24-h Ambulatory Blood Pressure Measurements Research Articles

PP.14.07] LONG-TERM CHANGES IN LEFT VENTRICULAR GEOMETRY IN TREATED HYPERTENSIVE PATIENTS

Objective: to identify risk factors related to changes on left ventricular (LV) geometry in treated hypertensive patients after a mean period of 10 years. Design and method: 114 patients were examined initially and after 10 years. All patients underwent echocardiography, 24-h ambulatory blood pressure (BP) monitoring and measurement of fasting and postprandial immunoreactive insulin concentration on 60 and 120 min of standard oral glucose-tolerance test (OGTT). During 10 years patients have been treated by their primary care doctor with different antihypertensive drugs. Results: Initially the number of patients in 1st group with normal LV mass index (LVMI) and in 2nd group with LV hypertrophy (LVH) were 52 (46%) and 62 (54%), respectively (Table). Among patients without LVH the prevalence of normal geometry was 29% and concentric LV remodeling was 17%. In 2nd group 26 (23%) patients had concentric LVH and 36 (31%) patients had eccentric LVH. At the end of study the amount of patients with LVH increased to 95 patients (83%), predominantly it was patients (62%) with concentric LVH. After 10 years in 26 (50%) patients from 1st group was formed concentric LVH. In both groups average 24-h BP has been reduced, but BP goal rates haven’t been achieved. Multiple regression analysis demonstrated that baseline 24-h SBP index was predictor of LVMI (ß = −0.461, ρ = 0.001) and IVS (ß = −0.543, ρ = 0.0001), baseline night-time SBP was predictor of PWT (ß = 0.441, ρ = 0.0001) and baseline night-time DBP was predictor of RWT (ß = 0.273, ρ = 0.03) and δ plasma insulin concentration at 120 min of OGTT (ß = 0.364, p = 0.03) had prognostic value of LVMI.Conclusions: After 10 years of poorly controlled treatment the prevalence of concentric LVH increased to 83%. The development and progression of concentric LVH were associated with baseline night-time BP, systolic night-day BP ratio and postprandial hyperinsulinemia.

Number of ablated spots in the course of renal sympathetic denervation in CKD patients with uncontrolled hypertension: EnligHTN vs. Standard irrigated cardiac ablation catheter

BackgroundHypertension was both a mutual cause and the main concern of chronic kidney disease (CKD). Blood pressure control is more problematic in the company of CKD. This study compares the effects of renal sympathetic denervation (RSD) on 24-h ambulatory blood pressure measurements (ABPM) and renal function in individuals with CKD and uncontrolled hypertension by unlike a number of ablated spots using the EnligHTN catheter and the standard irrigated cardiac ablation catheter (SICAC), Flexability. MethodsThe 112 subjects were randomly divided into two groups according to the catheter that would be used in the procedure EnligHTN (n=56) or Flexability (n=56). Into each group, we created 5 subgroups according to the number of ablated spots: 4, 8, 12, 16 and 20. All of them were followed for exactly 6 months to assess all the parameters measured in this investigation. ResultsComparing the Δ 24-h systolic ABPM according to the number of ablated spots 4 and 20 for EnligHTN vs. Flexability, respectively, the differences were: −3.6±0.9 vs. −6.3±1.4mmHg (P<0.0001), and −13.9±4.8 vs. −36.3±4.3mmHg (P<0.0001). The comparisons between Δ estimated glomerular filtration rate (eGFR) according to the number of ablated spots 4 and 20 for EnligHTN vs. Flexability, respectively, were: +2.7±4.0 vs. +6.0±8.4mL/min/1.73m2 (P=0.2287), and +11.9±6.0 vs. +21.4±8.7mL/min/1.73m2 (P=0.0222). ConclusionThe RSD reduced the mean 24-h ABPM in subjects with CKD and uncontrolled hypertension and improved the renal function in both groups. These effects were more marked and important in subgroups underwent a great number of ablated spots using the SICAC.

The shorter the person, the higher the blood pressure: a birth cohort study.

