Ambulatory Blood Pressure Monitoring Recordings Research Articles

Masked hypertension is highly prevalent among patients with high-normal office blood pressure - based on the results of the Hungarian ABPM Registry

Abstract Background Current European guidelines recommend initiating antihypertensive treatment for patients with high-normal office blood pressure (HNOBP) if their cardiovascular (CV) risk is very high.1 Ambulatory blood pressure monitoring (ABPM) is a recommended tool to identify whitecoat- (WCH) and masked hypertension (MH), and both conditions can be present in patients with HNOBP. Purpose The purpose of our study was to assess the prevalence of white-coat and masked hypertension in patients with HNOBP, the proportion of very high CV risk, and to identify the predictors of WCH and MH. Methods We collected data from the Hungarian ABPM Registry, which is an ongoing, multicenter, open-label, observational study including 38720 adult patients. ABPMs were performed with validated Meditech ABPM-06 monitors. We analyzed the ABPM curves of 4389 HNOBP patients. In the diagnosis of hypertension, 24 hour-, daytime- and nighttime mean BP values were each considered separately. OBP measurements and ABPMs were performed by GPs, internists and cardiologists. 89 patients were excluded due to missing data. Results ABPM recordings confirmed MH in 67.4%(n=2899) of the cases, while WCH in 15.3%(n=659). In 17.3%(n=742) BP was in HN category both in the office and with ABPM (apparent high-normal blood pressure /appHNBP/). WCH patients (57.11±17.47) were older, than appHNBP (54.54±16.9), and MH patients (53.38±16.70)(p<0.001). WCH (19.4%, n=489) and appHNBP (19.4%, n=488) were more frequent among females, than in males (14.3%, n=254; 9.6%, n=170, respectively, p<0.001). However, MH was more prevalent in males compared to females (76.2%(n=1355) vs 61.2%(n=1544), respectively, p<0.001). Snoring, obesity and diabetes mellitus were more frequent in MH than in appHNBP and WHC patients (Snoring: 30.6%(n=887) vs. 25.7%(n=191) vs. 20.8%(n=137), p<0.001; Obesity: 22.9%(n=663) vs. 16.0%(n=119) vs. 13.4%(n=88), p<0.001;Diabetes mellitus: 12.1%(n=350) vs. 8.9%(n=66) vs. 9.9%(n=65), respectively, p=0.025). Independent predictors of WCH were age (OR=1.01[1.003;1.02]), female sex (OR=1.50[1.19;1.89]) and snoring (OR=0.76[0.59;0.97]). Independent predictors of MH were male sex (OR=1.69[1.43;2.00]), snoring (OR=1.27[1.06;1.53]) and obesity (OR=1.55[1.25;1.92]). 76% of all patients received antihypertensive treatment irrespective of the BP groups (WCH: 76.2%(n=502), appHNBP: 76.3%(n=566), MH: 76.5%(n=2217), p=NS). 11.7%(n=502) of all patients had very high CV risk and only 2.5%(n=25) did not receive antihypertensive treatment. Similar results were found among WCH, appHNBP and MH patients (very high CV risk: 13.8%(n=91) vs. 11.2%(n=83) vs.11.7%(n=328), p=NS; no treatment: 1.9%(n=3) vs. 1.7%(n=3) vs. 2.8%(n=19), p=NS). Conclusions In patients with HNOBP, MH is highly prevalent. MH might be suspected in young, obese, male patients with diabetes mellitus and snoring. WCH was more frequent in older females. Based on our data, the majority of patients with HNOBP and very high CV risk are treated.

P214 PREDICTION OF AMBULATORY BRACHIAL CUFF-BASED OSCILLOMETRIC PULSE WAVE VELOCITY USING A NOVEL METHOD FOR ESTIMATING TOTAL ARTERIAL COMPLIANCE

Background and Objective: Total arterial compliance (Ct) serves as a critical determinant of arterial hemodynamics, providing insights into the mechanical and structural characteristics of large arteries and influencing ventricular-arterial coupling. To estimate Ct, we developed a method utilizing data from 24-hour ambulatory blood pressure monitoring (24-h ABPM) recordings. Our objective is to evaluate the reliability of Ct in estimating oscillometric pulse wave velocity (oPWV), with the potential to eliminate the requirement for additional oPWV measurements. Methods: A cross-sectional study was conducted, involving 162 patients who underwent 24-h ABPM, resulting in a total of 8,113 blood pressure (BP) recordings. oPWV was measured during 24-h ABPM using a Custo Screen 310 device (Custo, Ottobrunn, Germany), which has been validated. Ct was estimated employing a two-element Windkessel model based on mean systolic pressure. The formula utilized for Ct estimation was Ct/BSA= (38/PPth)×(4/5)×(Td/T)-(3/7), where BSA denotes body surface area, Td represents diastolic time, T signifies the cardiac period, and PPth denotes theoretical pulse pressure. A linear regression model (LRM) was developed to estimate oPWV from Ct. Results: Among the participants, 55.1% were men, with an average age of 55.7±16.2 years and a body mass index of 27.4±3.7 kg/m2. The analyzed records revealed an average systolic blood pressure of 125.6±18.7 mmHg, diastolic blood pressure of 79.5±12.2 mmHg, heart rate of 71.0±12.2 beats per minute, Ct of 0.9±0.3 mL/mmHg, and oPWV of 7.2±1.8 m/s. The best predictive model (R2=0.42; r=0.65) for oPWV was based on the ratio of systolic time (Ts) to Ct as follows: oPWV=3.3 × 6.0 ×[Ts/(Ct/BSA)]. Indexed Ct demonstrated an inverse relationship with oPWV (Figure). Residuals analysis confirmed compliance with assumptions. Conclusions: The Ts/Ct ratio inversely predicts oPWV, indicating an inverse relationship between Ct and oPWV in this population. These findings suggest that estimated Ct has the potential to replace oPWV in clinical practice for cardiovascular risk stratification.

