Average 24-hour Systolic Blood Pressure Research Articles

Relationship between office and ambulatory blood pressure and various stress coping strategies in young adults

Aim. To study the relationship between office and ambulatory blood pressure (BP) and various stress coping strategies in healthy young adults.Material and methods. The design of the cross-sectional study included individuals of health status groups I or II aged 20 to 29 years with office BP <140/90 mm Hg. All individuals included in the study underwent office BP measurement and 24-hour ambulatory BP monitoring (ABPM). To determine the frequency of coping strategies, a Ways of Coping Questionnaire was used. For statistical analysis, the Stattech program, version 4.0.6 (Russia) was used.Results. The study included 347 participants, including 101 (29,1%) males; the median age was 22 (21-23) years. Linear dependencies were established between office BP and various ABPM parameters with three stress coping strategies: confrontation, avoidance, and seeking social support. The frequency of confrontation correlated with the greatest number of parameters, both assessed in office BP and ABPM. A direct dependence was noted between confrontation and office systolic blood pressure (SBP) (ρ=0,109; p=0,042) and diastolic blood pressure (DBP) (ρ=0,174; p=0,001), as well as average 24-hour SBP (ρ=0,120; p=0,025) and average day-time SBP (ρ=0,128; p=0,017). The avoidance frequency also directly correlated with the level of office DBP (ρ=0,158; p=0,003). With an increase in avoidance use by 1 point, clinical DBP increases by 0,13 mm Hg. At the same time, an inverse linear relationship was established between the strategy of seeking social support and night-time DBP (ρ=-0,112; p=0,036). With an increase in the frequency of seeking social support by 1 point, a decrease in the average night-time DBP by 0,07 mm Hg is expected.Conclusion. In young people, the level of office and outpatient BP linearly depends on the frequencies of using three models of coping behavior: confrontation, avoidance, and seeking social support.

Interventions aimed to increase average 24-h systolic blood pressure reduce blood pressure drops in patients with reflex syncope and orthostatic intolerance.

Systolic blood pressure (SBP) drops recorded by 24-h ambulatory blood pressure (BP) monitoring (ABPM) identify patients with susceptibility to reflex syncope and orthostatic intolerance. We tested the hypothesis that treatments aimed to increase BP (reassurance, education, and lifestyle measures plus pharmacological strategies) can reduce SBP drops. This was a multicentre, observational proof-of-concept study performed in patients with reflex syncope and/or orthostatic intolerance and with SBP drops on a screening ABPM. Among 144 eligible patients, 111 underwent a second ABPM on average 2.5 months after start of treatment. Overall, mean 24-h SBP increased from 114.1 ± 12.1 to 121.4 ± 14.5 mmHg (P < 0.0001). The number of SBP drops <90 and <100 mmHg decreased by 61%, 46% during daytime, and by 48% and 37% during 24-h period, respectively (P < 0.0001 for all). The dose-response relationship between difference in 24-h average SBP increase and reduction in number of SBP drops reached a plateau around ∼15 mmHg increase of 24-h SBP. The reduction in SBP drop rate was consistent and significant in patients who underwent deprescription of hypotensive medications (n = 44) and in patients who received BP-rising drugs (n = 67). In patients with reflex syncope and/or orthostatic intolerance, an increase in average 24-h SBP, regardless of the implemented strategy, significantly reduced the number of SBP drops and symptom burden. A 13 mmHg increase in 24-h SBP appears to represent the optimal goal for aborting the maximal number of SBP drops, representing a possible target for future interventions. ClincalTrials.gov identifier: NCT05729724.

New definition of hypotension in patients with reflex syncope using 24-hour ambulatory blood pressure monitoring (SynABPM Study)

