; therefore, more rigorous blood pressure control should be emphasized.
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      References

        • Manolis A.J.
        • Rosei E.A.
        • Coca A.
        • Cifkova R.
        • Erdine S.E.
        • Kjeldsen S.
        • Lip G.Y.
        • Narkiewicz K.
        • Parati G.
        • Redon J.
        • Schmieder R.
        • Tsioufis C.
        • Mancia G.
        Hypertension and atrial fibrillation: diagnostic approach, prevention and treatment. Position paper of the Working Group 'Hypertension Arrhythmias and Thrombosis' of the European Society of Hypertension.
        J Hypertens. 2012; 30: 239-252
        • Andrade J.
        • Khairy P.
        • Dobrev D.
        • Nattel S.
        The clinical profile and pathophysiology of atrial fibrillation: relationships among clinical features, epidemiology, and mechanisms.
        Circ Res. 2014; 114: 1453-1468
        • Kannel W.B.
        • Wolf P.A.
        • Benjamin E.J.
        • Levy D.
        Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates.
        Am J Cardiol. 1998; 82: 2N-9N
      1. Stroke Prevention in Atrial Fibrillation Investigators. Risk Factors for thromboembolism during aspirin therapy in patients with atrial fibrillation. J Stroke Cerebrovasc Dis 1995:147–157.

        • Hart R.G.
        • Pearce L.A.
        • McBride R.
        • Rothbart R.M.
        • Asinger R.W.
        Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trials. The Stroke Prevention in Atrial Fibrillation (SPAF) Investigators.
        Stroke. 1999; 30: 1223-1229
        • Hart R.G.
        • Pearce L.A.
        • Rothbart R.M.
        • McAnulty J.H.
        • Asinger R.W.
        • Halperin J.L.
        Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy. Stroke Prevention in Atrial Fibrillation Investigators.
        J Am Coll Cardiol. 2000; 35: 183-187
        • Wang Z.
        • Whiteside S.P.H.
        • Sim L.
        • Farah W.
        • Morrow A.S.
        • Alsawas M.
        • Barrionuevo P.
        • Tello M.
        • Asi N.
        • Beuschel B.
        • Daraz L.
        • Almasri J.
        • Zaiem F.
        • Larrea-Mantilla L.
        • Ponce O.J.
        • LeBlanc A.
        • Prokop L.J.
        • Murad M.H.
        A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study.
        JAMA. 2003; 290: 1049-1056
        • Badheka A.O.
        • Patel N.J.
        • Grover P.M.
        • Shah N.
        • Patel N.
        • Singh V.
        • Deshmukh A.J.
        • Mehta K.
        • Chothani A.
        • Savani G.T.
        • Arora S.
        • Rathod A.
        • Marzouka G.R.
        • Lafferty J.
        • Mehta J.L.
        • Mitrani R.D.
        Optimal blood pressure in patients with atrial fibrillation (from the AFFIRM Trial).
        Am J Cardiol. 2014; 114: 727-736
        • Pisters R.
        • Lane D.A.
        • Marin F.
        • Camm A.J.
        • Lip G.Y.
        Stroke and thromboembolism in atrial fibrillation.
        Circ J. 2012; 76: 2289-2304
        • Rao M.P.
        • Halvorsen S.
        • Wojdyla D.
        • Thomas L.
        • Alexander J.H.
        • Hylek E.M.
        • Hanna M.
        • Bahit M.C.
        • Lopes R.D.
        • De Caterina R.
        • Erol C.
        • Goto S.
        • Lanas F.
        • Lewis B.S.
        • Husted S.
        • Gersh B.J.
        • Wallentin L.
        • Granger C.B.
        • Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) Steering Committee and Investigators
        Blood pressure control and risk of stroke or systemic embolism in patients with atrial fibrillation: results From the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) Trial.
        J Am Heart Assoc. 2015; (pii: e002015): 4
        • Dekker F.W.
        • de Mutsert R.
        • van Dijk P.C.
        • Zoccali C.
        • Jager K.J.
        Survival analysis: time-dependent effects and time-varying risk factors.
        Kidney Int. 2008; 74: 994-997
        • Chobanian A.V.
        • Bakris G.L.
        • Black H.R.
        • Cushman W.C.
        • Green L.A.
        • Izzo Jr, J.L.
        • Jones D.W.
