Elevated Clinic Blood Pressure Research Articles

Same-Day Primary Care Referral Versus Usual Care for Patients With Elevated Blood Pressures Seen in a Preoperative Clinic.

Background While several studies have suggested that anesthesia and surgical care episodes provide an opportunity to improve the diagnosis and treatment of hypertension, few studies have implemented and tested pragmatic care coordination efforts for this population. The present study aimed to examine the effects of same-day primary care referral vs. usual care on outpatient hypertension treatment among patients with elevated preoperative clinic blood pressure (BP). Methodology With institutional review board approval of the project as a quality improvement (QI) initiative not requiring consent, we conducted a prospective QI project comparing same-day preoperative primary care referral vs. usual care within comparable cohorts of US Veterans presenting to a preoperative evaluation clinic with elevated BP for whom treatment assignment was based on prior primary care clinic affiliation. Outpatient BP, antihypertensive medications, and antihypertensive dosages at the initial visit and for one year after the initial preoperative clinic visit were followed in the electronic health record. Results Between June 1, 2018, and June 1, 2019, one of the two on-site primary care groups (Firm A) at our facility agreed to accommodate same-day BP referrals. Patients in the second primary care group received standard preoperative care (Firm B). Charts for the pseudo-randomized cohort of Firm A and B patients were compared after 12 months to assess for changes in BP and hypertension treatment. Firm A and B patients were similar in demographics. Overall, 68 (91%) Firm A patients were correctly referred for primary care appointments. Moreover, 28 of 68 (41.2%) patients adhered to the same-day referral recommendation, with the remainder declining to attend the primary care visit. BPs were similar between Firm A and Firm B groups at 3, 6, 9, and 12 months post-intervention. Firm A adherent patients (i.e., those attending the referral) received hypertension treatment intensification sooner than Firm A non-adherent and Firm B patients (median (interquartile range) days to intensification = 21 (0.5-103.5) vs. 154 (45.5-239) and 170 (48-220), respectively; p = 0.038 and p = 0.048, respectively). Conclusions Our protocol achieved a high degree of same-day primary care referral (91%) in hypertensive patients presenting at the preoperative clinic. Although this limited study did not demonstrate improved BP control in patients who received same-day primary care, this group did show increased rates of rapid treatment intensification which may infer improved long-term health outcomes. Further work examining logistical barriers to patients attending same-day referrals is warranted.

Inter-arm blood pressure difference and cardiovascular risk estimation in primary care: a pilot study.

Systolic inter-arm differences (IAD) in blood pressure (BP) contribute independently to cardiovascular risk estimates. This can be used to refine predicted risk and guide personalised interventions. To model the effect of accounting for IAD in cardiovascular risk estimation in a primary care population free of pre-existing cardiovascular disease. A cross-sectional analysis of people aged 40-75 years attending NHS Health Checks in one general practice in England. Simultaneous bilateral BP measurements were made during health checks. QRISK2, atherosclerotic cardiovascular disease (ASCVD), and Framingham cardiovascular risk scores were calculated before and after adjustment for IAD using previously published hazard ratios. Reclassification across guideline-recommended intervention thresholds was analysed. Data for 334 participants were analysed. Mean (standard deviation) QRISK2, ASCVD, and Framingham scores were 8.0 (6.9), 6.9 (6.5), and 10.7 (8.1), respectively, rising to 8.9 (7.7), 7.1 (6.7), and 11.2 (8.5) after adjustment for IAD. Thirteen (3.9%) participants were reclassified from below to above the 10% QRISK2 threshold, three (0.9%) for the ASCVD 10% threshold, and nine (2.7%) for the Framingham 15% threshold. Knowledge of IAD can be used to refine cardiovascular risk estimates in primary care. By accounting for IAD, recommendations of interventions for primary prevention of cardiovascular disease can be personalised and treatment offered to those at greater than average risk. When assessing elevated clinic BP readings, both arms should be measured to allow fuller estimation of cardiovascular risk.

Comparison of community and clinic-based blood pressure measurements: A cross-sectional study from Haiti.

