Daytime Ambulatory Blood Pressure Research Articles

Prevalence of masked hypertension in attended versus unattended office blood pressure measurement.

There is a controversial debate regarding whether unattended blood pressure (BP) measurement should be regarded as the new gold standard of office BP measurement. Unattended BP measurement eliminates the white-coat effect and reduces external influences on the patient. On the other hand, it might underestimate real-life BP. The present study compares the prevalence of masked hypertension using attended versus unattended office BP measurements. We performed a cross-sectional study on 213 patients in a general practitioner's outpatient clinic and compared attended and unattended office BP with 24h-ambulatory BP monitoring (24h-ABPM). Masked hypertension was defined as pressure ≥135/85mmHg in daytime ABPM with office systolic BP<140/90mmHg. Median attended and unattended office BPs were 140/86 and 134/80mmHg with a median 24h-BP of 129/79mmHg and daytime ABP of 133/82mmHg. The number of patients with masked hypertension was 45/213 (21.2%) using unattended and 23/213 (10.8%) using attended office BP measurements (p<.0001). Bland-Altman analysis revealed a 7.4mmHg systolic and 6.2mmHg diastolic bias between the attended versus unattended office BP, and two systolic and -1.7mmHg diastolic biases between the unattended office BP and daytime ambulatory BP. In linear regression analysis, an unattended office BP of 134mmHg corresponded to 140mmHg in attended BP measurement. Using a cut-off of 135/85mmHg instead of 140/90mmHg in unattended office BP measurement, the rate of masked hypertension was 26/213 (12.2%). Thus, unattended office BP measurement results in a substantial increase in the prevalence of masked hypertension using the traditional definition of hypertension. The present findings suggest that it might be reasonable to use a definition of 135/85mmHg.

Effect of Drug Monitoring on Adherence and Blood Pressure: A Multicenter Randomized Clinical Trial.

Drug concentration in blood or urine is an acknowledged method to detect non-adherence. Observational studies suggest that informing patients about low or absent serum drug levels improves blood pressure (BP). We performed a multicenter randomized clinical trial to test the hypothesis that therapeutic drug monitoring (TDM) could improve drug adherence and BP in patients with uncontrolled hypertension and reduced adherence to antihypertensive drugs. Patients were ≥18 years on stable treatment with at least two antihypertensive agents. We planned to randomize 80 non-adherent patients with a systolic daytime ambulatory BP (ABPM) ≥135 mmHg to TDM-intervention or not. The control group and the study-personnel who measured BP remained uninformed about serum drug measurements throughout. All patients and physicians were blinded for BPs. Lifestyle advice and detailed information on disease process and importance of BP treatment were given to both groups. From 2017 to 2022, we randomized 46 diagnosed non-adherent from a total of 606 patients with uncontrolled hypertension. The TDM-group had a 6.7 (±14.5) mmHg reduction from 147.9 (±10.3) to 141.1 (±14.1) mmHg, and the control group experienced a 7.3 (±13.2) mmHg reduction from 147.1 (±9.2) to 139.1 (±17.4) mmHg, p=0.9 between groups. Adherence improved in both groups, 73% in the TDM group and 59% in the control group became adherent at three months, p=0.51. In our prospective multicenter clinical trial of uncontrolled and non-adherent hypertensive patients, we found no additional effect of therapeutic drug monitoring (TDM) on blood pressure and drug adherence compared with standard care.

Novel biomarkers in patients with uncontrolled hypertension with and without kidney damage

Introduction Estimated glomerular filtration rate (eGFR) and urine albumin/creatinine ratio (ACR) are insensitive biomarkers for early detection of hypertension-mediated organ damage (HMOD). In this nationwide cross-sectional study, we assessed potential biomarkers for early HMOD in healthy persons and patients with hypertension. We hypothesised that plasma levels of biomarkers: (1) are different between healthy controls and patients with hypertension, (2): can classify patients with hypertension according to the degree of hypertension severity. Design and methods Patients with hypertension prescribed ≥2 antihypertensive agents were selected from a multicentre study. Healthy controls were selected from an ongoing study of living kidney donor candidates. Uncontrolled hypertension was defined as systolic daytime ambulatory blood pressure ≥135 mmHg. Kidney HMOD was defined by ACR > 3.0 mg/mmol or eGFR < 60 mL/min/1.73 m2. Patients with hypertension were categorised into three groups: (1) controlled hypertension; (2) uncontrolled hypertension without kidney HMOD; (3) uncontrolled hypertension with kidney HMOD. Fifteen biomarkers were analysed using a Luminex bead-based immunoassay, and nine fell within the specified analytical range. Results Plasma levels of Interleukin 1 receptor antagonist (IL-1RA), neutrophil gelatinase-associated lipocalin (NGAL) and uromodulin were significantly different between healthy controls (n = 39) and patients with hypertension (n = 176). In regression models, with controlled hypertension (n = 55) as the reference category, none of the biomarkers were associated with uncontrolled hypertension without (n = 59) and with (n = 62) kidney HMOD. In models adjusted for cardiovascular risk factors and eGFR, osteopontin (OPN) was associated with uncontrolled hypertension without kidney HMOD (odds ratio (OR) 1.77 (1.05–2.98), p = 0.03), and regulated upon activation normal T-cell expressed and secreted (RANTES) with uncontrolled hypertension with kidney HMOD (OR 0.57 (0.34–0.95), p = 0.03). Conclusions None of the biomarkers could differentiate our hypertension groups when established risk factors were considered. Plasma OPN may identify patients with uncontrolled hypertension at risk for kidney HMOD.

