BP Surge Research Articles

Abstract MP01: Clinical Characteristics of Morning Blood Pressure Surge in Patients with Autonomic Failure

Autonomic failure (AF) is characterized by orthostatic hypotension (OH), but most of these patients also have nocturnal supine hypertension (SH), which has been associated with end-organ damage, pressure natriuresis, and worsening of daytime OH. About 30% of patients with SH, however, have a preserved nocturnal BP dipping that is likely associated with a morning BP surge (MBPS). To determine the pattern of MBPS and its association with dipping, natriuresis, and morning OH, we studied 92 AF patients (67±1 yr, 59% males; 32 multiple system atrophy and 60 peripheral autonomic failure [pAF]). Patients were studied off BP medications and placed on a low monoamine, caffeine-free diet containing 150 mEq/d sodium and 70 mEq/d potassium. Nocturnal BP was assessed every 2 hours from 8pm-8am, followed by a 10-minute standing test. Urine was collected for 24 hours and divided into two 12-hour periods. As expected, we found that dipping (systolic BP [SBP] fall ≥10% during nighttime sleep [12am-6am] from baseline [8pm to 10pm]) occurred in 33% of patients, with an average decrease of 35±5 mmHg at 4am. The MBPS (SBP increase at 8am from the average of 3 nighttime SBPs centered on the lowest one) was 10±2 mmHg (range -83 to 77 mmHg; MBPS≥ 20 mmHg, 23%). MBPS was negatively correlated with the magnitude of dipping (r=-0.328, p<0.001; dippers 18±3 vs. nondippers 6±3 mmHg; p=0.010) and mean nighttime SBP (r=-0.230, p=0.028). The night-to-day ratio of sodium (r=-0.417, p=0.002) and urine (r=-0.292, p=0.037) excretion was also negatively correlated with MBPS, indicating that patients with greater MBPS had decreased natriuresis during the night compared to the day. In the morning, a greater MBPS was associated with a larger SBP drop on standing (r=-0.242, p=0.034). No associations were found between MBPS and age, sex, history of essential hypertension, or the underlying diagnosis of AF. To assess the hemodynamic mechanisms of the MBPS, we studied 17 AF patients (67±2 yr, 14 males, all pAF). We found that MBPS (13±5 mmHg, range -18 to 56 mmHg) was associated with an increase in systemic vascular resistance (SVR, r=0.777, p=0.01) and a higher augmentation index (Aix@75, r=0.516, p=0.049). In conclusion, a subset of AF patients had a preserved dipping pattern and an MBPS despite severe impairment of BP regulation. MBPS was associated with increased SVR, lower nighttime SBP, and lower night-to-day natriuresis, but the higher supine SBP in the morning was associated with worse OH.

EXERCISE AS MEDICINE; CHRONOTHERAPY IN HYPERTENSION MANAGEMENT

Objective: Adequate blood pressure regulation is a critical target in the management of hypertension and CVD. Circadian rhythms are increasingly recognized for their impacts on health outcomes including vascular function and metabolism. We posited that optimized exercise combined with chronotherapy will lead to meaningful improvements in BP, vascular health, and cardiovascular outcomes by coordinating the timing of interventions with diurnal rhythms. Design and method: Our studies, funded by National Institute of Health (NIH), are focused on ambulatory BP monitoring (ABPM) to capture circadian variations in BP, including nocturnal BP and morning surge. In particular, the project focuses on the efficacy of physical activity to improve nocturnal BP. We are using a 48-hr period of ABPM to reliably access nocturnal BP, which has not been implemented in other exercise studies focusing on ambulatory BP, in addition to measuring sleep with actigraphy. Given nocturnal BP is recognized as a strong indicator of cardiovascular health and outcomes, examining how interventions modify this ambulatory BP outcome is needed to understand the effect of the intervention on health and future risk. Results: Our preliminary data on all non-Hispanic 22 female subjects included 7 African Americans with average age of 68 and average BMI of 30.6. Mean seated BP (all BP values reported in mm of Hg) was 135/73 while awake BP from ABPM was 135/76 and awake central BP (calculated with device using a proprietary algorithm) was 126/78. Mean asleep BP determined from analysis of wrist actigraphy data was 117/61 and mean asleep central BP was 112/64. Mean nocturnal BP (calculated by average of the 4 lowest systolic blood pressure measures during the asleep period, waiting at least 1 hour after going to bed) was 116.7/61.6. Average nocturnal systolic dip was 30.4 and nocturnal diastolic dip was 14.4 with percentage nocturnal dips at 20.3% and 14.2% respectively. Conclusions: In our preliminary results, we found that evening exercise as chronotherapy in hypertensive post-menopausal patients showed significant nocturnal dipping of blood pressure.

