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  • 1.
    Alcala, Karine
    et al.
    International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, 150 Cours Albert Thomas, Lyon, France.
    Mariosa, Daniela
    International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, 150 Cours Albert Thomas, Lyon, France.
    Smith-Byrne, Karl
    Cancer Epidemiology Unit, Oxford Population Health, University of Oxford, Oxford, United Kingdom.
    Nasrollahzadeh Nesheli, Dariush
    International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, 150 Cours Albert Thomas, Lyon, France.
    Carreras-Torres, Robert
    Group of Digestive Diseases and Microbiota, Institut d'Investigació Biomèdica de Girona-IDIBGI, Salt, Spain.
    Ardanaz Aicua, Eva
    Navarra Public Health Institute, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain; CIBER in Epidemiology and Public Health (CIBERESP), Madrid, Spain.
    Bondonno, Nicola P
    Danish Cancer Society Research Center, Copenhagen, Denmark; School of Biomedical Sciences, University of Western Australia, Royal Perth Hospital, Perth, Australia; Institute for Nutrition Research, School of Medical and Health Sciences, Edith Cowan University, Perth, Australia.
    Bonet, Catalina
    Unit of Nutrition and Cancer, Catalan Institute of Oncology, ICO, Nutrition and Cancer Group, Bellvitge Biomedical Research Institute-(IDIBELL), l'Hospitalet de Llobregat, Barcelona, Spain.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Bueno-De-Mesquita, Bas
    Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands.
    Chirlaque, María-Dolores
    CIBER in Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Epidemiology, Regional Health Council, IMIB-Arrixaca, Murcia University, Murcia, Spain.
    Christakoudi, Sofia
    Department of Epidemiology and Biostatistics, Imperial College London, Norfolk Place, St Mary's Campus, London, United Kingdom; MRC Centre for Transplantation, King's College London, London, United Kingdom.
    Heath, Alicia K
    Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom.
    Kaaks, Rudolf
    Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
    Katzke, Verena
    Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
    Krogh, Vittorio
    Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Milan, Italy.
    Ljungberg, Börje
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Urology and Andrology.
    Martin, Richard M
    Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.
    May, Anne
    Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.
    Melander, Olle
    Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden; Department of Emergency and Internal Medicine, Skåne University Hospital, Malmö, Sweden.
    Palli, Domenico
    Cancer Risk Factors and Life-Style Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy.
    Rodriguez-Barranco, Miguel
    Escuela Andaluza de Salud Pública (EASP), Granada, Spain; Instituto de Investigación Biosanitaria Ibs. GRANADA, Granada, Spain; Centro de Investigacion Biomedica en Red de Epidemiologia y Salud Publica, Madrid, Spain.
    Sacerdote, Carlotta
    Unit of Cancer Epidemiology, Cittàdella Salute e della Scienza University-Hospital, Turin, Italy.
    Stocks, Tanja
    Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
    Tjønneland, Anne
    Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
    Travis, Ruth C.
    Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
    Vermeulen, Roel
    Institute for Risk Assessment Sciences (IRAS), Utrecht University, Utrecht, Netherlands.
    Chanock, Stephen
    Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, MD, Bethesda, United States.
    Purdue, Mark
    Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, MD, Bethesda, United States.
    Weiderpass, Elisabete
    International Agency for Research on Cancer (IARC/WHO), Lyon, France.
    Muller, David
    Imperial College London, London, United Kingdom.
    Brennan, Paul
    International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, 150 Cours Albert Thomas, Lyon, France.
    Johansson, Mattias
    International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, 150 Cours Albert Thomas, Lyon, France.
    The relationship between blood pressure and risk of renal cell carcinoma2022In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 51, no 4, p. 1317-1327Article in journal (Refereed)
    Abstract [en]

    Background: The relation between blood pressure and kidney cancer risk is well established but complex and different study designs have reported discrepant findings on the relative importance of diastolic blood pressure (DBP) and systolic blood pressure (SBP). In this study, we sought to describe the temporal relation between diastolic and SBP with renal cell carcinoma (RCC) risk in detail. Methods: Our study involved two prospective cohorts: the European Prospective Investigation into Cancer and Nutrition study and UK Biobank, including >700 000 participants and 1692 incident RCC cases. Risk analyses were conducted using flexible parametric survival models for DBP and SBP both separately as well as with mutuality adjustment and then adjustment for extended risk factors. We also carried out univariable and multivariable Mendelian randomization (MR) analyses (DBP: ninstruments = 251, SBP: ninstruments = 213) to complement the analyses of measured DBP and SBP. Results: In the univariable analysis, we observed clear positive associations with RCC risk for both diastolic and SBP when measured ≥5 years before diagnosis and suggestive evidence for a stronger risk association in the year leading up to diagnosis. In mutually adjusted analysis, the long-term risk association of DBP remained, with a hazard ratio (HR) per standard deviation increment 10 years before diagnosis (HR10y) of 1.20 (95% CI: 1.10-1.30), whereas the association of SBP was attenuated (HR10y: 1.00, 95% CI: 0.91-1.10). In the complementary multivariable MR analysis, we observed an odds ratio for a 1-SD increment (ORsd) of 1.34 (95% CI: 1.08-1.67) for genetically predicted DBP and 0.70 (95% CI: 0.56-0.88) for genetically predicted SBP. Conclusion: The results of this observational and MR study are consistent with an important role of DBP in RCC aetiology. The relation between SBP and RCC risk was less clear but does not appear to be independent of DBP.

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  • 2.
    Brunstrom, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lindholm, Lars H.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Perspective from Sweden on the global impact of the 2017 american college of cardiology/american heart association hypertension guidelines: a "sprint" beyond evidence in the United States2018In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 137, no 9, p. 886-888Article in journal (Other academic)
  • 3.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Cardiovascular outcomes in the Da Qing Diabetes Prevention Study2014In: The Lancet Diabetes & Endocrinology, ISSN 2213-8587, Vol. 2, no 7, p. 539-540Article in journal (Refereed)
  • 4.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Effect of antihypertensive treatment at different blood pressure levels2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background

    High blood pressure is associated with an increased risk of cardiovascular disease and premature death. The shape of association between blood pressure and the risk of cardiovascular events is debated. Some researchers suggest that the association is linear or log-linear, whereas others suggest it is J-shaped. Randomized controlled trials of antihypertensive treatment have been successful in hypertension, but ambiguous in the high normal blood pressure range. Previous systematic reviews have not found any interaction between baseline systolic blood pressure and treatment effect, with beneficial effects at systolic blood pressure levels well below what is currently recommended. These reviews, however, use a method to standardize treatment effects and study weights according to within-trial blood pressure differences that may introduce bias.

    Methods

    We performed two systematic reviews to assess the effect of antihypertensive treatment on cardiovascular disease and mortality at different blood pressure levels. The first review was limited to people with diabetes mellitus. The second review included all patient categories except those with heart failure and acute myocardial infarction. Both reviews were designed with guidance from Cochrane Collaborations Handbook for Systematic Reviews of Interventions, and are reported according to PRISMA guidelines. We included randomized controlled trials assessing any antihypertensive agent against placebo or any blood pressure targets against each other. Results were combined in random-effects meta-analyses, stratified by baseline systolic blood pressure. Non-stratified analyses were performed for coronary heart disease trials and post-stroke trials. Interaction between blood pressure level and treatment effect was assessed with Cochran’s Q in the first review, and multivariable-adjusted metaregression in the second review.

    The third paper builds on data from the second paper, and assesses the effect of standardization according to within-trial blood pressure differences on the results of meta-analyses. We performed non-standardized analyses, analyses with standardized treatment effects, and analyses with standardized treatment effects and standard errors. We compared treatment effect measures and heterogeneity across different methods of standardization. We also compared treatment effect estimates between fixed-effects and random-effects meta-analyses within each method of standardization. Lastly, we assessed the association between number of events and study weights, using linear regression.

    Results

    Forty-nine trials assessed the effect of antihypertensive treatment in people with diabetes mellitus. Treatment effect on cardiovascular mortality and myocardial infarction decreased with lower baseline systolic blood pressure. Treatment reduced the risk of death and cardiovascular disease if baseline systolic blood pressure was 140 mm Hg or higher. If baseline systolic blood pressure was below 140 mm Hg, however, treatment increased the risk of cardiovascular death by 15 % (0-32 %).

    Fifty-one trials assessed the effect of antihypertensive treatment in primary prevention. Treatment effect on cardiovascular mortality, major cardiovascular events, and heart failure decreased with lower baseline systolic blood pressure. If baseline systolic blood pressure was 160 mm Hg or higher treatment reduced the risk of major cardiovascular events by 22 % (95 % confidence interval 13-30 %). If systolic blood pressure was 140-159 mm Hg treatment reduced the risk by 12 % (4-20 %), whereas if systolic blood pressure was below 140 mm Hg, treatment effect was neutral (4 % increase to 10 % reduction). All-cause mortality was reduced if systolic blood pressure was 140 mm Hg or higher, with neutral effect at lower levels.

    Twelve trials compared antihypertensive treatment against placebo in people with coronary heart disease. Mean baseline systolic blood pressure was 138 mm Hg. Treatment reduced the risk of major cardiovascular events by 10 % (3-16 %), whereas the effect on mortality was neutral (7 % increase to 11 % reduction).

    Standardization of treatment effects resulted in more extreme effect estimates for individual trials. This caused increased between-study heterogeneity, and different results with fixed- and random-effects model. Standardization of standard errors shifted weights from trials with many events to trials with large blood pressure differences. This caused biased overall effect estimates. Standardization of standard errors also resulted in wider confidence intervals, masking the previously increased heterogeneity. This reduced the possibility to find different treatment effects at different blood pressure levels.

    Conclusion The effect of antihypertensive treatment depends on blood pressure level before treatment. Treatment reduces the risk of death and cardiovascular disease if baseline systolic blood pressure is 140 mm Hg or higher. Below this level, treatment is potentially harmful in people with diabetes, has neutral effect in primary prevention, but might offer additional protection in people with coronary heart disease. Standardization should generally be avoided in meta-analyses of antihypertensive treatment. Previous meta-analyses using standardized methods should be interpreted with caution.