White-coat effect and masked hypertension in patients with high-normal office blood pressure: results of the Hungarian ABPM Registry.

Blood pressure (BP) lowering therapy in hypertension can markedly reduce the risk of cardiovascular diseases. In case of high-normal office blood pressure (oBP), the initiation of antihypertensive medication is recommended by guidelines in patients with very high cardiovascular risk. The aims of this study were to evaluate the presence of white-coat high-normal BP (WhHNBP) and masked hypertension in high-normal oBP and to explore the prevalence of untreated very high cardiovascular risk patients. Data of the Hungarian Ambulatory Blood Pressure Monitoring (ABPM) Registry between September 2020 and November 2023 were used in our analysis. From 38 720 uploaded ABPM curves with clinical data, 4300 individuals were categorized as having high-normal oBP. Among those, 3285 (76.4%) were on antihypertensive treatment. Based on the ABPM recordings, high-normal BP was confirmed in 20.5% ( n = 881), while WhHNBP was present in 27.6% ( n = 1188) and masked hypertension in 51.9% ( n = 2231). Similar results were found in treated and untreated subjects or patients as well. Independent predictors of WhHNBP were age [odds ratio (OR) 1.02 (95% confidence interval, 95% CI: 1.01-1.02), P < 0.001], female sex [OR: 1.59 (1.32-1.92), P < 0.001] and snoring [OR: 0.70 (0.57-0.86), P < 0.001]. Independent predictors of masked hypertension were male sex [OR: 1.31 (1.12-1.54), P < 0.001] and obesity [OR: 1.71 (1.39-2.09), P < 0.001]. Five hundred and two individuals had very high cardiovascular risk with high-normal oBP and only 25 of them were untreated. In high-normal oBP, WhHNBP or masked hypertension is present in three out of four individuals. Most of the patients with high-normal oBP and very high cardiovascular risk are already treated with antihypertensive drugs.

WHITE-COAT EFFECT AND MASKED HYPERTENSION IN HIGH-NORMAL OFFICE BLOOD PRESSURE: RESULTS OF THE HUNGARIAN ABPM REGISTRY

Objective: White-coat hypertension refers to the untreated condition in which BP is elevated in the office but is normal when measured by ambulatory blood pressure monitoring (ABPM), home blood pressure monitoring (HBPM) or both. However, white-coat effect can be present in high-normal blood pressure (BP) category as well. The aims of this study were to evaluate the presence of white-coat effect and masked hypertension in high-normal office BP (OBP) and also to explore the prevalence of untreated very high CV risk (CVD) patients with high-normal OBP. Design and method: Data of the Hungarian ABPM Registry were used in our analysis. Results: From 14 817 uploaded ABPM curves with clinical data 1 255 subjects were categorized as having high-normal OBP. 999 (79.6%) were on antihypertensive treatment. Based on the ABPM recordings apparent high-normal BP was found in 35.9% (n=450), white-coat effect was present in 28.5% (n=358) and masked hypertension was diagnosed in 35.6% (n=447). Similar results were found in treated and untreated subjects as well. Independent predictors of white-coat effect were age (OR: 1.014 (95%CI:1.006-1.023), p=0.001), male sex (OR: 0.565 (0.432-0.739), p&lt;0.001), and obesity (OR: 1.994 (1.480-2.687), p&lt;0.001). Independent predictors of masked hypertension were age (OR: 1.014 (95%CI:1.005-1.023), p=0.003), heart rate (OR: 1.028 (1.011-1.044), p=0.01) and obesity (OR:1.679 (1.262-2.234), p&lt;0.001). 142 subjects had very high CV risk with high-normal OBP and only 7 of them were untreated. With ABPM only one of them had apparent high-normal BP. Conclusions: In high-normal OBP ABPM is a useful tool to diagnose white-coat effect and masked hypertension. Untreated high-normal OBP with very high CV risk is a very rare condition in the general practitioner practice when ABPM is also recommended to evaluate the true blood pressure phenotype before therapeutic decisions.

