24-h Ambulatory Blood Pressure Monitoring Research Articles

Effect of air pollutants on ambulatory blood pressure

Background and methodologyAir pollutants have a significant impact on public health.The aim of the study was to find out the relationship between ambulatory blood pressure measured by 24-h ambulatory blood pressure monitoring (ABPM) and the atmospheric pollutants that are measured regularly (PM10, PM2.5, NO2 and SO2). An observational study of temporal and geographic measurements of individual patients (case-time series design) was carried out in Primary Care Centres and Hypertension Units in the Barcelona metropolitan area. We included 2888 hypertensive patients≥18 years old, untreated, with a first valid ABPM performed between 2005 and 2014 and with at least one air pollution station within a radius of <3km. Results and conclusionsThe mean age was 54.3 (SD 14.6) years. 50.1% were women and 16.9% of the sample were smokers. Mean 24-h blood pressure (BP) was 128.0 (12.7)/77.4 (9.7) mmHg. After adjusting for mean ambient temperature and different risk factors, a significant association was found between ambulatory diastolic BP (DBP) and PM10 concentrations the day before ABPM. For each increase of 10μg/m3 of PM10, an increase of 1.37mmHg 24-h DBP and 1.48mmHg daytime DBP was observed. No relationship was found between PM2.5, NO2 and SO2 and ambulatory BP, nor between any pollutant and clinical BP.The concentration of PM10 the day before the ABPM is significantly associated with an increase in 24-h DBP and daytime DBP.

The Impact of Timing of Fixed Dose Triple Antihypertensive Combinations on Ambulatory Blood Pressure Monitoring Parameters

ABSTRACT Introduction Re-establishing “dipping” physiology significantly reduces cardiovascular events. The aim was to investigate the effect of timing of fixed dose triple antihypertensive combinations on blood pressure (BP) control. Methods One hundred sixteen consecutive patients (62.7 ± 10.7 years, 38 men) with grade II hypertension were randomized into four groups. Group 1 and Group 2 patients were given angiotensin converting enzyme inhibitor-based triple antihypertensive pills to be taken in the morning or evening, respectively while Group 3 and Group 4 patients were given angiotensin receptor blocker (ARB) based triple antihypertensive pills to be taken in the morning or evening, respectively. All patients underwent 24-h ambulatory BP monitoring 1 month after the initiation of treatment. Results There were not any significant differences in the characteristics, BP values and loads among groups. All patients in each group had good BP control. Dipping pattern in systolic BP was observed significantly less in Group 3 patients taking ARB in the morning (3 patients) compared to other groups (12 patients) in each group, [P = .025]. Similarly, dipping pattern in diastolic BP was observed significantly less in Group 3 patients (4 patients) compared to others (13 patients) in Group 1 and 15 patients in Group 2 and Group 4, [P = .008]. Nondipping pattern was significantly associated with taking ARB in the morning, even when adjusted by age, sex, and other comorbidities. Conclusion Fixed dose triple antihypertensive drug combinations enable good BP control regardless of the timing of drug while ARB-based ones may be taken in the evening to ensure dipping physiology.

#5805 ACCURACY OF FIXED 24-H AMBULATORY BLOOD PRESSURE RECORDINGS FOR DIAGNOSING HIGH 48-H AMBULATORY BLOOD PRESSURE IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Hypertension is highly prevalent in hemodialysis patients. Ambulatory-BP-monitoring (ABPM) during the 44-h interdialytic interval is recommended for hypertension diagnosis and management in these subjects. This study assessed the diagnostic accuracy of fixed 24-h ABPM recordings with 44-h BP in hemodialysis patients. Method 242 Greek hemodialysis patients that underwent valid 48-h ABPM (Mobil-O-Graph NG device) were included in the analysis. We used 44-h BP used as reference method and tested the accuracy of the following BP metrics: 1st 24-h without HD period (20h-1st), 1st 24-h including HD period (24h-1st) and 2nd 24-h (24h-2nd). Results All studied metrics showed strong correlations with 44-h SBP/DBP (20h-1st: r = 0.973/0.978, 24h-1st: r = 0.964/0.972 and 24h-2nd: r = 0.978/0.977, respectively). In Bland-Altman analysis, small between-method differences (−1.70, −1.19 and +1.45 mmHg) with good 95% limits-of-agreement ([−10.83 to 7.43], [−11.12 to 8.74] and [−6.33 to 9.23] mmHg, respectively) for 20h-1st, 24h-1st and 24h-2nd SBP were observed. The sensitivity/specificity and κ-statistic for diagnosing 44-h SBP≥130 mmHg were high for 20h-1st SBP (87.2%/96.0%, κ-statistic = 0.817), 24h-1st SBP (88.7%/96.0%, κ-statistic = 0.833) and 24h-2nd SBP (95.0%/88.1%, κ-statistic = 0.837). Similar observations were made for DBP. In ROC-analyses, all studied BP metrics showed excellent performance with high Area-Under-the-Curve values (20h-1st: 0.983/0.992; 24h-1st: 0.984/0.987 and 24h-2nd: 0.982/0.989 for SBP/DBP respectively). Conclusion Fixed 24-h ABPM recordings during either the first or the second day of interdialytic interval have high accuracy and strong agreement with 44-h BP in hemodialysis patients. Thus, ABPM recordings of either the first or the second interdialytic day could be used for hypertension diagnosis and management in these subjects.