Abstract Background Diagnostic criteria for ambulatory blood pressure monitoring (ABPM) in patients with suspected reflex syncope are lacking. Purpose We hypothesized that patients with reflex syncope have a higher prevalence of systolic blood pressure (SBP) drops on ABPM than control subjects and we aimed to define the SBP cut-off values that allow identification of patients with hypotensive susceptibility. Methods We compared ABPM data from reflex syncope patients and controls, matched by average 24-hour SBP, age, sex and hypertension. Patients with constitutional hypotension, orthostatic hypotension, predominant cardioinhibition or competing causes of syncope were excluded. Daytime and night-time SBP drops (&amp;lt;110, 100, 90, 80 mmHg) were assessed. Findings were validated in an independent sample. Results In the Derivation cohort, daytime SBP drops were significantly more common in 158 syncope patients than 329 controls. One or more daytime drop &amp;lt;90 mmHg provided the best diagnostic yield (91% specificity, 32% sensitivity, Odds Ratio [OR]=4.6, p=0.001). Two or more-daytime drops &amp;lt;100 mmHg achieved 84% specificity and 40% sensitivity (OR=3.5, p=0.001). Results were confirmed in the Validation cohort: one or more daytime SBP drop &amp;lt;90 mmHg provided 94% specificity and 29% sensitivity (OR=6.2, p&amp;lt;0.001), while two or more daytime SBP drops &amp;lt;100 mmHg achieved 83% specificity and 35% sensitivity (OR=2.6, p&amp;lt;0.001) (Figure 1). Conclusion SBP drops during ABPM are more common in reflex syncope patients than in controls. Cut-off values that may be applied in clinical practice are defined. This study expands the current indications for ABPM to patients with reflex syncope. Funding Acknowledgement Type of funding sources: None.

AMBULATORY BLOOD PRESSURE MONITORING: A NEW DIAGNOSTIC APPROACH FOR DETECTION OF HYPOTENSION IN REFLEX SYNCOPE (SYNABPM 1 STUDY)

Objective: Diagnostic criteria for ambulatory blood pressure monitoring (ABPM) in patients with suspected reflex syncope are lacking. We hypothesized that patients with reflex syncope have a higher prevalence of systolic blood pressure (SBP) drops on ABPM. Design and method: We conducted a retrospective analysis comparing ABPM data from reflex syncope patients and controls, matched by average 24-hour SBP, age, sex and hypertension. Patients with constitutional hypotension, orthostatic hypotension, predominant cardioinhibition or competing causes of syncope were excluded. Daytime and night-time SBP drops (&lt;110, 100, 90, 80 mmHg) were assessed. Hypotensive susceptibility was defined likely or possible for cut-offs achieving the highest sensitivity among those with specificity &gt; 90% and 80–90%, respectively. Findings were validated in an independent sample. Results: In the Derivation cohort, daytime SBP drops were significantly more common in 158 syncope patients than 329 controls. One or more daytime drop &lt; 90 mmHg provided the best diagnostic yield (91% specificity, 32% sensitivity, Odds Ratio [OR] = 4.6, p = 0.001). Two or more-daytime drops &lt; 100 mmHg achieved 84% specificity and 40% sensitivity (OR = 3.5, p = 0.001). Results were confirmed in the Validation cohort: one or more daytime SBP drop &lt; 90 mmHg provided 94% specificity and 29% sensitivity (OR = 6.2, p &lt; 0.001), while two or more daytime SBP drops &lt; 100 mmHg achieved 83% specificity and 35% sensitivity (OR = 3.5, p &lt; 0.001) Conclusions: SBP drops during ABPM are more common in reflex syncope patients than in controls. Cut-off values that may be applied in clinical practice are defined. This study expands the current indications for ABPM to patients with reflex syncope.

AMBULATORY BLOOD PRESSURE MONITORING IN HUNGARY: THE FIRST CROSS-SECTIONAL RESULTS OF AN OPEN LABEL, PROSPECTIVE, OBSERVATIONAL STUDY

Objective: Background: Ambulatory blood pressure monitoring (ABPM) is gold standard method in the diagnosis and follow-up of hypertensive patients. There is no systematic assessment on the daily practice of the utilization of ABPM in Hungary. Aim: The goal of the project is to assess the indication and the number of monitoring, and to analyze the blood pressure results. Design and method: This is a multicenter, open-label, observational non-interventional study. Data collection is performed in GPs’ practices and in outpatient clinics of cardiology and internal medicine. Meditech ABPM-06 monitors are used for ABPM measurements. Basic patients’ data are documented in an eCRF and all ABPM data are transferred through a closed online surface into the database for further analysis. Results: 7498 ABPM were performed between 21st of February and 21st of December, 2021. The monitoring was performed mainly by GPs (62%). The average age of the patients was 54.4 years (12–96 years). More than half of the patients (54%) were female. The indication of ABPM was elevated blood pressure (BP) at home (59.7%), labile BP (41.5%), therapy control (17.0%), suspicion of white coat hypertension (13.5%), suspicion of masked hypertension (2.5%), suspicion of nocturnal hypertension (3.2%) and suspicion of secondary hypertension (1.3%). The average duration of hypertension among hypertensive patients was 9.8 years (1–73 years). 32.6% of the patients were newly diagnosed as hypertensive. The average 24-hour systolic blood pressure was 133.9 mmHg, the average diastolic blood pressure was 79.3 mmHg, while the average pulse rate was 73.2 beats/min. The 24-hour average percent time elevation of systolic and diastolic blood pressure was 53.0% and 38.8%, respectively. The average systolic diurnal index was 9.6%, the average diastolic diurnal index was 13.3%. Conclusions: The two most frequent indication for ABPM in the routine practice are elevated home BP and labile BP values. One third of the patients was newly diagnosed as hypertensive subject. ABPM was performed mainly in patients with uncontrolled hypertension. The routine use of ABPM may increase the awareness of hypertension.

