Correlations of Circadian Rhythm Disorder of Blood Pressure with Arrhythmia and Target Organ Damage in Hypertensive Patients.
Zeng Lixiong,Zhang Zhihui,Wang Xiaoyan,Tu Shan,Ye Fei
Medical science monitor : international medical journal of experimental and clinical research
BACKGROUND The aim of this study was to investigate the correlations of circadian rhythm disorder of blood pressure with arrhythmia and target organ damage in hypertensive patients. MATERIAL AND METHODS A total of 198 patients admitted and treated in our hospital from May 2018 to April 2019 were selected to receive 24-h ambulatory blood pressure monitoring. The nighttime blood pressure decrease rate is 0-10% in people with normal circadian rhythm of blood pressure. In the present study, we divided patients into a normal circadian rhythm group (normal circadian rhythm of blood pressure, n=132) and a circadian rhythm disorder group (circadian rhythm disorder of blood pressure, n=66) according to the circadian rhythm of blood pressure. The systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean pulse pressure (PP) were observed, and dynamic electrocardiography was performed to observe the status of arrhythmia. Finally, the degree of damage to target organs such as heart, brain, and kidney was compared. RESULTS The circadian rhythm disorder group had remarkably higher daytime SBP (d-SBP), daytime DBP (d-DBP), and daytime PP (d-PP) but clearly lower nighttime SBP (n-SBP), nighttime DBP (n-DBP), and nighttime PP (n-PP) than in the normal circadian rhythm group (P<0.0001). The detection rate of arrhythmia and the degree of target organ damage were clearly higher in the circadian rhythm disorder group compared with the normal circadian rhythm group (P<0.0001). Moreover, the incidence rates of heart disease, cerebrovascular disease, and nephropathy were higher in the circadian rhythm disorder group than in the normal circadian rhythm group (P<0.0001). CONCLUSIONS The circadian rhythm disorder of blood pressure in hypertensive patients probably increases the risk of arrhythmia and worsens the target organ damage, so attention should be paid to the adjustment of disordered blood pressure rhythm in hypertensive patients in clinical practice.
Nocturnal Hypertension: Neglected Issue in Comprehensive Hypertension Management.
Kristanto Andi,Adiwinata Randy,Suminto Silvia,Kurniawan Benny N,Christianty Finna,Sinto Robert
Acta medica Indonesiana
The body circardian rhythm affects blood pressure variability at day and night, therefore blood pressure at day and night might be different. Nocturnal hypertension is defined as increase of blood pressure >120/70mmHg at night, which is caused by disturbed circadian rhythm, and associated with higher cardiovascular and cerebrovascular events also mortality in hypertensive patients. Nocturnal hypertension and declining blood pressure pattern, can only be detected by continuous examination for 24 hours, also known as ambulatory blood pressure measurement (ABPM). Chronotherapy, has become a strategy for managing the hypertensive nocturnal patients, by taking hypertensive medication at night to obtain normal blood pressure decrease in accordance with the normal circadian rhythm and, improving blood pressure control.
The interaction between blood pressure variability, obesity, and left ventricular mechanics: findings from the hypertensive population.
Tadic Marijana,Cuspidi Cesare,Pencic Biljana,Andric Anita,Pavlovic Sinisa U,Iracek Olinka,Celic Vera
Journal of hypertension
OBJECTIVE:The aim of this study was to determine the relationship between blood pressure (BP) variability and left ventricular (LV) mechanical function in untreated normal-weight, overweight, and obese hypertensive patients. METHODS:This cross-sectional study included 144 untreated hypertensive study participants who underwent 24-h ambulatory BP monitoring and complete two (2DE) and three-dimensional echocardiography (3DE). All the patients were divided into three groups according to their BMI: normal-weight patients (BMI < 25 kg/m), overweight patients (25 ≤ BMI < 30 kg/m), and obese patients (BMI ≥ 30 kg/m). RESULTS:Daytime, night-time, and 24-h BP variability progressively increased from normal-weight, throughout overweight, to obese hypertensive study participants. 2DE and 3DE LV longitudinal, circumferential and radial strains, as well as 3DE area strain, were significantly lower in obese hypertensive patients than in normal-weight and overweight study participants. 3DE LV volumes indexed for BSA did not differ significantly among the three observed groups. Night-time and 24 h BP variability indices, more than daytime BP variability parameters, were associated with 2DE and 3DE longitudinal and circumferential strains independent of BMI, LV mass index, and average 24-h SBP and DBP values. CONCLUSION:BP variability and LV deformation are significantly affected by obesity in untreated hypertensive patients. BP variability is associated with 2DE and 3DE LV mechanics independently of main clinical and echocardiographic characteristics.
The Association between Obesity, Blood Pressure Variability, and Right Ventricular Function and Mechanics in Hypertensive Patients.
Tadic Marijana,Cuspidi Cesare,Vukomanovic Vladan,Kocijancic Vesna,Celic Vera,Stanisavljevic Dejana
Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography
BACKGROUND:The purpose of this investigation was to evaluate the association between blood pressure (BP) variability and right ventricular (RV) mechanical function in normal-weight, overweight, and obese untreated patients with hypertension. METHODS:This retrospective cross-sectional study included 127 untreated subjects with hypertension who underwent 24-hour ambulatory BP monitoring and complete two-dimensional and three-dimensional echocardiographic examination. All participants were divided into three groups according to body mass index (BMI): normal-weight patients (BMI < 25 kg/m(2)), overweight patients (25 ≤ BMI < 30 kg/m(2)), and obese patients (BMI ≥ 30 kg/m(2)). RESULTS:Daytime, nighttime, and 24-hour BP variability parameters were higher in overweight and obese subjects with hypertension than in lean subjects. Two-dimensional RV longitudinal strain and systolic strain rate were significantly lower in obese patients with hypertension than in normal-weight patients (-24.1 ± 3% vs -23.3 ± 3.2% vs -21.7 ± 3.3%, P = .004). Three-dimensional echocardiographic RV volumes indexed to body surface area were lower in lean and overweight subjects than in obese participants with hypertension (mean RV end-diastolic volume index, 65 ± 6 vs 67 ± 7 vs 71 ± 8 mL/m(2), P = .001), while three-dimensional RV ejection fraction decreased in the same direction (60 ± 4% vs 58 ± 3% vs 57 ± 3%, P < .001). Nighttime BP variability indices, more than daytime BP variability parameters, correlated with two-dimensional RV global longitudinal strain and three-dimensional echocardiographic RV volumes. CONCLUSIONS:BP variability and RV structure, function, and mechanics are significantly affected by obesity in patients with untreated hypertension. BP variability is significantly associated with RV remodeling in patients with hypertension.
Correlation between blood pressure variability and subclinical target organ damage in patients with essential hypertension.
El Mokadem Mostafa,Boshra Hesham,Abd El Hady Yasser,Kasla Amany,Gouda Ahmed
Journal of human hypertension
High blood pressure (BP) variability is associated with the increased risk of cardiovascular and renal damage together with increased cardiovascular mortality. The aim of our study was to investigate the relationship between BP variability and subclinical target organ damage (TOD) in patients with controlled essential hypertension. One hundred patients with controlled essential hypertension were randomly selected from outpatient clinic of Beni-Suef University hospital. All patients were subjected to full history taking, physical examination, three separate office BP measurements for assessment of long-term BP variability, ambulatory BP monitoring for short-term variability, and finally different investigations for subclinical TOD. We had 73 patients with subclinical TOD. Long-term visit-to-visit variability was evaluated by measuring SD (standard deviation) and CV (coefficient of variance) of systolic and diastolic BP. None of the parameters of long-term BP variability were significantly higher among patients with TOD compared with those without TOD. For short-term variability evaluated by ambulatory BP monitoring, average real variability (ARV) was the only parameter that had a significant consistent association with TOD in contrast to SD and CV. Finally, Daytime systolic ARV, nighttime diastolic ARV, and age were independent predictors of TOD (P values = 0.014, 0.018, 0.047, and 0.02, respectively). We concluded that ARV could be an appropriate index of BP variability and a more useful predictor of TOD in contrast to other parameters of BP variability.
Blood pressure variability and its association with echocardiographic parameters in hypertensive diabetic patients.
Massierer Daniela,Leiria Liana Farias,Severo Mateus Dorneles,Ledur Priscila Dos Santos,Becker Alexandre Dalpiaz,Aguiar Fernanda Mus,Lima Eliandra,Freitas Valéria Centeno,Schaan Beatriz D,Gus Miguel
BMC cardiovascular disorders
BACKGROUND:Blood pressure (BP) variability is associated with target organ damage in hypertension and diabetes. The 24 h ambulatory blood pressure monitoring (24 h-ABPM) has been proposed as an evaluation for BP variability using several indexes [standard deviation (SD) of mean BP, coefficient of variation (CV), BP variation over time (time-rate index)]. METHODS:We evaluated the association between BP variability measured by 24 h-ABPM indexes and echocardiographic variables in a cross-sectional study in 305 diabetic-hypertensive patients. RESULTS:Two groups were defined by the median (0.55 mmHg/min) of time-rate systolic BP (SBP) index and classified as low or high variability. Age was 57.3 ± 6.2 years, 196 (64.3%) were female. Diabetes duration was 10.0 (5.0-16.2) years, HbA1c was 8.2 ± 1.9%. Baseline clinical characteristics were similar between low (n = 148) and high (n = 157) variability groups. Office SBP and systolic 24 h-ABPM were higher in the high variability group (139.9 mmHg vs 146.0 mmHg, P = 0.006; 128.3 mmHg vs 132.9 mmHg, P = 0.019, respectively). Time-rate index, SD and CV of SBP, were higher in high variability group (P < 0.001; P < 0.001 and P = 0.003, respectively). Time-rate index was not independently associated with the echocardiography's variables in multiple linear model when adjusting for age, 24 h-ABPM, diabetes duration and HbA1c. The multiple linear regression model revealed that the significant and independent determinants for septum thickness, relative wall thickness and posterior wall thickness (parameters of left ventricular hypertrophy) were: age (p = 0.025; p = 0.010; p = 0.032, respectively) and 24 h-SBP (p < 0.001 in the three parameters). CONCLUSION:BP variability estimated by 24 h-ABPM is not independently associated with echocardiographic parameters in diabetic-hypertensive patients.
[The impact of long- and short-time blood pressure variability on glomerular filtration rate in elderly population].
Wang Yang,Zheng Xiaoming,An Shasha,Li Zhifang,Zhang Wenyan,Li Chunhui,Zhao Hualing,Song Lu,Chen Shuohua,Zheng Yao,Ruan Chunyu,Wu Shouling
Zhonghua xin xue guan bing za zhi
OBJECTIVE:To investigate the impact of long-time and short-time blood pressure variability (BPV) on glomerular filtration rate (eGFR) in elderly population. METHODS:A total of 2 464 participants aged of ≥60 years old without history of stroke and coronary heart disease were selected with random sampling method from the individuals underwent health check up in Tangshan Kailuan Hospital, Kailuan Linxi Hospital, Kailuan Zhaogezhuang Hospital between 2006 and 2013. The study participants were asked to join a face-to-face interview every two years. Long-time BPV was defined as the standard deviation of all SBP values at the baseline visit and following visits, short-time BPV was defined as the standard deviation of day time blood pressure and night time blood pressure which was derived from 24 hours ambulatory blood pressure monitoring. Multivariate linear regression models were used to test the impact of long- and short-time BPV on eGFR. RESULTS:The study included 3 participants groups including the long-time SBPV group (2 279 participants), the short-time SBPV group (1 636 participants) and the long- plus short-time SBPV group (1 632 participants). Participants were further sub grouped by median value (NO.1<meadian and NO.2>median value). eGFR in the long-time SBPV NO.1 and NO.2 group was 83.19 and 81.49 ml·min(-1)·1.73 m(-2) respectively, in the short time SBPV NO.1 and NO.2 group was 83.53 and 80.81ml·min(-1)·1.73 m(-2) of the day time, and was 83.20 and 81.14 ml·min(-1)·1.73 m(-2) of the night time, respectively. eGFR in the long- plus short-time SBPV NO.1 and NO.2 group was 83.21 and 81.08 ml·min(-1)·1.73 m(-2) of the long-time SBPV, and was 83.53 and 80.75 ml·min(-1)·1.73 m(-2) of the day time, and was 83.18 and 81.11 ml·min(-1)·1.73 m(-2) of the night time. Significant linear relationship was found between higher day time SBPV and lower eGFR (P<0.05). After adjusting for confounding parameters including age, sex, body mass index, 1 mmHg(1 mmHg=0.133 kPa) of day time SBPV increase was related 0.21 ml·min(-1)·1.73 m(-2) eGFR decrease (P<0.05). CONCLUSION:The higher day time SBPV is associated with reduced eGFR in the elderly population.Clinical Trail Registry Chinese Clinical Trial Registry, ChiCTR-TNC-11001489.
Aortic stiffness and blood pressure variability in young people: a multimodality investigation of central and peripheral vasculature.
Boardman Henry,Lewandowski Adam J,Lazdam Merzaka,Kenworthy Yvonne,Whitworth Polly,Zwager Charlotte L,Francis Jane M,Aye Christina Y L,Williamson Wilby,Neubauer Stefan,Leeson Paul
Journal of hypertension
INTRODUCTION:Increased blood pressure (BP) variability is a cardiovascular risk marker for young individuals and may relate to the ability of their aorta to buffer cardiac output. We used a multimodality approach to determine relations between central and peripheral arterial stiffness and BP variability. METHODS:We studied 152 adults (mean age of 31 years) who had BP variability measures based on SD of awake ambulatory BPs, 24-h weighted SD and average real variability (ARV). Global and regional aortic distensibility was measured by cardiovascular magnetic resonance, arterial stiffness by cardio-ankle vascular index (CAVI) and pulse wave velocity (PWV) by SphygmoCor (carotid-femoral) and Vicorder (brachial-femoral). RESULTS:In young people, free from overt cardiovascular disease, all indices of SBP and DBP variability correlated with aortic distensibility (global aortic distensibility versus awake SBP SD: r = -0.39, P < 0.001; SBP ARV: r = -0.34, P < 0.001; weighted 24-h SBP SD: r = -0.42, P < 0.001). CAVI, which closely associated with aortic distensibility, also related to DBP variability, as well as awake SBP SD (r = 0.19, P < 0.05) and weighted 24-h SBP SD (r = 0.24, P < 0.01), with a trend for SBP ARV (r = 0.17, P = 0.06). In contrast, associations with PWV were only between carotid-femoral PWV and weighted SD of SBP (r = 0.20, P = 0.03) as well as weighted and ARV of DBP. CONCLUSION:Greater BP variability in young people relates to increases in central aortic stiffness, strategies to measure and protect aortic function from a young age may be important to reduce cardiovascular risk.
Short-term blood pressure variability outweighs average 24-h blood pressure in the prediction of cardiovascular events in hypertension of the young.
