Childhood Adversity Is Linked to Blood Pressure Dysfunction
A difficult childhood may be associated with a risk of poor blood pressure regulation, researchers reported. In some studies, blood pressure variability has been associated with an elevated risk of cardiovascular disease and complications from hypertension.
Researchers at the Augusta University Medical College of Georgia investigated the effect of adverse childhood experiences (eg, childhood abuse or neglect, dysfunctional homes, or low socioeconomic status) during the transition from childhood to adulthood. Earlier research has linked adverse childhood experiences to faster increase of blood pressure in adulthood.
The investigators conducted periodic around-the-clock blood pressure monitoring to capture daytime and nighttime readings in 373 participants between the ages of 7 and 38 during a 23-year period. Participants who reported childhood adversity were 17% more likely to have blood pressure that was higher than the clinical definition of hypertension during the daytime.
"Adverse environments in early life have been consistently associated with the increased risk of hypertension in later life," said Shaoyong Su, PhD, lead author and Associate Professor of Pediatrics at Augusta University Medical College of Georgia. "We found that children who experienced childhood abuse or neglect, dysfunctional homes, and low socioeconomic status were far more likely to have higher blood pressure at night, as well as blood pressure variability over 24 hours, in addition to more rapid onset of hypertension at an earlier age."
Twenty-four-hour ambulatory blood pressure is considered a better predictor of organ damage and cardiovascular events because it can assess not only nighttime blood pressure levels, but also the blood pressure variability in real life. Blood pressure was monitored as many as 15 times during the study.
Researchers said that there was no difference in blood pressure regulation at various ages, thus suggesting that the patterns of adverse events in childhood are similar through young adulthood.
Most physicians focus on average blood pressure readings, but the new findings suggest that they should also ask younger patients about childhood adversity and watch for high blood pressure variability, noted Dr. Su. "This is not something most clinicians currently address, but it is a simple step that could identify many individuals at risk of adult hypertension and help them achieve control at an earlier age. This could avoid problems as they age," he added.
Blood pressure variability has been linked to various problems in adults, including decreased brain function in older adults, increased risk of stroke, and poorer post-stroke recovery. Likewise, early-onset hypertension and prehypertension have been linked to adverse preclinical cardiovascular disease, including left ventricular hypertrophy and evidence of increased arterial stiffness.
The current study was funded by the NIH and the National Heart Lung and Blood Institute.
Poor Sleep May Increase Risk for Irregular Heart Rhythms
Disruptions in sleep may increase the risk of atrial fibrillation, according to preliminary research. Obstructive sleep apnea, sleep interrupted by pauses in breathing, is a known risk factor for atrial fibrillation, which can lead to stroke, heart failure, and other heart-related complications. But whether there is a relationship between disrupted sleep and atrial fibrillation in the absence of sleep apnea is unclear.
Researchers at the University of California, San Francisco examined three sources of data, each using a different approach, to isolate and confirm the effects of poor sleep on atrial fibrillation. Their analyses of these studies showed that disrupted sleep, including insomnia, may be independently associated with atrial fibrillation. People who reported frequent nighttime awakening had an approximately 26% higher risk of developing atrial fibrillation, compared with those who did not wake up many times. In addition, people diagnosed with insomnia had a 29% higher risk of developing atrial fibrillation, compared with those without insomnia.
"The idea that these three studies gave us consistent results was exciting," said lead study author Matt Christensen, a fourth-year medical student at the University of Michigan in Ann Arbor. Past research has shown a link between poor sleep among people with atrial fibrillation. This study, however, focused on people whose pre-existing sleep disruptions were associated with developing atrial fibrillation later in life.
The data sources included the Health eHeart Study, an Internet-based cross-sectional study of more than 4,600 people; the Cardiovascular Health Study, an 11-year longitudinal study of more than 5,700 people, of whom almost 1,600 (28%) developed atrial fibrillation; and the California Healthcare Cost and Utilization Project, a hospital-based database spanning five years and covering almost 14 million patients.
In all three studies, researchers adjusted for the effects of obstructive sleep apnea and atrial fibrillation risk factors that might also be related to sleep. Some of those factors were age, sex, race, diabetes, high blood pressure, heart failure, and smoking.