EARLY MORNING HEMODYNAMIC CHANGES AND LEFT VENTRICULAR HYPERTROPHY AND MORTALITY IN HEMODIALYSIS PATIENTS

Objective: Amplified early morning increase in BP, a phenomenon accompanied by a parallel rise in heart rate (HR), is a marker of high cardiovascular risk in the general population. The early morning changes in these parameters have not been investigated in the hemodialysis population. Design and method: In a pilot, single center, study including a series of 58 hemodialysis patients we measured the pre-awakening BP and HR surges and the nocturnal dipping of the same parameters as well as other established indicators of autonomic function (weighted 24h systolic BP and HR variability) and tested their relationship with the left ventricular mass index (LVMI) and with the risk of death over a median follow up of 40 months. Results: The pre-awakening HR surge (r = -0.46, P = 0.001) was inversely associated with LVMI and the risk of death [HR (1 unit): 0.89, 95% CI: 0.83-0.96, P = 0.001] while the corresponding BP surge largely failed to associate with these outcomes. The link between the pre-awakening HR surge with LVMI and death was robust and largely independent of established risk factors in the hemodialysis population, including the nocturnal dipping of BP. Weighted 24h systolic BP and HR variability did not correlate with LVMI (all P>0.11) nor with the risk of death (P>0.11) and these parameters were also independent of the nocturnal dipping of systolic BP and HR. Conclusions: This pilot study suggests that the low early morning changes in HR, likely reflecting enhanced sympathetic activity, entail a high risk for LVH and mortality in the hemodialysis population.

0493 A new perspective on exploring the predictive factors of blood pressure reduction during CPAP treatment in OSA

Abstract Introduction The predictive factors of BP response to continuous positive airway pressure (CPAP) in obstructive sleep apnea (OSA) are still being explored. We aimed to assess the antihypertensive effect of CPAP considering the obstructive respiratory event-triggered BP surge profiles in 130 subjects with severe OSA and untreated hypertension. Methods Nocturnal BP was monitored continuously and synchronized with polysomnography. Event-triggered BP surge profiles were studied: BP surge as the value of event-related systolic BP elevation; BP index as the number of BP surge events of ≥10 mmHg per hour. Patients were then divided into two groups according to the median BP index (high and low BP surge groups) and assigned to 4 weeks of CPAP. Changes in BPs and plasma biomarkers were compared. After the initial evaluation, patients with a better BP response in the high BP surge group were then followed up for the second evaluation at 24 months. Results Overall, a modest decrease was observed in both office and asleep BPs at the 4-week follow-up; however, BPs dropped more markedly in patients in high BP surge group than those in low BP surge group, in both office systolic BP (SBP:5.3 mmHg vs.2.2 mmHg, P=.005) and diastolic (DBP:4.0mmHg vs.1.2 mmHg, P=.011), especially the asleep SBP (9.0mmHg vs.2.1 mmHg, P<.001). For 30 cases in the high BP surge group, optimal BP control was achieved in 60.0% of patients and BP < 140/90mmHg reached up to 83.3% after 24 months of CPAP. Linear regression revealed that BP index was significantly associated with BP decrease during CPAP treatment. Conclusion Our results suggest that high event-triggered BP surge was a sensitive predictor of BP response to CPAP in patients with severe OSA and hypertension. Support (if any)

EARLY MORNING HEMODYNAMIC CHANGES AND LEFT VENTRICULAR HYPERTROPHY AND MORTALITY IN HEMODIALYSIS PATIENTS

Objective: An exaggeration of the early morning increase in BP, a phenomenon accompanied by a parallel rise in heart rate (HR), is a marker of high cardiovascular risk. The early morning changes in these parameters have not been investigated in the hemodialysis population. Design and method: In a pilot, single center, study including a series of 58 patients we measured the pre-awakening BP and HR surges and the nocturnal dipping of the same parameters as well as other established indicators of autonomic function (weighted 24 h systolic BP and HR variability) and tested their relationship with the left ventricular mass index (LVMI) and with the risk of death over a median follow up of 40 months. Results: The pre-awakening HR surge (r = -0.46, P = 0.001) but not the corresponding BP surge (r = -0.1, P = 0.98) associated with LVMI and the risk of death [HR (1 unit): 0.89, 95% CI: 0.83–0.96, P = 0.001]. The link between the pre-awakening HR surge with these outcome measures was robust and largely independent of established risk factors in the hemodialysis population including the systolic BP dipping. Weighted 24 h systolic BP (SD) and HR (SD) variability did not correlate with LVMI (all P> 0.11) nor with the risk of death (P > 0.11). Overall, among markers of early morning hemodynamic changes and of hemodynamic variability, the pre-awakening HR surge was the strongest correlate of LVMI and a the strongest predictor of death. Conclusions: This pilot study suggests that low early morning changes in HR, a biomarker reflecting sympathetic activity, entail a high risk for LVH and mortality in the hemodialysis population.

