Combination of treatment intensity score and interankle diastolic blood pressure is associated with cardiovascular prognosis among adults with controlled hypertension who have pre-existing cardiovascular disease

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Ambulatory Blood Pressure Monitoring: Profiles in Chronic Kidney Disease Patients and Utility in Management.

Prognosis in Relation to Blood Pressure Variability

> Two statisticians meet . > > -How do you do? > > -How do I do? Compared to whom? > > — Anonymous Thomas Pickering coined the term white-coat hypertension to denote individuals who were not on treatment for hypertension but who had elevated office blood pressure and normal daytime blood pressure measured with ambulatory blood pressure monitoring (ABPM). Clearly, these individuals would be at low cardiovascular risk.1 The traditional definition of white-coat hypertension is based, therefore, on an elevated office blood pressure with a normal blood pressure during the awake period with ABPM. However, because of the contribution of asleep blood pressure as a predictor of outcome, it seems counterproductive to exclude this period from consideration. The most recent European guidelines2 propose, therefore, an alternative definition of white-coat hypertension, which encompasses subjects with office systolic/diastolic blood pressure readings of ≥140/90 mm Hg and a 24-hour blood pressure <130/80 mm Hg. The purpose of this review is to provide new insights into the characteristics, definitions, and cardiovascular risk assessment in persons with white-coat hypertension, and it will be limited primarily to ABPM with a primary focus on prospective studies. ### Prevalence and Diagnosis White-coat hypertension occurs in 15% to 30% of subjects with an elevated office blood pressure,2,3 and the phenomenon is reasonably reproducible.2,4 Although there are no pathognomonic diagnostic features of white-coat hypertension, this condition occurs more frequently in women, older adults, nonsmokers, recently diagnosed patients with hypertension with a limited number of conventional blood pressure measurements in the office setting who have mild hypertension, pregnant women, and subjects without evidence of target organ damage.2,5,6 The misdiagnosis of subjects with white-coat hypertension as being truly hypertensive can result in them being penalized for employment and insurance rating, as well as being prescribed unnecessary lifelong treatment with potential side …

Out-of-Office Blood Pressure Monitoring: A Comparison of Ambulatory Blood Pressure Monitoring and Home (Self) Monitoring Of Blood Pressure.

This is an update of a Cochrane review published in 2012 of initiation of antihypertensive monotherapy or step-up therapy in people with untreated mild hypertension (systolic blood pressure 140 to 159 mmHg or diastolic blood pressure 90 to 99 mmHg, or both) and no pre-existing cardiovascular disease. The original review demonstrated no difference in the incidence of all-cause mortality, total cardiovascular events (stroke, myocardial infarction, and congestive heart failure), stroke incidence, coronary heart disease, or withdrawal due to adverse effects (WDAEs). Evidence for antihypertensive pharmacotherapy in people with mild hypertension for primary prevention remains uncertain in the literature with conflicting studies. We therefore performed an update of the original Cochrane review to reassess whether initiation of antihypertensive pharmacotherapy compared to placebo or no treatment in people with untreated mild hypertension and no pre-existing cardiovascular disease reduces the risk of all-cause mortality, total cardiovascular events, stroke, coronary heart disease, or WDAEs. To reassess the efficacy and risks of initiating antihypertensive pharmacotherapy in adults with untreated mild hypertension and no pre-existing cardiovascular disease. The primary objective was to reassess the risk of all-cause mortality and total cardiovascular events (defined as fatal and non-fatal strokes, myocardial infarction, and congestive heart failure). The secondary objectives were to reassess the risk of stroke (fatal and non-fatal), coronary heart disease (fatal and non-fatal myocardial infarction and sudden cardiac death), and WDAEs. We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to June 2024. We included randomized controlled trials (RCTs) of at least one-year duration comparing initiation on antihypertensive monotherapy or step-up therapy, or both, versus placebo or no treatment in participants with mild hypertension and no pre-existing cardiovascular disease. Our critical outcomes were all-cause mortality and total cardiovascular events. Important outcomes were stroke, coronary heart disease (fatal and non-fatal myocardial infarction and sudden cardiac death), and WDAEs. Two review authors assessed risk of bias independently and in duplicate using Cochrane's RoB 1 tool. Two review authors performed title and abstract screening, full-text review, and data extraction independently and in duplicate. We calculated risk ratio (RR) along with 95% confidence interval (CI) for all-cause mortality, total cardiovascular events, stroke events, coronary heart disease events, and WDAEs with the Mantel-Haenszel test and a fixed-effect model. We assessed the certainty of the evidence using the GRADE approach. We included five trials involving a total of 9124 participants, of whom 4593 received antihypertensives and 4531 received placebo or no treatment. All five trials reported all-cause mortality; four trials reported total cardiovascular events and strokes; three trials reported coronary heart disease; and one trial reported WDAEs. There may be little to no reduction in all-cause mortality (RR 0.85, 95% CI 0.64 to 1.14; 5 trials, 9124 participants; low-certainty evidence), total cardiovascular events (RR 0.93, 95% CI 0.69 to 1.24; 4 trials, 7292 participants; low-certainty evidence), or coronary heart disease (RR 1.12, 95% CI 0.80 to 1.57; 3 trials, 7080 participants; low-certainty evidence). There may be a decreased risk of stroke (RR 0.41, 95% CI 0.20 to 0.84; 4 trials, 7292 participants; low-certainty evidence) and an increase in WDAEs (RR 4.80, 95% CI 4.14 to 5.57; 1 trial, 17,354 participants; low-certainty evidence) with antihypertensives. We downgraded the certainty of evidence for all outcomes due to imprecision, indirectness, and risk of bias. In people with untreated mild hypertension and no pre-existing cardiovascular disease, initiation of antihypertensive monotherapy or step-up therapy may not reduce all-cause mortality, total cardiovascular events, or coronary heart disease compared to those who received placebo or no treatment. There may be a reduction in stroke, but possibly also an increase in WDAEs. CIHR Grant to the Hypertension Review Group and British Columbia Ministry of Health Grant to the Therapeutics Initiative. Protocol (2007): doi.org/10.1002/14651858.CD006742. Original review (2012): doi.org/10.1002/14651858.CD006742.pub2.

