Japan Morning Surge-Home Blood Pressure Study Research Articles

Home systolic blood pressure time in therapeutic range and cardiovascular risk: the practitioner-based nationwide J-HOP study extended.

Time in therapeutic range (TTR) for office systolic blood pressure (SBP) is an independent predictor of major cardiovascular events. However, the clinical implications of TTR for home SBP have not yet been investigated. This study determined the association between TTR of home SBP and cardiovascular events in individuals with ≥1 cardiovascular risk factor who were enrolled in The Japan Morning Surge-Home Blood Pressure (J-HOP) study. The therapeutic range for home SBP was defined as home SBP of 100-135 mmHg during the 13-day baseline period of the J-HOP study. Participants were divided into subgroups based on quartiles of TTR for home SBP, and the risk of cardiovascular events was determined in each quartile. During a mean 6.3 years of follow-up in 4070 participants (mean age 65 years), cardiovascular events included stroke in 92, coronary artery disease in 119, heart failure in 41 and aortic dissection in 8. The adjusted hazard ratio (95% confidence interval) for the risk of total cardiovascular events in participants with home SBP TTR in the lowest (100%) versus highest quartile (<15.3%) was 1.74 (1.16-2.61); the corresponding hazard ratio for stroke events was 2.11 (1.06-4.21). A 10% decrease in home SBP TTR was associated with a 4% increase in the risk of total cardiovascular events (p = 0.033) and a 9% increase in the risk of stroke (p = 0.004). The significant association seen between home SBP TTR and the occurrence of cardio- and cerebrovascular events highlights the importance of achieving stable reductions in home SBP and minimizing day-by-day home BP variability.Clinical Trial Registration: University Hospital Medical Information Network Clinical Trials Registry, UMIN000000894 (J-HOP study).

RISK STRATIFICATION OF STAGE B HEART FAILURE USING HOME BLOOD PRESSURE MONITORING AND EFFECT ON THE INCIDENCE OF HEART FAILURE

Objective: Recently, the international guideline recommends use of the universal definition of Stage B heart failure (HF) based on cardiac biomarkers for risk stratification of asymptomatic HF. There is a few study reporting the association between home blood pressure (BP) and the stage B of HF. We thus assessed this issue by using the dataset of the nationwide prospective study regarding home BP monitoring, the Japan Morning Surge Home BP (J-HOP) study. Design and method: In the J-HOP study, 4,310 outpatients with cardiovascular risk were enrolled and underwent a consecutive 14-days home BP monitoring in morning and evening. In the present study, we assessed 3,218 participants after excluding participants with pre-history of HF and other cardiovascular diseases and lack of data in biomarkers. NT-proBNP 125pg/ml or Hs-cTnT &gt;0.014ng/ml in women, &gt;0.022ng/ml in men were defined as the Stage B of HF based on the guideline (n = 604). Results: In the multivariable logistic model, increase of morning home systolic BP was significantly associated with the risk of the stage B of HF (adjusted OR per 10mmHg, 1.25; 95%CI, 1.16–1.33). After followed-up of median 6 years, 19 patients were hospitalized for HF. The stage B of HF was at greater risk of developing heart failure than the stage A patients (adjusted HR, 3.76; 95% CI, 1.40–10.06) in the multivariable Cox model. Conclusions: From our findings, morning home BP might be useful for risk stratification of early stage of HF.

Peak home blood pressure as an earlier and strong novel risk factor for stroke: the practitioner-based nationwide J-HOP study extended.

While home blood pressure (BP) measurement is recommended for hypertension management, the clinical implications of peak home BP values have not been well studied. This study investigated the association between pathological threshold or frequency of peak home BP and cardiovascular events in patients with ≥1 cardiovascular risk factor. The Japan Morning Surge-Home Blood Pressure (J-HOP) study enrolled participants from 2005-2012 with extended follow-up from December 2017 to May 2018, which generated the dataset for this analysis. Average peak home systolic BP (SBP) was defined as average of the highest three BP values on 14-day measurement period. Patients were divided into quintiles of peak home BP, and the risk of stroke, coronary artery disease (CAD) and atherosclerotic cardiovascular disease (ASCVD; stroke+CAD) was determined. In 4231 patients (mean 65 years) followed for 6.2 years there were 94 strokes and 124 CAD events. The adjusted hazard ratio (HR) (95% CI) for the risk of stroke and ASCVD in patients with average peak home SBP in the highest versus lowest quintile was 4.39 (1.85-10.43) and 2.04 (1.24-3.36), respectively. Risk was greatest for stroke in the first 5 years: HR 22.66 (2.98-172.1). The pathological threshold of average peak home SBP for 5-year stroke risk was 176 mmHg. There was a linear association between the number of times peak home SBP > 175 mmHg and stroke risk. Peak home BP was a strong risk factor for stroke, especially within the first 5 years. We propose exaggerated peak home SBP > 175 mmHg as an early and strong novel risk factor for stroke.