Ambulatory Arterial Stiffness Index is Associated with the Presence and Severity of Coronary Artery Disease

ObjectiveTo evaluate the relationship between the ambulatory arterial stiffness index (AASI) and the degree of coronary stenosis, and assess its predictive value for the presence and severity of coronary artery disease (CAD).Materials and methodsIn total, 619 consecutive patients who presented with exertional anginal symptoms and/or acute coronary syndrome between January 2021 and December 2022 underwent elective non-urgent CAG with no emergency conditions and performed 24-h ambulatory blood pressure monitoring (ABPM) were included in this study and were divided into the control group (n = 68) and CAD group (n = 551) according to the angiography results. Ambulatory Arterial Stiffness Index (AASI) is obtained from the 24-h ABPM recordings, defined as 1 minus the regression slope of diastolic blood pressure on systolic blood pressure values. CAD complexity was determined by the Gensini score (GS). The patients with CAD were stratified according to the tertiles of the Gensini score (GS < 24 versus GS > 48), and GS > 48 is considered severe coronary artery disease. To explore the relationship between AASI and the severity of CAD, Spearman correlation analysis was conducted. Logistic regression analysis was then performed to determine the influence of AASI on CAD as well as severe CAD. Moreover, a Receiver Operating Characteristic (ROC) curve was constructed to assess the predictive value of AASI for CAD and severe CAD.ResultsThe CAD group had a substantially higher median AASI than the control group [0.47 (0.4, 0.58) vs.0.32 (0.24, 0.41), P < 0.001]. There was a positive correlation between AASI and Gensini score. Compared to controls, patients in low-, medium-, and high-GS had significantly higher levels of AASI in a rising trend (P < 0.001). Logistic regression demonstrated that AASI was an independent contributor to CAD and severe CAD. The area under the curve (AUC) for AASI in predicting CAD was 0.806 (P < 0.001), and for predicting high-GS CAD was 0.663 (P < 0.001).ConclusionAASI was associated with CAD and the severity of coronary stenosis and demonstrated predictive potential for both CAD and severe CAD.

Blood Pressure Variability and Ocular Vestibular-Evoked Myogenic Potentials Are Independently Associated With Orthostatic Hypotension.

We delineated the association between otolithic dysfunction and blood pressure (BP) variability. We prospectively recruited 145 consecutive patients (age=71 [59-79] years, median [interquartile range]; 76 females) with orthostatic intolerance between December 2021 and December 2023 at a tertiary hospital in South Korea. Each patient underwent evaluations of cervical and ocular vestibular-evoked myogenic potentials (oVEMPs), 24-h noninvasive ambulatory BP monitoring (ABPM), and a head-up tilt-table test using the Finometer device. As measures of BP variability, the standard deviations (SDs) of the systolic BP (SBPSD) and the diastolic BP were calculated based on serial ABPM recordings. Patients were divided into those with orthostatic hypotension (OH, n=68) and those with a normal head-up tilt-table test despite orthostatic intolerance (NOI, n=77) groups. A multivariable logistic regression analysis showed that OH was associated with bilateral oVEMP abnormalities (p=0.021), SBPSD (p=0.012), and female sex (p=0.004). SBPSD was higher in patients with OH than in those with NOI (p<0.001), and was not correlated with n1-p1 amplitude (p=0.491) or normalized p13-n23 amplitude (p=0.193) in patients with OH. The sensitivity and specificity for differentiating OH from NOI were 72.1% and 67.5%, respectively, at a cutoff value of 12.7 mm Hg for SBPSD, with an area under the receiver operating characteristic curve of 0.73. Bilaterally deficient oVEMP responses may be associated with OH regardless of 24-h BP variability, reflecting the integrity of the otolith-autonomic reflex during orthostasis. Alternatively, 24-h BP variability is predominantly regulated by the baroreflex, which also participates in securing orthostatic tolerance complementary to the vestibulo-autonomic reflex.

THE IMPACT OF COVID-19 PANDEMIC ON BLOOD PRESSURE CONTROL IN PATIENTS WITH TREATED HYPERTENSION. RESULTS OF EUROPEAN SOCIETY OF HYPERTENSION STUDY (ESH ABPM COVID-19 STUDY)

Objective: We aimed to assess the impact of the COVID-19 pandemic on blood pressure (BP) control assessed by office and ambulatory blood pressure monitoring (ABPM) in patients with treated hypertension. Design and method: Clinical and BP data were collected from 32 centres including Excellence Centres of the European Society of Hypertension. Two groups of patients were compared. Group1 (‘pandemic’) consisting of participants who have undergone two ABPM recordings (visits): visit-2 during the COVID-19 pandemic, and visit-1 performed 9 - 15 months prior to visit-2. Participants in Group2 (‘pre-pandemic’) had two repeated ABPMs, both performed before the pandemic within 9 - 15 months interval between visits. Results: Overall, 3384 ABPMs were collected from 1692 patients (50.5% men). 759 patients constituted Group1 and 933 patients Group2. Study groups did not differ regarding sex, age, or body weight. The duration of hypertension and frequency of first-line antihypertensive drug use at visit-1 were also similar in both groups. Beta-blockers were the only class of drugs with a significant decrease between visits (difference between visit-2 and visit-1) in Group1. At visit-1, there were no differences in all BP phenotypes (office and ABPM values) or hypertension control rates (27% vs 26.6%; p = 0.62) between study groups. At visit-2 significantly higher office BP was observed in Group1 compared to Group2, with a mean difference of +2.09 mmHg (p = 0.028) and +1.39 mmHg (p = 0.026) for systolic (SBP) and diastolic (DBP) BP, respectively. Moreover, on visit-2, higher 24-hour daytime and nighttime SBP and DBP were observed in Group1 as compared to Group2. Of note, the prevalence of uncontrolled hypertension (when considering both office and ABPM) was also higher at visit-2 in Goup1 than in Group2 (25.8% vs 20.0%; p = 0.005). Both SBP and DBP, regardless of the measurement method, dropped between visit-1 to visit-2, but to a lesser extent in Group1. Thus, the magnitude of BP decrease between visits was smaller in Group1 (delta24SBP: -1.04 vs -3.2 mmHg; p &lt; 0.001 and delta24DBP: -1.22 vs -1.93 mmHg; p = 0.038). Conclusions: The results of the study indicate a negative impact of the COVID-19 pandemic on BP control both in office and during ABPM.

