Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality

Although increased blood pressure is one of the most powerful predictors of cardiovascular morbidity, the prediction for the individual patient is relatively weak. One reason for this is the inherent variability of blood pressure and the distortions associated with clinic measurement. It is widely accepted that blood pressure measured in the clinic commonly overestimates pressure measured in nonmedical settings and that the discrepancy between the 2 varies greatly from 1 individual to another. On the grounds that it is the average level of blood pressure to which the circulation is exposed over prolonged periods of time that causes the adverse effects of hypertension, rather than the pressure at any 1 moment, such as during a clinic visit, it is logical to suppose that ambulatory blood pressure will give a better prediction of risk than clinic pressure. A subgroup of patients with mild hypertension whose blood pressure is high only in medical settings has been identified as having white coat hypertension; this group typically comprises ≈20% of the hypertensive population.1 This is a potentially useful concept because it may help to define a group of patients who are at relatively low risk of cardiovascular morbidity and hence do not merit antihypertensive drug treatment. However, the definition of white coat hypertension is arbitrary and depends both on the cutoff point chosen to define a hypertensive clinic pressure and a normal ambulatory pressure. In this issue of Circulation, a study reported by Khattar et al2 on the follow-up of a cohort of hypertensive patients established by Dr Jim Raftery at Northwick Park Hospital in London throws new light on the role of 24-hour ambulatory blood pressure monitoring (ABPM) in predicting cardiovascular morbidity. The principal finding was that patients with white coat hypertension were at substantially reduced risk of morbidity compared with …

sponsorship: The European Union (HEALTH-F7-305507 HOMAGE) and the European Research Council (Advanced Researcher Grant 2011-294713-EPLORE and Proof-of-Concept Grant 713601-uP-ROPHET) currently support research at the Studies Coordinating Centre in Leuven. (European Union|HEALTH-F7-305507 HOMAGE, European Research Council|2011-294713-EPLORE, European Research Council|713601-uP-ROPHET)