Palatini Paolo,Saladini Francesca,Mos Lucio,Fania Claudio,Mazzer Adriano,Cozzio Susanna,Zanata Giuseppe,Garavelli Guido,Biasion Tiziano,Spinella Paolo,Vriz Olga,Casiglia Edoardo,Reboldi Gianpaolo
Journal of hypertension
OBJECTIVE:The association of short-term blood pressure (BP) variability (BPV) with cardiovascular events (CVEs) is controversial. Aim of this study was to investigate whether BPV measured as weighted 24-h SD was associated with CVE in a prospective cohort study of young patients screened for stage 1 hypertension. METHODS:We performed 24-h ambulatory BP monitoring in 1206 participants aged 33.1 ± 8.5 years, untreated at baseline examination. Participants were divided into two categories with low (<12.8 mmHg) or high (≥12.8 mmHg) SBPV. Hazard ratios for CVE associated with BPV expressed either as continuous or categorical variable were computed from multivariable Cox models. RESULTS:During 15.4 ± 7.4 years of follow-up there were 69 fatal and nonfatal CVE. In multivariable Cox models, high SBPV was an independent predictors of CVE [2.75 (1.65-4.58); P = 0.0001] and of coronary events [3.84 (2.01-7.35), P < 0.0001]. Inclusion in the model of development of hypertension requiring treatment during the follow-up, did not reduce the strength of the associations. Addition of SBPV to fully adjusted models had significant impact on risk reclassification and integrated discrimination (relative integrated discrimination improvement for BPV as continuous variable: 13.5%, P = 0.045, and for BPV as categorical variable: 26.6%, P = 0.001). When the coefficient of variation was used as BPV metric similar results were obtained. Of note, in all Cox models average 24-h BP was no longer an independent predictor of outcome after BPV was included. CONCLUSION:Short-term BPV adds to the risk stratification for cardiovascular events in young-to-middle-age patients screened for stage 1 hypertension over and above traditional 24-h ambulatory monitoring indexes.
Relationship between blood pressure variability and target organ damage in elderly patients.
Li C-L,Liu R,Wang J-R,Yang J
European review for medical and pharmacological sciences
OBJECTIVE:To investigate the relationship between 24 h systolic blood pressure variability (SBPV) and target organ damage in elderly patients with essential hypertension. PATIENTS AND METHODS:180 elderly patients (≥ 80 y) with hypertension admitted to our hospital from January 2015 to January 2017 were selected as hypertension group and divided into high blood pressure variability (BPV) group and low BPV group according to the 50th percentile (P50) of 24 h SBPV, while 90 elderly non-hypertension patients admitted during the same period were enrolled as control group. 24 h ambulatory blood pressure values of patients in the three groups were recorded. The total cholesterol (TC), left ventricular mass index (LVMI), carotid artery intima-media thickness (IMT), 24 h microalbuminuria (MA) and complications with cardiovascular disease in patients of the three groups were compared and analyzed. Logistic analysis was conducted with MA, IMT and LVMI as the dependent variables and the remaining risk factors as the independent variables. RESULTS:24 h SBPV and daytime SBPV (d SBPV) in patients of the hypertension group were significantly higher than those in the control group (p < 0.01); the incidences of coronary heart disease and atherosclerotic plaque as well as IMT, LVMI and MA were higher in the high BPV group than those in the low BPV group (p < 0.05 or p < 0.01). The multivariate results showed that 24 h SBPV was associated with IMT, LVMI and MA. CONCLUSIONS:BPV can serve as an important indicator to predict target organ damage in elderly patients with essential hypertension. 24 h SBPV can reflect the degree of target organ damage in elderly hypertensive patients.
Blood Pressure Variability and Prediction of Target Organ Damage in Patients With Uncomplicated Hypertension.
Veloudi Panagiota,Blizzard Christopher L,Head Geoffrey A,Abhayaratna Walter P,Stowasser Michael,Sharman James E
American journal of hypertension
BACKGROUND:The average of multiple blood pressure (BP) readings (mean BP) independently predicts target organ damage (TOD). Observational studies have also shown an independent relationship between BP variability (BPV) and TOD, but there is limited longitudinal data. This study aimed to determine the effects of changes in mean BP levels compared with BPV on left ventricular mass index (LVMI) and aortic pulse wave velocity (aPWV). METHODS:Mean BP levels (research-protocol clinic BP (clinic BP), 24-hour ambulatory BP, and 7-day home BP) and BPV were assessed in 286 patients with uncomplicated hypertension (mean age 64±8 SD years, 53% women) over 12 months. Reading-to-reading BPV (from 24-hour ambulatory BP) and day-to-day BPV (from 7-day home BP) were assessed at baseline and 12 months, and visit-to-visit BPV (clinic BP) was assessed from 5 visits over 12 months. LVMI was measured by 3D echocardiography and aPWV with applanation tonometry. RESULTS:The strongest predictors of the changes in LVMI (ΔLVMI) were the changes in mean 24-hour systolic BPs (SBPs) (P < 0.02). Similarly, the strongest predictors of the changes in aPWV (ΔaPWV) were the changes in mean 24-hour ambulatory SBPs (P < 0.01) and the changes in mean clinic SBP (P < 0.001). However, none of the changes in BPV were independently associated with ΔLVMI or ΔaPWV (P > 0.05 for all). CONCLUSIONS:Changes in mean BP levels, but not BPV, were most relevant to changes in TOD in patients with uncomplicated hypertension. Thus, from this point of view, BPV appears to have limited clinical utility in this patient population.
24-Hour blood pressure variability as a predictor of short-term echocardiographic changes in normotensive women with past history of preeclampsia/eclampsia.
AbdelWahab Mohammad AbdelKader,Farrag Hazem Mohammad-Ali,Saied Cristina Eid
OBJECTIVES:To investigate the association between 24-hr blood pressure variability (BPV) and subclinical echocardiographic changes and microalbuminuria in normotensive women with history of preeclampsia/eclampsia. BACKGROUND:Ambulatory blood pressure monitoring (ABPM) has been used as a valuable method in determining cardiovascular (CV) risk and target organ damage. Although hypertension and proteinuria that define preeclampsia/eclampsia may resolve in the majority of women, a significantly greater risk of CV and renal disease is present in their later life. METHODS:101 normotensive women with a past history of preeclampsia/eclampsia and 42 age-matched normal volunteers were subjected to 24-hr ABPM, echocardiography for estimation of left ventricular mass (LVM) index and Aortic distensibility/stiffness indices. Urinary albumin/creatinine ratio was also estimated. RESULTS:There was significantly higher standard deviation (SD) and average reading variability (ARV) indices of BPV in the study group compared to controls (p < 0.001 for all). There were significantly higher LVM index, aortic stiffness index and microalbuminuria in the study group (p < 0.001 for all). There was significant positive correlation between all BPV indices and LVM index, aortic stiffness index (except for SD and ARV of diastolic BP for nighttime) and microalbuminuria. Stepwise regression analysis revealed that ARV of systolic BP for daytime can independently predict LVM index (r = 0.688, p < 0.001), impaired aortic distensibility (r = 0.557, p < 0.001) and microalbuminuria (r = 0.696, p < 0.001). CONCLUSIONS:The BPV indices correlated with subclinical echocardiographic changes and microalbuminuria in normotensive women with history of preeclampsia/eclampsia. The ARV of systolic BP for daytime could early predict such changes in those apparently healthy women.
Relationship between carotid artery sclerosis and blood pressure variability in essential hypertension patients.
Chi Xianglin,Li Min,Zhan Xia,Man Honghao,Xu Shunliang,Zheng Dingchang,Bi Jianzhong,Wang Yingcui,Liu Chengyu
Computers in biology and medicine
OBJECTIVES:This study aimed to investigate the relationship between the presence of carotid arteriosclerosis (CAS) and blood pressure variability (BPV) in patients with essential hypertension. METHODS:One hundred and forty four essential hypertension patients underwent ambulatory BP monitoring for 24h after hospitalization. Common BPV metrics were calculated. General clinical parameters, including age, gender, height, weight, history of coronary heart disease, stroke, diabetes, hypertension, smoking and drink, were recorded. Biochemical indices were obtained from a blood test. Carotid intima-media thickness (IMT) and carotid plaques were assessed to separate patients into a non-CAS group (IMT≤0.9mm; n=82) and a CAS group (IMT>0.9mm; n=62). BPV metrics and clinical parameters were analyzed and compared between the two groups. Multivariate logistic regression analysis was performed to determine the associated risk factors of CAS. RESULTS:Multivariate logistic regression analysis revealed that two BPV metrics, the standard deviation of daytime systolic blood pressure (SSD) (OR: 1.587, 95%CI: 1.242-2.028), the difference between average daytime SBP and nighttime SBP (OR: 0.914, 95%CI: 0.855-0.977), as well as three clinical parameters (age, OR: 1.098, 95%CI: 1.034-1.167; smoking, OR: 4.072, 95%CI: 1.466-11.310, and fasting blood glucose, OR: 2.029, 95%CI: 1.407-2.928), were significant factors of CAS in essential hypertension patients. CONCLUSION:SSD, in combination with the ageing, smoking and FBG, has been identified as risk factors for CAS in patients with essential hypertension.
Association between blood pressure variability, cardiovascular disease and mortality in type 2 diabetes: A systematic review and meta-analysis.
Chiriacò Martina,Pateras Konstantinos,Virdis Agostino,Charakida Marietta,Kyriakopoulou Despoina,Nannipieri Monica,Emdin Michele,Tsioufis Konstantinos,Taddei Stefano,Masi Stefano,Georgiopoulos Georgios
Diabetes, obesity & metabolism
AIM:To investigate the associations of blood pressure variability (BPV), expressed as long-term (visit-to-visit) and short-term (ambulatory blood pressure monitoring [ABPM] and home blood pressure monitoring [HBPM]) and all-cause mortality, major adverse cardiovascular events (MACEs), extended MACEs, microvascular complications (MiCs) and hypertension-mediated organ damage (HMOD) in adult patients with type 2 diabetes. MATERIALS AND METHODS:PubMed, Medline, Embase, Cinahl, Web of Science, ClinicalTrials.gov and grey literature databases were searched for studies including patients with type 2 diabetes, at least one variable of BPV (visit-to-visit, HBPM, ABPM) and evaluation of the incidence of at least one of the following outcomes: all-cause mortality, MACEs, extended MACEs and/or MiCs and/or HMOD. The extracted information was analyzed using random effects meta-analysis and meta-regression. RESULTS:Data from a total of 377 305 patients were analyzed. Systolic blood pressure (SBP) variability was associated with a significantly increased risk of all-cause mortality (HR 1.12, 95% CI 1.04-1.21), MACEs (HR 1.01, 95% CI 1.04-1.17), extended MACEs (HR 1.07, 95% CI 1.03-1.11) and MiCs (HR 1. 12, 95% CI 1.01-1.24), while diastolic blood pressure was not. Associations were mainly driven from studies on long-term SBP variability. Qualitative analysis showed that BPV was associated with the presence of HMOD expressed as carotid intima-media thickness, pulse wave velocity and left ventricular hypertrophy. Results were independent of mean blood pressure, glycaemic control and serum creatinine levels. CONCLUSIONS:Our results suggest that BPV might provide additional information rather than mean blood pressure on the risk of cardiovascular disease in patients with type 2 diabetes.
Change in Blood Pressure Variability Among Treated Elderly Hypertensive Patients and Its Association With Mortality.
Chowdhury Enayet K,Nelson Mark R,Wing Lindon M H,Jennings Garry L R,Beilin Lawrence J,Reid Christopher M, ,
Journal of the American Heart Association
Background Information is scarce regarding effects of antihypertensive medication on blood pressure variability (BPV) and associated clinical outcomes. We examined whether antihypertensive treatment changes BPV over time and whether such change (decline or increase) has any association with long-term mortality in an elderly hypertensive population. Methods and Results We used data from a subset of participants in the Second Australian National Blood Pressure study (n=496) aged ≥65 years who had 24-hour ambulatory blood pressure recordings at study entry (baseline) and then after a median of 2 years while on treatment (follow-up). Weighted day-night systolic BPV was calculated for both baseline and follow-up as a weighted mean of daytime and nighttime blood pressure standard deviations. The annual rate of change in BPV over time was calculated from these BPV estimates. Furthermore, we classified both BPV estimates as and based on the baseline median BPV value and then classified BPV changes into , , , and . We observed an annual decline (mean±SD: -0.37±1.95; 95% CI, -0.54 to -0.19; <0.001) in weighted day-night systolic BPV between baseline and follow-up. Having constant stable: high BPV was associated with an increase in all-cause mortality (hazard ratio: 3.03; 95% CI, 1.67-5.52) and cardiovascular mortality (hazard ratio: 3.70; 95% CI, 1.62-8.47) in relation to the stable: low BPV group over a median 8.6 years after the follow-up ambulatory blood pressure monitoring. Similarly, higher risk was observed in the decline: high to low group. Conclusions Our results demonstrate that in elderly hypertensive patients, average BPV declined over 2 years of follow-up after initiation of antihypertensive therapy, and having higher BPV (regardless of any change) was associated with increased long-term mortality.
Clinical value of ambulatory blood pressure: Is it time to recommend for all patients with hypertension?
Solak Yalcin,Kario Kazuomi,Covic Adrian,Bertelsen Nathan,Afsar Baris,Ozkok Abdullah,Wiecek Andrzej,Kanbay Mehmet
Clinical and experimental nephrology
Hypertension is a very common disease, and office measurements of blood pressure are frequently inaccurate. Ambulatory Blood Pressure Monitoring (ABPM) offers a more accurate diagnosis, more detailed readings of average blood pressures, better blood pressure measurement during sleep, fewer false positives by detecting more white-coat hypertension, and fewer false negatives by detecting more masked hypertension. ABPM offers better management of clinical outcomes. For example, based on more accurate measurements of blood pressure variability, ABPM demonstrates that taking antihypertensive medication at night leads to better controlled nocturnal blood pressure, which translates into less end organ damage and fewer clinical complications of hypertension. For these reasons, albeit some shortcomings which were discussed, ABPM should be considered as a first-line tool for diagnosing and managing hypertension.
Role and Relevance of Blood Pressure Variability in Hypertension Related Co-morbidities.