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  • 5.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hypertension, the Swedish Patient Register, and Selection Bias2016In: JAMA Internal Medicine, ISSN 2168-6106, E-ISSN 2168-6114, Vol. 176, no 6, p. 862-863Article in journal (Refereed)
  • 6.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB).
    Måldos eller målvärde vid statinbehandling hos typ 2-diabetiker?2011In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 108, no 8Article in journal (Other academic)
  • 7. Brunström, Mattias
    et al.
    Andersson, Jonas
    Eliasson, Mats
    Fu, Michael
    Geriatrik och akutmottagning Östra, Sahlgrenska universitetssjukhuset, Göteborg.
    Hansson, Per-Olof
    Sahlgrenska universitetssjukhuset, Göteborg.
    Söderberg, Stefan
    SCORE2 – ett uppdaterat verktyg för att skatta kardiovaskulär risk: [SCORE2 - an updated model for cardiovascular risk prediction]2021In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 118, article id 21164Article in journal (Refereed)
    Abstract [en]

    Cardiovascular disease is the most important cause of death and life-years lost in Sweden today. Cardiovascular risk prediction is a cornerstone in primary prevention; the use of antihypertensive and lipid-lowering therapy is guided by absolute cardiovascular risk. The Systematic COronary Risk Evaluation (SCORE) model has been the most widely applied model in Sweden for almost two decades. Recently, an updated model called SCORE2 was published. The new risk prediction model is based on contemporary data, predicts the risk of incident cardiovascular disease in addition to cardiovascular mortality, and accounts for competing risks, thus overcoming some major limitations with SCORE. Sweden is classified as a moderate-risk country according to the new model; here we report the risk chart for moderate-risk countries translated into Swedish.

  • 8.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis2018In: JAMA Internal Medicine, ISSN 2168-6106, E-ISSN 2168-6114, Vol. 178, no 1, p. 28-36Article in journal (Refereed)
    Abstract [en]

    Importance: High blood pressure (BP) is the most important risk factor for death and cardiovascular disease (CVD) worldwide. The optimal cutoff for treatment of high BP is debated.

    Objective: To assess the association between BP lowering treatment and death and CVD at different BP levels.

    Data sources: Previous systematic reviews were identified from PubMed, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effect. Reference lists of these reviews were searched for randomized clinical trials. Randomized clinical trials published after November 1, 2015, were also searched for in PubMed and the Cochrane Central Register for Controlled Trials during February 2017.

    Study selection: Randomized clinical trials with at least 1000 patient-years of follow-up, comparing BP-lowering drugs vs placebo or different BP goals were included.

    Data extraction and synthesis: Data were extracted from original publications. Risk of bias was assessed using the Cochrane Collaborations assessment tool. Relative risks (RRs) were pooled in random-effects meta-analyses with Knapp-Hartung modification. Results are reported according to PRISMA guidelines.

    Main outcomes and measures: Prespecified outcomes of interest were all-cause mortality, cardiovascular mortality, major cardiovascular events, coronary heart disease (CHD), stroke, heart failure, and end-stage renal disease.

    Results: Seventy-four unique trials, representing 306 273 unique participants (39.9% women and 60.1% men; mean age, 63.6 years) and 1.2 million person-years, were included in the meta-analyses. In primary prevention, the association of BP-lowering treatment with major cardiovascular events was dependent on baseline systolic BP (SBP). In trials with baseline SBP 160 mm Hg or above, treatment was associated with reduced risk for death (RR, 0.93; 95% CI, 0.87-1.00) and a substantial reduction of major cardiovascular events (RR, 0.78; 95% CI, 0.70-0.87). If baseline SBP ranged from 140 to 159 mm Hg, the association of treatment with mortality was similar (RR, 0.87; 95% CI, 0.75-1.00), but the association with major cardiovascular events was less pronounced (RR, 0.88; 95% CI, 0.80-0.96). In trials with baseline SBP below 140 mm Hg, treatment was not associated with mortality (RR, 0.98; 95% CI, 0.90-1.06) and major cardiovascular events (RR, 0.97; 95% CI, 0.90-1.04). In trials including people with previous CHD and mean baseline SBP of 138 mm Hg, treatment was associated with reduced risk for major cardiovascular events (RR, 0.90; 95% CI, 0.84-0.97), but was not associated with survival (RR, 0.98; 95% CI, 0.89-1.07).

    Conclusions and relevance: Primary preventive BP lowering is associated with reduced risk for death and CVD if baseline SBP is 140 mm Hg or higher. At lower BP levels, treatment is not associated with any benefit in primary prevention but might offer additional protection in patients with CHD.

  • 9.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Benefits and harms of lower blood pressure treatment targets: systematic review and meta-analysis of randomised placebo-controlled trials2019In: BMJ Open, E-ISSN 2044-6055, Vol. 9, no 9, article id e026686Article in journal (Refereed)
    Abstract [en]

    Objectives To assess the effect of antihypertensive treatment in the 130-140mm Hg systolic blood pressure range. Design Systematic review and meta-analysis. Information sources PubMed, CDSR and DARE were searched for the systematic reviews, which were manually browsed for clinical trials. PubMed and Cochrane Central Register of Controlled Trials were searched for trials directly in February 2018. Eligibility criteria Randomised double-blind trials with >= 1000 patient-years of follow-up, comparing any antihypertensive agent against placebo. Data extraction and risk of bias Two reviewers extracted study-level data, and assessed risk of bias using Cochrane Collaborations risk of bias assessment tool, independently. Main outcomes and measures Primary outcomes were all-cause mortality, major cardiovascular events and discontinuation due to adverse events. Secondary outcomes were cardiovascular mortality, myocardial infarction, stroke, heart failure, hypotension-related adverse events and renal impairment. Results Eighteen trials, including 92 567 participants (34% women, mean age 63 years), fulfilled the inclusion criteria. Primary preventive antihypertensive treatment was associated with a neutral effect on all-cause mortality (relative risk 1.00, 95% CI 0.95 to 1.06) and major cardiovascular events (1.01, 0.96 to 1.06), but an increased risk of discontinuation due to adverse events (1.23, 1.03 to 1.47). None of the secondary efficacy outcomes were significantly reduced, but the risk of hypotension-related adverse events increased with treatment (1.71, 1.32 to 2.22). In coronary artery disease secondary prevention, antihypertensive treatment was associated with reduced risk of all-cause mortality (0.91, 0.83 to 0.99) and major cardiovascular events (0.85, 0.77 to 0.94), but doubled the risk of adverse events leading to discontinuation (2.05, 1.62 to 2.61). Conclusion Primary preventive blood pressure lowering in the 130-140mm Hg systolic blood pressure range adds no cardiovascular benefit, but increases the risk of adverse events. In the secondary prevention, benefits should be weighed against harms.

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  • 10.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Blood pressure targets in type 2 diabetes: a general perspective2016In: Cardiovascular Endocrinology, ISSN 2162-688X, Vol. 5, no 4, p. 122-126Article, review/survey (Refereed)
    Abstract [en]

    Blood pressure targets in patients with type 2 diabetes are currently being debated. This review summarizes the current treatment recommendations provided in American and European guidelines, and findings from systematic reviews and meta-analyses published during the last decade. We critically assess the basis for the recommendations provided in relation to the evidence presented in reviews. When reviews differ in their results, we discuss the reasons for such differences. The results from recent studies in patients without diabetes and their potential implications for recommendations in patients with diabetes are commented upon. Finally, we conclude what targets are best in line with the totality of the available evidence.

  • 11.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses2016In: The BMJ, E-ISSN 1756-1833, Vol. 352, article id i717Article, review/survey (Refereed)
    Abstract [en]

    Objective: To assess the effect of antihypertensive treatment on mortality and cardiovascular morbidity in people with diabetes mellitus, at different blood pressure levels.

    Design: Systematic review and meta-analyses of randomised controlled trials.

    Data sources: CENTRAL, Medline, Embase, and BIOSIS were searched using highly sensitive search strategies. When data required according to the protocol were missing but trials were potentially eligible, we contacted researchers, pharmaceutical companies, and authorities.

    Eligibility criteria: Randomised controlled trials including 100 or more people with diabetes mellitus, treated for 12 months or more, comparing any antihypertensive agent against placebo, two agents against one, or different blood pressure targets.

    Results: 49 trials, including 73 738 participants, were included in the meta-analyses. Most of the participants had type 2 diabetes. If baseline systolic blood pressure was greater than 150 mm Hg, antihypertensive treatment reduced the risk of all cause mortality (relative risk 0.89, 95% confidence interval 0.80 to 0.99), cardiovascular mortality (0.75, 0.57 to 0.99), myocardial infarction (0.74, 0.63 to 0.87), stroke (0.77, 0.65 to 0.91), and end stage renal disease (0.82, 0.71 to 0.94). If baseline systolic blood pressure was 140-150 mm Hg, additional treatment reduced the risk of all cause mortality (0.87, 0.78 to 0.98), myocardial infarction (0.84, 0.76 to 0.93), and heart failure (0.80, 0.66 to 0.97). If baseline systolic blood pressure was less than 140 mm Hg, however, further treatment increased the risk of cardiovascular mortality (1.15, 1.00 to 1.32), with a tendency towards an increased risk of all cause mortality (1.05, 0.95 to 1.16). Metaregression analyses showed a worse treatment effect with lower baseline systolic blood pressures for cardiovascular mortality (1.15, 1.03 to 1.29 for each 10 mm Hg lower systolic blood pressure) and myocardial infarction (1.12, 1.03 to 1.22 for each 10 mm Hg lower systolic blood pressure). Patterns were similar for attained systolic blood pressure.

    Conclusions: Antihypertensive treatment reduces the risk of mortality and cardiovascular morbidity in people with diabetes mellitus and a systolic blood pressure more than 140 mm Hg. If systolic blood pressure is less than 140 mm Hg, however, further treatment is associated with an increased risk of cardiovascular death, with no observed benefit.

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  • 12.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Ingen nytta med intensiv blodtrycksbehandling vid primärprevention2017In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 114, no 48, article id EW4XArticle in journal (Other academic)
  • 13.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lower blood pressure targets: to whom do they apply?2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 387, no 10017, p. 405-406Article in journal (Refereed)
  • 14.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nya riktlinjer för hypertoni-en pedagogisk utmaning2018In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 115, no 47, article id FDDYArticle in journal (Other academic)
  • 15.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Questionable Conclusions Regarding Blood Pressure End Points Reply2018In: JAMA Internal Medicine, ISSN 2168-6106, E-ISSN 2168-6114, Vol. 178, no 4, p. 575-576Article in journal (Refereed)
  • 16.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Response to 'SPRINTin context: meta-analysis of trials with baseline normotension and lowlevels of previous cardiovascular disease' Reply2018In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 36, no 7, p. 1603-1604Article in journal (Refereed)
  • 17.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    SPRINT in context: meta-analysis of trials with baseline normotension and low levels of previous cardiovascular disease2018In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 36, no 5, p. 979-986Article, review/survey (Refereed)
    Abstract [en]

    Objective: To estimate the effect of antihypertensive treatment in trials with baseline normotension and low levels of previous cardiovascular disease. To test if the results from SPRINT are compatible with those from other trials, and test the impact of SPRINT results on overall effect estimates. Methods: Systematic review and meta-analysis of randomized controlled trials with at least 1000 patient-years of follow-up, comparing antihypertensive treatment versus placebo, or different blood pressure goals against each other. Trials with at least 50% previous cardiovascular disease were excluded. Results: Sixteen trials, including 66816 participants, were included in the meta-analyses. Mean baseline SBP was 138mmHg, and mean difference between treatment arms was 5.5mmHg. Antihypertensive treatment was associated with a neutral effect on all-cause mortality [relative risk 0.98, 95% confidence interval (CI) 0.92-1.05] and major cardiovascular events (0.97, 0.91-1.03). Results from SPRINT differed significantly from those of other trials (P=0.012 for all-cause mortality; P=0.016 for major cardiovascular events), but overall effect estimates were similar when SPRINT was excluded (1.01, 0.95-1.06 for all-cause mortality; 0.98, 0.93-1.03 for major cardiovascular events). Treatment was associated with reduced risk of secondary outcomes stroke (0.84, 0.71-1.00) and heart failure (0.88, 0.78-0.98), although heterogeneity was high in the stroke analysis (I-2=54%). Conclusion: SPRINT results are not representative for trials with baseline normotension and low levels of previous cardiovascular disease. Antihypertensive treatment does not protect against death or major cardiovascular events in this setting.

