Daytime Ambulatory Blood Pressure Research Articles

PS 05-10 THE CLINICAL CHARACTERISTICS OF MASKED HYPERTENSION

Objective: Background: Masked hypertension, defined as a normal blood pressure (BP) in the clinic or office (<140/90 mmHg) but an elevated BP out of the clinic (ambulatory daytime BP or home BP > 135/85 mmHg), is associated with poor cardiovascular prognosis. Aims: We investigated the clinical characteristics of masked hypertension in patients who were treated with anti-hypertensive drugs. Design and Method: We enrolled 347 patients with essential hypertension and divided them into 2 groups on the basis of the difference between their weekly averaged home BP measured in morning right before hospital visit and office BP: (Group M: home BP > office BP, n = 135, and Group O: home BP Results: There were no differences in age, gender, duration of hypertension, number of BP-lowering medications and comorbidities between the two groups. Home BP was higher and office BP was lower in Group M compared with those in Group O (Home BP: 135.4 ± 11.5 / 75.0 ± 10.1 mmHg in Group M and 125.2 ± 9.2 / 71.3 ± 9.1 mmHg in Group O, p < 0.01, and Office BP: 126.0 ± 10.0 / 72.4 ± 9.6 mmHg in Group M and 136.0 ± 10.3 / 77.0 ± 8.6 mmHg in Group O, p < 0.01). Estimated salt intake assessed by urinary sodium excretion from spot samples was greater in Group M than in Group O (9.1 ± 2.9 g/day and 8.3 ± 2.3 g/day, p < 0.01). While plasma aldosterone concentration (PAC) was greater in Group M than in Group O (11.5 ± 4.9 ng/dl and 10.1 ± 4.6 ng/dl, p < 0.05), plasma renin activity (PRA) and PAC/PRA ratio was similar in the two groups. Conclusions: High salt intake and high PAC are associated with elevated home BP in patients with hypertension despite being well-controlled office BP on medications.

PP.26.11] RENAL DENERVATION USING THE ENLIGHTN RENAL DENERVATION SYSTEM IN ALTERNATIVE HYPERTENSIVE POPULATIONS

Objective: In this study, we examine real world experience with radiofrequency renal denervation (RDN) in patients with resistant hypertension and those with chronic kidney disease (CKD). Design and method: Patients were assigned to one of three groups; Group A (n = 139) OSBP >/ = 160 mmHg and estimated GFR (eGFR) >/ = 45 mL/min per 1.73 m2, Group B (n = 100), OSBP >/ = 140–159 mmHg and eGFR >/ = 45 mL/min per 1.73 m2 and Group C (n = 28), OSBP >/ = 140 mmHg and eGFR >/ = 15 mL/min per 1.73 m2. Results: A: Baseline mean office systolic BP (OSBP) 181.8 ± 15.9 mmHg, mean office diastolic BP (ODBP) 97.6 ± 15.9 mmHg. Mean 24-hour ambulatory SBP (ASBP) 159.5 ± 16.7 mmHg and mean 24-hour ambulatory DBP (ADBP) 88.8 ± 12.8 mmHg. The mean reduction in OSBP/ODBP was 21.2(±20.8) /13.8(±12.8) mmHg at 24-month follow up (p < 0.0001), ASBP/ADBP was 7.7 (±19.7) /5.4 (±)9.4 mmHg (p = 0.05/0.01). Baseline eGFR was 80.9 ± 20.6 mL/min/1.73 m2; 24-month eGFR was 80.3 ± 22.3 mL/min/1.73 m2. B: Baseline mean OSBP 149.1 ± 5.6 mmHg, ODBP 86.5 ± 11.5 mmHg, ASBP 146.7 ± 12.2 mmHg, and (ADBP) 86.7 ± 14.1 mmHg. The mean reduction in OSBP/ODBP was 6.2 (±13.9)/5.0 (±13.3) mmHg (p = 0.04/0.08) at 24-months, mean reduction in 24-hour ASBP/ADBP was 3.9 (±16.9)/2.4 (±7.9) mmHg (p = 0.3371/0.3290). Baseline eGFR was 77.9 ± 18.2 mL/min/1.73 m2; 24-month eGFR was 79.4 ± 18.2 mL/min/1.73 m2. C: Baseline mean OSBP 169.7 ± 20.2 mmHg, ODBP 85.7 ± 13.7 mmHg, ASBP 160.5 ± 17.9 mmHg, and ADBP 82.1 ± 14.7 mmHg. The mean reduction in OSBP/ODBP was 11.8 (±27.4)/3.8 (±19.2) mmHg (p = ns/p = ns) at 24-months, mean reduction in 24-hour ASBP/ADBP was 12.8 (±10.9) /6.3 (±7.5) mmHg (p = 0.03/0.09). Baseline eGFR was 35.3 ± 8 mL/min/1.73 m2; 24-month eGFR was 49.2 ± 8.1 mL/min/1.73 m2. Conclusions: RDN results in durable, highly significant and safe lowering of both office and ambulatory BP parameters in patients with severe uncontrolled hypertension up to 24-months following treatment. In patients with moderate uncontrolled-hypertension, RDN resulted in safe but modest reductions in office and 24-hour ambulatory BP at 24-months follow up. In patients with CKD, RDN results in safe, durable reduction in daytime ambulatory BP which was significant at 24-months follow up. The change in eGFR at 24-month was not significant in all groups and Serious Renal Artery Adverse Events occurred in < 2% of patients.