Hypertension (HTN) is the leading modifiable cardiovascular disease (CVD) risk factor in low and middle-income countries, and accurate and accessible blood pressure (BP) measurement is essential for identifying persons at risk. Given the convenience and increased use of community BP screening programs in low-income settings, we compared community and clinic BP measurements for participants in the Haiti CVD Cohort Study to determine the concordance of these two measurements. Participants were recruited using multistage random sampling from March 2019 to August 2021. HTN was defined as systolic BP (SBP) ≥ 140mmHg, diastolic BP (DBP) ≥ 90mmHg or taking antihypertensives according to WHO guidelines. Factors associated with concordance versus discordance of community and clinic BP measurements were assessed with multivariable Poisson regressions. Among 2,123 participants, median age was 41 years and 62% were female. Pearson correlation coefficients for clinic versus community SBP and DBP were 0.78 and 0.77, respectively. Using community BP measurements, 36% of participants screened positive for HTN compared with 30% using clinic BPs. The majority of participants had concordant measurements of normotension (59%) or HTN (26%) across both settings, with 4% having isolated elevated clinic BP (≥140/90 in clinic with normal community BP) and 10% with isolated elevated community BP (≥140/90 in community with normal clinic BP). These results underscore community BP measurements as a feasible and accurate way to increase HTN screening and estimate HTN prevalence for vulnerable populations with barriers to clinic access.

Abstract P487: Network Stressors, Personal Stressors, And Sustained Hypertension In African American Women

Introduction: Stressful life events (SLE) have been associated with poor cardiovascular health but most studies have focused on stressors that directly impact the individuals under study, or personal stressors. Research suggests that women, particularly African-American women, may actually be more vulnerable to network stressors (e.g. SLE that impact important others, such as children, spouses and friends). However, few studies have examined this phenomenon. Hypothesis: We tested the hypothesis that greater exposure to network, versus personal stressors, would be associated with elevated clinic blood pressure (BP) as well as BP in daily life, assessed via 48-hour ambulatory monitoring. Methods: Participants were 395 African-American women aged 30-45 (Mean= 39.5 ±4.6 yrs) from a range of educational backgrounds recruited from a large southeastern metropolitan area. SLE were assessed using a 22-item Stressful Life Events checklist and further classified into personal (e.g. “major accident/assault/robbery happened to you”) or network (e.g. “serious physical illness, injury or drug/alcohol problem in someone family member/friend”) stressors and summed. Clinic and 48-hr ambulatory BP measurements were assessed and sustained hypertension (HTN) was defined as both clinic (≥130/80mmHg) and ambulatory HTN (≥130/80mmHg), using 2017 AHA/ACC guidelines. Logistic regression analyses were used to examine the associations between types of stressors and sustained HTN after adjusting for age, education, body mass index, and BP meds. Results: Approximately 51.2% (N=211) of women had clinic HTN and 29.9% (N=123) of women had sustained HTN (elevated in both clinic and in daily life). In unadjusted multivariable logistic regression analyses, each additional network stressor was associated with a greater likelihood of having elevated clinic (OR-1.21 [1.04-1.40]) and sustained HTN (OR- OR-1.22 [1.04-1.43]). Findings for clinic (OR-1.25, [1.06-1.48]) and sustained HTN (OR-1.23, [1.04-1.46]) remained significant after adjustment for covariates. There were no significant associations between reports of personal stressors and either clinic, or sustained HTN in unadjusted or adjusted analyses. Discussion: Network, but not personal stressors, were associated with elevated rates of HTN, both in clinic and daily life for African-American women. Future research is needed to determine whether interventions targeting stress management for network stressors specifically might impact BP in this high-risk population.

Current status of white coat hypertension: where are we?

White coat hypertension (WCH) is characterised by an elevated clinic blood pressure (BP) with normal ambulatory or home BP. It is well recognised in clinical practice and occurs in approximately one-third of untreated patients with elevated clinic BP. Current evidence suggests that WCH is associated with cardiovascular risk factors, including the development of sustained hypertension and the presence of target organ damage. However, its effects on cardiovascular outcomes remain a matter of debate. There is also insufficient evidence from randomised controlled trials to determine whether WCH warrants treatment. This narrative review aims to provide an update on the current understanding of WCH. It focuses on the clinical characteristics and potential implications of WCH, its relationship to cardiovascular risk and the evidence regarding treatment. Gaps in existing research are also highlighted.

