Ambulatory blood pressure variability: a conceptual review.
Zawadzki Matthew J,Small Amanda K,Gerin William
Blood pressure monitoring
Ambulatory blood pressure (ABP) has long been recognized by researchers as the gold standard of blood pressure (BP) measurement. Researchers and clinicians typically rely on the mean measure of ABP; however, there is considerable variability in the beat-to-beat BP. Although often ignored, this variability has been found to be an independent predictor of cardiovascular disease and mortality. The aim of this paper is to provide a conceptual review of ABP variability (ABPV) focusing on the following: associations between ABPV and health, whether ABPV is reliable, how to calculate ABPV, predictors of ABPV, and treatments for ABPV. Two future directions are discussed involving better understanding ABPV by momentary assessments and improving knowledge of the underlying physiology that explains ABPV. The results of this review suggest that the unique characteristics of ABPV provide insight into the role of BP variability in hypertension and subsequent cardiovascular illness.
[Ambulatory blood pressure monitoring is a useful tool for all patients].
de la Sierra A
Hipertension y riesgo vascular
Clinical blood pressure measurement (BP) is an occasional and imperfect way of estimating this biological variable. Ambulatory blood pressure monitoring (ABPM) is by far the best clinical tool for measuring an individual's blood pressure. Mean values over 24h, through the daytime and at night all make it more possible to predict organic damage and the future development of the disorder. ABPM enables the detection of white-coat hypertension and masked hypertension in both the diagnosis and follow-up of treated patients. Although some of the advantages of ABPM can be reproduced by more automated measurement without the presence of an observer in the clinic or self-measurement at home, there are some other elements of great interest that are unique to ABPM, such as seeing what happens to a patient's BP at night, the night time dipping pattern and short-term variability, all of which relate equally to the patient's prognosis. There is no scientific or clinical justification for denying these advantages, and ABPM should form part of the evaluation and follow-up of practically all hypertensive patients. Rather than continuing unhelpful discussions as to its availability and acceptability, we should concentrate our efforts on ensuring its universal availability and clearly explaining its advantages to both doctors and patients.
[Current clinical aspects of ambulatory blood pressure monitoring].
Sauza-Sosa Julio César,Cuéllar-Álvarez José,Villegas-Herrera Karla Montserrat,Sierra-Galán Lilia Mercedes
Archivos de cardiologia de Mexico
Systemic arterial hypertension is the prevalentest disease worldwide that significantly increases cardiovascular risk. An early diagnosis together to achieve goals decreases the risk of complications significatly. Recently have been updated the diagnostic criteria for hypertension and the introduction of ambulatory blood pressure monitoring. The introduction into clinical practice of ambulatory blood pressure monitoring was to assist the diagnosis of «white coat hypertension» and «masked hypertension». Today has also shown that ambulatory blood pressure monitoring is better than the traditional method of recording blood pressure in the office, to the diagnosis and to adequate control and adjustment of drug treatment. Also there have been introduced important new concepts such as isloted nocturnal hypertension, morning blood pressure elevation altered and altered patterns of nocturnal dip in blood pressure; which have been associated with increased cardiovascular risk. Several studies have shown significant prognostic value in some stocks. There are still other concepts on which further study is needed to properly establish their introduction to clinical practice as hypertensive load variability, pulse pressure and arterial stiffness. In addition to setting values according to further clinical studies in populations such as elderly and children.
Magnitude of blood pressure reduction in the placebo arms of modern hypertension trials: implications for trials of renal denervation.
Patel Hitesh C,Hayward Carl,Ozdemir Baris Ata,Rosen Stuart D,Krum Henry,Lyon Alexander R,Francis Darrel P,di Mario Carlo
Hypertension (Dallas, Tex. : 1979)
Early phase studies of novel interventions for hypertension, such as renal sympathetic denervation, are sometimes single-armed (uncontrolled). We explored the wisdom of this by quantifying the blood pressure fall in the placebo arms of contemporary trials of hypertension. We searched Medline up to June 2014 and identified blinded, randomized trials of hypertension therapy in which the control arm received placebo medication or a sham (placebo) procedure. For nonresistant hypertension, we have identified all such trials of drugs licensed by the US Food and Drug Administration since 2000 (5 drugs). This US Food and Drug Administration-related restriction was not applied to resistant hypertension trials. This produced 7451 patients, who were allocated to a blinded control from 52 trials of nonresistant hypertension and 694 patients from 8 trials of resistant hypertension (3 drugs and 2 interventions). Systolic blood pressure fell by 5.92 mm Hg (95% confidence interval, 5.14-6.71; P<0.0001) in the nonresistant cohort and by 8.76 mm Hg (95% confidence interval, 4.83-12.70; P<0.0001) in the resistant cohort. Using metaregression, the falls were larger in trials that did not use ambulatory blood pressure monitoring as an inclusion criterion (z=2.84; P=0.0045), in those with higher baseline blood pressures (z=-0.3; P=0.0001), and in those where the patients were prescribed a continuous background of antihypertensives (z=-2.72; P=0.0065). The nontrivial magnitude of these apparent blood pressure reductions with perfectly ineffective intervention (placebo) illustrates that efficacy explorations of novel therapies for hypertension, once safety is established, should be performed with a randomized, appropriately controlled, and blinded design.
The effect of fixed-dose combination of valsartan and amlodipine on nighttime blood pressure in patients with non-dipper hypertension.
Erdoğan Doğan,İçli Atilla,Aksoy Fatih,Akçay Salaheddin,Yücel Habil,Ersoy İbrahim,Özaydın Mehmet
Turk Kardiyoloji Dernegi arsivi : Turk Kardiyoloji Derneginin yayin organidir
OBJECTIVE:Failure to decrease blood pressure (BP) during the night is associated with higher cardiovascular (CV) morbidity and mortality. There is strong evidence that fixed-dose combinations (FDCs) of antihypertensive agents are associated with significant improvement and non-significant adverse effects. The aim of the present study was to evaluate whether FDC affected nocturnal BP favorably in patients with uncontrolled, non-dipper hypertension (HT). METHODS:All non-dipper hypertensives were either newly diagnosed with stage 2-3 HT or had HT uncontrolled with monotherapy. Patients (n=195) were consecutively assigned to 4 treatment groups: FDC of valsartan/amlodipine (160/5 mg), free-drug combination of valsartan 160 mg and amlodipine 5 mg, amlodipine 10 mg, and valsartan 320 mg. Ambulatory blood pressure monitoring (ABPM) was repeated at 4th and 8th week. RESULTS:Average 24-h (24-hour) and nocturnal BP were similar among the groups at baseline evaluation, and had significantly decreased by the fourth week of treatment. However, BP continued to decrease only slightly between the 4th and 8th weeks in the valsartan and amlodipine monotherapy groups, but continued to decrease significantly in both combination groups. After 4 weeks, day-night BP difference and day-night BP % change were significantly elevated in the combination and valsartan groups. Between the 4th and 8th weeks, however, day-night BP difference and day-night BP % change continued to rise only in the FDC group, nearly reducing to baseline levels in the free-drug combination and valsartan groups. An additional 2.2 mmHg decrease was observed in the FDC group, compared to the free-drug combination group. CONCLUSION:In non-dipper HT, FDC of valsartan and amlodipine improved diurnal-nocturnal ratio of BP and provided 24-h coverage.
Comparison of valsartan and amlodipine on ambulatory blood pressure variability in hypertensive patients.
Eguchi Kazuo,Imaizumi Yuki,Kaihara Toshiki,Hoshide Satoshi,Kario Kazuomi
Clinical and experimental hypertension (New York, N.Y. : 1993)
We tested the hypothesis that calcium channel blockers (CCBs: amlodipine group, n = 38)) are superior to angiotensin receptor blockers (ARBs: valsartan group, n = 38) against ambulatory blood pressure variability (BPV) in untreated Japanese hypertensive patients. Both drugs significantly reduced ambulatory systolic and diastolic BP values. With regard to BPV, standard deviation (SD) in SBP did not change with the administration of either drug, but the ARB significantly increased SD in awake DBP (12 ± 4-14 ± 4 mmHg). The ARB also significantly increased the coefficients of variation (CVs)in awake and 24-h SBP/DBP (all P < 0.05), but amlodipine did not change the CV. CCB significantly reduced the maximum values of awake SBP (193 ± 24-182 ± 27 mmHg, P = 0.02), sleep SBP (156 ± 18-139 ± 14 mmHg, P < 0 .001), and awake and sleep DBP (P < 0.01 in both cases), but the ARB did not change the maximum BP values. In conclusion, a once-daily morning dose of CCB amlodipine was more effective at controlling ambulatory BPV than ARB valsartan, especially in reducing maximum BP levels.
Patterns of ambulatory blood pressure: clinical relevance and application.
O'Brien Eoin,Kario Kazuomi,Staessen Jan A,de la Sierra Alejandro,Ohkubo Takayoshi
Journal of clinical hypertension (Greenwich, Conn.)
Ambulatory blood pressure measurement (ABPM) is now recommended in all patients suspected of having hypertension. However, in practice, the mean daytime pressures are often used to make diagnostic and therapeutic decisions, and the information from abnormal patterns of blood pressure behavior is often overlooked. This paper presents daytime patterns (eg, white coat hypertension and siesta dipping), nocturnal patterns (eg, dipping, non-dipping, reverse dipping, and the morning surge), and discusses ambulatory hypotension, and abnormal patterns and indices of related hemodynamic parameters (eg, heart rate, pulse pressure, and blood pressure variability).
Prognostic Value of Nondipping and Morning Surge in Elderly Treated Hypertensive Patients With Controlled Ambulatory Blood Pressure.
Pierdomenico Sante D,Pierdomenico Anna M,Coccina Francesca,Lapenna Domenico,Porreca Ettore
American journal of hypertension
BACKGROUND:The independent prognostic significance of nondipping and morning surge (MS) of blood pressure (BP) in treated hypertensive patients with controlled ambulatory BP is not yet clear. We investigated the association between the aforesaid ambulatory BP parameters and cardiovascular risk in elderly treated hypertensive patients with normal achieved ambulatory BP. METHODS:The occurrence of a composite end-point (stroke, coronary events, heart failure, and peripheral revascularization) was evaluated in 391 elderly treated hypertensive patients (age range 60-90 years) with controlled ambulatory BP (both daytime BP <135/85 mm Hg and nighttime BP <120/70 mm Hg). According to nighttime change and MS of systolic BP, subjects were divided in dippers with normal or high MS (>23 mm Hg) and nondippers. RESULTS:During the follow-up (9.3 ± 4.6 years, range 0.5-20 years), 76 events occurred. The event-rate was 2.09 per 100 patient-years. After adjustment for age, gender, left ventricular (LV) hypertrophy, asymptomatic LV systolic dysfunction at baseline and left atrial enlargement, dippers with high MS (hazard ratio 2.45, 95% confidence interval 1.27-4.73, P = 0.007) and nondippers (hazard ratio 2.04, 95% confidence interval 1.18-3.53, P = 0.01) were at higher cardiovascular risk than dippers with normal MS. CONCLUSIONS:In elderly treated hypertensive patients with normal achieved ambulatory BP, dippers with high MS and nondippers are at increased cardiovascular risk.
Prevalence and clinical outcomes of white-coat and masked hypertension: Analysis of a large ambulatory blood pressure database.
Tocci Giuliano,Presta Vivianne,Figliuzzi Ilaria,Attalla El Halabieh Nadia,Battistoni Allegra,Coluccia Roberta,D'Agostino Michela,Ferrucci Andrea,Volpe Massimo
Journal of clinical hypertension (Greenwich, Conn.)
The aim of this study was to analyze prevalence and clinical outcomes of the following clinical conditions: normotension (NT; clinic BP < 140/90 mm Hg; 24-hour BP < 130/80 mm Hg), white-coat hypertension (WCHT; clinic BP ≥ 140 and/or ≥90 mm Hg; 24-hour BP < 130/80 mm Hg), masked hypertension (MHT; clinic BP < 140/90 mm Hg; 24-hour BP ≥ 130 and/or ≥80 mm Hg), and sustained hypertension (SHT; clinic BP ≥ 140 and/or ≥90 mm Hg; 24-hour BP ≥ 130 and/or ≥80 mm Hg) in a large cohort of adult untreated individuals. Systematic research throughout the medical database of Regione Lazio (Italy) was performed to estimate incidence of myocardial infarction (MI), stroke, and hospitalizations for HT and heart failure (HF). Among a total study sample of 2209 outpatients, 377 (17.1%) had NT, 351 (15.9%) had WCHT, 149 (6.7%) had MHT, and 1332 had (60.3%) SHT. During an average follow-up of 120.1 ± 73.9 months, WCHT was associated with increased risk of hospitalization for HT (OR 95% CI: 1.927 [1.233-3.013]; P = .04) and HF (OR 95% CI: 3.449 [1.321-9.007]; P = .011). MHT was associated with an increased risk of MI (OR 95% CI: 5.062 [2.218-11.550]; P < .001), hospitalization for HT (OR 95% CI: 2.553 [1.446-4.508]; P = .001), and for HF (OR 95% CI: 4.214 [1.449-12.249]; P = .008). These effects remained statistically significant event after corrections for confounding factors including age, BMI, gender, smoking, dyslipidaemia, diabetes, and presence of antihypertensive therapies.
Blood pressure variability over 24 h: prognostic implications and treatment perspectives. An assessment using the smoothness index with telmisartan-amlodipine monotherapy and combination.