OP.7D.02] INCREASE IN PLASMA COPEPTIN CONCENTRATION IN PATIENTS WITH CONFIRMED RESISTANT ESSENTIAL HYPERTENSION

Objective: The lack of consensus regarding the role of vasopressin in uncontrolled hypertension may be due to the use of assays with limited sensitivity. We used plasma copeptin concentration (PCop), a reliable surrogate marker for plasma vasopressin, to evaluate its role in a large population of patients with resistant (RH) and non-resistant (NRH) essential hypertension. Design and method: 166 patients with RH to > = 3 antihypertensive drugs, including a diuretic (office BP > = 140 or 90 mmHg), entered a 4-week standardized treatment with irbesartan 300 mg + HCTZ 12.5 mg + amlodipine 5 mg to confirm RH by ABPM (daytime ambulatory BP > = 135/85 mmHg). We compared PCop, plasma renin (PRC) and aldosterone concentration (PAC) and urine osmolality (Uosm) and estimated glomerular filtration rate (eGFR) after 4 weeks between patients with confirmed RH (n = 140) and NRH (n = 26). Results: Patients with RH were more frequently men, had significantly lower PRC, but similar PAC than patients with NRH. PCop was about 2-fold higher in patients with RH than in those with NRH (P = 0.001 adjusted on sex, plasma Na, daytime SBP and eGFR) even though similar plasma Na (p = 0.9). RH Uosm, 24-h and urinary output and correlation between Uosm log-PCop did not significantly differ between the two groups.Conclusions: Patients with RH to a 4-week standardized triple therapy had a 2-fold lower PRC (indicating a persistance of volume expansion) and a 2-fold higher PCop than those of patients NRH. The increase in PCop was not explained by changes in plasma Na, nor by peripheral (renal) resistance to vasopressin. This suggests a primary central stimulation of AVP secretion in RH associated with biological signs of volume expansion.

PS 11-83 ONE-YEAR OUTCOMES OF THE RANDOMIZED OSLO-RDN STUDY

Objective: The blood pressure (BP) lowering effect of renal sympathetic denervation (RDN) in treatment resistant hypertension (TRH) shows variation among the few randomized studies. The duration of antihypertensive effect and long-term effect and safety of RDN require further follow-up. We aimed to report the office and ambulatory (BP) changes and long-term safety at 12-month follow-up. Design and Method: Patients with apparent TRH (n = 65) were referred specifically for RDN and those with secondary and spurious hypertension (n = 26) were excluded. TRH was defined as office systolic BP>140 mmHg despite maximally tolerated doses of at least 3 antihypertensive drugs including a diuretic. Additionally, ambulatory daytime systolic BP > 135 mmHg following witnessed intake of antihypertensive drugs was required, after which 20 patients had normalized BP, indicating poor drug adherence. Patients with true TRH were randomized and underwent RDN with Symplicity catheter (n = 9) versus adjusted drug treatment (n = 10). Results: 24-hour ambulatory systolic and diastolic BPs in the drug adjustment group changed from 151 ± 13/84 ± 7 mmHg (±SD) at baseline to 131 ± 12/75 ± 5 mmHg at 12 months (p < 0.0005 for all), and in the RDN group from 149 ± 9/89 ± 7 to 141 ± 11/83 ± 5 mmHg (p = 0.07 and p = 0.04, respectively). The absolute difference in change between groups in systolic BP was significantly higher in favor of the drug adjustment group (p = 0.01). Office, daytime and nighttime ambulatory BPs changed in parallel to the 24-hour ambulatory BPs. However 2 patients in RDN group considered as a responder since they have sustained reduction of 24-hour ambulatory systolic BP by more than 15 mmHg. There were no significant changes in renal arteries assessed by MRI or CT scans after 12 months follow-up. No deterioration of renal function was found. Conclusions: RDN has inferior BP lowering effects compared to adjusted drug treatment in patients with TRH. However, RDN is safe and this encourages future research to identify characteristics of patients who might respond to RDN.