Short adult stature is known to be associated with increased cardiovascular morbidity and mortality, but the underlying explanatory mechanisms remain largely unknown. The purpose of the current study was to evaluate the relationship between height and blood pressure (BP), a major determinant of cardiovascular disease (CVD). We performed BP measurements including 24-h ambulatory BP measurements in 534 participants (mean age 61 ± 3 years, 51.3% women) from the Helsinki Birth Cohort Study. None of the study participants had medication affecting vasculature or BP. We assessed the influence of height on CVD risk factors with a standardized z-score representing the difference from the mean value for the whole study cohort. Daytime SBP, pulse pressure, and mean arterial pressure showed significant inverse associations with height (adjusted for age, leisure-time physical activity, body fat percentage, and smoking). Height was by itself a strong determinant of pulse pressure independently of BMI. In addition, total cholesterol, triglycerides, and apolipoprotein B concentrations decreased with increasing height. Shorter individuals have higher BP levels than taller individuals. This may at least partly explain the inverse association between height and CVD. In normal weight and slightly overweight individuals, the relationship between BP and height is independent of BMI and adiposity.

A Network Meta-Analysis of Clinical Management Strategies for Treatment-Resistant Hypertension: Making Optimal Use of the Evidence

BackgroundWith the addition of surgical interventions to current medicinal treatments, it is increasingly challenging for clinicians to rationally choose among the various options for treating patients with apparent treatment-resistant hypertension (ATRHTN).This study aims to establish the comparative effectiveness of mineralocorticoid receptor antagonists (MRA), renal denervation (RDN), darusentan and central arteriovenous anastomosis (CAA) for patients with ATRHTN by performing a network meta-analysis.MethodsData Sources: Studies from recent meta-analyses for RDN and placebo effect were supplemented with a systematic search for MRAs in ATRHTN in the Pubmed, EMBASE, CINAHL and Cochrane databases through November 2016.Study Selection: Randomized controlled trials comparing treatment options for patients with ATRHTN.Data Extraction and Synthesis: Data were extracted using predefined data extraction forms, including the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. A Bayesian random effects model was used to conduct a network meta-analysis. Spironolactone was used as the main comparator.Main Outcomes and Measures: Reduction in 24-h ambulatory blood pressure measurement (ABPM).ResultsTwenty articles met our inclusion criteria, and seven treatment alternatives were compared. Compared to MRA, CAA had the highest probability of being more effective, further reducing 24-h SBP (−4.8 mmHg [−13.0, 3.7]) and 24-h DBP (−9.7 mmHg [−18, -0.63]). This difference is likely to be clinically meaningful, with a probability of 78 and 96% at a threshold of a 2-mmHg reduction in blood pressure.ConclusionsWhen compared to MRA as anchor, darusentan, CAA and RDN are not more effective in achieving a clinically significant reduction in ambulatory blood pressure in individuals with apparent treatment-resistant hypertension.

Cardiovascular and metabolic risk in pediatric patients with congenital adrenal hyperplasia due to 21 hydroxylase deficiency.

The aim of the study was to evaluate the cardiovascular and metabolic risk profile in pediatric patients with congenital adrenal hyperplasia (CAH). A cross-sectional study was performed in 27 CAH patients (8-16 years). Blood samples were taken to evaluate circulating cardiovascular risk (CVR) markers. Insulin resistance (IR) was evaluated by homeostatic model assessment (HOMA)-IR. Blood pressure (BP) was evaluated by office BP measurements and 24-h ambulatory BP measurements (24-h ABPM). Dual energy X-ray absorptiometry (DXA) scans were performed in patients >12 years. Body mass index (BMI) standard deviation score (SDS) was elevated (0.67), with seven patients being overweight and four obese. DXA scans showed percentage body fat SDS of 1.59. Office BP levels were higher than reference values. Twenty-four hour ABPM showed systolic hypertension (n=5), while 11 patients had a non-dipping BP profile. HOMA-IR was >75th percentile in 12 patients. CAH patients develop an unfavorable CVR profile already in childhood with increased BMI, increased fat mass, elevated BP levels, a non-dipping BP profile and IR compared to population reference values.

Asymptomatic hyperuricemia is a strong risk factor for resistant hypertension in elderly subjects from general population.

