Ambulatory Blood Pressure Control Research Articles

SEX DIFFERENCES IN AMBULATORY BLOOD PRESSURE TRAJECTORIES AND BLOOD PRESSURE VARIABILITY IN HEMODIALYSIS PATIENTS

Objective: Ambulatory blood pressure (BP) control is worse in men than in women with chronic kidney disease (CKD) and this may partially explain the faster CKD progression in men. The aim of this study is to investigate possible sex-differences in ambulatory BP levels, BP trajectories, and BP variability (BPV) in hemodialysis patients. Design and method: 129 male and 91 female hemodialysis patients that underwent 48-h ABPM with Mobil-O-Graph-NG were included in this analysis. Ambulatory BP levels over the 2-day interdialytic interval (including two daytime and two nighttime periods) were recorded. We calculated the standard deviation (SD), weighted SD (wSD), coefficient of variation (CV), and average real variability (ARV) of BP with validated formulas. Results: Age, dialysis vintage, antihypertensive treatment and history of major comorbidities did not differ between men and women. Pre-dialysis SBP levels did not differ between men and women (145.1 ± 22.7 vs 145.9 ± 25.7mmHg, p = 0.808), but DBP was marginally higher in men (87.6 ± 14.0 vs 84.0 ± 13.7mmHg, p = 0.055). 48-h SBP/DBP (137.2 ± 17.4/81.9 ± 12.1mmHg vs 132.2 ± 19.2/75.9 ± 11.7mmHg, p = 0.045/ < 0.001) as well as DBP during the 1st and SBP/DBP during the 2nd 24-h period were significantly higher in men than in women. Similarly, daytime SBP/DBP was significantly higher in men (138.3 ± 17.5/83.2 ± 12.3mmHg vs 131.9 ± 19.4/76.4 ± 11.5mmHg. p = 0.011/< 0.001). No significant between-group differences were detected for nighttime SBP. All SBP variability indices were similar between men and women; DBP-SD, DBP-wSD and DBP-ARV were higher in men (44-h DBP-ARV 9.4 ± 1.8 vs 8.6 ± 1.9, p = 0.002). No significant differences were revealed in the dipping pattern between men and women. Conclusions: Ambulatory BP levels and trajectories, as well as DBP variability indices are higher in men than women hemodialysis patients. This worse ambulatory BP profile in male compared to female patients may impact on the incidence of cardiovascular events.

MO705: Factors Associated with Uncontrolled Ambulatory Hypertension in Peritoneal Dialysis Patients

Abstract BACKGROUND AND AIMS Hypertension among patients on long-term peritoneal dialysis (PD) is common and remains often inadequately control (Cocchi et al. Prevalence of hypertension in patients on peritoneal dialysis: results of an Italian multicentre study. Nephrol Dial Transplant. 1999; 14(6): 1536–40; Vaios et al.. Assessment and management of hypertension among patients on peritoneal dialysis. Clin J Am Soc Nephrol. 2019; 14(2): 297–305). The aim of the present study was to describe the epidemiology of hypertension using the ‘gold-standard’ method of ambulatory blood pressure monitoring (ABPM) and to identify determinants of inadequate ambulatory blood pressure (BP) control in this high-risk population. METHOD In 140 stable patients receiving PD in four centers of Northern Greece, we performed 24-h ABPM using the oscillometric Mobil-O-Graph device (IEM, Stolberg Germany) (Franssen and Imholz. Evaluation of the Mobil-O-Graph new generation ABPM device using the ESH criteria. Blood Press Monit. 2010; 15(4): 229–31). Hypertension was defined as 24-h ambulatory BP ≥ 130/80 mmHg or current use of at least 1 BP-lowering medication (Williams et al. 2018 ESC/ESH guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018; 36(10): 1953–2041). The volume status of study participants was assessed with the method of bioimpedance spectroscopy (Fresenius Medical Care, Bad Homburg, Germany). Univariate and multivariate binary logistic regression analysis was performed to identify factors that were independently associated with uncontrolled ambulatory hypertension. RESULTS Ambulatory hypertension was diagnosed in 95% of the patients enrolled in the study. Despite the fact that 96.9% of hypertensives were being treated with an average of 2.4 BP-lowering medications daily, adequate control of 24-h ambulatory BP was achieved in only 38.3% of them. In univariate regression analysis, there was a significant interaction of uncontrolled ambulatory hypertension with the mode of PD, history of cardiovascular disease and smoking status. In multivariate analysis, among variables inserted in the model, the higher overhydration index in bioimpedance spectroscopy [odds ratio (OR): 1.308; 95% confidence interval (CI): 1.023–1.673/L higher overhydration] and the history of cardiovascular disease (OR: 3.069; 95% CI: 1.157–8.140) were the two factors that were associated with higher odds of uncontrolled ambulatory hypertension. In contrast, the presence of residual diuresis ≥ 0.5 L/24 h (OR: 0.304; 95% CI: 0.105–0.881) was the only parameter associated with lower odds of inadequate ambulatory BP control. CONCLUSION Among patients on PD, ambulatory hypertension is highly prevalent and remains often poorly controlled, despite the extensive use of antihypertensive drug therapy. Achievement of adequate volume control and long-term preservation of residual kidney function appear to be two attractive non-pharmacological strategies for optimization of the management of hypertension in this high-risk population.