Ambulatory Blood Pressure in Chronic Kidney Disease: Ready for Prime Time?

A prospective controlled study was designed to compare automated 24-hour ambulatory blood pressure monitoring with intermittent blood pressure recordings obtained using a sphymomanometer. Blood pressure was measured in 20 hospitalized preeclamptic women in the third trimester. Data obtained using the Spacelabs automated blood pressure monitor was recorded over a period of 24 hours, and thereafter stored and processed in a computer. During the same 24 hour period, blood pressure and heart rate were measured by experienced staff at 07.00, 10.00, 13.00, 15.00, 18.00 and 21.00 hours, with the patient in a semi-recumbent position using a conventional mercury sphygmomanometer with a cuff of appropriate size. Korotkoff phase 5 was used as the indicator of diastolic blood pressure in all recordings by the staff. The main outcome measures were systolic and diastolic blood pressure, mean arterial blood pressure and maternal heart rate. Automated ambulatory monitoring was well tolerated and gave 91.6% successful readings. The mean differences between the blood pressure readings recorded by the monitor and of intermittent mercury sphygmomanometry during daytime were 0.7 (95% confidence interval -2.6 to 4.0) mmHg for the mean arterial blood pressure, -1.7 (95% confidence interval -6.8 to 3.5) mmHg for the systolic blood pressure, and 1.9 (95% confidence interval -2.2 to 6.0) mmHg for the diastolic blood pressure. The mean differences between day-time and night-time monitored blood pressures were 4.3 (95% confidence interval 0.8 to 7.8) mmHg, 4.6 (95% confidence interval 2.0 to 7.2) mmHg, and 4.4 (95% confidence interval 1.5 to 7.2) mmHg, respectively. The number of patients diagnosed as being hypertensive was similar whether automated blood pressure monitor or mercury sphymomanometry was used. Mean maternal heart rate recorded by the monitor or by the staff did not differ. Automated ambulatory blood pressure monitoring is reliable and might improve our understanding of the dynamic changes in blood pressure in pre-eclamptic women and may be a more suitable method to assess the blood pressure control achieved by different drugs.

Funding Acknowledgements Aga Khan University Faculty of Health Sciences Research Committee (#80096) On Behalf PC BP (Post Clinic Blood Pressure) Study Group Background The gold standard Ambulatory Blood Pressure Monitoring (ABPM) eliminates white coat effect. However, it is expensive and 24 hours long, making it cumbersome. Prior studies in other populations have investigated the utility of shorter intervals in which ABPM can be used to get the same results as 24-hour ABPM. Purpose Our objective was to determine if 3-hour ABPM correlates with 24-hour ABPM in the Pakistani population. Methods A cross-sectional study, involving 150 participants as part of the PC ABP (post clinic ambulatory blood pressure) study, was conducted in the cardiology clinics, starting 2015. Participants ≥18years of age and were either hypertensive or referred for assessment of hypertension were included. Pregnant females were excluded. Blood pressure (BP) readings were taken with an ambulatory BP monitor over a 24 hour period, every half hour during daytime and every hour during nighttime. After excluding the first hour called the white-coat window, the mean of the first 6 systolic readings taken every half hour during the daytime was calculated and was called systolic 3-hour ABPM. Pearson correlation coefficients were calculated and Bland Altman plots were constructed to determine the correlation and limits of agreement between mean systolic 3-hour ABPM and mean daytime ABPM. Results Of 150 participants, 49% were male. Of all participants, 76% were hypertensive. Mean age of the participants was 60.3 ± 11.9 years. Mean systolic 3-hour ABPM was 135.0 ± 16mmHg. Mean systolic daytime ABPM was 134.7 ± 15mmHg respectively. Pearson correlation coefficient between mean systolic 3-hour ABPM and mean systolic daytime ABPM was 0.85 (p-value of &amp;lt;0.001). The difference between systolic 3-hour ABPM and systolic daytime ABPM was 0.3mmHg (95% Confidence Interval -1.1 to 1.7mmHg). The limits of agreement were 18mmHg to -17mmHg for systolic 3-hour ABPM and systolic daytime ABPM. Conclusion Three-hour ABPM correlates well with 24-hour gold standard ABPM in the Pakistani population. We suggest using this shortened study for the assessment of hypertension where a full ABPM cannot be conducted due to expense or logistic reasons, thus saving time and upfront cost.