Ambulatory blood pressure monitoring in treated patients with hypertension in the COVID-19 pandemic - The study of European society of hypertension (ESH ABPM COVID-19 study)

Purpose The coronavirus disease 2019 (COVID-19) pandemic and the subsequent lockdown profoundly affected almost all aspects of daily life including health services worldwide. The established risk factors for increased blood pressure (BP) and hypertension may also demonstrate significant changes during the pandemic. This study aims to determine the impact of the COVID-19 pandemic on BP control and BP phenotypes as assessed with 24-hour ambulatory BP monitoring (ABPM). Materials and Methods This is a multi-centre, observational, retrospective and comparative study involving Excellence Centres of the European Society of Hypertension across Europe. Along with clinical data and office BP, ABPM recordings will be collected in adult patients with treated arterial hypertension. There will be two groups in the study: Group 1 will consist of participants who have undergone two ABPM recordings - the second one occurring during the COVID-19 pandemic, i.e. after March 2020, and the first one 9–15 months prior to the second. Participants in Group 2 will have two repeated ABPM recordings - both performed before the pandemic within a similar 9–15 month interval between the recordings. Within each group, we will analyse and compare BP variables and phenotypes (including averaged daytime and night-time BP, BP variability, dipper and non-dipper status, white-coat and masked hypertension) between the two respective ABPM recordings and compare these changes between the two groups. The target sample size will amount to least 590 participants in each of the study groups, which means a total of at least 2360 ABPM recordings overall. Expected outcomes As a result, we expect to identify the impact of a COVID-19 pandemic on blood pressure control and the quality of medical care in order to develop the strategy to control cardiovascular risk factors during unpredictable global events.

PS-C09-9: AMBULATORY BLOOD PRESSURE CHARACTERISTICS IN CHINESE OBESE HYPERTENSIVE PATIENTS: A POPULATION-BASED AMBULATORY BLOOD PRESSURE MONITORING COHORT STUDY

Background: Ambulatory blood pressure monitoring (ABPM) is increasingly recommended for clinical practice, but more knowledge about the characteristics of Chinese obese hypertensive patients ABPM remains to further explore. This study aimed to assess the features in Chinese obese and hypertensive patients from multi-regions ambulatory blood pressure database in China. Methods: In this cohort, 35,367 hypertensive patients who were eligible for this study including 19,380 men (54.8%) and 15,987 women (45.2%) aged from 19 to 99 were recruited. ABPM characteristics were defined according to European guidelines. Overweight was defined as BMI 18.5 kg/m2 or greater, and obesity BMI 25 kg/m2 or greater. Hypertension was defined as elevated mean ambulatory BP (135/85 mmHg greater in day-time, 120/70 mmHg greater in night-time, 130/80 mmHg greater over 24-h). There are four kinds of blood pressure circadian rhythm, dippers, non-dippers, reverse dippers and extreme dippers. Results: Based on the ABPM recordings, 70.5% of participants had 24-h hypertension, 26.1% had dippers rhythm. 2.6% of participants had normal weight, 51.0% were overweight, 38.2% were obesity, and 8.2% were in severe obesity state. Considering blood pressure circadian rhythm, 48% non-dippers rhythm, 23.6% reverse dippers rhythm and 2.3% extreme dippers rhythm. Among participants who were obesity and severe obesity, 48% and 45.1% of patients were non-dippers. Severe obesity patients had higher 24-h blood pressures, especially in independent nocturnal hypertension. The prevalence of reverse dippers rhythm hypertension increased with age and the obesity degree. A positive association between blood pressure level and variability was observed, and within-person and between-person SD and CV were of similar magnitude. Conclusions: In Chinese obese hypertensive population, circadian rhythm blood pressure variation is an underappreciated problem on the population level. Therefore, the ambulatory blood pressure monitoring in obese hypertensive population needs to be expanded.

The rationale, protocol and preliminary results of the ESH ABPM COVID-19 study.

