Ambulatory Blood Pressure Measurements Research Articles

CORRELATION BETWEEN CLINIC AND AMBULATORY BLOOD PRESSURE MEASUREMENT

Objective: Blood pressure (BP) measurements taken in the clinic provide limited information about the BP load. Ambulatory blood pressure monitoring (ABPM) provide a more comprehensive assessment of blood pressure over the course of a day. This study examined the correlation between clinic and ambulatory BP measurements. Design and method: We collated clinic and 24 hour ambulatory BP data of 100 patients aged > 18 years from the outpatient cardiology clinic of Mohamed Taher Maamouri University hospital in Nabeul (n = 100) over a six months period (July-December 2021). Laying of ABPM was performed using a Bravo Mini validated device from Sun Tech Medical. We used the Pearson correlation coefficient (r) to measure the strength of the relationship between these two measurements methods. Results: The mean age of our population was 59.14±13.12 years (range 21-92 years), composed of 47 women and 53 men. The most frequent reason for carrying out ABPM was the monitoring of hypertensive patients in 84% of cases, 16% were done to confirm the diagnosis of hypertension. ABPM confirmed the diagnosis of hypertension in 62.5% and detected 18.75% isolated nocturnal hypertension in patients with suspected hypertension and 14.3% masked uncontrolled nocturnal hypertension in hypertensive patients. Concordance was found in 66% of cases between clinic measurement and the 24-hour ABPM data. There was a weak correlation between clinic systolic BP and 24-hour ambulatory systolic BP (P <0.001; r = 0.349; Curve A) and moderate correlation between clinic diastolic BP and 24-hour ambulatory diastolic BP (P <0.001; r = 0.566; Curve B). Conclusions: The correlation between these two methods isn’t important mainly explained by variation of BP especially at night detected by ABPM which remains the reference method for diagnosing and monitoring hypertension

SEASONAL EFFECT ON BLOOD PRESSURE VARIABILITY IN HYPERTENSIVE PATIENTS ASSESSED BY DIFFERENT MEASUREMENT METHODS

Objective: The seasonal variation in temperature is well known to affect the level of blood pressure (BP). However, its impact on BP variability is uncertain. This study investigated the seasonal variation in BP variability in hypertensive patients assessed using office and out-of-office BP measurements. Design and method: Adult hypertensives on stable antihypertensive drug treatment were assessed with office (OBP), home (HBP), and ambulatory BP (ABP) measurements in winter, next summer, and in the next winter. BP variability was quantified using the standard deviation (SD) and coefficient of variation (CV). Results: Fifty-eight participants had complete data for winter and summer (mean age 65.2±7.9 [SD], 64% males, 21% obese, 48% smokers, 11% diabetes, 18% cardiovascular disease, 28% on a single antihypertensive drug, 38% on 2 drugs, 34% on > 2 drugs). OBP, HBP and daytime ABP were lower in summer than in winter (P<0.01), whereas nighttime ABP was unchanged (P = NS) (Figure). SD and CV for systolic OBP were higher in winter than summer (P<0.01/<0.05, respectively). BP variability assessed by HBP and ABP measurement did not differ in winter and summer (Figure). Forty participants had complete data for winter-summer-next winter. OBP, HBP and daytime ABP were higher in the second winter compared with summer excluding any order effect. Respective CV values showed no difference (p = NS). Conclusions: These preliminary data suggest that despite the considerable impact of seasonal changes in temperature on the levels of BP, its variability is not affected. Thus, variability appears to be an intrinsic feature of the individual's BP behaviour, which is largely unaffected by extrinsic seasonal factors.

RESULTS OF SIMULTANEOUS LEFT AND RIGHT UPPER ARM 24-HOUR AMBULATORY BLOOD PRESSURE MEASUREMENT: A WAKE UP-CALL FOR BETTER HYPERTENSION MANAGEMENT

Objective: Cuff-based 24-hour ambulatory blood pressure (BP) measurement is considered as the gold standard for hypertension diagnosis and treatment monitoring, its clinical value being ubiquitously accepted. This study wants to quantify the measurement discrepancies in simultaneous and synchronized 24-hour ambulatory BP measurements on both arms. Identifying and understanding measurement uncertainties could improve future hypertension management and further stimulate research on alternative, cuff-less systems with adequate measurement precision. Methods: We conducted simultaneous 24-hour ambulatory BP measurements on both arms in 52 healthy young adults. Broadly used and validated cuff-devices (BoSo TM-2430) were synchronized to start BP measurement within one second of each other. Further, we recorded cuff-pressures of both cuff-based devices and the hydrostatic pressure differences between both cuffs throughout the recording. We then scored pressure curves for disturbances (e.g., pressure spikes during deflation) and were able to correct measurements for hydrostatic differences between the arms. This enabled us to not only quantify the extent of measurement inaccuracy but to describe its origins and possible countermeasures. Design and method: Measured BP levels from left and right arm showed limits of agreement in the Bland Altman Plot of > 33 mmHg for systolic and > 30 mmHg for diastolic values over 24 h. Daytime values deviated more than nocturnal values (systolic: > 35 mmHg vs. > 27 mmHg systolic, and diastolic: > 32 mmHg vs. > 24 mmHg, respectively). Linear regression retrieved R2 = 0.39 (p < 0.001) for systolic and R2 = 0.20 (p < 0.001) for diastolic values. Exclusion of artefactual cuff pressure curves improved limits of agreement to > 23 mmHg for systolic and > 19mmHg for diastolic measurements. Subsequently, it improved correlation coefficients to R2 = 0.54 (p < 0.001) for systolic and R2 = 0.35 (p < 0.001) for diastolic values. Correction of hydrostatic differences between the arms had a negligible effect on limits of agreement and strength of correlation. Results: Comparison of synchronized 24-hour BP measurements obtained on both arms showed large measurement uncertainties with possible implications on clinical grading of hypertension and dipping pattern. Exclusion of artefactual cuff pressure curves, not detected by the conventional software of BP devices, mitigates the effect but cannot eliminate worrying discrepancies. These results strongly support the need to further investigate the clinical implications of BP measurement uncertainty. They should further stimulate research on alternative means of BP measurement which might overcome some of the problems related to cuff-based BP monitoring.