  • 18.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Standardization according to blood pressure lowering in meta-analyses of antihypertensive trials: comparison of three methodological approaches2018In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 36, no 1, p. 4-15Article, review/survey (Refereed)
    Abstract [en]

    OBJECTIVE: Assess how standardization of relative risks (RRs) and standard errors (SEs), according to blood pressure differences within trials, affects heterogeneity, overall effect estimates and study weights in meta-analyses of antihypertensive treatment.

    METHOD: Data from a previous systematic review were used. Three sets of analyses were performed, using both random-effects and fixed-effects model for meta-analyses. First, we used raw data from the included trials. Second, we standardized RRs as if SBP was reduced by 10 mmHg in all trials. Third, we standardized both RRs and SEs.

    RESULTS: When RRs were standardized according to blood pressure lowering, heterogeneity between trials increased (I = 36 vs. 93% for mortality). This conferred large differences in treatment effect estimates using random-effects and fixed-effects model (RR 0.79, 95% confidence interval 0.70-0.89, respectively, 0.97, 0.94-0.99). When SEs were standardized, confidence intervals for individual trials widened, resulting in lower power to detect heterogeneity across trials. Study weights were dissociated from number of events in trials (P < 0.0001, R = 0.99 before standardization vs. P = 0.063, R = 0.05 after standardization). This induced a secondary shift in weight from trials with lower baseline SBP to trials with higher baseline SBP, resulting in exaggerated overall effect estimates.

    CONCLUSION: Standardization of RRs exaggerates differences between trials and makes meta-analyses highly sensitive to choice of statistical method. Standardization of SEs masks heterogeneity and results in biased effect estimates.

  • 19.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Thrombolysis in acute stroke2015In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 385, no 9976, p. 1394-1395Article in journal (Refereed)
  • 20.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Kjeldsen, Sverre E.
    Department of Cardiology, Institute for Clinical Medicine, Ullevaal Hospital, University of Oslo, Oslo, Norway.
    Effect of antihypertensive treatment in isolated systolic hypertension (ISH): systematic review and meta-analysis of randomised controlled trials2023In: Blood Pressure, ISSN 0803-7051, E-ISSN 1651-1999, Vol. 32, no 1, article id 2226757Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Isolated systolic hypertension (ISH) in middle-aged and elderly is associated with high cardiovascular risk, but no randomised controlled trial has assessed the effect of antihypertensive treatment in ISH using today's definition, i.e. systolic blood pressure (SBP) ≥140 mmHg and diastolic blood pressure (DBP) <90 mmHg.

    METHODS: A systematic review and meta-analysis of randomised controlled trials was performed. Studies with ≥1000 patient-years of follow-up, comparing more intensive versus less intensive BP targets, or active drug versus placebo, were included if the mean baseline SBP was ≥140 mmHg and the mean baseline DBP was <90 mmHg. The primary outcome was major adverse cardiovascular events (MACE). Relative risks from each trial were pooled in random-effects meta-analyses, stratified by baseline and attained SBP level.

    RESULTS: Twenty-four trials, including 113,105 participants (mean age 67 years; mean blood pressure 149/83 mmHg) were included in the analysis. Overall, treatment reduced the risk of MACE by 9% (relative risk 0.91, 95% confidence interval 0.88-0.93). Treatment was more effective if baseline SBP was ≥160 mmHg (RR 0.77, 95% CIs 0.70-0.86) compared to 140-159 mmHg (RR 0.92, 95% CIs 0.89-0.95; p = 0.002 for interaction), but provided equal additional benefit across all attained SBP levels (RR 0.80, 95% CIs 0.70-0.92 for <130 mmHg, RR 0.92, 95% CIs 0.89-0.96 for 130-139 mmHg, and RR 0.87, 95% CIs 0.82-0.93 for ≥140 mmHg; p = 0.070 for interaction).

    CONCLUSIONS: These findings support antihypertensive treatment of isolated systolic hypertension, regardless of baseline SBP, to target SBP <140 mmHg and even <130 mmHg if well tolerated.

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  • 21.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Dahlström, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lindholm, Lars Hjalmar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lönnberg, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hallström, Sara
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Persson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    From efficacy in trials to effectiveness in clinical practice: The Swedish Stroke Prevention Study2016In: Blood Pressure, ISSN 0803-7051, E-ISSN 1651-1999, Vol. 25, no 4, p. 206-211Article in journal (Refereed)
    Abstract [en]

    Blood pressure treatment has shown great efficacy in reducing cardiovascular events in randomized controlled trials. If this is effective in reducing cardiovascular disease in the general population, is less studied. Between 2001 and 2009 we performed an intervention to improve blood pressure control in the county of Vasterbotten, using Sodermanland County as a control. The intervention was directed towards primary care physicians and included lectures on blood pressure treatment, a computerized decision support system with treatment recommendations, and yearly feed back on hypertension control. Each county had approximately 255000 inhabitants. Differences in age and incidence of cardiovascular disease were small. During follow-up, more than 400000 patients had their blood pressure recorded. The mean number of measurements was eight per patient, yielding a total of 3.4 million blood pressure recordings. The effect of the intervention will be estimated combining the blood pressure data collected from the electronic medical records, with data on stroke, myocardial infarction and mortality from Swedish health registers. Additional variables, from health registers and Statistics Sweden, will be collected to address for confounders. The blood pressure data collected within this study will be an important asset for future epidemiological studies within the field of hypertension.

  • 22.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Eliasson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nilsson, Peter M.
    Institutionen för kliniska vetenskaper, Lunds universitet, Sweden.
    Berne, Christian
    Institutionen för kliniska vetenskaper, Uppsala universitet, Sweden.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Rekommenderade blodtrycksmål vid typ 2-diabetes bör kvarstå2016In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 113, no 39, article id D9FPArticle in journal (Other academic)
  • 23.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eliasson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Nilsson, Peter M
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Blood pressure treatment levels and choice of antihypertensive agent in people with diabetes mellitus: an overview of systematic reviews2017In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 35, p. 435-462Article, review/survey (Refereed)
    Abstract [en]

    OBJECTIVE: Multiple systematic reviews address the effect of antihypertensive treatment in people with diabetes. Here, we summarize current systematic reviews concerning antihypertensive treatment effect at different blood pressure (BP) levels, and relative treatment effect of different antihypertensive agents.

    METHODS: We searched MEDLINE, BIOSIS, DARE and CDSR during years 2005-2016. Eligibility criteria, number of trials and participants, outcomes analysed, statistical methods used for data synthesis, and principal results were extracted for each review. Review quality was assessed using the assessment of multiple systematic reviews tool.

    RESULTS: We found four reviews concerning BP treatment level. These consistently showed that the effect of antihypertensive treatment on mortality, cardiovascular disease and coronary heart disease was attenuated at lower BP levels. If SBP was more than 140 mmHg, treatment reduced all-cause and cardiovascular mortality, cardiovascular disease, stroke, myocardial infarction and heart failure. If SBP was less than 140 mmHg, treatment increased the risk of cardiovascular death. We found eight reviews concerning choice of agent. We found no difference between angiotensin-converting enzyme inhibitors, angotensin receptor blockers, beta-blockers, calcium channel blockers and diuretics in preventing all-cause or cardiovascular mortality, combined cardiovascular disease, coronary heart disease and end-stage renal disease. Minor differences exist for stroke and heart failure. Data were limited on people with type 1 diabetes and very elderly patients with type 2 diabetes. None of the reviews concerning choice of agent included all relevant trials.

    CONCLUSION: The available evidence supports treatment in people with type 2 diabetes and SBP more than 140 mmHg, using any of the major antihypertensive drug classes.

  • 24.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Kjeldsen, Sverre E.
    Department of Cardiology, University of Oslo, Ullevaal Hospital, Norway.
    Kreutz, Reinhold
    Department of Clinical Pharmacology and Toxicology, Charité Medical University, Berlin, Germany.
    Gjesdal, Knut
    Department of Cardiology, University of Oslo, Ullevaal Hospital, Norway.
    Narkiewicz, Krzysztof
    Department of Hypertension and Diabetology, Medical University of Gdansk, Poland.
    Burnier, Michel
    Service of Nephrology and Hypertension, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
    Oparil, Suzanne
    Vascular Biology and Hypertension Program, Department of Medicine, University of Alabama, Birmingham, United States.
    Mancia, Giuseppe
    University of Milano-Bicocca, Milan, Italy.
    Missing verification of source data in hypertension research: The HYGIA PROJECT in perspective2021In: Hypertension, ISSN 0194-911X, E-ISSN 1524-4563, Vol. 78, no 2, p. 555-558Article in journal (Refereed)
  • 25.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden.
    Dahlström, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Lindholm, Lars H.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lönnberg, Göran
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Association of Physician Education and Feedback on Hypertension Management With Patient Blood Pressure and Hypertension Control2020In: JAMA Network Open, E-ISSN 2574-3805, Vol. 3, no 1, article id e1918625Article in journal (Refereed)
    Abstract [en]

    Importance: Elevated systolic blood pressure (SBP) is the most important risk factor for premature death worldwide. However, hypertension detection and control rates continue to be suboptimal.

    Objective: To assess the association of education and feedback to primary care physicians with population-level SBP and hypertension control rates.

    Design, Setting, and Participants: This pooled series of 108 population-based cohort studies involving 283 079 patients used data from primary care centers in 2 counties (Västerbotten and Södermanland) in Sweden from 2001 to 2009. Participants were individuals aged 18 years or older who had their blood pressure (BP) measured and recorded in either county during the intervention period. All analyses were performed in February 2019.