P116 Post-stroke White Coat Hypertension/Effect is Associated with Greater Arterial Stiffness

ObjectiveWhite coat hypertension/effect (WCH/E) describes an elevated clinic blood pressure (BP) with normal daytime ambulatory BP (ABPM) values. It is not clear whether WCH/E is associated with adverse vascular risk. This study aimed to determine the relationship between WCH/E and arterial stiffness in a cohort of patients who had a transient ischaemic attack (TIA) or lacunar stroke (LS).Design and MethodThe Arterial Stiffness In Lacunar Stroke and TIA (ASIST) study recruited 96 patients, aged over 40 years old, with a confirmed diagnosis of TIA or LS in the preceding 14 days. Patients were grouped by BP. Thirty-four patients were excluded (n = 6 declined ABPM, n = 3 masked hypertension and n = 25 sustained hypertension). Thirty-two patients with normal BP (clinic BP < 140/90 mmHg and day-time ABPM < 135/85 mmHg), and 30 patients with WCH/E (clinic BP > 140/90 mmHg and day-time ABPM < 135/85 mmHg) were recruited. Arterial stiffness was measured using carotid-femoral pulse wave velocity (PWV), (Complior®, ALAM Medical) and carotid-ankle vascular index (CAVI), (VaSera VS-1500 N®, Fukuda Denshi).ResultsCompared to patients with normal BP, patients with WCH/E were older, had a higher body mass index (BMI) and higher arterial stiffness measured by CAVI (10.3 ± 1.3 vs 9.4 ± 1.7, p = 0.027), and PWV (11.9 ± 3.0 vs 9.6 ± 2.3 ms−1, p = 0.002). The WCH/E cohort had more lacunar strokes (p = 0.039).ConclusionIn this population of post-stroke patients, those with WCH/E had greater arterial stiffness and a higher prevalence of lacunar stroke. These results suggest that WCH/E is associated with adverse cardiovascular risk.Normotension (N = 32)WCH/E (N = 30)Statistical significanceMale, n (%)21(66)22(73)0.511Age (years)69.9 ± 11.575.7 ± 9.30.033BMI (kg/m2)25 ± 428 ± 40.014Anti-hypertensive use, n (%)19(59)23(77)0.146Clinic systolic BP (mmHg)125 ± 9155 ± 13<0.001Clinic diastolic BP (mmHg)75 ± 781 ± 80.003Daytime systolic ABPM (mmHg)114 ± 10121 ± 100.007Daytime diastolic ABPM (mmHg)73 ± 772 ± 70.586CAVI9.4 ± 1.710.3 ± 1.30.027PWV (ms−1)9.6 ± 2.311.9 ± 3.00.002Stroke typeTIA, n (%)25(78)16(53)0.039Lacunar, n (%)7(22)14(47)Data expressed as mean ± standard deviation or number (percentage). Significance determined by t-test. Chi-squared used for anti-hypertensive use, gender and stroke type.

POST-STROKE WHITE COAT HYPERTENSION/EFFECT IS ASSOCIATED WITH GREATER ARTERIAL STIFFNESS

Objective: White coat hypertension/effect (WCH/E) describes an elevated clinic blood pressure (BP) with normal daytime ambulatory BP (ABPM) values. It is not clear whether WCH/E is associated with adverse vascular risk. This study aimed to determine the relationship between WCH/E and arterial stiffness in a cohort of patients who had a transient ischaemic attack (TIA) or lacunar stroke (LS). Design and method: The Arterial Stiffness In Lacunar Stroke and TIA (ASIST) study recruited 96 patients, age >40-years-old, with a confirmed diagnosis of TIA or LS in the preceding 14 days. Patients were grouped by BP. Thirty-four patients were excluded (n = 6 declined ABPM, n = 3 masked hypertension and n = 25 sustained hypertension). Thirty-two patients with normal BP (clinic BP < 140/90mmHg and day-time ABPM < 135/85mmHg), and 30 patients with WCH/E (clinic BP >/ = 140/90mmHg and day-time ABPM < 135/85mmHg) were recruited. Arterial stiffness was measured using carotid-femoral pulse wave velocity (PWV), (Complior®, ALAM Medical) and carotid-ankle vascular index (CAVI), (VaSera VS-1500N®, Fukuda Denshi). Results: Compared to patients with normal BP, patients with WCH/E were older, had a higher body mass index (BMI) and higher arterial stiffness measured by CAVI (10.3 ± 1.3 vs 9.4 ± 1.7, p = 0.027), and PWV (11.9 ± 3.0 vs 9.6 ± 2.3 ms-1, p = 0.002). The WCH/E cohort had more lacunar strokes (p = 0.039).Conclusions: In this population of post-stroke patients, those with WCH/E had greater arterial stiffness and a higher prevalence of lacunar stroke. These results suggest that WCH/E is associated with adverse cardiovascular risk.

Left ventricular myocardial dysfunction in young and middle-aged ischemic stroke patients: the Norwegian stroke in the young study.