Chronic Kidney Disease and Left Ventricular Hypertrophy. Potent Modifiers of the Prognostic Impact of Circadian Blood Pressure Changes.

It is unclear whether the prognostic value of blood pressure (BP) changes from day to night is modified by concomitant risk factors and organ damage. We studied 3247 clinically hypertensive patients who underwent off-therapy 24-hour ambulatory BP monitoring during their initial diagnostic work-up. Over a mean 9.9-year follow-up, 292 patients developed a first primary outcome event (composite of nonfatal myocardial infarction, nonfatal stroke, cardiovascular death, hospitalization for heart failure) and 281 died. The day-night BP changes were analyzed as night-to-day systolic BP ratio and included in semiparametric Cox models. After allowance for age, sex, diabetes, cigarette smoking, low-density lipoprotein cholesterol, serum uric acid and average 24-hour systolic BP, the night-to-day systolic BP ratio maintained an independent association with outcome (hazard ratio, 1.17 [1.01-1.35]; P=0.041). When 2 markers of organ damage, chronic kidney disease and left ventricular hypertrophy, were added to the model, the night-to-day systolic BP ratio failed to maintain an independent association with outcome (hazard ratio, 1.19 [0.97-1.31]). The Akaike Information Criterion and the Schwarz-Bayes Information Criterion showed that, after allowance for other covariables, the night-to-day systolic BP ratio: (1) provided less information when compared with chronic kidney disease and left ventricular hypertrophy and (2) did not improve information provided by chronic kidney disease and left ventricular hypertrophy. Results were comparable on all-cause death as well as using categories of the night-day systolic BP ratio (extreme dippers, dippers, nondippers, reverse dippers). Chronic kidney disease and left ventricular hypertrophy are potent modifiers of the prognostic value of the circadian BP changes.

Diurnal rhythm of blood pressure in patients with polycythemia vera.

Polycythemia vera increases the risk of hypertension, but there is limited information about the effect on daily blood pressure fluctuations. This study aimed to demonstrate how diurnal blood pressure rhythm is affected in polycythemia vera patients. Fifty (50) patients (33 men; mean age 48 ± 15 years) with a diagnosis of polycythemia vera and 51 age and sex-matched healthy subjects for the control group were prospectively evaluated. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were evaluated by ambulatory blood pressure monitoring (ABPM) as average 24-hour, daytime and nighttime measures. Average 24-hour SBP and DBP, daytime SBP and DBP were similar in both groups. However, nighttime SBP and DBP were significantly higher in the polycythemia vera group compared with the control group (125.3 ± 17.2 and 73.7 ± 12.2 vs. 118.9 ± 12.2 and 69.5 ± 8.5; P = 0.034 and P = 0.044). Both nocturnal SBP fall and nocturnal DBP fall were blunted in the polycythemia vera group compared with the control group (-6.9 ± 8.9 and -11.3 ± 12.2 vs. -11.6 ± 7.7 and -16.3 ± 12.0, respectively). Both hemoglobin and hematocrit levels were positively correlated with nocturnal SBP fall (r = 0.306, P = 0.002 and r = 0.355, P < 0.001; respectively) in all patients. We found that the polycythemia vera group had significantly decreased nocturnal dipping compared with healthy controls. The SBP fall was also positively correlated with hemoglobin and hematocrit levels.

Association of Extreme Nocturnal Dipping With Cardiovascular Events Strongly Depends on Age.