DIFFERENTIAL DETERMINANTS OF AMBULATORY VS. HOME MORNING BLOOD PRESSURE MEASURED BY A SINGLE MULTISENSOR BLOOD PRESSURE MONITORING DEVICE: THE HI-JAMP STUDY BASELINE DATA

Objective: Out-of-office blood pressure (BP) monitoring using ambulatory BP (ABP) monitoring (ABPM) and home BP (HBP) monitoring (HBPM) is recommended for hypertension management. However, BP level measured by ABPM and HBPM may not be consistent even when evaluated the same time-window, morning. This study investigated the determinants of the difference between ABP and HBP in the morning time measured by a multisensor BP monitoring device equipped with a high-sensitivity actigraph and a thermometer. Design and method: Medicated hypertension patients enrolled in the Home-Activity ICT-based Japan Ambulatory Blood Pressure Monitoring Prospective (HI-JAMP) Study consecutively underwent office BP monitoring, 24-h ABPM (with 30-min intervals), and 5-day HBPM (twice each morning and evening) using the same multisensor BP monitoring device (TM-2441; A&amp;D Company, Tokyo). Morning ABP (average of 4 readings within 2-h after waking) and morning HBP (average of HBP readings measured in the morning over a HBPM period) were compared. In addition, this device recorded the wearer's fine-scale physical movement during a 24-h ABPM period and stored temperature data at the time of each BP measurement. Hourly averages of physical activity and temperatures at the time of HBPM (i.e., room temperature) were used for the analysis. Results: Among 2322 patients (males 53.2%, 69.2±11.5 years, average office systolic BP [SBP] 132.8±18.8 mmHg), morning home SBP was 2.4 mmHg higher than morning ambulatory SBP with standard deviation of 15.9 mmHg (ABP &lt; HBP). In a multivariable analysis including conventional risk factors, older age and larger number of antihypertensive agents were significantly associated with [HBP &gt; ABP], while history of cardiovascular disease (CVD) was significantly associated with [ABP &gt; HBP]. In the analysis additionally including physical activity in the morning and room temperature at the morning HBP measurement, higher activity level was significantly contributed to [ABP &gt; HBP] and lower room temperature was significantly contributed to [HBP &gt; ABP]. Conclusions: In treated hypertensive patients, HBPM is recommended especially if the patient is older, taking multiple antihypertensive agents, or living in an environment with lower room temperatures in the winter, while ABPM is recommended if the patient has a history of CVD.

THE CLINICAL RELEVANCE OF ADOPTING DIFFERENT DEFINITIONS OF NIGHT-TIME WHEN ASSESSING NOCTURNAL BLOOD PRESSURE

Objective: For hypertension diagnosis, the current European guidelines recommend to combine repeated office readings with use of out-of-office blood pressure (BP) measurements, like ambulatory blood pressure monitoring (ABPM). The drop of systolic BP during night (dipping behaviour) is one of the most important information offered by 24h ABPM. Night-time is most defined as the time period between 22 and 6 h. However, ambulatory sleep studies have shown that individual sleep behaviour is heterogenous. Shifted, shortened, or prolonged time-in-bed (TIB) may lead to changes in classification of dipping behaviour. Additionally, 20% of the population suffers from insomnia, meaning that during TIB patients are partially awake. We investigated nocturnal BP and dipping classification based on actual sleep time vs. individual TIB vs. 22 - 6 h. Design and method: Thirty adults (9 women, mean age 65.1 ± 9.5 years) underwent ABPM via a validated Boso TM- 2430 device. Simultaneously, motor activity and body position were recorded (SOMNOtouch™ NIBP, SOMNOmedics) allowing determination of individual TIB and actual sleep time. Results: In nine patients (30%), individual TIB was shifted by more than two hours, usually being shifted towards later hours. Mean duration of TIB was 7:18h (2:13h to 10:08h). Mean sleep efficiency in individual TIB was 85.6% compared to 72.4% in standard 22 - 6 h. When defining TIB as 22 - 6 h, prevalence of non-dippers was 63% (n = 19). After analysing the corrected TIB, only 37% (n = 11) remained non-dippers. Individual adoption of TIB led to a change in dipping classification in 27% (n = 8) of patients (in all cases from non-dipper to dipper). Considering only BP values during actual sleep, dipping classification changed in another four patients, two patients changing from non-dipper to dipper while two patients changed from dipper to extreme dipper. Conclusions: In 12 out of 30 patients (40%), BP dipping classification changed when adjusting TIB individually and considering BP values during actual sleep. This study highlights that individually determined TIB and exclusion of wake phases during night is of critical importance for a correct assessment of dipping behaviour and may play an important role in optimizing the clinical management of arterial hypertension.

