Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Commentary
  • Published:

Blood pressure and vascular cognitive impairment: the debate continues

Journal of Human Hypertension volume 20, pages 1–3 (2006)Cite this article

The role of hypertension in the aetiology of vascular disease and the beneficial effects of antihypertensive treatment in preventing vascular events are well established. There is even evidence to suggest that antihypertensives treatment may reduce vascular risk, even in normotensive individuals. In contrast, the cognitive effects of blood pressure (BP) lowering remain a subject of considerable controversy.1 Epidemiological studies show conflicting results; although elevated BP in midlife has been associated with higher prevalence of white matter injury in the brain and cognitive decline in later years, lower BP in old age has been associated with poorer intellectual function.2, 3, 4, 5, 6 In addition, intervention studies with antihypertensives have shown opposing effects of BP reduction on cognitive function, further adding to the debate.7, 8, 9

Much of the controversy regarding the relationship between BP and cognition results from differences in definitions, subjects, methodologies and assessment techniques both for cognitive function and white matter disease between studies, as well as the confounding effects of antihypertensives treatment and comorbidities. In addition, very few studies have investigated the relationship between dynamic changes in BP, progression of white matter disease and cognitive performance in the same group of patients. The paper by van Boxtel et al.10 in this issue is the first study in which the relationship between BP, white matter disease load and cognitive performance has been examined systematically in the same cohort of subjects. BP was assessed using ambulatory 24-h BP measurement, which not only is superior to casual BP measurements in predicting hypertension-induced cerebrovascular disease but also allows the effects of physiological variations in BP to be assessed. The difficulties in assessing white matter disease progression are well known, and the use of previously validated MR techniques further strengthens the study. Estimation of structural damage has been complemented by assessment of cerebral function using quantifiable, reproducible and sensitive neuropsychological indices of executive dysfunction, the hallmark of hypertensive subcortical cerebral disease.11 Consistent with previous studies, van Boxtel et al.10 demonstrated higher systolic BP and pulse pressures to be related to the presence and severity of white matter lesion load. However, no clear relationship was demonstrated between white matter lesion load and cognitive performance parameters or between diurnal BP rhythm and structural or functional cerebral damage. Furthermore, small vessel disease load and cognitive performance was not affected by nocturnal dip in BP.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Birns J, Markus H, Kalra L . Blood pressure reduction for vascular risk: is there a price to be paid? Stroke 2005; 36: 1308–1313.

    Article  Google Scholar 

  2. Guo Z, Fratiglioni L, Winblad B, Viitanen M . Blood pressure and performance on the Mini-Mental State Examination in the very old: cross-sectional and longitudinal data from the Kungsholmen Project. Am J Epidemiol 1997; 145: 1106–1113.

    Article  CAS  Google Scholar 

  3. Liao D, Cooper L, Cai J, Toole JF, Bryan NR, Hutchinson RG et al. Presence and severity of cerebral white matter lesions and hypertension, its treatment, and its control. The ARIC Study. Atherosclerosis risk in communities study. Stroke 1996; 27: 2262–2270.

    Article  CAS  Google Scholar 

  4. Swan GE, DeCarli C, Miller BL, Reed T, Wolf PA, Jack LM et al. Association of midlife blood pressure to late-life cognitive decline and brain morphology. Neurology 1998; 51: 986–993.

    Article  CAS  Google Scholar 

  5. Dufouil C, de Kersaint-Gilly A, Besancon V, Levy C, Auffray E, Brunnereau L et al. Longitudinal study of blood pressure and white matter hyperintensities: the EVA MRI Cohort. Neurology 2001; 56: 921–926.

    Article  CAS  Google Scholar 

  6. de Leeuw FE, de Groot JC, Oudkerk M, Witteman JC, Hofman A, van Gijn J et al. Hypertension and cerebral white matter lesions in a prospective cohort study. Brain 2002; 125: 765–772.

    Article  Google Scholar 

  7. Prince M, Bird AS, Blizard RA, Mann AH . Is the cognitive function of older patients affected by antihypertensive treatment? Results from 54 months of the Medical Research Council's trial of hypertension in older adults. BMJ 1996; 312: 801–805.

    Article  CAS  Google Scholar 

  8. Forette F, Seux M, Staessen J, Thijs L, Birkenhager WH, Babarskiene MR et al. Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet 1998; 352: 1347–1351.

    Article  CAS  Google Scholar 

  9. The Progress Collaborative Group. Effects of blood pressure lowering with Perindopril and Indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Arch Inter Med 2003; 163: 1069–1075.

