Japan Morning Surge-Home Blood Research Articles

Nighttime blood pressure and glucose control impacts on left ventricular hypertrophy: The Japan Morning Surge Home Blood Pressure (J-HOP) Study.

Several studies investigated the association between nighttime blood pressure (BP) and left ventricular hypertrophy (LVH) in diabetes, but since most of these studies were conducted in diabetes populations only, they did not compare differences in the impact of nighttime BP on LVH in subjects without diabetes. Moreover, data about the impact of glucose control in diabetes on the relationship between nighttime BP and LVH are sparse. We classified 1277 adults (age 64.7 ± 11.8 years) performing ambulatory BP monitoring while enrolled as part of the Japan Morning Surge Home Blood Pressure (J-HOP) study into groups according to the control status of daytime BP (systolic BP [SBP] < 135 mmHg or ≥135 mmHg), nighttime BP (SBP < 120 mmHg or ≥120 mmHg), and diabetes (HbA1c < 7.0% or ≥7.0%). LVH was assessed by echocardiography. LVH according to echocardiographic criteria was identified in 33.7% of the participants. The group with poorly controlled diabetes plus uncontrolled nighttime BP (n = 90) had a 2.1-fold higher risk of LVH compared to the group with controlled nighttime BP and non-diabetes (n = 505) (odds ratio [OR] 2.10, 95% confidence interval [CI]: 1.29-3.44). No association was observed between uncontrolled daytime BP and diabetes for LVH. In the participants with poorly controlled diabetes (n = 146), uncontrolled nighttime BP posed a 3.1-fold higher risk of LVH compared to controlled nighttime BP (OR 3.12, 95%CI: 1.47-6.62). This association was not found in controlled diabetes. Uncontrolled nighttime BP was associated with a risk of LVH, especially among individuals with poorly controlled diabetes.

S-46-4: NONDIPPER PULSE RATE PATTERN WAS ASSOCIATED WITH BLOOD PRESSURE VARIABILITY AND INCREASE OF BNP: J-HOP STUDY

Background: The association between nondipper pulse rate (PR) pattern was reported. However, the association between nondipper PR pattern, blood pressure variability and hypertensive target organ damage remains unclear. Methods: Ambulatory BP monitoring (ABPM) was conducted in 1,003 hypertensive patients enrolled in the Japan Morning Surge Home Blood Pressure (J HOP) Study. Ambulatory BP monitoring was performed on a weekday with an automatic system that recorded the wearers BP and PR every 30 minutes for 24 hours. Nondipper PR status was defined as (awake PR minus sleep PR)/awake PR &lt; 0.1, and we evaluated standard deviation (SD) of systolic BP in daytime and nighttime as BP variability. We also measured the brain natriuretic peptide level (BNP), and conducted echocardiography to estimate the left ventricular mass index (LVMI). Results: The SD of systolic BP in nighttime, BNP and LVMI in patients with nondipper PR (N = 247) were higher than that in patients with dipper PR (N = 756, SD of systolic BP: 13.3 ± 4.6 vs. 12.7 ± 4.1 mmHg, p = 0.041; median BNP: 25.2 vs. 17.6 pg/dL, p &lt; 0.001, LVMI: 101.4 ± 29.1 vs. 97.3 ± 42.2 g/m2, p = 0.021). Systolic BP in nighttime in patient with nondipper PR was similar to that in patient with dipper PR (119.5 ± 15.2 vs. 119.9 ± 15.1 mmHg, p = 0.63). The SD of systolic BP in nighttime was associated with BNP and LVMI (BNP: r = 0.08, p = 0.006; LVMI r = 0.10, p = 0.001). Nondipper PR was independently associated with BNP (β = 0.10, p &lt; 0.001), but not with LVMI (β = 0.03, p = 0.37) after adjustment for systolic BP and SD of systolic BP in nighttime. Conclusions: Nondipper PR pattern was associated with blood pressure variability and hypertensive target organ damage in patients with cardiovascular risk factor.