PS 05-30 CIRCADIAN BLOOD PRESSURE PATTERN, EPICARDIAL FAT THICKNESS AND LEFT ATRIAL FUNCTION

Objective: Epicardial adipose tissue reflects visceral adiposity and inflammation which can contribute to the fibrotic remodeling of the atrial myocardium. We aimed to investigate the relationship of echocardiographic epicardial fat thickness (EFT) and left atrial (LA) deformation parameter with diurnal blood pressure (BP) changes in patients with recently diagnosed essential hypertension. Design and method: This cross-sectional study included 511 recently diagnosed hypertensive patients, who underwent echocardiography and 24-hours ambulatory BP monitoring. EFT was measured with echocardiography, and global LA strain was obtained by two-dimensional speckle imaging with automated software. The patients were classified as non-dippers if their daytime ambulatory systolic and diastolic blood pressure did not decrease by at least 10% during the night. Results: The mean EFT, LA volume index as well as left ventricular (LV) filling pressure (E/Ea) were significantly higher in hypertensive patients, especially in non-dippers (all p < 0.001), whereas global LA strain was significantly lowest in non-dippers (normotensives; 23.2 ± 2.0% vs. dippers = 19.0 ± 3.3% vs. non-dippers = 17.4 ± 3.0%, P < 0.001). Moreover, LA strain was significantly associated with LV filling pressure (r = −0.422, p < 0.001), EFT (r = −0.187, p < 0.001), and 24 hour mean BP variability (r = −0.184, p < 0.001). Conclusions: Non-dipper hypertensive patients were associated with increased EFT and impaired LA deformation. This indicates that these subjects may be more prone to atrial rhythm disturbances.

OP.1A.10] CONVENTIONAL AND AMBULATORY BLOOD PRESSURE AS PREDICTORS OF RETINAL ARTERIOLAR NARROWING

Objective: To investigate to what extent conventional (CBP) and daytime ambulatory (ABP) blood pressure predict narrowing of the retinal microvasculature. Design and method: In a population-based longitudinal study, 783 white Flemish participants (mean age, 38.2 years; 51.3% women) were randomly recruited, whose blood pressure was measured at baseline and follow-up and who underwent retinal photography at follow-up. CBP and ABP were averaged of five consecutive auscultatory readings and ambulatory oscillometric readings (10 AM–8 PM) programmed at 20 minute intervals. Systolic/diastolic HT thresholds were 140/90 mmHg for CBP and 135/85 mmHg for ABP. Central retinal arteriolar (CRAE) and venular (CRVE) equivalents and their ratio (AVR) were used as retinal traits post-processed by Vasculomatic ala Nicola software. Results: In multivariable-adjusted models including both CBP and ABP at baseline, CRAE changes after 10.3 years (median) were unrelated to CBP (P > = 0.14), whereas ABP predicted CRAE narrowing (P < = 0.01). Per 1-SD increment in systolic/diastolic blood pressure, the association sizes were -0.95 μm (95% confidence interval, -2.20 to 0.30)/ -0.75 μm (-1.93 to 0.42) for CBP and -1.76 μm (-2.95 to -0.58)/-1.48 μm (-2.61 to -0.34) for ABP. CRVE was not related to CBP or ABP, while associations of AVR with blood pressure mirrored those of CRAE, the numerator of the ratio. In multivariable-adjusted models with baseline ABP and follow-up CBP, CRAE decreased (P < = 0.049) by -1.61/-1.04 μm and by -2.60/-2.40 μm in relation to baseline daytime and follow-up conventional systolic/diastolic blood pressures, respectively. Compared with normotension (normal CBP and ABP; prevalence, 77.6%), HT patients had smaller CRAE (147.5 vs. 152.7 μm; P < 0.001) and AVR (0.68 vs. 0.70; P = 0.001). CRAE and AVR were not different (P > = 0.06) between normotension and white-coat HT (elevated CBP and normal ABP; 5.4%) and between masked HT (normal CBP and elevated ABP; 10.2%) and HT (elevated CBP and ABP; 6.8%). Conclusions: The paradigm that retinal arterial narrowing precedes HT can be explained by the limitations of CBP measurement, including the nonidentification of masked HT.

Adherence to Antihypertensive Treatment and the Blood Pressure-Lowering Effects of Renal Denervation in the Renal Denervation for Hypertension (DENERHTN) Trial.