In clinical practice, patient characteristics predicting resistant hypertension (RH) include higher blood pressure levels, left ventricular hypertrophy, older age, obesity, chronic kidney disease and diabetes. On the contrary little is known about the role of serum uric acid (SUA) as a risk factor for RH in subjects from general population. 580 elderly subjects aged ≥65 years were enrolled in the Risk Of Vascular complications Impact of Genetics in Old people (ROVIGO) study. RH was defined as the failure to maintain blood pressure values below 140mmHg (systolic) and 90mmHg (diastolic) despite therapeutic interventions that include appropriate lifestyle measures plus adherence to treatment with full doses of at least three antihypertensive drugs, including a diuretic. RH was confirmed using 24-h ambulatory blood pressure measurement. Hyperuricemic was defined as the subjects having SUA ≥6.8mg/dl or taking uricosuric drugs. Gender-specific odds ratio (OR) for RH was calculated by logistic regression analysis. The prevalence of RH was 5.7% in the cohort and was higher in women (8.3%) than in men (3.0%, p<0.05). Independent of chronic kidney disease (OR 3.89, 95% confidence interval 1.49-10.1), hyperuricemia predicted resistant hypertension in women (odds ratio 3.11, 95% confidence intervals 1.06-9.1, p=0.03) but not in men. In elderly women from the general population, an SUA value of ≥6.8mg/dl triples the risk of RH. SUA assessment should be recommended to better define the pattern of risk associated with RH.

Early 24-hour blood pressure response to Roux-en-Y gastric bypass in obese patients

Recently, it has been proposed, that the blood pressure (BP) lowering effect of gastric bypass surgery not only is explained by the obtained weight loss, but that the anatomical rearrangement of the gut after ‘malabsorptive’ surgical techniques, such as the laparoscopic Roux-en-Y gastric bypass (LRYGB), may affect BP through a change in a putative 'entero-renal' axis. If so one could anticipate a reduction in BP even before a noticeable weight loss was obtained. The purpose of the present study was to investigate the very early BP response to LRYGB surgery. Ten severely obese hypertensive (mean BMI 40.8 kg/m2) and 10 severely obese normotensive (mean BMI 41.7 kg/m2) patients underwent 24-h ambulatory blood pressure measurements (24 h ABPMs) before LRYGB and again day 1 and day 10 after LRYGB. No change in 24 h BP was observed day 1 after LRYGB. Day 10 after surgery both hypertensive and normotensive patients demonstrated a significant 12.6 mmHg and 9.5 reduction in systolic BP (SBP), respectively. Mean arterial pressure (MAP) decreased by 8.3 and 5.4 mmHg. At day 10 postoperatively, a weight loss of 7.9 kg in the hypertensive patients and 7.0 kg in the normotensive patients was observed. The reduction in BP after LRYGB takes place before any substantial weight loss has occurred. The reason for this remains speculative, but obese hypertensive patients may clearly benefit from the operation even if the goal of achieving ‘normoweight’ is not obtained.

Relationship between 24-h urine sodium/potassium ratio and central aortic systolic blood pressure in hypertensive patients.

Studies evaluating the relationship between measured 24-h urine sodium (24HUNa), potassium (24HUK) and aortic blood pressure (BP) are rare, and no such study has been performed with an Asian population. We evaluated the relationship between 24HUNa, 24HUK, casual BP, 24-h ambulatory BP and aortic BP by analyzing data from 524 participants with valid 24-h urine collection, 24-h ambulatory BP and central BP measurements (mean age 48.1±9.8 years, 193 men). Hypertension was defined as a 24-h ambulatory BP ⩾130/80 mm Hg or current treatment for hypertension (n=219). The participants with hypertension and high 24HUNa (mean 210.5±52.0 mmol per day, range 151.0-432.0) showed higher 24-h systolic (P=0.037) and diastolic BP (P=0.037) and aortic systolic BP (AoSBP, P=0.038) than the participants with hypertension and low 24HUNa (mean 115.7±25.0 mmol per day, range 45.6-150.0), adjusted for confounders. The participants with hypertension and a high ratio of 24HUNa and 24HUK (24HUNa/24HUK, mean 4.03±1.00, range 2.93-7.96) had higher AoSBP than the participants with hypertension and a low 24HUNa/24HUK ratio (mean 2.13±0.54, range 0.53-2.91), adjusted for confounders (P=0.026). The participants with hypertension demonstrated a significant linear relationship between AoSBP and 24HUNa/24HUK ratio that was independent of 24HUNa, according to the multiple regression analysis (P=0.047). In hypertensive patients, 24HUNa/24HUK was positively and more strongly related to AoSBP compared with 24HUNa alone. The result indicates that high sodium and low potassium intake may increase the subsequent risk of cardiovascular disease by elevating AoSBP.