MO858: Early Morning Haemodynamic Changes and Left Ventricular Hypertrophy and Mortality In Haemodialysis Patients

Abstract BACKGROUND AND AIMS Amplified early morning increase in BP, a phenomenon accompanied by a parallel rise in heart rate (HR), is a marker of high cardiovascular risk in the general population. The early morning changes in these parameters have not been investigated in the haemodialysis population. METHOD In a pilot, single centre, study including a series of 58 haemodialysis patients we measured the pre-awakening BP and HR surges and the nocturnal dipping of the same parameters as well as other established indicators of autonomic function (weighted 24h systolic BP and HR variability) and tested their relationship with the left ventricular mass index (LVMI) and with the risk of death over a median follow up of 40 months. RESULTS The pre-awakening HR surge (r = –0.46; P = 0.001) was inversely associated with LVMI and the risk of death [HR (1 unit): 0.89, 95% confidence interval: 0.83–0.96; P = 0.001] while the corresponding BP surge largely failed to associate with these outcomes. The link between the pre-awakening HR surge with LVMI and death was robust and largely independent of established risk factors in the haemodialysis population, including the nocturnal dipping of BP. Weighted 24 h systolic BP and HR variability did not correlate with LVMI (all P > 0.11) nor with the risk of death (P > 0.11) and these parameters were also independent of the nocturnal dipping of systolic BP and HR. CONCLUSION This pilot study suggests that the low early morning changes in HR, likely reflecting enhanced sympathetic activity, entail a high risk for LVH and mortality in the haemodialysis population.

Specifics of daily blood pressure monitoring in patients with systemic hypertension and obstructive sleep apnoea: a case-control study

Background. The comorbidity of arterial hypertension (AH) and obstructive sleep apnea syndrome (OSA) is becoming increasingly common in clinical practice. However, the priority strategy for selecting antihypertensive therapy in such patients is yet to be defined. 24-hour blood pressure monitoring is important for determining an approach to controlling hypertension.Objectives. To study specific features of 24-hour blood pressure monitoring in comorbid AH– OSA patients.Methods. A total of 130 AH patients were surveyed. The main cohort (1) included AH–OSA patients (n = 90, mean age 54.93 ± 1.04 years), control cohort (2) — non-OSA AH patients (n = 40, mean age 57.92 ± 1.29 years). All patients had a general clinical examination with 24-hour blood pressure monitoring. OSA was verified in overnight respiratory polygraphy using an Alice PDx diagnostic appliance (USA).Results. The following specific features of 24-hour blood pressure monitoring were identified in the comorbid patients: a statistically significant growth of mean 24-hour systolic and average BP, as well as mean nocturnal systolic, diastolic and average BP; a statistically significant growth of mean 24-hour systolic, diastolic and average BP load indices. In addition, the AH-OSA patients had the statistically higher pulse pressure, systolic and average BP variability, as well as morning BP surge rate. The 24-hour BP dynamics in OSA patients had predominant morbid profiles and higher non-dipper and night-peaker rates compared to the control cohort.Conclusion. The identified specific features reflect a high risk of adverse cardiovascular events in AH–OSA comorbid patients, an earlier damage of target organs and negative prognosis of comorbidity, which warrants a further analysis of AH-specific clinical picture and personalisation of blood pressure control measures in such patients.

Early morning hemodynamic changes and left ventricular hypertrophy and mortality in hemodialysis patients.

An exaggeration of the early morning increase in BP, a phenomenon accompanied by a parallel rise in heart rate (HR), is a marker of high cardiovascular risk. The early morning changes in these parameters have not been investigated in the hemodialysis population. In a pilot, single center study including a series of 58 patients we measured the pre-awakening BP and HR surges and the nocturnal dipping of the same parameters as well as other established indicators of autonomic function (weighted 24h systolic BP and HR variability) and tested their relationship with the left ventricular mass index (LVMI) and with the risk of death over a median follow up of 40months. The pre-awakening HR surge (r = -0.46, P = 0.001) but not the corresponding BP surge (r = -0.1, P = 0.98) was associated with LVMI and the risk of death [HR (1 unit): 0.89, 95% CI 0.83-0.96, P = 0.001]. The link between the pre-awakening HR surge with these outcome measures was robust and largely independent of established risk factors in the hemodialysis population, including the nocturnal dipping of BP. Weighted 24h systolic BP and HR variability did not correlate with LVMI (all P > 0.11) nor with the risk of death (P > 0.11) and were also independent of the nocturnal dipping of systolic BP and HR. This pilot study suggests that the low early morning changes in HR, likely reflecting enhanced sympathetic activity, entail a high risk for left ventricular hypertrophy (LVH) and mortality in the hemodialysis population.

