ESC: Coffee, Naps, and Depression in Hypertension

LONDON -- Long midday naps were associated with lower blood pressure, while a daily espresso habit and depression were linked to worse control in hypertension, observational studies suggested.

The studies presented here at the European Society of Cardiology (ESC) meeting, though, brought calls for caution in attributing causality.

"It's the accumulating evidence of how important our lifestyle is," commented Christi Deaton, PhD, RN, of the University of Cambridge Institute of Public Health in Cambridge, England.

These attempts at determining avenues for non-pharmacologic management of hypertension reflect the challenge of getting the condition controlled, noted Ian Graham, PhD, of Trinity College in Dublin and co-chair of the ESC press conference where the results were discussed.

"It's an enormous public health challenge," he told MedPage Today. "We'd really like to know more about things that affect blood pressure. In today's session we were looking at three of those."

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Naps Healthy for Hypertensives?

People who slept for at least an hour at midday had 4-mm Hg lower average 24-hour ambulatory systolic blood pressure than non-nappers (P=0.004), after adjusting for potential confounders such as age, gender, body mass index, smoking, salt and coffee intake, alcohol use, and exercise in a prospective cohort study.

Midday sleepers also had small advantages in pulse wave velocity and left atrium diameter (odds ratios 0.78 and 0.89, P=0.017 and P=0.019) suggesting less damage to the arteries and heart, Manolis Kallistratos, MD, PhD, of Asklepieion Voula General Hospital in Athens, and colleagues reported.

"We have to keep in mind that a reduction of blood pressure of just 2 mm Hg may decrease the relative risk of cardiovascular risk by up to 10%, so these 6 mm Hg [difference in average office-measured blood pressure] may have prognostic significance," Kallistratos told reporters at the press conference.

The prospective study included 386 men and women (average age 61.4) with fairly well-controlled arterial hypertension.

Interestingly, siesta takers also were slightly more likely to be "dippers" at night (2% more than people not sleeping an hour midday).

"It's not a trial, it's observational, but it's quite a big effect and could very well be genuine" Graham noted, adding, "It would be difficult to make a strong recommendation on this evidence, but it would be a not unreasonable thing."

It's well documented that nighttime sleep -- and even just rest -- can reduce blood pressure, José Ramón González-Juanatey, MD, PhD, of Spain's University of Santiago de Compostela and also a co-chair of the press conference, noted.

"It's a good explanation of these results -- the changes in sympathetic and parasympathetic drive after the REM period of sleep," he said.

Espresso Bad for Blood Pressure?

A daily espresso habit was associated with worsening hypertension and cardiovascular events, with a linear relationship between the number of drinks and risk in adults, ages 18 to 45, with initially mild hypertension (P=0.032 and P=0.0017, respectively), according to the prospective HARVEST study from Italy.

Drinking four or more cups of espresso a day was associated with significant 3.2-fold higher likelihood of cardiovascular events (mostly heart attacks) over the 12.5 years of follow-up after adjustment for other lifestyle factors, cholesterol, blood pressure, changes in weight, and incident hypertension and prediabetes.

Development of prediabetes was also linked to espresso intake and attenuated the associations with cardiovascular events, suggesting that link is mediated in part by long-term influence on glucose metabolism, Lucio Mos, MD, of the Hospital of San Daniele del Friuli in Udine, and colleagues reported.

While the link between coffee and hypertension has been controversial, "there are very good reasons why coffee intake should relate in younger people to hypertension," Graham said. "Coffee is a stimulant."

González-Juanatey suggested that sympathetic drive likely plays a role in this association as well and supported a recommendation for reduced intake by younger people with stage 1 hypertension.

However, Graham was more circumspect.

"Whether that translates to a decrease in blood pressure by stopping it would require a randomized controlled trial, but it's plausible and logical that it would," he added in an interview.

The study included 1,201 people, ages 18 to 45 years, without diabetes who were participating in the prospective HARVEST (Hypertension and Ambulatory Recording VEnetia STudy) at 17 hypertension units in Italy. They had untreated stage 1 hypertension, with a systolic blood pressure of 140 to 159 mm Hg or diastolic blood pressure of 90 to 99 mm Hg or both.

Among them, 26.3% didn't drink any coffee, 62.7% were moderate consumers of one to three cups a day, and 10.0% were heavy users drinking four or more cups of coffee a day.

Depression and Hypertension

The combination of hypertension and depression symptoms was associated with synergistic risk of recurrent major cardiovascular events (P=0.03), Bhautesh Jani, MBBS, of the Institute of Health and Wellbeing at the University of Glasgow in Scotland, and colleagues found.

The combination of systolic blood pressure of 160 mm Hg or higher or diastolic 100 mm Hg or higher and elevated hospital anxiety and depression score (HADS-D) was associated with 83% higher risk than seen with normal blood pressure and no depressive symptoms after adjustment for factors including demographics, cholesterol, antidepressant use, and medical comorbidities.

The risks were significant but less than 25% elevated for either risk factor alone.

In their clinic practice-based study of 35,537 people living in the community with existing heart disease, diabetes or stroke in Scotland, 11% had a further stroke or heart attack, developed heart failure or died from heart disease during 4 years of follow-up.

"This is not a randomized controlled trial so we don't know if screening would be of any benefit, but it's another line of inquiry which we need to think about," Jani concluded.

Graham agreed on cautious interpretation.

"Maybe it's a slight chicken and egg [problem], because are they depressed because they've had an event? Or do they get another event because they're depressed?" he said. "There seems to be some kind of synergy. Whatever that means we don't know, because there's no good evidence that treating depression lowers risk.

"But it should be a signal to try harder with ordinary risk factors -- to try harder on blood pressure, cholesterol, and smoking in somebody who has had an event and is depressed," he added.

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This article was first published on MedPage Today and reprinted with permission. Free registration is required.

• The study by Mos' group was sponsored by "Associazione 18 Maggio 1370."
• The study by Jani's group was sponsored by the Chief Scientist Office, Scottish Government.
• Mos, Graham, Kallistratos, and Jani disclosed no relevant relationships with industry.
• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
• last updated:08.31.2015

Primary Source: European Society of Cardiology

• Source Reference: Mos L, et al "Long term cardiovascular and metabolic effects of coffee consumption in young hypertensive subjects: results from HARVEST study" ESC 2015.

Secondary Source:European Society of Cardiology

• Source Reference: Kallistratos M, et al "Association of mid-day naps occurrence and duration with BP levels in hypertensive patients. A prospective observational study" ESC 2015.

Additional Source:European Society of Cardiology

Source Reference: Jani B, et al "Blood Pressure control, presence of depressive symptoms and clinical outcomes at 4 years in patients with cardiometabolic disease" ESC 2015.