    Exposures: An intervention comprising education and feedback for primary care physicians in Västerbotten County (intervention group) compared with usual care in Södermanland County (control group).

    Main Outcomes and Measures: Difference in mean SBP levels between counties and likelihood of hypertension control in the intervention county compared with the control county during 24 months of follow-up.

    Results: A total of 136 541 unique individuals (mean [SD] age at inclusion, 64.6 [16.1] years; 57.0% female; mean inclusion BP, 142/82 mm Hg) in the intervention county were compared with 146 538 individuals (mean [SD] age at inclusion, 65.7 [15.9] years; 58.3% female; mean inclusion BP, 144/80 mm Hg) in the control county. Mean SBP difference between counties during follow-up, adjusted for inclusion BP and other covariates, was 1.1 mm Hg (95% CI, 1.0-1.1 mm Hg). Hypertension control improved by 8.4 percentage points, and control was achieved in 37.8% of participants in the intervention county compared with 29.4% in the control county (adjusted odds ratio, 1.30; 95% CI, 1.29-1.31). Differences between counties increased during the intervention period and were more pronounced in participants with higher SBP at inclusion. Results were consistent across all subgroups.

    Conclusions and Relevance: This study suggests that SBP levels and hypertension control rates in a county population may be improved by educational approaches directed at physicians and other health care workers. Similar strategies may be adopted to reinforce the implementation of clinical practice guidelines for hypertension management.

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  • 26.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Public Health and Community Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Dahlström, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Lindholm, Lars H.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Association of education and feedback on hypertension management with risk for stroke and cardiovascular disease2022In: Blood Pressure, ISSN 0803-7051, E-ISSN 1651-1999, Vol. 31, no 1, p. 31-39Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Education and feedback on hypertension management has been associated with improved hypertension control. This study aimed to assess the effectiveness of such interventions to reduce the risk of stroke and cardiovascular events. MATERIALS AND METHODS: Individuals ≥18 years with a blood pressure (BP) recording in Västerbotten or Södermanland County during the study period 2001 to 2009 were included in 108 serial cohort studies, each with 24 months follow-up. The primary outcome was risk of first-ever stroke in Västerbotten County (intervention) compared with Södermanland County (control). Secondary outcomes were first-ever major adverse cardiovascular event (MACE), myocardial infarction, and heart failure, as well as all-cause and cardiovascular mortality. All outcomes were analysed using time-to-event data included in a Cox proportional hazards model adjusted for age, sex, hypertension, diabetes, coronary artery disease, atrial fibrillation, systolic BP at inclusion, marital status, and disposable income. RESULTS: A total of 121 365 individuals (mean [SD] age at inclusion 61.7 [16.3] years; 59.9% female; mean inclusion BP 142.3/82.6 mmHg) in the intervention county were compared to 131 924 individuals (63.6 [16.2] years; 61.2% female; 144.1/81.1 mmHg) in the control county. A first-ever stroke occurred in 2 823 (2.3%) individuals in the intervention county, and 3 584 (2.7%) individuals in the control county (adjusted hazard ratio 0.96, 95% CI 0.90 to 1.03). No differences were observed for MACE, myocardial infarction or heart failure, whereas all-cause mortality (HR 0.91, 95% CI 0.87 to 0.95) and cardiovascular mortality (HR 0.91, 95% CI 0.85 to 0.98) were lower in the intervention county. CONCLUSIONS: This study does not support an association between education and feedback on hypertension management to primary care physicians and the risk for stroke or cardiovascular outcomes. The observed differences for mortality outcomes should be interpreted with caution.

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  • 27.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Svensson, Per
    Karolinska Institutet - Institutionen för klinisk forskning och utbildning, Södersjukhuset Stockholm, Sweden Karolinska Institutet - Institutionen för klinisk forskning och utbildning, Södersjukhuset Stockholm, Sweden.
    Blodtryckssänkande till natten – komplement men inte praxis: metodologiska problem i Hygia-studien gör att fler resultat bör inväntas innan ordinationen ändras: [Evening dosing of antihypertensive drugs - future studies should be awaited before changing clinical practice]2019In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 116, article id FXFEArticle in journal (Refereed)
    Abstract [en]

    Night-time blood pressure is an independent prognostic marker for cardiovascular disease. Evening dosing of antihypertensive agents can reduce night-time blood pressure and restore night-time blood pressure dipping pattern. In the Hygia Chronotherapy Trial, evening dosing of antihypertensive agents was compared to morning dosing, with dramatic effects on cardiovascular events and total mortality. We review possible limitations of the Hygia trial, including aspects of randomization, allocation concealment, outcome reporting and imbalance between groups. Based on these limitations, the trial should be interpreted with caution and future studies should be awaited before changing clinical practice.

  • 28.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Svensson, Per
    VO kardiologi, Södersjukhuset; Institutionen för klinisk forskning och utbildning, Södersjukhuset, Karolinska institutet, Stockholm.
    Critical appraisal trumps timing of antihypertensive medications: [Studie avfärdar fördelar med blodtryckssänkande till natten]2022In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 119, article id 22131Article in journal (Refereed)
    Abstract [en]

    Treatment In Morning versus Evening (TIME) was a pragmatic randomized controlled trial, including more than 21 000 people with medically treated hypertension. Participants were randomized to morning or evening intake of their antihypertensive medications and followed for an average of 5.2 years. Results were completely neutral, as opposed to the heavily criticized Hygia trial published in 2019. These findings are of clinical importance because they show that it does not matter if patients take their antihypertensive medications in the morning or evening. They are also of general scientific interest because they highlight the importance of post publication peer review and the need for replication of surprising scientific findings.

  • 29.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Thomopoulos, Costas
    Department of Cardiology, Helena Venizelou Hospital, Athens, United States.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Kreutz, Reinhold
    Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Germany (R.K.), Charitéplatz 1, Berlin, Germany.
    Mancia, Giuseppe
    University of Milano-Bicocca, Milan, United States.
    Methodological Aspects of Meta-Analyses Assessing the Effect of Blood Pressure-Lowering Treatment on Clinical Outcomes2022In: Hypertension, ISSN 0194-911X, E-ISSN 1524-4563, Vol. 79, no 3, p. 491-504Article in journal (Refereed)
    Abstract [en]

    Systematic reviews and meta-analyses are often considered the highest level of evidence, with high impact on clinical practice guidelines. The methodological literature on systematic reviews and meta-analyses is extensive and covers most aspects relevant to the design and interpretation of meta-analysis findings in general. Analyzing the effect of blood pressure-lowering on clinical outcomes poses several challenges over and above what is covered in the general literature, including how to combine placebo-controlled trials, target-trials, and comparative studies depending on the research question, how to handle the potential interaction between baseline blood pressure level, common comorbidities, and the estimated treatment effect, and how to consider different magnitudes of blood pressure reduction across trials. This review aims to address the most important methodological considerations, to guide the general reader of systematic reviews and meta-analyses within our field, and to help inform the design of future studies. Furthermore, we highlight issues where published meta-analyses have applied different analytical strategies and discuss pros and cons with different strategies.

  • 30.
    Charchar, Fadi J.
    et al.
    Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia; Department of Physiology, University of Melbourne, Melbourne, Australia; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.
    Prestes, Priscilla R.
    Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia.
    Mills, Charlotte
    Department of Food and Nutritional Sciences, University of Reading, Reading, United Kingdom.
    Ching, Siew Mooi
    Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang; Department of Medical Sciences, School of Medical and Live Sciences, Sunway University, Bandar Sunway, Selangor, Malaysia.
    Neupane, Dinesh
    Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, United States.
    Marques, Francine Z.
    Hypertension Research Laboratory, School of Biological Sciences, Monash University; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, United Kingdom.
    Sharman, James E.
    Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
    Vogt, Liffert
    Department of Internal Medicine, Section Nephrology, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands.
    Burrell, Louise M.
    Department of Medicine, University of Melbourne, Austin Health, Melbourne, Australia.
    Korostovtseva, Lyudmila
    Department of Hypertension, Almazov National Medical Research Centre, St Petersburg, Russian Federation.
    Zec, Manja
    School of Nutritional Sciences and Wellness, University of Arizona, Tucson, United States; Colorado Program for Musculoskeletal Research, Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, United States.
    Patil, Mansi
    Department of Nutrition and Dietetics, Asha Kiran JHC Hospital, Chinchwad; Hypertension and Nutrition, Core Group of IAPEN India, India.
    Schultz, Martin G.
    Department of Internal Medicine, Section Nephrology, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands.
    Wallen, Matthew P.
    Caring Futures Institute, Flinders University, Adelaide, Australia.
    Renna, Nicolás F
    Unit of Hypertension, Hospital Español de Mendoza, School of Medicine, National University of Cuyo, IMBECU-CONICET, Mendoza, Argentina.
    Islam, Sheikh Mohammed Shariful
    Institute for Physical Activity and Nutrition, Deakin University, Geelong, Australia.
    Hiremath, Swapnil
    Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa, Canada.
    Gyeltshen, Tshewang
    Graduate School of Public Health, St. Luke's International University, Tokyo, Japan.
    Chia, Yook-Chin
    Department of Medical Sciences, School of Medical and Life Sciences, Sunway University, Selangor, Malaysia; Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
    Gupta, Abhinav
    Department of Medicine, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, India.
    Schutte, Aletta E.
    School of Population Health, University of New South Wales, George Institute for Global Health, NSW, Sydney, Australia; Hypertension in Africa Research Team, SAMRC Unit for Hypertension and Cardiovascular Disease, North-West University; SAMRC Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
    Klein, Britt
    Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia.
    Borghi, Claudio
    Department of Medical and Surgical Sciences, Faculty of Medicine, University of Bologna, Bologna, Italy.
    Browning, Colette J.
    Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia.
    Czesnikiewicz-Guzik, Marta
    School of Medicine, Dentistry and Nursing-Dental School, University of Glasgow, United Kingdom; Department of Periodontology, Prophylaxis and Oral Medicine; Jagiellonian University, Krakow, Poland.
    Lee, Hae-Young
    Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.
    Itoh, Hiroshi
    Department of Internal Medicine (Nephrology, Endocrinology and Metabolism), Keio University, Tokyo, Japan.
    Miura, Katsuyuki
    NCD Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Campbell, Norm R. C.
    Libin Cardiovascular Institute, Department of Medicine, University of Calgary, Calgary, Canada.
    Akinnibossun, Olutope Arinola
    Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia.
    Veerabhadrappa, Praveen
    Kinesiology, Division of Science, Pennsylvania State University, PA, Reading, United States.
    Wainford, Richard D.
    Department of Pharmacology and Experimental Therapeutics, Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, United States; Division of Cardiology, Emory University, Atlanta, United States.
    Kruger, Ruan
    Hypertension in Africa Research Team (HART), North-West University, Potchefstroom; MRC Research Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa.
    Thomas, Shane A.
    Health Innovation and Transformation Centre, Federation University Australia, Ballarat, Australia.
    Komori, Takahiro
    Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
    Ralapanawa, Udaya
    Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
    Cornelissen, Véronique A.
    Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium.
    Kapil, Vikas
    William Harvey Research Institute, Centre for Cardiovascular Medicine and Devices, NIHR Barts Biomedical Research Centre, BRC, Faculty of Medicine and Dentistry, Queen Mary University London; Barts BP Centre of Excellence, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom.
    Li, Yan
    Department of Cardiovascular Medicine, Shanghai Institute of Hypertension, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China.
    Zhang, Yuqing
    Department of Cardiology, Fu Wai Hospital, Chinese Academy of Medical Sciences, Chinese Hypertension League, Beijing, China.
    Jafar, Tazeen H.
    Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore; Duke Global Health Institute, Duke University, NC, Durham, United States.
    Khan, Nadia
    Department of Medicine, University of British Columbia, Vancouver, Canada.
    Williams, Bryan
    University College London (UCL), Institute of Cardiovascular Science, National Institute for Health Research (NIHR), UCL Hospitals Biomedical Research Centre, London, United Kingdom.
    Stergiou, George
    Hypertension Centre STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece.
    Tomaszewski, Maciej
    Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester; Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom.
    Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension2024In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 42, no 1, p. 23-49Article in journal (Refereed)
    Abstract [en]

