Ambulatory Blood Pressure In Patients Research Articles

#1478 Effect of low vs standard dialysate sodium on 48-h ambulatory blood pressure in patients with intradialytic hypertension: a randomized crossover study

Abstract Background and Aims Intradialytic hypertension (IDH) is associated with increased risk for cardiovascular events and mortality. Patients with IDH exhibit higher 48-h blood pressure (BP) levels than patients without this condition. Volume and sodium excess are considered a major factor contributing in the development of this phenomenon. This study evaluated the effect of low (137 mEq/L) compared to standard (140 mEq/L) dialysate sodium concentration on 48-h BP in patients with IDH. Method In this randomized, single-blind, crossover study, 29 patients with IDH underwent 4 hemodialysis sessions with low (137 mEq/L) followed by 4 sessions with standard (140 mEq/L) dialysate sodium or vice-versa. Mean 48-h BP, pre-/post-dialysis and intradialytic BP, pre-dialysis weight, interdialytic weight gain (IDWG) and lung ultrasound B-lines were assessed. Results Mean 48-h SBP/DBP were significantly lower with low compared to standard dialysate sodium concentration (137.6 ± 17.0/81.4 ± 13.7 mmHg with low vs 142.9 ± 14.5/84.0 ± 13.9 mmHg with standard dialysate sodium, p = 0.005/p = 0.007 respectively); SBP/DBP levels were also significantly lower during the 44-h and different 24-h periods. Low dialysate sodium significantly reduced post-dialysis (SBP/DBP: 150.3 ± 22.3/91.2 ± 15.1 mmHg with low vs 166.6 ± 17.3/94.5 ± 14.9 mmHg with standard dialysate sodium, p < 0.001/p = 0.134 respectively) and intradialytic (141.4 ± 18.0/85.0 ± 13.4 mmHg with low vs 147.5 ± 13.6/88.1 ± 12.5 mmHg with standard dialysate sodium, p = 0.034/p = 0.013, respectively) BP compared with standard dialysate sodium. Pre-dialysis weight, IDWG and pre-dialysis B-lines were also significantly decreased with low dialysate sodium. Conclusion Low dialysate sodium concentration significantly reduced 48-h ambulatory BP compared with standard dialysate sodium in patients with IDH. These findings support low dialysate sodium as a major non-pharmacologic approach for BP management in patients with IDH. Registered at ClinicalTrials.gov with study number NCT05430438.

Effect of antihypertensive agents on sleep apnea and ambulatory blood pressure in patients with hypertension: A randomized controlled trial

BackgroundObstructive sleep apnea (OSA) and hypertension are common conditions that may be linked through sympathetic activation and water retention. We hypothesized that diuretics, which reduce the body water content, may be more effective than amlodipine, a blood pressure (BP)-lowering agent implicated with edema, in controlling OSA in patients with hypertension. We also aimed to compare the effects of these treatments on ambulatory blood pressure monitoring (ABPM). MethodsIn a randomized, double-blind clinical trial, we compared the effects of chlorthalidone/amiloride 25/5 mg with amlodipine 10 mg on OSA measured by portable sleep monitor and BP measured by ABPM. The study included participants older than 40 who had moderate OSA (10–40 apneas/hour of sleep) and BP within the systolic range of 140–159 mmHg or diastolic range of 90–99 mmHg. ResultsThe individuals in the experimental groups were comparable in age, gender, and other relevant characteristics. Neither the combination of diuretics nor amlodipine alone reduced the AHI after 8 weeks of treatment (AHI 26.3 with diuretics and 25.0 with amlodipine. P = 0.713). Both treatments significantly lowered office, 24-h, and nighttime ABP, but the two groups had no significant difference. ConclusionChlorthalidone associated with amiloride and amlodipine are ineffective in decreasing the frequency of sleep apnea episodes in patients with moderate OSA and hypertension. Both treatments have comparable effects in lowering both office and ambulatory blood pressure. The notion that treatments could offer benefits for both OSA and hypertension remains to be demonstrated. Trial registration clinicaltrials. gov identifierNCT01896661.

Ambulatory Blood Pressure in Patients With Rheumatoid Arthritis: Association With Immune Activation.

The prevalence of hypertension, a major cardiovascular risk factor, is increased in patients with rheumatoid arthritis (RA) and may be driven by immune activation. The purpose of this study was to determine if ambulatory 24-hour blood pressure (BP) is elevated in RA vs control participants and whether it is associated with immune activation. We conducted a cross-sectional study of 46 patients with RA and 23 control participants. Participants wore an ambulatory BP monitor that obtained diurnal BP every 15-30 minutes and nocturnal BP every 30 minutes. Inflammatory mediators in plasma were measured using an inflammation proteomics panel. Differences in BP measurements were assessed by Mann-Whitney U test, and association with inflammatory mediators was assessed by Spearman correlation. Patients with RA and control participants had similar office BP, but median ambulatory systolic BP (SBP) measurements (24-hour [RA 121 mmHg vs control 116 mmHg; P = 0.01], diurnal [RA 128 mmHg vs control 120 mmHg; P = 0.003], and nocturnal [RA 112 mmHg vs control 103 mmHg; P = 0.002]) were higher in patients with RA. Patients with RA also had higher nocturnal diastolic BP (DBP; RA 63 mmHg vs control 57 mmHg; P = 0.02), but other DBP measurements were similar. Nocturnal BP dipping was less in patients with RA (12%) compared to control participants (16%; P = 0.02). In patients with RA, higher 24-hour and nocturnal SBPs and less nocturnal dipping were strongly correlated with a wide range of inflammatory mediators. Despite similar office measurements, 24-hour and nocturnal SBP measurements were higher in patients with RA than in control participants and were strongly associated with inflammation.