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

For a long time, since its identification in the early 1980s, white coat hypertension (WCH), alternatively termed “isolated clinic hypertension,” has widely been considered a completely innocent blood pressure (BP) phenotype, that is, a condition for which the normality of BP outside the medical environment, assessed by ambulatory or home BP monitoring, entails a prognostic value similar to normotension.1, 2 However, challenging this traditional view, an increasing amount of evidence supports the concept that WCH has an intermediate risk between normotension and sustained hypertension. In a recent meta-analysis of 23 cohorts including 20 445 initially untreated individuals, WCH (defined as high clinic BP but normal out-of-office BP, either by ambulatory of home measurements) was associated with an adjusted 38 and 20% increased risk of cardiovascular disease and total mortality compared with normotension.3 Originally limited to untreated individuals, the definition has more recently been generalized to individuals treated with BP lowering drugs in whom only clinic BP fails to reach the therapeutic target (ie, white coat uncontrolled hypertension [WUCH]). The association of WUCH with cardiovascular disease and mortality has been reported to be somewhat weaker than that of WCH. Findings from a registry-based, multicenter, national cohort including 63 910 adults showed that WUCH, unlike WCH, exhibited a nonsignificant increase in full-adjusted risk of cardiovascular (HR 1.04, CI: 0.65-1.66, P = .86) and all-cause mortality (HR 1.06, CI: 0.82-1.37, P = .66).4 The outcome discrepancy in WCH and WUCH is probably due to the fact that this latter group is more likely to have more frequent medical checks that, in turn, impact favorably on a variety of unhealthy conditions contributing to total cardiovascular risk and, last but not least, benefits from the protective effect of antihypertensive drugs. Since WCH is quite frequently diagnosed in everyday clinical practice, this condition has important implications for public health. WCH has been estimated to occur in approximately 20%-30% of the general hypertensive population, and its prevalence depends on several individual clinical characteristics (ie, age, gender, office BP, body mass index, and comorbidities) as well as on methods (ambulatory or home BP measurement) and BP cutoffs used to define normal out-of-office values.5 According to the 2018 European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines, definition of WCH traditionally relies on elevated office BP (≥140 mm Hg systolic BP and/or ≥90 mm Hg diastolic BP) during repeated visits concomitant with BP values below the accepted thresholds for ambulatory (ie, mean 24-hour systolic BP/diastolic BP <130 and <80 mm Hg) or home hypertension (ie, systolic BP/diastolic BP <135 and <85 mm Hg).6 As for ambulatory BP criteria, due to the clinical and prognostic implications of nocturnal BP, it has been suggested that WCH diagnosis should be preferentially based on mean 24-hour BP, rather than on daytime BP thresholds, thereby incorporating nocturnal BP values in the assessment of this condition. However, it is important to note that in 2017 the American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines updated the classification of both office and ambulatory hypertension recommending lower BP thresholds that is 130/80 mm Hg for office and 125/75 mm Hg for 24-hour BP, respectively.7 In view of the differences between the two guidelines, the impact of the new American BP diagnostic criteria compared with traditional ones (ie, confirmed by the ESH/ESC guidelines) on the prevalence of office hypertension has been investigated by some studies that, as expected, found marked increases in the prevalence of both untreated and uncontrolled hypertension.8 On the contrary, the impact of the 2017 ACC/AHA recommendations on the detection of WCH and WUCH in current practice is scanty. Thus, we have addressed this topic in a large cohort of patients referred to a single outpatient hypertension center to confirm the diagnosis of office hypertension or evaluate the efficacy of antihypertensive therapy. A total of 7364 individual 24-hour ambulatory BP recordings from untreated individuals and treated hypertensive patients with office systolic BP ≥ 140 mm Hg and/or diastolic BP ≥ 90 mm Hg were analyzed. Based on office and 24-hour ambulatory BP values, subjects were divided into four groups: (a) untreated elevated office systolic or diastolic BP and normal 24-hour ambulatory BP, that is, WCH; (b) untreated elevated office systolic or diastolic BP and elevated 24-hour ambulatory BP, that is, sustained hypertension; (c) treated elevated office systolic or diastolic BP and normal 24-hour ambulatory BP (<130/80 mm Hg), that is, WUCH; and (d) treated elevated office and 24-hour systolic or diastolic BP, that is, uncontrolled hypertension. The prevalence rates WCH and WUCH were assessed according to both European and American hypertension guidelines whose normal 24-hour BP thresholds are <130/80 and 125/75 mm Hg, respectively. A total of 1284 patients were classified as WCH (17.4%) and 1950 as WUCH (26.5%) according to the 2018 ESH/ESC guidelines; the corresponding numbers, based on the 2017 AHA/ACC guidelines, were 697 (9.4%) and 1156 (15.6%), respectively. These findings strongly suggest that the detection of both WCH and WUCH markedly decreases when applying the AHA/ACC 24-hour BP thresholds and, at the same time, an opposite trend occurs for the sum of sustained untreated and uncontrolled hypertension (from 56% to 75%). However, it should not be ignored that the classification of BP patterns has limited reproducibility over time. As for WUCH, a recent comprehensive analysis of the European Lacidipine Study on Atherosclerosis showed that its reproducibility was worse than that of patients showing control or lack of control of both office and ambulatory BP.9 Whether the use of lower 24-hour BP criteria for defining WCH and WUCH can improve cardiovascular risk stratification and preventive strategies in the hypertensive population remains an open question. Data from the Intensive Versus Standard Ambulatory Blood Pressure Lowering to Prevent Functional Decline In the Elderly (INFINITY) study in which intensive treatment of ambulatory BP in older patients was well tolerated and associated with a significant reduction of cardiovascular can be considered an argument in favor of lower ambulatory normality thresholds.10 In a practical perspective, the large discrepancy between the two guidelines in detecting BP patterns at different cardiovascular risks (ie, WCH/WUCH versus sustained/uncontrolled hypertension) observed in our registry-based study urgently raises the problem of defining shared diagnostic criteria aimed at optimizing therapeutic strategies worldwide. None.