Whether extreme dipping is associated with cardiovascular events (CVE) is unclear. The present study was conducted to test the hypothesis that the prognostic role of extreme dipping varies as a function of age. The analysis was performed in 10 868 participants (53% men) aged 53±15 (mean±SD) years enrolled in 8 prospective studies. Using the ambulatory systolic blood pressure nocturnal decline, we identified 4 groups: dippers (>10%-20%), nondippers (>0%-10%), reverse dippers (≤0%), and extreme dippers (>20%). The association between dipping category and CVE was estimated as a function of age using Cox models adjusted for sex, average 24-hour systolic blood pressure, and traditional risk factors. During a median follow-up of 5.7 years, there were a total of 829 CVE (168 fatal). For extreme dippers, no increase in risk of CVE was observed among the participants <70 years (hazard ratio, 0.99 [95% CI, 0.73-1.34]; P=0.93) compared with dippers. In contrast, among the participants ≥70 years, there was a significant increase in risk (hazard ratio, 1.88 [95% CI, 1.14-3.11]; P=0.013). Among the octogenarians, the hazard ratio (95% CI) for CVE were 2.34 (1.12-4.93) for nondippers (P=0.024), 3.91 (1.75-8.73) for reverse dippers (P=0.001), and 4.12 (1.64-10.37) for extreme dippers (P=0.003) compared with dippers. These data show that extreme dipping is not associated with poorer outcome in people younger than 70 years. A U-shaped relationship between nocturnal blood pressure dipping and adverse outcome is present in subjects older than 70 years. In the octogenarian extreme dippers, the risk of CVEs was 4× higher than in the dippers and similar to that in the reverse dippers.

Prognostic value of average real variability of systolic blood pressure in elderly treated hypertensive patients.

The independent prognostic significance of ambulatory blood pressure variability in the elderly is incompletely clear. We investigated the prognostic value of average real variability of 24-hour blood pressure in elderly treated hypertensive patients. The occurrence of a combined end-point including stroke, coronary events, heart failure requiring hospitalization and peripheral revascularization was evaluated in 757 elderly treated hypertensive patients. According to tertiles of average real variability of 24-hour systolic blood pressure patients were classified as having low (≤8.66 mmHg; n = 252), medium (8.67-10.05 mmHg; n = 252) or high (>10.05 mmHg; n = 253) average real variability. During the follow-up (6.9 ± 3.4 years, range 0.4-12.9 years), 195 events occurred. The event rate of the population was 3.74 per 100 patient-years. After adjustment for age, sex, previous events, diabetes, estimated glomerular filtration rate, left ventricular hypertrophy, left atrial enlargement, asymptomatic left ventricular systolic dysfunction at baseline, 24-hour systolic blood pressure, non-dipping and dipping with high morning surge of blood pressure, patients with high average real variability were at higher cardiovascular risk than those with low average real variability (hazard ratio 1.64, 95% confidence interval 1.12-2.40). In elderly treated hypertensive patients, high average real variability of 24-hour systolic blood pressure is associated with higher cardiovascular risk independently of other risk markers, average 24-hour systolic blood pressure and circadian blood pressure changes.

SHORT-TERM BLOOD PRESSURE VARIABILITY AND CARDIOVASCULAR EVENTS

Objective: Prognostic data on short-term blood pressure variability derived from 24-hour ambulatory monitoring are still limited, even though the prognostic value of long-term visit-to-visit variability in blood pressure seems to be established. The main objective of this study is to assess the prognostic value of blood pressure variability based on 24-hour ambulatory blood pressure measurements, independent of ambulatory central pressure, in the Bordeaux cohort of hypertensive patients. Design and method: We included a total of 914 patients in our study, with an average age of 54 ± 14 years. To be included, subjects had to have undergone 24-hour ambulatory blood pressure monitoring at baseline with four hourly measurements day and night and accurate determination of their wake-up time and bedtime. Patients were followed for 120 ± 78 months on average, during which we recorded 163 cardiovascular events and 58 deaths. Results: In the univariate survival analysis, only the standard deviations of day and nighttime systolic blood pressure (SBP), and day, night and 24-hour heart rate (HR) were found to be associated with occurrence of cardiovascular events. Among these parameters, the standard deviations of night SBP and 24-hour heart rate variability showed the strongest association with the outcome variable. We used the ratio of nighttime SBP SD to 24-hour HR SD as the main variable explanatory for the multivariate survival analysis. In these analyses, the predictive value of variability remains significant with the introduction of major cardiovascular risk factors and average 24-hour SBP, but disappears when 24-hour central pulse pressure is included in the model. Conclusions: In conclusion, the variability of the nocturnal systolic blood pressure determined by 4-hourly ambulatory measurements over 24 hours and heart rate variability are significantly associated with the occurrence of cardiovascular events, independently of average 24-hour systolic blood pressure. However, the significance of this relationship disappears when central pulse pressure is considered.