Influence of an acute fast on ambulatory blood pressure and autonomic cardiovascular control.

Evidence suggests that intermittent fasting improves cardiovascular health by reducing arterial blood pressure, but contributing mechanisms are unclear. The purpose of this study was to determine the influence of an acute fast on hemodynamics, muscle sympathetic nerve activity (MSNA), and autonomic control at rest and during an arterial pressure challenge. Twenty-five young normotensive volunteers were tested twice, in the fed and fasted (24 h) states (randomized). Twenty-four hour ambulatory blood pressure was measured before an autonomic function test, which consisted of a 10-min period of controlled breathing (CB) at 0.25 Hz followed by 3, 15-s Valsalva maneuvers (VMs). We recorded the ECG, beat-to-beat arterial pressure, and MSNA throughout the autonomic test. Vagal-cardiac modulation via heart rate variability (HRV) was assessed in both time and frequency domains, cardiovagal baroreflex sensitivity (cvBRS) was assessed with linear regression, and stroke volume was estimated from pulse contour. All fed versus fasted comparisons presented are different at P < 0.05. Fasting reduced ambulatory mean arterial pressure (81 ± 1 vs. 78 ± 1 mmHg) and heart rate (69 ± 2 vs. 65 ± 2 beats/min). CB revealed enhanced HRV through increased R-R intervals (992 ± 30 vs. 1,059 ± 37 ms) and normalized high frequency (HFnu) R-R interval spectral power (55 ± 3 vs. 62 ± 3%). Estimated stroke volume was higher after fasting (by 13%) as was cvBRS (20 ± 2 vs. 26 ± 5 ms/mmHg) and cvBRS during phase IV of the VM (9 ± 1 vs. 12 ± 1 ms/mmHg). MSNA (n = 12) did not change (16 ± 11 vs. 15 ± 8 bursts/min; P = 0.18). Our results show that acute fasting is consistent with improved cardiovascular health: such improvements are driven by reduced ambulatory arterial pressure and enhanced vagal-cardiac modulation.

Abstract TP215: Principal Hospital Admission Of Hypertension Foreshadows 3-month Ischemic And Hemorrhagic Stroke

Introduction: Hypertension is a well-recognized risk factor for acute ischemic stroke (AIS) and intraparenchymal hemorrhagic (IPH). We performed a nationwide analysis to evaluate the rate of AIS and IPH readmission comparing patients with hypertension as a principal versus non-principal diagnosis. Methods: Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmission Database, we included patients with index admission diagnosis (principal or non-principal) of hypertension from 2016 to 2018. Hypertension, AIS, IPH, and other diagnoses were identified based on standard ICD-10 CM codes. Patients with AIS or IPH diagnoses during the index admission were excluded. We determined post-discharge 90-day admission trends by Kaplan-Meier estimates in patients with principal versus non-principal diagnosis of hypertension. We then constructed Cox regression models to determine associations between principal diagnosis of hypertension and AIS or IPH admission rates, with adjustment to age, gender, insurance type, zip code income quartile, index admission disposition, and Elixhauser comorbidities. Results: Of the 36,173,682 patients identified, 586,613 (1.62%) had a principal diagnosis of hypertension during the index admission. Patients with a principal diagnosis of hypertension were more likely to have an AIS or IPH during 90-day follow up versus non-principal diagnosis of hypertension (Figure). In the Cox regression model after the aforementioned adjustments, a principal diagnosis of hypertension was significantly associated with AIS (HR 2.37, 95% CI 2.23-2.53, P &lt; 0.001) and IPH admission (HR 2.25, 95% CI 1.97-2.56, P &lt; 0.001). Conclusion: Patients with hypertensive conditions warranting hospitalization as principal diagnosis are at increased risk of AIS and IPH in the first 90-days after discharge. Post-discharge planning should include intensive ambulatory blood pressure monitoring and control by outpatient providers.

Ambulatory blood pressure and hypertension control in children with autosomal recessive polycystic kidney disease: clinical experience from two central European tertiary centres.