Hypertension is highly prevalent in ischemic stroke patients, but less is known about its impact on subclinical left ventricular (LV) dysfunction in such patients. Conventional and speckle tracking echocardiography was performed in 276 young (15-44 years) and middle-aged (45-60 years) ischemic stroke patients (mean age 50 ± 9 years, 66% men). Hypertension was defined as a history of hypertension, use of antihypertensive medications, persistently elevated blood pressure (BP) during hospitalization or elevated clinic BP (≥140/90 mmHg) and ambulatory BP (≥130/80 mmHg) at follow-up visits. LV myocardial dysfunction was assessed by peak systolic global longitudinal (GLS) and circumferential strain (GCS). Hypertension was present in 68% of patients and associated with higher age, BMI and LV mass, male sex and the presence of diabetes (all P < 0.01). Compared with normotensive patients, hypertensive patients had significantly lower peak systolic GLS (-16 ± 3 vs. -19 ± 2%, P < 0.001) and GCS (-16 ± 3 vs. -18 ± 4%, P < 0.001) while ejection fraction did not differ between groups (P = 0.134). In univariable regression analyses, reduced peak systolic GLS and GCS were both associated with hypertension (β = 0.43 and 0.29, respectively, both P < 0.001). The association with hypertension remained significant for GLS (β = 0.25) after adjustment for LV mass, ejection fraction, male sex, obesity and diabetes (multiple R = 0.35, P < 0.001), whereas the association of hypertension with reduced peak systolic GCS was attenuated. In ischemic stroke survivors, hypertension was associated with reduced peak systolic GLS but not GCS independent of confounders.

Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality

BackgroundEvidence for the influence of ambulatory blood pressure on prognosis derives mainly from population-based studies and a few relatively small clinical investigations. This study examined the associations of blood pressure measured in the clinic (clinic blood pressure) and 24-hour ambulatory blood pressure with all-cause and cardiovascular mortality in a large cohort of patients in primary care.MethodsWe analyzed data from a registry-based, multicenter, national cohort that included 63,910 adults recruited from 2004 through 2014 in Spain. Clinic and 24-hour ambulatory blood-pressure data were examined in the following categories: sustained hypertension (elevated clinic and elevated 24-hour ambulatory blood pressure), “white-coat” hypertension (elevated clinic and normal 24-hour ambulatory blood pressure), masked hypertension (normal clinic and elevated 24-hour ambulatory blood pressure), and normotension (normal clinic and normal 24-hour ambulatory blood pressure). Analyses were conducted with Cox regression models, adjusted for clinic and 24-hour ambulatory blood pressures and for confounders.ResultsDuring a median follow-up of 4.7 years, 3808 patients died from any cause, and 1295 of these patients died from cardiovascular causes. In a model that included both 24-hour and clinic measurements, 24-hour systolic pressure was more strongly associated with all-cause mortality (hazard ratio, 1.58 per 1-SD increase in pressure; 95% confidence interval [CI], 1.56 to 1.60, after adjustment for clinic blood pressure) than the clinic systolic pressure (hazard ratio, 1.02; 95% CI, 1.00 to 1.04, after adjustment for 24-hour blood pressure). Corresponding hazard ratios per 1-SD increase in pressure were 1.55 (95% CI, 1.53 to 1.57, after adjustment for clinic and daytime blood pressures) for nighttime ambulatory systolic pressure and 1.54 (95% CI, 1.52 to 1.56, after adjustment for clinic and nighttime blood pressures) for daytime ambulatory systolic pressure. These relationships were consistent across subgroups of age, sex, and status with respect to obesity, diabetes, cardiovascular disease, and antihypertensive treatment. Masked hypertension was more strongly associated with all-cause mortality (hazard ratio, 2.83; 95% CI, 2.12 to 3.79) than sustained hypertension (hazard ratio, 1.80; 95% CI, 1.41 to 2.31) or white-coat hypertension (hazard ratio, 1.79; 95% CI, 1.38 to 2.32). Results for cardiovascular mortality were similar to those for all-cause mortality.ConclusionsAmbulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. White-coat hypertension was not benign, and masked hypertension was associated with a greater risk of death than sustained hypertension. (Funded by the Spanish Society of Hypertension and others.)

Circadian hemodynamics in men and women with high blood pressure: dipper vs. nondipper and racial differences.