Notched P-Wave on Digital Electrocardiogram Predicts Cardiovascular Events in Patients with Cardiovascular Risks: The Japan Morning Surge Home Blood Pressure Study

Background: The relationship between notched P-wave characteristics on digital electrocardiogram (ECG) and long-term cardiovascular events remains unclear. Methods: We enrolled 810 subjects from the Japan Morning Surge Home Blood Pressure study who had one or more 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. We compared two definitions: P-waves were defined as “notched” if the peak-to-peak distance in the M shape was ≥20 ms or ≥40 ms in lead II. We assessed the left atrial diameter and left ventricular mass index (LVMI) by echocardiography. The primary endpoint was defined as a composite endpoint that combines fatal events (stroke, heart failure, coronary artery disease, and sudden death) and nonfatal events (acute myocardial infarction, angina, congestive heart failure, stroke, and aortic dissection). Results: The mean follow-up period was 101 ± 34 months, during which 85 cardiovascular events occurred. When we defined a notched P-wave as ≥20 ms 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: 1.83; 95% confidence interval: 1.01–3.31, p = 0.045). When we defined a notched P-wave as ≥40 ms in the M shape (n = 25), the hazard ratio of cardiovascular events in the notched P-wave group was not significant after adjustment for covariates (hazard ratio: 1.52; 95% confidence interval: 0.51–4.53, p = 0.455). The left atrial diameter and LVMI in the patients in the notched P-wave group (peak-to-peak distance of ≥20 ms in the M shape) were significantly higher than those in the control group (left atrial diameter: 38.8 ± 5.9 vs. 36.8 ± 5.0 mm, p = 0.001; LVMI: 103.9 ± 27.7 vs. 96.3 ± 25.7 g/m2, p = 0.010). Conclusions: The notched P-wave by digital ECG analysis was associated with cardiovascular events and left atrial enlargement.

Atrial fibrillation is associated with cardiovascular events in obese Japanese with one or more cardiovascular risk factors: The Japan Morning Surge Home Blood Pressure (J-HOP) Study.

The impacts of atrial fibrillation (AF) and home blood pressure (BP) on the cardiovascular prognosis of obese individuals have not been clarified. We analyzed the differences in the prognosis (including the effect of the home BP of AF patients with/without obesity) in a Japanese population with cardiovascular risk factors. We enrolled 3,586 patients from the J‐HOP study who had at least one cardiovascular risk factor. We conducted 12‐lead electrocardiography, and the group of AF patients was determined as those whose electrocardiography revealed AF. Obesity was defined as a body mass index >25 kg/m2. The primary end points were fatal/nonfatal cardiovascular events (myocardial infarction, stroke, hospitalization for heart failure, and aortic dissection). Among the obese patients, those with AF (n = 36) suffered more significantly cardiovascular events (log rank 7.17, p = .007) compared to the patients with sinus rhythm (n = 1,282), but among the non‐obese patients, the rates of cardiovascular events were similar (log rank 0.006, p = .94) in the AF patients (n = 48) and sinus rhythm patients (n = 2220). After adjusting for age, sex, office/home BP, smoking, diabetes, and creatinine level, AF was an independent predictor of cardiovascular events in the obese group (hazard ratio [HR] 3.05, 95%CI: 1.17‐7.97, p = .023). Home systolic BP was also a predictor of cardiovascular events in the obese group independent of the risk of AF (per 10 mm Hg: HR 1.36, 95%CI: 1.02‐1.83, p = .039). In conclusion, AF was an independent predictor of cardiovascular events in obese patients after adjusting for home BP.

Automatically assessed P-wave predicts cardiac events independently of left atrial enlargement in patients with cardiovascular risks: The Japan Morning Surge-Home Blood Pressure Study.

A prolonged P‐wave in electrocardiography (ECG) reflects atrial remodeling and predicts the development of atrial fibrillation (AF). The authors enrolled 810 subjects in the Japan Morning Surge Home Blood Pressure (J‐HOP) study who had ≥1 cardiovascular (CV) risk factor. The duration of P‐wave was automatically analyzed by standard 12‐lead electrocardiogram. Left atrial (LA) enlargement and left ventricular hypertrophy (LVH) were measured on echocardiography. The primary end points were fatal/nonfatal cardiac events: myocardial infarction, sudden death, and hospitalization for heart failure. The maximum P‐wave duration (Pmax) from the 12 leads was selected for analysis. The authors compared four prolonged P‐wave cutoffs (Pmax = 120, 130, 140, 150 ms) and cardiac events. LA diameter and left ventricular mass index (LVMI) were significantly associated with Pmax (r = 0.08, P = .02 and r = 0.17, P < .001, respectively). When the cutoff level was Pmax 120 or 130 ms, prolonged P‐wave was not associated with cardiac events (P = .45 and P = .10), but when a prolonged P‐wave was defined as Pmax ≥ 140 ms (n = 50) or Pmax ≥ 150 ms (n = 19), the patients in those groups had significantly higher incidence of cardiac events than others (P < .001 and P = .03). A Cox proportional hazards model including age, gender, body mass index, smoking, regular drinker, hypertension, dyslipidemia, diabetes, office systolic blood pressure, heart rate, LA enlargement, and LVH revealed that prolonged P‐wave defined as Pmax ≥ 140 ms was independently associated with cardiac events (hazard ratio: 4.23; 95% confidence interval: 1.30–13.77; P = .02). In conclusion, the automatically assessed prolonged P‐wave was associated with cardiac events independently of LA enlargement and LVH in Japanese patients with CV risks.

