Ambulatory Blood Pressure Monitoring In Hypertension Research Articles

Ambulatory Hypertension in a Pediatric Cohort of Sickle Cell Disease

▪Background and Objectives: Hypertension is an established risk factor for subsequent cardiovascular and renal disease in children as well as adults. Sickle Cell Disease (SCD) is a genetic disorder associated with anemia with the major manifestation of vaso-occlusive crises. While this disease entity involves most organ systems causing vascular and pulmonary injury, little is known about blood pressure (BP) levels or prevalence of hypertension in children and adolescents with SCD.Methods: We enrolled 41 children with severe genotypes of SCD (39 with Hb SS disease and 2 with Hb Sβ0 thalassemia). Study participants underwent 24-hour ambulatory blood pressure monitoring (ABPM). Clinical information regarding duration of SCD, SCD-related complications, requirement for chronic blood transfusion and chronic hydroxyurea therapy were obtained. Baseline characteristics obtained on each participant included age, gender, weight, height, body mass index (BMI) percentile, BMI-Z score and clinic BP. Serum creatinine and cystatin C were obtained to assess estimated glomerular filtration rate (eGFR) with age-based formulas. A random urine sample was obtained for standard urinalysis, albumin and creatinine estimation, to calculate urine albumin to creatinine ratio.Results: Based on ABPM study results participants were categorized into three groups as normal ABPM, abnormal ABPM, or hypertension ABPM (ambulatory hypertension, masked hypertension or severe ambulatory hypertension). The term abnormal ABPM designated participants who did not have normal ABPM or hypertension, but had other abnormal parameters on ABPM (presence of pre-hypertension and/or lack of normal nocturnal dipping). SCD children in the three groups were similar with respect to distribution of age, BMI z-scores, renal function, urine albumin excretion, urine osmolality, hemoglobin, history of chronic blood transfusion, and hydroxyurea therapy. Twelve participants (29.3%) met criteria for hypertension based on ABPM. Of the 12 hypertensive participants, three had clinic hypertension with ambulatory hypertension; and nine had masked hypertension detected on ABPM. Youngest child with ABPM confirmed hypertension was six years of age. Another 18 participants (43.9%) had some abnormal ABPM parameters that were largely present in the sleep period of ABPM.Conclusions: Findings from our study indicate that BP abnormalities are not uncommon in SCD children. Overall, the distribution of confirmed hypertension, largely manifested by masked hypertension, is high in pediatric participants with SCD; as young as 6 years of age. The underlying cause for the relatively high prevalence of masked hypertension and abnormal ABPM parameters including absence of nocturnal BP dip in children with SCD is unclear. Based on our findings more attention should be given to monitoring and management of BP in children with SCD. Early identification of hypertension in SCD children can confer benefit because hypertension is an important modifiable risk factor for progression of cardiovascular and renal disease.Acknowledgment: Research reported in this publication was supported by the National Institute Of General Medical Sciences of the National Institutes of Health under Award Number P20GM109021; National Kidney Foundation Young Investigator Grant and DE-CTR-ACCEL grant number U54-GM104941 (PI: Binder-Macleod). [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

High prevalence of masked uncontrolled hypertension in people with treated hypertension

There are limited data on the quality of treated blood pressure (BP) control during normal daily life, and in particular, the prevalence of 'masked uncontrolled hypertension' (MUCH) in people with treated and seemingly well-controlled BP is unknown. This is important because masked hypertension in 'treatment naïve' patients is associated with a high risk of cardiovascular events. We therefore conducted the first study to define the prevalence and characteristics of MUCH among a large sample of hypertensive patients in routine clinical practice in whom BP was treated and controlled to recommended clinic BP goals. We analysed data from the Spanish Society of Hypertension ambulatory blood pressure monitoring (ABPM) Registry and identified patients with treated and controlled BP according to current international guidelines (clinic BP <140/90 mmHg). Masked uncontrolled hypertension was diagnosed in these patients if despite controlled clinic BP, the mean 24-h ABPM average remained elevated (24-h systolic BP ≥130 mmHg and/or 24-h diastolic BP ≥80 mmHg). From 62 788 patients with treated BP in the Spanish registry, we identified 14 840 with treated and controlled clinic BP, of whom 4608 patients (31.1%) had MUCH according to 24-h ABPM criteria (mean age 59.4 years, 59.7% men). The prevalence of MUCH was significantly higher in males, patients with borderline clinic BP (130-9/80-9 mmHg), and patients at high cardiovascular risk (smokers, diabetes, obesity). Masked uncontrolled hypertension was most often because of poor control of nocturnal BP, with the proportion of patients in whom MUCH was solely attributable to an elevated nocturnal BP almost double that solely attributable to daytime BP elevation (24.3 vs. 12.9%, P < 0.001). The prevalence of masked suboptimal BP control in patients with treated and well-controlled clinic BP is high. Clinic BP monitoring alone is thus inadequate to optimize BP control because many patients have an elevated nocturnal BP. These findings suggest that ABPM should become more routine to confirm BP control, especially in higher risk groups and/or those with borderline control of clinic BP.