The 'nondipping' pattern of circadian blood pressure (BP) variation is an established independent predictor of adverse cardiovascular outcomes. Although this phenomenon has been widely studied, its underlying circadian hemodynamics of cardiac output and systemic vascular resistance (SVR) have not been well characterized. We evaluated the hypothesis that BP nondipping would be associated with a blunted night-time reduction in SVR in a biracial sample of 140 (63 African-American and 77 white) men and women with elevated clinic BP (130-159/85-99 mmHg). Twenty-four-hour ambulatory hemodynamics were assessed using standard ambulatory BP monitoring coupled with synchronized ambulatory impedance cardiography. Using the criterion of less than 10% dip in SBP, there were 51 nondippers (SBP dip = 7.3 ± 2.6%) and 89 dippers (SBP dip = 15.5 ± 3.4%). There was minimal change in cardiac output from daytime to night-time in both dippers and nondippers. However, SVR decreased from daytime to night-time, but nondippers compared with dippers exhibited a significantly attenuated decrease in SVR from daytime to night-time (7.8 vs. 16.1%, P < 0.001). Relative to their white counterparts, African-Americans also exhibited blunted SBP dipping (10.9 vs. 14.6%, P < 0.001) as well as an attenuated decrease in SVR (10.8 vs. 15.6%, P < 0.001). Overall, these findings indicate that blunted night-time BP dipping is associated with impairment of the systemic vasodilation that is characteristic of the night-time sleep period and is especially prominent among African-Americans. In the context of high BP, these findings suggest that nondipping may be a manifestation, or marker, of more advanced vascular disease.

Current approach to masked hypertension: From diagnosis to clinical management

The term 'masked hypertension phenomenon' was first described by the late Professor Thomas Pickering and is commonly defined as having a normal clinic blood pressure (BP) but an elevated 'out of office' reading. In the main, these elevated readings have been provided through ambulatory BP monitoring (ABPM), but sometimes home BP monitoring is used. It is now largely accepted that ABPM gives a better classification of risk than clinic BP. Thus, the elevated ABPM levels should relate to higher cardiovascular risk, and it follows that these people may be regarded as being genuinely hypertensive and at higher cardiovascular risk. The problem for clinical practice is how to identify and manage these individuals. The phenomenon should be suspected in individuals who have had an elevated clinic BP at some time, in young individuals with normal or normal-high clinic BP who have early left ventricular hypertrophy, in individuals with a family history of hypertension in both parents, patients with multiple risks for cardiovascular disease and perhaps diabetic patients. Masked hypertension appears to be more prevalent in individuals of male gender, with younger age, higher heart rate, obesity or high cholesterol levels and in smokers. Those with masked hypertension are at higher risk of events such as stroke and have a higher prevalence of target organ damage, for example, nephropathy. In conclusion, most of the debate around this topic relates to its reliable identification. Given the higher ambulatory mean blood pressure values there is an increased cardiovascular risk making this diagnosis important.

Abstract 071: An Attenuated Nocturnal Dip in Systemic Vascular Resistance is Associated With Increased Left Ventricular Mass

Introduction: Previous work from our laboratory has demonstrated that the nocturnal “dip” in blood pressure (BP) is due primarily to a decrease in systemic vascular resistance (SVR), and that nondipping is associated with a blunted nighttime reduction in SVR. In this analysis, we examined the hypothesis that a blunted nocturnal SVR fall is associated with increased LV mass. Methods: 24-hour ambulatory hemodynamics were assessed in a biracial sample of 116 men and women with elevated clinic BP (130-159/80-99 mmHg). Ambulatory BP monitoring was coupled with synchronized measurements of cardiac output by ambulatory impedance cardiography. Values for SVR were derived for each ambulatory BP measurement. Left ventricular (LV) mass was measured by echocardiography and indexed by height 2.7 to adjust for differences in body size. Multivariable regression models were used to examine the relationships between LV mass index and demographic characteristics, anthropomorphic variables, daytime ambulatory systolic BP, and dipping of SVR and systolic BP. Results: The study cohort averaged 45.3 ± 8.3 years of age; 42% (49 of 116) of the subjects were female and 47% (54 of 116) were African American. The mean body mass index (BMI) was 28.3 ± 3.8 kg/m 2 . The mean daytime ambulatory systolic BP was 137 ± 11 mmHg; the systolic BP dip averaged 13 ± 5%, and the nocturnal fall in SVR averaged 13 ± 15%. In a model that included age, sex, race, BMI, and daytime systolic BP, daytime systolic BP was significantly associated with LV mass index (b=0.33, p=0.0004). The SVR percent dip, (b=-0.21, p=0.02) but not the percent dip in systolic BP (b=-0.15, p=0.11), was an independent predictor LV mass index when added to this model. Conclusions: A blunted nocturnal dip in SVR is associated with increased LV mass index, independent of daytime systolic BP. This finding suggests that an attenuated nighttime fall in SVR may contribute to left ventricular hypertrophy.