In a separate analysis, the same researchers reviewed a subset of participants in the Cardiovascular Health Study to understand the effect of sleep disruptions during different sleep phases on the risk of atrial fibrillation in patients without obstructive sleep apnea. The analysis showed that having less REM sleep than other sleep phases during the night is linked to a higher likelihood of developing atrial fibrillation.
"By examining the actual characteristics of sleep, such as how much REM sleep you get, it points us toward a more plausible mechanism. There could be something particular about how sleep impacts the autonomic nervous system," said Mr. Christensen.
Another possible explanation for the link between sleep disruptions and atrial fibrillation is that frequent waking puts extra stress on the heart's chambers, said Mr. Christensen. Participants in this analysis were also enrolled in the Sleep Heart Health Study. They had a formal sleep study to objectively measure sleep quality. That element strengthened the study's conclusions because it did not rely on self-reported data, said Mr. Christensen.
In this analysis, 1,131 people (average age, 77) participated in a study with almost 10 years of follow-up. Researchers measured how long participants slept, how well they slept, how long it took to fall asleep, and the patterns of sleep (ie, how much time was spent in REM sleep vs non-REM sleep). Then they analyzed the sleep disruptions' effects to control the effects of age, sex, race, smoking, diabetes, high blood pressure, and other risk factors.
The exact link between sleep and the development of atrial fibrillation is still a mystery, but we are getting closer to a clear picture, said the study authors. "Ultimately, even without a clear understanding of the responsible mechanisms, we believe these findings suggest that strategies to enhance sleep quality, such as incorporating known techniques to improve sleep hygiene, may help prevent this important arrhythmia," said senior author Gregory Marcus, MD, MAS, a cardiologist at the University of California, San Francisco.
Poor sleep is a known contributor to other heart disease risk factors such as high blood pressure, obesity, and stroke. Getting enough physical activity, avoiding too much caffeine, and having an evening routine are good starting tips for sound sleep, said the researchers.
This study was funded in part by the Sarnoff Cardiovascular Research Foundation, the NIH, and the Agency for Healthcare Research and Quality.
Popular Heartburn Medication May Increase Ischemic Stroke Risk
Proton pump inhibitors (PPIs), which are used to reduce stomach acid and treat heartburn, may increase the risk of ischemic stroke, according to preliminary research. "PPIs have been associated with unhealthy vascular function, including heart attacks, kidney disease and dementia," said Thomas Sehested, MD, lead author and a researcher at the Danish Heart Foundation in Copenhagen. "We wanted to see if PPIs also posed a risk for ischemic stroke, especially given their increasing use in the general population."
Researchers analyzed the records of 244,679 Danish patients (average age, 57) who had an endoscopy. During nearly six years of follow up, 9,489 patients had an ischemic stroke for the first time in their lives. Researchers determined whether the stroke occurred while patients were using one of the following four PPIs: omeprazole, pantoprazole, lansoprazole, and esomeprazole.
For ischemic stroke, researchers found that overall stroke risk increased by 21% when patients were taking a PPI. At the lowest doses of the PPIs, the researchers found slight or no increased stroke risk. At the highest dose of these four PPIs, stroke risk increased by amounts ranging from 30% percent for lansoprazole to 94% for pantoprazole. There was no increased risk of stroke associated with another group of acid-reducing medications known as H2 blockers, which includes famotidine and ranitidine.
In comparison with nonusers, users of PPI were older and had more health conditions, including atrial fibrillation, at baseline (3.4% vs 3.8%). The study accounted for age, gender, and medical factors, including high blood pressure, atrial fibrillation, heart failure, and the use of certain pain relievers that have been linked to heart attack and stroke.
The authors believe that their findings, along with those of previous studies, should encourage more cautious use of PPIs. Most PPIs in the United States are now available over the counter, noted Dr. Sehested. "At one time, PPIs were thought to be safe, without major side effects. This study further questions the cardiovascular safety of these drugs."
Although their study did not find a link between H2 blockers and stroke, the authors could not say that this group of drugs would be better for patients than PPIs. Doctors prescribing PPIs should carefully consider whether their use is warranted and for how long, said Dr. Sehested. "We know from prior studies that a lot of individuals are using PPIs for a much longer time than indicated, which is especially true for elderly patients."