The DENERHTN trial (Renal Denervation for Hypertension) confirmed the blood pressure-lowering efficacy of renal denervation added to a standardized stepped-care antihypertensive treatment for resistant hypertension at 6 months. We report the influence of adherence to antihypertensive treatment on blood pressure control. One hundred six patients with hypertension resistant to 4 weeks of treatment with indapamide 1.5 mg/d, ramipril 10 mg/d (or irbesartan 300 mg/d), and amlodipine 10 mg/d were randomly assigned to renal denervation plus standardized stepped-care antihypertensive treatment, or the same antihypertensive treatment alone. For standardized stepped-care antihypertensive treatment, spironolactone 25 mg/d, bisoprolol 10 mg/d, prazosin 5 mg/d, and rilmenidine 1 mg/d were sequentially added at monthly visits if home blood pressure was ≥135/85 mm Hg after randomization. We assessed adherence to antihypertensive treatment at 6 months by drug screening in urine/plasma samples from 85 patients. The numbers of fully adherent (20/40 versus 21/45), partially nonadherent (13/40 versus 20/45), or completely nonadherent patients (7/40 versus 4/45) to antihypertensive treatment were not different in the renal denervation and the control groups, respectively (P=0.3605). The difference in the change in daytime ambulatory systolic blood pressure from baseline to 6 months between the 2 groups was -6.7 mm Hg (P=0.0461) in fully adherent and -7.8 mm Hg (P=0.0996) in nonadherent (partially nonadherent plus completely nonadherent) patients. The between-patient variability of daytime ambulatory systolic blood pressure was greater for nonadherent than for fully adherent patients. In the DENERHTN trial, the prevalence of nonadherence to antihypertensive drugs at 6 months was high (≈50%) but not different in the renal denervation and control groups. Regardless of adherence to treatment, renal denervation plus standardized stepped-care antihypertensive treatment resulted in a greater decrease in blood pressure than standardized stepped-care antihypertensive treatment alone. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01570777.

True Resistant Hypertension Following Observed Drug Ingestion: A Systematic Evaluation.

The authors investigated the role of poor drug adherence in treatment-resistant hypertension following observed drug ingestion in 102 patients. Median blood pressures (BPs) were 170/91 mm Hg at referral, 153/84 mm Hg prior to, and 142/79 mm Hg during a 4- to 6-hour period after drug ingestion. Median daytime ambulatory BP monitoring (ABPM) over the following 24 hours was 142/80 mm Hg. Median BP at a final follow-up clinic visit was 147/79 mm Hg. The cumulative number of patients achieving a goal of <140/90 mm Hg in clinic or <135/85 mm Hg mean on ABPM was 57 (56%), with a further nine (9%) controlled at the final follow-up clinic visit. Thus, 65% of patients achieved a systolic BP <140 mm Hg at any point immediately prior to, or after, drug ingestion; the residual 35% were considered to have true resistant hypertension. In conclusion, among patients with suspected resistant hypertension, a minority were truly treatment-resistant following observed drug ingestion and BP monitoring.

Arterial stiffness and its relationship to clinic and ambulatory blood pressure: a longitudinal study in non-dialysis chronic kidney disease.

Both arterial stiffness and systolic blood pressure (BP) are established cardiovascular risk factors, yet little is known about their interrelationship in chronic kidney disease (CKD). The goal of this prospective study was to describe the trajectory of aortic pulse wave velocity (PWV) and BP and to compare the longitudinal interrelationship of BP (clinic and 24 h ambulatory recording) with the PWV. Clinic BP was taken in two ways: at the time of the measurement of the PWV (Clinic-S) and as an average of triplicate measurements on three separate occasions within 1 week (Clinic-M). 24 h ambulatory BP was measured using a validated monitor and PWV was measured in the aorta using an echo-Doppler technique. Among 255 veterans with CKD followed for over up to 4 years, the rate of change of log PWV was inversely related to the baseline PWV; the trajectories were variable among individuals and the net population change was no different from zero. In contrast, systolic BP significantly increased, but linearly, and a strong relationship was seen between cross-sectional and longitudinal changes in Clinic-M systolic BP and log PWV. In contrast, a longitudinal relationship between Clinic-S and log PWV was absent. In the case of 24-h ambulatory BP, a strong cross-sectional change was seen between awake and 24 h systolic BP but not between sleep BP and log PWV. In conclusion, among people with CKD, the PWV changes over time and is inversely related to the baseline PWV. An average of clinic BP measurements taken over three visits, but not single measurements, are useful to assess the PWV and its change over time. Differences exist between ambulatory BP monitoring recording during the sleep and awake states in their ability to predict the PWV. Taken together, these data support the view that among those with CKD not on dialysis, targeting clinic BP taken on multiple occasions using a standardized methodology or daytime ambulatory systolic BP may slow the progression of arterial damage.

