Ambulatory Blood Pressure Recordings Research Articles

Nocturnal blood pressure dipping and left ventricular hypertrophy among hypertensive outpatients in a Ghanaian hospital.

To investigate the association between the extent of nocturnal systolic blood pressure decline and left ventricular hypertrophy in patients with primary hypertension who were receiving antihypertensive drug therapy. This was a cross-sectional hospital-based study from November 2020 to March 2021. The study was conducted at the Polyclinic of Korle Bu Teaching Hospital, Ghana. Outpatients ≥18 years old with primary hypertension who were receiving antihypertensive drug therapy. Each participant underwent a 24-hour ambulatory blood pressure monitoring and a transthoracic echocardiogram. Left ventricular hypertrophy and the extent of mean systolic blood pressure decline during sleep. 180 participants were recruited, comprising 110 (61.1%) females. The participants' mean (±SD) age was 57.6 ± 11.0 years. 80% had a non-dipping blood pressure pattern, and 43.9% had left ventricular hypertrophy. Uncontrolled office blood pressure was an independent predictor of left ventricular hypertrophy in these patients (AOR 2.010, 95% CI 1.048-3.855, p=0.036); however, a non-dipping nocturnal systolic blood pressure status was not (AOR 1.849, 95% CI 0.850-4.022, p=0.121). 61.1% had abnormal left ventricular geometry, with concentric hypertrophy being the predominant geometric pattern. Left ventricular hypertrophy and non-dipping nocturnal blood pressure were common in these hypertensive Ghanaian patients on antihypertensive therapy. Left ventricular hypertrophy was associated with uncontrolled office blood pressure but not the extent of nocturnal systolic blood pressure declines during a single 24-hour ambulatory blood pressure recording. None declared.

Immune Metabolic Reprogramming by Excess Dietary Salt in Salt Sensitive Hypertension via CXCL8

Salt sensitivity of blood pressure (SSBP) is when blood pressure changes parallel to salt loading/ depletion and is an independent risk factor for cardiovascular disease. Despite its importance, there is no feasible diagnosis, which limits investigational studies to identify therapeutic targets. We have found that immune cells mediate SSBP via Epithelial Sodium Channel (ENaC). CXCL8/(IL-8), a known chemoattractant plays a well-known role in glycolysis. We hypothesize that CXCL8 mediates immune metabolic reprogramming of immune cells to glycolysis via ENaC. To test this hypothesis, we performed bulk and single cell RNA sequencing in human monocytes from individuals from a modified Weinberger inpatient salt loading/ depletion protocol. The participants were instructed to refrain from taking their blood pressure medication for 2 weeks prior to the salt loading/depletion protocol. Blood and urine samples were collected, as well as ambulatory blood pressure recording. We found that changes in immune cell activation via isolevuglandin (IsoLG) protein-adducts mirror changes in salt balance and blood pressure in salt sensitive but not salt resistant individuals. We confirmed that these in vivo changes can be recapitulated in vitro. In addition, we found that salt-loading both in vivo and in vitro increases antigen presenting cell production of IL-8, which was reversed after salt depletion in salt sensitive, but not salt resistant people. ENaC inhibition by amiloride prevented the high salt-induced production of IL-8. Moreover, high salt induced blood pressure changes of expression of CXCL8 (p = 0.01553, r = 0.8067) were significant along with varying expression of glycolytic genes, including hexokinase 1(HK1)(p = 0.04190, r = -0.7249), phosphofructokinase (PFKP)(p = 0.05932, r = 0.6879) and galactose mutarotase (GALM) (p = 0.04176, r = 0.5138). Seahorse analysis revealed increased extracellular acidification rate (ECAR) in high salt conditioned monocytes, which was associated with mitochondrial dysfunction. Our results suggest that high salt intake reprograms antigen presenting cell metabolism to glycolysis via IL-8 signaling. Furthermore, targeting IL-8 and mitochondrial switching to glycolysis may not only provide novel therapeutic approaches, but also important biomarkers for diagnosis of salt sensitivity of blood pressure. 1R03HL155041-01 (Kirabo, PI), 1R01HL144941-01A1 (Kirabo, PI), 5R01HL147818-22 (Kleyman & Kirabo), 1R01HL157584-01 (Shibao, Kirabo — MPI), R01DK135764 (Kon, Shelton, Kirabo — MPI), R21TW012635 (Kirabo, Masenga — MPI), Meharry Medical College: School of Graduate Studies T32AI007281, T32GM14492, andT32HL00773. This is the full abstract presented at the American Physiology Summit 2024 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.

Accuracy of 24 h ambulatory blood pressure recordings for diagnosing high 44 h blood pressure in hemodialysis: a diagnostic test study.