Objective: The aims of the study were to evaluate the prevalence and factors associated with Masked Hypertension in nursing professionals. Design and method: This was a cross-sectional study of 182 nursing professionals (38.07.5 years, 82.4% women). Office blood pressure measurement and 24-hour Ambulatory Blood Pressure Monitoring (ABPM) were applied in a usual work day. An interview was conducted to evaluate biopsychosocial, related to work and life habits variables. Fasting venous blood was drawn for biochemical analysis. Masked Hypertension was defined as office blood pressure less or equal 140/90 mmHg and mean daytime ABPM greater or equal 135/85 mmHg and non-use of antihypertensive treatment. Poisson regression with robust variance was performed, with values of p < 0.05 being considered statistically significant. Results: The prevalence of Masked Hypertension was 19.8% [95% confidence interval:15.67–23.93). The characteristics of the study sample were: shift work (61.0%), referred stress (44.0%), use of alcoholic beverage (28.6%), problematic consumption of alcohol (34.6%), dyslipidemia (24.2%), high risk for diabetes (20.3%), moderate work-related stress (73.6%), common mental disorders (60.4%), poor sleep quality (91.8%), burnout (41.8%) and had no blood pressure drop during sleep (nondippers) – systolic blood pressure 40.7%, diastolic blood pressure 30.2%). The nursing professionals with masked hypertension, had significantly higher than no masked hypertension: mean 24-hour, daytime and nighttime systolic/diastolic blood pressure in the 24-hour Ambulatory Blood Pressure Monitoring. Participants with masked hypertension were more elderly (age greater or equal 30 years); were married or separated / divorced / widowed or Conjugal/common law relationship; shift work (prevalence ratio: 2.40, [95% confidence interval:1.24–4.64), using drugs to inhibit sleep (prevalence ratio: 5.25, [95% confidence interval: 2.94–9.34), problematic consumption of alcohol (prevalence ratio: 5.19, 95% confidence interval:1.73–15.55) or not consuming alcohol (prevalence ratio: 3.93, 95% confidence interval:1.49–10.38) and referred hypertension (prevalence ratio: 0.24, 95% confidence interval: 0.13–0.44). Conclusions: Nursing professionals presented a high prevalence of Masked Hypertension which was associated with hypertension, variables related to work and habits or lifestyles. The 24-hour Ambulatory Blood Pressure Monitoring should be routine in occupational health checks in health workers, especially shift workers.

Nocturnal hypertension and non-dipping blood pressure are each associated with increased risk of cardiovascular disease. We determined differences in nocturnal hypertension and non-dipping systolic/diastolic blood pressure among black and white men and women who underwent 24-hour ambulatory blood pressure monitoring at the Coronary Artery Risk Development in Young Adults study Year 30 Exam in 2015-2016. Asleep and awake periods were determined from actigraphy complemented by sleep diaries. Nocturnal hypertension was defined as mean asleep systolic/diastolic blood pressure ≥120/70mmHg. Non-dipping systolic and diastolic blood pressure, separately, were defined as a decline in awake-to-asleep blood pressure <10%. Among 767 participants, the prevalence of nocturnal hypertension was 18.4% and 44.4% in white and black women, respectively, and 36.4% and 59.9% in white and black men, respectively. After multivariable adjustment and compared with white women, the prevalence ratio (95% confidence interval) for nocturnal hypertension was 1.65 (1.18-2.32) for black women, 1.63 (1.14-2.33) for white men, and 2.01 (1.43-2.82) for black men. The prevalence of non-dipping systolic blood pressure was 21.5% and 41.0% in white and black women, respectively, and 20.2% and 37.9% in white and black men, respectively. Compared with white women, the multivariable-adjusted prevalence ratio (95% confidence interval) for non-dipping systolic blood pressure was 1.66 (1.18-2.32), 0.91 (0.58-1.42) and 1.66 (1.15-2.39) among black women, white men, and black men, respectively. Non-dipping diastolic blood pressure did not differ by race-sex groups following multivariable adjustment. In conclusion, black women and men have a high prevalence of nocturnal hypertension and non-dipping systolic blood pressure.