Parati Gianfranco,Schumacher Helmut
Hypertension research : official journal of the Japanese Society of Hypertension
In-office blood pressure (BP) measurements have recognized limitations, including the inability to collect BP information over a long period of time, and during an individual's usual daily activities. Home or ambulatory BP monitoring (ABPM) may therefore be used to complement conventional office measurements, thereby improving prognostic value. Of particular relevance is the ability of 24 h ABPM to quantify the degree of BP variability over 24 h, which has been shown to be a significant and independent risk factor for cardiovascular (CV) morbidity and mortality. Twenty-four hour BP variability is indeed strongly associated with clinical outcomes, and the ability of ABPM to provide a quantification of BP throughout the 24-h period during an individual's normal daily routine is one of the reasons for its high prognostic value. The smoothness index (SI) provides a useful measure of antihypertensive treatment efficacy over the 24 h dosing period, its values being highest with antihypertensive agents that have large and consistent effects across 24 h. Telmisartan and amlodipine are long-acting antihypertensive drugs that, in combination, not only reduce 24 h mean BP more than the respective monotherapies but also provide a significantly greater SI. The provision of homogeneous 24 h BP control has important clinical implications. Maintaining smooth BP over the entire 24 h dosing period may contribute to the improvement of CV outcomes, and reductions in BP variability may decrease end organ damage, and reduce CV risk.
Hypertension and blood pressure variability management practices among physicians in Singapore.
Setia Sajita,Subramaniam Kannan,Tay Jam Chin,Teo Boon Wee
Vascular health and risk management
PURPOSE:There are limited data on blood pressure variability (BPV) in Singapore. The absence of updated local guidelines might contribute to variations in diagnosis, treatment and control of hypertension and BPV between physicians. This study evaluated BPV awareness, hypertension management and associated training needs in physicians from Singapore. MATERIALS AND METHODS:Physicians from Singapore were surveyed between September 8, 2016, and October 5, 2016. Those included were in public or private practice for ≥3 years, cared directly for patients ≥70% of the time and treated ≥30 patients for hypertension each month. The questionnaire covered 6 main categories: general blood pressure (BP) management, BPV awareness/diagnosis, home BP monitoring (HBPM), ambulatory BP monitoring (ABPM), BPV management and associated training needs. RESULTS:Responses from 60 physicians (30 general practitioners [GPs], 20 cardiologists, 10 nephrologists) were analyzed (77% male, 85% aged 31-60 years, mean 22 years of practice). Approximately 63% of physicians considered white-coat hypertension as part of BPV. The most common diagnostic tool was HBPM (overall 77%, GPs 63%, cardiologists 65%, nephrologists 70%), but ABPM was rated as the tool most valued by physicians (80% overall), especially specialists (97%). Withdrawn Singapore guidelines were still being used by 73% of GPs. Approximately 48% of physicians surveyed did not adhere to the BP cutoff recommended by most guidelines for diagnosing hypertension using HBPM (>135/85 mmHg). Hypertension treatment practices also varied from available guideline recommendations, although physicians did tend to use a lower BP target for patients with diabetes or kidney disease. There were a number of challenges to estimating BPV, the most common of which was patient refusal of ABPM/HBPM. The majority of physicians (82%) had no training on BPV, but stated that this would be useful. CONCLUSION:There appear to be gaps in knowledge and guideline adherence relating to the assessment and management of BPV among physicians in Singapore.
[The effects of olmesartan on ambulatory blood pressures and blood pressure variability in patients with mild to moderate essential hypertension].
Li Jing,Qin Tingli,Jiang Hong,Wang Hao,Ke Yuannan
Zhonghua nei ke za zhi
OBJECTIVE:To evaluate the effect of olmesartan medoxomil tablets (olmesartan) in comparison with Olmetec on 24 h ambulatory blood pressure (ABPM) and blood pressure variability (BPV) in patients with mild to moderate hypertension. METHODS:A randomized, double-blind, double-mimic controlled trial was performed.Forty-eight patients with mild to moderate essential hypertension were randomly into treatment group (olmesartan) and control group (Olmetec) for eight weeks. The ABPM was taken before and at the end of the trial. RESULTS:After eight weeks, treatment with olmesartan induced a significant reduction in ABPM in patients [(9 ± 3)/(11 ± 3) mmHg(1 mmHg = 0.133 kPa)], which is similar with the reduction by Olmetec [(9 ± 4)/(9 ± 5) mmHg], P > 0.05. This situation holds for BPV with the standard deviations of 24 h, systolic blood pressure/diastolic blood pressure of pre-treatment and pro-treatment were (10 ± 2)/(11 ± 3) mmHg vs (10 ± 3)/(12 ± 2) mmHg in olmesartan group, and (10 ± 3)/(11 ± 3) mmHg vs (12 ± 3)/(12 ± 4) mmHg in Olmetec group. (3) There is no difference in the rate of adverse event between olmesartan (10.42%) and Olmetec (8.33%) treatment (P > 0.05). CONCLUSION:Similar to Olmetec, treatment with olmesartan once daily can significantly reduce ABPM in patients with mild to moderate essential hypertension.
Prediction of treatment-induced changes in target-organ damage using changes in clinic, home and ambulatory blood pressure.
Karpettas Nikos,Destounis Antonis,Kollias Anastasios,Nasothimiou Efthimia,Moyssakis Ioannis,Stergiou George S
Hypertension research : official journal of the Japanese Society of Hypertension
Cross-sectional studies have shown that ambulatory and home blood pressure (ABP and HBP, respectively) measurements are more closely associated with preclinical organ damage than are office measurements. This study investigated the association between treatment-induced changes in BP assessed by the three methods and the corresponding changes in organ damage. Untreated hypertensives were evaluated with office, ABP and HBP measurements and indices of organ damage (echocardiographic left-ventricular mass index (LVMI), pulse wave velocity (PWV), albuminuria) before and after 12 months of treatment. A total of 116 subjects completed the study (mean age 50.7±10.5 years, 69 men (59%), mean follow-up 13.4±1.4 months). The treatment-induced change in the LVMI was correlated with changes in BP and pulse pressure (PP) assessed by all methods. The change in PWV was correlated with changes in home systolic and ABP and PP and with the change in home diastolic BP. Albuminuria showed no correlations. In linear regression models, changes in home BP and PP had the strongest predictive ability for the change in the LVMI, whereas the change in ABP was the strongest predictor of the change in PWV. The change in office BP had no predictive value. HBP and ABP measurements appear to be superior to office BP measurements and should be considered complementary rather than interchangeable methods for monitoring the effects of antihypertensive treatment on target-organ damage.
Associations between body mass index, ambulatory blood pressure findings, and changes in cardiac structure: relevance of pulse and nighttime pressures.
Fedecostante Massimiliano,Spannella Francesco,Giulietti Federico,Espinosa Emma,Dessì-Fulgheri Paolo,Sarzani Riccardo
Journal of clinical hypertension (Greenwich, Conn.)
Ambulatory blood pressure monitoring (ABPM) is central in the management of hypertension. Factors related to BP, such as body mass index (BMI), may differently affect particular aspects of 24-hour ABPM profiles. However, the relevance of BMI, the most used index of adiposity, has been underappreciated in the determination of specific aspects of 24-hour ABPM profiles in hypertension. The authors evaluated the association between BMI and aspects of ABPM together with their associations with cardiac remodeling in 1841 patients. A positive association of BMI with 24-hour, daytime, and nighttime pulse pressure in untreated normal weight and overweight/obese hypertensive patients and a positive association of BMI with nocturnal BP parameters in treated overweight/obese hypertensive patients was observed. The clinical relevance of these findings was supported by the positive significant correlations of BMI-related BPs with left ventricular mass and atrial diameter.
How in-office and ambulatory BP monitoring compare: A systematic review and meta-analysis.
Reino-Gonzalez Sergio,Pita-Fernández Salvador,Seoane-Pillado Teresa,López-Calviño Beatriz,Pértega Díaz Sonia
The Journal of family practice
Purpose:We performed a literature review and meta-analysis to ascertain the validity of office blood pressure (BP) measurement in a primary care setting, using ambulatory blood pressure measurement (ABPM) as a benchmark in the monitoring of hypertensive patients receiving treatment. Methods:We conducted a literature search for studies published up to December 2013 that included hypertensive patients receiving treatment in a primary care setting. We compared the mean office BP with readings obtained by ABPM. We summarized the diagnostic accuracy of office BP with respect to ABPM in terms of sensitivity, specificity, and positive and negative likelihood ratios (LR), with a 95% confidence interval (CI). Results:Only 12 studies met the inclusion criteria and contained data to calculate the differences between the means of office and ambulatory BP measurements. Five were suitable for calculating sensitivity, specificity, and likelihood ratios, and 4 contained sufficient extractable data for meta-analysis. Compared with ABPM (thresholds of 140/90 mm Hg for office BP; 130/80 mmHg for ABPM) in diagnosing uncontrolled BP, office BP measurement had a sensitivity of 81.9% (95% CI, 74.8%-87%) and specificity of 41.1% (95% CI, 35.1%-48.4%). Positive LR was 1.35 (95% CI, 1.32-1.38), and the negative LR was 0.44 (95% CI, 0.37-0.53). Conclusion:Likelihood ratios show that isolated BP measurement in the office does not confirm or rule out the presence of poor BP control. Likelihood of underestimating or overestimating BP control is high when relying on in-office BP measurement alone.
Screening for Hypertension and Lowering Blood Pressure for Prevention of Cardiovascular Disease Events.
Viera Anthony J
The Medical clinics of North America
Hypertension affects 1 in 3 American adults. Blood pressure (BP)-lowering therapy reduces the risk of cardiovascular disease. The United States Preventive Services Task Force recommends all adults be screened for hypertension. Most patients whose office BP is elevated should have out-of-office monitoring to confirm the diagnosis. Ambulatory BP monitoring is preferred for out-of-office measurement, but home BP monitoring is a reasonable alternative. Guidelines for treatment are stratified by age (<60 vs >60 years) and include cutoffs for recommended treatment BPs and target BP goals. Quality of hypertension care is improved by incorporating population health management using registries and medication titration.
[Measurement of blood pressure variability and the clinical value].
Kékes Ede,Kiss István
Authors have collected and analyzed literature data on blood pressure variability. They present the methods of blood pressure variability measurement, clinical value and relationships with target organ damages and risk of presence of cardiovascular events. They collect data about the prognostic value of blood pressure variability and the effects of different antihypertensive drugs on blood pressure variability. They underline that in addition to reduction of blood pressure to target value, it is essential to influence blood pressure fluctuation and decrease blood pressure variability, because blood pressure fluctuation presents a major threat for the hypertensive subjects. Data from national studies are also presented. They welcome that measurement of blood pressure variability has been included in international guidelines.
Home blood pressure monitoring: primary role in hypertension management.
Stergiou George S,Kollias Anastasios,Zeniodi Marilena,Karpettas Nikos,Ntineri Angeliki
Current hypertension reports
In the last two decades, considerable evidence on home blood pressure monitoring has accumulated and current guidelines recommend its wide application in clinical practice. First, several outcome studies have shown that the ability of home blood pressure measurements in predicting preclinical target organ damage and cardiovascular events is superior to that of the conventional office blood pressure measurements and similar to that of 24-hour ambulatory monitoring. Second, cross-sectional studies showed considerable agreement of home blood pressure measurements with ambulatory monitoring in detecting the white-coat and masked hypertension phenomena, in both untreated and treated subjects. Third, studies have shown larger blood pressure decline by using home blood pressure monitoring instead of office measurements for treatment adjustment. Fourth, in treated hypertensives, home blood pressure monitoring has been shown to improve long-term adherence to antihypertensive drug treatment and thus, has improved hypertension control rates. These data suggest that home blood pressure should no longer be regarded as only a screening tool that requires confirmation by ambulatory monitoring. Provided that an unbiased assessment is obtained according to current recommendations, home blood pressure monitoring should have primary role in diagnosis, treatment adjustment, and long-term follow-up of most cases with hypertension.
Differing Effects of Aliskiren/Amlodipine Combination and High-Dose Amlodipine Monotherapy on Ambulatory Blood Pressure and Target Organ Protection.
Mizuno Hiroyuki,Hoshide Satoshi,Fukutomi Motoki,Kario Kazuomi
Journal of clinical hypertension (Greenwich, Conn.)
The aim of this study was to compare an aliskiren/amlodipine combination with high-dose amlodipine monotherapy on ambulatory blood pressure monitoring (ABPM) and organ protection. The study was a prospective, randomized, multicenter, open-label trial in elderly essential hypertensive patients. A total of 105 patients with clinic BP (CBP) ≥140/90 mm Hg with amlodipine 5 mg were randomly allocated to aliskiren (150-300 mg)/amlodipine (5 mg) (ALI/AML group, n=53) or high-dose amlodipine (10 mg) (h-dAML group, n=52) and treated for 16 weeks. Each patient's CBP, ABPM, urine albumin-to-creatinine ratio (UACR), and brachial-ankle pulse wave velocity (baPWV) were measured at baseline and at the end of the study. The ALI/AML and h-dAML groups showed similarly reduced mean 24-hour SBP, daytime SBP, nighttime SBP, and baPWV. However, UACR reduction was significantly greater in the ALI/AML group (P=.02). ALI/AML was significantly less effective in reducing early-morning BP (P=.002) and morning BP surge (P=.001) compared with h-dAML.
Morning hypertension is more common in elderly hypertensive patients with controlled documented office blood pressure in primary care clinics: the Minhang study.