Clinic Blood Pressure Underestimates Ambulatory Blood Pressure in an Untreated Employer-Based US Population: Results From the Masked Hypertension Study.

Ambulatory blood pressure (ABP) is consistently superior to clinic blood pressure (CBP) as a predictor of cardiovascular morbidity and mortality risk. A common perception is that ABP is usually lower than CBP. The relationship of the CBP minus ABP difference to age has not been examined in the United States. Between 2005 and 2012, 888 healthy, employed, middle-aged (mean±SD age, 45±10.4 years) individuals (59% female, 7.4% black, 12% Hispanic) with screening BP <160/105 mm Hg and not taking antihypertensive medication completed 3 separate clinic BP assessments and a 24-hour ABP recording for the Masked Hypertension Study. The distributions of CBP, mean awake ABP (aABP), and the CBP-aABP difference in the full sample and by demographic characteristics were compared. Locally weighted scatterplot smoothing was used to model the relationship of the BP measures to age and body mass index. The prevalence of discrepancies in ABP- versus CBP-defined hypertension status-white-coat hypertension and masked hypertension-were also examined. Average systolic/diastolic aABP (123.0/77.4±10.3/7.4 mm Hg) was significantly higher than the average of 9 CBP readings over 3 visits (116.0/75.4±11.6/7.7 mm Hg). aABP exceeded CBP by >10 mm Hg much more frequently than CBP exceeded aABP. The difference (aABP>CBP) was most pronounced in young adults and those with normal body mass index. The systolic difference progressively diminished, but did not disappear, at older ages and higher body mass indexes. The diastolic difference vanished around age 65 and reversed (CBP>aABP) for body mass index >32.5 kg/m2. Whereas 5.3% of participants were hypertensive by CBP, 19.2% were hypertensive by aABP; 15.7% of those with nonelevated CBP had masked hypertension. Contrary to a widely held belief, based primarily on cohort studies of patients with elevated CBP, ABP is not usually lower than CBP, at least not among healthy, employed individuals. Furthermore, a substantial proportion of otherwise healthy individuals with nonelevated CBP have masked hypertension. Demonstrated CBP-aABP gradients, if confirmed in representative samples (eg, NHANES [National Health and Nutrition Examination Survey]), could provide guidance for primary care physicians as to when, for a given CBP, 24-hour ABP would be useful to identify or rule out masked hypertension.

Hypertension types defined by clinic and ambulatory blood pressure in 14 143 patients referred to hypertension clinics worldwide. Data from the ARTEMIS study.

The Ambulatory blood pressure Registry TEleMonitoring of hypertension and cardiovascular rISk project was designed to set up an international registry including clinic blood pressure (CBP) and ambulatory blood pressure (ABP) measurements in patients attending hypertension clinics in all five continents, aiming to assess different daily life hypertension types. Cross-sectional ABP, CBP and demographic data, medical history and cardiovascular risk profile were provided from existing databases by hypertension clinics. Hypertension types were evaluated considering CBP (≥140/90 mmHg) and 24-h ABP (≥130/80 mmHg). Overall, 14 143 patients from 27 countries across all five continents were analyzed (Europe 73%, Africa 3%, America 9%, Asia 14% and Australia 2%). Mean age was 57 ± 14 years, men 51%, treated for hypertension 46%, cardiovascular disease 14%, people with diabetes 14%, dyslipidemia 33% and smokers 19%. The prevalence of hypertension was higher by CBP than by ABP monitoring (72 vs. 60%, P < 0.0001). Sustained hypertension (elevated CBP and ABP) was detected in 49% of patients. White-coat hypertension (WCH, elevated CBP with normal ABP) was more common than masked hypertension (elevated ABP with normal CBP) (23 vs. 10%; P < 0.0001). Sustained hypertension was more common in Europe and America and in elderly, men, obese patients with cardiovascular comorbidities. WCH was less common in Australia, America and Africa, and more common in elderly, obese women. Masked hypertension was more common in Asia and in men with diabetes. Smoking was a determinant for sustained hypertension and masked hypertension. Our analysis showed an unbalanced distribution of WCH and masked hypertension patterns among different continents, suggesting an interplay of genetic and environmental factors, and likely also different healthcare administrative and practice patterns.