Office blood pressure (BP) measurements are not the most accurate method to diagnose hypertension. Home BP monitoring (HBPM) and 24-hour ambulatory BP monitoring (ABPM) are out-of-office alternatives, and ABPM is considered the reference standard for BP assessment. To systematically review the accuracy of oscillometric office and home BP measurement methods for correctly classifying adults as having hypertension, defined using ABPM. PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and DARE databases and the American Heart Association website (from inception to April 2021) were searched, along with reference lists from retrieved articles. Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes as needed. Random effects summary sensitivity, specificity, and likelihood ratios (LRs) were calculated for BP measurement methods for the diagnosis of hypertension. ABPM (24-hour mean BP ≥130/80 mm Hg or mean BP while awake ≥135/85 mm Hg) was considered the reference standard. A total of 12 cross-sectional studies (n = 6877) that compared conventional oscillometric office BP measurements to mean BP during 24-hour ABPM and 6 studies (n = 2049) that compared mean BP on HBPM to mean BP during 24-hour ABPM were included (range, 117-2209 participants per analysis); 2 of these studies (n = 3040) used consecutive samples. The overall prevalence of hypertension identified by 24-hour ABPM was 49% (95% CI, 39%-60%) in the pooled studies that evaluated office measures and 54% (95% CI, 39%-69%) in studies that evaluated HBPM. All included studies assessed sensitivity and specificity at the office BP threshold of 140/90 mm Hg and the home BP threshold of 135/85 mm Hg. Conventional office oscillometric measurement (1-5 measurements in a single visit with BP ≥140/90 mm Hg) had a sensitivity of 51% (95% CI, 36%-67%), specificity of 88% (95% CI, 80%-96%), positive LR of 4.2 (95% CI, 2.5-6.0), and negative LR of 0.56 (95% CI, 0.42-0.69). Mean BP with HBPM (with BP ≥135/85 mm Hg) had a sensitivity of 75% (95% CI, 65%-86%), specificity of 76% (95% CI, 65%-86%), positive LR of 3.1 (95% CI, 2.2-4.0), and negative LR of 0.33 (95% CI, 0.20-0.47). Two studies (1 with a consecutive sample) that compared unattended automated mean office BP (with BP ≥135/85 mm Hg) with 24-hour ABPM had sensitivity ranging from 48% to 51% and specificity ranging from 80% to 91%. One study that compared attended automated mean office BP (with BP ≥140/90 mm Hg) with 24-hour ABPM had a sensitivity of 87.6% (95% CI, 83%-92%) and specificity of 24.1% (95% CI, 16%-32%). Office measurements of BP may not be accurate enough to rule in or rule out hypertension; HBPM may be helpful to confirm a diagnosis. When there is uncertainty around threshold values or when office and HBPM are not in agreement, 24-hour ABPM should be considered to establish the diagnosis.

Managing White‐Coat Effect

BackgroundOverweight (Ow) and obesity (Ob) influence blood pressure (BP) and left ventricular hypertrophy (LVH). It is unclear whether the presence of metabolic syndrome (MetS) independently affects echocardiographic parameters in hypertension.Methods380 Ow/Ob essential hypertensive patients (age ≤65 years) presenting for referred BP control-related problems. MetS was defined according to NCEP III/ATP with AHA modifications and LVH as LVM/h2.7 ≥49.2 g/m2.7 in males and ≥46.7 g/m2.7 in females. Treatment intensity score (TIS) was used to control for BP treatment as previously reported.ResultsHypertensive patients with MetS had significantly higher BMI, systolic and mean BP, interventricular septum and relative wall thickness and lower ejection fraction than those without MetS. LVM/h2.7 was significantly higher in MetS patients (59.14±14.97 vs. 55.33±14.69 g/m2.7; p = 0.022). Hypertensive patients with MetS had a 2.3-fold higher risk to have LVH/h2.7 after adjustment for age, SBP and TIS (OR 2.34; 95%CI 1.40–3.92; p = 0.001), but MetS lost its independent relationship with LVH when BMI was included in the model.ConclusionsIn Ow/Ob hypertensive patients MetS maintains its role of risk factor for LVH independently of age, SBP, and TIS, resulting in a useful predictor of target organ damage in clinical practice. However, MetS loses its independent relationship when BMI is taken into account, suggesting that the effects on MetS on LV parameters are mainly driven by the degree of adiposity.

Ambulatory blood pressure monitoring in dialysis patients and estimation of mean interdialytic blood pressure