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

Comparison of two single-pill dual combination antihypertensive therapies in Chinese patients: a randomized, controlled trial

BackgroundCurrent hypertension guidelines recommend combination of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker with a calcium-channel blocker or thiazide diuretic as initial antihypertensive therapy in patients with monotherapy uncontrolled hypertension. However, to what extent these two different combinations are comparable in blood pressure (BP)-lowering efficacy and safety remains under investigation, especially in the Chinese population. We investigated the BP-lowering efficacy and safety of the amlodipine/benazepril and benazepril/hydrochlorothiazide dual therapies in Chinese patients.MethodsIn a multi-center, randomized, actively controlled, parallel-group trial, we enrolled patients with stage 1 or 2 hypertension from July 2018 to June 2021 in 20 hospitals and community health centers across China. Of the 894 screened patients, 560 eligible patients were randomly assigned to amlodipine/benazepril 5/10 mg (n = 282) or benazepril/hydrochlorothiazide 10/12.5 mg (n = 278), with 213 and 212 patients, respectively, who completed the study and had a valid repeat ambulatory BP recording during follow-up and were included in the efficacy analysis. The primary outcome was the change from baseline to 24 weeks of treatment in 24-h ambulatory systolic BP. Adverse events including symptoms and clinically significant changes in physical examinations and laboratory findings were recorded for safety analysis.ResultsIn the efficacy analysis (n = 425), the primary outcome, 24-h ambulatory systolic BP reduction, was − 13.8 ± 1.2 mmHg in the amlodipine/benazepril group and − 12.3 ± 1.2 mmHg in the benazepril/hydrochlorothiazide group, with a between-group difference of − 1.51 (p = 0.36) mmHg. The between-group differences for major secondary outcomes were − 1.47 (p = 0.18) in 24-h diastolic BP, − 2.86 (p = 0.13) and − 2.74 (p = 0.03) in daytime systolic and diastolic BP, and − 0.45 (p = 0.82) and − 0.93 (p = 0.44) in nighttime systolic and diastolic BP. In the safety analysis (n = 560), the incidence rate of dry cough was significantly lower in the amlodipine/benazepril group than in the benazepril/hydrochlorothiazide group (5.3% vs 10.1%, p = 0.04).ConclusionsThe amlodipine/benazepril and benazepril/hydrochlorothiazide dual therapies were comparable in ambulatory systolic BP lowering. The former combination, compared with the latter, had a greater BP-lowering effect in the daytime and a lower incidence rate of dry cough.Trial registrationClinicalTrials.gov, NCT03682692. Registered on 18 September 2018.

Study protocol for the Heads-Up trial: a phase II randomized controlled trial investigating head-up tilt sleeping to alleviate orthostatic intolerance in Parkinson’s Disease and parkinsonism

BackgroundIn persons with Parkinson’s Disease (PD) or certain forms of atypical parkinsonism, orthostatic hypotension is common and disabling, yet often underrecognized and undertreated. About half of affected individuals also exhibit supine hypertension. This common co-occurrence of both orthostatic hypotension and supine hypertension complicates pharmacological treatments as the treatment of the one can aggravate the other. Whole-body head-up tilt sleeping (HUTS) is the only known intervention that may improve both. Evidence on its effectiveness and tolerability is, however, lacking, and little is known about the implementability.MethodsIn this double-blind multicenter randomized controlled trial (phase II) we will test the efficacy and tolerability of HUTS at different angles in 50 people with PD or parkinsonism who have both symptomatic orthostatic hypotension and supine hypertension. All participants start with one week of horizontal sleeping and subsequently sleep at three different angles, each maintained for two weeks. The exact intervention will vary between the randomly allocated groups. Specifically, the intervention group will consecutively sleep at 6°, 12° and 18°, while the delayed treatment group starts with a placebo angle (1°), followed by 6° and 12°. We will evaluate tolerability using questionnaires and compliance to the study protocol. The primary endpoint is the change in average overnight blood pressure measured by a 24-hour ambulatory blood pressure recording. Secondary outcomes include orthostatic blood pressure, orthostatic tolerance, supine blood pressure, nocturia and various other motor and non-motor tests and questionnaires.DiscussionWe hypothesize that HUTS can simultaneously alleviate orthostatic hypotension and supine hypertension, and that higher angles of HUTS are more effective but less tolerable. The Heads-Up trial will help to clarify the effectiveness, tolerability, and feasibility of this intervention at home and can guide at-home implementation.Trial registrationClinicalTrials.gov NCT05551377; Date of registration: September 22, 2022.

Impact of CPAP Therapy on the Autonomic Nervous System.