RELATION BETWEEN WAIST CIRCUMFERENCE AND THE RENAL HEMODYNAMIC IN PATIENTS WITH UNCOMPLICATED HYPERTENSION GRADE 1-2

Objective: Abdominal adiposity, measured by waist circumference (WC), is associated with increased mortality in patients with hypertension. Little is known about the impact of abdominal obesity on the renal perfusion and function in patients with hypertension. We analyzed whether abdominal adiposity changes renal hemodynamics in 36 patients with uncomplicated hypertension grade 1-2 without other cardiovascular (CV) disease. Design and method: We analysed the renal hemodynamic using steady state input clearance with infusion of para-aminohippuric acid and inulin, respectively. Intraglomerular pressure and resistances of the afferent (RA) and efferent (RE) arterioles were calculated according to the Gomez equation. The study population was divided in into two groups based on median of WC of the total study population. Results: The study cohort consisted of 36 male, non-smoking individuals, aged 36 ± 10 years with mean WC of 96.1 ± 10.4 cm and mean BMI of 27 ± 3.8 kg/m2. True hypertension was confirmed using 24-hour ambulatory blood pressure (BP) measurement. Patients in the high WC group (19 patients) showed mean office BP of 145/ 90 mmHg and mean 24-hour ambulatory BP of 139/ 86 mmHg, whereas patients in the low WC group (17 patients) showed mean office BP of 144/ 88 mmHg and mean 24-hour-ambulatory BP of 140/ 86 mmHg (office BP: p = 0.895/ p = 0.662, 24-hour-ambulatory BP: p = 0.645/ p = 0.918). Renal vascular resistance and RA were higher in the high WC compared to the low WC group, whereas glomerular filtration rate and renal plasma flow were lower in the high WC compared to the low WC group (table 1). Conclusions: Higher WC in young, male patients with hypertension grade 1-2 without other cardiovascular disease was associated with increased renal vascular resistance predominantly at the afferent site leading to reduced glomerular filtration rate.

RELATIONSHIPS OF OFFICE, AMBULATORY, AND HOME BLOOD PRESSURE WITH ORGAN INJURY BIOMARKERS

Objective: International guidelines recommend out-of-office blood pressure (BP) monitoring including ambulatory and home BP. Although the superiority of ambulatory and home BP is controversial, home BP is more prevalent in plactice and there is a gap with the guidelines. We assessed this issue by conducting the analysis of relationship of BP with clinical biomarkers. Design and method: We analyzed the relationship of office, ambulatory, and home BP with organ injury biomarkers including urine-albumin creatinine ratio (UACR), serum b-type natriuretic peptide (BNP), serum high-sensitive troponin T (hsTnT), echocardiographic left ventricular mass index (LVMI), and brachial-ankle pulse wave velocity (baPWV) in 1,172 outpatients who underwent both ambulatory and home BP measurements and examined serum and urine tests and others. Results: In the univariate analysis of Pearson's correlation, average of morning and evening home systolic BP (SBP) was strongly related with log-transformed BNP, log-transformed hsCRP, LVMI, and baPWV compared with 24-h ambulatory systolic BP (log-transformed UACR [n = 1432], r = 0.24 in home SBP versus r = 0.18 in ambulatory SBP, P = 0.17 in z-test for comparison of these correlations; log-transformed BNP [n = 1432], r = 0.17 vs. r = -0.04, P<0.01; log-transformed hsTnT [n = 1092], r = 0.19 vs. r = -0.03, P<0.01; LVMI [n = 1036], r = 0.23 vs. r = 0.10, P<0.01; baPWV [n = 1361], r = 0.31 vs. r = 0.08, P<0.01). In the multivariable linear regression models for log-transformed BNP, log-transformed hsTnT, and LVMI, the model-fit were improved when adding home SBP to the model including 24-h ambulatory SBP, but these relationships were not shown in vice versa. In addition, we also used Structural Equation Modeling for assessment of relationship of office, ambulatory, and home SBP with clinical biomarkers. Conclusions: Our findings suggested the superiority of home BP in the relationship with several biomarkers for hypertensive organ damage compared with ambulatory BP, which may provide a rationale for the management on hypertension using home BP monitoring in clinical practice conducted in many countries including Japan.