Low dialysate sodium and 48-h ambulatory blood pressure in patients with intradialytic hypertension: a randomized crossover study.

Intradialytic-hypertension (IDH) is associated with increased risk for cardiovascular events and mortality. Patients with IDH exhibit higher 48-h blood pressure (BP) levels than patients without this condition. Volume and sodium excess are considered a major factor contributing in the development of this phenomenon. This study evaluated the effect of low (137mEq/L) compared to standard (140mEq/L) dialysate sodium concentration on 48-h BP in patients with IDH. In this randomized, single-blind, crossover study, 29 patients with IDH underwent 4 hemodialysis sessions with low (137mEq/L) followed by 4 sessions with standard (140mEq/L) dialysate sodium or vice-versa. Mean 48-h BP, pre-/post-dialysis and intradialytic BP, pre-dialysis weight, interdialytic weight gain (IDWG) and lung ultrasound B-lines were assessed. Mean 48-h SBP/DBP were significantly lower with low compared to standard dialysate sodium concentration (137.6±17.0/81.4±13.7mmHg with low vs 142.9±14.5/84.0±13.9mmHg with standard dialysate sodium, p=0.005/p=0.007 respectively); SBP/DBP levels were also significantly lower during the 44-h and different 24-h periods. Low dialysate sodium significantly reduced post-dialysis (SBP/DBP: 150.3±22.3/91.2±15.1mmHg with low vs 166.6±17.3/94.5±14.9mmHg with standard dialysate sodium, p<0.001/p=0.134 respectively) and intradialytic (141.4±18.0/85.0±13.4mmHg with low vs 147.5±13.6/88.1±12.5mmHg with standard dialysate sodium, p=0.034/p=0.013, respectively) BP compared with standard dialysate sodium. Pre-dialysis weight, IDWG and pre-dialysis B-lines were also significantly decreased with low dialysate sodium. Low dialysate sodium concentration significantly reduced 48-h ambulatory BP compared with standard dialysate sodium in patients with IDH. These findings support low dialysate sodium as a major non-pharmacologic approach for BP management in patients with IDH.Registered at ClinicalTrials.gov with study number NCT05430438.

Lifestyle Medicine as a Treatment for Resistant Hypertension.

Approximately 10% of the adults with hypertension fail to achieve the recommended blood pressure treatment targets on 3 antihypertensive medications or require ≥ 4 medications to achieve goal. These patients with 'resistant hypertension' have an increased risk of target organ damage, adverse clinical events, and all-cause mortality. Although lifestyle modification is widely recommended as a first-line approach for the management of high blood pressure, the effects of lifestyle modifications in patients with resistant hypertension has not been widely studied. This review aims to provide an overview of the emerging evidence on the benefits of lifestyle modifications in patients with resistant hypertension, reviews potential mechanisms by which lifestyles may reduce blood pressure, and discusses the clinical implications of the recent findings in this field. Evidence from single-component randomized clinical trials demonstrated that aerobic exercise, weight loss and dietary modification can reduce clinic and ambulatory blood pressure in patients with resistant hypertension. Moreover, evidence from multi-component trials involving exercise and dietary modification and weight management can facilitate lifestyle change, reduce clinic and ambulatory blood pressure, and improve biomarkers of cardiovascular risk. This new evidence supports the efficacy of lifestyle modifications added to optimized medical therapy in reducing blood pressure and improving cardiovascular risk biomarkers in patients with resistant hypertension. These findings need to be confirmed in larger studies, and the persistence of benefit over extended follow-up needs further study.

Machine Learning-Based prediction of Post-Treatment ambulatory blood pressure in patients with hypertension