Obstructive sleep apnea (OSA) is a significant risk factor for cardiovascular disease (CVD) with increasing prevalence. An important mechanism of CVD development is a dysregulation of the autonomic nervous system (ANS). This prospective and controlled cohort study aimed to investigate ANS function in OSA including the response to long-term continuous positive airway pressure (CPAP) therapy by analyzing 24 h Holter electrocardiogram and 24 h Holter ambulatory blood pressure recording parameters. The study enrolled 57 patients who were newly diagnosed with severe OSA. After 6 months of CPAP therapy, 37 patients had a good therapy adherence (usage of CPAP device >4 h per night), and their data were analyzed. The difference in nocturnal diastolic blood pressure values before and after CPAP therapy reached statistical significance (76 (68-84) vs. 74 (63-80) mmHg, p = 0.0439). Lower nocturnal values after CPAP therapy of SDNN (101.5 vs. 95 ms, p = 0.0492) and RMSSD (29.5 vs. 26 ms, p = 0.0193) were found. An increase in diurnal spectral power (1742 vs. 2112 ms2, p = 0.0282) and a decrease in nocturnal spectral power (3256 vs. 2124 ms2, p = 0.0097), nocturnal VLF band (2493 vs. 1485.4 ms2, p = 0.0176), nocturnal LF band (638.7 vs. 473 ms2, p = 0.0097), and nocturnal HF band (234.9 vs. 135.7 ms2, p = 0.0319) was found. The results showed an imbalance of the ANS with a sympathetic predominance, especially during the night hours and in those with arterial hypertension. The impact of CPAP therapy on the improvement in ANS parameters was more pronounced at night, in men, and those with arterial hypertension.

Effect of initial treatment with a single pill containing quadruple combination of quarter doses of blood pressure medicines versus standard dose monotherapy on ambulatory blood pressure indices

Abstract Background The QUARTET trial showed that a combination of four ultra-low-dose blood pressure (BP) medications lowered mean unattended office BP more effectively than initial monotherapy. Purpose To investigate the effects of a combination of four ultra-low-dose blood pressure (BP) medications on ambulatory BP changes. Methods Australian adults (≥18 years) with hypertension who were untreated or on monotherapy were eligible for participation in the QUARTET study. Overall, 591 participants were randomly assigned to receive either the quadpill (containing irbesartan 37.5 mg, amlodipine 1.25 mg, indapamide 0.625 mg, and bisoprolol 2.5 mg) or an indistinguishable monotherapy control (irbesartan 150 mg). The difference in 24-hour, daytime and night-time systolic and diastolic ambulatory BP at 12 and 52 weeks were pre-defined secondary outcomes. Reported parameters for this analysis were derived from ambulatory BP recordings of 576 participants that fulfilled pre-defined validation criteria. Results Of 576 participants, 289 were randomized to the quadpill group and 287 to the monotherapy group. At baseline, 24-h systolic/diastolic BP was 139.2/81.0 mmHg in the monotherapy vs. 139.8/81.3 in the quadpill group, daytime BP was 142.5/83.5 vs 143.4/84.0 mmHg, and night-time BP was 125.1/70.7 vs. 125.4/70.7 mmHg. At 12 weeks, mean 24-h ambulatory systolic and diastolic BP were 7.7 (95%CI: 9.6, 5.8) and 5.3 (95%CI: 6.5, 4.1) mmHg lower in the quadpill versus monotherapy group (p<0.001 for both). Similar reductions were observed for daytime (8.1/5.7 mmHg lower in quadpill compared to montherapy group) and night-time (6.3/4.0 mmHg lower in quadpill compared to monotherapy group) BP (all p<0.001) at 12 weeks. The reduction in systolic and diastolic ambulatory BP variability were more pronounced in the quadpill group at 12 weeks, the 24-h standard deviation was reduced by -1.2 (-1.8, -0.5) mmHg for systolic and -0.9 (-1.5, -0.4) mmHg diastolic BP. The rate of BP control (24 hours BP ≥130 and/or ≥80 mmHg) at 12 weeks was higher in the quadpill group (77% vs 50%; p<0.001). These effects were maintained at 52 weeks. Conclusion A quadruple quarter-dose combination compared to monotherapy resulted in greater ambulatory BP lowering across the entire 24-hour period with higher ambulatory BP control rates at both 12 and 52 weeks. These findings further substantiate the efficacy of an ultra-low-dose quadpill-based BP lowering strategy – which has been previously shown not to increase the rate of side effects - and extends it to ambulatory BP measurements.

Cardiovascular variability, sociodemographics, and biomarkers of disease: the MIDUS study.

Introduction: Like heart rate, blood pressure (BP) is not steady but varies over intervals as long as months to as short as consecutive cardiac cycles. This blood pressure variability (BPV) consists of regularly occurring oscillations as well as less well-organized changes and typically is computed as the standard deviation of multiple clinic visit-to-visit (VVV-BP) measures or from 24-h ambulatory BP recordings (ABPV). BP also varies on a beat-to-beat basis, quantified by methods that parse variation into discrete bins, e.g., low frequency (0.04-0.15Hz, LF). However, beat-to-beat BPV requires continuous recordings that are not easily acquired. As a result, we know little about the relationship between LF-BPV and basic sociodemographic characteristics such as age, sex, and race and clinical conditions. Methods: We computed LF-BPV during an 11-min resting period in 2,118 participants in the Midlife in the US (MIDUS) study. Results: LF-BPV was negatively associated with age, greater in men than women, and unrelated to race or socioeconomic status. It was greater in participants with hypertension but unrelated to hyperlipidemia, hypertriglyceridemia, diabetes, elevated CRP, or obesity. LF-diastolic BPV (DBPV), but not-systolic BPV (SBPV), was negatively correlated with IL-6 and s-ICAM and positively correlated with urinary epinephrine and cortisol. Finally, LF-DBPV was negatively associated with mortality, an effect was rendered nonsignificant by adjustment by age but not other sociodemographic characteristics. Discussion: These findings, the first from a large, national sample, suggest that LF-BPV differs significantly from VVV-BP and ABPV. Confirming its relationship to sociodemographic risk factors and clinical outcomes requires further study with large and representative samples.