Self-measured worksite blood pressure and its association with organ damage in working adults: Japan Morning Surge Home Blood Pressure (J-HOP) worksite study.

The effects of elevations in blood pressure (BP) on worksite stress as an out‐of‐office BP setting have been evaluated using ambulatory BP monitoring but not by self‐measurement. Herein, we determined the profile of self‐measured worksite BP in working adults and its association with organ damage in comparison with office BP and home BP measured by the same home BP monitoring device. A total of 103 prefectural government employees (age 45.3 ± 9.0 years, 77.7% male) self‐measured their worksite BP at four timepoints (before starting work, before and after a lunch break, and before leaving the workplace) and home BP in the morning, evening, and nighttime (at 2, 3, and 4 a.m.) each day for 14 consecutive days. In the total group, the average worksite systolic BP (SBP) was significantly higher than the morning home SBP (129.1 ± 14.3 vs. 124.4 ± 16.4 mmHg, p = .026). No significant difference was observed among the four worksite SBP values. Although the average worksite BP was higher than the morning home BP in the study participants with office BP < 140/90 mmHg (SBP: 121.4 ± 9.4 vs. 115.1 ± 10.4 mmHg, p < .001, DBP: 76.0 ± 7.7 vs. 72.4 ± 8.4 mmHg, p = .013), this association was not observed in those with office BP ≥ 140/90 mmHg or those using antihypertensive medication. Worksite SBP was significantly correlated with the left ventricular mass index evaluated by echocardiography (r = 0.516, p < .0001). The self‐measurement of worksite BP would be useful to unveil the risk of hypertension in working adults who show normal office and home BP.

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.

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.

The Combination of Non-dipper Heart Rate and High Brain Natriuretic Peptide Predicts Cardiovascular Events: The Japan Morning Surge-Home Blood Pressure (J-HOP) Study.

BACKGROUNDWe hypothesized that the association between the dipping heart rate (HR) pattern and cardiovascular (CV) events differs according to the brain natriuretic peptide (BNP) level.METHODSWe examined a subgroup of 1,369 patients from the Japan Morning Surge Home Blood Pressure study; these were patients who had CV risk factors and had undergone ambulatory blood pressure (BP) monitoring. HR non-dipping status was defined as (awake HR − sleep HR)/awake HR <0.1, and high BNP was defined as ≥35 pg/ml. We divided the patients into four groups according to their HR dipper status (dipping or non-dipping) and BNP level (normal or high).RESULTSThe mean follow-up period was 60 ± 30 months. The primary endpoints were fatal/nonfatal CV events (myocardial infarction, angina pectoris, stroke, hospitalization for heart failure, and aortic dissection). During the follow-up period, 23 patients (2.8%) in the dipper HR with normal BNP group, 8 patients (4.4%) in the non-dipper HR with normal BNP group, 24 patients (9.5%) in the dipper HR with high-BNP group, and 25 patients (21.0%) in the non-dipper HR with high-BNP group suffered primary endpoints (log rank 78.8, P < 0.001). Non-dipper HR was revealed as an independent predictor of CV events (hazard ratio, 2.13; 95% confidence interval, 1.35–3.36; P = 0.001) after adjusting for age, gender and smoking, dyslipidemia, diabetes mellitus, chronic kidney disease, BNP, non-dipper BP, 24-h HR, and 24-h systolic blood pressure.CONCLUSIONSThe combination of non-dipper HR and higher BNP was associated with a higher incidence of CV events.

Nighttime Blood Pressure Measured by Home Blood Pressure Monitoring as an Independent Predictor of Cardiovascular Events in General Practice.