Impact of diabetic status and contribution of office and home blood pressure across diabetic status for cardiovascular disease: the J-HOP study.

Few studies have investigated whether the prognostic power of home blood pressure (BP) for cardiovascular disease (CVD) events differs across subjects with different diabetic status. We used the dataset of the J-HOP (Japan Morning Surge-Home Blood Pressure) study, which enrolled patients having cardiovascular risks to investigate relationships between home BP and CVD events. We classified the patients as having diabetes mellitus (DM), prediabetes or normal glucose metabolism (NGM) as follows: for DM, a self-reported history of physician-diagnosed DM and/or use of DM medication, a fasting plasma glucose ≥126 mg/dL, a casual plasma glucose level ≥200 mg/dL or hemoglobin A1c (HbA1c) ≥6.5% (n = 1034); for prediabetes, HbA1c of 5.7-6.4% (n = 1167), and for NGM, those who remained (n = 2024). CVD outcome was defined as coronary artery disease, stroke or heart failure. During a median 6.2 ± 3.8 years of follow-up, 259 CVD events occurred. Analysis found both prediabetes (Unadjusted Hazard ratio [uHR], 1.43; 95% confidence interval [CI], 1.05-1.95), and DM (uHR, 2.13; 95% CI, 1.59-2.85) as risks of CVD compared to NGM. In DM, patients with a 10-mmHg elevation of office systolic BP (SBP) and morning home SBP had 16% and 14% higher risks for CVD events. In the prediabetes group, only an elevated morning home SBP conferred a risk of CVD events (uHR, 1.15; 95% CI, 1.00-1.31), but this association did not hold for the adjusted model. Like DM, prediabetes should be recognized as a risk for CVD events, albeit weakly. Elevated home BP contributes to increased CVD risk in diabetes. Our study demonstrated the impact of prediabetes and diabetes on CVD and the impact of office and home BP on CVD events in each group.

PS-BPC03-5: OFFICE AND HOME BLOOD PRESSURE AND CARDIOVASCULAR DISEASE IN PATIENTS WITH DIABETES, PREDIABETES AND NORMAL GLUCOSE METABOLISM

Objective: Few studies have investigated whether the association between home blood pressure (BP) and cardiovascular disease (CVD) events is different according to prediabetes and diabetes populations. The main purpose of this study is to clarify the impact of home BP and office BP on CVD events in prediabetes and diabetes. Design and method: We used the database of the J-HOP (Japan Morning Surge-Home Blood Pressure) study, which enrolled 4,310 patients having at least one cardiovascular risk. We classified the patients with a self-reported clinical history of a physician's diagnosis, using of medication of diabetes mellitus, a fasting plasma glucose greater than or equal to 126 mg/dL, a casual plasma glucose level greater than or equal to 200 mg/dL or hemoglobin A1c (HbA1c;NGSP) greater than or equal to 6.5 % as diabetes (n = 1,034), those with HbA1c 5.7–6.4 % as prediabetes (n = 1,167), and the remaining patients as the patients with normal glucose metabolism (NGM) (n = 2,024). Outcome was measured against composite CVD outcome (first occurrence of coronary artery disease, stroke and heart failure). Results: During a median 6.2 ± 3.8 year follow-up, 259 CVD events occurred. Prediabetes was a risk of CVD events (Unadjusted Hazard ratios [uHR],1.43; 95% confidence interval [CI], 1.05–1.95) and this association was followed by diabetes (uHR, 2.13; 95%CI, 1.59–2.85) compared to NGM. In NGM group, the adjusted HR expressing the risk of composite CVD events, were 1.15 (95%CI, 1.01–1.31) and 1.18 (95%CI, 1.03–1.36), 1.01(95%CI, 0.88–1.15) per 10 mmHg increase of morning and evening home systolic BP (SBP), office SBP, respectively. In diabetes, increased home SBP as a risk of composite CVD events had similar tendency and office SBP was also associated with a risk of CVD (adjusted HR, 1.16; 95%CI, 1.02–1.31). In prediabetes group, only morning home SBP was associated with a risk of CVD events (uHR, 1.15; 95%CI, 1.00–1.31), but was not in adjusted model. Conclusion: Prediabetes was a risk for CVD events as well as diabetes. Increased home BP contributes to CVD risk in diabetes, albeit weakly in prediabetes.