Kumar Ashok,Kalmath B C,Abraham Georgi,Christopher Johann,Kaparthi Pln,Fischer Louie,Deshpande Neeta,Mishra N K,Raj Praveen,Javerani Rajesh,Goyal Ramesh,Dsouza Reefa,Joshi Shashank R
The Journal of the Association of Physicians of India
Despite maintaining mean blood pressure at optimal levels, cardiovascular complications still occur in hypertensive patients. Blood pressure variability (BPV) has been implicated as a prominent factor responsible for incurring this additional risk. In this review we attempted to generate a consensus on the importance of BPV in the hypertension management and to evaluate different therapeutic options available to reduce BPV. Panel comprising of 11 leading experts from India in different areas of clinical practice (including nephrology, diabetes and endocrinology, cardiology, and critical care medicine) was convened. The board reviewed up to date literature on BPV, shared personal experiences from their clinical practice, and debated their opinions on the significance of BPV in hypertension management and also on various therapeutic options available to control it. The reviewers agreed that BPV is frequently observed in hypertensive individuals and it is a critical factor in hypertension management. Blood pressure variability can be measured by ambulatory blood pressure monitoring, home blood pressure monitoring, and office blood pressure monitoring. Members concurred that variations in blood pressure that are 10 standard deviations above the mean blood pressure should be considered as pathologically significant and such variations should be reduced using pharmacological therapies. The board opined that Angiotensin II Receptor Blockers,Calcium Channel Blockers etc such as Olmesartan, Nifedipine can be used to reduce BPV. As a way forward, the panel recommends to bridge the evidence gap that establishes a possible direct relationship between BPV and cardiovascular complications. Blood pressure variability has paramount role in the current hypertension management scenario. To reduce disease burden and increase quality of life of hypertensive individuals, physicians should consider lowering BPV along with physiological BP levels.
Relation between blood pressure variability and early renal damage in hypertensive patients.
Yin L-H,Yan W-J,Guo Z-X,Zhou F-Z,Zhang H-Y
European review for medical and pharmacological sciences
OBJECTIVE:The objective of the present study was to observe the relation between blood pressure variability (BPV) and early renal damage in hypertensive patients. PATIENTS AND METHODS:A total of 118 hypertensive patients were consecutively selected. General parameters including sex, age, duration, and grade of hypertension, antihypertensive drugs taken, smoking status, blood sugar, blood lipid level, body mass index, indexes of 24-h ambulatory blood pressure monitoring and renal function including cystatin C (CysC), serum creatinine (SCr), angiotensin II (Ang II), microalbuminuria (mALb), and urine creatinine (UCr) were measured. Glomerular filtration rate (eGFR), endogenous creatinine clearance rate (Ccr), and urine albumin/creatinine ratio (UACR) were calculated by CysC level, SCr level, and mALb and UCr level respectively. The 24-h ambulatory blood pressure monitoring indexes included 24-h mean systolic blood pressure variability (24h-SBPV), 24-h mean diastolic blood pressure variability (24h-DBPV), day mean systolic blood pressure variability (d-SBPV), day mean diastolic blood pressure variability (d-DBPV), night mean systolic blood pressure variability (n-SBPV), and night mean diastolic blood pressure variability (n-DBPV). RESULTS:Sixty-four hypertensive patients (54.24%) were non-dipper, and the baseline data of the two groups were comparable. The 24h-SBPV, 24h-DBPV, d-DBPV, n-SBPV and SCr, eGFR, and Ccr of the two groups showed no significant differences. The d-SBPV, n-DBPV, CysC, and Ang II of the non-dipper group were significantly higher than those of the dipper group (p<0.05). The mALb in both groups increased and was more obvious in the non-dipper group. UACR of the non-dipper group was significantly higher than that of dipper group (p<0.05), while UCr showed no difference. By Pearson correlation, d-SBPV and n-DBPV correlated positively (p<0.05) with CysC, Ang II, mALb, and UACR. CONCLUSIONS:BPV of hypersensitive patients, especially the d-SBPV and n-DBPV, was closely related to indexes of early renal damage including CysC, Ang II, mALb, and UACR.
Visit-to-visit (long-term) and ambulatory (short-term) blood pressure variability to predict mortality in an elderly hypertensive population.
Chowdhury Enayet K,Wing Lindon M H,Jennings Garry L R,Beilin Lawrence J,Reid Christopher M,
Journal of hypertension
OBJECTIVES:To explore the association of different types of blood pressure (BP) variability measures estimated from either short-term ambulatory reading-to-reading or long-term clinic visit-to-visit BP records with long-term survival in an elderly treated hypertensive population. METHODS:A subset of patients (n = 508) aged at least 65-years was studied from the Second Australian National Blood Pressure study. We estimated SBP and DBP BP variability as the SD of ambulatory (24-h, daytime, night-time) and clinic visit-to-visit BP directly from all corresponding on-treatment within-individual BP records. Ambulatory 'weighted day-night' variability was calculated as a weighted mean of daytime and night-time SD. Cox-proportional hazard models adjusted for baseline risk factors (Model 1) and corresponding on-treatment BP (Model 2) or average night-time SBP (best predictive BP measure for outcome) (Model 3) were used to determine the relationship between long-term outcome and BP variability. RESULTS:Over a median of 10.6 years, 101 patients died from any cause, of which 51 deaths were cardiovascular. We observed increase in 'daytime' and 'weighted day-night' SBP/DBP variability was significantly associated with increased all-cause mortality in all models. For cardiovascular mortality, only 'weighted day-night' SBP variability significantly predicted risk in all models (Model 3 hazard ratio: 1.09, 95% confidence interval: 1.00-1.19, P = 0.04). Long-term BP variability was not associated with any outcome. On direct comparison, both 'daytime' and 'weighted day-night' BP variability measures provided similar prognostic information. CONCLUSION:Short-term 'daytime' and 'weighted day-night' SBP variability from ambulatory BP recordings was a better predictor of mortality in elderly treated hypertensive patients than long-term BP variability from visit-to-visit BP recordings.
Clinical implication of visit-to-visit blood pressure variability.
Hypertension research : official journal of the Japanese Society of Hypertension
In clinical practice, out-of-office blood pressure (BP) measurements, i.e., ambulatory BP monitoring and home BP measurement, provide superior results, reproducibility, and evaluation of the effect of antihypertensive drugs compared with office BP measurement. However, following a report on the clinical impact of visit-to-visit BP variability, in addition to the results of a clinical trial, office BP measurement has regained prominence in clinical and research settings. Many reports have been published on the association between visit-to-visit BP variability and cardiovascular outcomes. However, other indexes of BP variability besides visit-to-visit BP variability can be evaluated in the office. In addition, methodology has been developed for calculation of visit-to-visit BP variability. Although most studies have shown a positive association between visit-to-visit BP variability and cardiovascular outcomes, this association was not observed in some studies. Further research is still needed for clarification.
Higher Blood Pressure Variability in White Coat Hypertension; from the Korean Ambulatory Blood Pressure Monitoring Registry.
Kang In Sook,Pyun Wook Bum,Shin Jinho,Ihm Sang-Hyun,Kim Ju Han,Park Sungha,Kim Kwang-Il,Kim Woo-Shik,Kim Soon Gil,Shin Gil Ja
Korean circulation journal
BACKGROUND AND OBJECTIVES:Blood pressure variability (BPV) was recently shown to be a risk factor of stroke. White coat hypertension (WCH) used to be regarded as innocuous, but one long-term follow-up study reported that WCH increased stroke rate compared to normotension (NT). In this study, we aimed to evaluate the relationship between WCH and BPV. SUBJECTS AND METHODS:We analyzed 1398 subjects from the Korean Ambulatory Blood Pressure Registry, who were divided into NT (n=364), masked hypertension (n=122), white coat hypertension (n=254), and sustained hypertension (n=658) groups. RESULTS:Baseline characteristics were similar among groups. The average real variability (ARV), a highly sensitive BPV parameter, was highest in the WCH group, followed by the sustained hypertension, masked hypertension, and NT groups. The results persisted after being adjusted for covariates. The WCH vs. sustained hypertension results (adjusted mean±standard error) were as follows: 24-h systolic ARV, 22.9±0.8 vs. 19.4±0.6; 24-h diastolic ARV, 16.8±0.6 vs. 14.3±0.5; daytime systolic ARV, 21.8±0.8 vs. 16.8±0.6; and daytime diastolic ARV, 16.2±0.6 vs. 13.4±0.5 (p<0.001 for all comparisons). CONCLUSION:From the registry data, we found that subjects with WCH or masked hypertension had higher BPV than NT. However, long-term follow-up data assessing the clinical influences of WCH on stroke are needed.
Ambulatory Blood Pressure Variability Increases Over a 10-Year Follow-Up in Community-Dwelling Older People.
McDonald Claire,Pearce Mark S,Wincenciak Joanna,Kerr Simon R J,Newton Julia L
American journal of hypertension
BACKGROUND:Greater ambulatory blood pressure variability (ABPV) is associated with end-organ damage and increased mortality. Age-related changes in the cardiovascular and autonomic nervous systems make age-associated increases in ABPV likely. Cross-sectional studies support this hypothesis, showing greater ABPV among older compared to younger adults. The only longitudinal study to examine changes in ABPV, however, found ABPV decreased over 5 years follow-up. This unexpected observation probably reflected the highly selected nature of the study participants. METHODS:In this longitudinal study, we assessed changes in ABPV over 10 years in a community-cohort of older people. In addition, we examined the extent to which ABPV was predicted by demographics, cardiovascular risk factors, and medication. Clinical examination and 24-hour ambulatory blood pressure monitoring were carried out at baseline and at 10 years follow-up in 83 people, median age 70 years. ABPV was calculated using SD and coefficient of variation (Cv). Three time periods were examined: daytime, nighttime, and 24 hours. RESULTS:Daytime and 24-hour, systolic and diastolic, SD, and Cv were significantly greater at follow-up than at baseline (P < 0.001 in all cases). Mean BP did not change. CONCLUSIONS:Multilevel modeling showed follow-up interval had a significant, positive effect on SD and Cv (P < 0.004), independent of age, sex, and medication.ABPV increased over a 10-year follow-up despite stable mean BP. ABPV may therefore be an additional target for treatment in older people. Future studies should examine what degree of ABPV is harmful and if control of ABPV reduces adverse outcome.
Digital Management of Hypertension Improves Systolic Blood Pressure Variability.
Milani Richard V,Wilt Jonathan K,Milani Alexander R,Bober Robert M,Malamud Eric,Entwisle Jonathan,Lavie Carl J
The American journal of medicine
BACKGROUND:Higher systolic blood pressure variability has been shown to be a better predictor of all-cause and cardiovascular disease mortality, stroke, and cardiac disease compared with average systolic blood pressure. METHODS:We evaluated the impact of a digital hypertension program on systolic blood pressure variability in 803 consecutive patients with long-standing hypertension who had been under the care of a primary care physician for a minimum of 12 months prior to enrollment (mean 4.7 years). Blood pressure readings were transmitted directly from home using a digitally connected blood pressure unit. Medication adjustments and lifestyle coaching was performed virtually via a dedicated team of pharmacists and health coaches. Systolic blood pressure variability was grouped by quartile and measured using the standard deviation (SD) of all systolic blood pressure values per individual. RESULTS:The mean age was 67 ± 12 years, 41% were male, submitting 3.3 ± 3.7 blood pressures per week. Under usual care, only 30% of patients were in the lowest-risk quartile, and 21% of patients were in the highest risk. After 24 months, the mean systolic blood pressure variability progressively fell from 12.8 ± 4.3 mm Hg to 9.9 ± 5.1 mm Hg (P <0.0001) with 57% of patients achieving the lowest-risk quartile. CONCLUSIONS:The majority of patients with hypertension under usual care have elevated systolic blood pressure variability exposing them to higher risk of cardiovascular disease events. Digital management of hypertension that includes weekly submission of home readings leads to improvement in average systolic blood pressure as well as systolic blood pressure variability over time, which should improve cardiovascular prognosis.
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.
Extent of, and variables associated with, blood pressure variability among older subjects.
Morano Arianna,Ravera Agnese,Agosta Luca,Sappa Matteo,Falcone Yolanda,Fonte Gianfranco,Isaia Gianluca,Isaia Giovanni Carlo,Bo Mario
Aging clinical and experimental research
BACKGROUND:Blood pressure variability (BPV) may have prognostic implications for cardiovascular risk and cognitive decline; however, BPV has yet to be studied in old and very old people. AIMS:Aim of the present study was to evaluate the extent of BPV and to identify variables associated with BPV among older subjects. METHODS:A retrospective study of patients aged ≥ 65 years who underwent 24-h ambulatory blood pressure monitoring (ABPM) was carried out. Three different BPV indexes were calculated for systolic and diastolic blood pressure (SBP and DBP): standard deviation (SD), coefficient of variation (CV), and average real variability (ARV). Demographic variables and use of antihypertensive medications were considered. RESULTS:The study included 738 patients. Mean age was 74.8 ± 6.8 years. Mean SBP and DBP SD were 20.5 ± 4.4 and 14.6 ± 3.4 mmHg. Mean SBP and DBP CV were 16 ± 3 and 20 ± 5%. Mean SBP and DBP ARV were 15.7 ± 3.9 and 11.8 ± 3.6 mmHg. At multivariate analysis older age, female sex and uncontrolled mean blood pressure were associated with both systolic and diastolic BPV indexes. The use of calcium channel blockers and alpha-adrenergic antagonists was associated with lower systolic and diastolic BPV indexes, respectively. CONCLUSIONS:Among elderly subjects undergoing 24-h ABPM, we observed remarkably high indexes of BPV, which were associated with older age, female sex, and uncontrolled blood pressure values.
Relation of blood pressure variability to left ventricular function and arterial stiffness in hypertensive patients.
Shin Sung-Hee,Jang Ji-Hoon,Baek Yong-Soo,Kwon Sung-Woo,Park Sang-Don,Woo Seong-Ill,Kim Dae-Hyeok,Kwan Jun
Singapore medical journal
INTRODUCTION:Variability of blood pressure (BP) has been reported to be related to worse cardiovascular outcomes. We examined the impact of daytime systolic BP variability on left ventricular (LV) function and arterial stiffness in hypertensive patients. METHODS:Ambulatory BP monitoring (ABPM) and echocardiography were performed in 116 hypertensive patients. We assessed BP variability as standard deviations of daytime systolic BP on 24-hour ABPM. Conventional echocardiographic parameters, area strain and three-dimensional diastolic index (3D-DI) using 3D speckle tracking were measured. Arterial stiffness was evaluated by acquiring pulse wave velocity (PWV) and augmentation index. RESULTS:Patients with higher BP variability showed significantly increased left ventricular mass index (LVMI) and late mitral inflow velocity, as well as decreased E/A (early mitral inflow velocity/late mitral inflow velocity) ratio, area strain and 3D-DI than those with lower BP variability (LVMI: p = 0.02; A velocity: p < 0.001; E/A ratio: p < 0.001; area strain: p = 0.02; 3D-DI: p = 0.04). In addition, increased BP variability was associated with higher PWV and augmentation index (p < 0.001). Even among patients whose BP was well controlled, BP variability was related to LV mass, diastolic dysfunction and arterial stiffness. CONCLUSION:Increased BP variability was associated with LV mass and dysfunction, as well as arterial stiffness, suggesting that BP variability may be an important determinant of target organ damage in hypertensive patients.
Relation of short-term blood pressure variability to early renal effects in hypertensive patients with controlled blood pressure.