BP PHENOTYPES IN PATIENTS UNDERGOING LONG-TERM PERITONEAL DIALYSIS DEFINED WITH HOME VERSUS AMBULATORY BP MONITORING

Objective: The concomitant assessment of office with out-of-office blood pressure (BP) measurements enables the identification of white-coat and masked hypertension. The aim of the present study was to explore the prevalence of these BP phenotypes in end-stage kidney disease patients undergoing peritoneal dialysis (PD) with the use of home versus ambulatory BP monitoring. Design and method: In 140 patients receiving long-term PD in 4 centers of Northern Greece, we assessed the BP with the following methods: (i) triplicate office BP measurements after a 5-minute seated rest with the automatic device HEM 705-CP (Omron, HealthCare); (ii) home BP measurements twice daily for 7 consecutive days with validated BP monitors; (iii) 24-hour ambulatory BP monitoring with the oscillometric device Mobil-O-Graph (IEM, Stolberg, Germany). The BP phenotypes were diagnosed using the threshold of 140/90 mmHg for office measurements and the threshold of 135/85 mmHg for home and daytime ambulatory BP recordings, respectively. Results: When office BP recordings were assessed together with home BP measurements, 57 patients (40.7%) were classified as normotensives, 8 patients (5.7%) had white-coat hypertension, 21 patients (15.0%) had masked hypertension and the remaining 54 patients (38.6%) had sustained hypertension. With the evaluation of office and daytime ambulatory BP, 59 patients (42.1%) had normotension, 13 patients (9.1%) had white-coat hypertension, 19 patients (13.6%) had masked hypertension and 49 patients (35.0%) had sustained hypertension. In 119 out of 140 patients (85.0%), there was absolute agreement between home and daytime ambulatory BP in the diagnosis of BP phenotype (k-coefficient: 0.775, P<0.001). Conclusions: The present study shows that among patients undergoing PD, there is satisfactory agreement between home and daytime ambulatory BP in the identification of phenotypes of white-coat and masked hypertension.

Pathophysiology, Diagnosis, and Management of Hypertension in the Elderly.

There is a high prevalence of systemic arterial hypertension in the elderly; 70% of adults >65 years have this disease. A key mechanism in the development of hypertension in the elderly is increased arterial stiffness. This accounts for the increase in systolic blood pressure and pulse pressure and fall in diastolic blood pressure (isolated systolic hypertension) that are commonly seen in the elderly, compared with younger persons. The diagnosis of hypertension is made on the basis of in-office blood pressure measurements together with ambulatory and home blood pressure recordings. Lifestyle changes are the cornerstone of management of hypertension. Comprehensive guidelines regarding blood pressure threshold at which to start pharmacotherapy as well as target blood pressure levels have been issued by both European and American professional bodies. In recent years, there has been considerable interest in intensive lowering of blood pressure in older patients with hypertension. Several large, randomized controlled trials have suggested that a strategy of aiming for a target systolic blood pressure of <120 mm Hg (intensive treatment) rather than a target of <140 mm Hg (standard treatment) results in significant reduction in the incidence of adverse cardiovascular events and total mortality. A systolic blood pressure treatment of <130 mm Hg should be considered favorably in non-institutionalized, ambulatory, free living older patients. In contrast, in the older patient with a high burden of comorbidities and limited life expectancy, an individualized team-based approach, based on clinical judgment and patient preference should be adopted. An increasing body of evidence for older adults with hypertension suggests that intensive blood pressure lowering may prevent or at least partially prevent cognitive decline.