Abstract P202: The Effects of Sodium (Na) Reduction and the Dash Diet on Ambulatory Blood Pressure in Black and Non-Black Individuals: Results From the DASH-Na Trial

Background: Black individuals compared to White individuals tend to have higher nighttime BP. It has been hypothesized that lifestyle changes will reduce and potentially eliminate this disparity. Objectives: To determine the effect of reduced Na and the DASH diet, alone and combined, on ambulatory blood pressure (ABP) in Blacks (B) and Non-Blacks (NB, mostly white). Methods: Participants (n=335, 58% B) were randomly assigned to eat a control diet or the DASH diet. On their assigned diet, each participant had three, randomly ordered, 30d feeding periods with different Na levels (low, medium, and high). ABP was measured at the end of each period. Results: Before feeding, mean office SBP was similar in B and NB (135.5 and 134.5 mmHg, respectively). On the reference diet (control diet with high Na), daytime and nighttime SBP were higher in B than NB adults (Table). Compared to the ref diet, reducing Na and consuming the DASH diet, alone and combined, substantially lowered daytime and nighttime systolic ABP in Black and Non-Black individuals. The DASH diet combined with low Na reduced daytime SBP in B and NB with no significant B-NB difference, i.e. no racial disparity in daytime SBP; otherwise, B-NB differences were present in daytime SBP for Na reduction alone and DASH diet alone. For nighttime SBP, there was a consistent pattern such that Na reduction alone, DASH diet alone, and the DASH diet with low Na reduced nighttime SBP in B and NB, but in each case, B had significantly higher nighttime SBP levels than NB. For DBP, Na reduction alone, DASH diet alone, and combined DASH with low Na reduced daytime and nighttime BP in B and NB, but significant B-NB differences persisted (data not shown). Conclusions: Reducing dietary Na and consuming the DASH diet, alone and combined, substantially lowered ABP in Black and Non-Black individuals. However, racial disparities in ABP mostly persisted. These results highlight the importance of implementing both the DASH diet and Na reduction as a means to reduce BP throughout the day, regardless of racial background.

The role of wearable home blood pressure monitoring in detecting out-of-office control status

Ambulatory blood pressure (ABP) and home blood pressure (HBP) monitoring is currently recommended for management of hypertension. Nonetheless, traditional HBP protocols could overlook diurnal fluctuations, which could also be linked with adverse cardiovascular outcomes. In this observational study, we studied among a group of treated hypertensive patients (N = 62, age: 52.4 ± 10.4 years) by using out-of-office ABP and wearable HBP. They received one session of 24-h ABP measurement with an oscillometric upper-arm monitor, and totally three sessions of 7-day/6-time-daily wearable HBP measurement separated in each month with HeartGuide. Controlled hypertension is defined as an average BP <130/80 mmHg for both daytime ABP and HBP. There was substantial reliability (intraclass correlation coefficient, ICC 0.883–0.911) and good reproducibility (Cohen’s kappa = 0.600) for wearable HBP measurement, especially before breakfast and after dinner. Among all patients, 27.4% had both uncontrolled HBP and ABP, 30.6% had uncontrolled HBP only, while 6.5% had uncontrolled ABP only. Female gender and increased numbers of anti-hypertensive agents are correlated with controlled hypertension. Patients with uncontrolled hypertension had a significantly higher maximal daytime blood pressure, which was previously signified as an imperial marker for cardiovascular risk. In conclusion, wearable HBP monitoring in accordance with a dedicated daily-living schedule results in good reliability and reproducibility. Patients with an uncontrolled wearable HBP should benefit from repeated HBP or ABP measurement for risk stratification.