Rationale and study design of the prospective, longitudinal, observational cohort study "rISk strAtification in end-stage renal disease" (ISAR) study.

BackgroundThe ISAR study is a prospective, longitudinal, observational cohort study to improve the cardiovascular risk stratification in endstage renal disease (ESRD). The major goal is to characterize the cardiovascular phenotype of the study subjects, namely alterations in micro- and macrocirculation and to determine autonomic function.Methods/designWe intend to recruit 500 prevalent dialysis patients in 17 centers in Munich and the surrounding area. Baseline examinations include: (1) biochemistry, (2) 24-h Holter Electrocardiography (ECG) recordings, (3) 24-h ambulatory blood pressure measurement (ABPM), (4) 24 h pulse wave analysis (PWA) and pulse wave velocity (PWV), (5) retinal vessel analysis (RVA) and (6) neurocognitive testing. After 24 months biochemistry and determination of single PWA, single PWV and neurocognitive testing are repeated. Patients will be followed up to 6 years for (1) hospitalizations, (2) cardiovascular and (3) non-cardiovascular events and (4) cardiovascular and (5) all-cause mortality.Discussion/conclusionWe aim to create a complex dataset to answer questions about the insufficiently understood pathophysiology leading to excessively high cardiovascular and non-cardiovascular mortality in dialysis patients. Finally we hope to improve cardiovascular risk stratification in comparison to the use of classical and non-classical (dialysis-associated) risk factors and other models of risk stratification in ESRD patients by building a multivariable Cox-Regression model using a combination of the parameters measured in the study.Clinical trials identifierClinicalTrials.gov NCT01152892 (June 28, 2010)

OS 24-01 ASSESSMENT OF TARGET-ORGAN DAMAGE IN ADOLESCENT WHITE COAT AND SUSTAINED HYPERTENSION

The aim of the present study was to assess whether a difference exists between endothelial function, intima–media thickness (IMT) and left ventricular mass index (LVMI) in healthy non-hypertensive, white-coat hypertensive (WCH) and sustained hypertensive (SH) adolescents. All young people attending high school in Debrecen, Hungary (n = 10,359) participated in the study. Three blood pressure (BP) measurements were taken separated by 5 min intervals. If their BP exceeded the 90th percentile stratified for gender, age and height, the measurements were repeated 2 more times. Based on 9 readings we found 216 hypertensive individuals. All measurements were obtained by a validated Omron M4 device. Fifty-nine normotensive and 120 hypertensive adolescents were enrolled in this study. Hypertensive patients were classified into WCH (n = 47) and SH (n = 73) based on 24-h ambulatory blood pressure measurements. Both normotensive and hypertensive individuals underwent routine laboratory tests, IMT measurements on the common carotid arteries and transthoracic echocardiography to measure LVMI. The nitric-oxide level of WCH adolescents were lower than the normotensives (30.6 ± 11 μmol/l vs. 38.8 ± 7.9 μmol/l; p < 0.001) and their data did not differ from SH (28.7 ± 22.4 μmol/l). The endothelin-1 level was significantly higher in hypertensives compared to the control group 3.1 ± 3.9 fmol/ml vs 1.1 ± 1.1 fmol/l; p < 0.001). IMT was higher both in WCH and SH compared with healthy normotensive individuals (controls: 0.048 ± 0.01 cm, WCH: 0.056 ± 0.01 cm, SH: 0.054 ± 0.012 cm, both p < 0.001 compared with controls). There was no difference between the LVMI of control individuals and WCH (LVMI: 35.5 ± 10.3 g/m2.7 and 37.7 ± 11.2 g/m2.7). LVMI in sustained hypertension group (44.1 ± 14.1 g/m2.7) was significantly higher both compared with WCH (p < 0.05), and healthy adolescents (p < 0.001). Target-organ damage develops in a stepwise fashion in adolescent hypertension. The endothelial dysfunction and the increased IMT can be demonstrated not only in sustained but also in white-coat form of adolescent hypertension, indicating that WCH is a potential abnormal condition.