Ambulatory hypertension diagnosed by 24-h mean ambulatory versus day and night ambulatory blood pressure thresholds in children: a cross-sectional study

BackgroundThe agreement between the commonly used ambulatory blood pressure (ABP) thresholds to diagnose ambulatory hypertension in children (patient’s 24-h mean ABP classified by 24-h 95th ABP percentile threshold, American Heart Association [AHA] threshold, or patient’s day and night mean ABP classified by day-night 95th ABP percentile thresholds) is not known. We evaluated the agreement among 24-h ABP threshold, AHA threshold, and day-night ABP thresholds to diagnose ambulatory hypertension, white coat hypertension (WCH) and masked hypertension (MH).MethodsIn a cross-sectional study design, we analyzed ABP recordings from 450 participants with suspected hypertension from a tertiary care outpatient hypertension clinic. The American Academy of Pediatrics thresholds were used to diagnose office hypertension.ResultsThe 24-h ABP threshold and day-night ABP thresholds classified 19% ABP (95% confidence interval [CI], 0.15–0.23) differently into ambulatory normotension/hypertension (kappa [κ], 0.58; 95% CI, 0.51–0.66). Ambulatory hypertension diagnosed by 24-h ABP threshold in 27% participants (95% CI, 0.22–0.32) was significantly lower than that by day-night ABP thresholds in 44% participants (95% CI, 0.37–0.50; P < 0.001). The AHA threshold had a stronger agreement with 24-h ABP threshold than with day-night ABP thresholds for classifying ABP into ambulatory normotension/hypertension (k 0.94, 95% CI 0.91–0.98 vs. k 0.59, 95% CI 0.52–0.66). The diagnosis of ambulatory hypertension by the AHA threshold (26%; 95% CI, 0.21–0.31) was closer to that by 24-h ABP threshold (27%, P = 0.73) than by day-night ABP thresholds (44%, P < 0.001). Similar agreement pattern persisted among these ABP thresholds for diagnosing WCH and MH.ConclusionsThe 24-h ABP threshold classifies a lower proportion of ABP as ambulatory hypertension than day-night ABP thresholds. The AHA threshold exhibits a stronger agreement with 24-h ABP than with day-night ABP thresholds for diagnosing ambulatory hypertension, WCH and MH. Our findings are relevant for a consistent interpretation of hypertension by these ABP thresholds in clinical practice.

Short-term blood pressure variability and outcomes in non-dialysis chronic kidney disease.

BackgroundBlood pressure variability (BPV) is associated with cardiovascular and all-cause mortality, and has been demonstrated in dialysis patients, but has been poorly studied and remains controversial in non-dialysis chronic kidney disease (CKD) patients. We investigated the effect of short-term BPV on prognosis in this population.MethodsA total of 245 stage 1–4 CKD patients with 24-h ambulatory blood pressure recordings were recruited. BPV was evaluated by standard deviation, coefficient of variation, and variation independent of the mean, respectively. All subjects were followed up to the composite end-point event or until January 15, 2020. Patients were divided into two groups based on 24-h median variation independent of the mean, and demographics, laboratory indicators and echocardiogram results were compared. Logistic regression was used to analyze the risk factors for increased BPV. Multivariate Cox regression and Kaplan-Meier survival analysis were used to explore the relationship between BPV and renal prognosis and major cardiovascular events.ResultsThe mean age was 42.07 ± 12.66 years, with 141 males (57.55%). Multivariate Logistic regression analysis showed that high BMI (OR 1.110, P = 0.017), hyperkalemia (OR 2.227, P = 0.040), increased left ventricular end-diastolic diameter (OR 1.103, P = 0.010) and hypertension (OR 2.525, P = 0.002) were independent risk factors for high BPV. Kaplan-Meier survival analysis showed that renal and cardiovascular outcomes were better in the low BPV group than in the high BPV group (P = 0.006; P = 0.002). After adjusting for age, sex and traditional kidney related risk factors, BPV were not independently associated with renal outcomes. High BPV (HR 4.662, P = 0.017) was the main independent risk factor for major cardiovascular events in CKD.ConclusionsIn non-dialysis CKD, short-term BPV was associated with major cardiovascular disease but not renal progression. BMI, hypertension, potassium balance, and left ventricular end-diastolic diameter influenced short-term BPV.

Home Blood Pressure monitoring: An economical, reliable, and convenient Tool over ambulatory Blood Pressure monitoring in Patients on Dialysis.