Purpose. Pre-treatment prediction of individual blood pressure (BP) response to anti-hypertensive medication is important to determine the specific regimen for promptly and safely achieving a target BP. This study aimed to develop supervised machine learning (ML) models for predicting patient-specific treatment effects using 24-hour ambulatory BP monitoring (ABPM) data.Materials and Methods. A total of 1,129 patients who had both baseline and follow-up ABPM data were randomly assigned into training, validation and test sets in a 3:1:1 ratio. Utilising the features including clinical and laboratory findings, initial ABPM data, and anti-hypertensive medication at baseline and at follow-up, ML models were developed to predict post-treatment individual BP response. Each case was labelled by the mean 24-hour and daytime BPs derived from the follow-up ABPM.Results. At baseline, 616 (55%) patients had been treated using mono or combination therapy with 45 anti-hypertensive drugs and the remaining 513 (45%) patients had been untreated (drug-naïve). By using CatBoost, the difference between predicted vs. measured mean 24-hour systolic BP at follow-up was 8.4 ± 7.0 mm Hg (% difference of 6.6% ± 5.7%). The difference between predicted vs. measured mean 24-hour diastolic BP was 5.3 ± 4.3 mm Hg (% difference of 6.8% ± 5.5%). There were significant correlations between the CatBoost-predicted vs. the ABPM-measured changes in the mean 24-hour Systolic (r = 0.74) and diastolic (r = 0.68) BPs from baseline to follow-up. Even in the patients with renal insufficiency or diabetes, the correlations between CatBoost-predicted vs. ABPM-measured BP changes were significant.Conclusion. ML algorithms accurately predict the post-treatment ambulatory BP levels, which may assist clinicians in personalising anti-hypertensive treatment.

Effect of weight loss on blood pressure changes in overweight patients: A systematic review and meta-analysis.

To determine quantitative differences between weight loss and changes in clinic blood pressure (BP) and ambulatory BP in patients with obesity or overweight, the authors performed a meta-analysis. PubMed, Embase, and Scopus databases were searched up to June 2022. Studies that compared clinic or ambulatory BP with weight loss were included. A random effect model was applied to pool the differences between clinic BP and ambulatory BP. Thirty-five studies, for a total of 3219 patients were included in this meta-analysis. The clinic systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly reduced by 5.79mmHg (95% CI, 3.54-8.05) and 3.36mmHg (95% CI, 1.93-4.75) after a mean body mass index (BMI) reduction of 2.27 kg/m2 , and the SBP and DBP were significantly reduced by 6.65mmHg (95% CI, 5.16-8.14) and 3.63mmHg (95% CI, 2.03-5.24) after a mean BMI reduction of 4.12 kg/m2 . The BP reductions were much larger in patients with a BMI decrease ≥3kg/m2 than in patients with less BMI decrease, both for clinic SBP [8.54mmHg (95% CI, 4.62-12.47)] versus [3.83mmHg (95% CI, 1.22-6.45)] and clinic DBP [3.45mmHg (95% CI, 1.59-5.30)] versus [3.15mmHg (95% CI, 1.21-5.10)]. The significant reduction of the clinic and ambulatory BP followed the weight loss, and this phenomenon could be more notable after medical intervention and a larger weight loss.

Chronic Effects of Oral Cannabidiol Delivery on 24-h Ambulatory Blood Pressure in Patients with Hypertension (HYPER-H21-4): A Randomized, Placebo-Controlled, and Crossover Study

Background: Recent data indicate that cannabidiol (CBD), a nonintoxicating constituent of cannabis, is involved in several aspects of cardiovascular regulation, including blood pressure (BP). However, the impact of chronic CBD administration on 24-h BP and vascular health has not been previously examined in patients with hypertension. The primary aim of this randomized, triple-blind, placebo-controlled, and crossover study was to examine the influence of chronic CBD on 24-h ambulatory BP and arterial stiffness in hypertensive patients. Methods: Seventy patients with mild or moderate primary hypertension, who were untreated or receiving standard of care therapy, were randomly assigned to receive either 5 weeks of oral CBD or placebo-matched controls. Following a >2-week washout period, patients were crossed over to alternate therapy. The primary outcome of the study was dynamic in 24-h ambulatory BP and was assessed using two-way repeated measure analysis of variance. Results: Administration of CBD reduced average 24 h mean, systolic, and diastolic BP after 2.5 weeks (-3.22±0.90 mmHg [95% confidence interval -1.01 to -5.44 mmHg], -4.76±1.24 mmHg [-1.72 to -7.80 mmHg], and -2.25±0.80 mmHg [-0.30 to -6.01 mmHg], respectively (all p<0.05); however, these values largely remained stable following the uptitration of CBD dosing. There were no changes in liver enzymes or serious adverse events (AEs). There was no significant difference in pulse wave velocity (group×factor interaction: F=1.50, p=0.226) at different time points, regardless of the intervention arm. Conclusions: In conclusion, chronic administration of CBD reduces ambulatory BP in those with untreated and treated hypertension. In addition, lack of serious AEs implies safety and tolerability of the above-noted CBD formulation. ClinicalTrials.gov ID: NCT05346562, Registered April 6th 2022.