Usefulness of ambulatory blood pressure monitoring (ABPM) in daily clinical practice: Data from the Spanish ABPM registry

1. Hypertension is one of the most important challenges for public health systems because of its high prevalence and its association with the risk of cardiovascular and renal diseases. 2. Adequate control of hypertension is low in population and medical settings, with physicians frequently misclassifying patients' blood pressure status based on readings taken in the clinic rather than ambulatory blood pressure measurements (ABPM). 3. Data from the Spanish Society of Hypertension ABPM registry support ABPM as a feasible option in the primary care setting, providing valuable information for the diagnosis and management of hypertension. By using ABPM rather than office BP monitoring, BP control can be doubled. This is an encouraging message to clinicians, although there is still a relatively large degree of undetected controlled and uncontrolled hypertension. 4. This short review describes the design, development and main results of the Spanish Society of Hypertension ABPM registry, a project based on a large-scale network of Spanish physicians trained in ABPM.

Abnormalities in ambulatory blood pressure monitoring in hypertensive patients with diabetes

Our aim was to assess the ambulatory blood pressure monitoring (ABPM) characteristics or patterns in hypertensive patients with diabetes compared with non-diabetic hypertensives. We performed a cross-sectional analysis of a 68,045 patient database from the Spanish Society of Hypertension ABPM Registry, a nation-wide network of >1200 primary-care physicians performing ABPM under standardized conditions in daily practice. We identified 12,600 (18.5%) hypertensive patients with diabetes. When compared with patients without diabetes, diabetic hypertensives exhibited higher systolic blood pressure (BP) levels in every ABPM period (daytime 135.4 vs. 131.8, and nighttime 126.0 vs. 121.0 mm Hg, P<0.001 for both) despite they were receiving more antihypertensive drugs (mean number 1.71 vs. 1.23, P<0.001). Consequently, diabetic patients suffered from lack of control of BP more frequently than non-diabetic subjects particularly during the night (65.5% vs. 57.4%, P<0.001). Prevalence of a non-dipping BP profile (64.2% vs. 51.6%, P<0.001) was higher in diabetic patients. In the other hand, prevalence of 'white-coat' hypertension in diabetic patients was 33.0%. We conclude that there was a remarkably high prevalence of alterations in ABPM in patients with diabetes. Abnormalities in systolic BP, particularly during the night, and in circadian BP pattern could be linked with the excess of BP-related cardiovascular risk of diabetes. A wider use of ABPM in diabetic patients should be considered.