        • Materson B.J.
        • Oparil S.
        • Wright Jr, J.T.
        • Roccella E.J.
        • National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee
        The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.
        JAMA. 2003; 289: 2560-2572
        • Wright Jr., J.T.
        • Williamson J.D.
        • Whelton P.K.
        • Snyder J.K.
        • Sink K.M.
        • Rocco M.V.
        • Reboussin D.M.
        • Rahman M.
        • Oparil S.
        • Lewis C.E.
        • Kimmel P.L.
        • Johnson K.C.
        • Goff Jr., D.C.
        • Fine L.J.
        • Cutler J.A.
        • Cushman W.C.
        • Cheung A.K.
        • Ambrosius W.T.
        • SPRINT Research Group
        A Randomized Trial of Intensive versus Standard Blood-Pressure Control.
        N Engl J Med. 2015; 373: 2103-2116
        • Weber M.A.
        • Schiffrin E.L.
        • White W.B.
        • Mann S.
        • Lindholm L.H.
        • Kenerson J.G.
        • Flack J.M.
        • Carter B.L.
        • Materson B.J.
        • Ram C.V.
        • Cohen D.L.
        • Cadet J.C.
        • Jean-Charles R.R.
        • Taler S.
        • Kountz D.
        • Townsend R.
        • Chalmers J.
        • Ramirez A.J.
        • Bakris G.L.
        • Wang J.
        • Schutte A.E.
        • Bisognano J.D.
        • Touyz R.M.
        • Sica D.
        • Harrap S.B.
        Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension.
        J Hypertens. 2014; 32: 3-15
        • Calhoun D.A.
        • Jones D.
        • Textor S.
        • Goff D.C.
        • Murphy T.P.
        • Toto R.D.
        • White A.
        • Cushman W.C.
        • White W.
        • Sica D.
        • Ferdinand K.
        • Giles T.D.
        • Falkner B.
        • Carey R.M.
        • American Heart Association Professional Education Committee
        Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research.
        Circulation. 2008; 117: e510-e526
        • Mancia G.
        • Fagard R.
        • Narkiewicz K.
        • Redon J.
        • Zanchetti A.
        • Böhm M.
        • Christiaens T.
        • Cifkova R.
        • De Backer G.
        • Dominiczak A.
        • Galderisi M.
        • Grobbee D.E.
        • Jaarsma T.
        • Kirchhof P.
        • Kjeldsen S.E.
        • Laurent S.
        • Manolis A.J.
        • Nilsson P.M.
        • Ruilope L.M.
        • Schmieder R.E.
        • Sirnes P.A.
        • Sleight P.
        • Viigimaa M.
        • Waeber B.
        • Zannad F.
        • Redon J.
        • Dominiczak A.
        • Narkiewicz K.
        • Nilsson P.M.
        • Burnier M.
        • Viigimaa M.
        • Ambrosioni E.
        • Caufield M.
        • Coca A.
        • Olsen M.H.
        • Schmieder R.E.
        • Tsioufis C.
        • van de Borne P.
        • Zamorano J.L.
        • Achenbach S.
        • Baumgartner H.
        • Bax J.J.
        • Bueno H.
        • Dean V.
        • Deaton C.
        • Erol C.
        • Fagard R.
        • Ferrari R.
        • Hasdai D.
        • Hoes A.W.
        • Kirchhof P.
        • Knuuti J.
        • Kolh P.
        • Lancellotti P.
        • Linhart A.
        • Nihoyannopoulos P.
        • Piepoli M.F.
        • Ponikowski P.
        • Sirnes P.A.
        • Tamargo J.L.
        • Tendera M.
        • Torbicki A.
        • Wijns W.
        • Windecker S.
        • Clement D.L.
        • Coca A.
        • Gillebert T.C.
        • Tendera M.
        • Rosei E.A.
        • Ambrosioni E.
        • Anker S.D.
        • Bauersachs J.
        • Hitij J.B.
        • Caulfield M.
        • De Buyzere M.
        • De Geest S.
        • Derumeaux G.A.
        • Erdine S.
        • Farsang C.
        • Funck-Brentano C.
        • Gerc V.
        • Germano G.
        • Gielen S.
        • Haller H.
        • Hoes A.W.
        • Jordan J.
        • Kahan T.
        • Komajda M.
        • Lovic D.