The coronavirus disease 2019 (COVID-19) pandemic and the subsequent lockdown profoundly affected almost all aspects of daily life including health services worldwide. The traditional risk factors for increased blood pressure (BP) and hypertension may also demonstrate significant changes during the pandemic. The ESH ABPM COVID-19 Study aims to determine the impact of the COVID-19 pandemic on BP control and BP phenotypes assessed with ambulatory BP monitoring (ABPM). This is a multi-center, observational, retrospective and comparative study involving Excellence Centres of the European Society of Hypertension across Europe. Along with clinical data office BP, 24-hour ABPM recordings will be collected in adult patients with treated arterial hypertension. There will be two groups in the study: Group 1 will consist of participants who have undergone two ABPM recordings - the second one occurring during the COVID-19 pandemic, i.e., after March 2020, and the first one 9-15 months prior to the second. Participants in Group 2 will have two repeated ABPM recordings - both performed before the pandemic within similar a 9-15 month interval between the recordings. We will analyze BP variables and phenotypes (including averaged daytime and nighttime BP, BP variability, dipper and non-dipper status, white-coat and masked hypertension) between the two respective ABPM recordings and compare these changes between the groups. Hypertension is one of the major risk factors for established cardiovascular disease (CVD). By extending our knowledge about effects of COVID-19 pandemic on BP control in patients with hypertension, we can propose appropriately effective strategies for providing adequate medical care in case of new pandemic waves and for long-term care, which will reduce incidence of CVD as a consequence of the current pandemic.

HIGH VERSUS LOW MEASUREMENT FREQUENCY DURING 24-HOUR AMBULATORY BLOOD PRESSURE MONITORING: A RANDOMIZED CONTROLLED CROSSOVER STUDY

Objective: We investigated whether the cuff inflation interval affects 24-hour ambulatory blood pressure monitoring (ABPM) values in patients with hypertension (HT). Design and method: HT patients (18+ years), typically with office BP above treatment target, were recruited from the hospital hypertension clinic and from 2 private cardiology clinics. Using a crossover study design, the participants were andomised to either a high or a low measurement frequency ABPM (HF-ABPM and LF-ABPM, respectively). HF-ABPM measured 3 times hourly during daytime and 2 times hourly during nighttime, while LF-ABPM measured BP once hourly throughout 24-hours. A second ABPM with opposite protocol was performed within 2–14 days after the first ABPM. Patients were instructed to keep daily activities alike on both days, and no changes in medication were allowed between measurements. To investigate the cuff inflation frequency on different BP levels, patients were assigned into 3 groups based on daytime systolic BP (SBP): normotension (&lt;135 mmHg), mild HT (135–154 mmHg), and moderate/severe HT (&gt;154 mmHg). Results: Data from 112 patients were andomis: 38 with normotension, 47 with mild HT, and 27 with moderate/severe HT. Mean age was 57.4 years (SD 14.5) and 45.6% were women. The percentage of successful measurements were 93.7% for HF-ABPM and 94.4% for LF-ABPM. Overall mean SBP was 137.1 mmHg (SD 15.5) for HF-ABPM and 138.0 mmHg (SD 16.3) for LF-ABPM with a difference of -0.9 mmHg (95% CI = -2.4; 0.5). The range in individual differences was however large, with 95% limits of agreement being -16.0;14.1 mmHg (Fig. 1). Mean SBP differences were -1.2 mmHg (95% CI = -3.5;1.2) for normotensives; 0.1 mmHg (-2.2; 2.4) in mild HT and -2.4 mmHg (-5.3; 0.5) in moderate/severe HT. These differences were not statistically different nor of relevant clinical significance. Conclusions: This is the first andomised study investigating whether cuff inflation frequency affects BP during a full 24-hour ABPM. In an adequately sized cohort, we found no difference between the two measurements strategies. Fewer measurements during ABPM could reduce discomfort and possibly increase acceptance of repeated ABPM recordings.

24-hour ambulatory blood pressure telemonitoring in patients at risk of atrial fibrillation: results from the TEMPLAR project.

Hypertension is the most common risk factor for atrial fibrillation (AF). The ability to screen for potential AF during blood pressure (BP) measurement may be a valuable tool for early AF detection. This study evaluated the frequency of irregular pulse rates suggestive of AF in subjects undergoing ambulatory BP monitoring (ABPM) and compared the characteristics of patients at low risk of presumed AF vs. those at high risk. ABPM recordings were obtained in 4419 subjects aged ≥65 years visiting 304 community pharmacies, with clinically validated automated monitors equipped with an algorithm for detecting possible AF episodes during BP measurement. Subjects with <30% of the readings suggestive of AF were categorized as having a low risk of AF, and those with ≥30% of readings were classified as high risk. A total of 531 subjects (12.0%) were categorized as having a high risk of AF, with the risk increasing with advancing age. Subjects at high risk of AF had lower average systolic BP, higher average diastolic BP and pulse rate (PR), increased BP and PR variabilities, and blunted sleep-associated reductions in BP and PR. In repeated recordings, the reliability of the AF detection algorithm per se was good (kappa 0.476, p = 0.0001; intraclass correlation coefficient 0.56, p = 0.0001). Simultaneous BP measurement and screening for potential AF by ABPM in elderly people in clinical practice may help improve BP control and the detection of subjects at high risk of AF. However, a finding of presumed AF must always be confirmed by an electrocardiogram (ECG).