Hypertension and cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients on dialysis. Blood pressure (BP) control is of paramount importance in reducing morbidity and mortality in this high-risk population, although there is no consensus on target BP. Ambulatory BP recording is considered gold standard in estimating the BP among patients on dialysis. But, ambulatory BP recording is cumbersome, not economical, and not easily available to Indian patients. Therefore, an easier and more convenient method has to be implemented to monitor the BP. Some studies demonstrated that home BP recordings may be promising in making a more accurate diagnosis of hypertension in hemodialysis patients. However, there is paucity of research that compares home-based BP monitoring with ambulatory BP recordings in patients on hemodialysis. The present study was thus planned to examine the hypothesis that out-of-dialysis unit BP measurement in the form of home-based measurement of BP is as efficacious as ambulatory BP monitoring (ABPM) in evaluating hypertension among patients on hemodialysis. To assess the accuracy of home-based BP monitoring in comparison to ABPM among chronic kidney disease (CKD) patients on hemodialysis. To assess the ability of home-based BP monitoring to detect hypertension among CKD patients on hemodialysis. This was a prospective observational study carried out in the Department of Medicine in a tertiary care hospital. The total duration of the study was 24 months. Fifty-two CKD patients on hemodialysis fulfilling the eligibility criteria were taken up for the study after informed consent. Blood pressure was measured using a standardized BP measuring equipment at home, thrice a day for 3 days in the interdialysis period. Also, all these patients were subjected to 24 hours of ABPM in the interdialysis period. Home-based BP monitoring records are then compared with the one-time ABPM records. All statistical calculations were done using computer programs Microsoft Excel 2007 (Microsoft Corporation, NY, USA) and SPSS (Statistical Product and Service Solutions; SPSS Inc., Chicago, Illinois, USA) version 21. In our study, the mean awake, asleep, and average ABPM readings of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 141.69/81.33, 139.39/80.04, and 141.23/80.67 mm Hg, respectively, while the mean SBP and DBP recorded on home-based measurements were 143.6 and 82.69 mm Hg, respectively. All the subjects showing mean SBP ≥140 mm Hg as per ABPM had home-based readings of above 140 mm Hg while 23 out of 27 patients (85.2%) with mean SBP &lt;140 mm Hg as per ABPM had similar observation by home-based monitoring (kappa 0.847; p&lt;0.01). All the subjects showing mean DBP ≥90 mm Hg as per ABPM had home-based readings of above 90 mm Hg while 42 out of 44 patients (95.5%) with mean DBP &lt;90 mm Hg as per ABPM had similar observation by home-based monitoring (kappa 0.866; p&lt;0.01). Our study shows that there is no difference between BP readings as observed by ABPM and home-based BP monitoring. Also, home-based BP monitoring can detect hypertension as effectively as ABPM among patients on hemodialysis, thereby making home-based BP monitoring a safe and reliable method of BP measurement in clinical practice.

A Study Comparing Office Blood Pressure with Ambulatory Blood Pressure in Successful Adult Kidney-Transplant Recipients at a Tertiary Care Center in North India

Introduction: Hypertension is common following successful renal transplantation and has adverse effects on cardio-vascular and graft health. Blood pressure (BP) readings obtained during clinical visits can be misleading and ambulatory blood pressure monitoring (ABPM) is a more reliable and accurate non-invasive method of BP monitoring. Aims and Objectives: To compare office BP with ambulatory BP recordings in successful adult kidney transplant recipients (KTRs). Material and Methods: Office BP (OBP) was measured with mercury sphygmomanometer according to standardized procedure as the mean of two readings taken 1 minute apart; thereafter, 24 hour ABPM was done using automated oscillometric device (Meditech device) in 56 KTRs. Results: OBP missed hypertension in 68% of KTRs who had normal OBP (masked phenomenon) and OBP overestimated hypertension in 11% of KTRs with uncontrolled OBP (white coat phenomenon). Thirty-four percent of patients were normal dippers, 32% non-dippers, 25% reverse dippers and 9% were extreme dippers. Conclusions: ABPM is a valuable tool in detecting dipping status, white coat and masked phenomena which are frequent problems among KTRs and should be considered as part of routine management of hypertension in KTRs.

Predictors of Hypertension Development 1 Year After Heart Transplantation.

Hypertension after heart transplantation (HTx) is common. We investigated predictors of and mechanisms for hypertension development during the first year after HTx, with particular attention toward immunosuppressive agents, reinnervation processes, and donor/recipient sex. Heart transplant recipients (HTxRs) were consecutively enrolled 7 to 12 wk after surgery and followed prospectively for 12 mo. Ambulatory blood pressure recordings and autonomic cardiovascular control assessments were performed at baseline and follow-up. Possible predictors of posttransplant hypertension development were investigated in bivariate linear regression analyses followed by multiple regression modeling. A total of 50 HTxRs were included; 47 attended the follow-up appointment at 12 mo. Mean systolic and diastolic blood pressure increased significantly during the observational period (systolic blood pressure from 133 to 139 mm Hg, P = 0.007; diastolic blood pressure from 81 to 84 mm Hg, P = 0.005). The blood pressure increment was almost exclusively confined to HTxRs with a female donor heart, doubling the cases of systolic hypertension (from 6 to 13/14; 46% to 93%, P = 0.031) and diastolic hypertension (from 7 to 14/14; 54% to 100%, P = 0.031) in this subgroup. Autonomic cardiovascular control assessments suggested tonically constricted resistance and capacitance vessels in recipients with female donor hearts. Immunosuppressive agents and reinnervation markers were not associated with hypertension development. Blood pressures increase during the first year after HTx, with female donor sex as a strong predictor of recipient hypertension development. The underlying mechanism seems to be enhanced peripheral vasoconstriction caused by attenuated cardiovascular homeostasis capabilities. Further studies are needed to confirm the results.