Wang Yan,Chen Ling,Wang Yajuan,Qain Yuesheng,Zhang Jin,Tang Xiaofeng,Li Yan,Zhu Dingliang
Journal of hypertension
BACKGROUND:Increased morning blood pressure (BP) has been associated with fatal and nonfatal cardiovascular events, especially in Asians. METHOD:To detect the control status of home BP, we performed a home BP monitoring study, including elderly patients with hypertension who had controlled documented office BP in Chinese primary care clinics. In 707 participants from Xinzhuang County Hospital in Shanghai, the home BP was measured by a memory-equipped device three times daily for seven consecutive days. RESULTS:The prevalence of uncontrolled hypertension was 51.3% in the morning and 42% in the evening. Uncontrolled morning hypertension was associated with age [odds ratio (OR): 1.074; 95% confidence interval (CI): 1.041-1.108], office SBP (OR: 1.027; 95% CI: 1.015-1.039), office DBP (OR: 1.042; 95% CI: 1.021-1.064), and the number of antihypertensive drugs taken (OR: 1.387; 95% CI: 1.059-1.817), whereas it was inversely associated with the use of long-acting antihypertensive drugs (OR: 0.588; 95% CI: 0.355-0.973). Compared with office BP, the home morning BP showed a more significant association with age and short-acting antihypertensive drugs. CONCLUSION:The prevalence of uncontrolled home BP is high in elderly Chinese hypertensive patients, especially in the morning, and home BP monitoring might be a feasible method for detecting it. The use of long-acting antihypertensive drugs might help to improve morning hypertension.
Comparison of patients' confidence in office, ambulatory, and home blood pressure measurements as methods of assessing for hypertension.
Viera Anthony J,Tuttle Laura A,Voora Raven,Olsson Emily
Blood pressure monitoring
OBJECTIVE:Uncertainty exists when relying on office (clinic) blood pressure (BP) measurements to diagnose hypertension. Home BP monitoring and ambulatory BP monitoring (ABPM) provide measurements that are more strongly associated with cardiovascular disease. The degree to which patients exhibit uncertainty about office BP measurements is unknown, as is whether they would have less uncertainty about other BP measurement methods. We therefore assessed people's confidence in methods of BP measurement, comparing perceptions about office BP monitoring, home BP monitoring, and ABPM techniques. METHODS:We surveyed adults who were 30 years or older (n=193), all whom had undergone office BP measurements, two sessions of 24-h ABPM, and two 5-day periods of home BP monitoring. Respondents were asked to indicate their level of confidence on a 1 to 9 scale that BP measurements represented their 'usual' BP. RESULTS:Respondents had least confidence that assessments of BP made by office measurements (median 6) represented usual BP and greater confidence that assessments made by home BP monitoring (median 7, P<0.0001 vs. office) and ABPM (median 8, P<0.0001 vs. office) did so. Confidence levels did not vary significantly by BP levels, age, sex, race, or education level. CONCLUSION:The finding that patients do not have a great deal of confidence in office BP measurements, but have a higher degree of confidence in home BP and ambulatory BP assessment methods may be helpful in guiding strategies to diagnose hypertension and improve antihypertensive medication adherence.
Effects of cigarette smoking on ambulatory blood pressure, heart rate, and heart rate variability in treated hypertensive patients.
Ohta Yuko,Kawano Yuhei,Hayashi Shinichiro,Iwashima Yoshio,Yoshihara Fumiki,Nakamura Satoko
Clinical and experimental hypertension (New York, N.Y. : 1993)
We investigated the influence of cigarette smoking on the levels and circadian patterns of blood pressure (BP), heart rate (HR), and HR variability (HRV) in hypertensive patients. Sixteen hypertensive smokers (57 ± 2 years old) receiving antihypertensive treatments participated in this study. Ambulatory monitoring of BP, HR, and electrocardiograms was performed every 30 min for 24 hours on a smoking day and nonsmoking day in a randomized crossover manner. Average 24-hour BP and daytime BP were significantly higher in the smoking period than in the nonsmoking period. No significant differences were observed in nighttime BP between the two periods. Average 24-hour and daytime HR, but not nighttime HR, were also higher in the smoking period than in the nonsmoking period. The daytime high frequency (HF) component of HRV was attenuated more in the smoking period than in the nonsmoking period. No significant differences were observed in the low frequency (LF) components of HRV or LF/HF ratio between the two periods. These results demonstrated that cigarette smoking increased the daytime and average 24-hour BP and HR, and the increases observed in daytime BP and HR were associated with the attenuation of parasympathetic nerve activity.
Ambulatory blood pressure monitoring in the 21st century.
O'Brien Eoin,White William B,Parati Gianfranco,Dolan Eamon
Journal of clinical hypertension (Greenwich, Conn.)
In clinical practice, ambulatory blood pressure monitoring (ABPM) tends to be used solely for diagnosing hypertension, especially to identify white-coat and masked hypertension. However, ABPM can provide additional information to guide the management and drug treatment of hypertension. In this brief review, the general principles governing the use of ABPM in clinical practice, such as the devices and software, recording requirements, the thresholds for the day, night and 24-hour periods and how often to repeat ABPM are summarized. The use of ABPM for diagnosing, determining the efficacy of treatment, and assessing the long-term control of hypertension are discussed.
Role of ambulatory blood pressure monitoring for the management of hypertension in Asian populations.
Hoshide Satoshi,Cheng Hao-Min,Huang Qifang,Park Sungha,Park Chang-Gyu,Chen Chen-Huan,Wang Ji-Gwang,Kario Kazuomi,
Journal of clinical hypertension (Greenwich, Conn.)
Out-of-clinic blood pressure (BP) measurement, eg, ambulatory BP monitoring, has a strong association with target organ damage and is a powerful predictor of cardiovascular events compared with clinic BP measurement. Ambulatory BP monitoring can detect masked hypertension or various BP parameters in addition to average 24-hour BP level. Short-term BP variability assessed by standard deviation or average real variability, diminished nocturnal BP fall, nocturnal hypertension, and morning BP surge assessed by ambulatory BP monitoring have all been associated with target organ damage and cardiovascular prognosis. Recently, the authors compared the degree of sleep-trough morning BP surge between a group of Japanese and a group of Western European untreated patients with hypertension and found that sleep-trough morning BP surge in Japanese persons was significantly higher than that in Europeans. Although Asian persons have been known to have a higher incidence of stroke than heart disease, the difference in characteristics of BP indices assessed by ambulatory BP monitoring might be the cause of racial differences in stroke incidence between Asian and Western populations. This review focuses on Asian characteristics for the management of hypertension using ambulatory BP monitoring.
Randomized Crossover Trial of the Impact of Morning or Evening Dosing of Antihypertensive Agents on 24-Hour Ambulatory Blood Pressure.
Poulter Neil R,Savopoulos Christos,Anjum Aisha,Apostolopoulou Martha,Chapman Neil,Cross Mary,Falaschetti Emanuela,Fotiadis Spiros,James Rebecca M,Kanellos Ilias,Szigeti Matyas,Thom Simon,Sever Peter,Thompson David,Hatzitolios Apostolos I
Hypertension (Dallas, Tex. : 1979)
Some data suggest that nocturnal dosing of antihypertensive agents may reduce cardiovascular outcomes more than daytime dosing. This trial was designed to evaluate whether ambulatory blood pressure monitoring levels differ by timing of drug dosing. Patients aged 18 to 80 years with reasonably controlled hypertension (≤150/≤90 mm Hg) on stable therapy of ≥1 antihypertensive agent were recruited from 2 centers in London and Thessaloniki. Patients were randomized to receive usual therapy either in the morning (6 am-11 am) or evening (6 pm-11 pm) for 12 weeks when participants crossed over to the alternative timing for a further 12 weeks. Clinic blood pressures and a 24-hour recording were taken at baseline, 12, and 24 weeks and routine blood tests were taken at baseline. The study had 80% power to detect 3 mm Hg difference in mean 24-hour systolic blood pressure (α=0.05) by time of dosing. A 2-level hierarchical regression model adjusted for center, period, and sequence was used. Of 103 recruited patients (mean age, 62; 44% female), 95 patients (92%) completed all three 24-hour recordings. Mean 24-hour systolic and diastolic blood pressures did not differ between daytime and evening dosing. Similarly, morning and evening dosing had no differential impact on mean daytime (7 am-10 pm) and nighttime (10 pm-7 am) blood pressure levels nor on clinic levels. Stratification by age (≤65/≥65 years) or sex did not affect results. In summary, among hypertensive patients with reasonably well-controlled blood pressure, the timing of antihypertensive drug administration (morning or evening) did not affect mean 24-hour or clinic blood pressure levels. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT01669928.
Effect of antihypertensive treatment on 24-h blood pressure variability: pooled individual data analysis of ambulatory blood pressure monitoring studies based on olmesartan mono or combination treatment.
Omboni Stefano,Kario Kazuomi,Bakris George,Parati Gianfranco
Journal of hypertension
OBJECTIVE:To evaluate the impact of olmesartan alone or combined with one to three antihypertensive drugs on 24-h blood pressure variability (BPV) and on distribution of BP reduction in a pooled individual data analysis of 10 double-blind, randomized, ambulatory BP monitoring (ABPM) studies. METHODS:ABPMs were performed before and after 6-12 weeks of treatment with placebo (n = 119), active control monotherapy [n = 1195, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), dihydropyridine calcium channel blockers (DCCBs)] olmesartan monotherapy (n = 1410), active control dual combination [n = 79, DCCB + thiazide diuretic (TD)], olmesartan dual combination (n = 637, DCCB or TD), and triple combination therapy (n = 102, DCCB+TD). 24-h BPV was calculated as unweighted or weighted SD of the mean BP, and average real variability. BP control was assessed by smoothness index and treatment-on-variability index. RESULTS:The greatest effect on 24-h systolic BPV/diastolic BPV was observed under olmesartan triple [-2.6/-1.9; -1.9/-1.3; -1.4/-1.3 mmHg] and active control dual combination [-1.8/-1.4; -1.9/-1.5; -1.2/-1.1 mmHg]. Smoothness indexes and treatment-on-variability indexes were significantly (P = 0.0001) higher under olmesartan dual (1.53/1.22, 1.67/1.29, 2.05/1.59), olmesartan triple (2.47/1.85, 2.80/2.06, 3.64/2.67), or active control dual combination (1.70/1.26, 1.85/1.33, 2.29/1.65) than under monotherapies (control: 0.86/0.73, 0.80/0.65, 1.01/0.82; olmesartan: 1.02/0.86, 0.95/0.78, 1.23/1.00). They were also greater in patients receiving high-dose olmesartan monotherapy or high-dose olmesartan dual combination than in the corresponding low-dose group. CONCLUSION:Olmesartan plus a DCCB and/or a TD produces a larger, more sustained, and smoother BP reduction than placebo and monotherapies, a desirable feature for a more effective prevention of the cardiovascular consequences of uncontrolled hypertension.
Evaluation of the Differences in the Effects of Antihypertensive Drugs on Blood Pressure Variability by 24-Hour Ambulatory Blood Pressure Monitoring in Chronic Cerebrovascular Disease.
Nishioka Ryoji,Kinoshita Shunsuke,Shiibashi Michio,Shimazu Tomokazu,Nakazato Yoshihiko,Yamamoto Toshimasa,Tamura Naotoshi,Araki Nobuo
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:It has been suggested that antihypertensive drug therapy is attributable to the lower blood pressure variability, we investigated the effects of 4 classes of antihypertensives on the blood pressure variability; in addition, we also compared the effects among 4 calcium channel blockers. METHODS:We measured the 24-hour blood pressure variability in 309 patients with a history of cerebrovascular disease treated with angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, β blocker, or calcium channel blocker. RESULTS:The daytime blood pressure variability treated with β blockers (14.3 ± 3.1) was higher than that treated with an angiotensin receptor blockers (11.5 ± 3.1) or calcium channel blockers (12.6 ± 3.4) in patients with cerebrovascular disease (P < .05). In the analysis of the patient distribution of blood pressure variability, patients receiving β blockers occurred more frequently in the higher blood pressure variability (P = .0023). Treatment with angiotensin receptor blockers and cilnidipine, which blocks N-type calcium channels, was shown to be more frequently associated with the lower blood pressure variability (P = .0202 and .0467). The mean blood pressure of patients grouped by distribution of blood pressure variability was found to be independent to blood pressure variability, for any of the antihypertensive drugs or calcium channel blockers examined. CONCLUSIONS:From the results, it is suggested that angiotensin receptor blocker and calcium channel blockers rather than β blockers may be more favorable for blood pressure management in patients with cerebrovascular disease. Among the calcium channel blockers, cilnidipine may be more favorable than other calcium channel blockers.
Use of ambulatory blood pressure monitoring to evaluate the selective angiotensin II receptor antagonist, telmisartan, and other antihypertensive drugs.