Incremento matutino de la presión arterial en pacientes con ictus isquémico reciente: el factor olvidado

IntroductionHigh morning BP surge (MBPS) has been associated with an increased risk of cardiovascular events. We evaluated the presence of a high MBPS in patients with recent ischaemic stroke. Material and methodsA case-control study was carried out. One hundred patients with an ischaemic stroke in the previous 6 months and fifty hypertensive patients without cardiovascular disease were included as controls. Results61 lacunar (LAC) and 39 non-lacunar (NLAC) strokes were studied. The mean age was 65±11 years, and 60 (40%) patients were women. High MBPS was present in 9% of strokes (in 5 LAC and 4 NLAC) and in 8% of controls (p not significant [NS]), with a similar mean value of MBPS in both groups: 23.9±14mmHg and 24.9±15mmHg respectively (p=NS), although the control patients had a higher office BP (systolic [p=.008] and diastolic [p=.0001]), 24h systolic BP (p=.028) and daytime systolic BP (p=.022). Among the stroke patients, high MBPS was associated with previous coronary heart disease (p=.005), circadian BP pattern (p=.029), but not with the type of antihypertensive treatment prescribed. In multivariate analysis, elevated MBPS was only associated with previous coronary artery disease (p=.001). ConclusionsApproximately one in ten patients with recent ischaemic stroke has a high MBPS. Strategies to detect and treat high MBPS after a stroke are needed.

Abstract 12778: A High Physiological Stress Response is Dependent on Call Type in Firefighters

Introduction: CVD and impaired cardiovascular health is noticeably more prevalent in firefighters (FF) than the general population, with over 50% of line-of-duty deaths being cardiovascular related. Many FF have hypertension but less than 25% have their BP under control. The BP and HR response to different calls and job activity in FF is unknown. Thus, we aimed to evaluate and quantify the physiological stress resulting from different types of calls and job activity (fire, medical, riding apparatus) through ambulatory blood pressure (ABP) monitoring. Hypothesis: We hypothesize that fire calls will result in the largest BP surge in FF compared to other types of calls and work conditions. Methods: FF (n=41; 37M, 4F) wore an ABP monitor for at least 12-hours while working. BP was measured every 30 min during daytime and 60 min during nighttime, if worn overnight. Data was analyzed when > 70% of readings were captured. FF were instructed to force an ABP reading when the pager sounded and whenever they felt they entered a stressful situation. Activity and call type were documented on a log sheet for each measurement. Results: The FF were experienced (16.9 ± 11.9 yrs as FF), overweight (BMI: 30.3 + 4.6 kg/m 2 ), middle aged (41.2 ± 13.1 yrs), and hypertensive with average ABP over the 12 hr shift at 131 ± 13.4 / 79.3 ± 8.8 mmHg and HR 75.7 ± 8.8 bpm. Systolic BP surged 19.2 ± 12.2 with fire calls and 18.7 ± 8.1 mmHg with medical calls. Diastolic BP surged 10.5 ± 9.9 with fire and 16.5 ± 10.5 mmHg with medical calls. There were no differences in BP, HR, or BP surge levels ( P >0.05 for all) between the types of measurements (fire, medical, apparatus, alarms). Compared to average ABP values, the response was higher with fire calls (143.9/85.5 mmHg, 85.5 bpm) than medical calls (139.0/87.0 mmHg, 90.5 bpm). Physiological responses were also high when FF rode apparatus (139.8/83.7 mmHg, 81.9 bpm) and received false alarms (137.6/82.6 mmHg, 83.4 bpm). Conclusion: Fire and medical calls resulted in the greatest CV response. On average, fire calls resulted in a 9% increase in systolic BP and medical calls a 9% increase in diastolic BP and a 16% increase in HR. Further investigation in a larger population is warranted to substantiate these results as well as study other variables that may affect BP and HR responses in FF.

Firefighters On Medication Have Worse Health Profiles But Larger Improvements With Diet & Exercise