    Hypertension, defined as persistently elevated systolic blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) at least 90 mmHg (International Society of Hypertension guidelines), affects over 1.5 billion people worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (e.g. coronary heart disease, heart failure and stroke) and death. An international panel of experts convened by the International Society of Hypertension College of Experts compiled lifestyle management recommendations as first-line strategy to prevent and control hypertension in adulthood. We also recommend that lifestyle changes be continued even when blood pressure-lowering medications are prescribed. Specific recommendations based on literature evidence are summarized with advice to start these measures early in life, including maintaining a healthy body weight, increased levels of different types of physical activity, healthy eating and drinking, avoidance and cessation of smoking and alcohol use, management of stress and sleep levels. We also discuss the relevance of specific approaches including consumption of sodium, potassium, sugar, fibre, coffee, tea, intermittent fasting as well as integrated strategies to implement these recommendations using, for example, behaviour change-related technologies and digital tools.

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  • 31.
    Eklund, Sanna
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Israelsson, Hanna
    Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Forsberg, Karin
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Malm, Jan
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    10-year mortality, causes of death and cardiovascular comorbidities in idiopathic normal pressure hydrocephalus2024In: Journal of Neurology, ISSN 0340-5354, E-ISSN 1432-1459, Vol. 271, p. 1311-1319Article in journal (Refereed)
    Abstract [en]

    Objective: The objective was to investigate 10-year mortality, causes of death and cardiovascular comorbidity in idiopathic normal pressure hydrocephalus (iNPH) and to evaluate their mutual associations.

    Methods: This prospective cohort study included 176 CSF-shunted iNPH patients, and 368 age- and sex-matched controls. At inclusion, participants were medically examined, had blood analyzed and answered a questionnaire. The vascular comorbidities investigated were smoking, diabetes, body mass index, blood pressure (BP), hyperlipidemia, kidney function, atrial fibrillation and, cerebro- and cardiovascular disease.

    Results: Survival was observed for a mean period of 10.3 ± 0.84 years. Shunted iNPH patients had an increased risk of death compared to controls (hazard ratio (HR) = 2.5, 95% CI 1.86–3.36; p < 0.001). After 10 years, 50% (n = 88) of iNPH patients and 24% (n = 88) of the controls were dead (p < 0.001). The risk of dying from cardiovascular disease, falls and neurological diseases were higher in iNPH (p < 0.05). The most common cause of death in iNPH was cardiovascular diseases (14% vs 7% for controls). Seven out of nine iNPH dying from falls had subdural hematomas. Systolic BP (HR = 0.985 95% CI 0.972–0.997, p = 0.018), atrial fibrillation (HR = 2.652, 95% CI 1.506–4.872, p < 0.001) and creatinine (HR = 1.018, 95% CI 1.010–1.027, p < 0.001) were independently associated with mortality for iNPH.

    Discussion: This long-term and population-matched cohort study indicates that in spite of CSF-shunt treatment, iNPH has shorter life expectancy. It may be important to treat iNPH in supplementary ways to reduce mortality. Both cardiovascular comorbidities and lethal falls are contributing to the excess mortality in iNPH and reducing these preventable risks should be an established part of the treatment plan.

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  • 32.
    Håkansson, Erik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Norberg, Helena
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB).
    Själander, Sara
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Lindmark, Krister
    Department of Clinical Sciences Danderyd Hospital, Karolinska Institute, Danderyd, Sweden.
    Prevalence and treatment of diabetes and pre-diabetes in a real-world heart failure population: a single-centre cross-sectional study2022In: Open heart, E-ISSN 2053-3624, Vol. 9, no 2, article id e002133Article in journal (Refereed)
    Abstract [en]

    Aims: The aim of this study was to investigate a real-world heart failure (HF) cohort regarding (1) prevalence of known diabetes mellitus (DM), undiagnosed DM and pre-diabetes, (2) if hf treatment differs depending on glycaemic status and (3) if treatment of DM differs depending on HF phenotype.

    Methods: All patients who had received a diagnosis of HF at Umeå University Hospital between 2010 and 2019 were identified and data were extracted from patient files according to a prespecified protocol containing parameters for clinical characteristics, including echocardiogram results, comorbidities, fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) values. Patients’ HF phenotype was determined using the latest available echocardiogram. The number of patients with previous DM diagnosis was assessed. Patients without a previous diagnosis of DM were classified as non-DM, pre-diabetes or probable DM according to FPG and HbA1c levels using WHO criteria.

    Results: In total, 2326 patients (59% male, mean age 76±13 years) with HF and at least one echocardiogram were assessed. Of these, 617 (27%) patients had a previous diagnosis of DM. Of the 1709 patients without a previous diagnosis of DM, 1092 (67%) patients had either an FPG or HbA1c recorded, of which 441 (41%) met criteria for pre-diabetes and 97 (9%) met criteria for probable diabetes, corresponding to 19% and 4% of the entire cohort, respectively. Patients with HF and diabetes were more often treated with diuretics and beta blockers compared with non-DM patients (64% vs 42%, p<0.001 and 88% vs 83%, p<0.001, respectively). There was no difference in DM treatment between HF phenotypes.

    Conclusions: DM and pre-diabetes are common in this HF population with 50% of patients having either known DM, probable DM or pre-diabetes. Patients with HF and DM are more often treated with common HF medications. HF phenotype did not affect choice of DM therapy.

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  • 33.
    Johansson, Cecilia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Örtendahl, Lina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lind, Marcus M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Andersson, Jonas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Johansson, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Diabetes, prediabetes, and atrial fibrillation: a population-based cohort study based on national and regional registers2023In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 294, no 5, p. 605-615Article in journal (Refereed)
    Abstract [en]

    Background: Previous studies have shown an increased risk for atrial fibrillation and atrial flutter (AF) in people with type 2 diabetes and prediabetes. It is unclear whether this increase in AF risk is independent of other risk factors for AF.

    Objective: To investigate the association between diabetes and different prediabetic states, as independent risk factors for the onset of AF.

    Methods: We performed a population-based cohort study in Northern Sweden, including data on fasting plasma glucose, oral glucose tolerance test, major cardiovascular risk factors, medical history, and lifestyle factors. Participants were divided into six groups depending on glycemic status and followed through national registers for AF diagnosis. Cox proportional hazard model was used to assess the association between glycemic status and AF, using normoglycemia as reference.

    Results: The cohort consisted of 88,889 participants who underwent a total of 139,661 health examinations. In the model adjusted for age and sex, there was a significant association between glycemic status and development of AF in all groups except the impaired glucose tolerance group, with the strongest association for the group with known diabetes (p-value <0.001). In a model adjusted for sex, age, systolic blood pressure, body mass index, antihypertensive drugs, cholesterol, alcohol, smoking, education level, marital status, and physical activity, there was no significant association between glycemic status and AF.

    Conclusions/interpretation: The association between glycemic status and AF disappears upon adjustment for potential confounders. Diabetes and prediabetes do not appear to be independent risk factors for AF.

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  • 34.
    Johansson, Elias
    et al.
    Umeå University, Faculty of Medicine, Wallenberg Centre for Molecular Medicine at Umeå University (WCMM). Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Gu, Thomas
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Castillo, Sebastian
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Neurosciences.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Holsti, Mari
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Wanhainen, Anders
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden.
    Intracerebral Haemorrhage after Revascularisation of Carotid Near Occlusion with Full Collapse2022In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 63, no 3, p. 523-524Article in journal (Other academic)
  • 35.
    Jussil, Heidi
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Chaimani, Anna
    Research Center of Epidemiology and Statistics (CRESS-UMR1153), INSERM, INRA, Universite de Paris, Paris, Île-de-France, France.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Comparative efficacy and acceptability of different antihypertensive drug classes for cardiovascular disease prevention: Protocol for a systematic review and network meta-analysis2021In: BMJ Open, E-ISSN 2044-6055, Vol. 11, no 3, article id 041982Article in journal (Refereed)
    Abstract [en]

    Introduction Clinical practice guidelines differ in their recommendations on first-line antihypertensive drug classes. No adequately powered randomised controlled trial have assessed all major drug classes against each other, and previous meta-analyses have mainly relied on pairwise meta-analyses for treatment comparisons.

    Methods and analysis A systematic review and network meta-analysis will be carried out to assess the efficacy and acceptability of all major antihypertensive drug classes. PubMed and CENTRAL were searched on 21 February 2020 to identify randomised controlled trials with at least 1000 person-years of follow-up, assessing any antihypertensive agent against other agents or placebo. All trials fulfilling the inclusion criteria will be assessed for risk of bias using the second version of Cochrane's risk of bias assessment tool. The study selection process, risk of bias assessment and data extraction are done by two authors in duplicate. Relative risks from individual trials will be combined in pairwise meta-analyses; in the absence of important intransitivity, random-effects network meta-analysis will be performed. The primary outcome for efficacy will be major adverse cardiovascular events, whereas the primary acceptability outcome will be treatment discontinuation for any reason. Additional outcomes include all-cause mortality, cardiovascular mortality, stroke, myocardial infarction, heart failure and acute renal failure. The impact of differences within drug classes will be explored through alternative networks, including analysing thiazide-like and thiazide-type diuretics separately.

    Ethics and dissemination This review will only process aggregated study level data and does not require ethical approval. The findings will be published in a peer-reviewed medical journal.