PS-C30-11: EFFECTS OF SGLT-2 INHIBITORS ON 24 H AMBP IN PATIENTS WITH TYPE 2 DIABETIC AND HYPERTENSION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: To analyze the effects of different types of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on 24-hour ambulatory blood pressure in patients with type 2 diabetes mellitus and hypertension. Method: In the meta-analysis, The PubMed, Web of science, and Cochrane Library were searched for relevant literature, and the references obtained from these sources were retrieved from inception till December 2020, Using sodium-glucose cotransporter 2 inhibito, hypertension and randomized controlled trial as keywords. The inclusion and exclusion criteria were formulated in accordance with the requirements of Cochrane systematic review. A total of 1354 articles were retrieved, 592 duplicate articles were excluded, 372 articles were excluded after reading the title and abstract, 87 articles were excluded from non-randomized control and irrelevant outcome indicators, and 7 studies with 2343 patients were finally included. Use RevMan5.3 software to compare the changes in 24-hour ambulatory blood pressure, day and night blood pressure of patients with type 2 diabetes and hypertension before and after treatment with different types and doses of SGLT2i. Results: A total of four types of SGLT-2i (Empagliflozin, Canagliflozin, Dapagliflozin, Ertugliflozin) were evaluated in the application of patients with type 2 diabetes and hypertension. The result showed that compared with placebo, SGLT2i could reduce the 24-hour systolic blood pressure of patients with type 2 diabetes and hypertension by 4.36mmHg, among which the antihypertensive effects of empagliflozin, canagliflozin, dapagliflozin and ertugliflozin were -4.59mmHg, -3.74mmHg, -5.06mmHg, -3.64mmHg, respectively; similarly, the 24-hour dynamic diastolic blood pressure decreased by 2.20mmHg, among which the antihypertensive effects of empagliflozin, canagliflozin, dapagliflozin and ertugliflozin were -2.38mmHg, -1.22mmHg, -2.00mmHg,- 2.69mmHg, respectively. At the same time, the systolic and diastolic blood pressure during the day and night decreased significantly. Conclusions: This meta-analysis shows that SGLT2i can have beneficial effects on the cardiovascular system by reducing 24-hour ambulatory blood pressure in patients with type 2 diabetes and hypertension, other than reducing blood sugar. Therefore, for patients with type 2 diabetes and hypertension, SGLT2i may be the best hypoglycemic choice.

P122 Association between variability of respiratory sleep indices and ambulatory blood pressure

Abstract Study Objectives Respiratory sleep indices are traditionally reported on the basis of the average total sleep time. The relationship between the hour-to-hour variability of these parameters and blood pressure (BP) has not been reported. Methods We evaluated the associations of the hour-to-hour variability of the apnea–hypopnea index (AHI), oxygen desaturation index (ODI), and lowest oxygen saturation with the 24-hour ambulatory BP in patients with hypertension and newly diagnosed obstructive sleep apnea. A total of 147 patients underwent polysomnography, based on which obstructive sleep apnea was diagnosed in 106 patients these patients underwent 24-hour ambulatory BP monitoring within the next 30 days. Each polysomnogram was divided into hourly reports to calculate the variability of the respiratory sleep indices. Variability independent of the mean was considered the primary measure of variability. Results The median number of hourly polysomnogram reports was 7 (range, 4–8).The hour-to-hour variability of both AHI and ODI, but not of the lowest oxygen saturation, was correlated with the 24-hour pulse pressure, 24-hour systolic BP, and awake systolic BP (p &amp;lt; 0.05 for all). The fully adjusted linear regression analysis indicated that the hour-to-hour variability of AHI and ODI remained associated with the 24-hour pulse pressure (AHI: β coefficient, 0.264 [95% CI, 0.033–0.495],p =0.026; ODI: β coefficient, 0.450 [95% CI, 0.174 - -0.726],p = 0.002). Conclusions The hour-to-hour variability of AHI and ODI is independently associated with the 24-hour pulse pressure. Further investigations are warranted to evaluate the clinical relevance of this new-found association.

PMON265 First Ever Placebo-Controlled Randomised Study of Testosterone on Ambulatory Blood Pressure and Heart Rate in Hypogonadal Men With Uncontrolled Type 2 Diabetes – STRIDE Study