Neutel J M
Blood pressure monitoring
Telmisartan (Micardis (R)) is a new, orally active, long-acting angio-tensin (Ang) II receptor antagonist that is effective in the treatment of hypertension. Ambulatory blood pressure monitoring (ABPM) has emerged as an important method for evaluating the consistency of the antihypertensive effects of a drug throughout the dosing interval. ABPM was used to evaluate the antihypertensive efficacy of telmisartan in several placebo-controlled, double-blind, multicenter studies. Patients with mild-to-moderate hypertension were allocated randomly to groups to receive telmisartan 40 or 80 mg, losartan 50 mg, or placebo, once daily in a 6-week, fixed-dose study, or telmisartan 40-120 mg, amlodipine 5-10 mg, or placebo, once daily in a 12-week, dose-titration study. Patients treated with telmisartan 40 and 80 mg or placebo in a separate 4-week, fixed-dose study were included in an additional analysis. Telmisartan 40 and 80 mg significantly decreased mean ambulatory systolic blood pressure (SBP) and diastolic blood pressure (DBP) relative to placebo for the entire 24 h period and in the following intervals: day (6 a.m. to 10 p.m.), morning (6 a.m. to noon), night (10 p.m. to 6 a.m), and the last 4 h of the dosing interval (P<0.01). Notably, telmisartan 40 or 80 mg was more effective than losartan, especially during the last 4-6 h of the dosing interval (P<0.05). Telmisartan 40- 120 mg tended to be more effective than amlodipine 5-10 mg in reducing SBP and DBP in each time interval, with significant differences between treatments noted for DBP in the last 4 h of the dosing interval and in the morning (P < 0.05). ABPM also revealed that the magnitude of the blood pressure decreasing effect with telmisartan was consistent throughout the dosing interval. These results demonstrate that telmisartan maintains a normal circadian blood pressure pattern and provides full 24 h blood pressure control with once-daily dosing.
Implementing ABPM into Clinical Practice.
Hinderliter Alan L,Voora Raven A,Viera Anthony J
Current hypertension reports
PURPOSE OF REVIEW:To review the data supporting the use of ambulatory blood pressure monitoring (ABPM), and to provide practical guidance for practitioners who are establishing an ambulatory monitoring service. RECENT FINDINGS:ABPM results more accurately reflect the risk of cardiovascular events than do office measurements of blood pressure. Moreover, many patients with high blood pressure in the office have normal blood pressure on ABPM-a pattern known as white coat hypertension-and have a prognosis similar to individuals who are normotensive in both settings. For these reasons, ABPM is recommended by the US Preventive Services Task Force to confirm the diagnosis of hypertension in patients with high office blood pressure before medical therapy is initiated. Similarly, the 2017 ACC/AHA High Blood Pressure Clinical Practice Guideline advocates the use of out-of-office blood pressure measurements to confirm hypertension and evaluate the efficacy of blood pressure-lowering medications. In addition to white coat hypertension, blood pressure phenotypes that are associated with increased cardiovascular risk and that can be recognized by ABPM include masked hypertension-characterized by normal office blood pressure but high values on ABPM-and high nocturnal blood pressure. In this review, best practices for starting a clinical ABPM service, performing an ABPM monitoring session, and interpreting and reporting ABPM data are described. ABPM is a valuable adjunct to careful office blood pressure measurement in diagnosing hypertension and in guiding antihypertensive therapy. Following recommended best practices can facilitate implementation of ABPM into clinical practice.
The effectiveness of combinated antihypertensive treatment in patients with essential hypertension of the ii-nd stage depending on the type of daily blood pressure profile and the type of remodelling of the left ventricle.
Niushko Tetiana Y,Tarasiuk Olena K,Sikalo Yulia K
Wiadomosci lekarskie (Warsaw, Poland : 1960)
OBJECTIVE:The aim: To evaluate the dynamics of structural and functional parameters of the heart, vessels in patients with hypertension of the II-nd stage under the influence of combined antihypertensive treatment depending on the type of the left ventricle remodelling and the profile of blood pressure (BP). PATIENTS AND METHODS:Materials and methods: The study involved 110 patients with hypertension of the II-nd stage. The ambulatory blood pressure monitoring, echocardiography and Doppler examination of the shoulder arteries were performed. Initial treatment included bisoprolol, lisinopril, hydrochlorothiazide. With impossibility of BP lowering to the target level, amlodipine has been added. RESULTS:Results: higher levels of BP in the "non-dipper" patients have led to the development of more pronounced changes in the heart and vessels compared with "dipper" patients. Three-component therapy was effective in patients with lower BP. The prescription of amlodipine has been found to be necessary for the majority of "non-dipper" patients and for the minority of "dipper". Combined therapy effectively controlled the BP at the level of the target and contributed to a decrease in the displays of remodelling of the heart and blood vessels. CONCLUSION:Conclusions: combined therapy used for 6 months reduces displays of disadaptive heart and vascular remodelling, diastolic, endothelial dysfunction. With the lack of efficacy of the therapy, which includes bisoprolol, lisinopril, hydrochlorothiazide, the adding of amlodipine to it can reach the target level of BP.
24-Hour blood pressure response to lower dose (30 mg) fimasartan in Korean patients with mild to moderate essential hypertension.
Lee Hae-Young,Kim Cheol-Ho,Song Jae-Kwan,Chae Shung Chull,Jeong Myung Ho,Kim Dong-Soo,Oh Byung-Hee
The Korean journal of internal medicine
BACKGROUND/AIMS:Fimasartan is an angiotensin type 1 receptor blocker (ARB) which has comparable efficacy and tolerability with other ARBs. The aim of this study was to evaluate 24-hour blood pressure (BP) lowering efficacy and the tolerability of the low dose fimasartan compared with valsartan in patients with mild to moderate hypertension. METHODS:This study was a phase II, prospective, multicenter, randomized, double-blind, parallel-grouped trial. A total of 75 hypertensive patients, whose mean ambulatory BP monitoring values were ≥ 135/85 mmHg, were randomized to either fimasartan 30 mg or valsartan 80 mg daily. The primary efficacy endpoint was the change in the mean 24-hour systolic BP (SBP) values from the baseline and at the week 8. Secondary endpoints included the change in the mean 24-hour diastolic BP values, the daytime and the nighttime mean BP values at week 8, the trough-to-peak (T/P) ratio and the smoothness index. RESULTS:At week 8, the mean 24-hour SBP values significantly decreased in both groups; -10.5 ± 11.9 mmHg (p < 0.0001) in the fimasartan group and -5.5 ± 11.6 mmHg (p = 0.0307) in the valsartan group. The difference between two groups was 4.3 ± 2.9 mmHg but there was no statistical significance (p = 0.1392). The global T/P ratio in the fimasartan 30 mg groups were 0.48 and 0.40 in the valsartan 80 mg group, respectively (p = 0.3411). The most frequent adverse events (AEs) were acute pharyngitis and there were no cases of severe AEs. CONCLUSIONS:In mild-to-moderate hypertensive patients, low dose (30 mg) fimasartan showed comparable 24-hour BP lowering efficacy compared with valsartan (80 mg). There was no difference in tolerability between two groups.
The smoothness of blood pressure control of ramipril in essential hypertensive Thai patients evaluation by 24-hour ambulatory blood pressure monitoring.
Uchaipichat Verawan,Koanantakul Banhan,Suthisisang Chuthamanee
Journal of the Medical Association of Thailand = Chotmaihet thangphaet
OBJECTIVE:Evaluate the efficacy of ramipril 2.5 and 5 mg once daily on the degree and homogeneity of 24-hour blood pressure reduction in essential hypertensive Thai patients. MATERIAL AND METHOD:Nineteen male subjects, aged 30 to 60 years, with newly diagnosed essential hypertension were evaluated using the 24-hour ambulatory blood pressure (24-h ABP) measurement. RESULTS:Twelve subjects responded and/or normalized with ramipril once daily, where the office and 24-h ABP were decreased significantly from baseline (p < 0.01). The percentage and magnitude of 24-h SBP/DBP loads after treatment were significantly decreased from 92 +/- 9.7/91 +/- 15.9 to 67 +/- 23.8/65 +/- 27.6 (p < 0.01) and from 23 +/- 10.6/16 +/- 5.3 mmHg to 17 +/- 10.3/10 +/- 4.8 mmHg ( p < 0.05). Trough to peak ratio for SBP/DBP was 0.59/0.52 (overall estimated) and 0.68 +/- 0.23/0.52 +/- 0.22 (individual estimated), while the smoothness index was 0.89/1.03. CONCLUSION:Ramipril 2.5 and 5 mg once daily exerted the smooth 24-hour blood pressure reduction in essential hypertensive Thai patients.
[Efficacy of monotherapy with 15 antihypertensive agents in treating essential hypertension assessed by 24-hour ambulatory blood pressure monitoring].
Hua Cong-Xiao,Hua Lu,Li Na,Wang Li,Pang Hui-Min,Ming Guang-Hua,Huang Yan,Cheng Xiao-Ru,Liu Hong,Wu Ying,Xu Li,Kang Jian,Xu Zhi-Min,Li Yi-Shi
Zhongguo yi xue ke xue yuan xue bao. Acta Academiae Medicinae Sinicae
OBJECTIVE:To evaluate the efficacy of the monotherapy of 15 agents in treating essential hypertension. METHODS:After 2-week wash-out, a total of 370 patients with seated diastolic blood pressure 95-114 mmHg and seated systolic blood pressure < 180 mmHg were randomized to different therapeutic groups. 24-hour ambulatory blood pressure monitoring was performed before medication and at the end of 8 weeks. RESULT:All the agents significantly reduced the 24 hour mean blood pressures after treatment except doxazosin, terazosin, and torasemide. CONCLUSION:The result suggested that the angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers and long-acting calcium antagonists were effective in treating essential hypertension, while the low-dose doxazosin, terazosin and torasemide can be used for combination therapy but not for monotherapy.
Use of ambulatory blood pressure monitoring to guide hypertensive therapy.
Singh Amita,Gianos Eugenia,Schwartzbard Arthur,Black Henry,Weintraub Howard
Current treatment options in cardiovascular medicine
OPINION STATEMENT:With the advent of noninvasive 24-hour ambulatory blood pressure monitoring (ABPM), clinicians have access to a wealth of individualized data for the hypertensive patient. This has led to a greater understanding of the pathophysiology of hypertension and its complications. This tool has provided more precise diagnostic criteria for hypertension and helped discover those with white coat and masked hypertension. Patterns noted on ABPM and correlated with outcomes have allowed for more accurate identification of patients at high risk of cardiovascular (CV) events, and have offered an additional prognostic tool. In addition, ABPM allows for the assessment of the efficacy and adequacy of blood pressure treatment. In the current paper, we will describe the essential components of ABPM, review the evidence detailing the prognostic information that can be derived from its use, highlight clinical scenarios wherein ABPM can offer invaluable diagnostic information, and describe applications of ABPM that evaluate the efficacy of treatment of the hypertensive patient.
Nurse-driven training courses: impact on implementation of ambulatory blood pressure monitoring.
Félez-Carrobé Estel,Sagarra-Tió Maria,Romero Araceli,Rubio Montserrat,Planas Lourdes,Pérez-Lucena María José,Baiget Montserrat,Cabistañ Cristina,Félez Jordi
The open nursing journal
BACKGROUND:Ambulatory blood pressure monitoring (ABPM) predicts cardiovascular risk and identifies white-coat and masked hypertension, efficacy of treatment and the circadian cycle of hypertensive patients. OBJECTIVE:To analyze the effectiveness of ABPM implementation thoughtout a nurse-driven training program. MATERIALS AND METHODOLOGY:Twenty eight professionals were involved in the study carried out in the primary care center of the metropolitan area of Barcelona that serves 34,289 inhabitants. The ABPM implementation program was driven by two nurses that held four education sessions. After a 2-year follow-up period, we assessed the outcome of attendance at the educational sessions. First, we evaluated whether the program increased the number of orders of ABPM. Second, we used a survey to evaluate to what extent the input of our educational sessions was understood by attendants. Third, we analyzed the effect ABPM results had on the treatment of patients with a bad control of their hypertension. RESULTS:After the training sessions we found a 6-fold increase in the number of patients undergoing ABPM. We analyzed 204 hypertensive individuals: 41% dippers, 34% were non-dippers, 20% were risers and 5% were extremely dippers. According to our survey, 100% of attendants had a good practice regarding ABPM management. However only 27% of riser patients were studied with a second ABPM. CONCLUSIONS:Specific training processes are needed for implementation of ABPM and an even more concentrated effort should be focused on training in the correct interpretation of ABPM results.
Implementing Home Blood Pressure Monitoring into Clinical Practice.
Liyanage-Don Nadia,Fung Deborah,Phillips Erica,Kronish Ian M
Current hypertension reports
PURPOSE OF REVIEW:To review data supporting the use of home blood pressure monitoring (HBPM) and provide practical guidance to clinicians wishing to incorporate HBPM into their practice. RECENT FINDINGS:HBPM more accurately reflects the risk of cardiovascular events than office blood pressure measurement. In addition, there is high-quality evidence that HBPM combined with clinical support improves blood pressure control. Therefore, HBPM is increasingly recommended by guidelines to confirm the diagnosis of hypertension and evaluate the efficacy of blood pressure-lowering medications. Nevertheless, HBPM use remains low due to barriers from the patient, clinician, and healthcare system level. Understanding these barriers is crucial for developing strategies to effectively implement HBPM into routine clinical practice. HBPM is a valuable adjunct to office blood pressure measurement for diagnosing hypertension and guiding antihypertensive therapy. Following recommended best practices can facilitate the successful implementation of HBPM and impact how hypertension is managed in the primary care setting.
Clinical practice of ambulatory versus home blood pressure monitoring in hypertensive patients.