Plasma microRNA-155-5p is increased among patients with chronic kidney disease and nocturnal hypertension

MicroRNAs play multiple roles in the regulation of blood pressure (BP). Nevertheless, to date, no study has assessed the association between microRNA plasma expression and BP control in chronic kidney disease (CKD) patients. Given this background, we evaluated the plasma expression of miR-155-5p, a translational inhibitor of angiotensin receptor type I, in CKD patients, to determine the association between miR-155-5p level and BP control. In this single-center cross-sectional study, we analyzed the miR-155-5p concentration by quantitative reverse transcriptase polymerase chain reaction using the U6 snRNA as a reference gene and 24-hour ambulatory blood pressure monitoring in CKD patients (stage ≥2) in relation to a control group of healthy age-matched and gender-matched individuals, with normal BP proven by the ambulatory blood pressure monitoring. We enrolled a total of 105 patients with CKD (stages 2–5, including 33 kidney renal transplant recipients), aged 59 ± 14 years; 47% males and 26 healthy volunteers (aged 55 ± 13, 50% male). Within the study group, a total of 36 patients (40%) presented with an average 24-hour systolic BP (SBP) ≥130 mm Hg and 41 patients (45%) presented nocturnal hypertension (NHT; SBP ≥120 mm Hg or diastolic BP ≥ 70 mm Hg). miRNA-155-5p was increased in plasma of CKD patients with median expression relative to control subjects equal to 2.92 (1.34–5.58). Interestingly, the plasma miRNA-155-5p expression was significantly higher in patients with NHT: 4.04 (2.92–10.8) versus 2.01 (1.21–3.07), P = .001 and its expression maintained an independent association with the average nocturnal SBP (coefficient B = 4.368, P = .047) by a multivariate regression analysis adjusted for confounders. The miR-155-5p was increased among CKD patients and further increased among subjects presenting with NHT. Further studies are warranted to determine the role of this non-coding RNA as a potential novel biomarker and therapeutic target in the non-dipping CKD individuals, characterized by increased cardiovascular risk.

P1270Effects of blood pressure variability on layer-specific longitudinal strain in hypertensionP1271 Left atrial dynamics and diastolic function in hypertensive patientsP1272Echocardiographic evaluation of right ventricular function in patients with chronic obstructive pulmonary disease in comparison with healthy groupP1273The impact of preeclampsia on myocardial recovery in women with peripartum cardiomyopahty - speckle tracking studyP1274Diagnostic accuracy of bedside lung ultrasonography in emergency (BLUE)

Our previous study showed sub-epicardial longitudinal strain (EpiLS) was an independent prognostic factor for worse outcome in regular treated hypertension but not global longitudinal strain (GLS) and sub-endocardial longitudinal strain (EndLS). Increased blood pressure variability (BPV) has been found associated with target organ damage in hypertension. However, effects of BPV on layer-specific longitudinal strain have not been well studied. The aim of this study was to investigate the effects of different blood pressure parameters on layer-specific longitudinal strain in hypertension. This study included 95 patients (57 men, age 65 ± 12 years) with uncomplicated hypertension who have been regularly treated for more than 1 year. Speckle tracking echocardiography was used for measurement of longitudinal deformation from 3 apical views of left ventricle. GLS was measured by automated function imaging (AFI). We further divided into sub-endocardial and sub-epicardial myocardium and measured their longitudinal strain by manual click-and-draw method and averaged from 3 apical views. Blood pressure parameters included office systolic blood pressure (SBP), office diastolic blood pressure (DBP), central SBP and DBP by tonometry, average 24-hour SBP and DBP, and BPV parameters by ambulatory blood pressure monitor. BPV parameters included standard deviation of daytime SBP (DSSD), standard deviation of nighttime SBP (NSSD), standard deviation of daytime DBP (DDSD), and standard deviation of nighttime DBP (NDSD). We divided subjects into low and high group according to median level of each strain. No blood pressure parameters were different between low and high EndLS group except week difference in NDSD (9.0 ± 3.4 vs. 7.8 ± 2.0 mmHg, p = 0.051). NSSD (11.2 ± 4.6 vs. 9.3 ± 2.9 mmHg, p = 0.027) and NDSD (9.1 ± 3.4 vs. 7.7 ± 2.0 mmHg, p = 0.031) were significant increased in low GLS group but not other parameters. DDSD (10.3 ± 3.0 vs. 9.0 ± 2.5 mmHg, p = 0.034), NSSD (11.4 ± 4.4 vs. 9.1 ± 3.1 mmHg, p = 0.006), and NDSD (9.2 ± 3.2 vs. 7.6 ± 2.2 mmHg, p = 0.012) were significantly increased in low EpiLS group. Only BPV parameters were associated with decreased longitudinal strain in hypertension. Effects of BPV were majorly noted in EpiLS.