: Arterial hypertension is a common complication in patients with autosomal recessive polycystic kidney disease (ARPKD), occurring in 33-75% of children when measured by office blood pressure (OBP). Ambulatory blood pressure monitoring (ABPM) is a superior tool for investigating blood pressure relative to OBP. The aim of our study was to investigate the prevalence and control of hypertension in children with ARPKD based on ABPM. This retrospective study evaluated 36 children with ARPKD and at least one ABPM performed in two our tertiary paediatric nephrology centres and 29 children with at least two ABPM. Ambulatory hypertension was defined as mean daytime or night-time BP at least 95th percentile or use of antihypertensives and controlled hypertension as normal ambulatory BP in children on antihypertensive drugs. The first ABPM study revealed ambulatory hypertension in 94% of children. Untreated or uncontrolled ambulatory hypertension was diagnosed in 67% and controlled hypertension in only 28%. Masked hypertension was found in 5.5% and white-coat hypertension in 14%. The last ABPM study revealed ambulatory hypertension in 86% (all 86% hypertensive children on drugs, i.e. no untreated hypertension), the prevalence of controlled hypertension increased to 59%. Masked hypertension was detected in 8.3% and white-coat hypertension in 10%. Ambulatory blood pressure correlated neither with kidney length nor with glomerular filtration rate. Echocardiography demonstrated left ventricular hypertrophy (LVH) in 27% of children at the time of their first ABPM. The prevalence of ambulatory hypertension is very high in children with ARPKD, while the control of hypertension improves over time.

Team-Based Care for Improving Hypertension Management: A Pragmatic Randomized Controlled Trial.

Objective: We evaluated the effect on long term blood pressure (BP) of an interprofessional team-based care (TBC) intervention, involving nurses, pharmacists, and physicians, compared to usual care.Methods: We conducted a pragmatic randomized controlled study in ambulatory clinics and community pharmacies in Switzerland (ClinicalTrials.gov: NCT02511093). Uncontrolled treated hypertensive patients were randomized to TBC or usual care (UC). In the TBC group, nurses and pharmacists met patients every 6 weeks to measure BP, assess lifestyle, support medication adherence, and provide health education for 6 months. After each visit, they wrote a report to the physician who could adjust antihypertensive therapy. The outcome was the intention-to-treat difference in mean daytime ambulatory blood pressure measurement (ABPM) and control (<135/85 mmHg) at 6 and 12 months.Results: Eighty-nine patients (60 men/29 women; mean (SD) age: 61(12) year) were randomized to TBC (n = 43) or UC (n = 46). At baseline, mean (SD) BP was 144(10)/90(8) mmHg and 147(12)/87(11) mmHg in the TBC and UC groups. At 6 months, the between-groups difference in daytime systolic ABPM was−3 mmHg [95% confidence interval (CI):−10 to +4; p = 0.45]; at 12 months, this difference was−7 mmHg [95% CI:−13 to−2; p = 0.01]. At 6 months, the between-groups difference in daytime diastolic ABPM was +2 mmHg [95% CI:−1 to +6; p = 0.20]; at 12 months, this difference was−2 mmHg [95% CI:−5 to +2; 0.42]. Upon adjustment for baseline covariates including baseline BP, the between-groups differences at 6 and 12 months were maintained. At 6 months, there was no difference in BP control. At 12 months, the TBC group tended to have a better control in systolic BP (p = 0.07) but not in diastolic BP (p = 0.33).Conclusion: While there was not significant effect on BP at 6 months of follow-up, the TBC intervention can help decrease long-term systolic BP among uncontrolled hypertensive patients.

Sex differences in ambulatory blood pressure levels, control, and phenotypes of hypertension in kidney transplant recipients.

Ambulatory blood pressure (BP) control is worse in men compared with women with chronic kidney disease (CKD) and this may partially explain the faster CKD progression in men. This is the first study investigating possible sex differences in prevalence, control and phenotypes of hypertension in kidney transplant recipients (KTRs) with office-BP and 24-h ambulatory BP monitoring (ABPM). This cross-sectional study included 136 male and 69 female stable KTRs who underwent office-BP measurements and 24-h ABPM. Hypertension thresholds for office and ambulatory BP were defined according to the 2017 ACC/AHA and 2021 KDIGO guidelines for KTRs. Age, time from transplantation, eGFR and history of major comorbidities did not differ between groups. Office SBP/DBP levels were insignificantly higher in men than women (130.3 ± 16.3/77.3 ± 9.4 vs. 126.4 ± 17.8/74.9 ± 11.5 mmHg; P = 0.118/0.104) but daytime SBP/DBP was significantly higher in men (128.5 ± 12.1/83.0 ± 8.2 vs. 124.6 ± 11.9/80.3 ± 9.3 mmHg; P = 0.032/P = 0.044). No significant between-group differences were detected for night-time BP. The prevalence of hypertension was similar by office-BP criteria (93.4 vs. 91.3%; P = 0.589), but higher in men than women with ABPM (100 vs. 95.7%; P = 0.014). The use of ACEIs/ARBs and CCBs was more common in men. Office-BP control was similar (43.3 vs. 44.4%, P = 0.882), but 24-h control was significantly lower in men than women (16.9 vs. 30.3%; P = 0.029). White-coat hypertension was similar (5.1 vs. 7.6%; P = 0.493), whereas masked hypertension was insignificantly more prevalent in men than women (35.3 vs. 24.2%; P = 0.113). BP levels, hypertension prevalence and control are similar by office criteria but significantly different by ABPM criteria between male and female KTRs. Worse ambulatory BP control in male compared with female KTRs may interfere with renal and cardiovascular outcomes.