Paolasso Jorge A,Crespo Florencia,Arias Viviana,Moreyra Eduardo A,Volmaro Ariel,Orías Marcelo,Moreyra Eduardo
Blood pressure monitoring
OBJECTIVES:This study aimed to analyze whether blood pressure (BP) measurement is concordant between ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), and determine whether the decision on treatment changes is similar on the basis of information provided by both methods. METHODS:Treated hypertensive patients were studied with ABPM and HBPM to evaluate therapeutic efficacy and/or diagnose resistant hypertension (HTN). Modification of pharmacological treatment was decided on the basis of pre-established criteria; therefore, the number of therapeutic changes between both techniques was compared. RESULTS:A total of 200 patients were included. The average daytime ABPM systolic blood pressure (SBP) was 136±16 compared with 136±15 (P=1) with HBPM; the average diurnal diastolic blood pressure (DBP) was 83±12 and 81±9, respectively (P=0.06). The concordance between both methods was very good for SBP [r=0.85; Bland-Altman 0.2 (95% confidence interval 0.9-1.4 mmHg)], and good for the DBP [r=0.77; Bland-Altman 1.8 (95% confidence interval 0.8-2.8 mmHg)]. Both methods were in agreement that HTN was controlled in 68 patients and that it was not controlled in 90 patients, that is, they were concordant in 158 patients (79%, κ=0.6). More patients required changes with ABPM than HBPM (149 vs. 99 patients, P<0.0001) CONCLUSION: There were no significant differences in the measurement of diurnal SBP and DBP between both methods. The concordance to determine proper control of HTN was 79%. There was a significant difference in the decision to modify the treatment in favor of the ABPM.
Using different methods to evaluate the efficacy of olmesartan medoxomil in Chinese patients with mild to moderate essential hypertension according to ambulatory blood pressure monitoring.
Jiang Hong,Ke Yuan-Nan,Sun Ning-Ling,Wang Ji-Guang,Hou Ming-Wei,Zhu Jun-Ren,
Blood pressure monitoring
OBJECTIVE:To evaluate the efficacy of olmesartan medoxomil in Chinese patients with mild to moderate essential hypertension using different methods according to ambulatory blood pressure monitoring. METHODS:Chinese patients 18-75 years of age with clinic diastolic blood pressure (BP) 90-109 mmHg and systolic BP less than 180 mmHg were treated with olmesartan medoxomil 20-40 mg once daily for 24 weeks to reach the goal BP (< 140/90 and < 130/80 mmHg in diabetes) in a multicenter study. The trough-to-peak ratio (T/P ratio) and the smoothness index (SI) for systolic/diastolic BP were calculated using different methods according to ambulatory blood pressure monitoring. RESULT:Olmesartan medoxomil 20-40 mg once daily reduced the systolic/diastolic ambulatory BP for 24-h, daytime, and night-time by 13.3 ± 16.3/7.6 ± 9.5, 13.9 ± 17.4/8.0 ± 10.4, and 12.3 ± 18.1/6.8 ± 10.2 mmHg in all eligible patients at week 24 from baseline (n = 87, P < 0.0001). The global and individual T/P ratios were 0.64/0.62 and 0.32/0.30 (n = 87) for systolic/diastolic BP, whereas these were 0.71/0.70 and 0.31/0.39 in fair responders (n = 71). Global and individual SI were 6.81/5.37 and 0.92/0.67 (n = 87) for systolic/diastolic BP, whereas these were 7.04/5.44 and 1.03/1.03 in fair responders (n = 71). Global and individual T/P ratios for systolic/diastolic BP were 0.75/0.82 and 0.45/0.46 in the 20 mg subgroup (n = 41), whereas these were 0.44/0.59 and 0.30/0.29 in the 40 mg subgroup (n = 30). Global and individual SI were 5.70/5.32 and 1.03/0.87 for systolic/diastolic BP in the 20 mg subgroup (n = 41), but these were 3.64/2.46 and 1.01/0.60 in the 40 mg subgroup (n = 30). CONCLUSION:The duration of the antihypertensive action of olmesartan medoxomil with 20-40 mg once daily can be assessed by the global T/P ratio and SI rather than the individual values, even in different populations and dosages.
Patients' preference for ambulatory versus home blood pressure monitoring.
Nasothimiou E G,Karpettas N,Dafni M G,Stergiou G S
Journal of human hypertension
Patient's preference might influence compliance with antihypertensive treatment and thereby long-term blood pressure (BP) control. This study compared patients' preference in using ambulatory (ABPM) versus home BP monitoring (HBPM). Subjects referred for hypertension were evaluated with 24-h ABPM and 7-day HBPM. Participants filled a questionnaire including demographics and Likert scale questions regarding their acceptance, preference, disturbance, activity restriction and feasibility of using ABPM and HBPM. A total of 119 patients were invited and 104 (87%) were included (mean age 51±11 years, 58% men, 38% time to work >8 h). A total of 82% reported a positive overall opinion for HBPM versus 63% for ABPM (P<0.05). 62% considered ABPM as more reliable than HBPM but 60% would choose HBPM for their next BP evaluation (P<0.05 for both comparisons). Moderate to severe discomfort from ABPM was reported by 55% and severe restriction of their daily activities by 30% compared with 13% and 7%, respectively, from HBPM (P<0.001 for both comparisons). The overall score for HBPM and ABPM (range 4-25; higher score indicating worse performance) was 6.6±2.5 and 10±4.0 (mean difference 4.4±4.6, P<0.001), respectively. In binary logistic regression models, neither previous experience with BP monitoring nor demographic characteristics appeared to influence patients' preference. These data suggest that HBPM is superior to ABPM in terms of overall acceptance and preference by hypertensive patients. Patients' preference deserves further research and should be taken into account in decision making in clinical practice.
Relationship between nocturnal blood pressure and 24-h urinary sodium excretion in a rural population in Korea.
Shin Jinho,Xu Enshi,Lim Young Hyo,Choi Bo Youl,Kim Bae Keun,Lee Yong Gu,Kim Mi Kyung,Mori Mari,Yamori Yukio
BACKGROUND:The relationship between sodium intake and blood pressure (BP) is affected by many factors such as absolute level of sodium intake, salt sensitivity, and the accuracy or the timing of the BP measurement. There is no epidemiologic study using both ambulatory BP monitoring (ABPM) and 24-h urine sample in a middle-aged general population. METHODS:In the rural area, Yeojoo County, Gyunggi Province in South Korea, 218 subjects with age between 30 and 59 years old were measured with ABPM and 24-h urine sample. ABPM device was TM2430, and the 24-h urine sample was collected using the aliquot cup. Metabolic syndrome (MetS) score was calculated by the sum of the number of abnormal criteria other than BP. RESULTS:For both ABPM and 24-h urine sample, 148 subject data was acceptable for the analysis by the creatinine equation and/or the completeness of collection. Age was 47.4 ± 8.3 years (range 30 to 59 years), and female was 85 (57.4%). In multiple linear regression analysis, sodium intake was not an independent factor for casual BPs and daytime BPs whereas sodium intake was an independent factor for nighttime systolic BP (β = 1.625, p = 0.0026) and nighttime diastolic BP (β = 1.066, p = 0.0017). When compared to the lowest quartiles of sodium intake, daytime diastolic BP and nighttime BPs were in the higher three quartile groups. CONCLUSIONS:Sodium intake was associated not with casual BPs and daytime BPs but with increased nighttime BPs in the middle-aged general population in Korea.
Large discrepancy between unobserved automated office blood pressure and ambulatory blood pressure in a high cardiovascular risk cohort.
Seo Jiwon,Lee Chan Joo,Oh Jaewon,Lee Sang-Hak,Kang Seok-Min,Park Sungha
Journal of hypertension
OBJECTIVES:Automated office blood pressure (AOBP) measurement has been shown to eliminate the white-coat effect and to be more concordant with ambulatory blood pressure monitoring (ABPM) and home blood pressure (BP) measurements. This study aimed to compare AOBP with ABPM in patients with a high cardiovascular risk. METHODS AND RESULTS:Participants were recruited from a prospective cohort study (Cardiovascular and Metabolic Disease Etiology Research Center-High Risk Cohort, clinicaltrials.gov: NCT02003781). A total of 1208 persons who had undergone both AOBP and ABPM within 7 days of each other were analyzed. The 95% limits of agreement between systolic AOBP and daytime ABPM SBP were -34.8 and 20.2 mmHg (mean difference = -7.3 ± 14.0). The mean differences in blood pressure across quintiles of AOBP distributions increased with decreasing systolic AOBP [-17.8 ± 11.2 (Q1, systolic AOBP <113 mmHg), -10.9 ± 11.1 (Q2, systolic AOBP 113-121 mmHg), -8.5 ± 10.7 (Q3, systolic AOBP 121-128 mmHg), -4.2 ± 11.8 (Q4, systolic AOBP 128-137 mmHg), 4.9 ± 14.2 (Q5, systolic AOBP >137 mmHg), P < 0.001]. The prevalence of masked hypertension phenomena was 310 (25.7%) and that of white-coat hypertension phenomena was 102 (8.4%). Large discrepancies were significantly associated with lower systolic AOBP, higher atherosclerotic cardiovascular disease risk score, and history of asymptomatic cardiovascular disease. CONCLUSION:The lower range of systolic AOBP exhibited a large discrepancy with daytime ABPM SBP. Moreover, higher cardiovascular risk was independently associated with larger discrepancy between AOBP and ABPM. The status of blood pressure control should be confirmed using out-of-office blood pressure measurements, even when using AOBP as a clinical BP reference in high-risk patients.
Medicare reimbursement policy for ambulatory blood pressure monitoring: A qualitative analysis of public comments to the Centers for Medicare and Medicaid Services.
Dixon Dave L,Salgado Teresa M,Luther James Matthew,Byrd James Brian
Journal of clinical hypertension (Greenwich, Conn.)
Ambulatory blood pressure monitoring (ABPM) is considered the best means of diagnosing hypertension. However, it is rarely used and is reimbursed only under narrow conditions. We sought to gain insight into the perceived value of ABPM among stakeholders who responded to the Centers for Medicare and Medicaid Services' (CMS) request for comments to inform the first revision of ABPM reimbursement policy in over 15 years. We found that most comments were classifiable in two main themes, current coverage and future coverage. Individuals and institutions representing multiple disciplines and specialties were highly supportive of expanding the current CMS coverage of ABPM, including for a wide range of clinical indications and populations. It is clear from the comments reviewed that there is wide support for expanding CMS coverage for ABPM. Broad support for a change in ABPM reimbursement policy may lead to changes in the way this technology is used in the United States.
Accuracy of home versus ambulatory blood pressure monitoring in the diagnosis of white-coat and masked hypertension.
Kang Yuan-Yuan,Li Yan,Huang Qi-Fang,Song Jie,Shan Xiao-Li,Dou Yu,Xu Xin-Juan,Chen Shou-Hong,Wang Ji-Guang
Journal of hypertension
BACKGROUND:We investigated accuracy of home blood pressure (BP) monitoring in the diagnosis of white-coat and masked hypertension in comparison with ambulatory BP monitoring. METHODS:Our study participants were enrolled in the China Ambulatory and Home BP Registry, and underwent clinic, home, and 24-h ambulatory BP measurements. We defined white-coat hypertension as an elevated clinic SBP/DBP (≥140/90 mmHg) and a normal 24-h ambulatory (<130/80 mmHg) or home SBP/DBP (<135/85 mmHg), and masked hypertension as a normal clinic SBP/DBP (<140/90 mmHg) and an elevated 24-h ambulatory (≥130/80 mmHg) or home SBP/DBP (≥135/85 mmHg). RESULTS:In untreated patients (n = 573), the prevalence of white-coat hypertension (13.1 vs. 19.9%), masked hypertension (17.8 vs. 13.1%), and sustained hypertension (46.4 vs. 39.6%) significantly (P ≤ 0.02) differed between 24-h ambulatory and home BP monitoring. In treated patients (n = 1201), only the prevalence of masked hypertension differed significantly (18.7 vs. 14.5%; P = 0.005). Regardless of the treatment status, home compared with 24-h ambulatory BP had low sensitivity (range 47-74%), but high specificity (86-94%), and accordingly low positive (41-87%), but high negative predictive values (80-94%), and had moderate diagnostic agreement (82-85%) and Kappa statistic (0.41-0.66). In untreated and treated patients, age advancing was associated with a higher prevalence of white-coat hypertension and a lower prevalence of masked hypertension defined by 24-h ambulatory (P ≤ 0.03) but not home BP (P ≥ 0.10). CONCLUSION:Home BP monitoring has high specificity, but low sensitivity in the diagnosis of white-coat and masked hypertension, and may therefore behave as a complementary to, but not a replacement of, ambulatory BP monitoring.
Home Blood Pressure Monitoring.
George Jacob,MacDonald Thomas
Hypertension is the most common preventable cause of cardiovascular disease. Home blood pressure monitoring (HBPM) is a self-monitoring tool that can be incorporated into the care for patients with hypertension and is recommended by major guidelines. A growing body of evidence supports the benefits of patient HBPM compared with office-based monitoring: these include improved control of BP, diagnosis of white-coat hypertension and prediction of cardiovascular risk. Furthermore, HBPM is cheaper and easier to perform than 24-hour ambulatory BP monitoring (ABPM). All HBPM devices require validation, however, as inaccurate readings have been found in a high proportion of monitors. New technology features a longer inflatable area within the cuff that wraps all the way round the arm, increasing the 'acceptable range' of placement and thus reducing the impact of cuff placement on reading accuracy, thereby overcoming the limitations of current devices.