Farrag Hazem M A,Amin Amr S,Abdel-Rheim Alaa-Eddin R
Blood pressure monitoring
INTRODUCTION:Microalbuminuria is a common early hypertension-mediated organ damage, which correlates with the overall cardiovascular risk and development of end-stage renal damage. Lately, blood pressure variability has shown an additive value over traditional BP measurement in prediction of cardiovascular and renal involvement. AIM:Investigate the relation between short-term blood pressure variability and microalbuminuria in controlled hypertensive patients. PATIENTS AND METHODS:Ninety non-diabetic hypertensive patients with controlled blood pressure and normal estimated glomerular filtration rate had 24-hour ambulatory blood pressure monitoring with calculation of short-term blood pressure variability indices (SD, coefficient of variation and average reading variability of systolic and diastolic blood pressure for 24-hour, daytime and nighttime], and measurement of the albumin/creatinine ratio. RESULTS:Patients were classified into group 1 (61 patients without microalbuminuria) and group 2 (29 patients with microalbuminuria). No significant difference was observed between both groups regarding age, sex, body mass index, office blood pressure, average 24-hour ambulatory blood pressure monitoring readings and dipping status, but significantly longer duration of hypertension in group 2. All blood pressure variability indices were significantly higher in group 2, which showed strong positive correlations with microalbuminuria level. Multivariate analysis represented an average reading variability of 24-hour systolic blood pressure as the most powerful independent predictor for microalbuminuria (r = 0.516, P = 0.001). Receiver operating characteristic curve analysis revealed that average reading variability of 24-hour systolic blood pressure (>12.55) could predict microalbuminuria (sensitivity = 89.7%, specificity = 88.5%, area under curve = 0.949, P = 0.001). CONCLUSION:Short-term blood pressure variability correlated well with early renal effects in controlled hypertensive patients. Average reading variability of 24-hour systolic blood pressure was the strongest predictor for microalbuminuria in such patients.
Blood pressure variability and cardiovascular disease: systematic review and meta-analysis.
Stevens Sarah L,Wood Sally,Koshiaris Constantinos,Law Kathryn,Glasziou Paul,Stevens Richard J,McManus Richard J
BMJ (Clinical research ed.)
OBJECTIVE: To systematically review studies quantifying the associations of long term (clinic), mid-term (home), and short term (ambulatory) variability in blood pressure, independent of mean blood pressure, with cardiovascular disease events and mortality. DATA SOURCES: Medline, Embase, Cinahl, and Web of Science, searched to 15 February 2016 for full text articles in English. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Prospective cohort studies or clinical trials in adults, except those in patients receiving haemodialysis, where the condition may directly impact blood pressure variability. Standardised hazard ratios were extracted and, if there was little risk of confounding, combined using random effects meta-analysis in main analyses. Outcomes included all cause and cardiovascular disease mortality and cardiovascular disease events. Measures of variability included standard deviation, coefficient of variation, variation independent of mean, and average real variability, but not night dipping or day-night variation. RESULTS: 41 papers representing 19 observational cohort studies and 17 clinical trial cohorts, comprising 46 separate analyses were identified. Long term variability in blood pressure was studied in 24 papers, mid-term in four, and short-term in 15 (two studied both long term and short term variability). Results from 23 analyses were excluded from main analyses owing to high risks of confounding. Increased long term variability in systolic blood pressure was associated with risk of all cause mortality (hazard ratio 1.15, 95% confidence interval 1.09 to 1.22), cardiovascular disease mortality (1.18, 1.09 to 1.28), cardiovascular disease events (1.18, 1.07 to 1.30), coronary heart disease (1.10, 1.04 to 1.16), and stroke (1.15, 1.04 to 1.27). Increased mid-term and short term variability in daytime systolic blood pressure were also associated with all cause mortality (1.15, 1.06 to 1.26 and 1.10, 1.04 to 1.16, respectively). CONCLUSIONS: Long term variability in blood pressure is associated with cardiovascular and mortality outcomes, over and above the effect of mean blood pressure. Associations are similar in magnitude to those of cholesterol measures with cardiovascular disease. Limited data for mid-term and short term variability showed similar associations. Future work should focus on the clinical implications of assessment of variability in blood pressure and avoid the common confounding pitfalls observed to date. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014015695.
Blood pressure (BP) assessment-from BP level to BP variability.
Feber Janusz,Litwin Mieczyslaw
Pediatric nephrology (Berlin, Germany)
The assessment of blood pressure (BP) can be challenging in children, especially in very young individuals, due to their variable body size and lack of cooperation. In the absence of data relating BP with cardiovascular outcomes in children, there is a need to convert absolute BP values (in mmHg) into age-, gender- and height appropriate BP percentiles or Z-scores in order to compare a patient's BP with the BP of healthy children of the same age, but also of children of different ages. Traditionally, the interpretation of BP has been based mainly on the assessment of the BP level obtained by office, home or 24-h BP monitoring. Recent studies suggest that it is not only BP level (i.e. average BP) but also BP variability that is clinically important for the development of target organ damage, including the progression of chronic kidney disease. In this review we describe current methods to evaluate of BP level, outline available methods for BP variability assessment and discuss the clinical consequences of BP variability, including its potential role in the management of hypertension.
Role of renin-angiotensin aldosterone system on short-term blood pressure variability in hypertensive patients.
Inoue Minako,Matsumura Kiyoshi,Haga Yoshie,Kansui Yasuo,Goto Kenichi,Ohtsubo Toshio,Kitazono Takanari
Clinical and experimental hypertension (New York, N.Y. : 1993)
The relationship between the renin-angiotensin aldosterone system and short-term blood pressure variability has not been well elucidated. Here, we investigated whether blood pressure variability determined by ambulatory blood pressure monitoring differed among patients with primary aldosteronism (PA), renovascular hypertension (RVHT), and essential hypertension (EHT). We examined 25 patients with PA, 28 patients with RVHT, and 18 patients with EHT. Ambulatory blood pressure monitoring was conducted in all patients. Short-term blood pressure variability was evaluated by calculating the standard deviation (SD), coefficient of variation (CV), and average real variability (ARV) of 24-h, daytime, and nighttime blood pressure values. Day-night differences in blood pressure were also determined. The mean 24-h systolic blood pressure (SBP) and the mean diastolic blood pressure (DBP) in the PA and RVHT groups were found to be comparable to those in the EHT group. The SD, the CV, nor the ARV of the 24-h, daytime, and nighttime blood pressures showed any significant differences among the three groups. The day-night differences in blood pressure were comparable among the three groups. The short-term blood pressure variabilities evaluated by ambulatory blood pressure monitoring were comparable among the patients with EHT, RVHT, and PA. The results suggest that the renin-angiotensin aldosterone system may contribute little to short-term blood pressure variability in individuals with hypertension.
The association between plasma homocysteine and ambulatory blood pressure variability in patients with untreated hypertension.
Li Suhua,Zhu Jieming,Wu Lin,Peng Long,Luo Yanting,Zhao Yunyue,Dong Ruimin,Chen Lin,Tang Xixiang,Liu Jinlai
Clinica chimica acta; international journal of clinical chemistry
BACKGROUND:Both homocysteine (Hcy) and blood pressure variability (BPV) are independent predictors of stroke, however, their relationship is rarely evaluated before. This study aimed to investigate the association Hcy and ambulatory BPV in subjects with untreated primary hypertension. METHODS:A total of 252 eligible patients were recruited. Plasma Hcy was measured and 24-h ambulatory blood pressure monitoring was performed for each subject. The systolic and diastolic BPV values were calculated as the SD of individual blood pressure values during 24h, daytime and nighttime, and then stratified by the tertiles of Hcy concentration (T1 to T3). Univariate and multivariate linear regression models were used to assess the relationships between Hcy tertiles and BPV variables. RESULTS:The mean values of Hcy from T1 to T3 were 7.51±1.21μmol/l, 11.09±1.07μmol/l and 19.14±6.26μmol/l, respectively. Systolic and diastolic mean blood pressures were similar among subjects with different Hcy tertiles. However, both systolic and diastolic BPV variables, no matter in 24-h, daytime or nighttime, were increasing significantly along with the rises in Hcy tertiles (all p<0.05 for linear trends analysis). Multivariate linear regression analysis indicated that Hcy tertiles were significantly associated with BPV variables, independently of mean blood pressures other confounding factors. In subgroup analysis, the associations between Hcy tertiles and BPV variables were enhanced by the increased risk stratification of hypertension. CONCLUSIONS:Plasma Hcy was positively and independently associated with ambulatory BPV in patients with untreated hypertension.
Association between mortality and blood pressure variability in hypertensive and normotensive elders: A cohort study.
Weiss Avraham,Beloosesky Yichayaou,Koren-Morag Nira,Grossman Alon
Journal of clinical hypertension (Greenwich, Conn.)
To evaluate the association between blood pressure variability (BPV) and mortality in the elderly, all blood pressure measurements recorded in a cohort of individuals 65 years and older were collected and the association between BPV coefficient of variation (BPV divided by mean arterial pressure) was calculated. Mortality during a 10-year period was compared between BPV coefficient of variation quartiles. Overall, 39 502 individuals 65 years and older were included in the analysis, of which 31 737 (80.3%) were hypertensive; 12 817 (32.4%) individuals died during the study period. Mortality was lower in the second and third blood pressure quartiles compared with the first quartile in both the normotensive and hypertensive groups. In both normotensive and hypertensive individuals, mortality was higher in the fourth quartile, but it was more pronounced in normotensive individuals (odds ratio, 1.18; 95% confidence interval, 1.06-1.31 in hypertensive individuals vs odds ratio, 1.27; 95% confidence interval, 1.17-1.37 in normotensive individuals). High and low BPV are associated with mortality in both hypertensive and normotensive elders.
Central blood pressure variability is increased in hypertensive patients with target organ damage.
de la Sierra Alejandro,Pareja Julia,Yun Sergi,Acosta Eva,Aiello Francesco,Oliveras Anna,Vázquez Susana,Armario Pedro,Blanch Pedro,Sierra Cristina,Calero Francesca,Fernández-Llama Patricia
Journal of clinical hypertension (Greenwich, Conn.)
We aimed to evaluate the association of aortic and brachial short-term blood pressure variability (BPV) with the presence of target organ damage (TOD) in hypertensive patients. One-hundred seventy-eight patients, aged 57 ± 12 years, 33% women were studied. TOD was defined by the presence of left ventricular hypertrophy on echocardiogram, microalbuminuria, reduced glomerular filtration rate, or increased aortic pulse wave velocity. Aortic and brachial BPV was assessed by 24-hour ambulatory BP monitoring (Mobil-O-Graph). TOD was present in 92 patients (51.7%). Compared to those without evidence of TOD, they had increased night-to-day ratios of systolic and diastolic BP (both aortic and brachial) and heart rate. They also had significant increased systolic BPV, as measured by both aortic and brachial daytime and 24-hours standard deviations and coefficients of variation, as well as for average real variability. Circadian patterns and short-term variability measures were very similar for aortic and brachial BP. We conclude that BPV is increased in hypertensive-related TOD. Aortic BPV does not add relevant information in comparison to brachial BPV.
Blood pressure variability: clinical relevance and application.
Parati Gianfranco,Stergiou George S,Dolan Eamon,Bilo Grzegorz
Journal of clinical hypertension (Greenwich, Conn.)
Blood pressure variability is an entity that characterizes the continuous and dynamic fluctuations that occur in blood pressure levels throughout a lifetime. This phenomenon has a complex and yet not fully understood physiological background and can be evaluated over time spans ranging from seconds to years. The present paper provides a short overview of methodological aspects, clinical relevance, and potential therapeutic interventions related to the management of blood pressure variability.
Morning surge in blood pressure and blood pressure variability in Asia: Evidence and statement from the HOPE Asia Network.
Sogunuru Guru P,Kario Kazuomi,Shin Jinho,Chen Chen-Huan,Buranakitjaroen Peera,Chia Yook C,Divinagracia Romeo,Nailes Jennifer,Park Sungha,Siddique Saulat,Sison Jorge,Soenarta Arieska A,Tay Jam C,Turana Yuda,Zhang Yuqing,Hoshide Satoshi,Wang Ji-Guang,
Journal of clinical hypertension (Greenwich, Conn.)
Hypertension is a major risk factor for cardiovascular and cerebrovascular diseases. To effectively prevent end-organ damage, maintain vascular integrity and reduce morbidity and mortality, it is essential to decrease and adequately control blood pressure (BP) throughout each 24-hour period. Exaggerated early morning BP surge (EMBS) is one component of BP variability (BPV), and has been associated with an increased risk of stroke and cardiovascular events, independently of 24-hour average BP. BPV includes circadian, short-term and long-term components, and can best be documented using out-of-office techniques such as ambulatory and/or home BP monitoring. There is a large body of evidence linking both BPV and EMBS with increased rates of adverse cardio- and cerebrovascular events, and end-organ damage. Differences in hypertension and related cardiovascular disease rates have been reported between Western and Asian populations, including a higher rate of stroke, higher prevalence of metabolic syndrome, greater salt sensitivity and more common high morning and nocturnal BP readings in Asians. This highlights a need for BP management strategies that take into account ethnic differences. In general, long-acting antihypertensives that control BP throughout the 24-hour period are preferred; amlodipine and telmisartan have been shown to control EMBS more effectively than valsartan. Home and ambulatory BP monitoring should form an essential part of hypertension management, with individualized pharmacotherapy to achieve optimal 24-hour BP control particularly the EMBS and provide the best cardio- and cerebrovascular protection. Future research should facilitate better understanding of BPV, allowing optimization of strategies for the detection and treatment of hypertension to reduce adverse outcomes.
Prognostic value of average real variability of systolic blood pressure in elderly treated hypertensive patients.
Coccina Francesca,Pierdomenico Anna M,Cuccurullo Chiara,Pierdomenico Sante D
Blood pressure monitoring
OBJECTIVE:The independent prognostic significance of ambulatory blood pressure variability in the elderly is incompletely clear. We investigated the prognostic value of average real variability of 24-hour blood pressure in elderly treated hypertensive patients. METHODS:The occurrence of a combined end-point including stroke, coronary events, heart failure requiring hospitalization and peripheral revascularization was evaluated in 757 elderly treated hypertensive patients. According to tertiles of average real variability of 24-hour systolic blood pressure patients were classified as having low (≤8.66 mmHg; n = 252), medium (8.67-10.05 mmHg; n = 252) or high (>10.05 mmHg; n = 253) average real variability. RESULTS:During the follow-up (6.9 ± 3.4 years, range 0.4-12.9 years), 195 events occurred. The event rate of the population was 3.74 per 100 patient-years. After adjustment for age, sex, previous events, diabetes, estimated glomerular filtration rate, left ventricular hypertrophy, left atrial enlargement, asymptomatic left ventricular systolic dysfunction at baseline, 24-hour systolic blood pressure, non-dipping and dipping with high morning surge of blood pressure, patients with high average real variability were at higher cardiovascular risk than those with low average real variability (hazard ratio 1.64, 95% confidence interval 1.12-2.40). CONCLUSIONS:In elderly treated hypertensive patients, high average real variability of 24-hour systolic blood pressure is associated with higher cardiovascular risk independently of other risk markers, average 24-hour systolic blood pressure and circadian blood pressure changes.