REPRODUCIBILITY AND PREDICTIVE VALUE OF WHITE COAT HYPERTENSION IN YOUNG TO MIDDLE AGE SUBJECTS

Objective: The reproducibility and the prognostic value of white-coat hypertension (WCH) is still debated. The aim of the study was to investigate the reproducibility of WCH assessed twice within 3 months and its predictive capacity for development of hypertension needing antihypertensive treatment (HT) in young-to-middle-age subjects screened for stage 1 hypertension. Design and method: We investigated 1096, 18-to-45-year old subjects from the HARVEST. Office BP and 24hour BP were measured at baseline and after 3 months. On the basis of BPs measured after 3 months, 132 participants were classified as normotensive, 159 as WCH, 195 as masked hypertensive and 610 as sustained hypertensive. The reproducibility of WCH, office hypertension, and ambulatory hypertension was evaluated with Kappa statistics. The predictive capacity of WCH defined with a single assessment or with double assessment was tested in multivariate Cox models (N = 1054). Results: Baseline WCH was confirmed at 3-month assessment in only 33.3% of participants, whereas 31.6% became normotensive, 8.8% masked hypertensive and 26.3% sustained hypertensive. Reproducibility evaluated with weighted Kappa was fair (0.27, 95%CI 0.20 - 0.37) for WCH, poor (0.14, 95%CI 0.09 - 0.19) for office Hypertension (BP> = 140/90 mmHg), and moderate (0.47, 95%CI 0.41 - 0.53) for ambulatory Hypertension (24hBP> = 130/80 mmHg). During 17.4 years of follow-up, 80.5% of participants developed HT. WCH assessed either at baseline (p = 0.86) or after 3 months (p = 0.16) was not a significant predictor of future HT. However, participants who had WCH both at baseline and after 3 months (N = 76) had an increased risk of HT compared to the normotensives (Hazard ratio, 1.50, 95%CI 1.06 - 2.13, p = 0.022). HRs were 1.35 (95%CI 1.02 - 1.80, p = 0.037) in participants with masked hypertension and 1.52 (95%CI 1.19 - 1.95, p < 0.001) in those with sustained hypertension. Conclusions: These results show that in young-to-middle-age individuals, WCH was confirmed in only one third of people at repeat assessment. This was mainly due to a poor reproducibility of office hypertension. WCH diagnosed with two but not with one BP assessment showed an increased risk of future HT. Our data indicate that people with WCH at first assessment should undergo a second set of ambulatory and office BP measurements before clinical decisions are made.

SUBCLINICAL TARGET ORGAN DAMAGE IN A SAMPLE OF CHILDREN WITH SOLITARY FUNCTIONING KIDNEY. A PRELIMINARY OBSERVATIONAL STUDY

Objective: Solitary Functioning Kidney (SFK) is a condition characterized by a single-functioning kidney. Children bearing this condition are exposed to an increased risk of subclinical organ damage (SOD) due to the compensatory hyperfiltration in the remaining kidney and increased peripheral blood pressure (pBP) values. The aim of the present study was to assess the impact of traditional (pBP) and novel (central systolic blood pressure, cSBP) cardiovascular risk factors on SOD in children and adolescents with solitary functional kidney. Design and method: Carotid ultrasonography was performed to measure carotid Intima-Media Thickness (cIMT), an index of subclinical atherosclerosis. Arterial stiffness was assessed by measuring carotid Distensibility Coefficient (cDC) and carotid-femoral Pulse Wave Velocity (PWV). Cardiac mass and remodeling were analyzed using transthoracic echocardiography. Central and peripheral (both office and ambulatory) BP measurements, as well as biochemical data from blood and urine samples were collected. Results: Forty-eight SFK children and adolescents were included, of whom 45.5% were hypertensive at the Ambulatory Blood Pressure Monitoring. Twenty-four patients had increased cIMT and RWT while 8.4% and 8.9% demonstrated a reduction of cDC and an increase of PWV. Two patients had a left ventricular mass index (LVMi) above the 95th percentile. cSBP correlated with all vascular indices measured (cIMT r = 0.43; cDC r = -0.33; PWV r = 0.42, p < 0.05) and with LVMi (r = 0.41; p = 0.005). Office pSBP correlated with cDC (r = -0.31; p = 0.03), PWV (r = 0.42 and p = 0.004) and LVMi (r = 0.33; p = 0.02). Regarding ABPM measurements, daytime systolic BP correlated with all vascular indices (cIMT r = 0.34, cDC r = -0.31, PWV r = 0.39 p < 0.005) but not with echocardiographic ones. No correlation was found between cardiovascular parameters and the estimated glomerular filtration rate or the urinary albumin to creatinine ratio. Conclusions: Our data show a high prevalence of subclinical atherosclerosis and cardiac remodeling in children and adolescents with SFK. A lesser proportion of patients presented an increased arterial stiffening. cSBP more than pBP (office or ambulatory) associates with SOD. Children with SFK could bear a greater cardiovascular risk pointing out the importance of early preventive efforts.