Short-Term and Long-Term Reproducibility of Hypertension Phenotypes Obtained by Office and Ambulatory Blood Pressure Measurements.
de la Sierra Alejandro,Vinyoles Ernest,Banegas José R,Parati Gianfranco,de la Cruz Juan J,Gorostidi Manuel,Segura Julián,Ruilope Luis M
Journal of clinical hypertension (Greenwich, Conn.)
The authors aimed to assess the reproducibility of normotension and white-coat, masked, and sustained hypertension in 839 untreated patients who underwent two separate assessments (median, 3; interquartile range, 0-13 months) by both office and ambulatory blood pressure (BP) monitoring (ABPM). The proportion of patients falling into the same category in the two assessments was: 52% normotension and 55% white-coat, 47% masked, and 82% sustained hypertension. The most frequent switch was to sustained hypertension (26% of white-coat and 33% of masked hypertension). No clinical factors predicted the change in category, except for higher office diastolic BP in patients with masked hypertension who developed sustained hypertension, compared with those who remained with masked hypertension (84±4 mm Hg vs 80±5 mm Hg; P=.006). The reproducibility of hypertension phenotypes was highly dependent on the time between assessments. The authors conclude that white-coat and masked hypertension phenotypes are only reproducible in the short-term, while they frequently shift towards sustained hypertension in the long-term.
[Effectiveness of blood pressure home monitoring. Synopsis of systematic reviews.]
Re Luca Giuseppe,Fusetti Viviana
INTRODUCTION:Home blood pressure monitoring (HmBPM) is as a valuable and useful tool for hypertension management; some uncertainties remain about benefits of intervention in clinical practice. OBJECTIVE:To assess the effects of home blood pressure monitoring on blood pressure values. METHODS:A search on the following databases The Cochrane Library, Medline, CINAHL, Embase, Web of Science was carried out on January the 12 2016 . The records retrieved were analysed independently and those which met the inclusion criteria were gathered as full text. In the synopsis were included only systematic reviews with meta-analysis of Randomised Controlled Trials comparing home blood pressure monitoring with ambulatory (ABPM) or hospital (HsBPM) blood pressure monitoring. AMSTAR checklist was used to evaluate reviews quality while for comparing meta-analysis it was proceeded to index of Higgins I2 analysis. RESULTS:Five systematic reviews met inclusion criteria. The overall methodological quality of included studies was high. Range of I2 was equal to 37%-72% (moderate to high heterogeneity). Compared to ABPM, HsBPM or standard of care, HmBPM was associated with moderate but statistically significant reduction in systolic blood pressure (weighted mean difference from -2.50 mmHg to -4.25 mmHg) and diastolic blood pressure (weighted mean difference from -1.45 mmHg to -2.37 mmHg). DISCUSSION:The reduced size of HmBPM effect results in a moderate benefit in clinical practice. Potential advantages on blood pressure control are dependent on patient ability to perform and interpret HmBPM results as well as health professionals to use recorded data to introduce or modify drug therapy and improve the overall compliance to antihypertensive treatment. CONCLUSIONS:HmBPM is more effective in reducing systolic and diastolic blood pressure compared to other interventions but the clinical significance of its effect is moderate.
Are Automated Blood Pressure Monitors Comparable to Ambulatory Blood Pressure Monitors? A Systematic Review and Meta-analysis.
Jegatheswaran Januvi,Ruzicka Marcel,Hiremath Swapnil,Edwards Cedric
The Canadian journal of cardiology
Ambulatory blood pressure (BP) monitoring (ABPM) provides an accurate assessment of BP and cardiovascular risk. BpTRU (BpTRU Medical Devices Ltd, Coquitlam, British Columbia, Canada) and other automated oscillometric BP monitors (AOBPs) have been proposed to replace ABPM. A systematic review was carried out to determine the accuracy of AOBP measurement, compared with ABPM. A literature search was performed using MedLine, EMBASE and CINAHL databases until Oct 28, 2016. We selected all studies that included intraindividual comparisons between AOBP monitoring and ABPM. Study selection, demographic characteristics, and BP values including details of BP measurement techniques were abstracted in duplicate. Quantitative synthesis was performed to report the weighted mean difference between systolic and diastolic BP measured using the 2 methods. From the 859 nonduplicate citations from the search, 19 full-text articles were selected for the systematic review. The median sample size was 226 (range, 17-654). In the pooled analysis, the weighted mean difference between the 2 methods for systolic BP was -1.52 mm Hg (95% confidence interval [CI], -3.29 to 0.25 mm Hg; P = 0.09) and for diastolic BP was 0.33 mm Hg (95% CI, -0.97 to 1.64; P = 0.62). The study-level difference in means for systolic BP ranged from -9.7 to 9 mm Hg with significant heterogeneity (Cochran Q = 270; I = 93.3; P < 0.001) and for diastolic BP ranged from -4 to 6 mm Hg with significant heterogeneity (Cochran Q = 382; I = 95.3; P < 0.001). Because of the significant heterogeneity we believe that use of the AOBP should not replace awake ambulatory BP (ABPM) as the reference standard.
Comparing Office, Central, Home and Ambulatory Blood Pressure in Predicting Left Ventricular Mass.
Aparicio Lucas Sebastian,Barochiner Jessica,Peuchot Veronica A,Giunta Diego H,Martínez Rocío,Morales Margarita S,Cuffaro Paula E,Waisman Gabriel D
Hipertension y riesgo vascular
The blood pressure measurement method that more accurately predicts a left ventricular mass is controversial, and the evidence suggesting superiority of central over brachial measurements is contradictory. The aim of this study was to compare the relationship between the different clinic and out-of-clinic blood pressure measurements methods with left ventricular mass in patients who attended a specialised hypertension centre for a central blood pressure measurement. An analysis was performed on the correlations between left ventricular mass and central and brachial blood pressure measurements made in the clinic, and home, as well as 24-h systolic blood pressure measurements. A linear regression analysis was then performed to assess the independent relationship of each blood pressure measurement with left ventricular mass. The results on 824 treated and 123 untreated patients showed no significant differences between correlations, although home readings tended to have the best correlations. In regression adjusted models, for each 10 mmHg increase in systolic home blood pressure the left ventricular mass increased 10 g/m (95% CI; 3.7-27, p=.01, R 0.38), and for 24-h ambulatory systolic blood pressure it increased 2.3 g/m (95% CI 0.76-3.9, p<.01, R 0.15) in treated and untreated patients, respectively. The association of systolic blood pressure with left ventricular mass was better explained by home and 24-h ambulatory monitoring than to clinic-based measurements in treated and untreated patients, respectively. In the clinic, however, the central measurement was not superior to brachial blood pressure.
Noninvasive optical coherence tomography imaging correlates with anatomic and physiologic end-organ changes in healthy normotensives with systemic blood pressure variability.
Dagel Tuncay,Afsar Baris,Sag Alan A,Derin Gozde,Kesim Cem,Tas Ayse Y,Sahin Afsun,Dincer Neris,Kanbay Mehmet
Blood pressure monitoring
OBJECTIVE:Blood pressure variability (BPV) is considered as a novel risk factor for cardiovascular disease including left ventricular hypertrophy, vascular stiffness, and renal dysfunction. In this study, we aimed to determine the relationship between ambulatory BPV with subclinical organ damage and vascular stiffness parameters in normotensive healthy subjects. METHODS:A total of 100 healthy subjects over 18 years of age were included in this cross-sectional study. We divided the participants into two groups according to the median value of the SD of mean 24-h blood pressure (BP) (Group 1: SD of mean 24-h BP <10.15 and Group 2: SD of mean 24-h BP >10.15). BPs of these subjects were recorded over a 24-h period using ambulatory BP monitoring. Mobil-O-Graph device was used to estimate the augmentation index (AIx), pulse wave velocity (PWV), and ambulatory BP measurement. The choroidal thickness was measured by using optical coherence tomography device. RESULTS:The mean age of the patients was 25.4 ± 5.0 years. Choroidal thickness was correlated with PWV, AIx, protein excretion, and SD of systolic and diastolic BP (P < 0.05). Additionally, participants with higher BP variability have lower choroidal thickness and higher AIx. CONCLUSION:We showed that even in normotensive subjects, BPV correlates with choroid thickness. Thus, BPV can be an early prognostic parameter for pathologic vascular changes.
The role of clinic blood pressure for the diagnosis of hypertension.
Ayan Mohamed,Kadavath Sabeeda,Campbell Patrick T
Current opinion in cardiology
PURPOSE OF REVIEW:Recent data from randomized clinical trials and updates to hypertension guidelines warrant a review of the literature for the diagnosis and management of hypertension in the clinic setting. Although there have been significant advances in ambulatory blood pressure (BP) monitoring and home BP monitoring, office BP (OBP) measurements remains the primary means of diagnosis and treatment. RECENT FINDINGS:The current review focuses on updated guidelines, proper technique, device selection, and the recent controversy regarding unattended BP measurements. We review the data on cardiovascular outcomes, the comparison of OBP with ambulatory BP monitoring and home BP monitoring and some of the pitfalls of OBP measurements. SUMMARY:The current review highlights the need for constant review of BP goals to minimize cardiovascular risk and some of the ongoing controversies regarding OBP measurements.
Development of Predictive Equations for Nocturnal Hypertension and Nondipping Systolic Blood Pressure.
Jaeger Byron C,Booth John N,Butler Mark,Edwards Lloyd J,Lewis Cora E,Lloyd-Jones Donald M,Sakhuja Swati,Schwartz Joseph E,Shikany James M,Shimbo Daichi,Yano Yuichiro,Muntner Paul
Journal of the American Heart Association
Background Nocturnal hypertension, defined by a mean asleep systolic blood pressure (SBP)/diastolic blood pressure (BP) ≥120/70 mm Hg, and nondipping SBP, defined by an awake-to-asleep decline in SBP <10%, are each associated with increased risk for cardiovascular disease. Methods and Results We developed predictive equations to identify adults with a high probability of having nocturnal hypertension or nondipping SBP using data from the CARDIA (Coronary Artery Risk Development in Young Adults) study (n=787), JHS (Jackson Heart Study) (n=1063), IDH (Improving the Detection of Hypertension) study (n=395), and MHT (Masked Hypertension) study (n=772) who underwent 24-hour ambulatory BP monitoring. Participants were randomized to derivation (n=2511) or validation (n=506) data sets. The prevalence rates of nocturnal hypertension and nondipping SBP were 39.7% and 44.9% in the derivation data set, respectively, and 36.6% and 44.5% in the validation data set, respectively. The predictive equation for nocturnal hypertension included age, race/ethnicity, smoking status, neck circumference, height, high-density lipoprotein cholesterol, albumin/creatinine ratio, and clinic SBP and diastolic BP. The predictive equation for nondipping SBP included age, sex, race/ethnicity, waist circumference, height, alcohol use, high-density lipoprotein cholesterol, and albumin/creatinine ratio. Concordance statistics (95% CI) for nocturnal hypertension and nondipping SBP predictive equations in the validation data set were 0.84 (0.80-0.87) and 0.73 (0.69-0.78), respectively. Compared with reference models including antihypertensive medication use and clinic SBP and diastolic BP as predictors, the continuous net reclassification improvement (95% CI) values for the nocturnal hypertension and nondipping SBP predictive equations were 0.52 (0.35-0.69) and 0.51 (0.34-0.69), respectively. Conclusions These predictive equations can direct ambulatory BP monitoring toward adults with high probability of having nocturnal hypertension and nondipping SBP.
Diagnosing Masked Hypertension Using Ambulatory Blood Pressure Monitoring, Home Blood Pressure Monitoring, or Both?
Anstey D Edmund,Muntner Paul,Bello Natalie A,Pugliese Daniel N,Yano Yuichiro,Kronish Ian M,Reynolds Kristi,Schwartz Joseph E,Shimbo Daichi
Hypertension (Dallas, Tex. : 1979)
Guidelines recommend measuring out-of-clinic blood pressure (BP) to identify masked hypertension (MHT) defined by out-of-clinic BP in the hypertensive range among individuals with clinic-measured BP not in the hypertensive range. The aim of this study was to determine the overlap between ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) for the detection of MHT. We analyzed data from 333 community-dwelling adults not taking antihypertensive medication with clinic BP <140/90 mm Hg in the IDH study (Improving the Detection of Hypertension). Any MHT was defined by the presence of daytime MHT (mean daytime BP ≥135/85 mm Hg), 24-hour MHT (mean 24-hour BP ≥130/80 mm Hg), or nighttime MHT (mean nighttime BP ≥120/70 mm Hg). Home MHT was defined as mean BP ≥135/85 mm Hg on HBPM. The prevalence of MHT was 25.8% for any MHT and 11.1% for home MHT. Among participants with MHT on either ABPM or HBPM, 29.5% had MHT on both ABPM and HBPM; 61.1% had MHT only on ABPM; and 9.4% of participants had MHT only on HBPM. After multivariable adjustment and compared with participants without MHT on ABPM and HBPM, those with MHT on both ABPM and HBPM and only on ABPM had a higher left ventricular mass index (mean difference [SE], 12.7 [2.9] g/m, P<0.001; and 4.9 [2.1] g/m, P=0.022, respectively), whereas participants with MHT only on HBPM did not have an increased left ventricular mass index (mean difference [SE], -1.9 [4.8] g/m, P=0.693). These data suggest that conducting ABPM will detect many individuals with MHT who have an increased cardiovascular disease risk.
A possible cause of epistaxis: increased masked hypertension prevalence in patients with epistaxis.