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).
Factors Associated with Blood Pressure Variability Based on Ambulatory Blood Pressure Monitoring in Subjects with Hypertension in China.
Li Wei,Yu YanXia,Liang Dehong,Jia En-Zhi
Kidney & blood pressure research
BACKGROUND/AIMS:We examined the factors associated with blood pressure variability in a multi-ethnicity prospective study in China to gain more evidence to guide the prevention and management of hypertension through risk factor intervention. METHODS:A total of 318 consecutive adult subjects aged 29-94 years with suspected or known hypertension were enrolled in this study. Blood pressure variability measurements were based on ambulatory blood pressure monitoring. To measure short-term reading-to-reading blood pressure variability in this study, we used the standard deviation(SD) of the blood pressure to estimate the blood pressure variability. RESULTS:The SDs of the blood pressure in this study ranged from 5.425 to 32.25, with a median of 10.81 (quartile range, 8.90-12.46). No significant difference regarding the level distribution of blood pressure variability was found across the various ethnicities. Spearman correlation analyses indicated that the SD of blood pressure was positively correlated with DSBP (r=0.302, p=<0.001), NSBP (r=0.383, p=<0.001), NDBP (r=0.230, p=<0.001), and FBG (r=0.129, p=0.023) and was negatively correlated with triglyceride (r=-0.289, p=<0.001), CR (r=-0.242, p=<0.001), HDL-C (r=-0.230, p=<0.001), LDL-C (r=-0.186, p=0.001), and apolipoprotein B levels (r=-0.157, p=0.006). Multiple linear regression analysis indicated that triglycerides (β=-0.217, p=<0.001), NSBP (β=0.174, p=0.003), FBG (β=0.128, p=0.024), DDBP (β=-0.128, p=0.022), and apolipoprotein A (β=-0.116, p=0.036) were significantly and independently associated with the blood pressure variability. CONCLUSIONS:In this study, blood pressure variability was significantly associated with not only blood pressure levels but also patient demographic, clinical and biochemical characteristics.
[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.
Blood pressure variability and arterial stiffness parameters derived from ambulatory blood pressure monitoring.
Kikuya Masahiro,Asayama Kei,Ohkubo Takayoshi
Multiple blood pressure (BP) measurements allow an evaluation of BP variability and BP‑derived arterial stiffness indices. Periodic variations in BP are well known, from beat‑to‑beat BP readings in intra‑arterial measurement to seasonal variations in BP. Diurnal BP variation has been investigated in relation to its prognostic value. People with night‑to‑day BP ratio of 1 or higher, that is, those with a higher nocturnal than daytime BP, were older than those with normal dipping status at baseline and had a greater risk of cardiovascular mortality and morbidity. Short‑term BP variability was evaluated using an intraindividual standard deviation or average real variability without any assumption of a periodic fluctuation. The ambulatory arterial stiffness index (AASI), which is derived from ambulatory BP monitoring, is a surrogate measure of arterial stiffness. An increased short‑term BP variability and the AASI have been linked to target organ damage and poor prognosis, while short‑term BP variability added only 1% or less to the prediction of a cardiovascular event. Although strict BP control at any time of the day is essential, studies are required to clarify how much additional benefit is derived from a treatment considering BP variability or the AASI in patients with hypertension.
Correlation of Blood Pressure Variability as Measured By Clinic, Self-measurement at Home, and Ambulatory Blood Pressure Monitoring.
Abellán-Huerta José,Prieto-Valiente Luis,Montoro-García Silvia,Abellán-Alemán José,Soria-Arcos Federico
American journal of hypertension
BACKGROUND:Blood pressure variability (BPV) has been postulated as a potential predictor of cardiovascular outcomes. No agreement exists as to which measurement method is best for BPV estimation. We attempt to assess the correlation between BPV obtained at the doctor's office, self-measurement at home (SMBP) and ambulatory BP monitoring (ABPM). METHODS:Eight weekly clinic BP measurements, 2 SMBP series, and 1 24-hour ABPM recording were carried out in a sample of treated hypertensive patients. BPV was calculated using the SD, the "coefficient of variation" and the "average real variability." Determinants of short-, mid-, and long-term BPV (within each measurement method) were also calculated. The different BPV determinants were correlated "intramethod" and "intermethod" by linear regression test. RESULTS:For the 104 patients (66.5 ± 7.7 years, 58.7% males), the ABPM BPV (SD, systolic/diastolic: 14.5 ± 3.1/9.8 ± 2.5 mm Hg) was higher than the SMBP (12.2 ± 9.8/7.4 ± 5.8 mm Hg; P < 0.001) and clinic BPV (10 ± 8.9/5.9 ± 4.9 mm Hg; P = 0.001). The main BPV correlation between methods was weak, with a maximum R2 = 0.17 (P < 0.001) between clinic and SMBP systolic BPV. The "intramethod" correlation of BPV yielded a maximum R2 = 0.21 (P < 0.001) between morning diastolic SMBP intershift/intermeans variability. The "intermethod" correlation of short-, mid-, and long-term BPV determinants was weak (maximum R2 = 0.22, P < 0.001, between clinic intraday variability/SMBP morning intershift variability). CONCLUSIONS:The "intramethod" and "intermethod" correlation between BPV determinants was weak or nonexistent, even when comparing determinants reflecting the same type of temporal BPV. Our data suggest that BPV reflects a heterogeneous phenomenon that strongly depends on the estimation method and the time period evaluated.
Morning Surge and Peak Morning Ambulatory Blood Pressure Versus Automated Office Blood Pressure in Predicting Cardiovascular Disease.
Andreadis Emmanuel A,Geladari Charalampia V,Angelopoulos Epameinondas T,Kolyvas George N,Papademetriou Vasilios
High blood pressure & cardiovascular prevention : the official journal of the Italian Society of Hypertension
INTRODUCTION:Automated office blood pressure (AOBP) has been recently shown to predict equally well to ambulatory blood pressure (ABP), conventional office blood pressure (OBP) and home blood pressure (HBP), cardiovascular (CV) events among hypertensives. AIM:To compare AOBP recording and ABP monitoring in order to evaluate morning blood pressure (BP) peak in predicting CV events and deaths in hypertensives. METHODS:We assessed 236 initially untreated hypertensives, examined between 2009 and 2013. The end points were CV and non-CV death and any CV event including myocardial infarction, evidence of coronary heart disease, heart failure hospitalization, severe arrhythmia, stroke, and symptomatic peripheral artery disease. We fitted proportional hazards models using the different modalities as predictors and evaluated their predictive performance using two metrics: the Akaike's Information Criterion, and Harrell's C-index. RESULTS:After a mean follow-up of 7 years, 23 subjects (39% women) had at least one CV event. In Cox regression models, systolic conventional OBP, AOBP and peak morning BP were predictive of CV events (p < 0.05). The Akaike Information Criterion showed smaller values for AOBP than peak morning BP, indicating a better performance in predicting CV events (227.2736 and 238.7413, respectively). The C-index was 0.6563 for systolic AOBP and 0.6243 for peak morning BP indicating a better predicting ability for AOBP. CONCLUSION:In initially untreated hypertensives, AOBP appears to be at least equally reliable to 24-h monitoring in the evaluation of morning BP peak in order to detect CV disease whereas the sleep-trough and preawakening morning BP surge did not indicate such an effect.
Clinical Significance and Therapeutic Implication of Nocturnal Hypertension: Relationship between Nighttime Blood Pressure and Quality of Sleep.
Cho Myeong Chan
Korean circulation journal
Recent global hypertension guidelines recommend an early, strict and 24-hour blood pressure (BP) control for the prevention of target organ damage and cardiovascular events. Out-of-office BP measurement such as ambulatory BP monitoring and home BP monitoring is now widely utilized to rule out white-coat hypertension, to detect masked hypertension, to evaluate the effects of antihypertensive medication, to analyze diurnal BP variation, and to increase drug adherence. Nocturnal hypertension has been neglected in the management of hypertension despite of its clinical significance. Nighttime BP and non-dipping patterns of BP are stronger risk predictors for the future cardiovascular mortality and morbidity than clinic or daytime BP. In addition to ambulatory or home daytime BP and 24-hour mean BP, nocturnal BP should be a new therapeutic target for the optimal treatment of hypertension to improve prognosis in hypertensive patients. This review will provide an overview of epidemiology, characteristics, and pathophysiology of nocturnal hypertension and clinical significance, therapeutic implication and future perspectives of nocturnal hypertension will be discussed.
Nocturnal hypertension and right heart remodeling.
Tadic Marijana,Cuspidi Cesare,Celic Vera,Pencic-Popovic Biljana,Mancia Giuseppe
Journal of hypertension
BACKGROUND:We sought to investigate right ventricular (RV) and right atrial mechanics in patients with daytime, night-time and daytime-night-time hypertension. METHODS:This cross-sectional study included 256 untreated patients who underwent 24-h ambulatory blood pressure monitoring and complete echocardiographic examination including strain analysis. Night-time hypertension was defined as nocturnal SBP at least 120 mmHg and/or DBP at least 70 mmHg and daytime hypertension as SBP at least 135 mmHg and/or DBP at least 85 mmHg. RESULTS:RV structure, diastolic function and global longitudinal RV strain in patients with nocturnal hypertension are intermediate between daytime and daytime-night-time hypertension. On the other side, RV systolic and diastolic strain rates referring to the RV free wall are significantly deteriorated in the patients with nocturnal and daytime-night-time hypertension in comparison with normotension and daytime hypertension. Right atrial conduit function is significantly reduced in the patients with nocturnal and day-night-time hypertension comparing with other two groups, whereas right atrial reservoir and pump functions are intermediate between daytime and daytime-night-time hypertension. A 24-h SBP is independently of other clinical and echocardiographic parameters associated with RV and right atrial global strain. CONCLUSION:RV mechanics is worse in night-time and daytime-night-time hypertensive patients than in normotensive controls and isolated daytime hypertensive patients. A 24-h SBP is independently associated with right heart mechanics.
Nocturnal hypertension in high-risk mid-pregnancies predict the development of preeclampsia/eclampsia.
Salazar Martin R,Espeche Walter G,Leiva Sisnieguez Carlos E,Leiva Sisnieguez Betty C,Balbín Eduardo,Stavile Rodolfo N,March Carlos,Olano Ricardo D,Soria Adelaida,Yoma Osvaldo,Prudente Marcelo,Torres Soledad,Grassi Florencia,Santillan Claudia,Carbajal Horacio A
Journal of hypertension
OBJECTIVE:The aim of this study was to test if hypertension detected by ambulatory blood pressure monitoring (ABPM) performed at mid-pregnancy, is a useful predictor for preeclampsia/eclampsia (PEEC). METHODS:The study was performed in women coursing high-risk mid-pregnancies. Office blood pressure (BP) was estimated as the mean of three values, taken by a specialized nurse after a 15-min interview, and office hypertension defined as at least 140/90 mmHg. Immediately after, an ABPM was started. Diurnal hypertension was defined as ABPM at least 135/85 mmHg during daily activities, nocturnal hypertension as ABPM at least 120/70 mmHg during night rest. The adjusted risk of PEEC was estimated using logistic regression. RESULTS:Eighty-seven women (mean age 31 ± 7 years) with 23 ± 2 weeks of pregnancy were included. The prevalence of office and ABPM hypertension was 13.8 and 40.2%, respectively. The concordance between both hypertension diagnosis was low (κ = 0.170, P = 0.044). Nocturnal hypertension (35.6%) was more frequent than diurnal hypertension (26.4%). Nocturnal hypertension markedly increased the relative risk of PEEC (OR 5.32, 95% CI 1.48-19.10). The risk of PEEC attributed to diurnal hypertension did not reach statistical significance; and when both, diurnal and nocturnal hypertension were included in the same model, only the second one was a significant predictor (P = 0.012). The relative risk associated with nocturnal hypertension increased for women not taking acetylsalicylic acid (ASA); (OR 11.40, 95% CI 2.35-55.25). CONCLUSION:Nocturnal hypertension at high-risk mid-pregnancy is a frequent condition and a strong predictor for PEEC; the risk doubled for women not taking ASA.
Health Behaviors, Nocturnal Hypertension, and Non-dipping Blood Pressure: The Coronary Artery Risk Development in Young Adults and Jackson Heart Study.
Sakhuja Swati,Booth John N,Lloyd-Jones Donald M,Lewis Cora E,Thomas Stephen J,Schwartz Joseph E,Shimbo Daichi,Shikany James M,Sims Mario,Yano Yuichiro,Muntner Paul
American journal of hypertension
BACKGROUND:Several health behaviors have been associated with hypertension based on clinic blood pressure (BP). Data on the association of health behaviors with nocturnal hypertension and non-dipping systolic BP (SBP) are limited. METHODS:We analyzed data for participants with ambulatory BP monitoring at the Year 30 Coronary Artery Risk Development in Young Adults (CARDIA) study exam in 2015-2016 (n = 781) and the baseline Jackson Heart Study (JHS) exam in 2000-2004 (n = 1,046). Health behaviors (i.e., body mass index, physical activity, smoking, and alcohol intake) were categorized as good, fair, and poor and assigned scores of 2, 1, and 0, respectively. A composite health behavior score was calculated as their sum and categorized as very good (score range = 6-8), good (5), fair (4), and poor (0-3). Nocturnal hypertension was defined as mean asleep SBP ≥ 120 mm Hg or mean asleep diastolic BP ≥ 70 mm Hg and non-dipping SBP as < 10% awake-to-asleep decline in SBP. RESULTS:Among CARDIA study and JHS participants, 41.1% and 56.9% had nocturnal hypertension, respectively, and 32.4% and 72.8% had non-dipping SBP, respectively. The multivariable-adjusted prevalence ratios (95% confidence interval) for nocturnal hypertension associated with good, fair, and poor vs. very good health behavior scores were 1.03 (0.82-1.29), 0.98 (0.79-1.22), and 0.96 (0.77-1.20), respectively in CARDIA study and 0.98 (0.87-1.10), 0.96 (0.86-1.09), and 0.86 (0.74-1.00), respectively in JHS. The health behavior score was not associated non-dipping SBP in CARDIA study or JHS after multivariable adjustment. CONCLUSIONS:A health behavior score was not associated with nocturnal hypertension or non-dipping SBP.
Nocturnal systolic hypertension is a risk factor for cardiac damage in the untreated masked hypertensive patients.
Li Jianhao,Cao Yalin,Liu Chen,Li Jiayong,Yao Fengjuan,Dong Yugang,Huang Huiling
Journal of clinical hypertension (Greenwich, Conn.)