IMPACT OF THE NUMBER OF OFFICE VISITS ON DIAGNOSING HYPERTENSION PHENOTYPES IN YOUNG INDIVIDUALS

Objective: To investigate the impact of measuring office blood pressure (BP) in an increasing number of visits on diagnosing hypertension phenotypes in young individuals. Design and method: Young individuals referred for elevated BP and healthy volunteers aged 6-25 years were evaluated with office BP measurements (3 visits; triplicate measurements; average of the last 2) and 24-hour ambulatory BP monitoring (ABP). Normotension (NT) was defined as normal office and ABP; Sustained hypertension (HT) as elevated office and ABP; White-coat hypertension (WCH) as elevated office but normal ABP; Masked hypertension (MH) as normal office with elevated ABP. Results: Analysis included 273 individuals (mean age 13.9±3.8 years, 69.6% males, BMI 24.6±4.8 kg/m2). Average office BP at 1st visit was 122.0±16.4/72.9±10.7 mmHg, systolic/diastolic, average of first 2 visits 120.6±15.4/72.3±10.2 and average of 3 visits 119.8±15.1/72.0±9.7 mmHg. The prevalence of NT, HT, MH and WCH was: 1st visit 55/17/8/20% respectively; average of first 2 visits 61/16/10/13%; average of 3 visits 63/15/11/11% respectively. The agreement between the 1st and the average of 1st-2nd visit was 92% for NT diagnosis (kappa = 0.83), 98% for HT (kappa = 0.92), 98% (kappa = 0.87) for MH and 92% for WCH (kappa = 0.70). The agreement between the 1st visit and the average of all 3 visits was 91% for NT (kappa = 0.81), 97% for HT (kappa = 0.89), 97% for MH (kappa = 0.83) and 91% for WCH (kappa = 0.64). Last, the agreement between ABP and office BP measurements for BP elevation was 72% for the 1st visit (kappa = 0.35), 77% for the average of the 1st-2nd visit (kappa = 0.41) and 78% for the average of 3 visits (kappa = 0.44). Conclusions: These findings suggest that in young individuals at least 2 office visits are required for optimal office BP evaluation which has reasonable agreement with ABP.

PRESCRIPTION OF SINGLE-PILL ANTIHYPERTENSIVE COMBINATION THERAPY

Objective: The need for polytherapy is common among people affected by arterial hypertension (AH). A single-pill combination is a response to decreased medication adherence, especially in elderly people often suffering from more than one disease, which tends to improve blood pressure control and cardiovascular outcomes. The aim of our study was to determine the frequency of use of a single-pill antihypertensive combination (SPC) therapy and possible differences in presence of comorbidities. Design and method: 324 hypertensive participants on pharmacological treatment were included in this research, of which 51.2% were men, and with an overall median age of 64 years (IQR = 17). For each participant undergoing 24-hour ambulatory blood pressure measurement, data about pharmacological therapy, weight, height and comorbidities such as chronic kidney disease (CKD) and diabetes mellitus (DM) were obtained from their most recent medical records combined with self reports. Body mass index (BMI) was calculated. Results: 148 (45.7%) participants were prescribed a SPC. Participants taking a SPC had lower presence of CKD (23.7% with CKD vs. 76.3% without CKD, p<0.001). No significant difference was found in the presence of DM (p = 0.496). Another interesting finding was more frequent use of SPC therapy among patients with higher BMI (p = 0.029). Conclusions: The results show that less than half of the participants in our study were prescribed an SPC. From this we can conclude that more attention should be paid to educating people about the options for antihypertensive treatment and simplifying therapy regimen. Another point we should highlight is the limited availability of SPCs in the treatment of hypertension in patients suffering from CKD.

MEDICATION ADHERENCE AND GENDER DIFFERENCE IN HYPERTENSIVE PATIENTS

Objective: One of the major clinical problems in the management of arterial hypertension (AH) is adherence to the medical regimen. Failure to adhere affects not only patients causing disease progression, reduced functional abilities as well as lower quality of life, but also the healthcare system due to medication waste and increased hospital visits and admissions. Data about hypertensive medication adherence in our region are lacking. Therefore, we aimed to assess medication adherence in our hypertensive patients in order to identify possible strategies to improve and enhance mentioned adherence. Design and method: This study included 324 participants with AH, of which 51.2 % were men, and with an overall median age of 64 years (IQR = 17). Along with the 24-hour ambulatory blood pressure measurement, each patient completed a medication adherence questionnaire, Morisky Medication Adherence Scale (MMAS-8). This self-reported questionnaire consists of 8 questions with a total score ranging from 0 to 8 and a lower score indicates lower adherence to the prescribed pharmacological antihypertensive therapy. Results: 51 (15.7%) participants had low, 114 (35.2%) had moderate and 159 (49.1%) had high medication adherence. There was no significant difference in MMAS-8 score regarding age (p = 0.334), however, men were found to have -higher adherence to antihypertensive therapy than women (58.5% vs. 41.5% had high adherence, respectively, p = 0.018). Conclusions: The results of our study showed that more than half of our hypertensive patients (50.9%) are not completely adherent to antihypertensive medication. Among all of them women were found to have lower adherence compared to men. Low medication adherence could lead to substantial worsening of disease as well as increased health care costs in care of hypertensive patients. Therefore, the presented results highlight the need for patient education and support to increase patient adherence in order to reduce cardiovascular risk.