Acar Baran,Yavuz Bunyamin,Yıldız Erdem,Ozkan Selcuk,Ayturk Mehmet,Sen Omer,Deveci Onur Sinan
Brazilian journal of otorhinolaryngology
INTRODUCTION:Epistaxis and hypertension are frequent conditions in the adult population. Masked hypertension is defined as a clinical condition in which a patient's office blood pressure level is <140/90mmHg, but the ambulatory or home blood pressure readings are in the hypertensive range. Many studies have proved that hypertension is one of the most important causes of epistaxis. The prevalence of this condition in patients with epistaxis is not well defined. OBJECTIVE:This study aimed to evaluate the prevalence of masked hypertension using the results of office blood pressure measurement compared with the results of ambulatory blood pressure monitoring. METHODS:Sixty patients with epistaxis and 60 control subjects were enrolled in the study. All patients with epistaxis and controls without history of hypertension underwent physical examination, including office blood pressure measurement, ambulatory or home blood pressure, and measurement of anthropometric parameters. RESULTS:Mean age was similar between the epistaxis group and the controls - 21-68 years (mean 42.9) for the epistaxis group and 18-71 years (mean 42.2) for the control group. A total of 20 patients (33.3%) in the epistaxis group and 7 patients (11.7%) in the control group (p=0.004) had masked hypertension. Night-time systolic blood pressure was significantly higher in patients with epistaxis than in the control group (p<0.005). However, no significant difference was found in daytime systolic blood pressure between the control group and the patients with epistaxis (p=0.517). CONCLUSION:This study demonstrates increased masked hypertension prevalence in patients with epistaxis. We suggest that all patients with epistaxis should undergo ambulatory or home blood pressure to detect masked hypertension, which could be a possible cause of epistaxis.
Relationship between body mass and ambulatory blood pressure: comparison with office blood pressure measurement and effect of treatment.
Baird Stacy W,Jin Zhezhen,Okajima Kazue,Russo Cesare,Schwartz Joseph E,Elkind Mitchell S V,Rundek Tatjana,Homma Shunichi,Sacco Ralph L,Di Tullio Marco R
Journal of human hypertension
Epidemiologic studies assessing the relationship between blood pressure (BP), body mass, and cardiovascular events have primarily been based on office BP measurements, and few data are available in the elderly. The aim of the present study was to evaluate the relationship between body mass index (BMI) and BP values obtained by ambulatory blood pressure monitoring (ABPM) as compared to office BP measurements, and the effect of anti-hypertensive treatment on the relationship. The study population consisted of 813 subjects participating in the cardiovascular abnormalities and brain lesions (CABL) study who underwent 24-h ABPM. Office BP (mean of two measurements) was found to be associated with increasing BMI, for both SBP (p ≤ 0.05) and DBP (p ≤ 0.001). In contrast, there was no association seen of increasing BMI with ABPM parameters in the overall cohort, even after adjusting for age and gender. However, among subjects not on anti-hypertensive treatment, office SBP and DBP measurements were significantly correlated with increasing BMI (p ≤ 0.01) as were daytime SBP and 24-h SBP, although with a smaller spread across BMI subgroups compared with office readings. In treated hypertensives, there was only a trend toward increasing office DBP and increasing DBP variability with higher BMI. Our results suggest that body mass may have a less significant influence on BP values in the elderly when ABPM rather than office measurements are considered, particularly in patients receiving anti-hypertensive treatment.
[Effect of combination antihypertensive therapy on circadian blood pressure and metabolic parameters in patients with type 2 diabetes mellitus].
Statsenko M E,Derevianchenko M V,Pastukhova O R
AIM:To assess effect of combined antihypertensive therapy with lisinopril and amlodipine on circadian blood pressure (BP), insulin resistance (IR), carbohydrate and lipid metabolism in patients with arterial hypertension (AH) and type 2 diabetes mellitus (DM). MATERIAL AND METHODS:Combination of amlodipine (6.0±0.4 mg/day) and lisinopril (12.0±0.9 mg/day) was given to 30 patients (age 40-65 years) with stage I-II AH and DM type 2) for 24 weeks. All patients underwent ambulatory BP monitoring. Parameter studied comprised glucose levels, glycosylated hemoglobin (HbAlc), basal insulin, lipid profile in the venous blood and insulin resistance (IR). All patients received glucose-lowering drugs and followed diet recommendations. RESULTS:All patients achieved target BP values and concentrations of HbAlc. After 24 weeks of treatment the following parameters were significantly different from baseline values: mean systolic BP (SBP) (-15.6%), mean diastolic BP (DBP), (-16.2%), time index (pressure load--PL) SBP day (-50.1%), PL DBP day (-51.3), PL DBP night (-59.2%), SBP variability (-15.8%), values of morning SBP and DBP increase (both -41.8%), rates of morning rise of SBP (-74.1%) and DBP (-65.8%), percentage of patients with increased variability of SBP (-36.7%), of DBP (- 23.3%), of SBP day (-36.7%), of DBP day (-30.0%). Significant decreases of fasting blood glucose level (-22.1%), concentrations of total cholesterol (-8.8%), low density lipoprotein cholesterol (-15%), triglycerides (-4.4%), and metabolic index (-32.7%) were also observed. CONCLUSION:In patients with hypertension and type 2 DM 24 week antihypertensive therapy with lisinopril and amlodipine significantly improved circadian blood pressure profile, reduced severity of IR without negative effect on carbohydrate and lipid metabolism.
Effects of different antihypertensive drugs on blood pressure variability in patients with ischemic stroke.
Ji M,Li S-J,Hu W-L
European review for medical and pharmacological sciences
OBJECTIVE:Blood pressure variation is one of the factors that affects the risk of stroke recurrence and prognosis. This study investigates the effects of calcium channel blockers and beta-blockers on blood pressure variability in severe ischemic stroke patients. PATIENTS AND METHODS:The clinical data of 24 patients with ischemic stroke in our intensive care unit were analyzed, and received amlodipine or metoprolol for more than 14 days with 24-hour ambulatory blood pressure monitoring. All patients aged 61-90 years, with GCS score ≤ 8 or associated with other organ dysfunction. RESULTS:Among these 24 ischemic stroke patients, 12 received amlodipine and 12 received metoprolol. The observation period was divided into two phases: 1-6 days and 7-14 days. The decrease in blood pressure was faster in the metoprolol group than in the amlodipine group, while the average standard deviation was significantly greater and the smoothness index was less. CONCLUSIONS:Metoprolol has faster onset than amlodipine and less blood pressure variability than metoprolol.
Functional vascular study in hypertensive subjects with type 2 diabetes using losartan or amlodipine.
Pozzobon Cesar Romaro,Gismondi Ronaldo A O C,Bedirian Ricardo,Ladeira Marcia Cristina,Neves Mario Fritsch,Oigman Wille
Arquivos brasileiros de cardiologia
BACKGROUND:Antihypertensive drugs are used to control blood pressure (BP) and reduce macro- and microvascular complications in hypertensive patients with diabetes. OBJECTIVES:The present study aimed to compare the functional vascular changes in hypertensive patients with type 2 diabetes mellitus after 6 weeks of treatment with amlodipine or losartan. METHODS:Patients with a previous diagnosis of hypertension and type 2 diabetes mellitus were randomly divided into 2 groups and evaluated after 6 weeks of treatment with amlodipine (5 mg/day) or losartan (100 mg/day). Patient evaluation included BP measurement, ambulatory BP monitoring, and assessment of vascular parameters using applanation tonometry, pulse wave velocity (PWV), and flow-mediated dilation (FMD) of the brachial artery. RESULTS:A total of 42 patients were evaluated (21 in each group), with a predominance of women (71%) in both groups. The mean age of the patients in both groups was similar (amlodipine group: 54.9 ± 4.5 years; losartan group: 54.0 ± 6.9 years), with no significant difference in the mean BP [amlodipine group: 145 ± 14 mmHg (systolic) and 84 ± 8 mmHg (diastolic); losartan group: 153 ± 19 mmHg (systolic) and 90 ± 9 mmHg (diastolic)]. The augmentation index (30% ± 9% and 36% ± 8%, p = 0.025) and augmentation pressure (16 ± 6 mmHg and 20 ± 8 mmHg, p = 0.045) were lower in the amlodipine group when compared with the losartan group. PWV and FMD were similar in both groups. CONCLUSIONS:Hypertensive patients with type 2 diabetes mellitus treated with amlodipine exhibited an improved pattern of pulse wave reflection in comparison with those treated with losartan. However, the use of losartan may be associated with independent vascular reactivity to the pressor effect.
Changes in 24 h ambulatory blood pressure and effects of angiotensin II receptor blockade during acute and prolonged high-altitude exposure: a randomized clinical trial.
Parati Gianfranco,Bilo Grzegorz,Faini Andrea,Bilo Barbara,Revera Miriam,Giuliano Andrea,Lombardi Carolina,Caldara Gianluca,Gregorini Francesca,Styczkiewicz Katarzyna,Zambon Antonella,Piperno Alberto,Modesti Pietro Amedeo,Agostoni Piergiuseppe,Mancia Giuseppe
European heart journal
AIM:Many hypertensive subjects travel to high altitudes, but little is known on ambulatory blood pressure (ABP) changes and antihypertensive drugs' efficacy under acute and prolonged exposure to hypobaric hypoxia. In particular, the efficacy of angiotensin receptor blockers in this condition is unknown. This may be clinically relevant considering that renin-angiotensin system activity changes at altitude. The HIGHCARE-HIMALAYA study assessed changes in 24 h ABP under acute and prolonged exposure to increasing altitude and blood pressure-lowering efficacy and safety of an angiotensin receptor blockade in this setting. METHODS AND RESULTS:Forty-seven healthy, normotensive lowlanders were randomized to telmisartan 80 mg or placebo in a double-blind, parallel group trial. Conventional and Ambulatory BPs were measured at baseline and on treatment: after 8 weeks at sea level, and under acute exposure to 3400 and 5400 m altitude, the latter upon arrival and after 12 days (Mt. Everest base camp). Blood samples were collected for plasma catecholamines, renin, angiotensin, and aldosterone. In both groups, exposure to increasing altitude was associated with: (i) significant progressive increases in conventional and 24 h blood pressure, persisting throughout the exposure to 5400 m; (ii) increased plasma noradrenaline and suppressed renin-angiotensin-aldosterone system. Telmisartan lowered 24 h ABP at the sea level and at 3400 m (between-group difference 4.0 mmHg, 95% CI: 2.2-9.5 mmHg), but not at 5400 m. CONCLUSION:Ambulatory blood pressure increases progressively with increasing altitude, remaining elevated after 3 weeks. An angiotensin receptor blockade maintains blood pressure-lowering efficacy at 3400 m but not at 5400 m.
Disproportional decrease in office blood pressure compared with 24-hour ambulatory blood pressure with antihypertensive treatment: dependency on pretreatment blood pressure levels.
Schmieder Roland E,Schmidt Stephanie T,Riemer Thomas,Dechend Ralf,Hagedorn Ina,Senges Jochen,Messerli Franz H,Zeymer Uwe
Hypertension (Dallas, Tex. : 1979)
The long-term relationship between 24-hour ambulatory blood pressure (ABP) and office BP in patients on therapy is not well documented. From a registry we included all patients in whom antihypertensive therapy needed to be uptitrated. Drug treatment included the direct renin inhibitor aliskiren or an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or drugs not blocking the renin-angiotensin system, alone or on top of an existing drug regimen. In all patients, office BP and 24-hour ABP were obtained at baseline and after 1 year with validated devices. In the study population of 2722 patients, there was a good correlation between the change in office BP and 24-hour ABP (systolic: r=0.39; P<0.001; diastolic: r=0.34; P<0.001). However, the numeric decrease in office BP did not correspond to the decrease in ABP in a 1:1 fashion, for example, a decrease of 10, 20, and 30 mm Hg corresponded to a decrease of ≈7.2, 10.5, and 13.9 mm Hg in systolic ABP, respectively. The disproportionally greater decrease in systolic office BP compared with ABP was dependent on the level of the pretreatment BP, which was consistently higher for office BP than ABP. The white coat effect (difference between office BP and ABP) was on average 10/5 mm Hg lower 1 year after intensifying treatment and the magnitude of that was also dependent on pretreatment BP. There was a disproportionally greater decrease in systolic office BP than in ABP, which for both office BP and ABP seemed to depend on the pretreatment BP level.
Twenty-four-hour ambulatory blood pressure changes in older patients with essential hypertension receiving monotherapy or dual combination antihypertensive drug therapy.
Lu Pei-Pei,Meng Xu,Zhang Ying,Li Yan-Qi,Wang Shu,Liu Li-Sheng,Wang Wen,Li Yu-Ling,Zhang Yu-Qing,Hu Ai-Hua,Zhou Xian-Liang,Ma Li-Hong
Journal of geriatric cardiology : JGC
Objective:To evaluate the differences in 24-hour ambulatory blood pressure (BP) in older patients with hypertension treated with the five major classes of antihypertensive drugs, as monotherapy or dual combination therapy, to improve daytime and nighttime BP control. Methods:We enrolled 1920 Chinese community-dwelling outpatients aged ≥ 60 years and compared ambulatory BP values and ambulatory BP control (24-hour BP < 130/80 mmHg; daytime mean BP < 135/85 mmHg; and nighttime mean BP < 120/70 mmHg), as well as nighttime BP dip patterns for monotherapy and dual combination therapy groups. Results:Patients' mean age was 71 years, and 59.5% of patients were women. Calcium channel blockers (CCBs) constituted the most common (60.3% of patients) monotherapy, and renin-angiotensin system (RAS) blockers combined with CCBs was the most common (56.5% of patients) dual combination therapy. Monotherapy with beta-blockers (BB) provided the best daytime BP control. The probabilities of having a nighttime dip pattern and nighttime BP control were higher in patients receiving diuretics compared with CCBs (OR = 0.52, = 0.05 and OR = 0.41, = 0.007, respectively). Patients receiving RAS/diuretic combination therapy had a higher probability of having controlled nighttime BP compared with those receiving RAS/CCB (OR = 0.45, = 0.004). Compared with RAS/diuretic therapy, BB/CCB therapy had a higher probability of achieving daytime BP control (OR = 1.27, = 0.45). Conclusions:Antihypertensive monotherapy and dual combination drug therapy provided different ambulatory BP control and nighttime BP dip patterns. BB-based regimens provided lower daytime BP, whereas diuretic-based therapies provided lower nighttime BP, compared with other antihypertensive regimens.