Nocturnal Non-dipping Blood Pressure Profile in Black Normotensives Is Associated with Cardiac Target Organ Damage.

A non-dipping pattern of nocturnal blood pressure in hypertensive patients is an established predictor of cardiovascular risk, especially in Blacks. However, data on non-dipping normotensives and cardiovascular risk in this population is sparse. In this study, we aim to determine if a non-dipping profile in a cohort of Black normotensives is associated with cardiac target organ damage. We studied ambulatory blood pressure patterns in 43 normotensive Black patients of Caribbean origin and classified their profiles as dippers (DP) and non-dippers (NDP) based on their nocturnal blood pressure profiles. Cardiac target organ damage was estimated from 2-D echocardiogram. The mean age of the cohort was 52 years. Both groups were similar with respect to baseline age, sex, weight, height, body mass index and daytime ambulatory BP. There was a statistically significant difference in nocturnal blood pressure between DP and NDP groups (112 ± 7/64 ± 2 mm Hg vs 117 ± 3/69 ± 2 mm Hg, P=.004). The NDP cohort showed evidence of cardiovascular target damage on echocardiography with a significantly increased relative wall thickness (.35 ± .07 cm vs .42 ± .05 cm, P=.001), left ventricular mass index (95 ± 14 vs 105 ± 14 g/m(2), P=.018) and left atrial volume index (26 ± 3.5 vs. 30 ± 3.4, P=.001). Left ventricular geometry in the non-dippers also showed increased concentric remodeling, concentric and eccentric hypertrophy. Our study demonstrates that nocturnal non-dipping of blood pressure in normotensive Blacks of Caribbean origin may be associated with cardiovascular end organ damage thereby providing new surveillance and therapeutic targets.

Conventional and Ambulatory Blood Pressure as Predictors of Retinal Arteriolar Narrowing.

At variance with the long established paradigm that retinal arteriolar narrowing trails hypertension, several longitudinal studies, all based on conventional blood pressure (CBP) measurement, proposed that retinal arteriolar narrowing indicates heightened microvascular resistance and precedes hypertension. In 783 randomly recruited Flemish (mean age, 38.2 years; 51.3% women), we investigated to what extent CBP and daytime (10 am to 8 pm) ambulatory blood pressure (ABP) measured at baseline (1989-2008) predicted the central retinal arteriolar equivalent (CRAE) in retinal photographs obtained at follow-up (2008-2015). Systolic/diastolic hypertension thresholds were 140/90 mm Hg for CBP and 135/85 mm Hg for ABP. In multivariable-adjusted models including both baseline CBP and ABP, CRAE after 10.3 years (median) of follow-up was unrelated to CBP (P≥0.14), whereas ABP predicted CRAE narrowing (P≤0.011). Per 1-SD increment in systolic/diastolic blood pressure, the association sizes were -0.95 µm (95% confidence interval, -2.20 to 0.30)/-0.75 µm (-1.93 to 0.42) for CBP and -1.76 µm (-2.95 to -0.58)/-1.48 µm (-2.61 to -0.34) for ABP. Patients with ambulatory hypertension at baseline (17.0%) had smaller CRAE (146.5 versus 152.6 µm; P<0.001) at follow-up. CRAE was not different (P≥0.31) between true normotension (normal CBP and ABP; prevalence, 77.6%) and white-coat hypertension (elevated CBP and normal ABP, 5.4%) and between masked hypertension (normal CBP and elevated ABP, 10.2%) and hypertension (elevated CBP and ABP, 6.8%). In conclusion, the paradigm that retinal arteriolar narrowing precedes hypertension can be explained by the limitations of CBP measurement, including nonidentification of masked and white-coat hypertension.

Short-term telemedical home blood pressure monitoring does not improve blood pressure in uncomplicated hypertensive patients.

Telemonitoring of home blood pressure measurements (TBPM) is a new and promising supplement to diagnosis, control and treatment of hypertension. We wanted to compare the outcome of antihypertensive treatment based on TBPM and conventional monitoring of blood pressure. Participants were recruited from a prevalence study among citizens aged 55-64 years in the municipality of Holstebro, Denmark. The study was a randomized, controlled, unblinded 3 months' trial. In the intervention group, antihypertensive treatment was based on TBPM with transmission of the measurements and subsequent communication by telephone or e-mail. In the control group, patients received usual care. Primary outcome was reduction in daytime ambulatory blood pressure measurements (ABPM) from baseline to 3 months' follow-up. Of 375 participants randomized, primary outcome data were available for 356 (95%). In both groups, daytime ABPM decreased significantly. The decrease in daytime ABPM in the intervention group was systolic/diastolic, -8±12/-4±7 mm Hg. This did not differ significantly from the control group's -8±13/-4±8 mm Hg. An equal number of participants obtained normal daytime ABPM, in the intervention group 17% (31/175) versus control 21% (37/181), P=0.34. We found that both TBPM patients and controls achieved a significant blood pressure reduction in this randomized, controlled, unblinded 3-month trial. We found no difference in blood pressure reduction or number of patients reaching blood pressure goals. Further information and education of some general practitioners seem to be relevant regarding blood pressure management and control of hypertension.