Renal denervation in treatment-resistant essential hypertension. A randomized, SHAM-controlled, double-blinded 24-h blood pressure-based trial.

Background:Renal denervation (RDN), treating resistant hypertension, has, in open trial design, been shown to lower blood pressure (BP) dramatically, but this was primarily with respect to office BP.Method:We conducted a SHAM-controlled, double-blind, randomized, single-center trial to establish efficacy data based on 24-h ambulatory BP measurements (ABPM). Inclusion criteria were daytime systolic ABPM at least 145 mmHg following 1 month of stable medication and 2 weeks of compliance registration. All RDN procedures were carried out by an experienced operator using the unipolar Medtronic Flex catheter (Medtronic, Santa Rosa, California, USA).Results:We randomized 69 patients with treatment-resistant hypertension to RDN (n = 36) or SHAM (n = 33). Groups were well balanced at baseline. Mean baseline daytime systolic ABPM was 159 ± 12 mmHg (RDN) and 159 ± 14 mmHg (SHAM). Groups had similar reductions in daytime systolic ABPM compared with baseline at 3 months [−6.2 ± 18.8 mmHg (RDN) vs. −6.0 ± 13.5 mmHg (SHAM)] and at 6 months [−6.1 ± 18.9 mmHg (RDN) vs. −4.3 ± 15.1 mmHg (SHAM)]. Mean usage of antihypertensive medication (daily defined doses) at 3 months was equal [6.8 ± 2.7 (RDN) vs. 7.0 ± 2.5 (SHAM)].RDN performed at a single center and by a high-volume operator reduced ABPM to the same level as SHAM treatment and thus confirms the result of the HTN3 trial.Conclusion:Further, clinical use of RDN for treatment of resistant hypertension should await positive results from double-blinded, SHAM-controlled trials with multipolar ablation catheters or novel denervation techniques.

Circadian and ultradian cardiovascular rhythmicity in obese children.

Altered circadian and ultradian blood pressure (BP) and heart rate (HR) rhythmicity have been described in diseases with increased cardiovascular risk. We analyzed cardiovascular rhythmicity in obese children. BP and HR rhythmicity was assessed with Fourier analysis from 24-h ambulatory BP measurements in 75 obese children and compared with an age- and gender-matched, lean healthy reference group of 150 subjects. Multivariate regression analysis was applied to identify significant independent factors explaining variability of rhythmicity. Prevalence of 24- and 6-h BP rhythmicity in the obese group was lower (p = 0.03 and p = 0.02), whereas the prevalence of HR rhythmicity was comparable in both groups. Excluding hypertensive participants, the results remained similar. Twenty-four-hour BP and HR acrophase were delayed in obese children (p = 0.004, p < 0.0001), 24-h BP amplitude did not differ (p = 0.07), and 24-h HR amplitude was blunted (p = < 0.0001). BP Mesor in the obese group was higher (p = 0.02); HR Mesor did not differ (p = 0.1). Multivariate regression analysis failed to identify a single anthropometric or blood pressure parameter explaining the variability of BP and HR rhythmicity. Prevalence and parameters of circadian and ultradian BP and HR rhythmicity in obese children are altered compared to a healthy reference group, independent of preexisting hypertension. • Altered cardiovascular rhythmicity has been described in children with different diseases such as primary hypertension or chronic renal failure. What is New: • This study reveals altered cardiovascular rhythmicity in obese children compared to an age and gender-matched healthy reference group independent from preexisting hypertension.

Blood Pressure Profile in the 7th and 11th Year of Life in Children Born Prematurely.