AW-AD-1: SEASONAL VARIATION IN DAY-BY-DAY BLOOD PRESSURE VARIABILITY AND ITS EFFECT ON CARDIOVASCULAR OUTCOMES

Although day-by-day home blood pressure (BP) variability has been associated with cardiovascular disease (CVD) risk, it remains unclear whether this association differs from season to season. The present study aimed to assess seasonal variation in day-by-day home BP variability (BPV) and its association with CVD risk. We analyzed the data from a nationwide, prospective observational study, the J-HOP (Japan Morning Surge-Home Blood Pressure) study, in which 14 consecutive days of home BP monitoring were conducted. The values of standard deviation (SDSBP), coefficient of variation (CVSBP), and average real variability (ARVSBP) of home systolic BP (SBP) were used as indices of day-by-day home BPV. Among 4231 participants (mean age, 64.9 ± 10.9 years, 46.7% male, 91.5% hypertensives), all three day-by-day home BPV indices were lower in summer than winter after adjusting for confounding factors. In winter, SDSBP, CVSBP, and ARVSBP were significantly associated with increased risk of CVD events (coronary artery disease, stroke, heart failure, and aortic dissection) (adjusted HR [95%CI] per 1-SD of SDSBP, 1.27 [1.03, 1.56]; CVSBP, 1.25 [1.03, 1.53]; ARVSBP, 1.44 [1.18, 1.77]). These relationships were also observed in the analysis of quartiles of BPV parameters (adjusted HR [95%CI] compared to the 1st quartile, 4th quartile of SDSBP 2.25 [1.05, 4.81]; CVSBP 2.91 [1.40, 6.03]; ARVSBP 2.71 [1.25, 5.89]). In other seasons, however, there were no significant associations between day-by-day home BPV and CVD event risk. Our findings indicate that day-by-day home BPV measured in winter is more strongly associated with future CVD incidence than that measured in other seasons.

Left ventricular mass as a predictor of cardiovascular events in the era of hypertension management using home blood pressure measurement: the J-HOP study.

Target organ damage (TOD) is associated with a risk of cardiovascular disease (CVD) independent of blood pressure (BP); however, this association has been observed based on the assessment of office BP. We studied 1641 patients (mean age 64.8 ± 11.7 years) with CVD risk factors who underwent home BP measurement over a 14-day period and evaluated TOD at baseline and then performed follow-up examination of the J-HOP (Japan Morning Surge-Home Blood Pressure) study results. During the median follow-up of 6.6 ± 3.5 years, 115 participants experienced a CVD event. After adjustment for CVD risk factors, including office systolic BP, the adjusted hazard ratios expressing the risk of CVD events were 1.30 (95% confidence interval, 1.15-1.52), 1.27 (1.04-1.56), and 1.25 (1.11-1.40) per one-SD increase in log-transformed urinary albumin creatinine ratio (UACR, 0.57 mg/gCre), brachial-ankle pulse wave velocity (baPWV, 342 cm/s) and left ventricular mass index (LVMI, 26.6 g/m2) assessed by echocardiography, respectively. Even after adding home systolic BP as a covariate, these associations remained except for the association with baPWV (all P < 0.05). The C-statistic for the base model including office and home systolic BP for the risk of CVD events was 0.783 (95% CI: 0.743, 0.824), which significantly increased to 0.795 (95% CI: 0.757, 0.834) after adding LVMI, and changed slightly but not significantly with the addition of UACR or baPWV. Adding UACR, baPWV, or both to the model including LVMI did not improve CVD event prediction. In the modern era of hypertension management using home BP measurement, TOD indicators, especially LVMI, provide superior CVD event prediction independent of and beyond home BP.

Association of treatment-resistant hypertension defined by home blood pressure monitoring with cardiovascular outcome.

In diagnosis of treatment-resistant hypertension (TRH), guidelines recommend out-of-office blood pressure (BP) measurements, ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM). Although evidence of an association between ABPM-evaluated TRH and cardiovascular disease (CVD) prognosis has accumulated, data are sparse regarding HBPM-evaluated TRH. We investigated this issue using data from the nationwide practice-based J-HOP (Japan Morning-Surge Home BP) study, which recruited 4,261 outpatients (mean age 64.9 years; 46.8% men; 91.5% hypertensives) who underwent morning and evening HBPM for 14 days. During 6.2 ± 3.8 years (26,418 person-years) follow-up, 270 total CVDs (stroke, coronary artery disease, aortic dissection, and heart failure) occurred. The adjusted hazard ratio (HR) (95% CIs) of uncontrolled TRH, i.e., uncontrolled BP using 3 classes of medications including diuretics or ≥4 classes of medications, for total CVD risk compared to controlled BP using <3 classes were 2.02 (1.38-2.94) and 1.81 (1.23-2.65) in home BP of 135/85 mmHg and 130/80 mmHg, respectively. Additionally, patients with TRH defined by guidelines, i.e., uncontrolled BP using 3 classes of medications including diuretics or controlled/uncontrolled BP using ≥4 classes of medications, also had higher total CVD risk compared to non-TRH under all home BP criteria. Moreover, in patients with uncontrolled apparent-TRH, i.e., TRH defined by office BP, uncontrolled home BP (≥135/85 mmHg) was still associated with atherosclerotic CVD (CVDs except heart failure) risk (adjusted HR [95% CI], 2.38 [1.09-5.19]). This is the first study to demonstrate an independent association between TRH evaluated by HBPM and CVD outcomes.