A comparative trial of blood pressure monitoring in a self-care kiosk, in office, and with ambulatory blood pressure monitoring

BackgroundAutomated measurement of blood pressure (BP) in designated BP kiosks have in recent years been introduced in primary care. If kiosk blood pressure (BP) monitoring provides results equivalent to in-office BP or daytime ambulatory BP monitoring (ABPM), follow-up of adult patients could be managed primarily by self-checks. We therefore designed a comparative trial and evaluated the diagnostic performance of kiosk- and office-based BP (nurse- versus physician-measured) compared with daytime ABPM.MethodsA trial of automated BP monitoring in three settings: a designated BP kiosk, by nurses and physicians in clinic, and by ABPM. The primary outcome was systolic and diastolic BP, with respective diagnostic thresholds of ≥135 mmHg and/or ≥ 85 mmHg for daytime ABPM and kiosk BP and ≥ 140 mmHg and/or ≥ 90 mmHg for office BP (nurse- and physician-measured).ResultsCompared with daytime ABPM, mean systolic kiosk BP was higher by 6.2 mmHg (95% confidence interval [CI] 3.8–8.6) and diastolic by 7.9 mmHg (95% CI 6.2–9.6; p < 0.001). Mean systolic BP taken by nurses was similar to daytime ABPM values (+ 2.0 mmHg; 95% CI − 0.2–4.2; p = 0.071), but nurse-measured diastolic values were higher, by 7.2 mmHg (95% CI 5.9–9.6; p < 0.001). Mean systolic and diastolic physician-measured BPs were higher compared with daytime ABPM (systolic, by 7.6 mmHg [95% CI 4.5–10.2] and diastolic by 5.8 mmHg [95% CI 4.1–7.6]; p < 0.001). Receiver operating characteristic curves of BP monitoring across pairs of systolic/diastolic cut-off levels among the three settings, with daytime ABPM as reference, demonstrated overall similar diagnostic performance between kiosk and nurse-measured values and over the curve performance for physician-measured BP. Accuracy with nurse-measured BP was 69.2% (95% CI 60.0–77.4%), compared with 65.8% (95% CI 56.5–74.3%) for kiosk BP.ConclusionsIn this study kiosk BP monitoring was not comparable to daytime ABPM but could be an alternative to in-office BP monitoring by trained nurses. The diagnostic performance of kiosk and nurse-measured BP monitoring was similar and better than that of physician-measured BP.Trial registrationClinicalTrials.gov (NCT04488289) 27/07/2020.

Blood pressure responses to testosterone therapy are amplified by hematocrit levels in opioid-induced androgen deficiency: a double-blind, randomized, placebo-controlled trial.

Our study aimed to examine the effect of testosterone replacement therapy (TRT) on blood pressure in opioid-treated men with relative hypogonadism, and whether the effect of TRT on blood pressure was modified by body composition, red blood cell levels, or carotid intima media thickness. Men (over 18 years old) receiving opioid treatment and total testosterone less than 12 nmol were randomly assigned to receive either TRT or placebo. Baseline and 6-month measurements included anthropometric measurements, office blood pressure (OBPM), 24-h ambulatory blood pressure, blood samples, and carotid ultrasound. The mean systolic OBPM increased by 6.2 mmHg (0.2-12.1) in the TRT group and decreased by 7.0 mmHg (1.0-15.1) in the placebo group, with a mean difference of 13.2 mmHg (3.4-23.1), P = 0.01. In the TRT group, a 10 mmHg increase in systolic OBPM was associated with an increase in hematocrit of 0.3% points (0.1-0.5) ( P = 0.01), whereas no association was observed in the placebo group ( P = 0.266). Daytime SBP showed a nonsignificant increase of 5.2 mmHg (-1.7, 12.1) ( P = 0.134) in the TRT group compared to that in the placebo group. However, the impact of TRT on the increase in daytime ambulatory blood pressure was significantly accentuated by baseline values of BMI, hematocrit, and hemoglobin. In conclusion, TRT was associated with higher OBPM compared to placebo, and the increase in blood pressure was linked to higher hematocrit during TRT. Our data suggest that men with opioid-induced androgen deficiency, particularly those with obesity or red blood cell levels in the upper normal range, are more susceptible to increased daytime SBP during TRT.

Agreement Between Guideline Thresholds Using an "All-in-One" Device to Measure Office, Home, and Ambulatory Blood Pressures.