USEFULNESS OF AMBULATORY BLOOD PRESSURE MEASUREMENTS IN HAEMODIALYSIS PATIENTS: A MONOCENTRIC CROSS-SECTIONAL STUDY EXTENDED TO A 5- YEAR FOLLOW-UP

Objective: Blood pressure (BP) control in haemodialysis (HD) patients is crucial given their very high cardiovascular risk. Per-dialytic BP levels do not accurately predict the cardiovascular mortality. Here, we compare the prognostic yield of 2 ambulatory BP measurement techniques in prevalent HD patients. Design and method: We recruited adult patients who had been on chronic HD for more than 3 months. Seven-day home BP monitoring (HBPM) (values of Day 1 discarded) and 44-h interdialytic ambulatory BP monitoring (iABPM) were performed. Pre- and post-dialysis BP levels were measured during the 6 dialysis sessions prior to iABPM. A 5-year follow-up was carried out to assess all-cause and cardio-vascular mortality. Results: We recruited 43 patients including 15 women. Mean age was 68.3±13 years, mean body mass index was 24.1±3.8 kg/m2, median dialysis vintage was 2.4 years [0.25;11], and 67% of patients were under anti-hypertensive medications. In patients considered as normotensive in pre-dialysis (n = 17), masked hypertension was found in 24% (11.6% of the entire cohort) and 29%, based on iABPM and HBPM, respectively. Conversely, among hypertensive patients in pre-dialysis (n = 26), “white-coat” hypertension was noted in 23% (14% of the entire cohort), either by iABPM or HBPM. In treated hypertensive patients, ambulatory techniques detected a higher proportion of uncontrolled hypertension (76% of cases in iABPM and HBPM) compared to pre-dialysis measurements (65% of cases). Focusing on the first 24 hours of iABPM underestimated the proportion of hypertensive patients (49% of the entire cohort) compared to the 44-h coverage (58% of the entire cohort). Restricting HBPM for only 3 days decreased the concordance with iABPM from 86% (k = 0.79) to 76.7% of cases (k = 0.67). After a 5-year follow-up, 25 patients were deceased including 6 patients from cardiovascular causes. All-cause mortality was associated in an adjusted model for age and gender with day-time systolic BP measured by iABPM (p = 0.045). Conclusions: In chronic HD patients, 44-h iABPM and 7-day HBPM show a reliable concordance and help to re-classify ∼25% of cases miscategorised on the basis of pre-dialysis measurements. Day-time systolic BP levels using iABPM were significantly associated with 5-year all-cause mortality.

CHANGES IN AMBULATORY BLOOD PRESSURE DURING THE TRANSITION TO RETIREMENT

Objective: Retirement is a major life event characterized by removal of work-related stressors and changes in health behaviours. The association between retirement and changes in blood pressure (BP), and particularly in ambulatory BP, has been scarcely studied. We aimed to examine changes in ambulatory BP during retirement transition. Design and method: Two hundred and fifty ageing workers (mean age 63.2 years, 84% women) from the Finnish Retirement and Aging study participated in annual office BP measurements and 114 (mean age 63.1, 90% women) of them underwent annual ambulatory BP measurements before and after retirement. On average, the participants provided data on ambulatory BP at 2.7 (range 2 - 4) measurements. We used generalized linear models to examine BP changes at retirement. The FIREA study was conducted in accordance with the Helsinki declaration and was approved by the Ethics Committee of Hospital District of Southwest Finland (ETMK: 84/1801/2014). All participants gave written informed consent. Results: Most marked changes in BP during the follow-up were observed for asleep SBP, which decreased before retirement, increased during retirement transition and plateaued after retirement (before retirement vs. retirement transition P = 0.07 and after retirement vs. retirement transition P = 0.02). Awake SBP and 24-h SBP declined with most apparent decrease before retirement (before retirement vs. retirement transition P = 0.07 and P = 0.07). Awake DBP and 24-h DBP showed relatively consistent decline throughout the follow-up with no differences between the time periods. SBP and DBP dipping reduced before and during retirement transition, but not after retirement. Among shift workers, asleep BP increased and BP dipping decreased more than in regular day workers. Conclusions: Retirement was found to associate with beneficial changes in awake BP but unfavourable changes in asleep BP, especially in shift workers.