Heart disease and sudden cardiac death account for an overwhelming number of on- and off-duty deaths in firefighters (FF). The alarm response, the FF lifestyle, and the heavy work of the job all add to the stress of firefighting. These inherent risks aggravate existing CVD, many FF are on medication regimen, yet it is unknown whether medication status affects vascular health in FF. Furthermore, using ambulatory BP (ABP) monitors to quantify the BP surge with alarm is a novel way to assess CVD risk in FF. PURPOSE: To compare changes in health after a 6-wk Mediterranean diet & circuit training program between medicated (MedFF) or non-medicated (NmFF) FF. METHODS: We included 40 FF who completed a 6-wk intervention. Pre- and post-testing included ABP monitoring, a fasted clinical appt, and fitness test. FF wore the ABP cuff for 12-hrs and were paged by emergency service dispatch or by a pager app (OnPage). When the pager sounded, they forced an ABP reading to measure BP surge. Fasted visit included BP, body fat, lipid panel, blood draw, and vascular health measures. VO2peak was measured on treadmill. Serum was isolated for ELISA analysis of superoxide dismutase (SOD) and C-reactive protein (CRP). RESULTS: MedFF were on medication for BP, cholesterol, and multiple other types. Nine of the FF reported multiple medications. MedFF (N = 19, 48.4 ± 2 yrs) had worse health and higher BP surges, but more improvements with diet+exercise compared to NmFF (N = 21, 31.7 ± 2 yrs), P < 0.05 with differences. MedFF had higher BP (130.2/81.3 vs 121.6/77.7 mmHg), higher average ABP (133.7/80.4 vs 123.7/75.2 mmHg), lower VO2peak (33.3 vs 37.1 ml/kg-min), lower FMD (8.5 vs 10.2 %), higher PWV (7.4 vs 5.7 m/s), and higher CRP (3.8 vs 3.1 mg/L) levels. MedFF also tend toward larger SBP and DBP surges with alarm (15.9 vs 13.9 mmHg SBP and 9.9 vs 8.1 mmHg DBP) and an improvement in surge after intervention (SBP surge 15.9 to 8.6 in MedFF vs 13.9 to 15.8 mmHg in NmFF; DBP surge 9.9 to 3.7 in MedFF vs 8.1 to 5.4 mmHg in NmFF). With intervention we found that BP lowered, body composition, vascular health, and VO2peak improved in MedFF. CONCLUSION: With this subset of data, we show that FF on medication have worse health profiles but may have larger improvements with exercise + diet. Data confirms the importance of wellness programs in the firehouse, in particular for FF already on medication.

A Novel Concept of the Sigma (∑) value for BP Surge Differentials.

A Novel Concept of the Sigma (∑) value for BP Surge Differentials.

Firefighters With More Service Have Smaller Blood Pressure Surge When The Pager Sounds

Cardiac incidents cause over 50% of LODD in firefighters (FF) and may be related to their BP responses. Also, years of service may affect FF stress and depression levels and impair overall health. Using ambulatory BP (ABP) monitoring to quantify the BP surge with alarm is a novel way to assess risk, and preliminary data showed that newer FF have higher BP surge. PURPOSE: To compare changes in health between FF with <10yr service (FF-10) and FF with >10yr service (FF+10) after a 6-wk Mediterranean diet & circuit training program. METHODS: We included 21 FF who completed a 6-wk intervention. Pre- and post-intervention testing included ABP monitoring with pager activation, a fasted clinical appt, and fitness testing. Participants wore the ABP cuff for 12-hrs, during which they were paged by a pager app (OnPage) or by emergency service dispatch. When the pager sounded, they were instructed to force an ABP reading to assess the BP surge. Average BP levels and surges were determined. Fasted visit included BP, body fat, lipid panel, and vascular health measures. Fitness test included a treadmill VO2peak and a battery of other fitness tests. Participants also completed a health history form and the DASS-21 questionnaire assessing stress, anxiety, and depression. RESULTS: FF+10 (N=12, 45.7 ± 3yrs) had worse health and lower BP surges, but larger improvements with intervention compared to FF-10 (N=9, 36.8 ± 6.2yrs), P<0.05 for differences. FF+10 had lower HDL levels (38.3 ± 2.2 vs 57.9 ± 9.7 mg/dl), were heavier (213.1 ± 8.6 vs 205.1 ± 8.6 lbs), had higher average SBP (136.6 ± 4.8 vs 126.9 ± 3.6 mmHg) and DBP (83.2 ± 2.8 vs 75.7 ± 2.8 mmHg) levels, higher pre-alarm and post-alarm BP, but had a smaller surge in SBP (11.6 ± 3.2 vs 15.0 ± 3.3 mmHg) and DBP (4.1 ± 2.7 vs 7.3 ± 1.7 mmHg) when the pager sounded. FF+10 also had worse overall psychometric scores: higher DASS-21 11.2 ± 5.3 vs 7.6 ± 1.3; depression 3.4 ± 1.3 vs 1.4 ± 0.3; and stress 5.4 ± 1.7 vs 3.3 ± 0.5; but similar anxiety scores 2.4 ± 1.0 vs 3.0 ± 0.9. With intervention, in FF+10 we found that BP lowered, fitness improved, and psychosocial constructs improved. CONCLUSION: With this subset of baseline data, we show that FF+10 have smaller BP surge, worse CV health, stress, and depression levels, but larger improvements with intervention compared to FF-10. Data confirms the importance of wellness programs for FF.