IMPACT OF CELIPROLOL THERAPY ON BLOOD PRESSURE AND HEART RATE IN PATIENTS WITH VASCULAR EHLERS-DANLOS SYNDROME

Objective: Vascular Ehlers-Danlos syndrome (vEDS) is an inherited connective tissue disorder characterized by arterial fragility. Celiprolol is a beta1-adrenoceptor antagonist with partial beta2 agonist activity that has been shown to reduce rates of vascular events in this setting, though the underlying mechanisms are not yet fully understood. Aim of the present study was to assess the impact of Celiprolol on blood pressure (BP) and heart rate (HR) in patients with vEDS. Design and method: Patients with genetically confirmed disease referred to our Institution between 2011 and 2022 were divided into two groups according to whether or not they were on Celiprolol therapy. The former were included if on Celiprolol at the dose of 400 mg daily for at least 12 months. Each participant underwent office blood pressure (BP) measurement, 24-h ambulatory BP monitoring (ABPM), and pulse wave analysis (PWA) of the radial artery with calculation of central pulse pressure (PP) and augmentation index (AIx). Results: Overall, 18 patients (11 females) were included. Mean age was 36 years and mean body mass index (BMI) was 22.1 kg/m2. Eleven patients were on Celiprolol therapy. No significant differences were found between groups in terms of age, sex, BMI, and presence of hypertension (p&gt;0.05). Patients on Celiprolol therapy displayed higher values of systolic BP (SBP) (124 vs 113 mmHg; p = 0.128), diastolic BP (DBP) (76 vs 67 mmHg; p = 0.236), mean BP (92 vs 83 mmHg; p = 0.173), and HR at office BP measurement, as well as lower AIx (126 vs 140%; p = 0.176) at PWA, although the difference was not statistically significant. Similarly, no significant difference was found for all ABPM parameters (24-h, day-time, and night-time SBP, DBP, mean BP, and HR), as well as central SBP, central DBP, central mean BP, and PP at PWA between groups (p&gt;0.05). Conclusions: Our study suggests little impact of Celiprolol therapy on both BP and HR in patients with vEDS, which hints additional mechanisms behind its protective effect in this clinical setting. Further studies on larger cohorts are needed to clarify these aspects.

DETERMINANTS OF OFFICE BLOOD PRESSURE VARIABILITY AND INSTABILITY IN CHILDREN, ADOLESCENTS AND YOUNG ADULTS

Objective: To evaluate the determinants of office blood pressure (BP) variability and instability within a single visit in young individuals. Design and method: Apparently healthy individuals aged 6-25 years referred for elevated blood pressure (BP) were subjected to triplicate office BP measurements in a single visit and 24h ambulatory BP monitoring. BP variability and instability were assessed separately for systolic and diastolic BP using: (i) standard deviation (SD) (ii) coefficient of variation (CV) (iii) average real variability (ARV) (iv) maximum office BP (Max) (v) maximum-minimum office BP difference (MMD) (vi) ratio of difference between 1st-3rd measurement to the average office BP (Relative change). White-coat effect was defined as the difference between office and daytime ambulatory BP. Results: 320 individuals were analyzed (mean age 13.6±3.6 years, 66.8% males, BMI z-score 1.12±0.96, average office BP 122.6±16.6/72.6±10.7 mmHg, 24h ambulatory BP 119.3±11.5/67.8±6.8). Based on office and 24h ambulatory BP, 21.3% of the participants had white-coat hypertension, 8.1% masked and 16.6% sustained hypertension. Age was associated with SD (r = 0.23, p&lt;0.001), CV (r = 0.11, p&lt;0.05), Max (r = 0.54, p&lt;0.001) and MMD (r = 0.23, p&lt;0.001) of office systolic BP, and Max (r = 0.29, p&lt;0.001) and ARV (r = 0.12, p&lt;0.05) of diastolic. In multivariable log-linear regression models [(independent variables: age, sex, BMI z-score, heart rate, office BP, white-coat effect (&gt; = 5/6 mmHg systolic/diastolic, 75th centile)], office BP was an independent determinant for indices of systolic BP variability and instability [SD (↓ = 0.01, p&lt;0.001), ARV (↓ = 0.01, p&lt;0.001), Max (↓ = 0.01, p&lt;0.001), MMD (↓ = 0.01, p&lt;0.001) and Relative change (↓ = 0.001, p&lt;0.05)], and for CV (↓ = -0.06, p&lt;0.001) and Max (↓ = 0.01, p&lt;0.001) of diastolic. White-coat effect was a significant determinant for CV of office systolic BP (↓ = 0.15, p&lt;0.05) and Relative change of office diastolic BP (↓ = 0.03, p&lt;0.05). Conclusions: These results suggest that in healthy children, adolescents, and young adults the indices of office BP variability and instability within the first visit seem to be determined by the level of office BP and the magnitude of the white-coat effect.

OFFICE BLOOD PRESSURE VARIABILITY AND INSTABILITY IN CHILDREN, ADOLESCENTS AND YOUNG ADULTS: ASSOCIATION WITH PRECLINICAL ORGAN DAMAGE

Objective: To evaluate the association of systolic blood pressure (SBP) variability and instability within a single office visit with preclinical target organ damage in young individuals. Design and method: Apparently healthy individuals aged 6-25 years referred for elevated blood pressure (BP) were subjected to triplicate office BP measurements in a single visit and 24h ambulatory BP monitoring. SBP variability and instability were quantified using (i) standard deviation (SD) (ii) coefficient of variation (CV) (iii) average real variability (ARV) (iv) maximum office SBP (v) maximum-minimum office SBP difference (MMD) (vi) ratio of difference between 1st-3rd measurement to the average office SBP (Relative change). Preclinical organ damage was evaluated by (i) carotid intima-media thickness (cIMT), (ii) carotid-femoral pulse wave velocity (PWV; Complior device), and (iii) echocardiographic left ventricular mass index (LVMI). Results: 301 individuals were analyzed (mean age 13.8±3.7 years, 66.8% males, BMI z-score 1.12±0.95, average office BP 122.6±16.9/72.5±10.7 mmHg, 24h ambulatory BP 119.1±11.4/67.8±6.8 mmHg). LVMI measurements were available in 258 participants, IMT in 208 and PWV in 60. LVMI, IMT and PWV were associated with office SBP (r = 0.30/0.23/0.42, respectively, p&lt; = 0.001), 24h ambulatory SBP (r = 0.35/0.33/0.48, p&lt; = 0.001) and maximum office SBP (r = 0.31/0.30/0.41, p&lt; = 0.001). LVMI and IMT were associated with SD (r = 0.14/0.15, p&lt;0.05) and MMD (r = 0.13/0.15, p&lt;0.05), while IMT and PWV with age (r = 0.31/0.38, p&lt;0.001). Other indices of variability were not associated with indices of organ damage. In stepwise multivariable linear regression models (independent variables: age, sex, BMI z-score, office SBP, 24h ambulatory SBP, maximum office SBP, SD, MMD), LVMI was determined by BMI z-score and 24h ambulatory SBP, IMT by age, male sex and 24h ambulatory SBP, and PWV by 24h ambulatory SBP. Conclusions: These results suggest that in young individuals the variability and instability of office SBP within a single visit are not associated with preclinical organ damage.