We developed an innovative automated home blood pressure (BP) monitoring method that measures BP while asleep repeatedly over several days. Our aim was to assess the predictive ability of nighttime BP obtained using the home BP device for incident cardiovascular disease (CVD) in general practice patients. We used data from the nationwide practice-based J-HOP (Japan Morning Surge-Home Blood Pressure) Nocturnal BP Study, which recruited 2545 Japanese with a history of or risk factors for CVD (mean age 63 years; antihypertensive medication use 83%). The associations between nighttime home BPs (measured at 2:00, 3:00, and 4:00 am using validated, automatic, and oscillometric home BP devices) and incident CVD, including coronary disease and stroke events, were assessed with Cox proportional hazards models. The mean±SD office, morning home, and nighttime home systolic BP (SBP)/diastolic BP were 140±15/82±10, 137±15/79±10, and 121±15/70±9 mm Hg, respectively. During a follow-up of 7.1±3.8 years (18,116 person-years), 152 CVD events occurred. A 10-mm Hg increase of nighttime home SBP was associated with an increased risk of CVD events (hazard ratios [95% CIs]: 1.201 [1.046-1.378]), after adjustments for covariates including office and morning home SBPs. The model fit assessed by the change in Goodness-of-Fit was improved when we added nighttime home SBP into the base models including office and morning home SBPs (Δ6.838 [5.6%]; P=0.009). This is among the first and largest nationwide practice-based study demonstrating that nighttime SBP obtained using a home device is a predictor of incident CVD events, independent of in-office and morning in-home SBP measurement. Clinical Trial Registration- URL: http://www.umin.ac.jp/icdr/index.html . Unique identifier: UMIN000000894.

Sex differences and the prognosis of depressive and nondepressive patients with cardiovascular risk factors: the Japan Morning Surge-Home Blood Pressure (J-HOP) study.

Depression is associated with mortality in patients with cardiovascular risk factors. The frequency and severity of depression and the association between depression and cardiovascular events have sex-specific and ethnic differences. We conducted this study to evaluate the sex-specific difference in the association between depression and cardiovascular prognosis in patients with cardiovascular risk factors. We enrolled 4025 patients (64.7 ± 10.9 years, 53% women, 47% men) with cardiovascular risk factors in the Japan Morning Surge-Home Blood Pressure study. Depressive symptoms were assessed using the Beck Depression Inventory (BDI). The follow-up period was 47 ± 24 months. The primary end points were all-cause mortality and nonfatal cardiovascular events. The BDI scores and the prevalence of depression were significantly higher in women than in men. When a BDI score of 16 was the cutoff, the primary end points in the depression group (n = 217) were significantly higher than those in the nondepression group (n = 1677) among men (adjusted hazard ratio 1.76, 95% confidence interval: 1.17, 2.64; P = 0.007). In women, the primary end points in the depression and nondepression groups were similar when BDI scores of 16, 14, and 10 were the cutoffs. In conclusion, depression defined by a BDI score ≥16 was associated with cardiovascular events in men with cardiovascular risk factors.

Integrated flow-mediated vasodilation response predicts cardiovascular events in elderly patients with cardiovascular risk factors: the Japan Morning Surge–Home Blood Pressure study

The integrated flow-mediated vasodilation (FMD) response has been associated with cardiovascular (CV) risk factors, but the association between the integrated FMD response and subsequent CV events has been unclear. We enrolled 555 patients who had at least one CV risk factor (hypertension, dyslipidemia, diabetes, or smoking). We measured the peak percentage change in diameter (ΔFMD), and integrated FMD response calculated as the area under the dilation curve over a 120-second dilation period (FMD-AUC120). Elderly patients (age ≥ 65 years, N = 270) in the lowest tertile of FMD-AUC120 (FMD-AUC120 < 5.6) had a higher rate of CV events compared with those in the two higher tertiles (FMD-AUC120 ≥ 5.6) (log rank 4.15, P = .041). The association remained significant after adjusting for covariates (hazard ratio 3.84, P = .007). In the 285 middle-aged patients (age < 65 years), the CV event rates were similar between patients in the lowest tertile and those in the two higher tertiles of FMD-AUC120 (log rank 0.39, P = .53). The CV event rates were similar between patients in the lowest tertile and those in the two higher tertiles of ΔFMD in elderly and middle-aged patient groups. In conclusion, integrated flow-mediated vasodilation response, but not ΔFMD, predicted CV events in elderly patients with CV risk factors.