Growth Differentiation Factor 15 Predicts Cancer Death in Patients With Cardiovascular Risk Factors: The J-HOP Study.

Background: Disease-related anorexia-cachexia is associated with poor prognosis of patients with cardiovascular disease (CVD) or cancer. Growth differentiation factor-15 (GDF-15) has emerged as a central regulator of appetite and body weight. However, the exact role of GDF-15 in lean patients has not been elucidated.Aim: Our aim is to evaluate whether the association of GDF-15 with mortality, including cancer death, differs according to body mass index (BMI) level.Methods and Results: We collected blood samples from 4,061 patients with CV risk factors who were enrolled in the nationwide practice-based J-HOP (Japan Morning Surge-Home Blood Pressure) study. Serum GDF-15 levels were determined by immunoassay analysis. During a mean follow-up period of 6.6 years, we observed 174 (6.7/1000 person-year) all-cause deaths, 68 (2.6/1000 person-year) cancer deaths, and 56 (2.2/1000 person-year) CV deaths. Patients were stratified according to the cut-points of GDF-15 at 1,200 ng/L and BMI at 22.5 and 25.0 kg/m2. The association between the GDF-15/BMI based study groups and each outcome was evaluated by Cox-proportional hazard models with adjustment for established risk factors. The multivariate Cox regression model showed that patients with elevated GDF-15 (≥1,200 ng/L) and low BMI (<22.5 kg/m2) were significantly associated with increased risk of all outcomes [all-cause death, hazard ratio (HR) 3.15, 95% confidence interval (CI) 1.85–5.34, p < 0.001; cancer death, HR 3.52, 95%CI 1.64–7.57, p = 0.001; CV death, HR 2.88, 95%CI 1.20–6.92, p = 0.018, respectively] compared to a reference group with non-elevated GDF-15 and normal BMI (22.5–25.0 kg/m2). In analyses of a subgroup with low BMI (<22.5 kg/m2), patients with elevated GDF-15 had 4.79-fold increased risk of cancer death and 11-fold greater risk of CV death when compared with patients with non-elevated GDF-15 (<1,200 ng/L) after adjustment for established risk factors.Conclusion: In patients with CV risk factors, GDF-15 was associated with all-cause, cancer, and CV death. This relationship was especially remarkable in patients with low BMI. The serum GDF-15 levels in patients with low BMI might be a useful marker to identify the potential for anorexia-cachexia associated with CVD and cancer.

GROWTH DIFFERENTIATION FACTOR-15 IS AN INDEPENDENT PREDICTOR OF CARDIOVASCULAR DISEASE IN JAPANESE PATIENTS WITH CARDIOVASCULAR RISK FACTORS: THE J-HOP STUDY

Objective: Growth differentiation factor-15 (GDF-15) is emerged as a novel biomarker to predict adverse outcomes in community-dwelling individuals and patients with cardiovascular (CV) disease. However, there is a paucity of information on the association between blood GDF-15 levels and adverse outcomes in outpatients with CV risk factors. In this study, we evaluated the prognostic value of GDF-15 in outpatients with CV risk factors and compared with those of other prognostic biomarkers: N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitive troponin T (hs-TnT). Design and method: We collected blood samples from 3,562 patients with CV risk factors in the J-HOP (Japan Morning Surge-Home Blood Pressure) study. Blood GDF-15 levels were determined by immunoassay analysis. During a mean follow-up period of 6.6 years, we recorded the incidence of adverse outcomes as follows: 1) cardiac events defined as ischemic heart disease and heart failure, 2) stroke events defined as ischemic stroke and cerebral hemorrhage, 3) all-cause death, and 4) cancer death. Patients were stratified according to tertiles of GDF-15. The association between GDF-15 and each outcome was evaluated by Cox-proportional hazard models adjusting for established risk factors and other biomarkers (hs-TnT and NT-proBNP). Results: We observed 141 (4.0%) cardiac events, 81 (2.3%) stroke events, and 155 (4.4%) death including 63 (1.8%) cancer death. Multivariate Cox regression model showed that patients in highest tertile of GDF-15 were independently and significantly associated with increased risk of stroke and death except for cardiac events [stroke events, hazard ratio (HR) 2.87, p = 0.008; all-cause death, HR 2.38, p = 0.007; cancer death, HR 2.48, p = 0.049; cardiac events; HR 1.07, p = 0.805, respectively] compared with lowest tertile after adjustment for established risk factors and other biomarkers. Furthermore, adding GDF-15 to the predictive models for stroke and death improved discrimination and reclassification more than adding other biomarkers to the models. Conclusions: In this study, GDF-15 predicts death and stroke except for cardiac events. Information of GDF-15 might be helpful when assessing the risk of death and stroke events in Japanese patients with CV risk factors.