Impact of Introducing Catheter-based Renal Denervation into Japan for Hypertension Management: Estimation of Number of Target Patients and Clinical Relevance of Ambulatory Blood Pressure Reduction.

New medical approaches to the autonomic nervous system, such as catheterbased renal denervation, have been introduced into clinical practice in the recent years for patients who have resistant hypertension. We estimate the number of subjects in Japan who would benefit from renal denervation when this treatment is introduced into Japan, based on data from the Jichi Medical University clinical trials. We also discuss the logical basis of changing the formerly used primary endpoint, i.e., office BP, to 24-hr ambulatory BP in future clinical trials. Among JAMP registry data, the total number of hypertensives was 5,858 and the patients who were prescribed ≥ 3 drugs including diuretics were 749. The poorly controlled hypertension rate was 32% in the group prescribed ≥ 3 drugs including diuretics and it constitutes 4.1% of the total hypertensive patients. We also analyzed the data of JMS ABPM cohort study wave 1 (811 patients). The hazard ratios (HRs) for each 10-mmHg increase in BP was 1.38 (95%CI 1.17-1.63, p&lt;0.001) for 24-hr BP and 1.18 (95%CI 1.05-1.33, p=0.006) for office BP. However, the significance for office BP was lost once the 24-hr, daytime and nighttime ambulatory BP data were added to the covariates. The prevalence of resistant hypertensive patients among all of the hypertensive patients is 4.1%. Based on this prevalence, the number of resistant hypertensive individuals in Japan would be 1,870,000 patients. In future renal denervation clinical studies in Japan, we should set the primary endpoint as a 24-hr systolic BP reduction measured by ABPM.

Effect of intensive versus standard clinic-based blood pressure management on ambulatory blood pressure - results from the sprint abpm study

The Systolic Blood Pressure Intervention Trial (SPRINT) was a 2-arm, multicenter, randomized clinical trial designed to test whether a treatment program aimed at reducing systolic blood pressure (SBP) to a lower goal than currently recommended will reduce cardiovascular disease. The goal of the SPRINT Ambulatory BP Ancillary Study was to evaluate the effect of intensive (SBP <120 mmHg) versus standard (SBP <140 mmHg) clinic-based BP targets on ambulatory BP, specifically nighttime SBP (primary outcome). Ambulatory BP was measured within 3 weeks of the 27 month follow-up visit in 876 participants at 15 SPRINT clinic sites. Spacelabs 90207 monitors were programmed to record BP every 30 minutes. Clinic BP was obtained after 5 minutes of rest using an automated device (Model 907, Omron Healthcare); the mean of three BP measurements was used for analyses. Average age at the time of ABPM was 71.5 years, 29% were female, 28% were black, and the average eGFR was 69.7 ml/min/1.73m2. Clinic and ambulatory BP (in mmHg) at the time of ABPM and group differences (standard-treatment minus intensive-treatment) are shown in the table. Additionally, Bland-Altman plots indicated poor concordance between office and daytime ambulatory BP with a Pearson correlation of 0.54 and limits of agreement of approximately -20 to 30 mmHg. In conclusion, a treatment regimen targeting office based SBP less than 120 mmHg lowers 24hr, daytime, and nighttime ambulatory BP and BP variability, but does not alter diurnal BP pattern (night/day BP ratio). Ambulatory BP monitoring confirms a large and significant BP difference between randomized groups despite the intervention being based on clinic BP. The difference in BP between intensive and standard clinic based BP targets was greater when measured with clinic than with 24 hour ambulatory BP, and daytime compared to nighttime BP. Given the poor agreement between clinic and 24 hour BP, ambulatory BP monitoring may be required to assess the effect of targeted hypertension therapy on out of office BP. Further studies are needed to assess whether targeting hypertension therapy based on ambulatory BP would reduce adverse outcomes compared to targeting clinic BP.

Lifetime racial/ethnic discrimination and ambulatory blood pressure: The moderating effect of age.