Prognostic Effect of the Nocturnal Blood Pressure Fall in Hypertensive Patients: The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) Meta-Analysis.

The prognostic importance of the nocturnal systolic blood pressure (SBP) fall, adjusted for average 24-hour SBP levels, is unclear. The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) examined this issue in a meta-analysis of 17 312 hypertensives from 3 continents. Risks were computed for the systolic night-to-day ratio and for different dipping patterns (extreme, reduced, and reverse dippers) relative to normal dippers. ABC-H investigators provided multivariate adjusted hazard ratios (HRs), with and without adjustment for 24-hour SBP, for total cardiovascular events (CVEs), coronary events, strokes, cardiovascular mortality, and total mortality. Average 24-hour SBP varied from 131 to 140 mm Hg and systolic night-to-day ratio from 0.88 to 0.93. There were 1769 total CVEs, 916 coronary events, 698 strokes, 450 cardiovascular deaths, and 903 total deaths. After adjustment for 24-hour SBP, the systolic night-to-day ratio predicted all outcomes: from a 1-SD increase, summary HRs were 1.12 to 1.23. Reverse dipping also predicted all end points: HRs were 1.57 to 1.89. Reduced dippers, relative to normal dippers, had a significant 27% higher risk for total CVEs. Risks for extreme dippers were significantly influenced by antihypertensive treatment (P<0.001): untreated patients had increased risk of total CVEs (HR, 1.92), whereas treated patients had borderline lower risk (HR, 0.72) than normal dippers. For CVEs, heterogeneity was low for systolic night-to-day ratio and reverse/reduced dipping and moderate for extreme dippers. Quality of included studies was moderate to high, and publication bias was undetectable. In conclusion, in this largest meta-analysis of hypertensive patients, the nocturnal BP fall provided substantial prognostic information, independent of 24-hour SBP levels.

Blood Pressure, Heart Rate Variability, and Renal Function in Nonsmoker and Smoker Hypertensive Patients.

Blood Pressure, Heart Rate Variability, and Renal Function in Nonsmoker and Smoker Hypertensive Patients.

Blood Pressure Variability and Left Ventricular Mass Index in Children

Clinical implications of blood pressure variability (BPV) on subclinical organ damage in children are unknown. The authors sought to explore the potential utility of two newly derived BPV indices: weighted standard deviation (wBPSD) and real average variability (ARV), as well as two standard ambulatory blood pressure indices: average 24-hour systolic blood pressure (SBP) and 24-hour SBP load, to identify children at high risk for left ventricular (LV) hypertrophy (LVH). The study group consisted of 67 consecutive children who were referred to our institution for evaluation of suspected hypertension. LV mass was estimated by M-mode echocardiography using Devereux's formula according to the Penn convention and indexed for height(2.7) . We found a statistically significant, positive correlation between 24-hour wBPSD and LV mass index (LVMI) (ρ=0.389; P=.002) and no correlation between 24-hour ARV and LVMI (P>.05). However, partial correlation analysis of 24-hour wBPSD adjusted for body mass index (BMI) and LVMI showed only a weak correlation (ρ=0.3; P=.022). By using multiple linear regression analysis in a model with LVMI as a dependent variable and 24-hour wBPSD, 24-hour ARV, and BMI as independent variables, only BMI showed statistically significant independent positive associations with LVMI (P=.028). Results of our study showed that currently used BPV indices (24-hour wBPSD and 24-hour ARV) are not clinically reliable parameters to identify children at risk for LVH. Apparent contribution of the 24-hour wBPSD parameter to LVMI is negligible and is secondary to its close correlation with BMI (ρ=0.335 P=.009).