BackgroundSeveral research trials have analyzed the impact of prematurity on the prevalence of hypertension (HT). However, prospective long-term studies are lacking.ObjectivesThe aim of this study was to evaluate the prevalence of HT at the age of 7 and 11 years in a regional cohort of preterm infants with a birth weight of ≤ 1000 g.Patients and MethodsThis study included 67 children with a birth weight of ≤ 1000 g who were born in Malopolska between September 2002 and August 2004. The control group consisted of 38 children born at term, matched for age. Each child underwent 24-h ambulatory blood pressure measurement (ABPM) twice, once at the age of 7 and again at 11 years. The presence of HT was estimated according to the mean arterial pressure (MAP) and a number of individual measurements.ResultsAt aged 7 years, preterm infants had a significantly higher incidence of HT, defined on the basis of MAP (15% vs. 0%; P < 0.02) and on the percent of individual measurements (56% vs. 33%, P < 0.036). After taking into account the group of patients who received anti-HT treatment after the first part of the study, the incidence of HT at the age of 11 years based on MAP was 19% vs. 10%. Based on the individual measurements, it was 36.5% in the preterm infants vs. 24% in the control group. The differences were not statistically significant. At both time points, the preterm group had a higher mean heart rate (HR) than the control group.ConclusionsChildren born prematurely are predisposed to HT in later life, in addition to the persistence of an increased HR.

Masked hypertension in newly diagnosed hypothyroidism: a pilot study

Masked hypertension (MH) is the association of normal office blood pressure (BP) with high ambulatory or home BP. This condition is associated with increased cardiovascular target organ damage, as true hypertension. Because the relation with hypothyroidism is controversial, we investigated it in a pilot longitudinal and controlled study. We consecutively enrolled 64 newly diagnosed hypothyroid patients, 38 subclinical (s-HYPO), and 26 overt (o-HYPO). The control group consisted of 50 euthyroid subjects seen at outpatient clinics. All participants underwent office and 24-h ambulatory BP measurement. BP monitoring revealed a higher prevalence of MH both in s-HYPO (26.3%) and in o-HYPO (15.4%) than in euthyroid subjects (10%, p=0.05); true hypertension also was more frequent in o-HYPO (11.5%) and s-HYPO (10.5%) than in controls (8%, p=0.03). The odds ratio for hypertension versus normotension confirmed a significantly increased risk of MH in hypothyroid patients versus euthyroid subjects (3.29, 1.08-10.08; p=0.02). In a subgroup of patients reevaluated after restoration of euthyroidism, an improvement of BP profile was observed, especially in s-HYPO subgroup, with a decreased prevalence of MH (from 25 to 10.7%) and true hypertension (from 10.7 to 3.4%). Hypothyroidism may be an important predictor of higher BP values, with an increased risk of MH. Because MH is a cardiovascular risk and can be reversed by thyroid hormone replacement, its presence should represent an indication for thyroid hormone replacement therapy also in patients with s-HYPO.

Effect of tumor necrosis factor-α inhibitors on ambulatory 24-h blood pressure

Tumor necrosis factor alpha (TNF-α) inhibitors are increasingly being used in inflammatory rheumatic diseases (IRD). The risk of cardiovascular disease is elevated in patients with IRD and TNF-α inhibitors reduce this risk. We assessed whether the beneficial effect of TNF-α inhibitors on cardiovascular risk is mediated by blood pressure reduction. We measured blood pressure levels with 24-h ambulatory blood pressure measurements device in patients with IRD before and 3 months after treatment with TNF-α inhibitors. The study population consisted of 15 subjects (6 men; mean age 45.9 ± 14.1 years). Most patients had either rheumatoid arthritis or psoriatic arthritis and adalimumab was the most common TNF-α inhibitor used. Mean 24-h systolic and diastolic blood pressure levels remained the same after treatment (121 ± 12/66 ± 7 before and 123 ± 11/67 ± 10 mm Hg after; p = 0.88 and 0.66, respectively). The study demonstrates that TNF-α inhibitors have no effect on blood pressure levels.