2018 Korean Society of Hypertension Guidelines for the management of hypertension: part II-diagnosis and treatment of hypertension.
Lee Hae-Young,Shin Jinho,Kim Gheun-Ho,Park Sungha,Ihm Sang-Hyun,Kim Hyun Chang,Kim Kwang-Il,Kim Ju Han,Lee Jang Hoon,Park Jong-Moo,Pyun Wook Bum,Chae Shung Chull
The standardized techniques of blood pressure (BP) measurement in the clinic are emphasized and it is recommended to replace the mercury sphygmomanometer by a non-mercury sphygmomanometer. Out-of-office BP measurement using home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) and even automated office BP (AOBP) are recommended to correctly measure the patient's genuine BP. Hypertension (HTN) treatment should be individualized based on cardiovascular (CV) risk and the level of BP. Based on the recent clinical study data proving benefits of intensive BP lowering in the high risk patients, the revised guideline recommends the more intensive BP lowering in high risk patients including the elderly population. Lifestyle modifications, mostly low salt diet and weight reduction, are strongly recommended in the population with elevated BP and prehypertension and all hypertensive patients. In patients with BP higher than 160/100 mmHg or more than 20/10 mmHg above the target BP, two drugs can be prescribed in combination to maximize the antihypertensive effect and to achieve rapid BP control. Especially, single pill combination drugs have multiple benefits, including maximizing reduction of BP, minimizing adverse effects, increasing adherence, and preventing cardiovascular disease (CVD) and target organ damage.
Systolic and diastolic short-term blood pressure variability and its determinants in patients with controlled and uncontrolled hypertension: a retrospective cohort study.
Pengo Martino F,Rossitto Giacomo,Bisogni Valeria,Piazza Daniele,Frigo Anna Chiara,Seccia Teresa Maria,Maiolino Giuseppe,Rossi Gian Paolo,Pessina Achille C,Calò Lorenzo A
Absolute blood pressure (BP) values are not the only causes of adverse cardiovascular consequences. BP variability (BPV) has also been demonstrated to be a predictor of mortality for cardiovascular events; however, its determinants are still unknown. This study considers 426 subjects with ambulatory BP monitoring (ABPM) measuring 24-h, diurnal and nocturnal absolute BP values and their standard deviations of the mean, along with nocturnal fall, age, sex and current treatment. Patients were divided in two subgroups, controlled and uncontrolled BP, and BPV of patients with "true" and "false" resistant hypertension was also analyzed. Nocturnal and 24-h BPV were higher in the group with uncontrolled hypertension. Multiple regression analysis showed that absolute BP, age, nocturnal fall, but not sex predicted BPV. Patients with "true" resistant hypertension had greater BPV than "false" resistant hypertension patients. Absolute BP resulted as the main determinant of 24-h and nocturnal BPV but not daytime BPV. Also nocturnal BP fall and age resulted as predictors of BPV in treated and untreated patients. Patients with "true" resistant hypertension have a higher BPV, suggesting a higher sympathetic activation. Evidence is still limited regarding the importance of short-term BPV as a prognostic factor and assessment of BPV cannot yet represent a parameter for routine use in clinical practice. Future prospective trials are necessary to define which targets of BPV can be achieved with antihypertensive drugs and whether treatment-induced reduction in BPV is accompanied by a corresponding reduction in cardiovascular events.
The Korean Society of Hypertension Guidelines for the Management of Hypertension in 2013: Its Essentials and Key Points.
Lee Hae-Young,Park Jeong Bae
Pulse (Basel, Switzerland)
The Korean Society of Hypertension published new guidelines for the management of hypertension in 2013 which fully revised the first Korean hypertension treatment guideline published in 2004. Due to shortage of Korean data, the Committee decided to establish the guideline in the form of an 'adaptation' of the recently released guidelines. The prevalence of hypertension was 28.5% in the recent Korean National Health and Nutrition Examination Survey in 2011, and the awareness, treatment, and control rates are generally improving. However, the risks for cerebrovascular disease and coronary artery disease which are attributable to hypertension were the highest in Korea. The classification of hypertension is the same as in other guidelines. The remarkable difference is that prehypertension is further classified as stage 1 and 2 prehypertension because the cardiovascular risk is significantly different within the prehypertensive range. Although the decision-making was based on office blood pressure (BP) measured by the auscultation method using a stethoscope, the importance of home BP measurement and ambulatory BP monitoring is also stressed. The Korean guideline does not recommend a drug therapy in patients within the prehypertensive range, even in patients with prediabetes, diabetes mellitus, stroke, or coronary artery disease. In an elderly population over 65 years old, drug therapy can be initiated when the systolic BP (SBP) is ≥160 mm Hg. The target BP is generally an SBP of <140 mm Hg and a diastolic BP (DBP) of <90 mm Hg regardless of previous cardiovascular events. However, in patients with hypertension and diabetes, the lower DBP control <85 mm Hg is recommended. Also, in patients with hypertension with prominent albuminuria, a more strict SBP control <130 mm Hg can be recommended. In lifestyle modification, sodium reduction is the most important factor in Korea. Five classes of antihypertensive drugs, including angiotensin-converting enzyme inhibitors, β-blockers, calcium antagonists, and diuretics, are equally recommended as a first-line treatment, whereas a combination therapy chosen from renin-angiotensin system inhibitors, calcium antagonists, and diuretics is preferentially recommended.
Impact of Ambulatory Blood Pressure Monitoring on Control of Untreated, Undertreated, and Resistant Hypertension in Older People in Spain.
Gijón-Conde Teresa,Graciani Auxiliadora,López-García Esther,Guallar-Castillón Pilar,Rodríguez-Artalejo Fernando,Banegas José R
Journal of the American Medical Directors Association
BACKGROUND AND OBJECTIVE:The impact of ambulatory blood pressure monitoring (ABPM) on hypertension control has not been fully assessed across the treatment spectrum in older community-living individuals and could have important implications; specifically, the number of untreated, undertreated, and treatment-resistant uncontrolled hypertensives in need of or with unnecessary drug treatment could vary with respect to studies based on conventional blood pressure (BP) measured in clinical settings. DESIGN, SETTING, AND PARTICIPANTS:Cross-sectional study conducted in 2012 among 1118 community-living individuals aged ≥60 years in Spain. MEASUREMENTS:Three conventional BP measurements at participants' homes and 24-hour ABPM were performed under standardized conditions. Uncontrolled hypertension (mean of the last 2 conventional BP readings ≥140/90 mm Hg) was considered undertreated if on 1 or 2 antihypertensive drugs, and apparently treatment-resistant if on ≥3 drugs. White-coat effect was defined as conventional BP ≥ 140/90 mm Hg and 24-hour BP <130/80 mm Hg. RESULTS:Of 720 hypertensive patients (mean age, 72.3 ± 6.3 years; 51.3%, males), 64.4% had conventional BP ≥ 140/90 mm Hg, and from these 39.9% were untreated, 49.5% undertreated, and 10.6% apparently treatment-resistant. Among uncontrolled hypertensive patients, the white-coat effect was present in 52.4% of those untreated, in 53.5% of undertreated, and in 49% of apparent treatment-resistant. These white-coat results were similar or even higher across alternative BP thresholds. CONCLUSIONS:One-half of older uncontrolled hypertensive patients studied at home were actually controlled according to ABPM, regardless of treatment status. This suggests reconsideration of treatment needs in these numerous white-coat hypertensive patients, who probably do not need drug treatment initiation or intensification.
Advantages of Ambulatory Blood Pressure Monitoring in Assessing the Efficacy of Antihypertensive Therapy.
De la Sierra Alejandro
Cardiology and therapy
The cumulative evidence in the past three decades situates ambulatory blood pressure monitoring (ABPM) as a central element in diagnosing and predicting the prognosis of subjects with hypertension. However, for various reasons, this diagnostic and prognostic importance has not been translated in equal measure into making decisions or guiding antihypertensive treatment. Mean 24-h, daytime, and night-time blood pressure estimates, the occurrence of divergent phenotypes between clinic measurements, and ABPM, as well as the main elements that determine blood pressure variability over 24 h, especially night-time dipping, are all elements that in addition to providing evidence for patient prognosis, can be used to guide antihypertensive treatment follow-up enabling greater precision in defining the effect of the drugs. In recent years, specific indices have been developed using 24-h monitoring, evaluate the duration of treatment action, the homogeneity of the effect over the monitoring period, and its possible effects on variability. In future controlled clinical trials on antihypertensive therapies it is necessary to evaluate the effects of those treatments on hard endpoints based on therapy guided by ABPM.
Effect of bedtime administration of blood-pressure lowering agents on ambulatory blood pressure monitoring results: A meta-analysis.
Sun Yuanyuan,Yu Xiao,Liu Junni,Zhou Nannan,Chen Liming,Zhao Yong,Li Xiaodong,Wang Jianchun,Cui Lianqun
BACKGROUND:Bedtime administration of antihypertensive drugs currently receives more at-tention, but no clear consensus has been reached on the blood pressure (BP)-lowering effect of this strategy. METHODS:We systematically searched literature for clinical trials of ingestion time of anti-hypertensive drugs evaluated by ambulatory blood pressure monitoring (ABPM) to perform a meta-analysis which aimed at determining the difference in diurnal, nocturnal, and 24-h mean of systolic BP (SBP) and diastolic BP (DBP), absolute BP reduction from baseline between bedtime administration group (experimental group) and morning (awaking) administration group (control group). RESULTS:The synthesis analysis showed that the level of BP in bedtime administration group was lower than the morning administration group, which reduced diurnal SBP/DBP by 1.67/1.13 mm Hg (p = 0.36/0.48), 24-h SBP/DBP by 2.78/0.36 mm Hg (p = 0.09/0.62), nocturnal SBP/DBP by 6.32/3.17 mm Hg (p = 0.03/0.007). Furthermore, there was lack of statistically significant differences in the diurnal mean of SBP/DBP reduction from baseline between the two groups (p = 0.94/0.85), but bedtime administration resulted in significant reduction from baseline in the nocturnal mean of SBP/DBP, by -4.72/-3.57 mm Hg (p = 0.01/0.05). Funnel plot demonstrated that there was no evidence of publication bias. CONCLUSIONS:Administration of ≥ 1 antihypertensive drugs at bedtime or evening results in a greater reduction of nocturnal hypertension than dosing in the morning without loss of efficacy of diurnal and 24 h mean BP reduction.
[Usefulness of night-time blood pressure measurement].
Pivin Edward,Megdiche Fatma,Burnier Michel,Wuerzner Grégoire
Revue medicale suisse
Since the use of ambulatory blood pressure monitoring (ABPM) in the beginning of the 70's, our perception of blood pressure based only on office blood pressure has been challenged. Indeed, more specific phenotypes such as white coat hypertension, masked hypertension or different circadian patterns of blood pressure have been described and studied. This has resulted in increased use of ambulatory blood pressure measurements for diagnostic and therapeutic purposes. The main focus of this paper is night-time blood pressure. We review, in a non-systematic way, the diagnostic, the prognostic and therapeutic utility of night-time blood pressure. Finally, studies in which antihypertensive drugs are given at night will be presented.
Ambulatory Blood Pressure Monitoring for the Effective Management of Antihypertensive Drug Treatment.
O'Brien Eoin,Dolan Eamon
PURPOSE:This purpose of this article is to review the current recommendations for ambulatory blood pressure measurement (ABPM) and the use of ABPM in assessing treatment. METHODS:We review current international guidelines and undertake a critical review of evidence supporting the clinical use of ABPM in effectively managing antihypertensive drug treatment. FINDINGS:Current guidelines emphasize the diagnostic superiority of ABPM, mainly from the ability of the technique to identify sustained hypertension by allowing for the exclusion of white-coat hypertension and by demonstrating the presence of masked hypertension. ABPM also offers diagnostic insights into nocturnal patterns of blood pressure, such as dipping and nondipping, reverse dipping, and excessive dipping, and the presence of nocturnal hypertension; although less attention is given to the nocturnal behavior of blood pressure in clinical practice, the nocturnal patterns of blood pressure have particular relevance in assessing the response to blood pressure-lowering medication. Surprisingly, although the current guidelines give detailed recommendations on the diagnostic potential and use of ABPM, there are scant recommendations on the benefits and application of the technique for the initiation of blood pressure-lowering therapy in clinical practice and virtually no recommendations on how it might be used to assess the efficacy of drug treatment. IMPLICATIONS:In view of a deficiency in the literature on the role of ABPM in assess the efficacy of drug treatment, we put forward proposals to correct this deficiency and guide the prescribing physician on the most appropriate drug administration and dosage over time.