Correspondence
nurse-led vascular care in lowering
vascular risk. Another study3 reported
the possible clinical benefit for
early dementia and denied clinical
effectiveness for advanced dementia,
which suggests that vascular care
would be useful for prevention rather
than management. Therefore, vascular
care might have a more important role
as a primary prevention of dementia
in resource-limited settings, including
rural areas or developing countries.
Second, although some previous
studies3–5 have reported that the
vascular care intervention was effective,
interventions by nurses varied greatly
across studies, such as in frequency and
targeted health conditions. Comparison
of detailed information of these
nurse-led vascular cares is worthwhile.
Therefore, a comparison of the method
of nurse-led care in Moll van Charante
and colleagues’ study with methods of
past studies would be useful.
We declare no competing interests.
*Tomohiro Morita, Asaka Higuchi,
Akihiko Ozaki, Yuki Shimada,
Tetsuya Tanimoto
t.morita526@gmail.com
Department of Internal Medicine, Soma Central
Hospital, Fukushima 976-0016, Japan (TM);
Department of Hematology, Toranomon Hospital,
Tokyo, Japan (AH); Department of Surgery (AO) and
Department of Neurosurgery (YS), Minamisoma
Municipal General Hospital, Fukushima, Japan; and
Department of Internal Medicine, Jyoban Hospital of
Tokiwa Foundation, Fukushima, Japan (TT)
1 Moll van Charante EP, Richard E, Eurelings LS,
et al. Effectiveness of a 6-year multidomain
vascular care intervention to prevent dementia
(preDIVA): a cluster-randomised controlled
trial. Lancet 2016; 388: 797–805.
2 Greving JP, Kaasjager HA, Vernooij JW, et al.
Cost-effectiveness of a nurse-led internet-based
vascular risk factor management programme:
economic evaluation alongside a randomised
controlled clinical trial. BMJ Open 2015;
5: e007128.
3 Richard E, Gouw AA, Scheltens P, van Gool WA.
Vascular care in patients with Alzheimer
disease with cerebrovascular lesions slows
progression of white matter lesions on MRI:
the evaluation of vascular care in Alzheimer’s
disease (EVA) study. Stroke 2010; 41: 554–56.
4 Richard E, Kuiper R, Dijkgraaf M, Van Gool WA.
Vascular care in patients with Alzheimer’s disease
with cerebrovascular lesions—a randomized
clinical trial. J Am Geriatr Soc 2009; 57: 797–805.
5 Andrieu S, Coley N, Lovestone S, Aisen PS,
Vellas B. Prevention of sporadic Alzheimer’s
disease: lessons learned from clinical trials and
future directions. Lancet Neurol 2015; 14: 926–44.
www.thelancet.com Vol 389 January 14, 2017
Hypertension control
and cardiovascular
disease
On the basis of Omran’s theory
of epidemiological transition,
Jacques Blacher and colleagues (July
30, p 530)1 provocatively propose
six strategies to reduce the burden
of hypertensive cardiovascular
disease. Notably, missing from their
list are strategies to minimise blood
pressure variability. In several large
randomised trials, such as ALLHAT2
and ASCOT,3 blood pressure variability
has been identified as a powerful
independent risk factor for stroke
and cardiovascular events.4–6 Of note,
not all antihypertensive drugs are
equally effective in reducing blood
pressure variability. The ALLHAT trial5
documented blood pressure variability
reduction to be best with amlodipine,
followed by chlorthalidone, whereas
lisinopril was much less efficacious
than were the other two. Given
the excessive variability, it is little
surprise that stroke reduction is left
to be desired in the lisinopril group.
Adjustment for blood pressure
variability explained the differences
in stroke and coronary heart disease
outcomes between amlodipine-
based and atenolol-based treatment
in the ASCOT trial.6 Increased residual
systolic blood pressure variability in
treated hypertension causes a high
risk of vascular events.7
Similar to blood pressure variability,
LDL cholesterol variability has been
identified as a powerful independent
predictor of death and cardiovascular
events. 8 Conceivably, the sixth
strategy of Blacher and colleagues’,1
namely the temporality of
antihypertensive therapy, might also
relate to blood pressure variability.
The fact that renin-angiotensin-
aldosterone system (RAAS) blockers
and β blockers are less effective with
increasing age might not be due to
only diminished RAAS activity, but
also to increased vascular stiffness.
Rigid stiff arteries enhance blood
pressure variability and are less
responsive to RAAS blockade than to
other agents such as calcium channel
blockers. We propose that reduction
of blood pressure variability should
be added as a seventh strategy to the
list of Blacher and colleagues’, which
could change hypertension therapy.
iStock
FHM has consultant or advisory relationships with
Daiichi Sankyo, Pfizer, Abbott, Servier, Medtronic,
WebMD, Ipca, American College of Cardiology,
Menarini, Relypsa, and the University of Utah.
SB has consultant or advisory relationships with
Daiichi Sankyo, Pfizer, Abbott, and Merck. UF and
SFR declare no competing interests.
*Franz H Messerli, Urs Fischer,
Stefano F Rimoldi, Sripal Bangalore
messerli.f@gmail.com
Division of Cardiology, Icahn School of Medicine,
Mount Sinai Hospital, New York, NY 10029, USA
(FHM); Department of Cardiology (SFR) and
Department of Neurology (UF), University of Bern,
Bern, Switzerland; and Department of Cardiology,
New York University, New York, NY, USA (SB)
1 Blacher J, Levy BI, Mourad JJ, Safar ME, Bakris G.
From epidemiological transition to modern
cardiovascular epidemiology: hypertension in
the 21st century. Lancet 2016; 388: 530–32.
2 ALLHAT Collaborative Research Group. Major
outcomes in high-risk hypertensive patients
randomized to angiotensin-converting
enzyme inhibitor or calcium channel blocker vs
diuretic: The Antihypertensive and Lipid-
Lowering Treatment to Prevent Heart Attack
Trial (ALLHAT). JAMA 2002; 288: 2981–97.
3 Jamerson K, Weber MA, Bakris GL, for the
ACCOMPLISH Trial Investigators. Benazepril
plus amlodipine or hydrochlorothiazide for
hypertension in high-risk patients. N Engl J Med
2008; 359: 2417–28.
4 Webb AJ, Fischer U, Mehta Z, Rothwell PM.
Effects of antihypertensive-drug class on
interindividual variation in blood pressure and
risk of stroke: a systematic review and
meta-analysis. Lancet 2010; 375: 906–15.
5 Muntner P, Whittle J, Lynch AI, et al.
Visit-to-visit variability of blood pressure and
coronary heart disease, stroke, heart failure,
and mortality: a cohort study. Ann Intern Med
2015; 163: 329–38.
6 Rothwell PM, Howard SC, Dolan E, et al.
Prognostic significance of visit-to-visit
variability, maximum systolic blood pressure,
and episodic hypertension. Lancet 2010;
375: 895–905.
7 Rothwell PM, Howard SC, Dolan E, et al, for the
ASCOT-BPLA and MRC Trial Investigators.
Effects of beta blockers and calcium-channel
blockers on within-individual variability in
blood pressure and risk of stroke. Lancet Neurol
2010; 9: 469–80.
8 Bangalore S, Breazna A, DeMicco DA, Wun CC,
Messerli FH. Visit-to-visit low-density
lipoprotein cholesterol variability and risk of
cardiovascular outcomes: insights from the
TNT trial. J Am Coll Cardiol 2015; 65: 1539–48.
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