Assessment of hypertension in kidney transplantation by ambulatory blood pressure monitoring: a systematic review and meta-analysis.

ABSTRACTBackground Hypertension (HTN) is common following renal transplantation and it is associated with adverse effects on cardiovascular (CV) and graft health. Ambulatory blood pressure monitoring (ABPM) is the preferred method to characterize blood pressure (BP) status, since HTN misclassification by office BP (OBP) is quite common in this population. We performed a systematic review and meta-analysis aimed at determining the clinical utility of 24-h ABPM and its potential implications for the management of HTN in this population.MethodsOvid-MEDLINE and PubMed databases were searched for interventional or observational studies enrolling adult kidney transplant recipients (KTRs) undergoing 24-h ABP readings compared with OBP or home BP. The main outcome was the proportion of KTRs diagnosed with HTN by ABPM, home or OBP recordings. Additionally, day–night BP variability and dipper/non-dipper status were assessed.ResultsForty-two eligible studies (4115 participants) were reviewed. A cumulative analysis including 27 studies (3481 participants) revealed a prevalence of uncontrolled HTN detected by ABPM of 56% [95% confidence interval (CI) 46–65%]. The pooled prevalence of uncontrolled HTN according to OBP was 47% (95% CI 36–58%) in 25 studies (3261 participants). Very few studies reported on home BP recordings. The average concordance rate between OBP and ABPM measurements in classifying patients as controlled or uncontrolled hypertensive was 66% (95% CI 59–73%). ABPM revealed HTN phenotypes among KTRs. Two pooled analyses of 11 and 10 studies, respectively, revealed an average prevalence of 26% (95% CI 19–33%) for masked HTN (MHT) and 10% (95% CI 6–17%) for white-coat HTN (WCH). The proportion of non-dippers was variable across the 28 studies that analysed dipping status, with an average prevalence of 54% (95% CI 45–63%).ConclusionsIn our systematic review, comparison of OBP versus ABP measurements disclosed a high proportion of MHT, uncontrolled HTN and, to a lesser extent, WCH in KTRs. These results suggest that HTN is not adequately diagnosed and controlled by OBP recordings in this population. Furthermore, the high prevalence of non-dippers confirmed that circadian rhythm is commonly disturbed in KTRs.

Analysis of ambulatory blood pressure monitoring data in patients with ankylosing spondylitis without clinically evident cardiovascular disease.

Ankylosing spondylitis (AS) is associated with an increased risk of cardiovascular morbidity and mortality. Parameters, such as non-dipper, average real variability (ARV), pulse pressure index (PPI), and ambulatory arterial stiffness index (AASI) obtained from ambulatory blood pressure monitoring (ABPM), provide information about adverse cardiovascular outcomes. In this study, these indexes were evaluated in patients with AS. Sixty-five patients with AS and 65 control subjects were included in this study. Non-dipper pattern, ARV, PPI, and AASI parameters were assessed using 24-h ABPM recordings. Twenty-four-hour systolic, diastolic, mean standard deviation, PPI, ARV, and AASI were higher in patients with AS (p < 0.05 all parameters). Non-dipper (43.1% vs. 21.5%, p = 0.007) and reverse dipper (10.8% vs. 0%, p = 0.013) patterns were more common in patients with AS. In addition, disease duration was moderately correlated with AASI and ARV (r = 0.36, p = 0.003; r = 0.31, p = 0.012, respectively). This study showed that PPI, AASI, ARV, and dipper pattern were impaired in patients with AS evaluated with ABPM.

Blood pressure phenotypes based on ambulatory monitoring in a general middle-aged population

Background Ambulatory blood pressure monitoring (ABPM) is increasingly recommended for clinical use, but more knowledge about the prevalence and variability in ABPM-derived phenotypes in the general population is needed. We describe these parameters in the community-based Swedish CArdioPulmonary bioImage Study (SCAPIS) cohort. Methods We examined 5881 men and women aged 50–64 with 24-hour ABPM recordings using validated monitors. ABPM phenotypes were defined according to European guidelines. White coat hypertension was defined as elevated office BP (≥140/90 mmHg) with normal mean ambulatory BP (<135/85 mmHg in day-time, <120/70 mmHg in night-time, <130/80 mmHg over 24-h); and masked hypertension as normal office BP (<140/90 mmHg) with elevated mean ambulatory BP (≥135/85 mmHg in day-time, ≥120/70 mmHg in night-time, ≥130/80 mmHg over 24-h). Blood pressure variability was assessed using the coefficient of variation (CV), standard deviation (SD), and average real variability. Results Based on the ABPM recordings, 36.9% of participants had 24-h hypertension, 40.7% had day-time hypertension, and 37.6% nocturnal hypertension. Among participants treated with anti-hypertensive drugs, one in three had elevated office blood pressures, and more than half had elevated 24-h, day-time or nocturnal blood pressures. Among participants without anti-hypertensive drugs, only one in six had elevated office blood pressures, but one in three had elevated 24-h, day-time or nocturnal blood pressures. Men had higher 24-h blood pressures, more masked hypertension, but less white-coat hypertension than women. The prevalence of white-coat hypertension increased with age, but not the prevalence of masked hypertension. A positive association between blood pressure level and variability was observed, and within-person and between-person SD and CV were of similar magnitude. The variance in ABPM on repeated measurements was substantial. Conclusions In the middle-aged general population, masked hypertension is an underappreciated problem on the population level.