Blood pressure (BP) thresholds for diagnosing and managing hypertension vary for office, home, and ambulatory readings, and between guideline documents. This analysis determined corresponding office, home, and ambulatory BP thresholds using baseline data from the HI-JAMP (Home-Activity Information and Communication Technology-Based Japan Ambulatory Blood Pressure Monitoring Prospective) study, which used a validated "all-in-one" BP monitoring device. Data from 2322 treated patients with hypertension who underwent office BP measurement, then 24-hour ambulatory BP monitoring, then home BP monitoring for 5 days were analyzed. Corresponding BP thresholds for office, home, and ambulatory measurements were determined using Deming regression. Values equivalent to office systolic BP (SBP) of 120 and 140 mm Hg were as follows: 115.9 and 127.7 mm Hg for 24-hour ambulatory SBP; 120.8 and 134.0 mm Hg for daytime ambulatory SBP; 104.9 and 117.9 mm Hg for nighttime ambulatory SBP; and 122.0 and 134.2 mm Hg for morning-evening average home SBP. Deming regression showed that morning-evening average home SBP and daytime ambulatory SBP were almost the same (home SBP=0.99×daytime ambulatory SBP+0.27 mm Hg; r=0.627). Morning-evening average home SBP values of 120 and 135 mm Hg were equivalent to daytime ambulatory SBP values of 119.1 and 133.9 mm Hg, respectively. A home SBP threshold of 130 mm Hg corresponded to 24-hour and nighttime ambulatory SBP values of 123.5 and 113.6 mm Hg, whereas a home SBP threshold of 135 mm Hg corresponded to 24-hour and nighttime ambulatory SBP values of 128.0 and 119.2 mm Hg. Ambulatory and home BP thresholds in this analysis were similar to those proposed by existing guidelines. The similarity between the home BP and daytime ambulatory BP thresholds was a clinically relevant finding.

Abstract 14132: Thirty-Six Month Results in Patients With Resistant Hypertension After Endovascular Ultrasound Renal Denervation in the RADIANCE-HTN TRIO Trial

Background: Endovascular ultrasound renal denervation (uRDN) has been shown to reduce blood pressure (BP) and medication burden in patients with resistant hypertension in the multicenter, blinded, randomized, sham-controlled RADIANCE-HTN TRIO trial through 6 months. We report the 36-month safety and durability of treatment effect on office BP (OBP) in the patients treated with uRDN. Methods: Patients with hypertension resistant to a 3-drug single-pill confirmed by daytime ambulatory BP ≥135/85 mmHg were randomized to uRDN (n=69) or sham procedure (n=67). From 2-5 months, if monthly home BP was ≥135/85 mmHg, prespecified standardized stepped-care antihypertensive treatment including an aldosterone antagonist (AA) was started under blinding to treatment assignment. After 6 months, patients were unblinded and received antihypertensive medications (AHM) at treating physicians’ discretion. We assessed changes in OBP of the uRDN group at 36 months vs. baseline and screening. Results: Forty-nine of 69 (71%) patients (age: 53.0 ± 7.4 years; 18% female) originally randomized to uRDN completed their 36-month follow-up. OBP at screening in those patients was 159/103 ± 15/10 mmHg on a mean of 3.9 AHM with 33% of patients on AA. Baseline OBP after starting the single-pill combination was 153/99 mmHg. At 36 months OBP changed by -14.5/-9.0 mmHg from screening (p&lt;0.001 for both) and -8.0/-5.0 mmHg from baseline (p=0.007; p=0.02) on a mean of 3.7 AHM with 41% of patients on AA. At 36 months, OBP change from baseline was irrespective of whether or not patients were taking AA. Given ambulatory BP was used to qualify patients at baseline, some patients had OBP &lt;140/90 mmHg. For those with baseline OBP ≥140/90 (n=39), change in OBP at 36 months from baseline was -12.9/-7.4 mmHg (p&lt;0.001 for both) on mean 3.6 AHM. No new uRDN-related long-term safety concerns were identified. Conclusion: In patients with resistant hypertension, the effectiveness and safety of uRDN were durable to 36 months.