    PROSPERO registration number CRD42020205482.

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  • 36.
    Kjeldsen, Sverre E
    et al.
    University of Oslo, Faculty of Medicine, Department of Cardiology, Ullevaal Hospital, Oslo, Norway.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Thomopoulos, Costas
    Department of Cardiology, Helena Venizelou Hospital, Athens, Greece.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Kreutz, Reinhold
    Charité – Charité – Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany.
    Mancia, Giuseppe
    University of Milano-Bicocca, Milan, Italy.
    Blood pressure reduction and major cardiovascular events in people with and without type 2 diabetes2022In: The Lancet Diabetes and Endocrinology, ISSN 2213-8587, E-ISSN 2213-8595, Vol. 10, no 12, p. 840-840Article in journal (Refereed)
  • 37.
    Kreutz, Reinhold
    et al.
    Charite-Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Germany.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Burnier, Michel
    Faculty of Biology and Medicine, University of Lausanne, Switzerland.
    Grassi, Guido
    Clinica Medica, University Milano-Bicocca, Milan, Italy.
    Januszewicz, Andrzej
    Department of Hypertension, National Institute of Cardiology, Warsaw, Poland.
    Kjeldsen, Sverre E.
    Institute for Clinical Medicine, University of Oslo, Norway.
    Muiesan, Maria L.
    Departments of Cardiology and Nephrology, Ullevaal Hospital, Oslo, Norway; OC 2 Medicina, ASST Spedali Civili di Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Italy.
    Thomopoulos, Costas
    Department of Cardiology, General Hospital of Athens Laiko, Greece.
    Tsioufis, Konstantinos
    First Department of Cardiology, Medical School, University of Athens, Hippokration Hospital, Athens, Greece.
    Mancia, Giuseppe
    University Milano-Bicocca, Italy.
    Beta-blocker bashing and downgrading in hypertension management: A fashionable trend representing a matter of concern2024In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 42, no 6, p. 966-967Article in journal (Refereed)
    Abstract [en]

    In their commentary, Shantsila et al.[1] while discussing some relevant issues of the 2023 Guidelines for the Management of Hypertension of the European Society of Hypertension (ESH) [2], for example, the length of the text and the involvement of only a few primary care physicians, they largely focus on the discussion on beta-blockers. The authors conclude that ‘the 2023 ESH Guidelines still argue in favour of beta-blockers that their clinical inferiority was simply to lesser blood pressure (BP) reduction rather than class effect’. However, this is an oversimplification that does not reflect the numerous arguments and facts that support the overall rationale of the 2023 ESH Guidelines for the recommended use of beta-blockers in the management of hypertension [2]. Taken together with other similar comments [3], it appears that it has become fashionable to down-grade beta-blockers and to dismiss the points already put forward in the 2023 ESH guidelines [2] and in previous publications revisiting beta-blocker benefits in detail [4,5]. Against this background, we use this opportunity to emphasize on key aspects of the beta-blocker discussion in brief. For a more comprehensive review of the literature, we refer to a very recent publication by us regarding the role of beta-blocker in hypertension [6].

  • 38.
    Kreutz, Reinhold
    et al.
    Charité - Universitatsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Thomopoulos, Costas
    Department of Cardiology, Helena Venizelou Hospital, Athens, Greece.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Mancia, Giuseppe
    University of Milano-Bicocca, Milan, Italy.
    Do recent meta-analyses truly prove that treatment with blood pressure-lowering drugs is beneficial at any blood pressure value, no matter how low?: A critical review2022In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 40, no 5, p. 839-846Article, review/survey (Refereed)
    Abstract [en]

    Current European guidelines for the management of hypertension and on cardiovascular disease prevention place the threshold for pharmacological treatment at a SBP level of 140 mmHg or above, with the exception of patients at very high risk (mainly because of coronary heart disease). This is in agreement with the current definition of hypertension, that is, the level of blood pressure at which the benefits of treatment outweigh the risks of treatment, as documented by clinical trials. This rationale and definition was recently challenged by meta-analyses using individual participant-level data from 48 randomized trials by the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC). The authors calculated for a fixed 5 mmHg pharmacological reduction of SBP an overall 10% risk reduction for major cardiovascular events. It was concluded that there was no reliable evidence of heterogeneity of treatment effects by baseline SBP categories; that the effect was independent from the presence of cardiovascular disease; applied also to old and very old individuals up to 84 years or beyond; and that BP-lowering was also beneficial in individuals with normal or high-normal SBP down to a baseline SBP less than 120 mmHg. In this report, we identify and discuss a number of shortcomings of the BPLTTC meta-analyses. In our view, the conclusions by the BPLTTC must be -together with accompanying suggestions to abandon the definition of hypertension - strongly rejected as they are not justified and may be harmful for cardiovascular health in individuals without hypertension.

  • 39.
    Kreutz, Reinhold
    et al.
    Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Thomopoulos, Costas
    Department of Cardiology, Helena Venizelou Hospital, Athens, Greece.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Mancia, Giuseppe
    University of Milano-Bicocca, Milan, Italy.
    Prescribing blood pressure lowering drugs irrespective of blood pressure?2022In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 40, no 5, p. 1050-1051Article in journal (Other academic)
  • 40. Kruger, Ruan
    et al.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Burger, Dylan
    Charchar, Fadi
    Climie, Rachel
    Mirabito Colafella, Katrina M.
    Kempny, Pablo
    Korostovtseva, Lyudmila
    Marques, Francine Z.
    Picone, Dean
    Romero, Cesar
    Steckelings, Ulrike M.
    Velkoska, Elena
    Wainford, Richard
    Wynne, Brandi M.
    Zanuzzi, Matias G.
    Highlights from the International Society of Hypertension's new investigators network during 20192020In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 38, no 5, p. 968-973Article in journal (Other academic)
    Abstract [en]

    The New Investigators Committee (NIC) of the International Society of Hypertension (ISH) is a dynamic group of junior doctors and scientists, actively involved in various society activities. This report highlights the events (scientific meetings and summer schools) and activities (social media, mentorship and networking) during 2019 including May Measurement Month and collaborative efforts with the ISH Women in Hypertension Research Committee (WiHRC). The ISH NIC is proud to sponsor awards for outstanding work by junior and emerging researchers at hypertension conferences and also provides opportunities to showcase their work on our social media features such as 'Our Fellows Work' and the New Investigator Spotlight of the month. In 2020, the ISH NIC aims to promote women in leadership roles and to foster strong collaborations with and between society committees and other scientific organizations.

  • 41.
    Lind, Lars
    et al.
    Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden.
    Markstad, Hanna
    Center for Medical Imaging and Physiology, Skåne University Hospital Lund University, Lund, Sweden; Experimental Cardiovascular Research, Clinical Research Center, Clinical Sciences, Lund University, Malmö, Sweden.
    Ahlström, Håkan
    Department of Surgical Sciences, Section of Radiology, Uppsala University, Uppsala, Sweden.
    Angerås, Oskar
    Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
    Brandberg, John
    Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Engström, Gunnar
    Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden.
    Engvall, Jan E.
    CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden; Department of Clinical Physiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Eriksson, Maria J.
    Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden.
    Eriksson, Mats
    Karolinska University Hospital, Stockholm, Sweden.
    Gottsäter, Anders
    Department of Medicine, Skåne University Hospital Malmö, Lund University, Lund, Sweden.
    Hagström, Emil
    Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
    Krachler, Benno
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Lampa, Erik
    Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden.
    Mannila, Maria
    Heart and Vascular Theme, Department of Cardiology and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden.
    Nilsson, Peter M.
    Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden.
    Nyström, Fredrik H.
    Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Persson, Anders
    CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden; Department of Radiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Redfors, Björn
    Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
    Sandström, Anette
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Themudo, Raquel
    Radiology Department, Karolinska University Hospital, Huddinge, Stockholm, Sweden; Division of Medical Imaging and Technology, Department of Clinical Sciences, Intervention and Technology at Karolinska Institutet, Stockholm, Sweden.
    Völz, Sebastian
    Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
    Ärnlöv, Johan
    Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden; School of Health and Social Studies, Dalarna University, Falun, Sweden.
    Östgren, Carl Johan
    CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Bergström, Göran
    Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Obesity is associated with coronary artery stenosis independently of metabolic risk factors: the population-based SCAPIS study2022In: Atherosclerosis, ISSN 0021-9150, E-ISSN 1879-1484, Vol. 362, p. 1-10Article in journal (Refereed)
    Abstract [en]

    Background and aims: Previous studies reported divergent results on whether metabolically healthy obesity is associated with increased coronary artery calcium and carotid plaques. We investigated this in a cross-sectional fashion in a large, well-defined, middle-aged population using coronary CT angiography (CCTA) and carotid ultrasound. Methods: In the SCAPIS study (50–65 years, 51% female), CCTA and carotid artery ultrasound were performed in 23,674 individuals without clinical atherosclerotic disease. These subjects were divided into six groups according to BMI (normal weight, overweight, obese) and the presence of metabolic syndrome (MetS) according to the NCEP consensus criteria. Results: The severity of coronary artery stenosis was increased in individuals with obesity without MetS compared to normal-weight individuals without MetS (OR 1.47, 95%CI 1.34–1.62; p < 0.0001), even after adjusting for non-HDL-cholesterol and several lifestyle factors. Such difference was not observed for the presence of carotid artery plaques (OR 0.94, 95%CI 0.87–1.02; p = 0.11). Obese or overweight individuals without any MetS criteria (except the waist criterion) showed significantly more pronounced stenosis in the coronary arteries as compared to the normal-weight individuals, while one criterion was needed to show increased plaque prevalence in the carotid arteries. High blood pressure was the most important single criterion for increased atherosclerosis in this respect. Conclusions: Individuals with obesity without MetS showed increased severity of coronary artery stenosis, but no increased occurrence of carotid artery plaques compared to normal-weight individuals without MetS, further emphasizing that obesity is not a benign condition even in the absence of MetS.