Day-Night Dip and Early-Morning Surge in Blood Pressure in Hypertension

We investigated the relationship between the day-night blood pressure (BP) dip and the early morning BP surge in an cohort of 3012 initially untreated subjects with essential hypertension. The day-night reduction in systolic BP showed a direct association with the sleep trough ( r =0.564; P &lt;0.0001) and the preawakening ( r =0.554; P &lt;0.0001) systolic BP surge. Over a mean follow-up period of 8.44 years, 268 subjects developed a major cardiovascular event (composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and heart failure requiring hospitalization) and 220 subjects died. In a Cox model, after adjustment for predictive covariates, including age, sex, diabetes mellitus, cigarette smoking, total cholesterol, left ventricular hypertrophy on ECG, estimated glomerular filtration rate, and average 24-hour systolic BP, a blunted sleep trough (≤19.5 mm Hg; quartile 1) and preawakening (≤9.5 mm Hg; quartile 1) BP surge was associated with an excess risk of events (hazard ratio, 1.66 [95% CI, 1.14–2.42]; P =0.009; hazard ratio, 1.71 [95% CI, 1.12–2.71]; P =0.013). After adjustment for the same covariates, neither the dipping pattern nor the measures of early morning BP surge were independent predictors of mortality. In conclusion, in initially untreated subjects with hypertension, a blunted day-night BP dip was associated with a blunted morning BP surge and vice versa. In these subjects, a blunted morning BP surge was an independent predictor of cardiovascular events, whereas an excessive BP surge did not portend an increased risk of events.

Blood Pressure Effects of Naproxcinod in Hypertensive Patients

The blood pressure (BP) effects of naproxcinod and naproxen were assessed in an 8-week, double-blind, crossover study in 131 hypertensive patients aged 50 to 74 years. Patients received naproxcinod 750 mg twice daily or naproxen 500 mg twice daily, then the alternate treatment, each for 14 days, with placebo run-in/washout before each active treatment period and 24-hour ambulatory BP monitoring conducted before and after each active treatment period. Mean change from baseline in average 24-hour systolic BP (SBP) after 2 weeks of treatment numerically favored naproxcinod 750 mg twice daily (least-squares [LS] mean for naproxcinod minus naproxen: -1.6 mm Hg; P=.12). Post hoc analyses showed statistically significant SBP differences favoring naproxcinod for the 8 elapsed hours (LS mean: -4.4 mm Hg; P<.0001) and the 24 hours following morning dosing (LS mean: -2.4 mm Hg; P=.006). Naproxcinod may be a beneficial alternative for patients with osteoarthritis requiring nonsteroidal anti-inflammatory drugs.

The Risk of Waking-Up

Through ambulatory blood pressure (BP) monitoring, we know that BP usually follows a distinct circadian rhythm, characterized by a nocturnal decline during sleep of 10% to 30%, followed by a moderate-to-marked increase coinciding with the time of awakening.1 For >2 decades, there has been great interest in the early morning period by preventive cardiologists and hypertension specialists, because it became evident that the onset of acute events, including sudden death, myocardial infarction, and stroke peak in the first 4 to 6 hours postawakening.2,3 Because BP, heart rate, and these cardiovascular events all follow the same temporal pattern, it has been suspected that a pathophysiological relationship exists between hemodynamic aberrations, such as the early morning BP surge and vascular damage.3 Previous researchers have characterized the morning BP surge associated with increased target organ injury.3,4 Risk factors for a profile of excessive early morning hypertension include older age, excessive alcohol and/or smoking, longer sleep times and later awakening times, cold weather climates, and day of the week (primarily Monday!).5,6 Several studies performed in the past decade have found significant relations among the early morning BP surge and vascular disease,7 cardiac hypertrophy,4 and white matter lesions of the brain.6,8 Prospective studies in Japanese individuals8,9 have demonstrated a clinical impact of the early morning BP surge in predicting cardiovascular events. In one such cohort with ≈3.5 years of follow-up, for each 10-mm Hg increase in the early morning systolic BP surge obtained at baseline, the risk of stroke increased by 22%.8 Of note, this change of BP on arising predicted cardiovascular events independently of age, the average 24-hour systolic BP, and antihypertensive therapy. …