Assessment of a strategy combining ambulatory blood pressure, adherence monitoring and a standardised triple therapy in resistant hypertension

Purpose Poor adherence to drug therapy and inadequate drug regimens are two frequent factors responsible for the poor blood pressure (BP) control observed in patients with apparent resistant hypertension. We evaluated the efficacy of an antihypertensive management strategy combining a standardised therapy with three long acting drugs and electronic monitoring of drug adherence in patients with apparent resistant hypertension. Materials and Methods In this multicentric observational study, adult patients with residual hypertension on 24 h ambulatory BP monitoring (ABMP) despite the use of three or more antihypertensive drugs could be included. Olmesartan/amlodipine (40/10 mg, single pill fixed-dose combination) and chlorthalidone (25 mg) were prescribed for 3 months in two separated electronic pills boxes (EPB). The primary outcome was 24 h ambulatory systolic BP (SBP) control at 3 months, defined as mean SBP <130 mmHg. Results We enrolled 48 patients (36.0% women) of whom 35 had complete EPB data. After 3 months, 52.1% of patients had 24 h SBP <130 mmHg. 24 h SBP decreased by respectively −9.1 ± 15.5 mmHg, −22.8 ± 30.6 mmHg and −27.7 ± 16.6 mmHg from the tertile with the lowest adherence to the tertile with the highest adherence to the single pill combination (p = 0.024). A similar trend was observed with tertiles of adherence to chlorthalidone. Adherence superior to 90% was associated with 24 h systolic and diastolic blood pressure control in multiple logistic regression analysis (odds ratio = 14.1 (95% confidence interval 1.1–173.3, p = 0.039). Conclusions A simplified standardised antihypertensive therapy combined with electronic monitoring of adherence normalises SBP in about half of patients with apparent resistant hypertension. Such combined management strategy enables identifying patients who need complementary investigations and those who rather need a long-term support of their adherence.

The Number of Pills, Rather Than the Type of Renin-Angiotensin System Inhibitor, Predicts Ambulatory Blood Pressure Control in Essential Hypertensives on Triple Therapy: A Real-Life Cross-Sectional Study.

IntroductionWe evaluated the prevalence and predictors of ambulatory blood pressure (BP) control in patients taking a triple antihypertensive therapy (renin–angiotensin system inhibitor + calcium channel blocker + thiazide/thiazide-like diuretic, in either free or fixed-dose combinations) containing an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB).MethodsWe performed an observational cross-sectional study on 520 consecutive patients with essential hypertension taking a stable triple therapy in whom 24-h ambulatory BP was evaluated. Both number of pills and antihypertensive treatment intensity (ATI), as possible pharmacological predictors of ambulatory BP control, were taken into account.ResultsA total of 189 (36.3%) patients were taking triple therapy with ACEi and 331 (63.7%) patients were taking triple therapy with ARB. Mean age was 62.7 ± 12.2 years. Patients on triple therapy with ACEi had a significantly lower ATI and took fewer antihypertensive pills than patients on triple therapy with ARB (22.2% of patients took a single-pill triple fixed-dose combination). Patients taking triple therapy with ACEi had higher prevalence of both 24-h (54.8% vs 44.0%; p = 0.019) and daytime BP control (61.8% vs 49.2%; p = 0.006) than patients taking triple therapy with ARB, even after adjusting for age, sex, body mass index, smoking habit, type 2 diabetes mellitus, estimated glomerular filtration rate, and ATI [OR 1.5 (95% CI 1.1–2.2) and OR 1.6 (95% CI 1.1–2.4), respectively]. However, these independent associations with ambulatory BP control were lost when the number of antihypertensive pills was included in the model.ConclusionThe higher prevalence of ambulatory BP control found in patients taking a triple therapy with ACEi was affected by the lower number of antihypertensive pills taken, which was also the key predictor of ambulatory BP control in our study. This confirms the importance of fixed-dose combinations in the management of essential hypertension.

Poorly controlled ambulatory blood pressure in outpatients with peripheral arterial disease.