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  • 42.
    Mancia, Giuseppe
    et al.
    University Milano-Bicocca, Milan, Italy.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Burnier, Michel
    Faculty of Biology and Medicine, University of Lausanne, Switzerland.
    Grassi, Guido
    Clinica Medica, University Milano-Bicocca, Milan, Italy.
    Januszewicz, Andrzej
    Department of Hypertension, National Institute of Cardiology, Warsaw, Poland.
    Kjeldsen, Sverre E.
    Institute for Clinical Medicine, University of Oslo, Norway; Departments of Cardiology and Nephrology, Ullevaal Hospital, Oslo, Norway.
    Muiesan, Maria Lorenza
    UOC 2 Medicina, ASST Spedali Civili di Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Italy.
    Thomopoulos, Costas
    Department of Cardiology, General Hospital of Athens Laiko, Greece.
    Tsioufis, Konstantinos
    First Department of Cardiology, Medical School, University of Athens, Hippokration Hospital, Greece.
    Kreutz, Reinhold
    Charite-Universitaetsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Germany.
    Rationale for the inclusion of β-blockers among major antihypertensive drugs in the 2023 European society of hypertension guidelines2024In: Hypertension, ISSN 0194-911X, E-ISSN 1524-4563, Vol. 81, no 5, p. 1021-1030Article, review/survey (Refereed)
    Abstract [en]

    We address the reasons why, unlike other guidelines, in the 2023 guidelines of the European Society of Hypertension β-blockers (BBs) have been regarded as major drugs for the treatment of hypertension, at the same level as diuretics, calcium channel blockers, and blockers of the renin-angiotensin system. We argue that BBs, (1) reduce blood pressure (the main factor responsible for treatment-related protection) not less than other drugs, (2) reduce pooled cardiovascular outcomes and mortality in placebo-controlled trials, in which there has also been a sizeable reduction of all major cause-specific cardiovascular outcomes, (3) have been associated with a lower global cardiovascular protection in 2 but not in several other comparison trials, in which the protective effect of BBs versus the other major drugs has been similar or even greater, with a slightly smaller or no difference of global benefit in large trial meta-analyses and a similar protective effect when comparisons extend to BBs in combination versus other drug combinations. We mention the large number of cardiac and other comorbidities for which BBs are elective drugs, and we express criticism against the exclusion of BBs because of their lower protective effect against stroke in comparison trials, because, for still uncertain reasons, differences in protection against cause-specific events (stroke, heart failure, and coronary disease) have been reported for other major drugs. These partial data cannot replace global benefits as the main deciding factor for drug choice, also because in the general hypertensive population whether and which type of event might occur is unknown.

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  • 43.
    Mancia, Giuseppe
    et al.
    University of Milano-Bicocca, Milan, Italy.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Burnier, Michel
    Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
    Grassi, Guido
    Clinica Medica, University of Milano-Bicocca, Milan, Italy.
    Januszewicz, Andrzej
    Department of Hypertension, National Institute of Cardiology, Warsaw, Poland.
    Muiesan, Maria Lorenza
    UOC 2 Medicina, ASST Spedali Civili di Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
    Tsioufis, Konstantinos
    First Department of Cardiology, Medical School, Hippokration Hospital, University of Athens, Athens, Greece.
    Kjeldsen, Sverre E.
    Departments of Cardiology and Nephrology, Institute for Clinical Medicine, and Ulleval Hospital, University of Oslo, Oslo, Norway.
    Kreutz, Reinhold
    Institute of Clinical Pharmacology and Toxicology, Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin and Humboldt- Universitaet zu Berlin, Berlin, Germany.
    Rationale of treatment recommendations in the 2023 ESH hypertension guidelines2024In: European journal of internal medicine, ISSN 0953-6205, E-ISSN 1879-0828, Vol. 121, p. 4-8Article in journal (Other academic)
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  • 44.
    Mancia, Giuseppe
    et al.
    University of Milano-Bicocca, Milan, Italy.
    Kreutz, Reinhold
    Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Burnier, Michel
    Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
    Grassi, Guido
    Clinica Medica, University Milano-Bicocca, Milan, Italy.
    Januszewicz, Andrzej
    Department of Hypertension, National Institute of Cardiology, Warsaw, Poland.
    Muiesan, Maria Lorenza
    ASST Spedali Civili di Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
    Tsioufis, Konstantinos
    First Department of Cardiology, Medical School, University of Athens, Hippokration Hospital, Athens, Greece.
    Agabiti-Rosei, Enrico
    Department of Clinical and Experimental Sciences, University of Brescia, Italy.
    Algharably, Engi Abd Elhady
    Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany.
    Azizi, Michel
    Université Paris Cité, Paris, France; AP-HP Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE; INSERM, Paris, United States.
    Benetos, Athanase
    CHRU-Nancy, Department of Geriatric Medicine and INSERM DCAC, Université de Lorraine, Nancy, France.
    Borghi, Claudio
    Department of Medical and Surgical Sciences-IRCCS AOU S. Orsola di Bologna, Bologna, Italy.
    Hitij, Jana Brguljan
    University Medical Centre Ljubljana, Department of Hypertension, Medical University Ljubljana, Ljubljana, Slovenia.
    Cifkova, Renata
    Center for Cardiovascular Prevention, Thomayer University Hospital; Department of Medicine II, Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic.
    Coca, Antonio
    Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Clínic, University of Barcelona, Spain.
    Cornelissen, Veronique
    Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium.
    Cruickshank, J Kennedy
    King's College, London, United Kingdom.
    Cunha, Pedro G.
    Center for the Research and Treatment of Arterial Hypertension and Cardiovascular Risk, Internal Medicine Department, Hospital Senhora da Oliveira, Guimarães/Minho University; Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho; ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal.
    Danser, A H Jan
    Department of Internal Medicine, Erasmus MC, Rotterdam, Netherlands.
    Pinho, Rosa Maria de
    Family and general practitioner, São João da Madeira, Portugal.
    Delles, Christian
    School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom.
    Dominiczak, Anna F.
    Regius Professor of Medicine, University of Glasgow, Glasgow, United Kingdom.
    Dorobantu, Maria
    University of Medicine and Pharmacy 'Carol Davila', Romanian Academy, Romania.
    Doumas, Michalis
    2nd Prop Department of Internal Medicine, Aristotle University, Thessaloniki, Greece.
    Fernández-Alfonso, María S
    Instituto Pluridisciplinar and Facultad de Farmacia, Universidad Complutense de Madrid; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
    Halimi, Jean-Michel
    Service de Néphrologie-Hypertension, Transplantation Rénale, CHRU Tours; Equipe d'Accueil EA4245, Université de Tours; INI-CRCT, Tours, France.
    Járai, Zoltán
    South-Buda Center Hospital St. Imre University Hospital, Budapest & Semmelweis University, Budapest, Hungary.
    Jelaković, Bojan
    Dept for Nephrology, Hypertension, Dialysis and Transplantation, School of Medicine, University of Zagreb, Zagreb, Croatia.
    Jordan, Jens
    Institute of Aerospace Medicine, German Aerospace Center; Medical Faculty, University of Cologne, Cologne, Germany.
    Kuznetsova, Tatiana
    Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
    Laurent, Stephane
    Paris-Cité University, Paris, France.
    Lovic, Dragan
    Singidunum University, Clinic for internal Disease Intermedica Cardiology Department, Hypertension Centre, Nis, Serbia.
    Lurbe, Empar
    Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition (CIBEROBN), Institute of Health Carlos III (ISCIII), Madrid, Spain; University of Valencia, Valencia, Spain.
    Mahfoud, Felix
    Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital and Saarland University, Homburg, Germany; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, MA, Cambridge, United States.
    Manolis, Athanasios
    Metropolitan Hospital, Greece.
    Miglinas, Marius
    Institute of Clinical Medicine, Faculty of Medicine, Vilnius University; Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.
    Narkiewicz, Krzystof
    Department of Hypertension and Diabetology, Medical University of Gdańsk, Gdańsk, Poland.
    Niiranen, Teemu
    Department of Internal Medicine, Turku University Hospital and University of Turku, Turku, Finland; Finnish Institute for Health and Welfare, Helsinki, Finland.
    Palatini, Paolo
    Studium Patavinum, Department of Medicine, University of Padova, Padova, Italy.
    Parati, Gianfranco
    IRCCS, Istituto Auxologico Italiano, Ospedale San Luca; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
    Pathak, Atul
    Princess Grace Hospital Monaco (Centre Hospitalier Princesse Grace, Monaco.
    Persu, Alexandre
    Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
    Polonia, Jorge
    CINTESIS; Faculty of Medicine of Porto, Portugal.
    Redon, Josep
    Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition (CIBEROBN), Institute of Health Carlos III (ISCIII), Madrid, Spain; Incliva Research Institute, University of Valencia; CIBEROBN, Institute of Health Carlos III (ISCIII), Madrid, Spain.
    Sarafidis, Pantelis
    1st Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Greece.
    Schmieder, Roland
    University Hospital Erlangen, Friedrich Alexander University Erlangen/Nürnberg, Germany.
    Spronck, Bart
    Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands.
    Stabouli, Stella
    First Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece.
    Stergiou, George
    Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece.
    Taddei, Stefano
    Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
    Thomopoulos, Costas
    Department of Cardiology, Helena Venizelou Hospital, Athens, Greece.
    Tomaszewski, Maciej
    Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester; Manchester Royal Infirmary, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom.
    Van de Borne, Philippe
    Department of Cardiology, Brussels, Belgium.
    Wanner, Christoph
    Division of Nephrology, Wuerzburg University Clinic, Wuerzburg, Germany.
    Weber, Thomas
    Cardiology Department, Klinikum Wels-Grieskirchen, Wels, Austria.
    Williams, Bryan
    Institute of Cardiovascular Sciences, University College London (UCL); National Institute for Health Research UCL Hospitals Biomedical Research Centre, London, UK.
    Zhang, Zhen-Yu
    Hypertension and Cardiovascular Epidemiology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
    Kjeldsen, Sverre E.
    Departments of Cardiology and Nephrology, Institute for Clinical Medicine, Ullevål Hospital, University of Oslo, Oslo, Norway.
    2023 ESH guidelines for the management of arterial hypertension the task force for the management of arterial hypertension of the European society of hypertension: endorsed by the international society of hypertension (ISH) and the European renal association (ERA)2023In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 41, no 12, p. 1874-2071Article in journal (Refereed)
  • 45.
    Rietz, Helene
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Pennlert, Johanna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nordström, Peter
    Department of Public Health and Caring Sciences, Clinical Geriatrics, Uppsala University, Uppsala, Sweden.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Blood pressure level in late adolescence and risk for cardiovascular events: a cohort study2023In: Annals of Internal Medicine, ISSN 0003-4819, E-ISSN 1539-3704, Vol. 176, no 10, p. 1289-1298Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Not enough is known about the association between blood pressure (BP) in adolescence and future cardiovascular events.

    OBJECTIVE: To measure this association using the 2017 American College of Cardiology/American Heart Association guidelines for classifying BP elevation.

    DESIGN: Cohort study.Sweden.

    PARTICIPANTS: Males in late adolescence who were conscripted into the military from 1969 to 1997.

    MEASUREMENTS: Baseline BP was measured at conscription. The primary outcome was a composite of cardiovascular death or first hospitalization for myocardial infarction, heart failure, ischemic stroke, or intracerebral hemorrhage.