SKIN SODIUM CONTENT AS A PREDICTOR OF BLOOD PRESSURE RESPONSE TO RENAL DENERVATION

Objective: In patients with treatment resistant hypertension (TRH), renal denervation (RDN) emerged as an adjacent therapeutic option. It has been detected that patients with TRH have elevated Sodium (Na) content in muscle and skin. This analysis aimed at evaluating whether tissue Na content predicts blood pressure (BP) response after RDN. Design and method: Radiofrequency device based endovascular RDN was performed in 53 patients with uncontrolled TRH (office BP&gt; = 140/90 mmHg and diagnosis confirmed by 24-h ambulatory BP monitoring) in our certified RDN center. Office and 24-h ambuatory BP were measured at baseline and after 6 months. To assess tissue Na content 23Na-MRI was performed at baseline prior to RDN. We splitted the study cohort based on the median systolic 24-h ambulatory BP reduction after 6 months into responders and non-responders and compared tissue Na content and baseline characteristics between these groups. The study was registered at http://www.clinicaltrials.gov (NCT01687725). Results: 53 patients were followed up for at least 6 months. Office systolic and diastolic BP were reduced by -12.9±21.1 mmHg and -7.7±12.5 mmHg and 24-h ambulatory systolic and diastolic BP were reduced by -8.6±14.0 mmHg and -4.7±9.5 mmHg after 6 months. Responder could be characterized as patients with low tissue sodium content in skin, more female patients, patients with aldosteron-antagonists, high baseline 24-h night-time heart rate and high LDL-cholesterol (see table, only p&lt;0.10 are shown). This results remained significant after adjustment for baseline 24-h SBP. Similar results were obtained if the two groups were created based on the median of 24-h day-time and night-time BP reduction after 6 months. Conclusions: We identified Na in skin, sex, 24-h night-time heart rate, aldosterone antagonists and LDL-cholesterol as predictors of the systolic BP response. We conclude that 23Na-MRI may assist to select patients with uncontrolled TRH who will have a clinically meaningful BP reduction following RDN treatment.

EFFECTS OF LIFESTYLE ADVICE ASSOCIATED WITH BEETROOT-BASED NUTRACEUTICAL ON 24-HOUR BLOOD PRESSURE IN A POPULATION WITH HIGH-NORMAL BLOOD PRESSURE OR GRADE 1 HYPERTENSION

Objective: 2018 ESH hypertension guideline supports life-style changes as initial approach to be taken in both subjects with high-normal blood pressure (BP) and patients with grade 1 hypertension and low cardiovascular (CV) risk. Among many nutraceuticals, most with unproven or unlikely benefits, bioactive substances enriched with nitrates, sources of nitric oxide (i.e. red beets) exert proven vasodilator effects and may decrease BP levels. Aim: to evaluate the effect of lifestyle advice and beetroot-based nutraceutical on 24-h BP in a population with high-normal BP or grade 1 hypertension and low CV risk. Design and method: Longitudinal study on 43 consecutive subjects referred to two hypertension centers. A 24-h ambulatory BP monitoring (ABPM) was performed at baseline and after 3 month the introduction of lifestyle advice and beetroot-based nutraceutical [Cosmony, Servier, a nutraceutical based on Beta vulgaris L. (500 mg of dry beetroot extract)]. Results: Mean age: 49.9±10.7 years. Male prevalence: 53.5%. Median follow-up: 98 (92-121) days. Overweight/obese prevalence: 58.1%. The 62.8% of subjects had a grade 1 hypertension. At baseline, 24-h BP, daytime BP and night-time BP were 127.2±6.8/79.6±5.6 mmHg, 131.3±7.5/83.4±5.5 mmHg and 117.8±7.7/70.2±5.0 mmHg, respectively. At follow-up, all BPs showed a statistically significant decrease (all p&lt;0.005), except for diastolic night-time BP (p = 0.074) (-3.4±5.9/-2.2±3.7 mmHg for 24h BP; -3.9±6.0/-3.0±4.0 for daytime BP and -3.3±7.4/-1.3±4.7 for night-time BP). The percentage of subject with daytime BP &lt;130/85 mmHg had increased from 25.6% at baseline to 48.8% at follow-up. The decrease in BP was independent of gender and overweight/obesity, whereas it was more evident in the group of grade 1 hypertensives compared with the group with high-normal BP. Conclusions: Lifestyle advice in association with a nutraceutical, source of nitric oxide, may be a valid initial non-pharmacological therapy in subjects with high-normal BP or grade 1 hypertension and low CV risk.