BackgroundPatients with peripheral arterial disease (PAD) are generally less intensively managed than patients with coronary heart disease (CHD), despite that their risk of complications is believed to be equivalent. Identification of PAD patients at risk of poorly controlled blood pressure (BP) could lead to improved treatment, thus lowering the risk of cardiovascular (CV) complications. We aimed to describe the prevalence of poorly controlled cardiovascular (CV) risk factors, focusing on BP, in outpatients with PAD diagnosed in a vascular ultrasound laboratory.MethodsConsecutive outpatients with carotid and/or lower extremity PAD were included (n = 402) and examined with blood sampling, clinical BP, and 24-h ambulatory BP measurements. A poorly controlled clinical BP was defined as ≥140/90 mmHg, ambulatory BP ≥130/80 mmHg, low-density lipoprotein (LDL)-cholesterol level ≥2.5 mmol/L, and glycated hemoglobin (HbA1c) level >53 mmol/mol in those with diabetes.ResultsMost of the patients had poorly controlled clinical (76.6%) and ambulatory BP (51.7%) profiles. Antihypertensive medications were prescribed in 84% of the patients. However, >40% of them used only 0–1 medication, and <25% of them used three or more agents. Clinical BP, a low number of medications, body mass index, and the presence of diabetes independently predicted a poorly controlled ambulatory BP. Nearly one-third of the patients were smokers, and most of the cohort had an LDL-cholesterol level of ≥2.5 mmol/L. An HbA1c level of >53 mmol/mol was present in 55% of diabetic patients.ConclusionPoorly controlled clinical and ambulatory systolic BP profiles were common. In addition, suboptimal control of other important CV risk factors was detected. The findings of this study highlight the need for better preventive efforts against CV risk factors in outpatients with PAD.

STATIN THERAPY IS ASSOCIATED WITH BETTER 24-HOUR AND NIGHT-TIME BLOOD PRESSURE CONTROL IN HYPERTENSIVE PATIENTS

Objective: Hypertension and dyslipidemia often coexist. Statin therapy was associated with lower blood pressure (BP) in some but not all studies. Aim: to evaluate the association between statin therapy and 24-hour BP in a large hypertensive population, using propensity score matching analysis. Design and method: Retrospective study on 1827 consecutive essential hypertensives evaluated with 24 h ambulatory BP monitoring. Anti-hypertensive treatment intensity (ATI) was calculated to compare different drug associations. We used a propensity score matching to compare two equally-sized cohorts of patients (369 patients in each group) with similar characteristics according to statin therapy (age, sex, body mass index, smoking habit, diabetes mellitus, total cholesterol, high-density lipoprotein cholesterol, triglycerides, low-density lipoprotein cholesterol, estimated glomerular filtration rate, glycaemia, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, calcium channel blocker, diuretic, mineralocorticoid receptor antagonist, beta-blocker, alfa-blocker, ATI, 24 h pulse pressure). Matching was performed on log-transformed propensity score in a 1:1 fashion with a caliper of 0.1, in order to account for the different baseline characteristics between statins and non-statins groups. Results: Mean age: 58.1 ± 13.8 years; male sex: 55%. Patients on statin therapy: 402 (22%). The different statins were taken as follows: atorvastatin (39.8%), simvastatin (35.8%), rosuvastatin (15.7%), pravastatin (5.6%), lovastatin (2.3%) and fluvastatin (0.8%). Patients on statins showed lower 24 h BP (-2.8/-7.1 mmHg), daytime (-3.3/-7.6 mmHg) and night-time BP (-2.5/-6.0 mmHg, all p &lt; 0.001). They also showed better ambulatory BP control, even after adjustment for confounders. The analyses on the groups derived from the propensity score matching (369 patients in each group) confirmed these results (OR 1.8 for 24 h BP control; OR = 1.6 for daytime BP control; OR = 1.7 for night-time BP control, all p &lt; 0.001). Conclusions: Conclusions: Statin therapy is associated with lower ABPM values in hypertensive patients. This result is not affected by the anti-hypertensive treatment intensity or by the several cofactors analyzed, but may depend on greater adherence to prescribed drug therapies as suggested by the assumption of a nocebo-tainted drug class. The cardiovascular benefit of statins is due to the reduction of blood cholesterol and effects on blood pressure may be just indirect.

SEASONAL VARIABILITY OF PULSE WAVE VELOCITY IS ASSOCIATED WITH CARDIOVASCULAR OUTCOMES IN HYPERTENSIVE PATIENTS

Objective: The seasonal changes of blood pressure in hypertensive patients have been investigated and attracted an increasing scientific interest during the past years, but seasonal changes of pulse wave velocity (PW) in hypertensive patients have not been studied. And it is unclear whether PW variations are related to cardiovascular risk. The aim of the study was the examination of prognostic value of individual variability of PW in 24-hour, daytime and nighttime periods of hypertensive patients from two regions of the Russia (Ivanovo and Saratov). Design and method: Patients aged 40–79 years who visited ambulatory clinics for various reasons we. All participants provided written informed consent. The ambulatory blood pressure monitoring (ABPM) was performed with the BPLab device, twice in all patients: in winter (December-February 2012–2014) and in summer (June-August 2012–2014). The interval between ABPMs was 6 months ± 7 days. The selection criteria for ABPM records were: duration &gt; = 23.5 hours, absence of data gaps &gt;1 hour, and &gt; = 56 readings per 24 hours. We analyzed the individual PW in 24-hour, daytime and nighttime differences in each patient. The participants were followed up until October 31-st 2019 (mean follow-up 6.4 ± 0.4 years). The complex endpoint included death (from any reasons), stroke, myocardial infarction, transient ischemic attack, angina pectoris, and development of heart failure. The preliminary analyses included ANOVA and descriptive statistics. Results: In total, 770 patients completed both visits. The outcome information was available in 528 patients: 335 from Ivanovo and 193 from Saratov (mean age 55 ± 10 years, 220 men). The endpoints were registered in 50 patients. We found the mean winter-summer PW difference in the group of patients with cardiovascular outcomes. In contrast, this difference was positive in the other group (see Table1). Conclusions: The inverse seasonal PW variability, which could reflect the abnormal biological response to outside temperature, may be associated with a higher risk of cardiovascular events, compared to patients with standard PW variability (PW is higher in winter, than in summer). Our data demonstrate the preliminary argument in favor of additional ambulatory BP and PW control. The problem of seasonal PW variability is needed further studying.