PROGRESSION OF HYPERTENSION-MEDIATED ORGAN DAMAGE IN PATIENTS WITH AND WITHOUT NONALCOHOLIC FATTY LIVER DISEASE

Objective: Nonalcoholic fatty liver disease (NAFLD) is the main cause of chronic liver disease and is associated with an increased risk of cardiovascular death. Fatty liver index (FLI) is a validated marker of NAFLD and can be used as a screening measure of hepatic steatosis. The purpose of the study was to compare the progression of hypertension-mediated organ damage (HMOD) in hypertensive patients with and without NAFLD. Design and method: Hypertensive patients (n = 60) without a history of cardiovascular disease participated in the study (mean age, 52 years; males, 55%; baseline clinic BP, 145/92 mmHg) and were followed for one year. In the baseline visit, FLI was calculated, and patients were divided into two groups by FLI below 60 or 60 or above (i.e., high-risk of NAFLD). All patients underwent clinic and 24-hour ambulatory BP measurements, echocardiographic examination, nailfold capillaroscopy, pulse wave velocity, and urinary albumin excretion assessment (albumin to creatinine ratio, [ACR]). Left ventricular mass index (LVMI) was also calculated using the Devereux formula. Results: In baseline visit, patients with FLI > or = 60 (n = 32) compared to the control group had higher values of ACR (26.5±57mg/g vs. 9.6±6.3 mg/g, p = 0.02) and lower values of capillary densities (75±18cap/mm2 vs. 86±12cap/mm2, p = 0.002), whereas there was no relative difference in PWV and LVMI. At the end of follow-up, patients with FLI > or = 60 had higher values of ACR (12.6±11.9 mg/g vs. 6.8±5.3 mg/g p = 0.025), PWV (9.9±2m/sec vs. 8.8±1.3 m/sec, p = 0.02), LVMI (81.4±13.2 g/m2 vs. 72.5±13.2 g/m2, p = 0.02) but lower number of capillaries (65.1±8.8 cap/mm2 vs. 79.6±7.5 cap/mm2, p<0.001). Linear regression analysis revealed that FLI > or = 60 was an independent determinant of follow-up ACR, PWV, LVMI, and the number of capillaries. Conclusions: Increased FLI may adversely modify the progression of HMOD in hypertension.

Metabolic syndrome as risk factor for left ventricular hypertrophy in children with chronic kidney disease.

The metabolic syndrome (MS), a cluster of clinical and biochemical abnormalities including insulin resistance, dyslipidemia and hypertension, is often diagnosed in chronic kidney disease (CKD) children. Left ventricular hypertrophy (LVH) is a major target organ damage in hypertension and an important cardiovascular risk factor in CKD patients. We aimed to identify the most significant risk factors of LVH in children with CKD. Children with CKD stage 1-5 were enrolled in the study. MS was diagnosed according to De Ferranti (DF) as ≥3 from 5 criteria. Ambulatory blood pressure measurements (ABPM) and echocardiographic evaluation were performed. LVH was defined as ≥95th percentile of LV mass index related to height and age. Clinical and laboratory parameters included: serum albumin, Ca, HCT, cystatin C, creatinine, estimated glomerular filtration rate (eGFR) based on Schwartz formula, triglycerides, high-density lipoprotein (HDL), proteinuria, BMI standard deviation score (SDS), height SDS, waist circumference, ABPM data. 71 children (28 girls/43 boys) with median age 14.05 (25%-75%:10.03-16.30) years and median eGFR 66.75 (32.76-92.32) ml/min/1.73m2 were evaluated. CKD stage 5 was diagnosed in 11 pts (15.5%). MS (DF) was diagnosed in 20 pts (28.2%). Glucose ≥ 110 mg/dL was present in 3 pts (4.2%); waist circumference ≥75th pc in 16 pts (22.5%); triglycerides ≥ 100 mg/dL in 35 pts (49.3%); HDL < 50mg/dL in 31 pts (43.7%) and BP ≥ 90th pc in 29 pts (40.8%), respectively. LVH was detected in 21 (29.6%) children. In univariate regression the strongest risk factor for LVH was CKD stage 5 (OR 4.9, p=0.0019) and low height SDS (OR 0.43,p=0.0009). In stepwise multiple logistic regression analysis (logit model) of the most important risk factors for LVH in CKD children, only three were statistically significant predictors: 1)MS diagnosis based on DF criteria (OR=24.11; 95%CI 1.1-528.7; p=0.043; Chi2=8.38,p=0.0038); 2), high mean arterial pressure (MAP SDS) in ABPM (OR=2.812; 95%CI 1.057-7.48; p=0.038;Chi2=5.91, p=0.015) and 3) low height SDS (OR=0.078; 95%CI 0.013-0.486;p=0.006; Chi2=25.01, p<0.001). In children with chronic kidney disease LVH is associated with the cluster of multiple factors, among them the components of MS, hypertension, stage 5 CKD and growth deficit were the most significant.

The Prognostic Role of Automated Office Blood Pressure Measurement in Hypertensive Patients with Chronic Kidney Disease.

The aim of this study was to evaluate the prognostic value of automated office blood pressure (AOBP) measurement in patients with hypertension and chronic kidney disease (CKD) stage 3-5 not on dialysis. At baseline, 140 patients were recruited, and blood pressure (BP) measurements with 3 different methods, namely, office blood pressure (OBP), AOBP, and ambulatory blood pressure measurement (ABPM), were recorded. All patients were prospectively followed for a median period of 3.4 years. The primary outcome of this study was a composite outcome of cardiovascular (CV) events (both fatal and nonfatal) or a doubling of serum creatine or progression to end-stage kidney disease (ESKD), whichever occurred first. At baseline, the median age of patients was 65.2 years; 36.4% had diabetes; 21.4% had a history of CV disease; the mean of estimated glomerular filtration rate (eGFR) was 33 mL/min/1.73 m2; and the means of OBP, AOBP, and daytime ABPM were 151/84 mm Hg, 134/77 mm Hg, and 132/77 mm Hg, respectively. During the follow-up, 18 patients had a CV event, and 37 patients had a renal event. In the univariate cox regression analysis, systolic AOBP was found to be predictive of the primary outcome (HR per 1 mm Hg increase in BP, 1.019, 95% CI 1.003-1.035), and after adjustment for eGFR, smoking status, diabetes, and a history of CV disease and systolic and diastolic AOBP were also found to be predictive of the primary outcome (HR per 1 mm Hg increase in BP, 1.017, 95% CI 1.002-1.032 and 1.033, 95% CI 1.009-1.058, respectively). In patients with CKD, AOBP appears to be prognostic of CV risk or risk for kidney disease progression and could, therefore, be considered a reliable means for recording BP in the office setting.