THE GLOBAL AMBULATORY BLOOD PRESSURE MONITORING (ABPM) IN HEART FAILURE WITH PRESERVED EJECTION FRACTION (HF-PEF) REGISTRY. RATIONALE, DESIGN AND OBJECTIVES

Objective: The prognosis of patients with heart failure and preserved ejection fraction (HFpEF), depends on multiple factors such as frailty and functional capacity, the presence of comorbidities and haemodynamic parameters including blood pressure (BP). Detailed definition of these prognostic factors may help identify effective management strategies. Our primary objective is to identify measures of BP recorded by ambulatory blood pressure monitoring (ABPM) that associated with hospital readmission due to HF or cardiovascular (CV) death, or functional decline in patients with HFpEF. Secondary objectives will be to examine the association between these measures and each of the components of the primary outcome separately and on non-CV death and all cause death, cognitive impairment and frailty. Design and method: In this prospective observational cohort of patients with stable HFpEF, ABPM will be obtained at baseline and at one year of follow-up. Inclusion criteria will be previous diagnosis of stable HFpEF defined as stable treatment or functional class for at least 4 weeks before study admission. A diagnosis of HFpEF (LVEF &gt; 45%) will be made according to the European Society of Cardiology guidelines. In addition to data on demographics and clinical examination, doppler echocardiography, office BP measurement, ABPM recordings, home BP measurement (HBPM), ECG, laboratory tests (serum creatinine, eGFR, Albumin/Creatinine/Ratio, lipid parameters, glucose, HbA1c, liver biology, albumin, prealbumin, blood cell count, ferritin and transferrin saturation rate, natriuretic peptides) will all be recorded. Functional and cognitive capacity will be assessed using the Barthel index and MOCA test, while frailty will be assessed using the Short Physical Performance Battery, and Frail Phenotype questionnaires. Results: We plan to include data from more than 80 investigators from more than 17 countries around the world during the next 5 years. This study has been registered at https://clinicaltrials.gov/ct2/show/NCT04065620 Conclusions: The Global Ambulatory Blood Pressure Monitoring (ABPM) in Heart Failure with Preserved Ejection Fraction (HFpEF) registry will allow us to assess the association between blood pressure and frailty in a global population of patients with HFPEF

WHICH AMBULATORY BLOOD PRESSURE PARAMETERS ARE RELATED TO COGNITIVE IMPAIRMENT AND DEMENTIA IN HYPERTENSIVE PATIENTS?

Objective: Ambulatory blood pressure monitoring (ABPM) parameters are more accurately linked to target organ damage than office or home blood pressure values. Few studies focus on the relationship between ABPM parameters and cognitive aging. We aimed to investigate the relationship between ABPM parameters and prevalence of cognitive impairment and dementia among hypertensive patients. Design and method: In the present paper, we included 294 consecutive hypertensive patients admitted to a Cardiovascular Rehabilitation Clinic aged between 50–91years (mean age: 68.6 ± 8.8 years; 50.3% female; 49.7% male). After routine clinical assessment all participants had an ABPM recording (on antihypertensive medical treatment), completed the Montreal Cognitive Assessment (MoCA) test used for the detection of cognitive impairment, and the Mini Mental State Examination (MMSE) test for detection of dementia. We divided patients in two groups acording to cognitive status based on these cutoff values: 26 points for MOCA score, respectively 24 points for MMSE score – and compared ABPM parameters of the two groups. Statistical analysis was performed with the IBM SPSS v.20 program. Results: In patients with cognitive impairment (MOCA &lt;26) we found significantly lower mean diastolic (69.9 vs. 72.4 mmHg, p = 0.023), daytime diastolic (72.0 vs. 75.1 mmHg, p = 0.012), nighttime diastolic (64.5 vs. 66.9 mmHg, p = 0.039), and higher pulse pressure values (average pulse pressure 61.5 vs. 55.5 mmHg, p = 0.002, daytime pulse pressure 61.7 vs. 56.6 mmHg, p = 0.003, nighttime pulse pressure (59.8 vs. 55.1 mmHg, p = 0.004). In patients with dementia (MMSE&lt;24) we found significant differences between nighttime systolic values (129.7 vs. 124.5 mmHg, p = 0.04), average pulse pressure (63.5 vs. 58.9 mmHg, p = 0.038), and nighttime pulse pressure (63.5 vs. 57.4 mmHg, p = 0.003), values compared to patients with normal cognitive function. Conclusions: The presence of cognitive impairment was related to lower diastolic values, and higher pulse pressure values, while dementia was associated with higher nighttime systolic values in the studied patient population. Lowering too much diastolic blood pressure leading to higher pulse pressure and insufficient control of systolic blood pressure over night could have deleterious effect on neurocognitive abilities of treated hypertensive patients.