INVERSE SEASONAL VARIATIONS OF AMBULATORY BLOOD PRESSURE ARE ASSOCIATED WITH CARDIOVASCULAR OUTCOMES IN HYPERTENSIVE PATIENTS

Objective: The seasonal changes of blood pressure (BP) in hypertensive patients have been widely investigated and attracted an increasing scientific interest during the past two decades. However, it is unclear whether these BP variations are related to cardiovascular risk. Design and method: We included patients aged 40–79 years who visited ambulatory clinics for various reasons. The main inclusion criteria were office BP 130/85-139/89 mm Hg, hypertension stage 1, or long-term antihypertensive therapy. The ambulatory blood pressure monitoring (ABPM) was performed with the BPLab device (Nizhny Novgorod, Russia), twice in all patients: in winter (December-February 2012–2014) and in summer (June-August 2012–2014). The interval between ABPMs was 6 months ± 7 days. The selection criteria for ABPM records were: duration &gt;23.5 hours, absence of data gaps &gt;1 hour, and &gt;55 readings per 24 hours. We analyzed the individual ambulatory and office seasonal BP differences in each patient. The participants were followed up until October 31st 2019 (mean follow-up 76.8 ± 5.1 months). The composite primary endpoint included death, myocardial infarction, stroke, transient ischemic attack, angina pectoris, and development of heart failure. The preliminary analyses included ANOVA, sensitivity analysis, and descriptive statistics. Results: 770 patients completed both visits. The outcome information was available in 528 patients: 335 from Ivanovo and 193 from Saratov (mean age 55 ± 10 years, 220 men). The endpoints were registered in 50 patients. We found the inverse mean winter-summer BP difference in the group of patients with cardiovascular outcomes (see table). In contrast, this difference was positive in the other group (see table). The sensitivity analysis (the winter-summer BP difference classified into 4 groups: inverse (&lt;0), small (0–5 mm Hg), medium (5–10 mm Hg), and large (&gt;10 mm Hg) variation) confirmed the hypothesis for 24-hour diastolic BP. We found no significant associations for office BP. Conclusions: The inverse seasonal BP variability may be associated with a higher risk of cardiovascular events; compared to patients with standard BP variability (BP is higher in winter, than in summer). Our data provide the tentative argument in favor of additional ambulatory BP control. The problem of seasonal BP variability warrants further investigation.

Effects of antihypertensive medication and high‐intensity interval training in hypertensive metabolic syndrome individuals

Pharmacological and non-pharmacological therapies are simultaneously prescribed when treating hypertensive individuals with elevated cardiovascular risk (ie, metabolic syndrome individuals). However, it is unknown if the interactions between antihypertensive medication (AHM) and lifestyle interventions (ie, exercise training) may result in a better ambulatory blood pressure (ABP) control. To test this hypothesis, 36 hypertensive individuals with metabolic syndrome (MetS) under long-term prescription with AHM targeting the renin-angiotensin-aldosterone system (RAAS) were recruited. Before and after 4months of high-intensity interval training (HIIT), participants completed two trials in a double-blind, randomized order: (a) placebo trial consisting of AHM withdrawal for 3days and (b) AHM trial where individuals held their habitual dose of AHM. In each trial, 24-h mean arterial pressure (MAP) was monitored and considered the primary study outcome. Secondary outcomes included plasma renin activity (PRA) and aldosterone concentration to confirm withdrawal effects on RAAS, along with the analysis of urine albumin-to-creatinine ratio (UACR) to assess kidney function. The results showed main effects from AHM and HIIT reducing 24-h MAP (-5.7mmHg, p<0.001 and -2.3mmHg, p=0.007, respectively). However, there was not interaction between AHM and HIIT on 24-h MAP (p=0.240). There was a main effect of AHM increasing PRA (p<0.001) but no effect on plasma aldosterone concentration (p= 0.368). HIIT did not significantly improve RAAS hormones or the UACR. In conclusion, AHM and HIIT have independent and additive effects in lowering ABP. These findings support the combination of habitual AHM with exercise training with the goal to reduce ABP in hypertensive MetS individuals.

Characteristics and control of the 24-hour ambulatory blood pressure in patients with metabolic syndrome.