Abstract 14025: Mild QTc Prolongation was Associated With Cardiovascular Events in Japanese Male Patients With Cardiovascular Risk Japan Morning Surge Home Blood Pressure (J-HOP) Study

Introduction: The relationships between QTc intervals and the risk of cardiovascular (CV) events could differ among ethnicities or between subjects with/without left ventricular hypertrophy (LVH). Hypothesis: We hypothesized that mild QTc prolongation was associated with CV events in Japanese patients with CV risk factors. Methods: Subjects were 3,592 patients enrolled in the Japan Morning Surge Home Blood Pressure Study who had one or more CV risk factors. Corrected QT intervals (QTc) were calculated using the Bazett formula. Prolonged QTc interval was defined as ≥440 ms in men and ≥460 ms in women on electrocardiogram (ECG). We divided patients into 3 subgroups according to the percentile of QTc (shortest 10%, middle 80%, and longest 10%). The primary endpoints were fatal/nonfatal CV events (myocardial infarction, stroke, hospitalization for heart failure, aortic dissection). The Sokolow-Lyon criteria (RV5(6)+SV1) ≥35 mm were used to diagnose LVH. Results: During the mean follow-up period of 48±39 months, there were 138 CV events. In male patients, those with prolonged QTc (N=57) were more likely to suffer CV events than those without prolonged QTc (N=1523) (log rank 6.22, p=0.013). A Cox proportional hazards model including age, hypertension, dyslipidemia and diabetes revealed that prolonged QTc was a significant independent predictor of CV events in male patients (hazard ratio 2.21, 95%CI 1.01-4.82, p=0.047). In female patients, CV events were similar in prolonged QTc (N=33) and non- prolonged QTc patients (N=1766, p=0.73). In male patients, the longest 10% of QTc patients (QTc≥406ms, N=157) were more likely to suffer CV events than those in the middle 80% of QTc patients (QTc 332-405ms, N=1265) and shortest 10% of QTc patients (QTc&lt;332ms, N=157) (log rank 16.57, p&lt;0.001). In the absence of LVH (N=1308), male patients in longest 10% of QTc suffered more CV events than those in the other groups (log rank 6.61, p=0.037), and in the presence of LVH (N=272), males in the longest 10% of QTc also suffered more CV events than those in the other groups (log rank 13.73, p=0.001).In female patients, CV events were similar in three subgroups. Conclusions: Mild QTc prolongation was associated with CV events in Japanese male patients with a CV risk with or without ECG-LVH.

ME 01-2 ASSESSMENT AND TREATMENT OF MORNING HYPERTENSION

Abstract The essential benefit of the management of is derived from the blood pressure (BP) lowering per se, indicating the importance of throughout 24 hours. Recent guidelines stressed the importance of home for the diagnosis and management of hypertension. It is well-known that cardiovascular events occur more frequently in the levels have been shown to increase during the period from night to early morning. Clinical research using ambulatory monitoring (ABPM) or home monitoring has clarified that and are more closely related to the cardiovascular risk than office (Kario et al. Circulation 2003;107:1401-1406).The importance of on-treatment HBPM for the cardiovascular prognosis of hypertensive individuals was recently revealed in the largest real-world prospective study, the Home blood pressure measurement with Olmesartan Naive patients to Establish Standard Target blood pressure (HONEST) study which enrolled more than 21 000 hypertensive patient. In prospective results of the HONEST study, in hypertensive patients treated with antihypertensive medication, even patients whose office is well-controlled, on-treatment uncontrolled prior to taking medication frequently remains high risk for both stroke and coronary disease (Kario, et al. Hypertension 2014;64:989-996; J Am Coll Cardiol 2016;67:1519-1527). In our nationwide Japanese cohort, the Japan Morning Surge Home Blood Pressure (J-HOP) Study, home was the best predictor of stroke event (Hoshide, Kario, et al. Hypertension 2016;68:54-61). Since Asians show greater surges (Hoshide, Kario, Parati et al. Hypertension 2016;68:54-61), it is particularly important for Asians to control as the first step to achieve 'perfect 24-hr control,' i.e., the 24-hr level, nocturnal dipping, and variability including (Kario. Ann Glob Health 2016;82:254-273).The first definition of morning hypertension was defined as the average of BPs >135 mmHg for systolic BP, or >85mmHg for diastolic BP, regardless of office BPs with the definition of >135/85 mmHg regardless office in Clinician's Manual on Early Morning Risk Management in Hypertension in 2004 (Science Press, London, UK, 2004). Masked hypertension may be used for with office <140/90 mmHg. Morning could be measured by both ABPM (2 hour-average of ambulatory BPs after arsing) and home monitoring (the average of 2 measurements in the during 3 or more days). Morning could be diagnosed not only by home monitoring, but also by ABPM (ambulatory hypertension). When information on the time of arising is not available, the highest 1 hour moving average of consecutive systolic BPs between 6am and 10am could be calculate as the Moving peak systolic BP (Kario. Essential manual of 24 hour blood pressure management. Wiley, UK, pp.1-158.2015). The risk of may be underestimated by monitoring device with intermittent measurements. The innovation of wearable surge monitoring which could measure continuously will clarify the risk of (Kario. Prog Cardiovasc Dis 2016, in press).We are now proposing a three-step strategy for the BP-guided management of using home monitoring as follows. Step 1: Morning systolic <145 mmHg should be achieved by treatment; Step 2: The guideline level of 135 mmHg systolic should then be reached, and Step 3: Approx. 125 mmHg or less, which presents the lowest risk of cardiovascular events, should be achieved and maintained (Kario. Essential manual of 24 hour blood pressure management. Wiley, UK, pp.1-158.,2015). Non-specific medication for controlling includes long-acting drugs. Once-daily dosing antihypertensive agents, now widely used as conventional antihypertensive medication, has decreased the patient burden and contributed to increased patient compliance. However, conventional antihypertensive medication using once-daily use of antihypertensive drugs was insufficient for controlling hypertension. Specific treatment includes the time of dosing of antihypertensive drugs and selecting the specific class of antihypertensive drugs, such as inhibitors of sympathetic activity or the renin-angiotensin system (RAS). Practically, bedtime dosing of antihypertensive drug, especially calcium channel blocker, alpha-blocker, RAS inhibitors suppress exaggerated without excessive nocturnal hypotension during sleep. These treatments also effective for nocturnal hypertension. On the other hand, specific drug for reducing nocturnal is diuretics including thiazide-type diuretics, indapamide, and aldosterone blockers. These drugs are effective for with non-dipper/riser pattern of nocturnal BP. The renal denervation is effective for reducing and the moving peak in the combination analysis of the HTN-3 and the HTN-Japan as well as nocturnal (Kario, Bakris, et al. Hypertension 2015;66:1130-1137).The BP-guided approach using home monitoring is the most promising first step leading to the anticipation medicine for the most effective antihypertensive treatment for cardiovascular disease (Kario. Prog Cardiovasc Dis 2016, in press).