Utility of ambulatory blood pressure monitoring in the evaluation of elevated clinic blood pressures in children

Although ambulatory blood pressure monitoring (ABPM) is recognized for its role in assessing white coat hypertension, other uses include evaluation of treatment adequacy, nocturnal hypertension, dipping status, and hypertension severity. We performed a retrospective study of ABPMs completed at a single center from November 2007 to October 2011 to determine the frequency of white coat hypertension, prehypertension, and hypertension in children and the correlation of these findings with office BPs. A total of 247 ABPMs were performed in 206 children, ages 4–20 years, including 48 recordings in 39 diabetic patients and 64 recordings in treated hypertensive patients. We found a poor correlation between hypertensive status based on clinic BP and diagnosis on ABPM, and evidence for a white coat effect. Among treated patients, ABPM results resulted in medication changes in 63%. We conclude that ABPM is a useful tool for characterizing hypertensive status and treatment adequacy in children.

The Utility of Ambulatory Blood Pressure Monitoring for Diagnosing White Coat Hypertension in Older Adults.

The beneficial effect of antihypertensive medication on reducing the risk of cardiovascular disease (CVD) events is supported by data from randomized controlled trials of older adults with hypertension. However, in clinical practice, overtreatment of hypertension in older adults may lead to side effects and an increased risk of falls. The diagnosis and treatment of hypertension is primarily based on blood pressure measurements obtained in the clinic setting. Ambulatory blood pressure monitoring (ABPM) complements clinic blood pressure by measuring blood pressure in the out-of-clinic setting. ABPM can be used to identify white coat hypertension, defined as elevated clinic blood pressure and non-elevated ambulatory blood pressure. White coat hypertension is common in older adults but does not appear to be associated with an increased risk of CVD events among this population. Herein, we review the current literature on ABPM in the diagnoses of white coat hypertension in older adults, including its potential role in preventing overtreatment.

White-Coat Effect Among Older Adults: Data From the Jackson Heart Study.

Many adults with elevated clinic blood pressure (BP) have lower BP when measured outside the clinic. This phenomenon, the "white-coat effect," may be larger among older adults, a population more susceptible to the adverse effects of low BP. The authors analyzed data from 257 participants in the Jackson Heart Study with elevated clinic BP (systolic/diastolic BP [SBP/DBP] ≥140/90mmHg) who underwent ambulatory BP monitoring (ABPM). The white-coat effect for SBP was larger for participants 60 years and older vs those younger than 60years in the overall population (12.2mmHg, 95% confidence interval [CI], 9.2-15.1mmHg and 8.4mmHg, 95% CI, 5.7-11.1, respectively; P=.06) and among those without diabetes or chronic kidney disease (15.2mmHg, 95% CI, 10.1-20.2 and 8.6mmHg, 95% CI, 5.0-12.3, respectively; P=.04). After multivariable adjustment, clinic SBP ≥150mmHg vs <150mmHg was associated with a larger white-coat effect. Studies are needed to investigate the role of ABPM in guiding the initiation and titration of antihypertensive treatment, especially among older adults.

PP.05.07

Objective: Recent guidelines suggest relying on the ambulatory blood pressure (BP) monitoring (ABPM) derived awake mean to corroborate the diagnosis of hypertension suspected by elevated clinic BP measurement. However, several prospective ABPM studies have found elevated sleep-time BP is a better predictor of cardiovascular disease (CVD) risk than awake BP mean, also in diabetes. We evaluated the combined contribution to CVD risk of clinic, awake, and asleep BP among patients with diabetes participants in the Hygia Project, designed to evaluate prospectively CVD risk by ABPM in primary care centers of Northwest Spain. Design and method: This study involved 2632 patients with type 2 diabetes, 1589 men/1043 women, 65.1 ± 11.6 years of age, with baseline BP ranging from normotension to sustained hypertension according to ABPM criteria, prospectively evaluated throughout a 4.1-year median follow-up. BP was measured at 20-min intervals from 07:00 to 23:00 h and at 30-min intervals at night for 48 h. During monitoring, subjects maintained a diary listing the times of going to bed at night and awakening in the morning. Results: The hazard ratios (HR) of total CVD events for each 1-SD elevation in clinic, awake, and asleep systolic BP (SBP) analyzed separately (adjusted for the significant influential characteristics of age, sex, chronic kidney disease, cigarette smoking, waist perimeter, and history of previous CVD event) were 1.25 [95%CI: 1.17–1.35]; 1.39 [1.30–1.50], and 1.51 [1.41–1.62], respectively (always P < 0.001). Exploration of the combined contribution of all three BP measurements revealed elevation in asleep SBP (HR = 1.55 [1.38–1.75], P < 0.001) but not in clinic BP (1.08 [0.99–1.18], P = 0.082) or awake BP (0.93 [0.82–1.06], P = 0.270) was the only independent BP parameter significantly associated with increased CVD risk. Conclusions: In patients with diabetes, sleep-time SBP mean, but not daytime clinic BP measurement or ABPM-derived awake BP mean, is the only significant and independent prognostic marker of CVD morbidity and mortality. These findings indicate ABPM, but not conventional clinic BP so far mistakenly used to diagnose hypertension and establish therapeutic targets, is a clinical necessity to accurately detect abnormal sleep-time BP and assess CVD risk in diabetes.