Abstract Background Testosterone has been historically believed to increase blood pressure(BP) and hence bad for heart despite no convincing evidence to prove this. Self-administered use of anabolic steroids has adverse cardiac effects including hypertension. Many RCTs that have looked at the effect of TRT have been BP measurements using mercury sphygmomanometer. Our study is the first RCT looking at the effect of testosterone on ambulatory BP in patients with type 2 diabetes and hypogonadism. Research design and methods: This is a randomised double blinded placebo-controlled add-on trial of intramuscular testosterone undecanoate (Nebido®) administered every 12 weeks in 65 hypogonadal men with poorly-controlled diabetes. Phase 1 patients were randomly assigned to either treatment or placebo arm for 6 months of TRT. Phase 2 was an open-labelled phase for 6 months and patients on placebo moved on to the treatment group wherein patients in the treatment group continued. Diurnal Ambulatory-BP measurements were performed with Spacelabs 90217 mounted on the non-dominant upper arm over 24-hours. Results Mean age of the cohort was 59(42-77)years. 55.4% of the patients had hypertension at baseline. Baseline characteristics were comparable between active/placebo groups apart from cardiovascular disease and hypertension which were significantly higher in the active group compared to placebo group (n=28 vs n=18, p=0.05), (n=23 vs n=13, p=0.008) respectively. There was no significant difference in 24-hours ambulatory average SBP or DBP before and after TRT for 6 months (SBP p=0.407, DBP p=0.649). There were no significant changes in average daytime or night-time SBP (p=0.291), (p=0.295) respectively or average daytime DBP (p=0.566) or night-time DBP (p=0.879) either. There was no significant difference in the total average heart rate and day time average heart rate however night time average heart rate showed a significant reduction of around 4 beats/minute (p=0.046) between the two groups at 6 months. There was no significant difference in the values for the above parameters in the normotensive group (average baseline ambulatory BP≤ 140/90 mm of Hg) and hypertensive group (≥ to 140/90 mm of Hg) either. There was no change in antihypertensive medications in the first 6 months. Mean 24-hour ambulatory BP components were compared at 0, 3, 6, 9 and 12 months for participants in the active group before and after treatment with testosterone undecanoate. There was no significant change in the total, day or night-time systolic or diastolic BP levels before and after the treatment. Conclusions Our study concludes that testosterone given as a replacement hormone in hypogonadal patients with type 2 diabetes does not increase 24-hour ambulatory systolic or diastolic BP. Our study also shows that testosterone causes a decrease in average night-time heart rate of 4 to 5 beats/minute and the cause and significance of such a decrease needs further detailed evaluation. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Peridialytic and intradialytic blood pressure metrics are not valid estimates of 44-h ambulatory blood pressure in patients with intradialytic hypertension

PurposeIn contrast to peridialytic blood pressure (BP), intradialytic and home BP measurements are accurate metrics of ambulatory BP load in hemodialysis patients. This study assessed the agreement of peridialytic, intradialytic, and scheduled interdialytic recordings with 44-h BP in a distinct hemodialysis population, patients with intradialytic hypertension (IDH).MethodsThis study included 45 IDH patients with valid 48-h ABPM and 197 without IDH. With 44-h BP used as reference method, we tested the accuracy of the following BP metrics: Pre- and post-dialysis, mean and median intradialytic, mean intradialytic plus pre/post-dialysis, and scheduled interdialytic BP (out-of-dialysis day: mean of 8:00am/8:00 pm readings).ResultsIn IDH patients, peridialytic and intradialytic BP metrics showed at best moderate correlations, while averaged interdialytic SBP/DBP exhibited strong correlation (r = 0.882/r = 0.855) with 44-h SBP/DBP. Bland–Altman plots showed large between-method-difference for peri- and intradialytic-BP, but only + 0.7 mmHg between-method difference and good 95% limits of agreement for averaged interdialytic SBP. The sensitivity/specificity and κ-statistic for diagnosing 44-h SBP ≥ 130 mmHg were low for pre-dialysis (72.5/40.0%, κ-statistic = 0.074) and post-dialysis (90.0/0.0%, κ-statistic = − 0.110), mean intradialytic (85.0/40.0%, κ-statistic = 0.198), median intradialytic (85.0/60.0%, κ-statistic = 0.333), and intradialytic plus pre/post-dialysis SBP (85.0/20.0%, κ-statistic = 0.043). Averaged interdialytic SBP showed high sensitivity/specificity (97.5/80.0%) and strong agreement (κ-statistic = 0.775). In ROC analyses, scheduled interdialytic SBP/DBP had the highest AUC (0.967/0.951), sensitivity (90.0/88.0%), and specificity (100.0/90.0%).ConclusionIn IDH patients, only averaged scheduled interdialytic but not pre- and post-dialysis, nor intradialytic BP recordings show reasonable agreement with ABPM. Interdialytic BP recordings only could be used for hypertension diagnosis and management in these subjects.

Hour-to-hour variability of respiratory sleep indices and ambulatory blood pressure.

Respiratory sleep indices are traditionally reported on the basis of the average total sleep time. The relationship between the hour-to-hour variability of these parameters and blood pressure (BP) has not been reported. We evaluated the associations of the hour-to-hour variability of the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and lowest oxygen saturation with the 24-h ambulatory BP in patients with hypertension and newly diagnosed obstructive sleep apnea. A total of 147 patients underwent polysomnography, based on which obstructive sleep apnea was diagnosed in 106 patients; these patients underwent 24-h ambulatory BP monitoring within the next 30 days. Each polysomnogram was divided into hourly reports to calculate the variability of the respiratory sleep indices. Variability independent of the mean was considered the primary measure of variability. The median number of hourly polysomnogram reports was 7 (range, 4-8). The hour-to-hour variability of both AHI and ODI, but not of the lowest oxygen saturation, was correlated with the 24-h pulse pressure, 24-h systolic BP, and awake systolic BP (p < 0.05 for all). The fully adjusted linear regression analysis indicated that the hour-to-hour variability of AHI and ODI remained associated with the 24-h pulse pressure (AHI: β coefficient, 0.264 [95% CI = 0.033-0.495], p = 0.026; ODI: β coefficient, 0.450 [95% CI = 0.174-0.726], p = 0.002). The hour-to-hour variability of AHI and ODI is independently associated with the 24-h pulse pressure. Further investigations are warranted to evaluate the clinical relevance of this new-found association.