Abstract 13043: Atrial Fibrillation is Associated With Cardiovascular Events in Obese Japanese With One or More Cardiovascular Risk Factors: Japan Morning Surge Home Blood Pressure (J-HOP) Study

Introduction: Obesity has been shown as a risk of incidence and durability of atrial fibrillation. However, the relationship between obesity and prognosis of patients with atrial fibrillation remains unclear. Hypothesis: We assessed the hypothesis that obesity was associated with cardiovascular events in atrial fibrillation patients with cardiovascular risk factors. Methods: We enrolled 3,585 patients in the Japan Morning Surge Home Blood Pressure Study who had one or more cardiovascular risk factors. We conducted 12-lead electrocardiography, and atrial fibrillation was identified based on electrocardiography. Obesity was defined as body mass index over than 25 kg/m2. The primary endpoints were fatal/nonfatal cardiovascular events (myocardial infarction, stroke, hospitalization for heart failure, aortic dissection). Results: The number of patients whose electrocardiograms revealed atrial fibrillation was eighty-four. In obese patients, atrial fibrillation patients (N=35) suffered more cardiovascular events (log rank 7.17, p=0.007) than sinus rhythm patients (N=1282), but in nonobese patients, cardiovascular events were similar (log rank 0.10, p=0.76) in atrial fibrillation (N=48) and sinus rhythm patients (N=2220). After adjusting for age, gender, hypertension, smoking, and diabetes, atrial fibrillation was an independent predictor of cardiovascular events in the obese group (hazard ratio 3.02, 95% confidence interval 1.18-7.78). Conclusions: There was a significant difference in the association between atrial fibrillation and subsequent cardiovascular events in the presence or absence of obesity. Weight reduction might improve the prognosis of atrial fibrillation patients.

Abstract 13330: Depression is Associated With Cardiovascular Events in Male but Not Female Patients With One or More Cardiovascular Risk Factors: Japan Morning Surge Home Blood Pressure (J-HOP) Study