THRESHOLDS FOR WHITE-COAT AND MASKED BLOOD PRESSURE EFFECTS: AN AMBULATORY BLOOD PRESSURE MONITORING STUDY

Objective: The values used to define white-coat and masked blood pressure (BP) effects are usually arbitrary. This study aimed at investigating the accuracy of various thresholds based on the differences (DBP) between office BP (OBP) and 24h-ambulatory BP monitoring (ABPM) to identify white-coat (WCH) and masked (MH) hypertension, which are phenotypes assumed to carry adverse prognosis. Design and method: This cross-sectional study included 11,350 [Derivation cohort; 45% men, mean age = 55.1 ± 14.1 years, OBP = 132.1 ± 17.6/83.9 ± 12.5 mmHg, ABPM = 121.6 ± 11.4/76.1 ± 9.6 mmHg, 25% using antihypertensive medications (AH)] and 7,220 [Validation cohort; 46% men, mean age = 58.6 ± 15.1 years, OBP = 136.8 ± 18.7/87.6 ± 13.0 mmHg, ABPM = 125.5 ± 12.6/77.7 ± 10.3 mmHg; 32% using AH] unique individuals who underwent OBP and ABPM measurements. We compared the sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and area under the curve (AUC) of 8 different ↗BP thresholds to detect WCH (↗systolicBP/↗diastolicBP = +28/+17, +20/+15, +20/+10, +16/+11, +15/+9, +14/+9 mmHg and ↗systolicBP = +13 and +10 mmHg) and eight different ↗BP thresholds to detect MH (↗systolicBP/↗diastolicBP = -14/-9, -5/-2, -3/-1, -1/-1, 0/0, +2/+2 mmHg and ↗systolicBP = -5 and -3 mmHg), built from formerly reported criteria in the literature. WCH was defined as OBP&gt; = 140/90mmHg and ABPM &lt; 130/80mmHg, and MH was defined as OBP &lt; 140/90mmHg and ABPM&gt; = 130/80mmHg. Results: The +20/+15 mmHg threshold showed the best AUC (0.804, 95%CI = 0.794 - 0.814) to detect WCH in the Derivation cohort, with sensitivity, specificity, PPV and NPV of 80.6%, 80.2%, 42.3%, and 95.8%, respectively. The +2/+2 mmHg threshold showed the highest AUC (0.741, 95%CI = 0.728 - 0.754) to detect MH, with sensitivity, specificity, PPV and NPV of 78.9%, 69.3%, 22.0% and 96.8%, respectively. Both threshold values also had the best accuracy to detect WCH (0.767, 95%CI = 0.754 - 0.780) and MH (0.767, 95%CI = 0.750 - 0.784) in the Validation cohort. In secondary analyses, these thresholds had the best accuracy to detect WCH and MH in individuals using or not AH, and to detect individuals with higher and lower office-than-home BP stages, respectively, in both cohorts. Conclusions: The +20/+15 and +2/+2 mmHg ↗BP thresholds had the best accuracy to detect hypertensive patients with WCH and MH, respectively, and may be indicators of marked white-coat and masked BP effects.

RELATIONSHIP OF ARTERIAL STIFFNESS AND BASELINE CEREBRAL SMALL VESSEL DISEASE SCORE, WITH THE OCCURRENCE OF NEW LESIONS AFTER 2 YEARS OF FOLLOW-UP, INDEPENDENTLY OF BP CONTROL

Objective: Hypertension is a prominent determinant of cerebral small vessel disease (cSVD). The aim of this study was to assess in subjects with a recent lacunar stroke, the factors associated with the occurrence of new lesions of cSVD after 2 years of follow-up. Design and method: Patients with a recent small subcortical infarct according to STRIVE criteria were consecutively included in this prospective study. Clinical BP was measured after 5 min of rest in a sitting position using a validated semiautomatic device (OMRON Digital Automatic Blood Pressure Monitor Model HEM-907XL, Kyoto, Japan). Three measurements of BP were averaged to determine values of clinical BP at baseline and at 3, 6, 12 and 24 months of follow-up. 24h-Ambulatory blood pressure monitoring (ABPM) was performed after hospital discharge within 30 days after stroke onset and after 2-years follow-up. The aortic pulse wave velocity (aPWV), the augmentation index (AIx) and 24h brachial and central BP (24h-ABPM) were measured by means of a Mobil-O-Graph PWV (IEM, Stolberg, Germany) device. The AIx was normalized for heart rate of 75 bpm (AIX75). Brain MRI was performed using a Phillips Achieva 1.5 T MRI at admission and at 2-years follow-up. Results: A total of 103 patients, aged 67.04 (10.9) years, 30.4% female, were included. Follow-up MRI was acquired in 92 patients. Backwards stepwise logistic regression analysis showed that 24h-PWV (OR 1.44 CI 95% 1.01-2,06 p = 0.044) and cSVD score (OR 2.3 CI 95% 1.41-3.77, p = 0.001) were associated with the presence of new lesions. Significance for 24h-PWV was lost after introducing age in de model, and only cSVD score remained significant (OR 2.33 CI95% 1.34-3.98, p = 0.002). The presence of new lesions was not significantly different between patients with or without BP control defined by BP &lt; 130/80 mm Hg during the 24h-ABPM. Conclusions: In subjects with a lacunar stroke, 24h-PWV and cSVD score were associated significantly with the presence of new lesions after 2 year of follow-up, independently of BP control

A SPECIFIC 3 MONTHS-PROGRAM TO IMPROVE NON-ADHERENCE IN UNCONTROLLED HYPERTENSION IMPROVES BLOOD PRESSURE CONTROL AND ASSOCIATED ORGAN DAMAGE (ATHAN CLINICAL TRIAL)