Relationship Between Home Blood Pressure and the Onset Season of Cardiovascular Events: The J-HOP Study (Japan Morning Surge-Home Blood Pressure).

The incidence of cardiovascular disease (CVD) increases during winter. The risk that elevated home blood pressure (BP) poses for CVD events that occur in each of 4 seasons is unclear. We conducted a post hoc analysis using the dataset from a nationwide cohort, the Japan Morning Surge-Home Blood Pressure (J-HOP) study, to assess the association between home BP and winter-onset CVD events. J-HOP participants who had cardiovascular risks conducted morning and evening home BP measurements for a 14-day period and were followed-up for the occurrence of CVD events. We analyzed 4,258 participants (mean age 64.9 years; 47% male; 92% hypertensives) who were followed-up for an average of 6.2 ± 3.8 years (26,295 person-years). We divided the total of 269 CVD events (10.2/1,000 person-years) by the season of onset as follows: 82 in the winter and 187 in the other seasons (spring, summer, and autumn). In the Cox models adjusted for covariates and the season when home BPs were measured at baseline, morning home systolic BP (SBP) was associated with both winter-onset and other season-onset CVD events: hazard ratio (HR) for winter 1.22, 95% confidence interval (CI) 1.06-1.42 per 10 mm Hg; HR for other seasons 1.11, 95% CI 1.00-1.23. Evening home SBP was associated with the other season-onset CVD events (HR 1.20, 95% CI 1.08-1.33 per 10 mm Hg), but not with the winter-onset CVD events. Our findings indicate that compared with evening home BP, morning home BP might be a superior predictor of winter-onset CVD events.

Different age-related impacts of lean and obesity on cardiovascular prognosis in Japanese patients with cardiovascular risks: The J-HOP (Japan Morning Surge-Home Blood Pressure) Study.

The relationship between lean and cardiovascular events has been shown to vary with age, but the relationship between age‐related lean and cardiovascular events in Asia has not been established. We divided patients enrolled in the J‐HOP (Japan Morning Surge‐Home Blood Pressure) study with one or more cardiovascular disease risks into three groups based on their body mass index (BMI): lean (BMI < 21), normal‐weight (21 ≤ BMI <27), and obese (BMI ≥ 27). We stratified the risk of cardiovascular events of lean and obesity compared to normal weight into the patients < 65 years old and those aged ≥ 65 years. A total of 286 cardiovascular disease events were observed during the follow‐up period (73 ± 46 months). Regarding the relationship between BMI and cardiovascular disease risk, both lean and obesity were independent prognostic factors: lean: hazard ratio (HR) 1.43, 95% confidence interval (CI): 1.02‐2.01, p = .040; obesity: HR 1.55, 95%CI: 1.13‐2.12, p = .006. In patients < 65 years old, the risk of cardiovascular disease of the lean patients was lower than that of the normal‐weight patients (HR 0.39, 95%CI: 0.12‐1.29, p = .124) and the risk of obesity patients was significantly higher (HR 1.77, 95%CI: 1.08‐2.92, p = .024). In the patients aged ≥ 65 years, lean was a significant independent factor of cardiovascular events compared to normal‐weight (lean: HR 1.70, 95%CI: 1.18‐2.47, p = .005). In conclusion, lean was an independent predictor of cardiovascular events in patients aged ≥ 65 years.