To determine whether the relationships of lifetime discrimination to ambulatory blood pressure (ABP) varied as a function of age in a sample of Black and Latino(a) adults ages 19 - 65. Participants were 607 Black (n = 318) and Latino(a) (n = 289) adults (49% female) who completed the Perceived Ethnic Discrimination Questionnaire-Community Version (PEDQ-CV), which assesses lifetime exposure to racism/ethnic discrimination. They were outfitted with an ABP monitor to assess systolic and diastolic blood pressure (SBP, DBP) across a 24-hr period. Mixed-level modeling was conducted to examine potential interactive effects of lifetime discrimination and age to 24-hr, daytime, and nighttime ABP after adjustment for demographic, socioeconomic, personality and life stress characteristics, and substance consumption covariates (e.g., smoking, alcohol). There were significant interactions of Age × Lifetime Discrimination on 24-hr and daytime DBP (ps ≤ .04), and in particular significant interactions for the Social Exclusion component of Lifetime Discrimination. Post hoc probing of the interactions revealed the effects of Lifetime Discrimination on DBP were seen for older, but not younger participants. Lifetime discrimination was significantly positively associated with nocturnal SBP, and these effects were not moderated by age. All associations of Lifetime Discrimination to ABP remained significant controlling for recent exposure to discrimination as well as all other covariates. Exposure to racial/ethnic discrimination across the life course is associated with elevated ABP in middle to older aged Black and Latino(a) adults. Further research is needed to understand the mechanisms linking discrimination to ABP over the life course. (PsycINFO Database Record

Night-time home versus ambulatory blood pressure in determining target organ damage

This study aimed to evaluate the association of night-time blood pressure (BP) assessed by home blood pressure (HBP) or ambulatory blood pressure (ABP) monitoring with preclinical target organ damage in untreated hypertension. Untreated hypertensive study participants were evaluated with ABP monitoring (24-h) and HBP monitoring during daytime (6 days, duplicate morning and evening measurements) and night-time (automated asleep measurements, three nights, 3-hourly measurements/night). Target organ damage was assessed by echocardiographic left ventricular mass index (LVMI), common carotid intima-media thickness (cIMT), urine albumin excretion (UAE), and ankle-brachial index (ABI). A total of 131 study participants were analysed [mean age 52.1 ± 11.9 (SD) years, BMI 29.9 ± 5.3 kg/m2, men 58%, cardiovascular disease history 6.1%]. Daytime and night-time HBP were slightly higher than the respective ABP values (mean difference for systolic daytime/night-time 3.5 ± 10.6/2.6 ± 9.8 mmHg, P < 0.01 for both comparisons and diastolic -0.3 ± 6.8/1.2 ± 6.2 mmHg, P = NS/0.02, respectively). There was a strong correlation between daytime ABP and HBP (r = 0.71/0.72, systolic/diastolic), as well as between the respective night-time values (r = 0.80/0.79; all P < 0.01). Night-time ABP and HBP presented strong and comparable correlations with all the indices of preclinical target organ damage. In multivariate analyses, both LVMI (R2 = 0.26) and cIMT (R2 = 0.25) were determined by night-time systolic HBP, age and male sex; UAE (R2 = 0.28) by night-time systolic HBP and male sex; ABI (R2 = 0.20) by male sex and night-time home pulse pressure. In untreated hypertensives, night-time BP assessed by home monitoring appears to be as good as night-time ambulatory monitoring in determining preclinical target organ damage.

Differences in night-time and daytime ambulatory blood pressure when diurnal periods are defined by self-report, fixed-times, and actigraphy: Improving the Detection of Hypertension study.

To determine whether defining diurnal periods by self-report, fixed-time, or actigraphy produce different estimates of night-time and daytime ambulatory blood pressure (ABP). Over a median of 28 days, 330 participants completed two 24-h ABP and actigraphy monitoring periods with sleep diaries. Fixed night-time and daytime periods were defined as 0000-0600 h and 1000-2000 h, respectively. Using the first ABP period, within-individual differences for mean night-time and daytime ABP and kappa statistics for night-time and daytime hypertension (systolic/diastolic ABP≥120/70 mmHg and ≥135/85 mmHg, respectively) were estimated comparing self-report, fixed-time, or actigraphy for defining diurnal periods. Reproducibility of ABP was also estimated. Within-individual mean differences in night-time systolic ABP were small, suggesting little bias, when comparing the three approaches used to define diurnal periods. The distribution of differences, represented by 95% confidence intervals (CI), in night-time systolic and diastolic ABP and daytime systolic and diastolic ABP was narrowest for self-report versus actigraphy. For example, mean differences (95% CI) in night-time systolic ABP for self-report versus fixed-time was -0.53 (-6.61, +5.56) mmHg, self-report versus actigraphy was 0.91 (-3.61, +5.43) mmHg, and fixed-time versus actigraphy was 1.43 (-5.59, +8.46) mmHg. Agreement for night-time and daytime hypertension was highest for self-report versus actigraphy: kappa statistic (95% CI) = 0.91 (0.86,0.96) and 1.00 (0.98,1.00), respectively. The reproducibility of mean ABP and hypertension categories was similar using each approach. Given the high agreement with actigraphy, these data support using self-report to define diurnal periods on ABP monitoring. Further, the use of fixed-time periods may be a reasonable alternative approach.