        • Mahrholdt H.
        • Olsen M.H.
        • Ostergren J.
        • Parati G.
        • Perk J.
        • Polonia J.
        • Popescu B.A.
        • Reiner Z.
        • Rydén L.
        • Sirenko Y.
        • Stanton A.
        • Struijker-Boudier H.
        • Tsioufis C.
        • van de Borne P.
        • Vlachopoulos C.
        • Volpe M.
        • Wood D.A.
        2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).
        Eur Heart J. 2013; 34: 2159-2219
        • James P.A.
        • Oparil S.
        • Carter B.L.
        • Cushman W.C.
        • Dennison-Himmelfarb C.
        • Handler J.
        • Lackland D.T.
        • LeFevre M.L.
        • MacKenzie T.D.
        • Ogedegbe O.
        • Smith Jr., S.C.
        • Svetkey L.P.
        • Taler S.J.
        • Townsend R.R.
        • Wright Jr., J.T.
        • Narva A.S.
        • Ortiz E.
        2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
        JAMA. 2014; 311: 507-520
        • Pisters R.
        • Lane D.A.
        • Nieuwlaat R.
        • de Vos C.B.
        • Crijns H.J.
        • Lip G.Y.
        A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.
        Chest. 2010; 138: 1093-1100
        • Lip G.Y.
        • Frison L.
        • Halperin J.L.
        • Lane D.A.
        Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score.
        J Am Coll Cardiol. 2011; 57: 173-180
        • Van Staa T.P.
        • Setakis E.
        • Di Tanna G.L.
        • Lane D.A.
        • Lip G.Y.
        A comparison of risk stratification schemes for stroke in 79,884 atrial fibrillation patients in general practice.
        J Thromb Haemost. 2011; 9: 39-48
        • Nagarakanti R.
        • Wallentin L.
        • Noack H.
        • Brueckmann M.
        • Reilly P.
        • Clemens A.
        • Connolly S.J.
        • Yusuf S.
        • Ezekowitz M.D.
        Comparison of characteristics and outcomes of dabigatran versus warfarin in hypertensive patients with atrial fibrillation (from the RE-LY Trial).
        Am J Cardiol. 2015; 116: 1204-1209
        • Lip G.Y.
        • Frison L.
        • Grind M.
        • SPORTIF Invetigators
        Effect of hypertension on anticoagulated patients with atrial fibrillation.
        Eur Heart J. 2007; 28: 752-759
        • Berwaerts J.
        • Webster J.
        Analysis of risk factors involved in oral-anticoagulant-related intracranial haemorrhages.
        QJM. 2000; 93: 513-521
        • Gage B.F.
        • Yan Y.
        • Milligan P.E.
        • Waterman A.D.
        • Culverhouse R.
        • Rich M.W.
        • Radford M.J.
        Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF).
        Am Heart J. 2006; 151: 713-719
        • Fang M.C.
        • Go A.S.
        • Chang Y.
        • Borowsky L.H.
        • Pomernacki N.K.
        • Udaltsova N.
        • Singer D.E.
        A new risk scheme to predict warfarin-associated hemorrhage: The ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study.
        J Am Coll Cardiol. 2011; 58: 395-401
        • Palareti G.
        • Cosmi B.
        Bleeding with anticoagulation therapy - who is at risk, and how best to identify such patients.
        Thromb Haemost. 2009; 102: 268-278
        • Hughes M.
        • Lip G.Y.
        • Guideline Development Group for the NICE national clinical guideline for management of atrial fibrillation in primary and secondary care
        Risk factors for anticoagulation-related bleeding complications in patients with atrial fibrillation: a systematic review.
        QJM. 2007; 100: 599-607
        • Whelton P.K.
        • Carey R.M.
        • Aronow W.S.
        • Casey Jr., D.E.
        • Collins K.J.
        • Dennison Himmelfarb C.
        • DePalma S.M.
        • Gidding S.
        • Jamerson K.A.
        • Jones D.W.
        • MacLaughlin E.J.
        • Muntner P.
        • Ovbiagele B.
        • Smith Jr., S.C.
        • Spencer C.C.
        • Stafford R.S.
        • Taler S.J.
        • Thomas R.J.
        • Williams Sr., K.A.
        • Williamson J.D.
        • Wright Jr, J.T.
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
        Hypertension. 2018; 71: e13-e115