Influence of Hydration Status and Plasma Copeptin on Ambulatory Blood Pressure in Healthy Young Adults

BACKGROUND: Adequate hydration is essential for regulating various physiological systems and may influence blood pressure (BP). Hypohydration is linked with elevated copeptin (surrogate of arginine vasopressin), which is associated with elevated cardiovascular disease risk. However, there is limited information on the influence of hydration and copeptin on ambulatory BP measures in young adults. Therefore, we sought to investigate associations between hydration, copeptin, and ambulatory BP. METHODS: We studied 41 participants (19 M/22 F, 24 White/17 Black, age 21±1 years, body mass index 26±5 kg/m 2 , screening BP 111± 10/67±8 mmHg; Mean ± SD) who provided a 24-hour urine sample. We measured urine specific gravity (USG), urine osmolality (OSM), and plasma copeptin as biomarkers of hydration. We used ambulatory BP monitoring (Suntech Oscar2) to assess BP during daytime (1000-2000) and nighttime (0000-0600). Our primary outcomes were plasma copeptin (pmol/L) and night-to-day BP dip ratio (nighttime/daytime BP) in dehydrated (USG &gt;1.020 or OSM &gt;800 mOsm/kg) vs euhydrated participants. Statistical procedures included Student’s t-tests and Mann-Whitney U tests. We also used Spearman’s rho correlation (controlling for BMI, sex, and race). We set α at ≤0.05. RESULTS: Copeptin concentration was elevated in dehydrated compared with euhydrated participants (USG: 6.6±2.9 vs 4.3±2.0 pmol/L, p&lt;0.005; OSM: 6.6±2.7 vs 4.1±2.0 pmol/L, p&lt;0.001). After controlling for BMI, sex, and race, copeptin was associated with USG (rho=0.44, p=0.005) and OSM (rho=0.51, p=0.001). Systolic and diastolic BP dip ratios did not differ by hydration status for either USG or OSM ( ps&gt;0.179). Additionally, adjusted BP dip ratios were not correlated with OSM or USG ( ps&gt;0.149). Plasma copeptin was not associated with BP dip ratios ( ps&gt;0.155) but was associated with absolute nocturnal systolic (rho=-0.34, p=0.036) and diastolic BP dip (rho=-0.33, p=0.041). When we split participants by low and high copeptin concentration (median split), higher copeptin was associated with a lower (i.e., worse) systolic BP dip ratio (0.87±0.06 vs 0.90±0.06, p=0.048) and lower absolute nocturnal systolic and diastolic BP dip ( ps&lt;0.01). CONCLUSIONS: Hydration biomarkers were correlated with plasma copeptin, but not ambulatory BP. The significance of our findings are that higher copeptin was associated with blunted nocturnal BP dipping in younger adults, which could predispose them to increased future cardiovascular disease risk. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

0843 Identifying the Minimum Number of Ambulatory Blood Pressure Measurements to Classify a Reliable Blood Pressure Dipping Status

Abstract Introduction Ambulatory blood pressure monitoring (ABPM) is recommended over office BP assessment as it enables quantification of the degree of nocturnal BP dipping (classifications: “dipping” = nighttime/daytime BP of &amp;lt; 0.9; “non-dipping” = ≥0.9), a robust predictor of future adverse events. However, ABPM can cause discomfort jeopardizing adherence to the 24-hour assessment. Current guidelines recommend at least 20/7 daytime/nighttime BP measurements for reliable classification of nocturnal dipping status, but recent reports suggest 8/4 daytime/nighttime measurements may be sufficient. This threshold for classification can reduce patient burden and potentially enhance clinical practice. We aimed to identify the minimum number of ambulatory BP measurements to determine a reliable dipping status. Methods Forty-three ostensibly healthy participants (50±10 years [mean±SD]) wore an ambulatory BP monitor for 24 hours with measurements every 20/30 minutes during the daytime/nighttime, respectively (maximum 48/16 daytime/nighttime measurements). We calculated each participant's dipping status using all available systolic BP measurements. We randomly selected 20-daytime plus 8-nighttime measurements, identified dipper statuses from all possibilities of 1-20 daytime and 1-8 nighttime measurements separately, and calculated the proportion of participants whose dipping status remained unchanged. We then evaluated all possible combinations starting with a minimum of 8 daytime/5 nighttime for consistency with participants’ full data set using a second random selection of 20/8 measurements Results We found that using 8-daytime (plus all available nighttime) measurements was sufficient for unchanged dipper status in 90% of possible combinations, and using 5-nighttime (plus all available daytime) measurements was sufficient for unchanged dipper status in 92% of possible combinations. Confirmatory analyses revealed that 8/5 daytime/nighttime combinations correctly identified dipper status in 84% of the &amp;gt;7 million combinations. 10/8 daytime/nighttime combination improved this to 86%, similar to 87% returned from the guidelines’ recommended combination of 20/7 daytime/nighttime measurements. Conclusion In ostensibly healthy people, current thresholds for ambulatory BP monitoring recommendation could result in ~13% misclassifications of dipping status compared to full datasets. However, considering that this measurement can cause discomfort and that dipping statuses can be unstable in 30% of individuals, 10/8 daytime/nighttime measurements may be a reliable alternative. Support (if any) NIH F32HL131308, R01HL163232, R01HL125893, R35HL155681, OHSU MRF and OFDIR.