Dipping Status, Ambulatory Blood Pressure Control, Cardiovascular Disease, and Kidney Disease Progression: A Multicenter Cohort Study of CKD

Ambulatory blood pressure (BP) monitoring allows concurrent evaluation of BP control and nocturnal BP dipping status, both related to adverse outcomes. However, few studies have assessed the prognostic role of combining information on dipping status and achieved ambulatory BP in patients with chronic kidney disease (CKD). Prospective observational cohort study. 906 patients with hypertension and CKD attending 1 of 3 Italian nephrology clinics. Four groups were defined by simultaneously classifying systolic ambulatory BP levels as being at goal (daytime SBP<135 and nighttime SBP<120 mm Hg) or above goal, and the presence or absence of nocturnal dipping (nighttime to daytime SBP ratio of<0.9 versus≥0.9). The composite of time to initiation of maintenance dialysis or estimated glomerular filtration rate (eGFR) decline≥50%, and the composite of fatal and nonfatal cardiovascular events. Multivariable Cox proportional hazards models were used to estimate risks of kidney disease progression and cardiovascular disease in the 4 exposure groups where nocturnal dipping with systolic ambulatory BP at goal was the reference group. The mean patient age was 63.8 years, 61% were male, and 26.4% had diabetes; eGFR was 41.1 ± 20.8 mL/min/1.73 m2. The dipping prevalence in each of the 4 groups was as follows: nocturnal dipping with ambulatory BP at goal, 18.6%; no nocturnal dipping with ambulatory BP at goal, 20.5%; nocturnal dipping with ambulatory BP above goal, 11.8%; and no nocturnal dipping with ambulatory BP above goal, 49.1%. Among patients with ambulatory BP above goal, the risk of cardiovascular events was greater in the absence (HR, 2.79 [95% CI, 1.64-4.75]) and presence (HR, 2.05 [95% CI, 1.10-3.84]) of nocturnal dipping. The same held true for risk of kidney disease progression (HRs of 2.40 [95% CI, 1.58-3.65] and 2.11 [95% CI, 1.28-3.48] in the absence and presence of nocturnal dipping, respectively). Patients at the ambulatory BP goal but who did not experience nocturnal dipping had an increased risk of the cardiovascular end point (HR, 2.06 [95% CI, 1.15-3.68]) and the kidney disease progression outcome (HR, 1.82 [95% CI, 1.17-2.82]). Lack of a diverse cohort (all those enrolled were White). Residual uncontrolled confounding. Systolic ambulatory BP above goal or the absence of nocturnal dipping, regardless of ambulatory BP, is associated with higher risks of cardiovascular disease and kidney disease progression among patients with CKD. Among patients with chronic kidney disease (CKD), ambulatory blood pressure (BP) monitoring improves the identification of individuals at high risk of clinical disease outcomes. Those with uncontrolled ambulatory BP are known to have a higher risk of developing cardiovascular disease and kidney disease progression, particularly when their ambulatory BP does not decline by at least 10% at night. Whether this is also true for patients with presence of optimal ambulatory BP levels but a BP pattern of no nighttime decline is largely unknown. We measured ambulatory BP in 900 Italian patients with CKD and followed them for several years. We found that, independent of ambulatory BP level, the absence of nighttime reductions in BP was associated with worsening of CKD and more frequent cardiovascular events. The absence of nighttime declines in BP is an independent risk factor for adverse events among patients with CKD. Future studies are needed to examine whether treating the absence of nighttime declines in BP improves clinical outcomes.

EFFECTS OF SGLT-2 INHIBITORS ON 24H AMBULATORY BLOOD PRESSURE IN PATIENTS WITH TYPE 2 DIABETIC AND HYPERTENSION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: To analyze the effects of different types of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on 24-hour ambulatory blood pressure in patients with type 2 diabetes mellitus and hypertension. Design and method: In the meta-analysis, The PubMed, Web of science, and Cochrane Library were searched for relevant literature, and the references obtained from these sources were retrieved from inception till December 2020. The inclusion and exclusion criteria were formulated in accordance with the requirements of Cochrane systematic review. A total of 1354 articles were retrieved, 592 duplicate articles were excluded, 372 articles were excluded after reading the title and abstract, 87 articles were excluded from non-randomized control and irrelevant outcome indicators, and 7 studies with 2343 patients were finally included. Use RevMan5.3 software to compare the changes in 24-hour ambulatory blood pressure, day and night blood pressure of patients with type 2 diabetes and hypertension before and after treatment with different types and doses of SGLT2i. Results: A total of four types of SGLT-2i were evaluated in the application of patients with type 2 diabetes and hypertension. The result showed that compared with placebo,SGLT2i could reduce the 24-hour systolic blood pressure of patients with type 2 diabetes and hypertension by 4.36mmHg (95%CI -5.92--2.79,p &lt; 0.001),among which the antihypertensive effects of empagliflozin, canagliflozin, dapagliflozin and ertugliflozin were -4.59mmHg, -3.74mmHg, -5.06mmHg, -3.64mmHg, respectively; similarly, the 24-hour dynamic diastolic blood pressure decreased by 2.20mmHg (95%CI -2.74, -1.65,p &lt; 0.001), among which the antihypertensive effects of empagliflozin, canagliflozin, dapagliflozin and ertugliflozin were -2.38mmHg, -1.22mmHg, -2.00mmHg,- 2.69mmHg, respectively. At the same time, the systolic and diastolic blood pressure during the day and night decreased significantly. Conclusions: his meta-analysis shows that SGLT2i can have beneficial effects on the cardiovascular system by reducing 24-hour ambulatory blood pressure in patients with type 2 diabetes and hypertension, other than reducing blood sugar. Therefore, for patients with type 2 diabetes and hypertension, SGLT2i may be the best hypoglycemic choice.