Objective: Introduction. The prognostic significance of white-coat (WCHT) and masked hypertension (MHT) compared to normotension (NT) and sustained hypertension (SHT) is still debated. Aim. To evaluate prevalence and long-term clinical outcomes of NT, WHCT, MHT and SHT. Design and method: Methods. We analysed home, clinic and 24-hour ambulatory blood pressure (BP) levels from a large cohort of untreated adult outpatients who were consecutively evaluated at out Hypertension Unit between January 2007 and December 2015. The following definitions were applied: NT (clinic BP <140/90 mmHg; 24-hour BP <130/80 mmHg), WCHT (clinic BP > = 140/90 mmHg; 24-hour BP <130/80 mmHg), MHT (clinic BP <140/90 mmHg; 24-hour BP > = 130/80 mmHg), and SHT (clinic BP > = 140/90 mmHg; 24-hour BP > = 130/80 mmHg). Systematic research throughout the regional medical database was performed to estimate incidence of myocardial infarction, stroke and hospitalizations for HT and heart failure (HF). Results: Results. Among a total study sample of 2,209 adult untreated individuals, 377 (17.1%) had NT, 351 (15.9%) WCHT, 149 (6.7%) MHT, and 1,332 (60.3%) SHT. During an average follow-up of 120.173.9 months, WCHT was associated to reduced risk of developing stable HT [OR 95% CI: 0.593 (0.450–0.780); P < 0.001] and high risk of hospitalization for HT [OR 95% CI: 1.927 (1.233–3.013); P = 0.04] and HF [OR 95% CI: 3.449 (1.321–9.007); P = 0.011], whereas MHT was associated to an increased risk of myocardial infarction [OR 95% CI: 5.090 (2.228–11.625);P < 0.001], hospitalization for HT [OR 95% CI: 2.553 (1.446–4.508); P = 0.001] and HF [OR 95% CI: 4.214 (1.449–12.249); P = 0.008] compared to SHT. Conclusions: Conclusions. Our findings confirmed that, despite relatively low prevalence, both WCHT and MHT were associated to high of developing myocardial infarction and hospitalizations for HT and HF.

How common is isolated nocturnal hypertension?

> 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 measurement in children and adolescents

sponsorship: The European Union (HEALTH-F7-2011-278249 EU-MASCARA, HEALTH-F7-305507 HOMAGE and the European Research Council Advanced Researcher Grant 294713 EPLORE) and the Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium (G.0881.13 and G.0880.13) currently support the Studies Coordinating Centre (Leuven, Belgium). (European Union|HEALTH-F7-2011-278249 EU-MASCARA, European Union|HEALTH-F7-305507 HOMAGE, European Union (European Research Council)|294713 EPLORE, Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium|G.0881.13, Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium|G.0880.13)

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

Ambulatory blood pressure provides a more comprehensive assessment than clinic blood pressure, and has been reported to better predict health outcomes than clinic or home pressure. We aimed to examine associations of clinic and 24-h ambulatory blood pressure with all-cause and cardiovascular mortality in a large cohort of primary care patients referred for assessment of hypertension. We did an observational cohort study using clinic and ambulatory blood pressure data obtained from March 1, 2004, to Dec 31, 2014, from the Spanish Ambulatory Blood Pressure Registry. This registry included patients from 223 primary care centres from the Spanish National Health System in all 17 regions of Spain. Mortality data (date and cause) were ascertained by a computerised search of the vital registry of the Spanish National Institute of Statistics. Complete data were available for age, sex, all blood pressure measures, and BMI. For each study participant, follow-up was from the date of their recruitment to the date of death or Dec 31, 2019, whichever occurred first. Cox models were used to estimate associations between usual clinic or ambulatory blood pressure and mortality, adjusted for confounders and additionally for alternative measures of blood pressure. For each measure of blood pressure, we created five groups (ie, fifths) defined by quintiles of that measure among those who subsequently died. During a median follow-up of 9·7 years, 7174 (12·1%) of 59 124 patients died, including 2361 (4·0%) from cardiovascular causes. J-shaped associations were observed for several blood pressure measures. Among the top four baseline-defined fifths, 24-h systolic blood pressure was more strongly associated with all-cause death (hazard ratio [HR] 1·41 per 1 - SD increment [95% CI 1·36-1·47]) than clinic systolic blood pressure (1·18 [1·13-1·23]). After adjustment for clinic blood pressure, 24-h blood pressure remained strongly associated with all-cause deaths (HR 1·43 [95% CI 1·37-1·49]), but the association between clinic blood pressure and all-cause death was attenuated when adjusted for 24-h blood pressure (1·04 [1·00-1·09]). Compared with the informativeness of clinic systolic blood pressure (100%), night-time systolic blood pressure was most informative about risk of all-cause death (591%) and cardiovascular death (604%). Relative to blood pressure within the normal range, elevated all-cause mortality risks were observed for masked hypertension (HR 1·24 [95% CI 1·12-1·37]) and sustained hypertension (1·24 [1·15-1·32]), but not white-coat hypertension, and elevated cardiovascular mortality risks were observed for masked hypertension (1·37 [1·15-1·63]) and sustained hypertension (1·38 [1·22-1·55]), but not white-coat hypertension. Ambulatory blood pressure, particularly night-time blood pressure, was more informative about the risk of all-cause death and cardiovascular death than clinic blood pressure. Spanish Society of Hypertension, Lacer Laboratories, UK Medical Research Council, Health Data Research UK, National Institute for Health and Care Research Biomedical Research Centres (Oxford and University College London Hospitals), and British Heart Foundation Centre for Research Excellence.