Accuracy of self-monitored blood pressure for diagnosing hypertension in primary care.

To assess the diagnostic accuracy of recommendations for self-monitoring blood pressure (BP) for diagnosing hypertension in primary care. Two hundred and forty-seven consecutive participants with raised (≥130 mmHg systolic) BP measured by their general practitioner from four primary care practices in the United Kingdom underwent 28 days of self-monitoring followed by 24-h ambulatory BP monitoring (ABPM). Diagnostic accuracy of the first 7 days of self-monitored BP (minimum 4 days, discarding readings on day 1) in detecting hypertension with ambulatory blood pressure was taken as reference. Two hundred and three participants were included, 109 (53.7%) of whom were diagnosed with hypertension using daytime ambulatory BP. The average of days 2-7 self-monitored BP correctly classified 150 of 203 participants [sensitivity 93.6%, 95% confidence interval (CI) 87.2-97.4%; specificity 51.1%, 95% CI 40.5-61.5%). However, the average of days 2-5 self-monitoring correctly classified 152 of 203 participants due to better specificity (53.2%, 95% CI 42.6-63.6%). In sensitivity analysis, diagnostic accuracy was not improved by inclusion of readings beyond day 5, and inclusion of readings taken on day 1 had no impact on diagnostic accuracy. Self-monitoring in the clinic was more accurate than readings taken by the general practitioner, but not self-monitoring outside of the clinic. Hypertension can be ruled out in the majority of patients with elevated clinic BP using the average of the first 5 consecutive days of self-monitored BP, supporting lower limits for self-monitoring readings in current guidelines. Performing readings beyond day 5 and including readings taken on the first day had no clinical impact on diagnostic accuracy.

Abstract P198: Clinic versus Out-of-Clinic Daytime Blood Pressure Among Older Adults: Data From the Jackson Heart Study

In the US, antihypertensive medication treatment decisions are primarily based on blood pressure (BP) measurements obtained in the clinic setting. The optimal systolic BP (SBP) goal for adults ≥60 years is controversial and a large difference between clinic and out-of-clinic daytime BP, a white-coat effect, may be present in older individuals. We estimated the white-coat effect and calculated the percentage of untreated and treated adults &lt;60 and ≥60 years with elevated clinic BP (defined as SBP/diastolic BP [DBP] ≥140/90 mmHg), but non-elevated out-of-clinic daytime BP (“daytime BP”, defined as SBP/DBP &lt;135/85 mmHg) among 257 African-American participants in the Jackson Heart Study with at least 10 daytime ambulatory BP measurements. For the overall population, the white-coat effect for SBP was 12.2 mmHg (95% confidence interval [CI]: 9.2-15.1) in older adults and 8.4 mmHg (95% CI: 5.7-11.1) in younger adults (p=0.06). After multivariable (MV) adjustment, this difference was 1.3 mmHg. Among those without diabetes or chronic kidney disease (CKD), the white coat effect for SBP was 15.2 mmHg (95% CI: 10.1-20.2) and 8.6 mmHg (95% CI: 5.0-12.3) for older and younger adults, respectively (p=0.04). After MV adjustment, this difference was 5.9 mmHg. Also, SBP ≥150 mmHg versus &lt;150 mm Hg was associated with a larger white-coat effect in the overall population after MV adjustment. Among those without CKD or diabetes, older age and SBP ≥150 mmHg were associated with a larger white-coat effect after MV adjustment. Among younger and older participants with elevated clinic BP, the prevalence of non-elevated daytime BP was 34% (95% CI: 26%-44%) and 32% (95% CI: 24%-40%), respectively (p=0.64), in the overall population and 35% (95% CI: 24%-48%) and 43% (95% CI: 31%-56%), respectively, for those without CKD or diabetes (p=0.37). In conclusion, a large white-coat effect was present among older adults. These data suggest a role for ambulatory blood pressure monitoring in preventing potential over-treatment for hypertension among older adults.