Epidemiology of Hypertension among Patients on Peritoneal Dialysis Using Standardized Office and Ambulatory Blood Pressure Recordings

Introduction: Prior studies conducted in peritoneal dialysis (PD) patients in the late 1990s provided considerably variable estimates of the prevalence and control of hypertension. The present study aimed to investigate the current state of hypertension management in this high-risk population. Methods: In 140 stable PD patients, we performed standardized automated office blood pressure (BP) measurements and 24-h ambulatory BP monitoring (ABPM) using the Mobil-O-Graph device (IEM, Germany). Office and ambulatory hypertension was diagnosed in patients with office BP ≥140/90 mm Hg and 24-h BP ≥130/80 mm Hg, respectively. Patients treated with ≥1 BP-lowering medications were also classified as hypertensives. Results: The prevalence of office and ambulatory hypertension was 92.9% and 95%, respectively. In all, 92.1% of patients were being treated with an average of 2.4 BP-lowering medications daily. Adequate BP control was achieved in 52.3% and 38.3% of hypertensives by office BP and ABPM, respectively. The agreement between these 2 techniques in the identification of patients with BP levels above the diagnostic thresholds of hypertension was moderate (k-statistic: 0.524). In all, 5% of patients were normotensives with both techniques, 31.4% had controlled hypertension, 5% had white-coat hypertension, 19.3% had masked hypertension, and 39.3% had sustained hypertension. Isolated nocturnal hypertension was detected in 23.6% of patients, whereas no patient had isolated daytime hypertension. Conclusion: Among PD patients, hypertension is highly prevalent and remains often inadequately controlled. The use of ABPM enables the better classification of severity of hypertension and identification of isolated nocturnal hypertension, which is a common BP phenotype in the PD population.

Association of peridialytic, intradialytic, scheduled interdialytic and ambulatory BP recordings with cardiovascular events in hemodialysis patients.

Ambulatory-BP-monitoring (ABPM) is recommended for hypertension diagnosis and management in hemodialysispatients due toits strong association with outcomes. Intradialytic and scheduled interdialytic BP recordings show agreement with ambulatory BP. This study assesses in parallel the association of pre-dialysis, intradialytic, scheduled interdialytic and ambulatory BP recordings with cardiovascular events. We prospectively followed 242 hemodialysis patients with valid 48-h ABPMs for a median of 45.7months to examine the association of pre-dialysis, intradialytic, intradialytic plus pre/post-dialysis readings, scheduled interdialytic BP, and 44-h ambulatory BP with outcomes. The primary end-point was a composite one, composed of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary revascularization procedure or peripheral revascularization procedure. Cumulative freedom from the primary end-point was significantly lower with increasing 44-h SBP (group 1, < 120mmHg, 64.2%; group 2, ≥ 120 to < 130mmHg 60.4%, group 3, ≥ 130 to < 140mmHg 45.3%; group 4, ≥ 140mmHg 45.5%; logrank-p = 0.016). Similar were the results for intradialytic (logrank-p = 0.039), intradialytic plus pre/post-dialysis (logrank-p = 0.044), and scheduled interdialytic SBP (logrank-p = 0.030), but not for pre-dialysis SBP (logrank-p = 0.570). Consideringgroup 1 as the reference group, the hazard ratios of the primary end-point showed a gradual increase with higher BP levels with all BP metrics, except pre-dialysis SBP. This pattern was confirmedin adjusted analyses. An inverse association of DBP levels with outcomes was shown with all BP metrics, which was no longer evident in adjusted analyses. Averaged intradialytic and scheduled home BP measurements (but not pre-dialysis readings) display similar prognostic associations with 44-h ambulatory BP in hemodialysis patients and represent valid metrics for hypertension management in these individuals.

Blood Pressure Variability: Mechanisms, Measurement, Subtypes, and Clinical Implications

The complex topic of short- and long-term blood pressure (BP) variability confounds the diagnosis, classification, and management of hypertension. True pathophysiologic BP variation (systematic and non-systematic deviations between- and within-individuals) is related to heart rate, respiration, complex responses of the sympathetic nervous system, vascular reactivity, and arterial stiffness. Measurement errors (systematic biases and random error) further compound the analysis. Most studies use serial clinic BP values, 24-hour ambulatory BP recordings, or home BP values with standard statistical indicators (standard deviation, variance, or coefficient of variation) or absolute real variability (mean difference of successive values). Clinical impact in retrospective secondary analyses includes a modest increase in cardiovascular disease (CVD) risk (equivalent to a few mmHg in mean systolic BP) yet questions remain whether adjustment for mean BP is needed. BP variability is reduced to a small degree by calcium antagonists and increased by ACE inhibitors, beta-blockers, and alpha-blockers but no interventional trial has addressed the question of whether reducing BP variability confers CVD risk protection. BP variability is not specifically discussed in practice guidelines but it is tacitly acknowledged by recommendations to repeat BP measurements, standardize technique, and confirm the hypertension diagnosis by home or ambulatory BP measurements to account for the “white coat effect.” There is no formal consensus on how to quantitate or manage BP variability despite a real-world need for better diagnostic and therapeutic guidance. Practitioners should thus focus on control of (mean) BP using combinations of agents that improve CVD outcomes. Future consensus guidance should directly address BP variability and should include educational materials for physicians, patient-contact staff, and patients.