Abstract 14614: The Automatically Assessed P-wave Notch Predicts Cardiovascular Events in Patients With Cardiovascular Risks: The Japan Morning Surge Home Blood Pressure (J-HOP) Study

Background: The notched P-wave characteristics is associated with atrial remodeling. However, the relationship between notched P-wave characteristics and long-term cardiovascular events remains unclear. Hypothesis: We hypothesized that the notched P-wave would be associated with cardiovascular events. Methods: We enrolled 810 subjects from the J-HOP Study who had ≥1 of four cardiovascular risk factors. Twelve-lead electrocardiography was conducted, and the peak-to-peak distance in the M-shape was calculated automatically using a 12-lead ECG Analysis system (Fukuda Denshi, Tokyo). We compared two definitions: P waves were defined as "notched" if the peak-to-peak distance in the M-shape was ≥20 msec or ≥40 msec in lead II. The primary endpoints were fatal/nonfatal cardiovascular events: myocardial infarction, stroke, hospitalization for heart failure, and aortic dissection. We assessed the left atrial diameter and left ventricular mass index (LVMI) by echocardiography. Results: The mean follow-up period was 101±34 months, and 85 cardiovascular events occurred. When we defined a notched P wave as ≥20msec in the M shape (n=92), a notched P wave was a significant predictor of cardiovascular events after adjustment for age, gender, and comorbidity (hazard ratio 1.80, 95%CI: 1.06-3.05). When we defined a notched P wave as ≥40msec in the M shape (n=25), the hazard ratio of cardiovascular events in the notched P-wave group was significantly borderline after adjustment for covariates (hazard ratio 2.23, 95%CI: 0.90-5.56). The left atrial diameter and LVMI in the patients in the notched P-wave group (≥20 msec in the M shape) were significantly higher than those in the control group (left atrial dia. 38.8±5.9 vs. 36.8±5.0 mm, p=0.001; LVMI 103.9±27.7 vs. 96.3±25.7 g/m 2 , p=0.010). Conclusion: The automatically assessed notched P wave was associated with cardiovascular events, left atrial enlargement and left ventricular hypertrophy.

Associations Between Day-by-Day Home Blood Pressure Variability and Renal Function and Albuminuria in Patients With and Without Diabetes.

The phenotype of diabetic kidney disease represents a lower estimated glomerular filtration rate (eGFR) and albuminuria. We investigated the association between day-by-day home blood pressure (BP) variability and the eGFR in subjects with diabetes and compared this association with that in subjects without diabetes. We then attempted to determine whether the association is present in albuminuria. We analyzed 4,231 patients with risk factors of cardiovascular disease (24.4% with diabetes) from the J-HOP (Japan Morning Surge-Home Blood Pressure) study. Home BP was measured in the morning and evening for 14 days. We calculated the SD, coefficient of variation, average real variability (ARV), and variation independent of the mean of the subjects' morning and evening home systolic BP (SBP) as the indexes of day-by-day home BP variability. A multiple linear regression analysis adjusted for covariates showed both average morning and evening SBP were associated with the log-transformed urine albumin-to-creatinine ratio (UACR) with and without diabetes (all P < 0.05), but not with the eGFR except for an association of average evening SBP in the no-diabetes group. None of the indexes of day-by-day morning and evening home SBP variability were associated with the log-transformed UACR except for the association between the ARV of home morning SBP in the diabetes group. All of the indexes of day-by-day morning and evening home SBP variability were associated with the eGFR only in the diabetes group (all P < 0.05). The association between increased day-by-day home BP variability and impaired renal function was unique in diabetes.

P313The automatically assessed P-wave axis predicts cardiovascular events in patients with cardiovascular risks: The Japan Morning Surge Home Blood Pressure (J-HOP) Study

Abstract Background An abnormal P-wave axis in electrocardiography predicts the development of atrial fibrillation (AF) and cardiovascular events. There have been few reports on the relationships among an automatically assessed P-wave duration, left atrial enlargement, left ventricular hypertrophy, and cardiovascular events in patients with cardiovascular risk factors. Purpose To determine the relationship among an abnormal P-wave axis, left atrial enlargement, left ventricular hypertrophy, and cardiovascular events in patients with cardiovascular risk factors. Methods We enrolled 829 subjects from the J-HOP Study who had ≥1 of four cardiovascular risk factors: hypertension, dyslipidemia, diabetes, and smoking. Twelve-lead electrocardiography was conducted, and the P-wave axis was calculated automatically using a 12-lead ECG Analysis system (Fukuda Denshi, Tokyo) according to the following formula: arctan{√3(II + III) / (2I + II-III)}. We divided the patients into three groups: those with a normal axis (0°–75°, n = 692), left axis deviation (&amp;lt;0°, n = 39), or right axis deviation (≥75°, n = 56). The primary endpoints were fatal/nonfatal cardiovascular events: myocardial infarction, stroke, hospitalization for heart failure, and aortic dissection. We conducted echocardiography and measured the left atrial (LA) diameter, left ventricular mass index (LVMI), and brain natriuretic peptide (BNP). Results The LA diameter, LVMI, and BNP in the patients with left axis deviation were significantly higher than those in the patients with a normal axis (LA diameter: 40.2 ± 7.0 vs. 37.0 ± 5.0, p = 0.008; LVMI: 105.7 ± 25.7 vs. 96.9 ± 25.2 g/m2, p &amp;lt; 0.001; median BNP: 41.6 vs. 16.5 pg/dL, p &amp;lt; 0.001). The mean follow-up period was 101 ± 34 months, and 92 cardiovascular events occurred. A Cox proportional hazards model including age, gender, smoking, history of hypertension, dyslipidemia, diabetes, LA dia., and LVMI revealed that left axis deviation of the P wave was independently associated with cardiovascular events (hazard ratio 2.31, 95%CI 1.18–4.55, p = 0.015). Conclusions: Leftward deviation of the automatically assessed P-wave axis was associated with left atrial enlargement, left ventricular hypertrophy, and cardiovascular events in patients with cardiovascular risk.