MO088: Peridialytic and Intradialytic Blood Pressure Measurements are Not Valid Estimates of 44-Hour Ambulatory Blood Pressure in Patients With Intradialytic Hypertension

Abstract BACKGROUND AND AIMS In contrast with pre- and post-dialysis blood pressure (BP), intradialytic and home BP measurements are accurate metrics of ambulatory BP load in hemodialysis patients. This study assessed the agreement of peridialytic, intradialytic and scheduled interdialytic recordings with 44-h interdialytic BP in a distinct hemodialysis population, patients with intradialytic-hypertension (IDH). METHOD 45 patients with IDH (defined as: SBP rise ≥ 10 mmHg from pre- to post-dialysis and post-dialysis SBP ≥ 150 mmHg) with valid 48-h ABPM and 197 without IDH were included in this analysis. With 44-h BP used as reference method, we tested the accuracy of the following BP metrics: Pre- and post-dialysis, intradialytic, intradialytic plus pre/post-dialysis readings and scheduled interdialytic BP (out-of-dialysis day: readings at 8:00 am, 8:00 pm or their average). RESULTS In patients with IDH, peri-dialytic and intradialytic BP metrics showed at best moderate correlations, while averaged-interdialytic-SBP/DBP exhibited strong correlation (r = 0.882/r = 0.855) with 44-h SBP/DBP. Bland-Altman plots showed large between-method difference for peri- and intradialytic BP, but only + 0.7 mmHg between-method difference and good 95% limits-of-agreement for averaged-interdialytic-SBP. The sensitivity/specificity and κ-statistic for diagnosing 44-h SBP ≥ 130 mmHg were low for pre-dialysis (72.5%/40.0%, κ-statistic = 0.074) and post-dialysis (90.0%/0.0%, κ-statistic = −0.110), intradialytic (85.0%/40.0%, κ-statistic = 0.198) and intradialytic plus pre/post-dialysis SBP (85.0%/20.0%, κ-statistic = 0.043). Averaged-interdialytic-SBP showed high values of sensitivity/specificity (97.5%/80.0%) and strong agreement (κ-statistic = 0.775). In ROC-analyses, the peri- and intradialytic BP metrics showed bad performance with low Area-Under-the-Curve values; scheduled interdialytic SBP/DBP had the largest AUC (0.967/0.951), along with the highest sensitivity(90.0%/88.0%) and specificity(100.0%/90.0%) for detecting elevated 44-h BP. CONCLUSION In patients with IDH, averaged-scheduled-interdialytic but not pre- and post-dialysis, nor intradialytic BP recordings show reasonable agreement with ambulatory BP. Interdialytic BP recordings only could be used for hypertension diagnosis and management in these subjects.

Effects of Vitamin D Supplementation on 24-Hour Blood Pressure in Patients with Low 25-Hydroxyvitamin D Levels: A Randomized Controlled Trial.

Accumulating evidence suggests that potential cardiovascular benefits of vitamin D supplementation may be restricted to individuals with very low 25-hydroxyvitamin D (25(OH)D) concentrations; the effect of vitamin D on blood pressure (BP) remains unclear. We addressed this issue in a post hoc analysis of the double-blind, randomized, placebo-controlled Styrian Vitamin D Hypertension Trial (2011–2014) with 200 hypertensive patients with 25(OH)D levels <30 ng/mL. We evaluated whether 2800 IU of vitamin D3/day or placebo (1:1) for 8 weeks affects 24-hour systolic ambulatory BP in patients with 25(OH)D concentrations <20 ng/mL, <16 ng/mL, and <12 ng/mL and whether achieved 25(OH)D concentrations were associated with BP measures. Taking into account correction for multiple testing, p values < 0.0026 were considered significant. No significant treatment effects on 24-hour BP were observed when different baseline 25(OH)D thresholds were used (all p-values > 0.30). However, there was a marginally significant trend towards an inverse association between the achieved 25(OH)D level with 24-hour systolic BP (−0.196 per ng/mL 25(OH)D, 95% CI (−0.325 to −0.067); p = 0.003). In conclusion, we could not document the antihypertensive effects of vitamin D in vitamin D-deficient individuals, but the association between achieved 25(OH)D concentrations and BP warrants further investigations on cardiovascular benefits of vitamin D in severe vitamin D deficiency.