Objective: To evaluate whether a specific 3-month(m) action plan to improve therapeutic adherence in patients with uncontrolled hypertension on ◊ 2 drugs results in a decrease in BP and whether this is maintained at 12m. Secondly, to assess if this correlates with an improvement in subclinical organ damage. Design and Method: Prospective, randomized clinical trial where patients attended consecutively in a Hypertension Unit with ambulatory 24h-BP ◊130/80 mmHg despite receiving at least 2 antihypertensive drugs and with therapeutic non-compliance confirmed by the determination of antihypertensive drugs in the urine, were randomized (1:1) to receive a specific 3-month program to improve adherence (INT = intervention) or routine follow-up (C = control). Antihypertensive treatment was not modified, but beyond 3m all patients received usual care. Before randomization, and at 3m and 12m, urinary screening for antihypertensive drugs and albuminuria, and 24h-ambulatory BP monitoring were determined. Results: Forty-six patients were randomized. At 3m, mean (95%CI) baseline-adjusted BP differences (INT vs. C) were -14.7 mmHg (-5.4 to -24.1), p = 0.001 and -10.0 mmHg (-3.9 to -16.2), p&lt;0.001 for 24h-SBP and 24h-DBP, respectively. The INT group maintained the BP decrease at 12m. vs. baseline: mean(95%CI) variation of 24h-SBP = -16.1 mmHg (-22.8 to -9.4), p&lt;0.001 and variation of 24h-DBP = -7.8 (-12.8 to -2.7), p = 0.002. In the INT group, the percentage of non-detected antihypertensive drugs decreased compared to baseline: median [IQR]: 40% [20-85.7], 0% [0-25], and 18.3 % [0-40] at baseline, 3m and 12m respectively; Z = -3.295 (p&lt;0.001) and Z = -3.055 (p = 0.002) for changes at 3m and 12m, respectively. Albuminuria (median [IQR]) decreased in the INT group: 27.1 mg/g [11.2-116.2] and 22.4 mg/g [6.4-91.9] at baseline and 12m, respectively (Z = -2.207, p = 0.027). At 12m, variation of albuminuria correlated with variation of 24h-BP but not with variation of percentage of non-detected antihypertensive drugs. Conclusions: a 3-month specific nursing intervention to improve therapeutic adherence results in improved BP control in patients with inadequate therapeutic compliance. This improvement continues beyond the completion of this program. Decreased BP correlates with a regression of albuminuria.

NOCTURNAL BLOOD PRESSURE DIPPING AND PRECLINICAL TARGET ORGAN DAMAGE IN YOUNG INDIVIDUALS

Objective: A blunted nighttime blood pressure (BP) decrease (non-dipping) has been linked to increased cardiovascular risk. Relevant research data in children and adolescents are scarce with most studies conducted in young individuals with medical conditions, e.g., diabetes. This study investigated the relationship of nighttime dipping with indices of preclinical target organ damage (TOD) in young individuals. Design and method: Individuals referred for suspected hypertension and healthy volunteers aged 6-25 years were evaluated with 24h ambulatory BP (ABP) monitoring. The nighttime BP dip was quantified as the percentage BP decline as compared to the daytime value. Non-dippers were defined as those with systolic and/or diastolic nighttime dip &lt;10%. TOD was assessed by echocardiographic left ventricular mass index (LVMI) and ultrasonographic determination of intima-media thickness of the common carotid artery (IMT). Results: 276 individuals were included (13.8±3.8 years, 67% males, 31.2% children, 56.1% adolescents, 12.7% adults, 3.3% healthy volunteers, BMI z-score 1.18±0.96, 37.4% obese, 25.7% with elevated 24h ABP, 27.9% with elevated nighttime BP). LVMI measurements were available in 257 and IMT in 205. The average systolic/diastolic dip was 12.1±4.7/19.6±6.3% and 30.4% of participants were classified as non-dippers. TOD indices were higher in non-dippers than in dippers (LVMI 30.5±8.2 versus 28.4±5.9 g/m2.7; IMT 0.517±0.054 versus 0.500±0.053 mm, p&lt;0.05 for both). In linear regression analysis, non-dipping was independently associated with LVMI (↓ = 2.14, p = 0.01) and IMT (↓ = 0.02, p = 0.02), after adjustment for sex, age, BMI z-score and 24h systolic ABP. However, after adjustment for the nighttime BP levels (instead of 24h ABP) this association lost its statistical significance. Conclusions: These data suggest that in young individuals nocturnal non-dipping is associated with TOD, but not after accounting for the nighttime BP levels.

ACUPUNCTURE IN ARTERIAL HYPERTENSION: EVALUATION OF ITS EFFICACY WITH BOTH OFFICE AND AMBULATORY BLOOD PRESSURE MEASUREMENTS

