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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 4, July/August 2021
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diastolic blood pressure, the second, lower number, that is
important to prevent brain tissue damage. Many people may
think of hypertension and stroke as diseases of older people,
but our results suggest that if we would like to keep a healthy
brain well into our 60s and 70s, we may have to make sure
our blood pressure, including the diastolic blood pressure,
stays within a healthy range when we are in our 40s and 50s.
‘The second important finding is that any increase in
blood pressure beyond the normal range is associated with
a higher amount of WMH. This suggests that even slightly
elevated blood pressure before it meets the criteria for
treating hypertension has a damaging effect on brain tissue.
‘Our results suggest that to ensure the best prevention
of WMH in later life, control of diastolic blood pressure, in
particular, may be required in early midlife, even for diastolic
blood pressure below 90 mmHg, while control of systolic
blood pressure may be more important in late life. The
long time interval between the effects of blood pressure in
midlife and the harms in late life emphasises how important
it is to control blood pressure long-term, and that research
has to adapt to consider the very long-term effects of often
asymptomatic problems in midlife.’
Potential mechanisms for the development of WMH
include damage to the delicate blood vessels in the brain
through sustained elevated pressures over time that directly
cause damage to the blood vessels; this leads to the lining of
the vessels becoming leaky and results inWMH. Alternatively,
diastolic pressure might cause large blood vessels to become
stiffer with time, which increases pulsations of blood pressure
to the brain. This causes high blood pressure with each heart
beat, rapid changes in blood pressure, and blood flow that
is too low between heart beats, resulting in damage to white
matter.
As MRI scans were only available at one time point, the
researchers could not quantify the progression of WMH
directly. Other limitations include that further analysis is
needed to identify differences in different regions of white
matter, and that although the researchers showed associations
with smoking and diabetes, the potential complex interaction
between risk factors, which also include high cholesterol levels,
obesity and kidney problems, require further investigation.
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