MO103PREDICTION OF CARDIOVASCULAR OUTCOMES WITH PERIDIALYTIC, INTRADIALYTIC, SCHEDULED INTERDIALYTIC AND AMBULATORY BP RECORDINGS IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Ambulatory-BP-monitoring (ABPM) is recommended for hypertension diagnosis and management in hemodialysis subjects due to high accuracy and strong associations with outcomes. The agreement and prediction of averaged intradialytic BP readings and home BP readings with ABPM and clinical outcomes is not known. This study assesses in parallel the association of pre-dialysis, intradialytic, scheduled interdialytic and ambulatory BP recordings with cardiovascular outcomes and mortality in this population. Method We prospectively followed for 49.1±25.6 months 242 hemodialysis patients with valid 48-hour ABPMs to examine the association of pre-dialysis, intradialytic, intradialytic plus pre/post-dialysis readings, scheduled interdialytic BP (the average of out-of-dialysis day readings at 8:00 am and 8:00 pm) and 44-hour ambulatory BP with outcomes. The primary end-point was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary revascularization procedure or peripheral revascularization procedure. Results Cumulative freedom from the primary end-point was significantly lower with increasing 44-hour SBP (group 1, &amp;lt;120 mmHg, 64.2%; group 2, ≥120 to &amp;lt;130 mmHg 60.4%, group 3, ≥130 to &amp;lt;140 mmHg 45.3%; group 4, ≥140 mmHg 45.5%; logrank-p=0.016). Similar were the results for intradialytic (logrank-p=0.039), intradialytic plus pre/post-dialysis (logrank-p=0.044), and scheduled interdialytic SBP (logrank-p=0.030), but not for pre-dialysis SBP (logrank-p=0.570). With group 1 as the reference group, the Hazard Ratios of the primary end-point showed a gradual increase with higher BP levels with all BP metrics, except pre-dialysis SBP. An inverse association of DBP levels with outcomes was shown with all BP metrics. Conclusion Averaged intradialytic and scheduled home BP measurements (but not pre-dialysis readings) display similar patterns of prognostic associations with 44-hour ambulatory BP in hemodialysis patients and represent valid metrics for hypertension management in these individuals.

NORMAL-TENSION GLAUCOMATOUS OPTIC NEUROPATHY IS RELATED TO BLOOD PRESSURE VARIABILITY IN THE MARACAIBO AGING STUDY

Objective: Optic nerve hypoperfusion might play a role in the pathogenesis of normal-tension glaucomatous optic neuropathy. Although the ocular perfusion pressure is partly determined by blood pressure levels, no previous study have addressed the risk of glaucomatous optic neuropathy in relation to blood pressure (BP) variability, independent of the BP level. We aimed this study o assess reading-to-reading BP variability of mean arterial pressure (MAP) in 24 h ambulatory BP recordings as risk factor for normal-tension glaucomatous optic neuropathy. Design and method: The Maracaibo Aging Study is a population-based epidemiological study conducted to investigate age-related diseases and which currently includes more than 3000 participants =&gt;40 years of age assessed between 1998 and 2015. For the present study, we selected 93 participants who underwent cross-sectional optical coherence tomography, visual field assessment and 24 h ambulatory BP monitoring (2011–2016). Glaucoma cases were defined as normal-tension glaucomatous optic neuropathy with and without visual field defects. BP variability was reading-to reading variability of 24 h MAP, a determinant of ocular perfusion pressure, captured by a variable independent of the BP level (VIMmap). ORs were expressed per 2 mm Hg (1 SD) increment in VIMmap. Odds ratios (ORs) were adjusted for BP level and confounders summarized or not in a propensity score. Results: Among the 93 participants (87.1% women; mean age, 61.9 years), 26 had open-angle glaucomatous optic neuropathy at both eyes; 14 with and 19 without visual field defects. The ORs ratios for glaucomatous optic neuropathy, expressed per 1 SD increment in VIMmap (2 mm Hg), were 2.17 (95% confidence interval, 1.33–3.53) unadjusted; 2.20 (1.35–3.61) adjusted for 24 h MAP level only; 1.93 (1.10–3.41) with additional adjustment for age, educational attainment, high-density lipoprotein cholesterol and office hypertension, and 1.95 (1.10–3.45) in models also including intraocular pressure. Conclusions: We confirmed our a priori hypothesis that BP variability, most likely operating via hypoperfusion of the optic nerve, is a risk factor for normal-tension glaucomatous optic neuropathy. 24-H ambulatory BP monitoring might therefore help in stratifying for risk of normal-tension glaucomatous optic neuropathy.