The nocturnal blood pressure (BP) has been identified as a prognostic factor for cardiovascular events. This study aimed to investigate the association between different patterns of nocturnal masked hypertension (MH) and the echocardiographic parameters in the untreated nocturnal MH patients. A total of 721 untreated MH patients (309 females and 412 males, mean age = 56.59 ± 15.20 years) from June 2006 and June 2016 were included and divided into nocturnal systolic MH (n = 77), nocturnal diastolic MH (n = 232), and nocturnal systolic/diastolic MH (n = 412) groups according to the ambulatory blood pressure monitoring. Baseline characteristics, office BP values, ambulatory BP monitoring parameters, and echocardiographic parameters were compared among the three groups. The independent factors associated with echocardiographic parameters were analyzed by multivariate linear regression. The nocturnal systolic group had the highest ratio of males, mean age, and office systolic BP (SBP), and the lowest office, 24-hour, daytime, nocturnal diastolic BP and heart rate among the three groups. The nocturnal diastolic group had the lowest interventricular septum (IVS) thickness, left atrium (LA) dimension, and left ventricular (LV) mass among the three groups. Multivariate linear regression analysis revealed that 24-hour, daytime, and nocturnal SBPs were all positively associated with LA dimension, IVS thickness, and LV mass (all B were positive and P < .050). Pearson's correlation analysis showed that nocturnal SBP was positively correlated with LA dimension, IVS thickness, and LV mass. These results suggested that different patterns of nocturnal MH had different echocardiographic outcomes. Nocturnal SBP was the independent factor associated with the echocardiographic parameters.
Short-term variability and nocturnal decline in ambulatory blood pressure in normotension, white-coat hypertension, masked hypertension and sustained hypertension: a population-based study of older individuals in Spain.
Gijón-Conde Teresa,Graciani Auxiliadora,López-García Esther,Guallar-Castillón Pilar,García-Esquinas Esther,Rodríguez-Artalejo Fernando,Banegas José R
Hypertension research : official journal of the Japanese Society of Hypertension
Blood pressure (BP) variability and nocturnal decline in blood pressure are associated with cardiovascular outcomes. However, little is known about whether these indexes are associated with white-coat and masked hypertension. We performed a cross-sectional analysis of 1047 community-dwelling individuals aged ⩾60 years in Spain in 2012. Three observer-measured home BPs and 24-h ambulatory blood pressure monitoring (ABPM) were performed under standardized conditions. BP variability was defined as BP s.d. and coefficient of variation. Differences in BP variability and nocturnal BP decrease between groups were adjusted for sociodemographic and clinical covariates using generalized linear models. Of the cohort, 21.7% had white-coat hypertension, 7.0% had masked hypertension, 21.4% had sustained hypertension, and 49.9% were normotensive. Twenty-four hour, daytime and night-time systolic BP s.d. and coefficients of variation were significantly higher in subjects with white-coat hypertension than those with normotension (P<0.05) and were similar to subjects with sustained hypertension. In untreated subjects, 24-h but not daytime or night-time BP variability indexes were significantly higher in subjects with white-coat hypertension than in those with normotension (P<0.05). Percentage decrease in nocturnal systolic and diastolic BP was greatest in the white-coat hypertension group and lowest in the masked hypertension group in all patients and untreated patients (P<0.05). Lack of nocturnal decline in systolic blood pressure was observed in 70.2% of subjects with normotension, 57.8% of subjects with white-coat hypertension, 78.1% of subjects with masked hypertension, and 72.2% of subjects with sustained hypertension (P<0.001). In conclusion, 24-h BP variability was higher in subjects with white-coat hypertension and blunted nocturnal BP decrease was observed more frequently in subjects with masked hypertension. These findings may help to explain the reports of increased cardiovascular risk in patients with white-coat hypertension and poor prognosis in those with masked hypertension, highlighting the importance of ABPM.
The association of nocturnal hypertension and nondipping blood pressure with treatment-resistant hypertension: The Jackson Heart Study.
Irvin Marguerite R,Booth John N,Sims Mario,Bress Adam P,Abdalla Marwah,Shimbo Daichi,Calhoun David A,Muntner Paul
Journal of clinical hypertension (Greenwich, Conn.)
Apparent treatment-resistant hypertension (aTRH), nocturnal hypertension, and nondipping blood pressure (BP) have shared risk factors. The authors studied the association between aTRH and nocturnal hypertension and aTRH and nondipping BP among 524 black Jackson Heart Study participants treated for hypertension. Nocturnal hypertension was defined by mean nighttime systolic BP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping BP was defined by mean nighttime to daytime systolic BP ratio >0.90. aTRH was defined by mean clinic systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg with three medication classes or treatment with four or more classes. The risk for developing aTRH associated with nondipping BP and nocturnal hypertension was estimated. After multivariable adjustment, participants with aTRH were more likely to have nocturnal hypertension (prevalence ratio, 1.20; 95% confidence interval, 1.03-1.39) and nondipping (prevalence ratio, 1.25; 95% confidence interval, 1.09-1.43). Over a median 7.3 years of follow-up, nocturnal hypertension and nondipping BP at baseline were not associated with developing aTRH after adjustment.
Nocturnal blood pressure patterns and cardiovascular outcomes in patients with masked hypertension.
Presta Vivianne,Figliuzzi Ilaria,D'Agostino Michela,Citoni Barbara,Miceli Francesca,Simonelli Francesca,Coluccia Roberta,Musumeci Maria Beatrice,Ferrucci Andrea,Volpe Massimo,Tocci Giuliano
Journal of clinical hypertension (Greenwich, Conn.)
Masked hypertension (MHT) is characterized by normal clinic and above normal 24-hour ambulatory blood pressure (BP) levels. We evaluated clinical characteristics and CV outcomes of different nocturnal patterns of MHT. We analyzed data derived from a large cohort of adult individuals, who consecutively underwent home, clinic, and ambulatory BP monitoring at our Hypertension Unit between January 2007 and December 2016. MHT was defined as clinic BP <140/90 mm Hg and 24-hour BP ≥ 130/80 mm Hg, and stratified into three groups according to dipping status: (a) dippers, (b) nondippers, and (c) reverse dippers. From an overall sample of 6695 individuals, we selected 2628 (46.2%) adult untreated individuals, among whom 153 (5.0%) had MHT. In this group, 67 (43.8%) were nondippers, 65 (42.5%) dippers, and 21 (13.7%) reverse dippers. No significant differences were found among groups regarding demographics, clinical characteristics, and prevalence of risk factors, excluding older age in reverse dippers compared to other groups (P < 0.001). Systolic BP levels were significantly higher in reverse dippers than in other groups at both 24-hour (135.6 ± 8.5 vs 130.4 ± 6.0 vs 128.2 ± 6.8 mm Hg, respectively; P < 0.001) and nighttime periods (138.2 ± 9.1 vs 125.0 ± 6.3 vs 114.5 ± 7.7 mm Hg; P < 0.001). Reverse dipping was associated with a significantly higher risk of stroke, even after correction for age, gender, BMI, dyslipidemia, and diabetes (OR 18.660; 95% IC [1.056-33.813]; P = 0.046). MHT with reverse dipping status was associated with higher burden of BP and relatively high risk of stroke compared to both dipping and nondipping profiles, although a limited number of CV outcomes have been recorded during the follow-up.
Masked Hypertension: Whom and How to Screen?
Anstey D Edmund,Moise Nathalie,Kronish Ian,Abdalla Marwah
Current hypertension reports
PURPOSE OF REVIEW:To review issues regarding the practical implementation of screening strategies for masked hypertension. RECENT FINDINGS:Masked hypertension has been associated with an increased risk of cardiovascular disease events and all-cause mortality. Recent guidelines have encouraged practitioners to use out-of-clinic monitoring to detect masked hypertension in some situations. However, it is unclear from these guidelines who should be screened or how to best measure out-of-office blood pressure. In this review, challenges to screening strategies for masked hypertension, and factors that should be considered when deciding to screen using ambulatory or home blood pressure monitoring. Masked hypertension is an important clinical phenotype to detect. Future research is needed in order to develop optimal screening strategies, and to understand population level implications of using ambulatory or home blood pressure monitoring on blood pressure control.
Asian management of hypertension: Current status, home blood pressure, and specific concerns in China.
Guo Qian-Hui,Zhang Yu-Qing,Wang Ji-Guang
Journal of clinical hypertension (Greenwich, Conn.)
Increasing life expectancy in the population means that the prevalence of hypertension in China will increase over the coming decades. Although awareness and control rates have improved, the absolute rates remain unacceptably low. Cardiovascular disease (CVD) is the biggest killer in China, and sharp increases in the prevalence of CVD risk factors associated with rapid lifestyle changes will contribute to ongoing morbidity and mortality. This highlights the importance of effectively diagnosing and managing hypertension, where home blood pressure monitoring (HBPM) has an important role. Use of HBPM in China is increasing, particularly now that Asia-specific guidance is available, and this out-of-office BP monitoring tool will become increasingly important over time. To implement these recommendations and guidelines, a Web-based and WeChat-linked nationwide BP measurement system is being established in China. Local guidelines state that both HBPM and ambulatory blood pressure monitoring should be implemented where available. In China, hypertension is managed most often using calcium channel blockers, followed by angiotensin receptor blockers or angiotensin-converting enzyme inhibitors. Key barriers to hypertension control in China are low awareness and control rates.
2020 Consensus summary on the management of hypertension in Asia from the HOPE Asia Network.
Kario Kazuomi,Park Sungha,Chia Yook-Chin,Sukonthasarn Apichard,Turana Yuda,Shin Jinho,Chen Chen-Huan,Buranakitjaroen Peera,Divinagracia Romeo,Nailes Jennifer,Hoshide Satoshi,Siddique Saulat,Sison Jorge,Soenarta Arieska Ann,Sogunuru Guru Prasad,Tay Jam Chin,Teo Boon Wee,Zhang Yu-Qing,Van Minh Huynh,Tomitani Naoko,Kabutoya Tomoyuki,Verma Narsingh,Wang Tzung-Dau,Wang Ji-Guang
Journal of clinical hypertension (Greenwich, Conn.)
Hypertension professionals from Asia have been meeting together for the last decade to discuss how to improve the management of hypertension. Based on these education and research activities, the Hypertension, brain, cardiovascular and renal Outcome Prevention and Evidence in Asia (HOPE Asia) Network was officially established in June 2018 and includes experts from 12 countries/regions across Asia. Among the numerous research and review papers published by members of the HOPE Asia Network since 2017, publications in three key areas provide important guidance on the management of hypertension in Asia. This article highlights key consensus documents, which relate to the Asian characteristics of hypertension, home blood pressure monitoring (HBPM), and ambulatory blood pressure monitoring (ABPM). Hypertension and hypertension-related diseases are common in Asia, and their characteristics differ from those in other populations. It is essential that these are taken into consideration to provide the best opportunity for achieving "perfect 24-hour blood pressure control", guided by out-of-office (home and ambulatory) blood pressure monitoring. These region-specific consensus documents should contribute to optimizing individual and population-based hypertension management strategies in Asian country. In addition, the HOPE Asia Network model provides a good example of the local interpretation, modification, and dissemination of international best practice to benefit specific populations.
Uric Acid Is Not Associated with Blood Pressure Phenotypes and Target Organ Damage According to Blood Pressure Phenotypes.
Cai Anping,Liu Lin,Siddiqui Mohammed,Zhou Dan,Chen Jiyan,Calhoun David A,Tang Songtao,Zhou Yingling,Feng Yingqing
American journal of hypertension
BACKGROUND:Hypertensive patients with increased serum uric acid (SUA) are at increased cardiovascular (CV) risks. Both the European and American hypertension guidelines endorse the utilization of 24h-ambulatory blood pressure monitoring (24h-ABPM) for hypertensive patients with increased CV risk. While there is difference in identifying UA as a CV risk factor between the European and American guidelines. Therefore, it is unknown whether 24h-ABPM should be used routinely in hypertensive patients with increased SUA. METHOD:To address this knowledge gap, we investigated 1) the correlation between SUA and 24h-ABP; 2) the association between SUA and BP phenotypes (controlled hypertension, white-coat uncontrolled hypertension [WCUH], masked uncontrolled hypertension [MUCH] and sustained uncontrolled hypertension [SUCH]); 3) the association between SUA and target organ damage (TOD: microalbuminuria, left ventricular hypertrophy [LVH] and arterial stiffness) according to BP phenotypes. RESULTS:In 1336 treated hypertensive patients (mean age 61.2 and female 55.4%), we found 1) there was no correlation between SUA and 24h, daytime, and nighttime SBP/DBP, respectively; 2) In reference to controlled hypertension, SUA increase was not associated WCUH (odds ratio [OR] 0.968, p=0.609), MUCH (OR 1.026, p=0.545) and SUCH (OR 1.003, p=0.943); 3) the overall prevalence of microalbuminuria, LVH and arterial stiffness was 2.3%, 16.7% and 23.2% respectively. After adjustment for covariates, including age, sex, smoking, body mass index, diabetes mellitus and estimated glomerular filtration rate, there was no association between SUA and TOD in all BP phenotypes. CONCLUSION:These preliminary findings did not support routine use of 24h-ABPM in treated hypertensive patients with increased SUA.
Blood Pressure Control and Cardiovascular Outcomes: Real-world Implications of the 2017 ACC/AHA Hypertension Guideline.
Lee Ji Hyun,Kim Sun-Hwa,Kang Si-Hyuck,Cho Jun Hwan,Cho Youngjin,Oh Il-Young,Yoon Chang-Hwan,Lee Hae-Young,Youn Tae-Jin,Chae In-Ho,Kim Cheol-Ho
The 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline lowered the threshold defining hypertension and treatment target from 140/90 mmHg to 130/80 mmHg. We compared the 2017 ACC/AHA guideline and the Eighth Joint National Committee (JNC8) report with regard to the current status of hypertension using the Korean National Health and Nutrition Examination Survey. The association between blood pressure (BP) control and long-term major cardiovascular outcomes (MACEs) was analyzed using the Korea National Health Insurance Service cohort. In the cross-sectional study with 15,784 adults, the prevalence of hypertension was expected to be 49.2 ± 0.6% based on the definition suggested by the 2017 ACC/AHA guideline versus 30.4 ± 0.6% based on the JNC8 report. In a longitudinal analysis with 373,800 hypertensive adults for the median follow-up periods of 11.0 years, the adults meeting the target goal BP goal of 2017 ACC/AHA guideline were associated with 21% reduced risk of MACEs compared with adults, not meeting 2017 ACC/AHA BP goal but meeting JNC8 target goal. In conclusion, substantial increase of prevalence of hypertension is expected by the 2017 ACC/AHA guideline. This study also suggests endorsing the aggressive approach would lead to an improvement in cardiovascular care.
Seasonal variation in blood pressure: Evidence, consensus and recommendations for clinical practice. Consensus statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability.