Tertiary work-up of apparent treatment-resistant hypertension

Objective: Treatment-resistant hypertension (TRH) has regained attention with development of new methods for treatment. However, the prevalence of TRH varies considerably from primary to secondary and tertiary care. We aimed to assess the prevalence of true TRH in a population of patients with apparent TRH in a university hospital setting of tertiary work-up and also investigate reasons for poor BP control and evaluate how work-up can be performed in general practice and secondary care.Methods: In this cohort study, we characterize a study population from Oslo Renal Denervation (RDN) Study. Patients (n = 83) were referred for RDN from secondary care. All patients underwent thorough medical investigation and 24-h ambulatory blood pressure measurements (24ABPM) after directly observed therapy (DOT). We then assessed reasons for lack of BP control.Results: Fifty-three of 83 patients did not have true TRH. Main reasons for non-TRH were poor drug adherence (32%), secondary hypertension (30%) and white coat hypertension (15%). Forty-seven percent achieved blood pressure control after DOT with subsequent 24ABPM. There were otherwise no statistically significant differences in patient characteristics between the true TRH and the non-TRH group.Conclusion: Despite being a highly selected cohort referred for tertiary work-up of apparent TRH, BP control was achieved or secondary causes were identified in almost two thirds of the patients. Thorough investigation according to guidelines and DOT with subsequent 24ABPM is needed in work-up of apparent TRH.

Associations between cystatin C-based eGFR, ambulatory blood pressure parameters, and in-clinic versus ambulatory blood pressure agreement in older community-living adults.

The objective of this study was to determine the relationship between chronic kidney disease [CKD; measured using cystatin C-based estimated glomerular filtration rate (eGFR)] and abnormal ambulatory blood pressure (including nocturnal dipping) in healthy older adults. Further, this study aimed to assess the agreement between clinic and ambulatory blood pressure monitoring. Serum cystatin C levels were measured to calculate eGFR. Participants underwent clinic and 24-h ambulatory blood pressure measurements. Multiple linear regression was performed to examine the association between reduced cystatin C-based eGFR (CKDcys) and blood pressure parameters. Bland-Altman analysis was carried out to evaluate the agreement between clinic and ambulatory measurements. The average age was 72 years. There were 60 individuals with CKDcys (eGFR<60 ml/min/1.73 m). Compared with those without CKDcys, individuals with CKDcys were older, more likely to have hypertension, and less likely to have normal dipping patterns. On multivariate analysis, the presence of CKDcys was found to be significantly associated with a lower mean ambulatory diastolic blood pressure (-2 mmHg, P=0.048), but not with nocturnal dipping or other blood pressure parameters. Clinic systolic blood pressure (SBP) significantly overestimated the mean wake-time ambulatory SBP; the mean difference was 11 mmHg for those without CKDcys (95% limits of agreement -14 to 35 mmHg) and 14 mmHg for those with CKDcys (95% limits of agreement -13 to 41 mmHg); there was no statistically significant effect modification by CKD status. In older, seemingly healthy adults, mild CKD was associated with lower ambulatory diastolic blood pressure. The presence of CKD did not affect interpretation of clinic versus ambulatory blood pressure monitoring, although the accuracy of clinic SBP was poor.

Low-dose hydrocortisone replacement is associated with improved arterial stiffness index and blood pressure dynamics in severely adrenocorticotrophin-deficient hypopituitary male patients.

Increased cardiovascular and cerebrovascular morbidity and mortality in hypopituitary subjects may be linked to inappropriate glucocorticoid exposure; however, the pathophysiology remains unclear. We aimed to examine the effect of three commonly prescribed hydrocortisone (HC) regimens on vascular risk factors. An open crossover study randomising ten hypopituitary men with severe adrenocorticotrophic hormone deficiency to three HC dose regimens: dose A (20mg mane and 10mg tarde), dose B (10mg mane and 10mg tarde) and dose C (10mg mane and 5mg tarde). Following 6 weeks on each regimen, participants underwent 24-h serum cortisol sampling, 24-h ambulatory blood pressure (BP) measurements, calculation of the Ambulatory Arterial Stiffness Index (AASI), oral glucose tolerance testing and fasting serum osteoprotegerin (OPG) sampling. There were no differences in 24-h BP between dose regimens and controls; however, low-dose HC replacement (dose C) was associated with the lowest AASI, indicating a less stiff arterial tree (P<0.05) compared with the other dose regimens. Loss of the physiologic nocturnal BP dip was more common in higher HC replacement regimens, although only significant for dose B compared with dose C (P=0.03). Twenty per cent of patients had abnormal glucose tolerance, but this was unrelated to dose regimen. OPG correlated strongly with 24-h BP in those on dose A only (r=0.65, P=0.04). Currently prescribed HC replacement doses do not result in significant differences in absolute BP levels or improvements in insulin sensitivity. However, lower HC doses may result in lower arterial stiffness and a more physiological nocturnal BP dip. Long-term studies are required to confirm these findings and evaluate their impact on vascular morbidity in this patient group.