Abstract 13463: Effect of an Intervention to Reduce Sedentary Behavior on Blood Pressure in Desk Workers: The RESET BP Randomized Clinical Trial (RCT)

Introduction: High sedentary behavior (SB) is associated with cardiovascular (CV) risk in cohort studies, yet definitive data from RCTs of SB reduction on CV risk factors is lacking. Hypothesis: A 3-month SB reduction intervention would decrease blood pressure (BP) and pulse wave velocity (PWV) in sedentary adults. Methods: We recruited desk workers with systolic BP (SBP) 120-159 mmHg or diastolic BP (DBP) 80-99 mmHg, not on antihypertensives, and reporting low physical activity. Participants were randomized 1:1 to a 3-month SB reduction intervention or control. The intervention targeted replacing sitting with standing and stepping via health coaching, a wrist-worn activity prompter, and a height-adjustable workstation. All day and work-specific SB, standing, stepping, and steps were measured by a thigh-worn triaxial accelerometer. Protocolized office SBP (primary outcome), DBP, and HR were measured in duplicate on two occasions at each baseline and 3 months; 24-hr ambulatory BP and carotid-femoral PWV via tonometry were also measured. Changes in outcomes were compared across groups using analysis of covariance and mixed models. Results: Participants (n=271) had mean age 45 y and BP 129/83 mmHg; 60% were female and 82% were non-Hispanic White. Retention was 97%. Intervention participants reduced SB during work (-1.3 hr/day) and across all waking hours (-1.1 hr/day) compared to controls (both p&lt;0.001). Intervention participants increased work-specific standing (1.2 hr/day), stepping (5 min/day) and steps (398/day) and all day standing (1.0 hr/day), stepping (7 min/day) and steps (528/day) compared to control (all p&lt;0.05). Yet, the intervention did not yield a greater reduction in BP or PWV vs. controls (all p&gt;0.05). Differences in changes were office SBP -0.24 mmHg (p=0.793), DBP 0.08 mmHg (p=0.894), and heart rate -2.75 (p=0.190). Findings were similar for 24-hr, daytime, and nighttime ambulatory BP averages (all &lt;1.2 mmHg; p&gt;0.05). Differences in PWV were higher (opposite from the hypothesized direction) in intervention vs. control and approached significance (0.18 m/s, p=0.07). Conclusions: In sedentary desk workers with mild-moderate untreated BP, this 3-month intervention reduced daily SB by about one hour but did not improve BP or PWV.

White coat effect in patients with hypertension

The article is devoted to various aspects of white coat effect (WCE) in patients with hypertension (HTN). WCE is due to the patient’s anxious response to office blood pressure (BP) measurement and is characterized by a BP increase. In patients with HTN, WCE is detected with a high frequency. Pronounced WCE in hypertensive patients is associated with worsening the HTN course and the prognosis of all-cause and cardiovascular mortality. In addition, BP increase in these patients during a doctor’s visit may lead to additional prescription of antihypertensive drugs, increasing costs and side effects. To identify WCE, a large number of methods are used, which can be divided into following groups: I – data from clinical and daytime ambulatory blood pressure measurement, II – clinical and home BP assessment, III – only ambulatory BP measurement, IV – clinical and laboratory BP data, and V – only clinical BP measurement. There are following WCE in patients with HTN: female sex, age, never smoking, as well as anxiety, introversion, etc. WCE is due to the patient’s anxiety state during office BP measurement and a conditioned reflex BP increase associated both with the physician presence and medical background. Severe WCE in some groups of patients with HTN may be associated with a worse prognosis compared with other hypertensive patients as follows: in individuals with a significant difference between clinical and ambulatory blood pressure levels or between the first and third BP office data, with a combination of resistant HTN and WCE, with WCE increasing from visit to visit, etc.

Skin sodium content as a predictor of blood pressure response to renal denervation

Patients with treatment resistant hypertension (TRH) are known to have elevated sodium (Na) content in muscle and skin. Renal denervation (RDN) emerged as an adjacent therapeutic option in this group of patients. This analysis aimed at evaluating whether tissue Na content predicts blood pressure (BP) response after RDN in patients with TRH. Radiofrequency-device based RDN was performed in 58 patients with uncontrolled TRH. Office and 24-h ambulatory BP were measured at baseline and after 6 months. To assess tissue Na content Na magnetic resonance imaging (Na-MRI) was performed at baseline prior to RDN. We splitted the study cohort into responders and non-responders based on the median of systolic 24-h ambulatory blood pressure (ABP) reduction after 6 months and evaluated the association between BP response to RDN and tissue Na content in skin and muscle. The study was registered at http://www.clinicaltrials.gov (NCT01687725). Six months after RDN 24-h ABP decreased by −8.6/−4.7 mmHg. BP-Responders were characterized by the following parameters: low tissue sodium content in the skin (p = 0.040), female gender (p = 0.027), intake of aldosterone antagonists (p = 0.032), high baseline 24-h night-time heart rate (p = 0.045) and high LDL cholesterol (p < 0.001). These results remained significant after adjustment for baseline 24-h systolic BP. Similar results were obtained when the median of day-time and night-time ABP reduction after 6 months were used as cut-off criteria for defining BP response to RDN. We conclude that in addition to clinical factors including baseline 24-h ABP Na-MRI may assist to select patients with uncontrolled TRH for RDN treatment.