Stergiou George S,Palatini Paolo,Modesti Pietro A,Asayama Kei,Asmar Roland,Bilo Grzegorz,de la Sierra Alejandro,Dolan Eamon,Head Geoffrey,Kario Kazuomi,Kollias Anastasios,Manios Efstathios,Mihailidou Anastasia S,Myers Martin,Niiranen Teemu,Ohkubo Takayoshi,Protogerou Athanasios,Wang Jiguang,O'Brien Eoin,Parati Gianfranco
Journal of hypertension
: Blood pressure (BP) exhibits seasonal variation with lower levels at higher environmental temperatures and higher at lower temperatures. This is a global phenomenon affecting both sexes, all age groups, normotensive individuals, and hypertensive patients. In treated hypertensive patients it may result in excessive BP decline in summer, or rise in winter, possibly deserving treatment modification. This Consensus Statement by the European Society of Hypertension Working Group on BP Monitoring and Cardiovascular Variability provides a review of the evidence on the seasonal BP variation regarding its epidemiology, pathophysiology, relevance, magnitude, and the findings using different measurement methods. Consensus recommendations are provided for health professionals on how to evaluate the seasonal BP changes in treated hypertensive patients and when treatment modification might be justified. (i) In treated hypertensive patients symptoms appearing with temperature rise and suggesting overtreatment must be investigated for possible excessive BP drop due to seasonal variation. On the other hand, a BP rise during cold weather, might be due to seasonal variation. (ii) The seasonal BP changes should be confirmed by repeated office measurements; preferably with home or ambulatory BP monitoring. Other reasons for BP change must be excluded. (iii) Similar issues might appear in people traveling from cold to hot places, or the reverse. (iv) BP levels below the recommended treatment goal should be considered for possible down-titration, particularly if there are symptoms suggesting overtreatment. SBP less than 110 mmHg requires consideration for treatment down-titration, even in asymptomatic patients. Further research is needed on the optimal management of the seasonal BP changes.
The disadvantage of morning blood pressure management in hypertensive patients.
Liu Kai,Xu Ying,Gong Shenzhen,Li Jiangbo,Li Xinran,Ye Runyu,Liao Hang,Chen Xiaoping
To investigate whether the control of morning blood pressure (MBP) reflects the control of blood pressure (BP) in other periods (daytime, nighttime and 24-hour) and to assess whether morning BP displays a closer association with subclinical target organ damage (TOD) than the BP measured in other periods.One thousand one hundred forty patients with primary hypertension who completed subclinical TOD detection and 24-hour ambulatory BP monitoring were included in the analysis. Pearson correlation analysis, Kappa consistency test, multiple linear regression analysis, and area under the receiver operating curve were used to analyze the data.Morning BP and daytime BP displayed good agreement, but not 24-hour BP , particularly the nighttime BP (all P < .001). Approximately 39.4% of the hypertensive patients receiving drug treatment who had achieved control of the morning BP presented masked nocturnal hypertension, which was associated with worse subclinical TOD. The BP measured in all periods correlated with subclinical TOD, and the correlation was more obvious in the treatment subgroup. However, morning BP did not independently affect subclinical TOD. Morning BP appeared to exhibit less discriminatory power than nighttime BP, particularly with respect to the urinary albumin to creatinine ratio.The use of morning BP for monitoring during hypertension management may not be enough. Masked uncontrolled nocturnal hypertension should be screened when morning BP is controlled.
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.
24 hour ambulatory blood pressure values corresponding to office blood pressure value of 130/80 mm Hg.
Rihacek Ivan,Frana Petr,Plachy Martin,Kianicka Bohuslav,Soucek Miroslav,Vasku Anna
BACKGROUND:24 hour ambulatory blood pressure monitoring (ABPM) values for patients who have office BP of 130/80 mm Hg have not been clearly reported. AIM:The determination of ABPM values in treated hypertensive subjects corresponding to a mean office BP of 130/80 mm Hg. METHODS:BP measurement in subjects 40-70 years old, by ABPM and mercury sphygmomanometer. The inclusion criteria were: mean office BP systolic (SBP) 128-132 mm Hg and diastolic (DBP) 78-82 mm Hg. Seventy six subjects met all study inclusion criteria. RESULTS:Mean office BP: SBP 129.5 ± 1.1 mm Hg, DBP 79.9 ± 1.3 mm Hg. Mean 24 hour BP: SBP 121.9 ± 2.0 mm Hg, DBP 73.1 ± 1.9 mm Hg. Mean awake BP: SBP 124.9 ± 2.4 mm Hg, DBP 75.5 ± 2.2 mm Hg. Mean asleep BP: SBP 109.1 ± 3.9 mm Hg, DBP 63.3 ± 4.0 mm Hg. CONCLUSIONS:The target values of ABPM identified in this study can be used in clinical practice and will contribute to risk stratification and treatment of hypertension.
Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children.
Nerenberg Kara A,Zarnke Kelly B,Leung Alexander A,Dasgupta Kaberi,Butalia Sonia,McBrien Kerry,Harris Kevin C,Nakhla Meranda,Cloutier Lyne,Gelfer Mark,Lamarre-Cliche Maxime,Milot Alain,Bolli Peter,Tremblay Guy,McLean Donna,Padwal Raj S,Tran Karen C,Grover Steven,Rabkin Simon W,Moe Gordon W,Howlett Jonathan G,Lindsay Patrice,Hill Michael D,Sharma Mike,Field Thalia,Wein Theodore H,Shoamanesh Ashkan,Dresser George K,Hamet Pavel,Herman Robert J,Burgess Ellen,Gryn Steven E,Grégoire Jean C,Lewanczuk Richard,Poirier Luc,Campbell Tavis S,Feldman Ross D,Lavoie Kim L,Tsuyuki Ross T,Honos George,Prebtani Ally P H,Kline Gregory,Schiffrin Ernesto L,Don-Wauchope Andrew,Tobe Sheldon W,Gilbert Richard E,Leiter Lawrence A,Jones Charlotte,Woo Vincent,Hegele Robert A,Selby Peter,Pipe Andrew,McFarlane Philip A,Oh Paul,Gupta Milan,Bacon Simon L,Kaczorowski Janusz,Trudeau Luc,Campbell Norman R C,Hiremath Swapnil,Roerecke Michael,Arcand Joanne,Ruzicka Marcel,Prasad G V Ramesh,Vallée Michel,Edwards Cedric,Sivapalan Praveena,Penner S Brian,Fournier Anne,Benoit Geneviève,Feber Janusz,Dionne Janis,Magee Laura A,Logan Alexander G,Côté Anne-Marie,Rey Evelyne,Firoz Tabassum,Kuyper Laura M,Gabor Jonathan Y,Townsend Raymond R,Rabi Doreen M,Daskalopoulou Stella S,
The Canadian journal of cardiology
Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines are introduced, and 1 existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke is revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed.
Ambulatory blood pressure in relation to interaction between dietary sodium intake and serum uric acid in the young.
Zhang Wei,Xu Jian-Zhong,Lu Xiao-Hong,Li Hua,Wang Dian,Wang Ji-Guang
PURPOSE:We hypothesise that dietary sodium intake interacts with serum uric acid to influence blood pressure (BP) in children and adolescents. In the present study, we investigated ambulatory BP in relation to hyperuricaemia, dietary sodium intake and their interaction in children and adolescents with hypertension. MATERIALS AND METHODS: A total of 616 study participants were 10-24 years old and had primary hypertension diagnosed after admission in a specialised inpatient ward. Ambulatory BP monitoring was performed during hospitalisation. 24-h urine was collected for measurements of electrolytes. Hyperuricaemia was defined as a serum uric acid of ≥327.25 μmol/L in patients <18 years old and of ≥420 and ≥360 μmol/L, respectively, in male and female patients ≥18 years old. RESULTS:In adjusted analyses, patients with hyperuricaemia ( = 283), compared with those with normal serum uric acid, had similar 24-h systolic BP (131.7 mmHg, = 0.54) and a significantly ( ≤ 0.005) lower 24-h diastolic BP (77.5 . 80.9 mmHg) and higher 24-h pulse pressure (54.2 . 51.7 mmHg). In similar adjusted analyses, 24-h ambulatory pulse pressure, but not systolic/diastolic BP ( ≥ 0.12), significantly differed across the quartile distributions of urinary sodium excretion ( for trend ≤ 0.04). Further adjusted analyses showed significant ( ≤ 0.04) interaction between serum uric acid and urinary sodium excretion in relation to 24-h systolic BP. In patients with hyperuricaemia ( = 0.04), but not those with normal serum uric acid ( 0.13), 24-h systolic BP was significantly associated with urinary sodium excretion, with a 6.5 ± 2.1 mmHg difference between quartiles 4 and 1. Similar results were observed for daytime and night-time BP and pulse pressure. CONCLUSIONS:Both hyperuricaemia and higher dietary sodium intake were associated with higher pulse pressure, and their interaction further heightened systolic BP.
Ambulatory blood pressure monitoring in type 2 diabetes and metabolic syndrome: a review.
Pierdomenico Sante D,Cuccurullo Franco
Blood pressure monitoring
We reviewed the literature on ambulatory blood pressure (BP) monitoring in type 2 diabetes mellitus (T2DM) (focusing on organ damage progression, prognosis, white coat hypertension, and masked hypertension) and metabolic syndrome (MetS). In the text we reported 21 articles about T2DM and 11 about MetS, part of which were included in meta-analyses. In T2DM, individual studies and meta-analyses indicate that 24-h pulse pressure and reduced night-time BP fall or reverse dipping predict organ damage progression, total cardiovascular events and all-cause mortality. Moreover, white coat hypertension seems to be less frequent in T2DM and its impact on cardiovascular complications remains controversial. In contrast, masked hypertension is more frequent in T2DM and seems to be associated with increased organ damage. Some studies reported higher ambulatory BP in patients with MetS, but these patients were older and had higher clinical BP than those without MetS. With regard to the circadian BP profile, contrasting data have been reported, although pooled data suggest a higher risk of nondipping in patients with MetS.
Awakenings change results of nighttime ambulatory blood pressure monitoring.
Lenz Maria C S,Martinez Denis
Blood pressure monitoring
OBJECTIVE:Investigate the effect of distinguishing nighttime and sleep on nocturnal blood pressure results in ambulatory blood pressure monitoring. METHODS:We recruited 36 patients, 29 men, with suspected obstructive sleep apnea/hypopnea syndrome attending a sleep clinic for diagnostic polysomnography and who agreed to wear a Spacelabs 90207 ambulatory blood pressure monitor during polysomnography. Their mean age was 45+/-11 years; body mass index (BMI), 30.8+/-5.4 kg/m; apnea-hypopnea index, 35+/-29 AH/h; 13 had a history of hypertension. A microphone attached to the ambulatory blood pressure monitor recorded its sounds in the polygraph and allowed us to classify each ambulatory blood pressure monitoring measurement as being made in electrographically-determined wake (e-wake) or sleep state (e-sleep). RESULTS:Patients were asleep during (mean+/-SD) 61+/-24% (range 0-100%) of the 14+/-1 nighttime blood pressure measurements. Systolic and diastolic ambulatory blood pressure monitoring readings were significantly higher during e-wake (121+/-12/73+/-9 mmHg) than during total nighttime (119+/-11/70+/-8 mmHg) and e-sleep (116+/-13/68+/-9 mmHg). On the basis of nighttime measurements, 22 patients (61%) had nocturnal hypertension. On the basis of measurements made during e-sleep, nocturnal hypertension was diagnosed in 12 patients (33%; chi2=5.54; P=0.018). A multiple linear regression model showed that the percentage of measurements made in e-sleep was the only variable that significantly explained the difference between nighttime and e-sleep blood pressure figures, when controlling for sex, age, BMI, apnea-hypopnea index, and lowest SaO2. CONCLUSION:During ambulatory blood pressure monitoring, nighttime blood pressure readings are higher than during e-sleep and this changes dipping and nocturnal hypertension classification.
Blood pressure load does not add to ambulatory blood pressure level for cardiovascular risk stratification.
Li Yan,Thijs Lutgarde,Boggia José,Asayama Kei,Hansen Tine W,Kikuya Masahiro,Björklund-Bodegård Kristina,Ohkubo Takayoshi,Jeppesen Jørgen,Torp-Pedersen Christian,Dolan Eamon,Kuznetsova Tatiana,Stolarz-Skrzypek Katarzyna,Tikhonoff Valérie,Malyutina Sofia,Casiglia Edoardo,Nikitin Yuri,Lind Lars,Sandoya Edgardo,Kawecka-Jaszcz Kalina,Filipovsky Jan,Imai Yutaka,Ibsen Hans,O'Brien Eoin,Wang Jiguang,Staessen Jan A,
Hypertension (Dallas, Tex. : 1979)
Experts proposed blood pressure (BP) load derived from 24-hour ambulatory BP recordings as a more accurate predictor of outcome than level, in particular in normotensive people. We analyzed 8711 subjects (mean age, 54.8 years; 47.0% women) randomly recruited from 10 populations. We expressed BP load as percentage (%) of systolic/diastolic readings ≥135/≥85 mm Hg and ≥120/≥70 mm Hg during day and night, respectively, or as the area under the BP curve (mm Hg×h) using the same ceiling values. During a period of 10.7 years (median), 1284 participants died and 1109 experienced a fatal or nonfatal cardiovascular end point. In multivariable-adjusted models, the risk of cardiovascular complications gradually increased across deciles of BP level and load (P<0.001), but BP load did not substantially refine risk prediction based on 24-hour systolic or diastolic BP level (generalized R(2) statistic ≤0.294%; net reclassification improvement ≤0.28%; integrated discrimination improvement ≤0.001%). Systolic/diastolic BP load of 40.0/42.3% or 91.8/73.6 mm Hg×h conferred a 10-year risk of a composite cardiovascular end point similar to a 24-hour systolic/diastolic BP of 130/80 mm Hg. In analyses dichotomized according to these thresholds, increased BP load did not refine risk prediction in the whole study population (R(2)≤0.051) or in untreated participants with 24-hour ambulatory normotension (R(2)≤0.034). In conclusion, BP load does not improve risk stratification based on 24-hour BP level. This also applies to subjects with normal 24-hour BP for whom BP load was proposed to be particularly useful in risk stratification.
Ambulatory blood pressure monitoring versus self-measurement of blood pressure at home: correlation with target organ damage.