Objective: A possible alternative to pharmacological antihypertensive therapies in grade 1 low risk hypertensive patients or in those experienced drugs adverse effects could be acupuncture. Design and method: We focused on its possible effects on BP both as Office BP (OBP) and as Ambulatory BP Monitoring (ABPM) evaluating it before starting a 6 weeks twice weekly (total 12 session) acupuncture cycle and after 2 months from its completion. In this prospective study we treated with acupuncture 45 patients: 24 of them presents high-normal BP values and low cardiovascular risk while 21 patients were on anti-hypertensive drug with slightly uncontrolled BP values (from 140 to 145 mmHg for Systolic BP – SBP – and/or from 90 to 95 mmHg for Diastolic BP – DBP). Results: Regarding SBP, a significant reduction have been observed for office values (from 134.2±15.7 to 125.1±12.2, p = 0.03), and for ABPM 24h (from 131.1±10.7 to 126.0±10.1, p = 0.01) and day-time values (from 134.7±10.5 to 127.1±18.4, p = 0.02). For DBP, only ABPM 24h and day-time values showed significant changes (from 85.3±9.1 to 82.1±7.5, p = 0.03; and from 88.5±9.3 to 85.7±7.8, p = 0.02). Within session SBP decrease was -5.8 mmHg (-3.75%) during the first session while it falls to -2.1 mmHg (-1.25%) and stands firmly under 2 mmHg for all the next session. At the last session SBP reduction was -1.9 mmHg (-1.6%). Conclusions: We found a significant reduction in office, 24h and day-time ABPM SBP determined by a 6-weeks twice weekly acupuncture cycle that lasts at least for the first two months after its completion.

DIETARY SODIUM RESTRICTION REDUCES NOCTURNAL BLOOD PRESSURE IN PATIENTS WITH TREATMENT RESISTANT HYPERTENSION

Objective: Patients with treatment resistant hypertension (TRH) are characterised by lack of blood pressure (BP) control despite antihypertensive treatment. They are at particular risk of cardiovascular disease and more likely to experience BP increase as a response to sodium loading than other individuals. In this study, we aimed to analyse if self-performed dietary sodium restriction could be implemented in patients with TRH. Moreover, we aimed to analyse the effect of this on nocturnal and 24h BP, and how BP changes were correlated to changes in plasma levels of BNP, nitric oxide and body water content. Design and method: The study was conducted as an interventional cross-over study including patients with TRH from 20-70 years. Patients were screened with 24h ambulatory BP monitoring initiated after observed intake of usual antihypertensive medication. They were included if 24h systolic BP&gt;130/80 mmHg. Study participation included two periods of 14 days; a standard period with usual diet and an interventional period with instructed dietary sodium restriction and handed-out sodium-free bread. At the end of each period, patients were examined with 24h BP monitoring, 24h urine collection (sodium excretion), blood samples (nitric oxide, BNP), and bioimpedance measurement (body water content). Results: Participation was completed by 15 patients with mean age 59 years and mean 24h BP 144/82 mmHg. Mean baseline urinary sodium excretion was 192(86) mmol/24h (11.2 grams of salt). As seen in Table 1, sodium excretion was reduced to 91 mmol/24h equalling 5.3 grams of salt. BP levels were reduced significantly. Plasma levels of nitric oxide increased significantly, and this was correlated to the change in 24h BP. Total body water content and plasma levels of BNP was reduced significantly. The changes in BP were not correlated to changes in sodium excretion, body water or BNP. Conclusions: Self-performed dietary sodium restriction could be implemented resulting in a significant reduction in BP levels. BP change was not related to changes in body water or sodium excretion. Increased levels of nitric oxide may be evidence of improved endothelial function and may be one of the involved mechanisms in BP decrease following sodium restriction

PREVALENCE OF WHITE-COAT AND MASKED HYPERTENSION AT DIFFERENT OFFICE BLOOD PRESSURE LEVELS IN UNTREATED SUBJECTS

Objective: The European Guidelines for the management of arterial hypertension support the use of out-of-office blood pressure (BP) measurements for confirming the diagnosis of hypertension and detecting BP phenotypes such as white-coat hypertension (WCH) and masked hypertension (MH), especially in patients with grade 1 hypertension and subjects with high normal BP. However, it is not clear enough, whether out-of-office blood pressure measurements should be performed in patients with higher grades of hypertension as well as in subjects with normal or optimal BP. The aim of our study was to investigate the prevalence of WCH in untreated patients with grade 1, grade 2 and grade 3 hypertension as well as the prevalence of MH in never treated subjects with high normal, normal and optimal BP values. Design and method: A total of 2357 untreated subjects referred to our Hypertension Unit for evaluation underwent 24-h ambulatory BP monitoring. According to their office BP levels were divided into 6 categories: optimal (&lt;120/80mmHg), normal (120/80 – 129/84mmHg), high normal (130/85 – 139/89mmHg), grade 1(140/90 – 159/99mmHg), grade 2 (160/100 – 179/109mmHg) and grade 3 (&gt; = 180/110mmHg). Subjects with office BP&gt; = 140/90mmHg and 24-h BP&lt;130/80mmHg were defined as WCHs and patients with office BP&lt;140/90mmHg and 24-h BP&gt; = 130/80mmHg as MHs. Statistical analysis was performed by means of chi-square test and one-way ANOVA. Results: The percentages of WCH were 53%, 31% and 24% for patients with grade 1, grade 2 and grade 3 hypertension, respectively. The percentages of MH were 34%, 29% and 17% for patients with high normal, normal and optimal BP, respectively. Conclusions: The prevalence of WCH is significantly higher in grade 1 hypertension, however patients with grade 2 and 3 hypertension present also high rates of WCH. Similarly, MH is more common in subjects with high normal BP, however high percentages are observed in subjects with normal and optimal BP. Our results support that out-of-office BP measurements should be performed across all office BP range for the optimal detection of WCH and MH.