Different Home Blood Pressure Thresholds to Predict Perfect 24-Hour Ambulatory Blood Pressure Control in Treated Hypertension Based on an "All-in-One" Device.

Home blood pressure (BP) is an important component of digital strategies for hypertension management. However, no studies have used the same device to investigate 24-hour BP control status in relation to different home BP control thresholds. Participants in the general practitioner-based, multicenter HI-JAMP study (Home-Activity Information and Communication Technology-Based Japan Ambulatory Blood Pressure Monitoring Prospective) underwent office BP measurement, then 24-hour ambulatory BP monitoring, then home BP monitoring for 5 days. A validated all-in-one BP monitoring device was used to measure office, home, and ambulatory BP. Baseline data were used to investigate ambulatory BP control status in individuals with well-controlled home BP based on the different guideline thresholds (125/75 mm Hg, 130/80 mm Hg, and 135/85 mm Hg). Data from 2269 patients were analyzed. For individuals with well-controlled home BP <135/85 mm Hg (59.5% of the total population), the prevalence of uncontrolled 24-hour (≥130/80 mm Hg), daytime (≥135/85 mm Hg), and nighttime ambulatory BP (≥120/70 mm Hg) was 19.9%, 18.5%, and 33.6%, respectively. Corresponding prevalence rates in the 42.7% of participants with well-controlled home BP <130/80 mm Hg were 13.4%, 12.9%, and 26.0%, and when well-controlled home BP was strictly defined as <125/75 mm Hg (23.9% of the population), prevalence of rates of uncontrolled 24-hour, daytime, and nighttime ambulatory BP were 7.0%, 9.0%, and 15.3%, respectively. Home BP control status defined using different thresholds could predict 24-hour ambulatory BP control status in treated hypertension. One-third of individuals still had uncontrolled nocturnal hypertension when home BP was controlled to <135/85 mm Hg, but ambulatory BP was quite well controlled when home BP was <125/75 mm Hg.

Abstract 118: Effects Of Aprocitentan, A Dual Endothelin Receptor Antagonist, On Blood Pressure In Black/African American Patients With Resistant Hypertension: Results From A Randomized, Controlled Study (PRECISION) Including A Withdrawal Phase

Background: Resistant hypertension is prevalent among Black/African American drug-treated hypertensives and may increase cardiovascular risk. We evaluated aprocitentan (APRO) for BP lowering in Black patients with resistant hypertension. Methods: Patients had sitting unattended automated office systolic BP (SBP) ≥140 mmHg despite use of ≥3 antihypertensives of different classes in the year prior. After 4 weeks of combination therapy (amlodipine, valsartan, hydrochlorothiazide), those still hypertensive could enter a 4-week single-blind placebo (PBO) run-in period, followed by a 4-week double-blind period wherein patients were randomized 1:1:1 to APRO 12.5 mg, 25 mg, or PBO. A 32-week single-blind period on APRO 25 mg followed. Patients were then re-randomized 1:1 to APRO 25 mg or PBO in a 12-week withdrawal period. The primary endpoint was change from baseline to Week 4 in mean trough SBP. Changes in SBP from withdrawal baseline (Week 36) to Week 40 and in 24-hour, daytime (09:00-21:00), and nighttime (01:00-06:00) ambulatory BP monitoring (ABPM) measures at Weeks 4 and 40 were also assessed. Results: Eighty-two of 730 patients (11.2%) were Black (APRO 12.5 mg, n = 28; 25 mg, n&amp;nbsp;= 28; PBO, n = 26). At Week 4, APRO and PBO produced similar office SBP reductions (least squares mean difference from PBO, 12.5 mg: 0.63 mmHg; 25 mg: 0.12 mmHg). However, APRO produced pronounced reductions vs PBO in mean 24-hour (12.5 mg: –3.23 mmHg; 25 mg: –7.85 mmHg), daytime (12.5 mg: –6.16 mmHg; 25 mg: –9.13 mmHg), and nighttime (12.5 mg: –2.63 mmHg; 25 mg: –8.53 mmHg) ambulatory SBP. Four weeks after withdrawal, office SBP increased with PBO vs APRO 25 mg (difference: +9.87 mmHg), which was confirmed with ambulatory SBP (difference, 25 mg; 24-hour: +8.13 mmHg, daytime: +3.39 mmHg, nighttime: +9.70 mmHg). Safety in Black patients was comparable to the overall population, with no new signals. During the double-blind period, treatment-emergent adverse events were reported in 6/28 (21.4%), 9/29 (31.0%), and 4/25 (16.0%) patients with APRO 12.5 mg, APRO 25 mg, and PBO. Edema or fluid retention occurred in 3/29 patients (10.3%) on APRO 25 mg, and no patients on APRO 12.5 mg or PBO. Conclusion: APRO was well tolerated and produced clinically relevant reductions in SBP by ABPM in Black patients.