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

Managing White‐Coat Effect

The term “white-coat hypertension” (WCH; also commonly referred to as isolated office hypertension) describes the transient increase in blood pressure (BP), resulting from an alerting reaction and pressor response, observed in certain individuals when attending a clinic or doctors’ office.1 The diagnosis of WCH is usually ascribed when clinic BPs exceed 135/85 mmHg and average daytime BPs do not. WCH could be dismissed as a risk factor for stroke and other cardiovascular events, because the increase in BP is transient and may be idiosyncratic to the clinic setting.2 However, WCH may be a marker of stress reactivity per se, because surges in BP that occur in the doctor’s office are indicative of BP surges in other stressful scenarios.3 The article by Verdecchia et al featured in this edition of Hypertension 4 reports data from 6000 Italian, Japanese, and American adults. The purpose of the study was to explore the relationship between classically defined WCH and incident stroke during a median follow-up of 5.4 years. When compared with normotensive controls, a tendency for increased stroke incidence was observed in patients with WCH (unadjusted hazard ratio, 1.15). However, because the variance around the estimates of effect is large (95% confidence interval, 0.61 to 2.16), this association is not statistically significant, despite this study being the largest of its kind to date. By contrast, a statistically significantly association between ambulatory hypertension and stroke was observed (unadjusted hazard ratio, 2.01; 95% confidence interval, 1.31 to 3.08). The hypothesis that Verdecchia et al test is important because vessels in the brain may be particularly susceptible to transient elevations in BP. Furthermore, because WCH is highly prevalent,5 even a relatively small increase in stroke risk on an individual level could convey a high population-attributable risk. Although Verdecchia et al have demonstrated using …

Aim. To study phenotypes of clinic and 24-hour ambulatory blood pressure (BP), to determine their associations with arterial stiffness parameters, and to assess global cardiovascular risk (CVR) in young patients with type 1 diabetes (T1D).Material and methods. The presented cross-sectional single-center study included 81 T1D patients without a history of hypertension (HTN) and other cardiovascular diseases (CVD) (men — 39%; median age — 27 years; median duration of T1D — 6 years). All participants underwent a routine clinical and laboratory testing, measurement of clinic and 24-hour ambulatory BP (BPLab Vasotens), assessment of central BP and arterial stiffness parameters using applanation tonometry technique. BP phenotypes were analyzed with diagnostic criteria for HTN by ESC/ESH 2018 guidelines. CVR was assessed using the SCORE 10-year risk calculator (ESC 2019). The differences were considered significant at p&lt;0,05.Results. The prevalence of true HTN was 6,2%, masked HTN — 38,3%. Isolated nocturnal HTN was revealed in 30,7% of patients with clinic BP &lt;140/90 mm Hg. The subgroup with masked HTN was dominated by patients with normal clinic BP (58,1%) and in most cases was characterized by isolated diastolic BP increase (64,5%). Masked HTN was associated with a higher carotid-femoral pulse wave velocity (PWV) (median — 7,2 versus 6,3 m/s, p=0,002). The most common profiles of nocturnal BP decrease were non-dipper (63.9%) and night-picker (16.6%). High and very high CVR was recorded in 87,7% of patients. Conclusion. Hypertension occurs in 44,5% of young patients with type 1 diabetes and is characterized by a high prevalence of masked isolated nocturnal HTN and non-dipping. Masked HTN is associated with a higher carotid-femoral PWV. High and very high 10-year CVR was recorded in 87,7% of patients.