Study limitations include an observational design, which cannot establish cause and effect, and the fact that nearly all the participants were white. Authors believe that a randomized controlled trial of PPIs and cardiovascular disease is warranted. This study was funded by the Danish Heart Foundation.
Catheter Ablations Reduce Risks of Recurrent Stroke
Patients with atrial fibrillation and a prior history of stroke who undergo catheter ablation to treat the abnormal heart rhythm lower their long-term risk of a recurrent stroke by 50%, according to research from the Intermountain Medical Center Heart Institute.
When medications are not successful in treating the arrhythmia, catheter ablations are used to create scar tissue in the upper left atrium of the heart that prevents rapid, chaotic electric currents, often from the pulmonary veins, from causing the abnormal rhythm.
"One of the most devastating complications of atrial fibrillation is a stroke, and its prevention is the treatment cornerstone of the abnormal heart rhythm," said Jared Bunch, MD, lead author of the study and Director of Electrophysiology at the Intermountain Medical Center Heart Institute in Salt Lake City. "Patients that have a prior history of stroke have a much greater risk of recurrent strokes. Our new research shows [that] the more successful we are in treating the abnormal rhythm through the process required with catheter ablation, the better chance we have of lowering a patient's long-term risk of stroke."
The Intermountain study compared a group of 140 patients, who had a prior history of stroke and underwent their first catheter ablation, with two other patient groups, both of which also had a prior history of stroke, including 416 patients with atrial fibrillation who did not receive a catheter ablation, and 416 patients with stroke who did not have atrial fibrillation. The patients were followed for five years and observed for recurrent outcomes of stroke, heart failure, and death.
The five-year risk of patients having another stroke was decreased in the patients who had a catheter ablation to treat atrial fibrillation, compared with the group that had no catheter ablation to treat their abnormal heart rhythm. The stroke rates of patients with atrial fibrillation who underwent an ablation procedure were similar to those of patients with no history of atrial fibrillation.
"One of the most important findings of this study was that stroke rates in patients that underwent an ablation were similar to [those of] patients with no history of atrial fibrillation. This suggests that our management approach can alter some of the negative effects and natural history of atrial fibrillation. As physicians, we spend a lot of our time and energy trying to prevent stroke. This study helps us understand better how our management approaches can alter stroke risk," said Dr. Bunch. "Our research shows that more aggressive treatment of atrial fibrillation by using catheter ablations will reduce the chances [that] a person will have a life-threatening stroke."
Migraine Increases Cardiovascular Risk in Women With Symptoms of Ischemic Heart Disease
Among women being evaluated for ischemic heart disease, those who reported a history of migraine headaches have an increased risk of future cardiovascular (CV) event. This finding is primarily driven by the more than twofold increased risk of stroke.
Data regarding the association between migraine headaches and CV events in women have been inconsistent. Cecil A. Rambarat, MD, a resident at the University of Florida in Gainesville, and colleagues conducted a study to determine the long-term risk of CV events among women with and without migraine headaches who were evaluated for suspected ischemic heart disease in the Women's Ischemia Syndrome Evaluation (WISE) Study.
Women reporting a history of migraine headache were identified from the WISE cohort. Extended follow-up data were available, for a median follow-up of six years. Cox proportional adjusted hazard ratios (HR) were constructed for time to first adverse CV event (ie, CV death, nonfatal myocardial infarction [MI], heart failure hospitalization, or nonfatal stroke) among women with and without migraine headaches. In addition, HRs were determined for each event separately, as well as for all-cause death, angina hospitalization, death or MI, and CV death or MI.
Data on self-reported migraine headaches were available for 917 women. A total of 224 (24.4%) women reported a history of migraine headaches. Compared with those who did not report a history of migraines, women with a history of migraine headaches had an increased adjusted risk of CV events (HR, 1.83) at a median follow-up of six years. This result was mainly due to an increase in the risk of stroke (HR, 2.33).
The variables for which Dr. Rambarat and colleagues adjusted the data included age, race, BMI, history of diabetes, hypertension, dyslipidemia, smoking, family history of coronary artery disease, WISE coronary artery disease severity score, and aspirin use.