    RESULTS: The study included 1 366 519 males with a mean age of 18.3 years. The baseline BP was classified as elevated (120 to 129/<80 mm Hg) for 28.8% of participants and hypertensive (≥130/80 mm Hg) for 53.7%. During a median follow-up of 35.9 years, 79 644 had a primary outcome. The adjusted hazard ratio was 1.10 for elevated BP (95% CI, 1.07 to 1.13), 1.15 for stage 1 isolated systolic hypertension (ISH) (CI, 1.11 to 1.18), 1.23 for stage 1 isolated diastolic hypertension (IDH) (CI, 1.18 to 1.28), 1.32 for stage 1 systolic-diastolic hypertension (SDH) (CI, 1.27 to 1.37), 1.31 for stage 2 ISH (CI, 1.28 to 1.35), 1.55 for stage 2 IDH (CI, 1.42 to 1.69), and 1.71 for stage 2 SDH (CI, 1.58 to 1.84). The cumulative risk for cardiovascular events also increased gradually across BP stages, ranging from 14.7% for normal BP to 24.3% for stage 2 SDH at age 68 years.

    LIMITATION: This was an observational study of Swedish men.

    CONCLUSION: Increasing BP levels in late adolescence are associated with gradually increasing risks for major cardiovascular events, beginning at a BP level of 120/80 mm Hg.

  • 46.
    Rosén, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Otten, Julia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Stomby, Andreas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine. Division of Prevention, Rehabilitation and Community Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Futurum, Region Jönköping County, Sweden.
    Vallin, Simon
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Oral glucose tolerance testing as a complement to fasting plasma glucose in screening for type 2 diabetes: population-based cross-sectional analyses of 146 000 health examinations in Västerbotten, Sweden2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, no 6, article id e062172Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To assess the effect of adding an oral glucose tolerance test (OGTT) to fasting plasma glucose (FPG) in terms of detection of type 2 diabetes (T2D) and impaired glucose tolerance (IGT).

    DESIGN: Retrospective analysis of serial cross-sectional screening study. SETTING: Population-based health examinations within primary care in Västerbotten County, Sweden.

    PARTICIPANTS: Individuals aged 40- 50 and 60 years with participation from 1985 to 2017. Those with previously diagnosed diabetes and FPG≥7 mmol/L were excluded.

    PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of hyperglycaemia on the OGTT (IGT and T2D defined as 2-hour postload capillary plasma glucose of 8.9-12.1 mmol/L and ≥12.2 mmol/L, respectively). Analyses were further stratified by age, sex and risk factor burden to identify groups at high or low risk of IGT and T2D on testing. The numbers needed to screen (NNS) to prevent one case of T2D through detection and treatment of IGT was estimated, combining prevalence numbers with average progression rates and intervention effects from previous meta-analyses.

    RESULTS: The prevalence of IGT ranged from 0.9% (95% CI 0.7% to 1.1%) to 29.6% (95% CI 27.4% to 31.7%), and the prevalence of T2D ranged from 0.06% (95% CI 0.02% to 0.11%) to 7.0% (95% CI 5.9% to 8.3%), depending strongly on age, sex and risk factor burden. The estimated NNS to prevent one case of T2D through detection and lifestyle treatment of IGT ranged from 1332 among 40-year-old men without risk factors, to 39 among 60-year-old women with all risk factors combined.

    CONCLUSIONS: The prevalence of hyperglycaemia on OGTT is highly dependent on age, sex and risk factor burden; OGTT should be applied selectively to high-risk groups to avoid unnecessary testing in the general population.

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  • 47. SCORE2 working group and ESC Cardiovascular risk collaboration,
    Brunström, Mattias (Contributor)
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Söderberg, Stefan (Contributor)
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    SCORE2 risk prediction algorithms: new models to estimate 10-year risk of cardiovascular disease in Europe2021In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 42, no 25, p. 2439-2454Article in journal (Refereed)
    Abstract [en]

    AIMS: The aim of this study was to develop, validate, and illustrate an updated prediction model (SCORE2) to estimate 10-year fatal and non-fatal cardiovascular disease (CVD) risk in individuals without previous CVD or diabetes aged 40-69 years in Europe.

    METHODS AND RESULTS: We derived risk prediction models using individual-participant data from 45 cohorts in 13 countries (677 684 individuals, 30 121 CVD events). We used sex-specific and competing risk-adjusted models, including age, smoking status, systolic blood pressure, and total- and HDL-cholesterol. We defined four risk regions in Europe according to country-specific CVD mortality, recalibrating models to each region using expected incidences and risk factor distributions. Region-specific incidence was estimated using CVD mortality and incidence data on 10 776 466 individuals. For external validation, we analysed data from 25 additional cohorts in 15 European countries (1 133 181 individuals, 43 492 CVD events). After applying the derived risk prediction models to external validation cohorts, C-indices ranged from 0.67 (0.65-0.68) to 0.81 (0.76-0.86). Predicted CVD risk varied several-fold across European regions. For example, the estimated 10-year CVD risk for a 50-year-old smoker, with a systolic blood pressure of 140 mmHg, total cholesterol of 5.5 mmol/L, and HDL-cholesterol of 1.3 mmol/L, ranged from 5.9% for men in low-risk countries to 14.0% for men in very high-risk countries, and from 4.2% for women in low-risk countries to 13.7% for women in very high-risk countries.

    CONCLUSION: SCORE2-a new algorithm derived, calibrated, and validated to predict 10-year risk of first-onset CVD in European populations-enhances the identification of individuals at higher risk of developing CVD across Europe.

  • 48.
    Shimanda, Panduleni Penipawa
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Shumba, Tonderai W
    Department of Occupational Therapy and Physiotherapy University of Namibia Windhoek Namibia.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Iipinge, Scholastika N
    Clara Barton School of Nursing, Welwitchia Health Training Centre Windhoek Namibia.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Preventive interventions to reduce the burden of rheumatic heart disease in populations at risk: a systematic review2024In: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, E-ISSN 2047-9980, Vol. 13, no 5, article id e032442Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Rheumatic heart disease (RHD) is a devastating yet preventable condition that disproportionately affects low-middle-income countries and indigenous populations in some high-income countries. Various preventive interventions have been implemented across the globe, but evidence for the effectiveness of these measures in reducing the incidence or prevalence of acute rheumatic fever and RHD is scattered. This systematic review aims to assess the effectiveness of preventive interventions and identify the strategies used to reduce the burden of RHD.

    METHODS AND RESULTS: A comprehensive search was conducted to identify relevant studies on RHD prevention interventions including interventions for primordial, primary, and secondary prevention. Effectiveness measures for the interventions were gathered when available. The findings indicate that school-based primary prevention services targeting the early detection and treatment of Group A Streptococcus pharyngitis infection with penicillin have the potential to reduce the incidence of Group A Streptococcus pharyngitis and acute rheumatic fever. Community-based programs using various prevention strategies also reduced the burden of RHD. However, there is limited evidence from low-middle-income countries and a lack of rigorous evaluations reporting the true impact of the interventions. Narrative synthesis was performed, and the methodological quality appraisal was done using the Joanna Briggs Institute critical appraisal tools.

    CONCLUSIONS: This systematic review underscores the importance of various preventive interventions in reducing the incidence and burden of Group A Streptococcus pharyngitis, acute rheumatic fever, and RHD. Rigorous evaluations and comprehensive analyses of interventions are necessary for guiding effective strategies and informing public health policies to prevent and reduce the burden of these diseases in diverse populations.

    REGISTRATION: URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020170503.

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  • 49.
    Shimanda, Panduleni Penipawa
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Clara Barton School of Nursing, Welwitchia Health Training Centre, Windhoek, Namibia.
    Shumba, Tonderai Washington
    University of Namibia.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Iipinge, Scholastika Ndatinda
    Welwitchia Health Training Centre.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Preventive interventions to reduce the burden of rheumatic heart disease in populations at risk: a systematic review protocol2021In: Systematic Reviews, E-ISSN 2046-4053, Vol. 10, no 1, article id 200Article in journal (Refereed)
    Abstract [en]

    Background: Rheumatic heart disease is preventable, yet associated with significant health burden, mostly in low-resourced settings. It is prevalent among children and young adults living in impoverished areas. Primordial, primary, and secondary preventive measures have been recommended through health interventions and comprehensive programmes, although most implemented interventions are the high-resourced settings. The proposed review aims to synthesise the evidence of prevention effectiveness of implemented health interventions for the prevention of rheumatic heart disease.

    Methods and design: This article describes a protocol for a systematic review. A predefined search strategy will be used to search for relevant literature published from the year 2000 to present. Electronic databases Medline, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials will be searched for the studies, as well as reference lists of relevant studies included. Risk of bias and quality appraisal will be done for the included studies using ROBINS-I tool and Cochrane tool for assessing risk of bias in randomised control trials. Findings will be analysed in subgroups based on the level of intervention and prevention strategy implemented. We will present the findings in descriptive formats with tables and flow diagrams.

    Discussion: This review will provide evidence on the prevention effectiveness of interventions or strategies implemented for the prevention of RHD. The findings of this will be significant for policy, practice, and research in countries planning to implement interventions.

    Registration: PROSPERO ID: CRD42020170503.

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  • 50.
    Skoglund Larsson, Linn
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Ljungberg, Johan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Johansson, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Brunström, Mattias
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Survival after surgery of the ascending aorta: a matched cohort study2022In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 62, no 3Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Surgery of ascending aortic aneurysms is performed prophylactically or acute. The expected survival after surgery is uncertain. The goal of this study was to compare mortality in people with aortic surgery with matched controls.

    METHODS: All patients undergoing ascending aortic surgery at Umeå University Hospital from 1988 to 2012, who previously participated in 1 of 3 population-based health surveys, were matched to 2 randomly selected controls from the same health survey and followed until death or until censoring on 24 August 2017, whichever came first. Mortality was calculated using the Kaplan-Meier method and the log-rank test. Cox regression analyses were made for all-cause mortality, adjusted for traditional cardiovascular risk factors. Deaths during the first 90 days after surgery and at >90 days postoperatively were studied separately.

    RESULTS: The median follow-up time was 9.2 years. A total of 61 of 189 patients and 51 of 370 controls died [hazard ratio (HR) 2.77, 95% confidence interval (CI) 1.91-4.01]. Mortality was increased during the first 90 days post-surgery (HR 43.4, 95% CI 5.83-323), as well as after the first 90 days (HR 1.90, 95% CI 1.25-2.88) and after acute surgery (HR 6.05, 95% CI 2.92-12.56) as well as after elective surgery (HR 2.10, 95% CI 1.35-3.27). Among 57 surgical patients with information about cause of death, 23 (40%) died of aortic disease.

    CONCLUSIONS: During follow-up, more patients died than matched controls. Findings were consistent when adjusting for traditional cardiovascular risk factors and across subgroups. Both short-term and long-term postoperative deaths were increased as well.

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