Therapeutic Phlebotomy in Patients with Grade 1 Hypertension: A Randomized-Controlled Trial.

Aim: Study aim was to investigate the effects of therapeutic phlebotomy on ambulatory blood pressure in patients with grade 1 hypertension. Methods: In this randomized-controlled intervention study, patients with unmedicated hypertension grade 1 were randomized into an intervention group (phlebotomy group; 500 mL bloodletting at baseline and after 6 weeks) and a control group (waiting list) and followed up for 8 weeks. Primary endpoint was the 24-h ambulatory mean arterial pressure between the intervention and control groups after 8 weeks. Secondary outcome parameters included ambulatory/resting systolic/diastolic blood pressure, heart rate, and selected laboratory parameters (e.g., hemoglobin, hematocrit, erythrocytes, and ferritin). Resting systolic/diastolic blood pressure/heart rate and blood count were also assessed at 6 weeks before the second phlebotomy to ensure safety. A per-protocol analysis was performed. Results: Fifty-three hypertension participants (56.7 ± 10.5 years) were included in the analysis (n = 25 intervention group, n = 28 control group). The ambulatory measured mean arterial pressure decreased by -1.12 ± 5.16 mmHg in the intervention group and increased by 0.43 ± 3.82 mmHg in the control group (between-group difference: -1.55 ± 4.46, p = 0.22). Hemoglobin, hematocrit, erythrocytes, and ferritin showed more pronounced reductions in the intervention group in comparison with the control group, with significant between-group differences. Subgroup analysis showed trends regarding the effects on different groups classified by serum ferritin concentration, body mass index, age, and sex. Two adverse events (AEs) (anemia and dizziness) occurred in association with the phlebotomy, but no serious AEs. Conclusions: Study results showed that therapeutic phlebotomy resulted in only minimal reductions of 24-h ambulatory blood pressure measurement values in patients with unmedicated grade 1 hypertension. Further high-quality clinical studies are warranted, as this finding contradicts the results of other studies.

Hypertensive Phenotypes and Pattern of Ambulatory Blood Pressure in Patients of Diabetes Mellitus of Kashmir Valley.

Background:Patients of diabetes mellitus (DM) with hypertension (HTN) have a fourfold increased risk of cardiovascular disease (CVD) as compared to normotensive nondiabetic controls. However, many patients of DM who are normotensive or have controlled blood pressure on office BP measurement (OBPM) may assume that they do not have increased risk of CVD but may be having HTN or uncontrolled blood pressure on ambulatory blood pressure monitoring (ABPM).Study Design Objective:A cross-sectional observational study to compare OBPM with ABPM and thus predict various hypertensive phenotypes like masked hypertension (MH) and white coat hypertension and pattern of blood pressure in diabetic patients of our population.Materials and Methods:Two hundred patients of DM with or without HTN were included in this study. The cases were subjected to detailed history, clinical examination, OBPM, and ABPM.Results:Out of 200 patients of DM, 32 were normotensives, 46 were hypertensives controlled on antihypertensive treatment, 22 were hypertensives not on anti-hypertensive treatment, and 100 were hypertensives uncontrolled on anti-hypertensive treatment. Among 32 normotensive diabetics, 17 (53%) patients had MH on ABPM. Out of these 32 normotensive patients, 7 (21.8%) had isolated nocturnal hypertension, 3 (9.3%) had isolated day-time HTN (IDH) and 7 (21.8%) had day-time and nocturnal HTN (DNH). Patients with MH had higher BMI, an observation that was statistically significant. Non-dipping pattern was found in 53% of patients of masked HTN. Out of 46 hypertensive diabetics with controlled OBPM on antihypertensive treatment, 26 (56.5%) had masked effect or masked uncontrolled hypertension on ABPM. Out of 22 diabetics with treatment naïve HTN, 7 (32%) were found to have white coat hypertension on ABPM. Fifteen (15%) patients out of 100 hypertensive diabetics with uncontrolled OBPM despite on anti-hypertensive were found to have white coat effect on ABPM. Patients with white coat effect had higher body mass index an observation that was statistically significant (p = 0.039). Non-dipping pattern was significantly associated with longer duration of diabetes (≥ 120 months), retinopathy and neuropathy.Conclusion:To rely exclusively on OBPM to diagnose HTN and monitor blood pressure may underestimate the CVD risk especially in diabetics. ABPM is a tool that may not only help clinicians in starting anti-HTN treatment perspicuously, but also may help in avoiding unnecessary anti-hypertensive treatment and/or withdrawing anti-hypertensive treatment as indicated and thus avoiding credulity.

Acute Aerobic Exercise Induces Short-Term Reductions in Ambulatory Blood Pressure in Patients With Hypertension: A Systematic Review and Meta-Analysis.

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