DETERMINANTS OF WITHIN-VISIT OFFICE BLOOD PRESSURE VARIABILITY AND INSTABILITY: EUROPEAN DATA FROM 1.053 INDIVIDUALS

Objective: Blood pressure (BP) variability is the physiological sequelae of the complex interaction of multiple neural, humoral, reflex, and behavioral factors. This analysis aimed to evaluate the determinants of BP variability and instability within a single office visit, which is routinely used for hypertension evaluation in clinical practice. Design and method: A retrospective analysis of cross-sectional data was performed, comprising adults with triplicate office BP measurements in a single office visit and 24h ambulatory BP monitoring collected within the context of prospective clinical studies in Finland, Greece, and United Kingdom. Indices of BP variability and instability included: (i) standard deviation (SD) (ii) coefficient of variation (CV) (iii) average real variability (ARV) (iv) maximum office BP (Max) (v) maximum-minimum difference (MMD) of office BP (vi) ratio of the difference between 1st-3rd measurement to the mean office BP (Relative change). White-coat effect was defined as the difference between office and daytime ambulatory BP. Results: Data from 1.053 individuals were analyzed (mean age 57.7 ± 11.3 years, males 50%, treated hypertensives 50.3%, average office BP 133.5 ± 18.7/83.5 ± 10.9 mmHg, daytime ambulatory BP 132.5 ± 14.1/80.7 ± 9.9 mmHg). All the indices of BP variability and instability were positively associated with average office BP, age, BMI, and white-coat effect, but with an inverse association between age and maximum diastolic BP (all p &lt; 0.05). In multivariable linear regression analysis systolic BP variability was mainly determined by average office systolic BP, and treatment for hypertension, while diastolic BP variability was determined by office diastolic BP and female sex (Table). Conclusions: These results suggest that the variability and instability of BP within a single office visit is mainly influenced by the BP level, female sex and the administration of antihypertensive treatment.

ACCURACY OF FIXED 24-H AMBULATORY BLOOD PRESSURE RECORDINGS FOR DIAGNOSING HIGH 44-H AMBULATORY BLOOD PRESSURE IN HEMODIALYSIS PATIENTS: A DIAGNOSTIC TEST STUDY

Objective: Hypertension is highly prevalent in hemodialysis patients. Ambulatory-BP-monitoring (ABPM) during the 44-h interdialytic interval is recommended for hypertension diagnosis and management in these subjects. This study assessed the diagnostic accuracy of fixed 24-h ABPM recordings with 44-h BP in hemodialysis patients. Design and method: 242 Greek hemodialysis patients that underwent valid 48-h ABPM (Mobil-O-Graph NG device) were included in the analysis. We used 44-h BP used as reference method and tested the accuracy of the following BP metrics: 1st 24-h without HD period (20h-1st), 1st 24-h including HD period (24h-1st) and 2nd 24-h (24h-2nd). Results: All studied metrics showed strong correlations with 44-h SBP/DBP (20h-1st: r = 0.973/0.978, 24h-1st: r = 0.964/0.972 and 24h-2nd: r = 0.978/0.977, respectively). In Bland-Altman analysis, small between-method differences (-1.70, -1.19 and +1.45 mmHg) with good 95% limits-of-agreement ([-10.83 to 7.43], [-11.12 to 8.74] and [-6.33 to 9.23] mmHg, respectively) for 20h-1st, 24h-1st and 24h-2nd SBP were observed. The sensitivity/specificity and ↓-statistic for diagnosing 44-h SBP grater or equal to 130 mmHg were high for 20h-1st SBP (87.2%/96.0%, ↓-statistic = 0.817), 24h-1st SBP (88.7%/96.0%, ↓-statistic = 0.833) and 24h-2nd SBP (95.0%/88.1%, ↓-statistic = 0.837). Similar observations were made for DBP. In ROC-analyses, all studied BP metrics showed excellent performance with high Area-Under-the-Curve values (20h-1st: 0.983/0.992; 24h-1st: 0.984/0.987 and 24h-2nd: 0.982/0.989 for SBP/DBP respectively). Conclusions: Fixed 24-h ABPM recordings during either the first or the second day of interdialytic interval have high accuracy and strong agreement with 44-h BP in hemodialysis patients. Thus, ABPM recordings of either the first or the second interdialytic day could be used for hypertension diagnosis and management in these subjects.

Importance of 24h ambulatory blood pressure monitoring in patients with acromegaly and correlation with cardiac magnetic resonance findings.

Arterial hypertension (AH) is prevalent in acromegaly, but few studies using 24-h ambulatory blood pressure monitoring (24h-ABPM) suggest that its frequency may be different from office blood pressure (OBP). Left ventricular hypertrophy (LVH) is one of the most frequent cardiac abnormalities. Cardiac magnetic resonance (CMR) is considered the gold standard to evaluate the heart. To compare the frequency of AH when measured by 24h-ABPM and by OBP and to correlate BP with cardiac mass. Patients over 18years of age with acromegaly underwent OBP evaluation and were later referred to the 24h-ABPM. Treatment-naïve patients were submitted to CMR. We evaluated 96 patients. From 29 non hypertensive patients by OBP, 9 had AH on 24h-ABPM. In the group of patients with a previous diagnosis of AH by OBP, 25 had controlled BP and 42 had abnormal BP on 24h-ABPM, when analyzed by OBP there were 28 with controlled BP. We observed a positive correlation between diastolic BP measured in 24h-ABPM and IGF-I levels, but we did not observe the same correlation with age, sex, body mass index and GH levels. The CMR was performed in 11 patients. We found a positive correlation of left ventricular mass (LVM) and BP of 24h-ABPM. In contrast, there was no correlation of OBP with CMR parameters. We observed, that 24h-ABPM in acromegaly allows the diagnosis of AH in some patients with normal BP in OBP and also to allow a better treatment. 24h-ABPM shows a better correlation with VM by CMR.