Time And Dose Of Blood Pressure Medication Improves Hidden Hypertension Risk In A Firefighter

Most firefighters (FF) are unaware of their BP levels, which increases their risk of undiagnosed hypertension. According to a recent study, BP medication taken at bedtime lowers levels more effectively and leads to a 66% decrease in the risk of fatal cardiac incidents. Using ambulatory BP (ABP) monitoring to measure BP over time is a recommended way to assess risk. PURPOSE: To provide evidence that time and dosage of BP medication can improve hypertension risk in FF. METHODS: We included 43 FF in an ongoing clinical trial. FF wore an ABP cuff for a period, and the overall average BP, daytime BP and nighttime BP levels were examined. FF also came to the lab for a clinical fasted visit including BP, body fat, and vascular health measures. For this sub-analysis, we report data from 1 FF who was found to have nocturnal hypertension and morning BP surge. RESULTS: Overall the entire group of FF were hypertensive with clinic BP of 128.7 ± 1.7/ 81.8 ± 1.2 mmHg, had high central BP measured by SphygmoCor® XCEL (121.8 ± 2.7/ 84 ± 1.5 mmHg), and had high average SBP measured by ABP (130.9 ± 1.5 mmHg). We identified several FF with nocturnal hypertension and high morning BP surge levels, and here we report on data on one. He was 53 yr old, weighed 226 lbs, had 36.1% body fat, was an uncontrolled hypertensive (140.5/84.5 mmHg), and had high central BP levels (134/81 mmHg). During the initial ABP monitoring, his daytime BP was 160.2/86.9 and nighttime BP was 178.9/87.1 mmHg. His BP rose in the morning to 203/104 mmHg and remained that level for 2hrs. The FF self-reported feeling headaches and a ‘rushing sensation’ during fire calls, so he took his ABP data to a clinician. Initially, he was prescribed BP med in AM. The doctor increased dosage and switched to nighttime medication. During follow-up ABP monitoring, the FF’s BP was much more controlled. His average daytime BP was 145.1/82.6, nighttime BP was 114.8/66.2, and morning BP was only 125/69 mmHg. CONCLUSION: With this case-study data from one FF in a larger clinical trial, we confirmed that timing and dosage of medication leads to improved BP levels. This further confirms that overall health awareness in FF is important. Fire chiefs and the firehouse medical director should encourage and increase BP monitoring. This one example proves to be a valuable anecdote when we enter firehouses and discuss our clinical trial.

MON-194 Phaeochromocytoma-Paraganglioma (PPGL): Post-Operative Hypotension Is a Vanishing Phenomenon

Background: Treatment of hemodynamic instability in patients with PPGL in the intra-and postoperative periods is challenging. Persistent postoperative hypotension is a common and serious complication, reportedly occurring in 30-60% of PPGL patients. This phenomenon reflects 1) high doses of pre-operative antihypertensive drugs; 2) low intravascular volume secondary to chronic catecholamine-induced vasoconstriction with pressure natriuresis; 3) the sudden drop in circulating catecholamines after surgery. It has been shown that tumor size and preoperative levels of catecholamines are directly related to the need for treatment with vasopressor agents in the early period after tumor removal. The aim of this study was to evaluate the efficacy and safety of the current perioperative treatment protocol for PPGL used in our Institute. Methods: We retrospectively reviewed the rate of hemodynamic instability and postoperative hypotension in relation to catecholamine levels, and the efficiency of preoperative pharmacological preparation in consecutive patients with PPGL treated between 2000-2019. Results: There were 39 patients (F/M 19/20; mean age 50.4 ±16.5 years) 33 of which had adrenal lesions and 6 had extra-adrenal tumors. Mean tumor size was 3.9 ±2.2 cm. Median metanephrine and normetanephrine levels were 5 and 10 fold the upper limit of the normal range respectively. All patients were treated with α-blockade (phenoxybenzamine-17, mean dose 60±38 mg/day; doxazosin-22; mean dose 9.6±6.1mg/day) along with β- blockade, and high sodium diet and IV saline 24 hours before the operation. The length of the preoperative preparation period was 3.4±2 weeks. Within the first 24-48 hours from surgery, no episodes of hypotension (<90 mmHg systolic pressure) were recorded. Mean systolic BP was 121 ±14 (range 95-150) with a mean diastolic BP of 70 ±11 (range 89-46). In contrast, intraoperative hypotension occurred in 22% of the patients; and BP surge occurred in 36% of patients, mostly during tumor manipulation. There were no differences between subjects with and without such BP rises/falls in terms of pre/post- surgical BP, catecholamine levels or type of medical treatment. Conclusion: In contrast with older literature and previous reports, the patients in our cohort did not experience postoperative hypotension. This is most likely due to tight BP control while avoiding pre-operative hypotension, and adequate volume control. We propose that proper preoperative management in the modern era can drastically minimize intraoperative hemodynamic instability and post-operative hypotension.