Introduction: Depression is associated with cardiovascular events, and the frequency of depression is higher in females than in males. However, the association between depression and cardiovascular events in patients with cardiovascular risk factors and the gender difference of the association remains unclear. Hypothesis: We assessed the hypothesis that depression was associated with a poor prognosis in patients with cardiovascular risk factors, and that the association is different in males and females. Methods: We enrolled 3,216 patients in the Japan Morning Surge Home Blood Pressure Study who had one or more cardiovascular risk factors. We conducted the Beck Depression Inventory (BDI). Depression was defined as having a BDI score ≥ 16. The primary endpoints were fatal/nonfatal cardiovascular events (myocardial infarction, stroke, hospitalization for heart failure, aortic dissection). Results: The mean follow-up period was 47±24 months, and 134 patients suffered primary endpoints. In male patients, depressive patients (N=184) were more likely to suffer cardiovascular events than non-depressive patients (N=1439) (log rank 6.79, p=0.009). In female patients, cardiovascular events were similar in depressive (N=347) and nondepressive patients (N=1246,log rank 0.06, p=0.81). A Cox proportional hazards model including age, history of hypertension, dyslipidemia and diabetes revealed that depression was a significant, independent predictor of primary endpoints in male patients (hazard ratio 2.01, 95% confidence interval 1.20-3.37, p=0.008). Conclusions: Depression is associated with cardiovascular events in male but not female patients with one or more cardiovascular risk factors.

Abstract 12837: Nondipper Pulse Rate Pattern is Associated With Cardiovascular Events, but Night Pulse Rate is Not: Japan Morning Surge Home Blood Pressure (J-HOP) Study

Introduction: Nondipper patterns of pulse rate (PR) as well as blood pressure (BP) have been associated with cardiovascular events. High night PR is also associated cardiovascular events. Hypothesis: We assessed the hypothesis that a nondipper PR pattern was independently associated with cardiovascular events in patients with cardiovascular risk factors, adjusting for night pulse rate. Methods: Ambulatory BP monitoring was conducted at baseline in 1443 patients who had one or more cardiovascular risk factors. PR nondipping status was defined as (awake PR - sleep PR)/awake PR &lt; 0.1. Results: The nondipper PR patients (N=339) were older (66.8±10.6 vs. 63.9±11.8, p&lt;0.001) and had a higher night PR (65.5±9.6 vs. 58.9±7.3/min, p&lt;0.001) than the dipper PR patients (N=1104). The mean follow-up period was 60±30 months; in that time 50 patients (4.5%) in the dipper PR group and 34 patients (10.0%) in the nondipper PR group suffered primary endpoints (log rank 22.2, p&lt;0.001). On the Cox proportional hazards model including age, gender and night systolic blood pressure, nondipper PR was an independent predictor of cardiovascular event (hazard ratio 2.38, 95% confidence interval 1.51-3.74, p&lt;0.001), but night PR was not (p=0.50). We analyzed four groups according to BP and PR dipping status, the combination of nondipper BP and nondipper PR constituted a higher risk of cardiovascular events and stroke than the sum of the other three combination risks (Log rank= 39.2, p&lt;0.001, figure). When we added the nondipper BP pattern in the model, nondipper PR remained an independent predictor of cardiovascular events (hazard ratio 2.29, 95% confidence interval 1.50-3.51, p&lt;0.001). After excluding patients who took beta blockers (N=1003), nondipper PR was an independent predictor of cardiovascular events (hazard ratio 2.16, 95% confidence interval 1.22-3.82, p=0.008). Conclusions: The nondipper PR pattern was associated with cardiovascular events, but night pulse rate was not.

LB03.01

Objective: Blood pressure (BP) self-measured at home is a more accurate prognosticator than conventionally measured BP. Home blood pressure (BP), which is mainly measured in morning and evening, is prognositically superior to office BP. Although morning BP, per se, is an important prognostic factor, much less information about this association is available in ambulatory patients. Design and method: In the Japan Morning Surge Home Blood Pressure (J-HOP) study, 4310 Japanese patients (mean age, 64.8 [SD, 10.9] years; 47% men) who had one or more than risk factor were recruited and followed up by their physicians, and measured home BP in the morning and evening on 14 consecutive days at baseline. Cardiovascular events were the combination of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, aortic dissection, and hospitalization for heart failure or angina performed with coronary angioplasty or coronary artery bypass graft surgery. Results: At the end of follow-up, clinical status was known for 99.4% of patients. During 3.9 years of follow-up (median), at least 1 cardiovascular events had occurred in 192 (incidence, 11.7/1000 patient-years), and 75 stroke events (4.3/1000 patient-years) and 122 cardiac and other vascular events (7.2/1000 patient-years) occurred. When we divided morning systolic BP (MSBP) into four groups (<135mmHg [n = 1948], 135–145mmHg [n = 1037], 145–155mmHg [n = 684], >155mmHg [n = 586]), the risk of cardiovascular events was increased in >155mmHg of MSBP compared with < 135mmHg (1.82; 95%CI [1.19–2.80]) after adjusted by covariates, and MSBP was not risk for cardiac and other vascular events. The risk for stroke events was higher in the group with 135–145mmHg (relative risk [RR], 2.48; 95% confidence interval [CI], 1.19–5.15), 145–155mmHg (2.71; 95%CI [1.25–5.85]), >155mmHg (4.13; 95%CI [1.92–8.90]) than those with <135mmHg. This association was similar after adjusting evening systolic BP. Conclusions: Uncontrolled morning BP assessed by home BP is associated with stroke in Japanese ambulatory patients.