The Effects of Cyclooxygenase-2 Inhibitors and Nonsteroidal Anti-inflammatory Therapy on 24-Hour Blood Pressure in Patients With Hypertension, Osteoarthritis, and Type 2 Diabetes Mellitus

Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors may attenuate the efficacy of antihypertensive agents in high-risk patients. Therefore, we conducted a double-blind, randomized trial to evaluate the effects of celecoxib, rofecoxib, and naproxen on 24-hour blood pressure (BP) in patients with type 2 diabetes, hypertension, and osteoarthritis. Patients were randomly assigned to treatment with 200 mg of celecoxib once daily (n = 136), 25 mg of rofecoxib once daily (n = 138), or 500 mg of naproxen twice daily (n = 130) for 12 weeks. Twenty-four-hour ambulatory BP monitoring and validated arthritis efficacy assessments were conducted at randomization and at weeks 6 and 12 of treatment. The primary end point was the mean change from baseline in average 24-hour systolic BP at week 6. Reductions in osteoarthritis symptoms, including pain, mobility, and stiffness, were similar in all treatment groups. The mean +/- SE 24-hour systolic BP following 6 weeks of therapy was increased significantly by rofecoxib (from 130.3 +/- 1.2 to 134.5 +/- 1.4 mm Hg; P < .001) but not by celecoxib (132.0 +/- 1.3 to 131.9 +/- 1.3 mm Hg; P = .54) or naproxen (133.7 +/- 1.5 to 133.0 +/- 1.4 mm Hg; P = .74). The BP difference between rofecoxib and celecoxib was 3.78 mm Hg (95% confidence interval, 1.18-6.38; P = .005); between rofecoxib and naproxen, 3.85 mm Hg (95% confidence interval, 1.15-6.55; P = .005). The proportion of patients with controlled hypertension at baseline who developed ambulatory hypertension by week 6 (24-hour systolic BP>135 mm Hg) was significantly greater with rofecoxib (30%) than with celecoxib (16%) (P = .05) but not significantly greater than with naproxen (19%). At equally effective doses for osteoarthritis management, treatment with rofecoxib but not celecoxib or naproxen induced a significant increase in 24-hour systolic BP. However, destabilization of hypertension control occurred to some extent in all 3 treatment groups; this phenomenon was seen more often in patients treated with rofecoxib than with the other therapies.

Ambulatory pulse pressure: a potent predictor of total cardiovascular risk in hypertension.

A wide pulse pressure (PP) is a marker of increased artery stiffness and high cardiovascular (CV) risk. To investigate the prognostic value of ambulatory PP, which is currently unknown, we studied 2010 initially untreated subjects with uncomplicated essential hypertension (mean age, 51.7 years; 52% men). All subjects underwent baseline procedures including 24-hour noninvasive ambulatory blood pressure (BP) monitoring. The mean duration of follow-up was 3.8 years (range, 0 to 11 years), and CV morbidity and mortality were the outcome measures. There were 200 major CV events (2.61 per 100 person-years), 36 of which were fatal (0.47 per 100 person-years). In the 3 tertiles of the distribution of office PP, the rate of total CV events (per 100 persons per year) was 1.38, 2. 12, and 4.34, respectively, and that of fatal events was 0.12, 0.30, and 1.07 (log-rank test, both P<0.01). In the 3 tertiles of the distribution of average 24-hour PP, the rate of total CV events was 1.19, 1.81, and 4.92, and that of fatal events was 0.11, 0.17, and 1. 23 (log-rank test, both P<0.01). After controlling for several independent risk markers including white coat hypertension and nondipper status, we found that ambulatory PP was associated with the biggest reduction in the -2 log likelihood statistics for CV morbidity (P<0.05 versus office PP). In each of the 3 tertiles of office PP, CV morbidity and mortality increased from the first to the third tertile of average 24-hour ambulatory PP (log-rank test, all P<0.01). Age, left ventricular hypertrophy, and nondipper status were independent predictors of CV mortality, and the further predictive effect of ambulatory PP (P<0.001) was marginally but not significantly superior to that of office PP and average 24-hour systolic BP. We conclude that ambulatory PP is a potent risk marker in essential hypertension. CV morbidity is more closely predicted by ambulatory than by office PP even after control for multiple risk factors.