Screening, diagnosis and treatment of hypertension in obese children: an international policy comparison

Hypertension in obese children may require a different diagnostic and treatment approach from that for children with secondary hypertension, yet there is neither consensus nor a clear guideline. The aim of this study was to assess how obese children with hypertension are currently diagnosed and treated by paediatric nephrologists, what obstacles exist and what can be improved. In the period May–November 2014, an online questionnaire was sent to all members of the European Society for Paediatric Nephrology (n = 2148). Questions focused on current practices and obstacles regarding screening, diagnosis and treatment of hypertension in obese children. A total of 214 paediatric nephrologists responded. Although nearly 100 % agreed that screening of obese children for hypertension is indicated, it was current practice in only 56 % of participating countries; 88 % of respondents diagnosed hypertension with 24-h ambulatory blood pressure measurement. Diagnostics used to rule out causes or consequences of hypertension varied among the respondents; they included, in particular, the use of serum renin/aldosterone, urine sodium/potassium, and dimercaptosuccinic acid scan. Concerning treatment, 45 % of respondents preferred to start treatment with a lifestyle program, 2 % with antihypertensive medication, and 40 % with both. For 73 % of respondents, angiotensin-converting enzyme-inhibitors or angiotensin receptor blockers were the drugs of first choice. The findings of this study emphasize the urgent need for an international guideline for screening, diagnosis and treatment of hypertension in obese children.

Effects of decompressive cervical surgery on blood pressure in cervical spondylosis patients with hypertension: a time series cohort study.

BackgroundPatients with cervical spondylosis myelopathy (CSM) and complicated with hypertension are often experiencing a blood pressure decrease after taking cervical decompressive surgery in clinical observations, but how this blood pressure reduction is associated with the surgery, which cut cervical sympathetic nervous, has never been rigorously assessed. Thus, the purpose of this study is to investigate the effect of cervical decompressive surgery on blood pressure among CSM patients with hypertension.Methods/DesignThe study will be a time series cohort study. Fifty eligible patients will be selected consecutively from the Peking University First Hospital. Two 24-h ambulatory blood pressure measurement (ABPM) will be taken before the surgery, apart by at least 3 days. The patients will be followed up for another two ABPMs at 1 and 3 months after the surgery.We will recruit subjects with cervical spondylosis myelopathy meeting operation indications and scheduled for receiving cervical decompressive surgery, aged 18–84 years, have a history of hypertension or office systolic blood pressure ≥140 mmHg on initial screening, and willing to participate in the study and provide informed consent. Exclusion criteria includes a history of known secondary hypertension, visual analogue scale (VAS) score ≥4, and unable to comply with study due to severe psychosis.The change in systolic ABPs over the four times will be analyzed to observe the overall pattern of the blood pressure change in relation to the surgery, but the primary analysis will be the comparison of systolic ABP between the 2nd and 3rd , 4th measurements (before and after the surgery). We will also calculate the regression-to-the-mean adjusted changes in systolic ABP as sensitivity analysis. Secondary endpoints are the changes in 24 h ABPM diastolic blood pressure, blood pressure control status, the use and dose adjustment of antihypertensive medication, and the incidence of operative complications. Primary outcome analyses will be carried out using analysis of covariance, as well as the first secondary endpoint.DiscussionThis study will inform us the important knowledge about cervical sympathetic nervous system (SNS) and blood pressure. Once confirmed, it may help to produce new method for control of hypertension, which is the leading cause of death in the world.Trial registrationThe study is registered to Clinical Trials.gov (NCT02016768).