Increased Arterial Stiffness Amplifies the Association Between Home Blood Pressure Variability and Cardiac Overload: The J-HOP Study.

Increased blood pressure (BP) variability, an index of hemodynamic stress, leads to cardiac overload and worse cardiovascular prognosis. The association between day-by-day home BP variability and NT-proBNP (N-terminal pro-B-type natriuretic peptide) as an index of cardiac overload may be amplified by increased arterial stiffness as assessed by brachial-ankle pulse wave velocity (baPWV). J-HOP (Japan Morning Surge-Home Blood Pressure) Study participants who were selected from a practitioner-based population with at least one cardiovascular risk factor underwent home BP monitoring, and their BP levels and SD, coefficient of variation, and average real variability as indexes of systolic BP variability were assessed. We analyzed 2115 individuals without prevalent heart failure and divided them into lower (<1800 cm/s, n=1464) and higher (≥1800 cm/s, n=651) baPWV groups. The higher baPWV group had significantly higher SDSBP, CVSBP, ARVSBP values, and NT-proBNP levels than the lower baPWV group (all P<0.001). In the higher baPWV group, a multiple linear regression analysis revealed that the SDSBP was associated with the NT-proBNP level after adjustment for traditional cardiovascular risk factors including the average home systolic BP (coefficient per 1 SD increase, 0.049 [95% CI, 0.018-0.081]; P=0.002). Similar trends were found for CVSBP (P=0.003) and ARVSBP (P=0.004). However, these associations were not found in the lower baPWV group. There was an interaction between all indexes of systolic BP variability and the NT-proBNP level according to lower or higher baPWV group (all P<0.05). Arterial stiffness amplified the association between home BP variability and cardiac overload.

Seasonal Variation of Home Blood Pressure and Its Association With Target Organ Damage: The J-HOP Study (Japan Morning Surge-Home Blood Pressure).

BackgroundAlthough seasonal variation of home blood pressure (BP) has been reported to be higher in winter, seasonal difference in home BP (HBP) and its association with target organ damage (TOD) remains unclear.MethodsThis is a cross-sectional study using the dataset from the Japan Morning Surge-Home Blood Pressure (J-HOP) study to assess seasonal differences in HBP, prevalence of masked hypertension, and association of HBP with TOD. The J-HOP study is a nationwide, multicenter prospective study whose participants with cardiovascular risks underwent morning and evening HBP measurements for a 14-day period in 71 institutions throughout Japan. Urine albumin–creatinine ratio (UACR) and serum-B-type natriuretic peptide (BNP) were obtained at enrollment.ResultsAmong 4,267 participants (mean age, 64.9 ± 10.9 years; 46.9% male; 91.4% hypertensives), 1,060, 979, 1,224, and 1,004 participants were enrolled in spring, summer, autumn, and winter, respectively. Morning and evening home systolic/diastolic BP levels, and prevalence of masked hypertension (office BP <140/90 mm Hg and HBP ≥135/85 mm Hg) were significantly lower in summer than other seasons after adjustment for covariates. When we assessed the interaction between BP parameters and each season for an association with TOD, we found the association between morning home diastolic BP and each of UACR and BNP was stronger in winter than other seasons (both P for interaction <0.05).ConclusionsIn this study, we revealed that the prevalence of masked hypertension was higher in other seasons than in summer and found a notable association between morning home diastolic BP and TOD in winter.