  10. Van Boxtel MPJ, Henskens LHG, Kroon AA, Hofman PAM, Groneneschild EHBM, Jolles J et al. Ambulatory blood pressure, asymptomatic cerebrovascular damage and cognitive function in essential hypertension. J Hum Hypertens, E-pub ahead of print: advance online publication, 15 September 2005; doi:10.1038/sj.jhh.1001934.

    Article  Google Scholar 

  11. O'Brien J, Erkinjuntii E, Reisberg B, Roman G, Sawada T, Pantoni L et al. Vascular cognitive impairment. Lancet Neurol 2003; 2: 89–93.

    Article  Google Scholar 

  12. Spence JD . Cerebral consequences of hypertension. J Hypertens 1996; 14: S139–S145.

    CAS  Google Scholar 

  13. Hassan A, Hunt BJ, O'Sullivan M, Parmar K, Bamford JM, Briley D et al. Markers of endothelial dysfunction in lacunar infarction and ischaemic leukoaraiosis. Brain 2003; 126: 424–432.

    Article  Google Scholar 

  14. de Reuck J . The human periventricular arterial blood supply and the anatomy of cerebral infarctions. Eur Neurol 1971; 5: 321–334.

    Article  CAS  Google Scholar 

  15. O'Sullivan M, Lythgoe DJ, Pereira AC, Summers PE, Jarosz JM, Williams SCR et al. Patterns of cerebral blood flow reduction in patients with ischaemic leukoaraiosis. Neurology 2002; 59: 321–326.

    Article  CAS  Google Scholar 

  16. Terborg C, Gora F, Weiller C, Rother J . Reduced vasomotor reactivity in cerebral microangiopathy. Stroke 2000; 31: 924–929.

    Article  CAS  Google Scholar 

  17. Isaka Y, Okamoto M, Ashia K, Imaizumi M . Decreased cerebrovascular dilatory capacity in subjects with asymptomatic periventricular hyperintensities. Stroke 1994; 25: 375–381.

    Article  CAS  Google Scholar 

  18. Barry DI . Cerebral blood flow in hypertension. J Cardiovasc Pharmacol 1985; 7 (Suppl 2): S94–S98.

    Article  Google Scholar 

  19. Kario K, Matsuo T, Kobayashi H, Imiya M, Matsuo M, Shimada K . Nocturnal fall of blood pressure and silent cerebrovascular damage in elderly hypertensive patients. Hypertension 1996; 27: 130–135.

    Article  CAS  Google Scholar 

  20. Kario K, Pickering TG, Matsuo T, Hoshide S, Schwartz JE, Shimada K . Stroke prognosis and abnormal nocturnal blood pressure falls in older hypertensives. Hypertension 2001; 38: 852–857.

    Article  CAS  Google Scholar 

  21. Kario K, Eguchi K, Hoshide S, Hoshide Y, Umeda Y, Mitsuhashi T et al. U-curve relationship between orthostatic blood pressure change and silent cerebrovascular disease in elderly hypertensives: orthostatic hypertension as a new cardiovascular risk factor. J A Coll Cardiol 2002; 40: 133–141.

    Article  Google Scholar 

  22. Kohara K, Igase M, Yinong J, Fukuoka T, Maguchi M, Okura T et al. Asymptomatic cerebrovascular damages in essential hypertension in the elderly. Am J Hypertens 1997; 10: 829–835.

    Article  CAS  Google Scholar 

  23. Kohara K, Jiang Y, Igase M, Takata Y, Fukuoka T, Okura T et al. Postprandial hypotension is associated with asymptomatic cerebrovascular damage in essential hypertensive patients. Hypertension 1999; 33: 565–568.

    Article  CAS  Google Scholar 

  24. Nakamura K, Oita J, Yamaguchi T . Nocturnal blood pressure dip in stroke survivors a pilot study. Stroke 1995; 26: 1373–1378.

    Article  CAS  Google Scholar 

  25. Kario K, Pickering TG . Blood pressure variability in elderly patients. Lancet 2000; 355: 1645–1646.

    Article  CAS  Google Scholar 

  26. DeCarli C, Fletcher E, Ramey V, Harvey D, Jagust WJ . Anatomical mapping of white matter hyperintensities (WMH): exploring the relationships between periventricular WMH, deep WMH, and total WMH burden. Stroke 2005; 36: 50–55.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Stroke Medicine, Guy's, King's and St Thomas's School of Medicine, Denmark Hill Campus, Bessemer Road, London, UK

    J Birns & L Kalra

Authors
  1. J Birns
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. L Kalra
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to L Kalra.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Birns, J., Kalra, L. Blood pressure and vascular cognitive impairment: the debate continues. J Hum Hypertens 20, 1–3 (2006). https://doi.org/10.1038/sj.jhh.1001940

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/sj.jhh.1001940

This article is cited by

Search

Advanced search

Quick links