Abstract 093: Does Ambulatory Blood Pressure Variability Predicts Target Organ Damage In Youth? The Ship Ahoy Study

Altered BP and HR variability are associated with abnormalities of cardiac structure and function in adults. Our aim was to determine if BP and HR variability increase prediction of subclinical cardiac changes in youth after adjustment for mean ambulatory BP (ABP) measures. We measured anthropometrics and performed echocardiography for left ventricular mass index (LVMI), LV systolic strain and LV diastolic function (e’/a’). ABP was measured with an oscillometric device and ABP mean percentiles were calculated per pediatric guidelines to adjust mean ABP for differences in age-, height- and sex. ABP and HR coefficients of variation (CV) were calculated as SD/mean. HR dipping was day mean HR - night mean HR. General linear models were used to determine if ABP and HR CV measures remained significant determinants of cardiac measures in models containing mean ABP levels, age, sex, race/ethnicity, BMIz, HR. Mean age was 15.6 ± 1.7 years (63% white, 59% male) with mean casual BP 122.7/71.6 mmHg ±12.3/10.5, mean daytime ABP 124.2/72.0 ± 11.3/7.7 mmHg. In linear models, DBP day CV, DBP nite CV and HR dip remained significant determinants of LVMI even after adjustment for covariates and ABP percentile (R 2 0.36, p &lt; 0.0001). HR nite CV was a determinant of e’/a’ after adjustments (R 2 0.16, p &lt; 0.0001). No BP or HR variability parameters enter the model for LV systolic strain. When stratified by ABP phenotype, participants with white coat HTN (WCH) had higher 24-hour BP, HR variability and HR dipping compared to other phenotypes. Measures of BP and HR variability which may represent altered autonomic tone, may affect LVM and diastolic function in youth especially those with WCH.

Influence of Recent Standing, Moving, or Sitting on Daytime Ambulatory Blood Pressure.

Background There are no recommendations for being seated versus nonseated during ambulatory blood pressure (BP) monitoring (ABPM). The authors examined how recent standing or moving versus sitting affect average daytime BP on ABPM. Methods and Results This analysis used baseline assessments from a clinical trial in desk workers with office systolic BP (SBP) 120 to 159 mm Hg or diastolic BP (DBP) 80 to 99 mm Hg. ABPM was measured every 30 minutes with a SunTech Medical Oscar 2 monitor. Concurrent posture (standing or seated) and moving (steps) were measured via a thigh-worn accelerometer. Linear regression determined within-person BP variability explained (R2) by standing and steps before ABPM readings. Mean daytime BP and the prevalence of mean daytime BP >135/85 mm Hg from readings after sitting (seated) or after recent standing or moving (nonseated) were compared with all readings. Participants (n=266, 59% women; age, 45.2±11.6 years) provided 32.5±3.9 daytime BP readings. Time standing and steps before readings explained variability up to 17% for daytime SBP and 14% for daytime DBP. Using the 5-minute prior interval, seated SBP/DBP was lower (130.8/79.7 mm Hg, P<0.001) and nonseated SBP/DBP was higher (137.8/84.3 mm Hg, P<0.001) than mean daytime SBP/DBP from all readings (133.9/81.6 mm Hg).The prevalence of mean daytime SBP/DBP ≥135/85 mm Hg also differed: 38.7% from seated readings, 70.3% from nonseated readings, and 52.6% from all readings (P<0.05). Conclusions Daytime BP was systematically higher after standing and moving compared with being seated. Individual variation in activity patterns could influence the diagnosis of high BP using daytime BP readings on ABPM.

Renal denervation in hypertension: An updated meta-analysis of the randomized controlled trials.