Interpretation of Ambulatory Blood Pressure Monitoring for Risk Stratification in Hypertensive Patients: The 'Ambulatory Does Prediction Valid (ADPV)' Approach.

Several outcome-based prospective investigations have provided solid data which support the prognostic value of 24 h ambulatory blood pressure over and beyond cardiovascular traditional risk factors. Average 24 h, daytime, and nighttime blood pressures are the principal components of the ambulatory blood pressure profile that have improved cardiovascular risk stratification beyond traditional risk factors. Furthermore, several additional ambulatory blood pressure measures have been investigated. The correct interpretation in clinical practice of ambulatory blood pressure monitoring needs a standardization of methods. Several algorithms for its clinical use have been proposed. Implementation of the results of ambulatory blood pressure monitoring in the management of individual subjects with the aim of improving risk stratification is challenging. We suggest that clinicians should focus attention on ambulatory blood pressure components which have been proven to act as the main independent predictors of outcome (average 24 h, daytime, and nighttime blood pressure, pulse pressure, dipping status, BP variability).

Office blood pressure versus ambulatory blood pressure measurement in childhood obesity

BackgroundThe prevalence of obesity-related co-morbidities is rising parallel to the childhood obesity epidemic. High blood pressure (BP), as one of these co-morbidities, is detected nowadays at increasingly younger ages. The diagnosis of elevated BP and hypertension, especially in the childhood population, presents a challenge to clinicians. The added value of ambulatory blood pressure measurement (ABPM) in relation to office blood pressure (OBP) measurements in obese children is unclear. Furthermore, it is unknown how many overweight and obese children have an abnormal ABPM pattern. In this study we evaluated ABPM patterns in a population of overweight and obese children and adolescents, and compared these patterns with regular OBP measurements.MethodsIn this cross-sectional study in overweight or obese children and adolescents aged 4–17 years who were referred to secondary pediatric obesity care in a large general hospital in The Netherlands, OBP was measured during a regular outpatient clinic visit. Additionally, all participants underwent a 24-hour ABPM on a regular week-day. Outcome measures were OBP, mean ambulatory SBP and DBP, BP load (percentage of readings above the ambulatory 95th blood pressure percentiles), ambulatory BP pattern (normal BP, white-coat hypertension, elevated BP, masked hypertension, ambulatory hypertension), and BP dipping.ResultsWe included 82 children aged 4–17 years. They had a mean BMI Z-score of 3.3 (standard deviation 0.6). Using ABPM, 54.9% of the children were normotensive (95% confidence interval 44.1–65.2), 26.8% had elevated BP, 9.8% ambulatory hypertension, 3.7% masked hypertension, and 4.9% white-coat hypertension. An isolated night-time BP load > 25% was detected in almost a quarter of the children. 40% of the participants lacked physiologic nocturnal systolic BP dipping. In the group of children with normal OBP, 22.2% turned out to have either elevated BP or masked hypertension on ABPM.ConclusionsIn this study a high prevalence of abnormal ABPM patterns in overweight or obese children and adolescents was detected. Additionally, OBP poorly correlated with the child’s actual ABPM pattern. Herewith, we emphasized the usefulness of ABPM as an important diagnostic tool in this population.

The effect of ambient air pollution on office, home and 24-h ambulatory blood pressure measurements.

Air pollution has recently been linked to a number of cardiovascular diseases, particularly hypertension (HT). In our study, we aimed to evaluate the association between air pollution and BP and compare the relationship BP measurement results obtained using different methods (office, home, and 24-h ambulatory BP monitoring (24-h ABPM)). This retrospective nested panel study performed with prospective Cappadocia cohort data investigated the relationships between particulate matter (PM) 10 and sulfur dioxide (SO2) and concurrent home, office, and 24-h ABPM data at each control performed over a two-year period. A total of 327 patients in the Cappadocia cohort were included in this study. On the day of office blood pressure measurement, there was an increase of 1.36 mmHg in SBP and 1.18 mmHg in DBP for every 10 µm/m3 rise in SO2 values. A mean three-day 10 µm/m3 increase in SO2 was linked to an increase of 1.60 mmHg in SBP and 1.33 mmHg in DBP. A 10 µm/m3 rise in mean SO2 on the day of 24-hour ABPM measurement was found to be associated with an increase of 1.3 mmHg in SBP and 0.8 mmHg in DBP. SO2 and PM 10 had no effect on home measurements. In conclusion, increased SO2 levels, during winter months in particular, can be association with an elevation in office BP values. Our study findings show that air pollution in the setting in which BP is measured may be associated with the results.