CONCORDANCE OF BP CONTROL ASSESSED BY OFFICE BP AND BY ABPM IN A LARGE COHORT OF TREATED HYPERTENSIVES: PP.14.06

Objective: To examine the concordance of blood pressure (BP) control by means of both office measurements and ambulatory BP monitoring (ABPM), in a large cohort of treated hypertensives from the Spanish Society of Hypertension ABPM Registry. Methods: A total of 43,499 hypertensives were analyzed. Office BP control was defined when BP <140/90 mmHg. Ambulatory BP control was considered by means of 3 different criteria: daytime BP <135/85 mmHg, 24-h BP <130/80 mmHg, and nightime BP <120/70 mmHg. Clinical characteristics were compared between patients with daytime BP below or above 135/85 mmHg. Results: Office BP control was 22.7%, daytime BP control was 52.0%, 24-h BP control was 44.8%, and nighttime BP control was 39.7%. Concordant control of BP was present in 17.4%, 15.7%, and 12.9%, by the 3 different criteria. The main source of difference between office and ABPM was the proportion of patients with isolated office resistance, the proportion of which, using the 3 aforementioned criteria was 34.5%, 29.1%, and 26.8%, respectively. When compared to patients with normal ABPM values, the presence of elevated daytime BP (higher than 135/85 mmHg) was associated (p < 0.001 for all comparisons) with male gender (57.5% vs 47.7%), diabetes (25.1% vs 20.9%), smoking (17.5% vs 12.5%), left ventricular hypertrophy on EKG (11.1 vs 9.1), and chronic kidney disease (3.0% vs 2.0%). Conclusions: BP control in the treated hypertensive population by using ABPM is twice as observed by office measurements. The proportion of patients with isolated office resistance (white coat) is relatively large. Normal values of ABPM in treated patients are more frequent in women, nondiabetic, and nonsmokers subjects, as well as in those without organ damage.

Implicaciones clínicas y de salud pública del proyecto CARDIORISC

Adequate control of hypertension is known to be low in population and medical settings. However, physicians frequently misclassify patients’ blood pressure (BP) status at the office compared with ambulatory BP monitoring (ABPM). Information from ABPM is important for better knowledge of BP management in clinical practice, as well as for public health purposes. In this article, we present the burden of underestimation and overestimation of BP control, respectively, revealed by ABPM, by using the Spanish Society of Hypertension ABPM Registry, based on a large-scale network of Spanish physicians trained in ABPM (CARDIORISC project). Approximately 24% of treated hypertensive patients (with indications of ABPM) had BP controlled in the office, and approximately 52% were controlled according to daytime ABPM. These findings convey an important clinical implication, an encouraging message to clinicians, namely, that they are actually doing better than evidenced by office-based data. Furthermore, ABPM revealed that, at the office, BP control is underestimated by physicians in one out of every three hypertensive patients and is overestimated in one out of every 20 patients. In other words, the burden of undetected controlled and uncontrolled hypertension is substantial. Moreover, based on data from the CARDIORISC project, approximately 4 million hypertensives are estimated to be truly controlled (ABPM-based) instead of 2 million (office-based), while a further 4 million are actually uncontrolled instead of 6 million. Hence, physicians should be aware that assessment of BP control may well be inadequate if based on office BP measurement alone. Furthermore, knowledge of these data may contribute to more efficient planning of health resources, since many hypertensive patients previously believed to be uncontrolled are in fact controlled. However, the use of ABPM also identifies previously undetected uncontrolled hypertensive patients, who are at higher cardiovascular risk than estimated by office-based methods, thereby implying additional costs. ABPM is rarely available at clinics, and an effort is thus needed to extend its use and indication in the future. Fortunately, in general, ABPM is more cost-effective than office BP in the follow-up of hypertension.

Cost effectiveness of 24-hour ambulatory blood pressure monitoring in evaluation and treatment of essential hypertension.

We wanted to determine if use of ambulatory blood pressure monitoring (ABPM) was cost effective, preventing unnecessary drug therapy in patients misdiagnosed as having essential hypertension, with elevated office blood pressures and normal ambulatory blood pressure. To address this issue we surveyed costs to the patient for antihypertensive drug therapy in 1990 of five local pharmacies in southeastern Michigan. Patients studied (n = 192) were seen in a private, general internal medicine practice in rural southeastern Michigan and received ABPM to assess the presence of hypertension and the adequacy of blood pressure treatment. We ascertained the average, minimal, and maximal drug cost to the patient per unit dose at the local pharmacies. The average yearly cost for patients on antihypertensive medications at pharmacies in southwestern Michigan was $578.40, with figures varying from $94.90 to $4361.75. Although there is no standard reimbursement amount for ABPM, at $188 per monitoring, the cost of monitoring this entire group of patients would offset exactly the cost of medication for the group of patients found to have only office hypertension. As such, third-party insurance carriers should consider reimbursement for ABPM in hypertension to decrease pharmaceutical cost and its attendant potential side effects. In conclusion, our study results suggest that ABPM is cost effective in an outpatient setting in preventing unwarranted drug therapy and the inappropriate diagnosis of hypertension.