Radiofrequency or ultrasound renal denervation (RDN) has shown conflicting results when used as an adjunctive option for hypertension management in randomized controlled trials (RCTs). We searched Pubmed, MEDLINE, and other online databases for RCTs comparing RDN versus sham-control procedures in patients with uncontrolled or resistant hypertension. The endpoints of interest were 24-h ambulatory (AMB) blood pressure (BP), daytime AMB BP, and office BP. We performed a random-effects meta-analysis using the inverse variance method to estimate mean difference (MD) with a 95% confidence interval (CI). Nine studies with 1643 patients were included in the final analysis. The mean follow-up was 5 months. As compared with the sham-controlled group, RDN was associated with a significant decrease in 24-h AMB BP (systolic [MD -4.20; 95% CI -5.36 to -3.03; p < 0.00001], diastolic [-2.38; -3.42 to -1.35]), and daytime AMB BP (systolic: -5.11; -6.75 to -3.47, diastolic: -2.88; -3.91 to -1.85). Similarly, office BP was reduced with RDN (systolic: -5.46; -7.12 to -3.81; diastolic: -3.17; -4.23 to -2.12) when compared with placebo. Our meta-analysis shows that RDN is associated with a significant reduction in the 24-h AMB BP, daytime AMB BP, and office BP.

Ambulatory daytime blood pressure versus tonometric blood pressure measurements in the laboratory: effect of posture.

To compare blood pressure (BP) in tonometric radial artery recordings during passive head-up tilt with ambulatory recordings and evaluate possible laboratory cutoff values for hypertension. Laboratory BP and ambulatory BP were recorded in normotensive (n = 69), unmedicated hypertensive (n = 190), and medicated hypertensive (n = 151) subjects. Mean age was 50.2 years, BMI 27.7 kg/m 2 , ambulatory daytime BP 139/87 mmHg, and 276 were male (65%). As supine-to-upright changes in SBP ranged from -52 to +30 mmHg, and in DBP from -21 to +32 mmHg, the mean values of BP supine and upright measurements were compared with ambulatory BP. The mean(supine+upright) systolic laboratory BP was corresponding to ambulatory level (difference +1 mmHg), while mean(supine+upright) DBP was 4 mmHg lower ( P < 0.05) than ambulatory value. Correlograms indicated that laboratory 136/82 mmHg corresponded to ambulatory 135/85 mmHg. When compared with ambulatory 135/85 mmHg, the sensitivity and specificity of laboratory 136/82 mmHg to define hypertension were 71.5% and 77.3% for SBP, and 71.7% and 72.8%, for DBP, respectively. The laboratory cutoff 136/82 mmHg classified 311/410 subjects similarly to ambulatory BP as normotensive or hypertensive, 68 were hypertensive only in ambulatory, while 31 were hypertensive only in laboratory measurements. BP responses to upright posture were variable. When compared with ambulatory BP, mean(supine+upright) laboratory cutoff 136/82 mmHg classified 76% of subjects similarly as normotensive or hypertensive. In the remaining 24% the discordant results may be attributed to white-coat or masked hypertension, or higher physical activity during out-of-office recordings.

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&lt;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.

DETERMINANTS OF WITHIN-VISIT OFFICE BLOOD PRESSURE VARIABILITY AND INSTABILITY: EUROPEAN DATA FROM 1.053 INDIVIDUALS

Objective: Blood pressure (BP) variability is the physiological sequelae of the complex interaction of multiple neural, humoral, reflex, and behavioral factors. This analysis aimed to evaluate the determinants of BP variability and instability within a single office visit, which is routinely used for hypertension evaluation in clinical practice. Design and method: A retrospective analysis of cross-sectional data was performed, comprising adults with triplicate office BP measurements in a single office visit and 24h ambulatory BP monitoring collected within the context of prospective clinical studies in Finland, Greece, and United Kingdom. Indices of BP variability and instability included: (i) standard deviation (SD) (ii) coefficient of variation (CV) (iii) average real variability (ARV) (iv) maximum office BP (Max) (v) maximum-minimum difference (MMD) of office BP (vi) ratio of the difference between 1st-3rd measurement to the mean office BP (Relative change). White-coat effect was defined as the difference between office and daytime ambulatory BP. Results: Data from 1.053 individuals were analyzed (mean age 57.7 ± 11.3 years, males 50%, treated hypertensives 50.3%, average office BP 133.5 ± 18.7/83.5 ± 10.9 mmHg, daytime ambulatory BP 132.5 ± 14.1/80.7 ± 9.9 mmHg). All the indices of BP variability and instability were positively associated with average office BP, age, BMI, and white-coat effect, but with an inverse association between age and maximum diastolic BP (all p &lt; 0.05). In multivariable linear regression analysis systolic BP variability was mainly determined by average office systolic BP, and treatment for hypertension, while diastolic BP variability was determined by office diastolic BP and female sex (Table). Conclusions: These results suggest that the variability and instability of BP within a single office visit is mainly influenced by the BP level, female sex and the administration of antihypertensive treatment.