Abstract P562: Firefighters Have Worse Cardiovascular Health And Mental Health Characteristics Than Civilians And Different Blood Pressure Surge Responses To Pager Activation

Introduction: Heart-related incidents cause over 50% of LODD in firefighters (FF). Physical, health-related, and emotional stress are all part of the FF job; and these all increase BP levels and cardiac risk. Using ambulatory BP (ABP) monitoring to measure BP over time and quantify the BP surge with alarm is a novel way to assess risk, so we compared a group of FF to Civilians. We hypothesized that FF would have worse CV health and higher BP surges compared to civilians. Methods: We included 43 FF and 30 Civilians who completed 3 visits: ABP monitoring with pager activation, a fasted clinical appt, and fitness testing. Participants wore the ABP cuff for a 12-hr period, during which they were paged by a pager app (OnPage) or by emergency service dispatch. When the pager sounded, they were instructed to force an ABP reading to assess the BP surge. Average BP levels and surges were determined. Fasted visit included BP, body fat, lipid panel, and vascular health measures. Fitness test included a treadmill VO 2peak and a battery of other fitness tests. Participants also completed a health history form and the DASS-21 questionnaire assessing stress, anxiety, and depression. Results: We found that FF (39.4 ± 2.2 yrs) had worse CV health, better fitness, but higher stress and depression levels compared to Civilians (39.7 ± 2.7 yrs), P&lt;0.05 for differences. FF had higher clinic SBP (128.7 ± 1.7 vs 119.7 ± 1.9), clinic DBP (81.8 ± 1.2 vs 75.7 ± 1.7), central arterial pressures measured by SphygmoCor® XCEL (121.8 ± 2.7 vs 112.3 ± 2.9 and 84 ± 1.5 vs 78.3 ± 2.3), and average SBP measured by ABP (130.9 ± 1.5 vs 119.6 ± 4.3 mmHg). FF had higher Pre-Alarm SBP levels (126.9 ± 3.3 vs 112.5 ± 4.8 mmHg) but similar Post-Alarm SBP levels. Thus, FF had a smaller SBP surge with alarm (12.5 ± 2.3 vs 16.2 ± 5.5 mmHg). Clinically, FF had similar cholesterol (183.5 ± 5.3 vs 188.9 vs 9.9) and LDL levels (117.9 ± 4.8 vs 116 ± 10.2 mg/dl), had similar BF percentages (29.4 ± 1.5 vs 31.7 ± 1.5 %), but were heavier (203.9 ± 5.5 vs 182.7 ± 7.3 lbs). FF also had lower HDL (46.8 ± 2.6 vs 59.9 ± 3.6 mg/dl), percent flow-mediated dilation (8.4 ± 0.8 vs 10.1 ± 1 %), and SEVR (156.1 ± 4.1 vs 172.6 ± 5.4) levels. For fitness, FF had similar VO 2peak (35.2 ± 0.9 vs 37.1 ± 1.8 ml/kg-min) but better plank pose (110.1 ± 9.5 vs 73.8 ± 6.7), wall sit (112.7 ± 15.9 vs 59.4 ± 5.2 sec), and #steps climbed in 2 min (320.8 ± 10.1 vs 280.2 ± 11.8). FF had worse overall psychometric characteristics: higher DASS-21 total score 13.9 ± 2.3 vs 5.5 ± 1.3; depression score 5.1 ± 1.3 vs 0.7 ± 0.3; stress score 5.9 ± 0.9 vs 2.7 ± 0.7; but similar anxiety scores 2.9 ± 0.4 vs 2 ± 0.6. Conclusions: In conclusion, with this subset of baseline data, we confirmed that FF have worse CV health, stress, depression and perceived health ratings. It is known that exercise and diet can improve all of these. Therefore, our participants are currently undergoing a diet and exercise intervention to assess changes in health, psychometric scores, and BP surge levels.

The usefulness of 24-hour blood pressure monitoring for the patients with atrial fibrillation: based on the variability of blood pressure parameters.