Prevalence of resistant hypertension and associated factors for blood pressure control status with optimal medical therapy using Korean ambulatory blood pressure monitoring registry data.

BackgroundResistant hypertension (RH) may be one of the cause of the plateau in improving the control rate in hypertension (HT) management. The misdiagnosis of RH by clinic blood pressure (BP) is important clinical problem. Aim of the study were to investigate the prevalence of RH by ambulatory blood pressure monitoring (ABPM) and the factor associated with control status of ambulatory BPs.MethodsFor 1230 subjects taking one or more antihypertensive medication (AHM) enrolled in the Korean Ambulatory Blood Pressure Monitoring (Kor-ABP) registry, the prevalence of RH was calculated which was defined as uncontrolled BP by three AHM classes including diuretic or BP in need of four or more AHM classes. The prevalence determined by clinic versus ambulatory BP was compared.ResultsThe age was 59.3 ± 12.5 years, and 44.3 % were female (n = 1230). Among them 72 subjects were taking three AHM drugs including diuretics and 105 subjects were taking four or more AHM classes. With uncontrolled daytime ambulatory BP in 41 among 72 subjects, prevalence of RH was 11.9 % (146/1230). By using nighttime BP criteria, there was significant difference in the prevalence of RH for clinic versus nighttime BP (146/177 vs. 159/177, p = 0.0124). For control status of daytime BP, masked uncontrolled BP was 16.9 % and controlled BP with white-coat effect was 14.1 %. For nighttime BP control status, odd ratios for smoking (0.624), drinking (1.512), coronary artery disease (0.604), calcium antagonist (1.705), and loop diuretics (0.454) were all significant.ConclusionThe prevalence itself was 11.9 % by daytime BP and it was significantly higher when using nighttime BP criteria. Control status of daytime BP was misclassified in 31.0 %. Smoking, drinking, coronary artery disease, calcium antagonist, and loop diuretics were associated with nighttime BP control status.

Renal artery sympathetic denervation: observations from the UK experience.

BackgroundRenal denervation (RDN) may lower blood pressure (BP); however, it is unclear whether medication changes may be confounding results. Furthermore, limited data exist on pattern of ambulatory blood pressure (ABP) response—particularly in those prescribed aldosterone antagonists at the time of RDN.MethodsWe examined all patients treated with RDN for treatment-resistant hypertension in 18 UK centres.ResultsResults from 253 patients treated with five technologies are shown. Pre-procedural mean office BP (OBP) was 185/102 mmHg (SD 26/19; n = 253) and mean daytime ABP was 170/98 mmHg (SD 22/16; n = 186). Median number of antihypertensive drugs was 5.0: 96 % ACEi/ARB; 86 % thiazide/loop diuretic and 55 % aldosterone antagonist. OBP, available in 90 % at 11 months follow-up, was 163/93 mmHg (reduction of 22/9 mmHg). ABP, available in 70 % at 8.5 months follow-up, was 158/91 mmHg (fall of 12/7 mmHg). Mean drug changes post RDN were: 0.36 drugs added, 0.91 withdrawn. Dose changes appeared neutral. Quartile analysis by starting ABP showed mean reductions in systolic ABP after RDN of: 0.4; 6.5; 14.5 and 22.1 mmHg, respectively (p < 0.001 for trend). Use of aldosterone antagonist did not predict response (p > 0.2).ConclusionIn 253 patients treated with RDN, office BP fell by 22/9 mmHg. Ambulatory BP fell by 12/7 mmHg, though little response was seen in the lowermost quartile of starting blood pressure. Fall in BP was not explained by medication changes and aldosterone antagonist use did not affect response.Electronic supplementary materialThe online version of this article (doi:10.1007/s00392-015-0959-4) contains supplementary material, which is available to authorized users.

Differences in night-time and daytime ambulatory blood pressure when diurnal periods are defined by self-report, fixed-times, and actigraphy: Improving the Detection of Hypertension study

Differences in night-time and daytime ambulatory blood pressure when diurnal periods are defined by self-report, fixed-times, and actigraphy: Improving the Detection of Hypertension study