SEASONAL VARIATION IN PREVALENCE OF MASKED UNCONTROLLED HYPERTENSION IN GENERAL PRACTICE OUTPATIENTS

Objective: Masked hypertension is generally known as a cardiovascular disease (CVD) risk factor at a same level comparable to sustained hypertension. However, there is no data on seasonal differences in the prevalence of masked hypertension in outpatients under hypertensive treatment in clinical practice. We thus assessed seasonal variation in prevalence of masked uncontrolled hypertension using dataset of the Japan Morning Surge-Home Blood Pressure (J-HOP) study. Design and method: The J-HOP study is a nation-wide prospective observational study to predict CVD events in clinical practice outpatients, and participants underwent home blood pressure (BP) measurements in the morning and evening for a 14-day period. Clinic and home BP levels, prevalence of masked uncontrolled hypertension were compared in participants divided by seasons when they measured HBP. Masked uncontrolled hypertension was defined as clinic BP < 140/90 mmHg and morning or evening home BP > 135/85 mmHg based on the current Japanese guideline. Results: Among 4271 participants (mean age, 64.9 ± 10.9 years; 47.0% male; 91.4% hypertensive patients, 67 institutions in various areas in Japan), morning home systolic BP was significantly lower in summer compared to other seasons (spring, 139.4 ± 15.5 mmHg; summer, 134.1 ± 15.6 mmHg; autumn, 139.4 ± 16.1 mmHg; winter, 140.3 ± 15.5 mmHg, p value < 0.01 in all comparison between summer and other seasons). Moreover, prevalence of masked uncontrolled hypertension was significantly higher in winter that that in summer (spring, 22.5%; summer, 18.1%; autumn, 22.7%; winter, 24.4%, p < 0.01 in comparison between summer and winter) (Figure). In multivariate logistic regression analysis, masked uncontrolled hypertension was lower in summer compared to spring as reference after adjusted host factors and clinic BP levels (odds ratio, 0.60; 95% confidence interval, 0.47 to 0.77, p < 0.001).Conclusions: The present study revealed prevalence of masked uncontrolled hypertension tended to be lower in summer. Measurement of home BP is thus more valuable than clinic BP for management of hypertension corresponding to changes of season.

A3322 Association of day-by-day blood pressure variability with cardiovascular event in Japanese population with diabetes

Objectives: Increased day-by-day blood pressure (BP) variability assessed by home BP measurement has been associated with cardiovascular events in general and clinical population. However, few studies have examined these associations in patients with diabetes. The aim of this study is to investigate the association of day-by-day home BP variability of cardiovascular events in patients with diabetes enrolled in Japan Morning Surge-Home Blood Pressure (J-HOP) Study. Methods: Of 4,310 participant enrolled in J-HOP study, 1015 had diabetes. They underwent home BP monitoring in the morning and evening over a 14-day period, and their BP levels and BP variability independent of the mean (VIM) were assessed. Incident cardiovascular (CV) events included cardiovascular morbidity and mortality. Results: Mean (SD) home systolic BP (SBP) levels over time and VIMSBP were 136.2 (14.7) mmHg and 6.7 (2.3) unit, respectively. During a 4-year follow-up period, 69 CV events occurred. Mean home SBP per 1SD was not associated with CV events (Hazard ratio, 1.22; 95% CI, 0.95, 1.58), whereas VIMSBP per 1SD was associated with CV events independently of cardiovascular risk included mean home SBP (HR, 1.44; 95% CI, 1.15, 1.79, P = 0.001). Conclusion: In Japanese population with diabetes, day-by-day BP variability was independently associated with cardiovascular events.

Morning Home Blood Pressure and Cardiovascular Events in a Japanese General Practice Population Over 80 Years Old: The J-HOP Study.

Home blood pressure (BP) measurement has been well accepted for use in the diagnosis and treatment of hypertension. However, data regarding the association between home BP levels and cardiovascular events in a general practice population aged ≥80 years are sparse. We analyzed the cases of 349 patients ≥80 years old from the Japan Morning Surge-Home Blood Pressure (J-HOP) Study, a nationwide practice-based study of 4,310 Japanese with a history of and/or risk factors for cardiovascular disease. Home BP measurements were performed twice daily (morning and evening) over 14 consecutive days at baseline. During a median follow-up of 3.0 years, 32 composite cardiovascular events (13 strokes and 19 nonstroke events) occurred. Higher morning systolic BP (SBP) was a significant risk factor for composite cardiovascular events (hazard ratio (HR) per 10mm Hg, 1.23; 95% confidence interval (CI): 1.01-1.50) and stroke events (HR per 10mm Hg, 1.47; 95% CI: 1.08-2.00) after adjustment by the 4-year cardiovascular risk scores and clinic SBP. In the adjusted model, morning diastolic BP also tended to be a significant risk factor of stroke events (HR per 5 mm Hg, 1.43; 95% CI: 1.00-2.05). However, these associations were not found for evening BP or clinic BP. Morning home BP showed a positive linear association with cardiovascular events, especially with stroke. This association was not observed for clinic BP or evening home BP. Based on these results, in very elderly Asian populations, measuring morning home BP might be important in clinical practice regardless of the individual's office BP level.