Abstract 13181: Characteristics of Diurnal Change of Pulse Rate in Resistant Hypertension

Introduction: Sympathetic hyperactivity is one of the most important causes of resistant hypertension. Ambulatory blood pressure monitoring (ABPM) allows measurement of blood pressure (BP) and pulse rate (PR) throughout the day, as well as measurement of diurnal variations in BP and PR, which are controlled by the autonomic nervous system. Hypothesis: We hypothesized that abnormal diurnal change of BP and PR are associated with resistant hypertension. Methods: We evaluated 1003 patients with hypertension who were enrolled in the Japan Morning Surge Home Blood Pressure Study and were using ABPM. Resistant hypertension was defined as clinic BP≧140/90 mmHg despite the use of optimal doses of 3 classes of antihypertensive drugs, including a diuretic. BP or PR dipper status was defined as (awake systolic BP (SBP) or PR-sleep SBP or PR)/awake SBP or PR ≧0.1. BP or PR nondipper status was defined as (awake SBP or PR-sleep SBP or PR)/awake SBP or PR &lt;0.1 and ≧0. BP and PR riser status were defined as awake SBP or PR &lt; sleep SBP or PR. Results: The numbers of PR nondippers and PR risers in the resistant hypertensive groups were significantly greater than those in the non-resistant hypertensive groups (x2=9.35, p=0.009), but there were no significant differences in the diurnal variation of BP between the resistant hypertensive and non-resistant hypertensive groups (x2=3.10, p=0.21). In the resistant hypertensive groups, the proportion of PR risers was approximately three-fold greater than that in the non-resistant hypertensive groups after adjustment for age, gender, 24-h BP, PR, and BP variation (Hazard ratio 2.94, 95%Cl 1.25-6.91, p=0.013), but there were no significant differences in the proportion of PR nondippers (Hazard ratio 1.36, 95%Cl 0.82-2.26, p=0.23). Conclusions: A riser pattern of PR was associated with resistant hypertension. ABPM may be useful to identify resistant hypertensive patients who have autonomic nervous system dysfunction.

Abstract 14799: Home Blood Pressure Range and 24-hr Ambulatory Blood Pressure Control: The Japan Morning Surge Home Blood Pressure (J-HOP) Study-ABPM Substudy

Background: Measures of home and ambulatory blood pressure monitoring (HBPM and ABPM) are crucial to evaluate BP control status in hypertensive patients. HBPM is widely used in clinical practice, but ABPM is used less frequently. Few studies have examined the threshold of home BP, suggesting well controlled BP in 24-hour BP, daytime BP, and nighttime BP . Methods: We analyzed data from the Japan Morning Surge Home Blood Pressure (J-HOP) Study, which included 1,439 patients with at least one cardiovascular risk factor (mean age 64.6 years, 47.8% men, 82.3% used antihypertensive medications). Both HBPM (three measures each in the morning and evening over 14 days, using the same semiautomatic HBP device with data memory and 24-hr ABPM were performed in all patients). Results: Of 355 patients with home systolic BP (HSBP) &lt;125mmHg, 78.9%, 76.9%, and 81.4% were classified as having well-controlled 24-hr SBP (&lt;130mmHg), daytime SBP (&lt;135mmHg), and nighttime SBP (&lt;120mmHg), respectively). In contrast, of 656 subjects with HSBP ≥135 mmHg, 67.5% were classified as having uncontrolled 24-hr SBP (≥130mm Hg). Of 428 patients with HSBP between 125mmHg and 134mmHg, only 54.9% were classified as having well-controlled 24-hr SBP. Conclusions: Among patients with high cardiovascular risk, nearly 80% of those with home systolic BP &lt;125mmHg were well-controlled for 24-hr SBP including nighttime systolic BP, whereas nearly 70% of those with &gt;135mmHg were uncontrolled for 24-hr systolic BP. The patients with HBP at 125-134mmHg require ABPM for the evaluation of their 24-hr BP control status.