Asian countries are facing an increasing prevalence of metabolic syndrome (MetS), which may aggravate the burden of cardiovascular diseases in this region. MetS is closely associated with ambulatory blood pressure (BP). Patients with MetS, compared to those without, had a twofold higher risk of new‐onset office, home, or ambulatory hypertension. Furthermore, the risk of new‐onset MetS in patients with white‐coat, masked and sustained hypertension was also doubled compared to normotensives. High‐risk masked hypertension and blunted nighttime BP dipping are common in patients with MetS, suggesting perfect 24‐hour BP control with long‐acting antihypertensive drugs and early initiation of combination therapy might be especially important for patients with MetS.

Sex difference in ambulatory blood pressure control associates with risk of ESKD and death in CKD patients receiving stable nephrology care.

It is unknown whether faster progression of chronic kidney disease (CKD) in men than in women relates to differences in ambulatory blood pressure (ABP) levels. We prospectively evaluated 906 hypertensive CKD patients (553 men) regularly followed in renal clinics to compare men versus women in terms of ABP control [daytime <135/85 and nighttime blood pressure (BP) <120/70 mmHg] and risk of all-cause mortality and end-stage kidney disease (ESKD). Age, estimated glomerular filtration rate and use of renin-angiotensin system inhibitors were similar in men and women, while proteinuria was lower in women [0.30 g/24 h interquartile range (IQR) 0.10-1.00 versus 0.42 g/24 h, IQR 0.10-1.28, P = 0.025]. No sex-difference was detected in office BP levels; conversely, daytime and nighttime BP were higher in men (134 ± 17/78 ± 11 and 127 ± 19/70 ± 11 mmHg) than in women (131 ± 16/75 ± 11, P = 0.005/P < 0.001 and 123 ± 20/67 ± 12, P = 0.006/P < 0.001), with ABP goal achieved more frequently in women (39.1% versus 25.1%, P < 0.001). During a median follow-up of 10.7 years, 275 patients reached ESKD (60.7% men) and 245 died (62.4% men). Risks of ESKD and mortality (hazard ratio and 95% confidence interval), adjusted for demographic and clinical variables, were higher in men (1.34, 1.02-1.76 and 1.36, 1.02-1.83, respectively). Adjustment for office BP at goal did not modify this association. In contrast, adjustment for ABP at goal attenuated the increased risk in men for ESKD (1.29, 0.98-1.70) and death (1.31, 0.98-1.77). In the fully adjusted model, ABP at goal was associated with reduced risk of ESKD (0.49, 0.34-0.70) and death (0.59, 0.43-0.80). No interaction between sex and ABP at goal on the risk of ESKD and death was found, suggesting that ABP-driven risks are consistent in males and females. Our study highlights that higher ABP significantly contributes to higher risks of ESKD and mortality in men.

Ambulatory blood pressure monitoring and blood pressure control in patients with coronary artery disease—A randomized controlled trial

BackgroundOffice blood pressure (OBP) is used for diagnosing and treating hypertension but ambulatory blood pressure measurement (ABPM) associates more accurately with patient outcome. BP control is important in secondary prevention but it is unknown whether the use of APBM improves BP-control in this setting. Our objective was to investigate whether physician awareness of ABP after percutaneous coronary intervention (PCI) improved BP-control. Methods: A total of 200 patients performed ABPM before and after their PCI follow-up visit. Patients were randomized to open (O) or concealed (C) ABPM results for the physician at the follow-up visit. The change in ABP and antihypertensive medication in relation to baseline ABP was compared between the two groups. Results: The average OBP (O and C: 128/76 mmHg) and ABP (O: 123/73 mmHg, C: 127/74 mmHg) was well controlled and did not change between the first and second measurement. A slight increase in systolic ABP during night time was observed in the open arm compared to the concealed arm. Among patients with high ABP (>130/80 mm Hg) at baseline more patients in the C compared to O group remained with a high ABP at the end of study 34/44 (77%) vs 19/34 (56%), p = 0.045. There was a positive correlation between baseline systolic ABP and ABP change in both the O (r = 0.41, p < 0.001) and the C (r = 0.24, p = 0.014) groups but the association was steeper in the open group (p = 0.035). In patients with low ABP an increase and in patients with high ABP a decrease in ABP was observed in the O group where more changes in medication were done. Conclusions: ABPM did not lower blood pressure in patients with CAD apart from in those with elevated ABP but led to more relevant changes in antihypertensive treatments. Further studies are needed to answer whether patient outcome is affected.

Ambulatory blood pressure and risk of new-onset atrial fibrillation in treated hypertensive patients.