Gaborieau Valérie,Delarche Nicolas,Gosse Philippe
Journal of hypertension
OBJECTIVE:Ambulatory blood pressure (BP) monitoring and home blood pressure measurements predicted the presence of target organ damage and the risk of cardiovascular events better than did office blood pressure. METHODS:To compare these two methods in their correlation with organ damage, we consecutively included 325 treated (70%) or untreated hypertensives (125 women, mean age = 64.5 +/- 11.3) with office (three measurements at two consultations), home (three measurements morning and evening over 3 days) and 24-h ambulatory monitoring. Target organs were evaluated by ECG, echocardiography, carotid echography and detection of microalbuminuria. Data from 302 patients were analyzed. RESULTS:Mean BP levels were 142/82 mmHg for office, 135.5/77 mmHg for home and 128/76 mmHg for 24-h monitoring (day = 130/78 mmHg; night = 118.5/67 mmHg). With a 135 mmHg cut-off, home and daytime blood pressure diverged in 20% of patients. Ambulatory and Home blood pressure were correlated with organ damage more closely than was office BP with a trend to better correlations with home BP. Using regression analysis, a 140 mmHg home systolic blood pressure corresponded to a 135 mmHg daytime systolic blood pressure; a 133 mmHg daytime ambulatory blood pressure and a 140 mmHg home blood pressure corresponded to the same organ damage cut-offs (Left ventricular mass index = 50 g/m, Cornell.QRS = 2440 mm/ms, carotid intima media thickness = 0.9 mm). Home-ambulatory differences were significantly associated with age and antihypertensive treatment. CONCLUSION:We showed that home blood pressure was at least as well correlated with target organ damage, as was the ambulatory blood pressure. Home-ambulatory correlation and their correlation with organ damage argue in favor of different cut-offs, that are approximately 5 mmHg higher for systolic home blood pressure.
Clinical applications for out-of-office blood pressure monitoring.
Zhu Hailan,Zheng Haoxiao,Liu Xinyue,Mai Weiyi,Huang Yuli
Therapeutic advances in chronic disease
Hypertension is one of the most common chronic diseases as well as the leading risk factor for cardiovascular disease (CVD). Efficient screening and accurate blood pressure (BP) monitoring are the basic methods of detection and management. However, with developments in electronic technology, BP measurement and monitoring are no longer limited to the physician's office. Epidemiological and clinical studies have documented strong evidence for the efficacy of out-of-office BP monitoring in multiple fields for managing hypertension and CVD. This review discusses applications for out-of-office BP monitoring, including home blood pressure monitoring (HBPM) and ambulatory blood pressure monitoring (ABPM), based on recent epidemiological data and clinical studies regarding the following factors: the detection of abnormal BP phenotypes, namely, white coat hypertension and masked hypertension; stronger ability to determine the prognosis for target organ damage and mortality; better BP control; screening for hypotension; and unique approaches to identifying circadian BP patterns and BP variability.
Pro: Ambulatory blood pressure should be used in all patients on hemodialysis.
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association
In the adult population in general and among people with chronic kidney disease in particular, it is now well established that hypertension is a major driver of renal disease progression and cardiovascular morbidity and mortality. Although the contribution of hypertension to cardiovascular morbidity and mortality among patients on long-term dialysis continues to be debated, a major barrier to detect hypertension as a risk factor for cardiovascular events in these patients has been the inability to diagnose hypertension. Largely to blame has been the easy availability of pre-dialysis and post-dialysis blood pressure recordings in stark contrast to ambulatory blood pressure measurements in dialysis patients to accurately diagnose the presence or control of hypertension. It is increasingly becoming clear that out-of-office blood pressure recordings are superior to clinic recordings in making a diagnosis, assessing target organ damage, evaluating prognosis and managing patients with hypertension. In this debate, I have been asked to defend the position that ambulatory blood pressure recordings should be systematically applied to all patients on hemodialysis.
Prevalence, Treatment, and Control Rates of Conventional and Ambulatory Hypertension Across 10 Populations in 3 Continents.
Melgarejo Jesus D,Maestre Gladys E,Thijs Lutgarde,Asayama Kei,Boggia José,Casiglia Edoardo,Hansen Tine W,Imai Yutaka,Jacobs Lotte,Jeppesen Jørgen,Kawecka-Jaszcz Kalina,Kuznetsova Tatiana,Li Yan,Malyutina Sofia,Nikitin Yuri,Ohkubo Takayoshi,Stolarz-Skrzypek Katarzyna,Wang Ji-Guang,Staessen Jan A,
Hypertension (Dallas, Tex. : 1979)
Hypertension is a major global health problem, but prevalence rates vary widely among regions. To determine prevalence, treatment, and control rates of hypertension, we measured conventional blood pressure (BP) and 24-hour ambulatory BP in 6546 subjects, aged 40 to 79 years, recruited from 10 community-dwelling cohorts on 3 continents. We determined how between-cohort differences in risk factors and socioeconomic factors influence hypertension rates. The overall prevalence was 49.3% (range between cohorts, 40.0%-86.8%) for conventional hypertension (conventional BP ≥140/90 mm Hg) and 48.7% (35.2%-66.5%) for ambulatory hypertension (ambulatory BP ≥130/80 mm Hg). Treatment and control rates for conventional hypertension were 48.0% (33.5%-74.1%) and 38.6% (10.1%-55.3%) respectively. The corresponding rates for ambulatory hypertension were 48.6% (30.5%-71.9%) and 45.6% (18.6%-64.2%). Among 1677 untreated subjects with conventional hypertension, 35.7% had white coat hypertension (23.5%-56.2%). Masked hypertension (conventional BP <140/90 mm Hg and ambulatory BP ≥130/80 mm Hg) occurred in 16.9% (8.8%-30.5%) of 3320 untreated subjects who were normotensive on conventional measurement. Exclusion of participants with diabetes mellitus, obesity, hypercholesterolemia, or history of cardiovascular complications resulted in a <9% reduction in the conventional and 24-hour ambulatory hypertension rates. Higher social and economic development, measured by the Human Development Index, was associated with lower rates of conventional and ambulatory hypertension. In conclusion, high rates of hypertension in all cohorts examined demonstrate the need for improvements in prevention, treatment, and control. Strategies for the management of hypertension should continue to not only focus on preventable and modifiable risk factors but also consider societal issues.
Ambulatory blood pressure monitoring: from old concepts to novel insights.
Kanbay Mehmet,Turkmen Kultigin,Ecder Tevfik,Covic Adrian
International urology and nephrology
Ambulatory blood pressure monitoring (ABPM) is an out-of-office technique for the assessment of 24-h blood pressure measurements. ABPM is indicated to diagnose many conditions, including white-coat hypertension, resistant hypertension, episodic hypertension, nocturnal hypertension, autonomic dysfunction, hypotension secondary to excessive usage of antihypertensive medication, and masked hypertension. ABPM gives a better prediction of clinical outcomes in patients with hypertension and cardiovascular diseases when compared to office blood pressure measurements. Recently, several new indices have been introduced with the aim of predicting various clinical end-points in several patient populations. In this review, we aimed to determine the clinical utility of 24-h ABPM and its potential implications for the management of hypertension in patients with a high risk of cardiovascular mortality and morbidity, as well as various novel indices that can predict clinical end-points in different patient populations.
Guidelines for blood pressure measurement: development over 30 years.
Stergiou George S,Parati Gianfranco,McManus Richard J,Head Geoffrey A,Myers Martin G,Whelton Paul K
Journal of clinical hypertension (Greenwich, Conn.)
In the last 2 decades, several scientific societies have published specific guidelines for blood pressure (BP) measurement, providing detailed recommendations for office, home, and ambulatory BP monitoring. These documents typically provided strong support for using out-of-office BP monitoring (ambulatory and home). More recently, several organizations recommended out-of-office BP evaluation as a primary method for diagnosing hypertension and for treatment titration, with office BP regarded as a screening method. Efforts should now be directed towards making ambulatory and home BP monitoring readily available in primary care and ensuring that such measurements are obtained by following current guidelines. Moreover, it should be mandatory for all published clinical research papers on hypertension to provide details on the methodology of the BP measurement.
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.
Home blood pressure measurement in prehypertension and untreated hypertension: comparison with ambulatory blood pressure monitoring and office blood pressure.
Zhuo Shang,Wen Wang,Li-Yuan Ma,Shu-Yu Wang,Yi-Xin Wang
Blood pressure monitoring
OBJECTIVES:(i) To explore blood pressure (BP) baseline characteristics in prehypertension (PH) and untreated essential hypertension (HT), and (ii) to evaluate whether simple home blood pressure (HBP) measurement can provide more reliable BP information than office blood pressure (OBP) in PH and untreated essential HT, and (iii) to investigate whether HBP measurement can also satisfactorily screen out masked hypertension (MH) and white-coat hypertension (WCH) by comparing with ambulatory blood pressure (ABP) monitoring. METHODS:We recruited 122 Beijing community volunteers. According to OBP measurement, they were divided into three groups, including PH group (n=51), stage 1 HT group (HT-1, n=51) and stage 2 HT group (HT-2, n=20). We calculated average OBP, HBP, and ABP, detection rate of MH, WCH, and nondipper status percentage in each group. RESULTS:Nondipper status percentage of PH, HT-1, and HT-2 was 54.9, 45.1, and 75%, respectively. Except for diastolic blood pressure difference between HBP and ABP, the others did not reach statistical significance. ABP correlated more strongly with HBP than OBP. Detection rate of MH in PH participants by HBP and ABP was 49.0 and 52.9% (P=0.56), respectively, and MH diagnostic agreement between ABP and HBP was moderate (kappa=0.53, 95% confidence interval: 0.30-0.76). Detection rate of WCH in stage 1 HT participants by HBP and ABP was 9.8 and 11.8% (P=0. 65), respectively, and WCH diagnostic agreement between ABP and HBP was moderate (kappa=0.49, 95% confidence interval: 0.10-0.87). CONCLUSION:Nondipper status percentage was higher in PH and untreated HT, and detection rate of MH in PH participants was also higher. The simple HBP measurement can provide more reliable and actual BP information and may be a feasibility of screening out MH and WCH for the clinical practice.
Ambulatory blood pressure monitoring in prehypertensive subjects.
Licitra Rosaria,Acconcia Maria Cristina,Puddu Paolo Emilio,Pannarale Giuseppe
Cardiovascular & hematological disorders drug targets
BACKGROUND:Although treatment of prehypertensives is feasible and effective, it is unclear how to define those who may benefit. We hypothesized that ambulatory blood pressure monitoring (ABPM) might be a tool for selecting prehypertensive subjects, classified according to the JNC 7, who later develop drug-treated hypertension. METHODS:Prehypertensives (n=107; 62 M, 45 F; age 50 ± 14 years) with or without cardiovascular risk factors were assessed for drug-treated hypertension development. They underwent ABPM at entry examination and were clinically followed-up for an average of 99 ± 42 months. Thereafter, subjects were divided into 2 groups according to the development of drug-treated hypertension. Stepwise logistic regression (LR) analysis was performed to assess the role of factors contributing independent prediction of outcome (i.e. drug-treated hypertension onset). RESULTS:In LR analysis body mass index [odds ratio (OR)=1.29, confidence intervals (CI)95% 1.03-1.62], female gender (OR=11.10, CI95% 2.66-46.30), total cholesterol (OR=1.03, CI95% 1.01-1.05), smoking (OR=3.90, CI95% 0.94-16.20), daytime SBP (OR=1.10, CI95% 1.01-1.19) and 24h DBP (OR=1.23, CI95% 1.08-1.41) predicted the development of hypertension. The criteria combining BP and clinical variables were superior to BP or clinical criteria alone in the correct classification of true positives and true negatives. Altogether there was an improvement of 14.02% (p < 0.01) in comparison to only clinical criteria. CONCLUSIONS:In the setting of global cardiovascular risk assessment, ABPM, in the early diagnosis of hypertension in prehypertensive individuals, appears as a useful tool, both diagnostically and prognostically, to index subjects who are suspected to be masked hypertensives.
Clinical Utility of Ambulatory Blood Pressure Monitoring (ABPM) in Newly Diagnosed Hypertensive Patients.
Salagre Santosh B,Khobragade Anup P
The Journal of the Association of Physicians of India
Background:Ambulatory Blood Pressure Monitoring (ABPM) has an upper hand in diagnosing hypertension accurately. Parameters obtained by ABPM helps us in diagnosing white coat hypertension, BP variability, dipping status and blood pressure load on organs (Hyperbaric Index) reflecting possible end organ damage. Objectives:To evaluate clinical utility of ABPM in stage 1 newly diagnosed hypertensive subjects, to compare ABPM readings with clinic blood pressure (Clinic BP), to study dipping pattern and White Coat Hypertension (WCH) in newly labeled hypertensives. Methodology:After institutional ethics committee approval and written informed consent from participants, an observational cross sectional prospective study was conducted in hypertension clinic of tertiary care hospital over a period of one and half years on 138 newly diagnosed stage I hypertensive patients. ABPM results were analyzed and compared with clinic BP. Results:86/138 (62.32%) patients were diagnosed to have true HT by ABPM. WCH was detected in 52/138 (37.68%) which is higher than that reported in international studies (21%). The mean pulse, mean systolic/diastolic BP, mean pulse pressure and MAP were significantly higher (p<0.0001) by clinic BP than ABPM. True hypertensive patients were having higher weight (p <0.001), had higher fasting blood sugar values (p=0.008) and BUN levels (p=0.034) than WCH patients. Hyperbaric Index was significantly higher for systolic and diastolic BP in true hypertensive patients as compared to WCH patients. Patients with WCH were predominantly males (71.15%), were younger (41.82 ± 12.77 years) than true hypertensives (46.45 ± 12.20years), (p =0.037). Dipping was detected in 33 (38.37%), non-dipping in 44 (51.16%) and reverse dipping in 9 (10.47%) patients. Conclusion:Our study reflects the clinical utility of ambulatory blood pressure monitoring not only for accurate diagnosis of hypertension but also for assessing the various parameters of blood pressure.
Twenty-Four-Hour Ambulatory Blood Pressure Monitoring.
Pena-Hernandez Camilo,Nugent Kenneth,Tuncel Meryem
Journal of primary care & community health
The diagnosis, management, and estimated mortality risk in patients with hypertension have been historically based on clinic or office blood pressure readings. Current evidence indicates that 24-hour ambulatory blood pressure monitoring should be an integral part of hypertension care. The 24-hour ambulatory monitors currently available on the market are small devices connected to the arm cuff with tubing that measure blood pressure every 15 to 30 minutes. After 24 hours, the patient returns, and the data are downloaded, including any information requested by the physician in a diary. The most useful information includes the 24-hour average blood pressure, the average daytime blood pressure, the average nighttime blood pressure, and the calculated percentage drop in blood pressure at night. The most widely used criteria for 24-hour measurements are from the American Heart Association 2017 guidelines and the European Society of Hypertension 2018 guidelines. Two important scenarios described in this document are white coat hypertension, in which patients have normal blood pressures at home but high blood pressures during office visits, and masked hypertension, in which patients are normotensive in the clinic but have high blood pressures outside of the office. The Centers for Medicare and Medicaid Services has made changes in its policy to allow reimbursement for a broader use of 24-hour ambulatory blood pressure monitoring within some specific guidelines. Primary care physicians should make more use of ambulatory blood pressure monitoring, especially in patients with difficult to manage hypertension.