The aim of this study was to test whether ambulatory blood pressure monitoring (ABPM) in patients with atrial fibrillation is reliable as in patients with sinus rhythm. This study included 92 persistent atrial fibrillation patients (50% females; mean age 70.49 ± 11.56 years) and 92 matched sinus rhythm patients (46% females; mean age 69.23 ± 12.63 years). The participants were examined simultaneously with 24-hour ABPM and 24-hour Holter electrocardiography. The mean 24-hour (24-hour-), daytime (day-) and nighttime (night-) BP, types of BP curve, morning systolic BP (SBP) surge (MBPS), the SD of BP readings and the coefficient of variability (the SD/mean BP × 100%) were compared between atrial fibrillation and sinus rhythm patients. No differences of 24-hour-, day- and night-SBP levels were observed between two groups. Meanwhile, the 24-hour-SD, day-SD and night-SD, as well as the coefficient of variability for SBP were also similar between two groups. There was no significant difference in the number of MBPS between the two groups. On diastolic BP (DBP), the similar 24 hour and day levels, the 24-hour-SD, day-SD and night-SD as well as the coefficient of variability were also similar between two groups. But the nighttime DBP levels and the night-SD were higher in atrial fibrillation than in sinus rhythm. ABPM provides data with similar SBP variability in patients with atrial fibrillation as in subject with normal cardiac rhythm. The ABPM on oscillometric method may be suitable for the atrial fibrillation patients, especially for the SBP evaluation.

A14860 Differential Effects of Aliskiren/Amlodipine Combination and High-dose Amlodipine Monotherapy on Ambulatory Blood Pressure and Target Organ Protection in Hypertensives and its Inadequate Blood Pressure Response in those who with Diabetes

Objectives: The first aim was to compare an aliskiren/amlodipine (ALI/AML) combination with high-dose amlodipine monotherapy on ambulatory blood pressure (ABP) reduction and target organ protection. The second aim was to compare the BP lowering effect of antihypertensive medication on ABP and clinic BP (CBP) between diabetes mellitus (DM) and non-DM patients. Methods: We performed a prospective, randomized, open-label trial in essential hypertensives: 105 patients (mean age: 77.1; male: 41.0%) with CBP over 140/90 mmHg with AML 5 mg were randomly allocated to ALI (150–300 mg) /AML (5 mg) (ALI/AML, n = 53) or high-dose amlodipine (10 mg) (h-dAML, n = 52), and were treated for 16 wks. To the next, we performed a subanalysis, dividing the 86 patients who completed the treatment period into the Non-DM (n = 75) and DM (n = 11), and compared reductions on ABP and CBP. Results: The ALI/AML and h-dAML group showed similarly reduced 24-h SBP, daytime SBP, nighttime SBP, and brachial-ankle pulse wave velocity. The urine albumin-to-creatinine ratio reduction was significantly greater in the ALI/AML (p = 0.02). However, ALI/AML was significantly less effective in reducing early-morning BP (4.0 ± 21.2 vs. − 10.8 ± 22.1 mmHg, p = 0.002) and morning BP surge (10.0 ± 23.2 vs. − 5.4 ± 20.3 mmHg, p = 0.001) compared to h-dAML. The Non-DM and DM group's CBP reduction was similar. However, 24-h SBP reduction (p = 0.01) and daytime SBP reduction (p = 0.01) were significantly smaller in DM compared to Non-DM patients. Conclusion: ALI/AML provided better renal protection than h-dAML. Although ALI/AML and h-dAML showed almost equal reduction on ABP, ALI/AML was significantly less effective in reducing early-morning BP and morning BP surge compared to h-dAML. The ABP reduction was weakened in DM patients.

Differing Effects of Aliskiren/Amlodipine Combination and High-Dose Amlodipine Monotherapy on Ambulatory Blood Pressure and Target Organ Protection.

The aim of this study was to compare an aliskiren/amlodipine combination with high-dose amlodipine monotherapy on ambulatory blood pressure monitoring (ABPM) and organ protection. The study was a prospective, randomized, multicenter, open-label trial in elderly essential hypertensive patients. A total of 105 patients with clinic BP (CBP) ≥140/90 mm Hg with amlodipine 5 mg were randomly allocated to aliskiren (150-300 mg)/amlodipine (5 mg) (ALI/AML group, n=53) or high-dose amlodipine (10 mg) (h-dAML group, n=52) and treated for 16 weeks. Each patient's CBP, ABPM, urine albumin-to-creatinine ratio (UACR), and brachial-ankle pulse wave velocity (baPWV) were measured at baseline and at the end of the study. The ALI/AML and h-dAML groups showed similarly reduced mean 24-hour SBP, daytime SBP, nighttime SBP, and baPWV. However, UACR reduction was significantly greater in the ALI/AML group (P=.02). ALI/AML was significantly less effective in reducing early-morning BP (P=.002) and morning BP surge (P=.001) compared with h-dAML.

Cronoterapia en hipertensión arterial

The blood pressure profile in most normo- and hypertensive subjects are currently known, as well as the impact their changes induced on the cardio- and cerebrovascular risk. Ambulatory blood pressure monitoring (ABPM) has contributed greatly to the knowledge of this parameter. It to correct the schedule of drug administration (chronotherapy) with changes in any component of the BP profile that have better correlation with risk. These include the nocturnal decrease and the morning BP surge. Investigations in this direction are still scarce, and multicenter studies need to be conducted that can answer the true preventive impact of such modifications.