The aim of this study was to evaluate the influence of clinic and ambulatory blood pressure (BP) on the occurrence of new‐onset atrial fibrillation (AF) in treated hypertensive patients. We studied 2135 sequential treated hypertensive patients aged >40 years. During the follow‐up (mean 9.7 years, range 0.4–20 years), 116 events (new‐onset AF) occurred. In univariate analysis, clinic, daytime, nighttime, and 24‐h systolic BP were all significantly associated with increased risk of new‐onset AF, that is, hazard ratio (95% confidence interval) per 10 mm Hg increment 1.22 (1.11–1.35), 1.36 (1.21–1.53), 1.42 (1.29–1.57), and 1.42 (1.26–1.60), respectively. After adjustment for various covariates in multivariate analysis, clinic systolic BP was no longer associated with increased risk of new‐onset AF, whereas daytime, nighttime, and 24‐h systolic BP remained significantly associated with outcome, that is, hazard ratio (95% confidence interval) per 10 mm Hg increment 1.09 (0.97–1.23), 1.23 (1.10–1.39), 1.16 (1.03–1.31), and 1.22 (1.06–1.40), respectively. Daytime, nighttime, and 24‐h systolic BP are superior to clinic systolic BP in predicting new‐onset AF in treated hypertensive patients. Future studies are needed to evaluate whether a better control of ambulatory BP might be helpful in reducing the occurrence of new‐onset AF.

Relationship Between The Blood Pressure Responses To Acute And Chronic Aerobic Exercise Among Adults With Hypertension

Aerobic exercise acutely reduces blood pressure (BP) 5-7 mmHg among adults with hypertension, termed postexercise hypotension (PEH). PEH has been shown to be highly correlated to the BP response to exercise training in the laboratory. However, this relationship has yet to be explored under ambulatory conditions and compared to a control sham session (CONTROL) which is necessary to account for the circadian variation in ambulatory BP (ABP). PURPOSE: To examine the relationship between PEH (ABPACUTE) and the systolic BP (ASBP) and diastolic ambulatory BP (ADBP) responses to aerobic exercise training (ABPCHRONIC). METHODS: Adults with hypertension (n=24) completed a graded-exercise stress test (GEST) and CONTROL before and after 12wk moderate intensity aerobic exercise training. Ambulatory BP was assessed immediately after each experiment until the next morning and averaged at hourly intervals over 19hr. ABPACUTE was the difference between pre-training GEST minus CONTROL ABP. ABPCHRONIC was post- minus pre-training CONTROL ABP. ANCOVA tested differences in ABP over time with resting BP as a covariate. Multiple variable regression examined relationships among ABPACUTE and ABPCHRONIC. RESULTS: Subjects were middle-aged (52.3±10.8y), physically inactive adults with hypertension (136.3±10.7 / 85.2±8.9mmHg). Following the GEST, ABPACUTE (ASBP/ADBP) were lower -5.9±5.7mmHg /-2.9±4.1mmHg than CONTROL (ps<0.006). Following 12wk of aerobic exercise training, post-training ABP CONTROL (137.9±11.0 / 81.7±6.5mmHg) was not different than pre-training ABP CONTROL (137.5±6.6 / 80.5±5.7; ps>0.404). Multivariable regression analysis revealed that resting SBP, body mass index (BMI), and ASBPACUTE explained ~40% of the variance in ASBPCHRONIC, with ASBPACUTE explaining ~17% of the variance in ASBPCHRONIC (p=0.03). Similarly, resting DBP, BMI, and ADBPACUTE explained ~40% of the variance in ADBPCHRONIC, while DBPACUTE explained ~11% of the variance to DBPCHRONIC (p=0.06). CONCLUSION: ABPACUTE explained ~11-17% of the variability in exercise training-induced changes in ABPCHRONIC. The magnitude of the correlations we observed between ABPACUTE and ABPCHRONIC under ambulatory conditions appear to be less than those reported previously in the laboratory and merit further investigation.

Statin therapy is associated with better ambulatory blood pressure control: a propensity score analysis.

Statin therapy was associated with lower blood pressure (BP) in some but not all studies. We evaluated the association between statin therapy and ambulatory BP in a large hypertensive population using 'propensity score matching'. Retrospective observational study on 1827 consecutive essential hypertensive patients evaluated with 24-h ambulatory BP monitoring. Antihypertensive treatment intensity (ATI) was calculated to compare different drug associations. We used a propensity score matching to compare two equally-sized cohorts of patients with similar characteristics according to statin therapy. Matching was performed on log-transformed propensity score in a 1 : 1 fashion with a caliper of 0.1, in order to account for the different baseline characteristics between statin and no-statin group. Mean age: 58.1 ± 13.8 years; male sex: 55%. Patients on statin therapy: 402 (22%). These patients showed lower 24-h BP (-2.8/-7.1 mmHg), daytime (-3.3/-7.6 mmHg) and night-time BP (-2.5/-6.0 mmHg, all P < 0.001). They also showed better ambulatory BP control, even after adjustment for confounding factors. The analyses on the groups derived from the 'propensity score matching' (369 patients in each group) confirmed these results (OR 1.8 for 24-h BP control; OR = 1.6 for daytime BP control; OR = 1.7 for night-time BP control, all P < 0.001). Statin therapy is associated with better ambulatory BP control in essential hypertensive patients. This result is not affected by the intensity of the antihypertensive treatment or by the several cofactors analyzed.