Reproducibility study of nocturnal blood pressure dipping in patients with high cardiovascular risk.

It has been shown that in most people there is a physiological reduction in blood pressure during nighttime sleep, it falling by approximately 10% compared to daytime values (dippers). On the other hand, in some people, there is no nighttime reduction (non‐dippers). Various studies have found an association between being a non‐dipper and a higher risk of cardiovascular disease, but few have assessed whether the nocturnal pattern is maintained over time. From the database of the TAHPS study, data were available on 225 patients, each of whom underwent 24‐hour ambulatory blood pressure monitoring (ABPM) on four occasions over a period of 5 months. We studied the reproducibility of the nocturnal BP dipping pattern with mixed linear analysis and also calculated the concordance in the classification of patients as dippers or non‐dippers. The intraclass correlation coefficients between the different ABPM recordings were 0.482 and 0.467 for systolic and diastolic blood pressure, respectively. Two‐thirds (67%) and 70% of the patients classified, respectively, as dippers or non‐dippers based on systolic and diastolic blood pressure readings in the first ABPM recording were found to have the same classification based on the subsequent recordings. We conclude that the reproducibility of nocturnal dipping patterns and concordance of dipper vs non‐dipper status in individual patients is modest and therefore that we should be cautious about recommending treatments or interventions based on these patterns.

Association of clinic and ambulatory heart rate parameters with mortality in hypertension.

Resting heart rate (HR) taken in the office has been shown to be associated with cardiovascular outcomes in the general population, hypertension and heart failure. It is unknown whether 24-h oscillographic pulse rate measurement as an approximation of HR derived from ambulatory blood pressure monitoring (ABPM) associates with cardiovascular outcomes in hypertensive patients. We evaluated ABPM recordings from 56 901 patients with complete 3373 421 HR measures entering the final analysis from the Spanish Blood Pressure Monitoring Registry for a median follow-up time of 5.1 years. We explored the association of office HR, mean 24-h HR, mean day HR, mean night HR as well as day-night HR differences, morning mean HR, morning HR surge and night peak HR to all-cause death, cardiovascular death and noncardiovascular death. Data were analyzed by Cox regression analysis, analysis of variance and chi-square test. The Spanish ABPM Registry recorded data in 223 primary care centers in Spain from 2004 until 31 December 2014 at the end of recruitment. Office HR was 3.5 bpm higher than mean 24-h HR, office mean HR versus mean night was 10.4 bpm higher and mean day versus mean night HR 9.3 bpm higher, while there were no relevant difference between office and mean day HR. Office mean, 24-h day and night HR more than 90 bpm were associated with an increased risk for all-cause and noncardiovascular death, whereas for cardiovascular death only mean night HR was predictive. The strongest association to all-cause death was observed with mean night HR [hazard ratio 3.80 (2.87-5.03)], mean 24-h HR [2.85 (2.30-3.54)] and mean day HR [2.22 (1.83-2.70)]. Day-night dipping of more than 8 bpm was associated with a 20% lesser risk on all-cause, cardiovascular and noncardiovascular death. Results were robust after adjusting for relevant risk indicators. HR parameters derived from ABPM provide important information, in particular association with death by mean night HR, mean 24-h HR and reduced day-night HR dipping less than 8 bpm superior to office HR.

Sleep-Disordered Breathing and 24-Hour Ambulatory Blood Pressure Monitoring in Renal Transplant Patients: Longitudinal Study.

BackgroundSleep‐disordered breathing (SDB) is considered a strong risk factor for hypertension in the general population. This disturbance is common in end‐stage kidney disease patients on long‐term hemodialysis and improves early on after renal transplantation. Whether SDB may be a risk factor for hypertension in renal transplant patients is unclear.Methods and ResultsWe investigated the long‐term evolution of simultaneous polysomnographic and 24‐hour ambulatory blood pressure (BP) monitoring recordings in a cohort of 221 renal transplant patients. Overall, 404 paired recordings were made over a median follow‐up of 35 months. A longitudinal data analysis was performed by the mixed linear model. The apnea‐hypopnea index increased from a median baseline value of 1.8 (interquartile range, 0.6–5.0) to a median final value of 3.6 (interquartile range, 1.7–10.4; P=0.009). Repeated categorical measurements of the apnea‐hypopnea index were directly associated with simultaneous 24‐hour, daytime, and nighttime systolic ambulatory BP monitoring (adjusted analyses; P ranging from 0.002–0.01). In a sensitivity analysis restricted to 139 patients with at least 2 visits, 24‐hour, daytime, and nighttime systolic BP significantly increased across visits (P<0.05) in patients with worsening SDB (n=40), whereas the same BP metrics did not change in patients (n=99) with stable apnea‐hypopnea index.ConclusionsIn renal transplant patients, worsening SDB associates with a parallel increase in average 24‐hour, daytime, and nighttime systolic BP. These data are compatible with the hypothesis that the link between SDB and hypertension is causal in nature. Clinical trials are, however, needed to definitively test this hypothesis.