Morning Ambulatory Blood Pressure Research Articles

OPTIMAL THRESHOLDS FOR AMBULATORY BLOOD PRESSURE IN PATIENTS WITH HIGH CARDIOVASCULAR RISK

Objective: Recent 2017 American College of Cardiology/American Heart Association hypertension guideline suggested new ambulatory blood pressure (ABP) thresholds, however there are arguments whether it is optimal for defining hypertension. The objective of this study was to find optimal ABP thresholds for outcomes especially in patients with high cardiovascular risk. Design and method: From the Cardiovascular and Metabolic Disease Etiology Research Center – High Risk Cohort (CMERC-HI), 2026 patients who had 24-hour ABP monitoring data were selected. Baseline 24-hour ABP, daytime ABP, nighttime ABP, morning ABP threshold were determined separately using Cox proportional hazard model with propensity scores adjustment. The composite of cardiovascular disease (CVD) outcomes (hospitalization with MI, stroke, or heart failure) and all-cause mortality were primary end-points of this study. Results: A total of 2026(median age, 60 years, 52.6% male) subjects were analyzed in this study. Median follow-up was 3.4 years. There were 54 CVD outcomes and all-cause mortality (8.1 per 1000 person-years). Compared to 24-hour ABP <135/85 mmHg, 24-hour ABP more than 135/85 mmHg was associated with significantly poor outcomes (HR 1.49, 95% CI, 1.02–2.17). However, 24-hour ABP more than 130/80 mmHg and 24-hour ABP more than 125/75 were not associated with significantly higher risk. For daytime ABP, the threshold of 140/90 mmHg was significantly related to higher risk of CVD outcomes or death, (HR 1.78, 95% CI, 1.04–3.05) rather than ABP 135/85 mmHg or 130/80 mmHg. For nighttime ABP, no cut-off level other than 125/75 mmHg (HR 1.58, 95% CI, 1.08–2.32) was statistically meaningful. There was no adequate threshold for morning ABP in this analysis. Conclusions: In patients with high risk for CVD, 135/85mmHg for 24hr-ABP, 140/90 mmHg for daytime ABP, 125/75 mmHg for nighttime ABP seemed to be the threshold associated with increased outcomes. The BP threshold suggested by the ACC/AHA guideline was not significantly associated with increased outcomes.

Response to HYVET Ambulatory Blood Pressure Substudy

Bursztyn et al1 speculate that our ambulatory blood pressure (ABP) participants were not representative of the whole trial. We agree this is possible but very unlikely in view of the similarity of the participant characteristics given in Table 1. As the elderly frequently nap, he wonders if this would substantially reduce daytime pressure. However, we also looked at morning ABP to confirm our findings, and …

Morning and smooth 24-h ambulatory blood pressure control is not achieved in general practice

The aim of this large-scale, practice-based observational study [Survey with HBPM and ABPM Under Real clinical conditions in General practice to Evaluate BP control in the early morning (SURGE)] was to ascertain the degree of morning and 24-h ambulatory blood pressure (ABP) control in hypertensive patients. Hypertensive patients [with uncontrolled clinic blood pressure (BP) >140/90 mmHg at screening] from nine different countries were included. Ambulatory BP monitoring was performed over 24 h at 15-min intervals during the day and at 20-min intervals during the night. Assessments included morning (0600-1159 h) and daytime ABP control (BP < 135/85 mmHg), and 24-h ABP control, which was set at levels less than 125/80 mmHg (ESH/ESC guidelines) and less than 130/80 mmHg (USA guidelines). A total of 3312 patients were enrolled [mean clinic BP: 153 ± 17/91 ± 10 mmHg; mean 24-h and morning ABP: 130 ± 15/77 ± 10 mmHg and 134 ± 16/80 ± 11 mmHg, respectively; antihypertensive use: 72.7% (n = 2409)]. Morning and daytime (period of activity) ABP control was observed in 45.2 and 47.4% of treated patients, respectively; 24-h ABP control was only achieved in 34.6% (ESH/ESC guidelines) and 44.7% (USA guidelines) of treated patients. There was 'poor agreement' between clinic BP and ABP regarding BP control as shown by a negative (≤0) κ coefficient in treated patients. Clinic BP control (<130/80 mmHg) and morning ABP control (<135/85 mmHg) was observed in 2.3 and 45.1% of diabetic patients, and in 2.4 and 43.6% of patients with left ventricular hypertrophy (LVH). Morning ABP control was 42.3% in patients with high/very high cardiovascular risk. Clinic BP, morning and 24-h ABP control rates were low in treated hypertensive patients, including those with comorbidities, such as diabetes or LVH.

Does White Coat Hypertension Require Treatment Over Age 80?

White coat hypertension is considered to be a benign condition that does not require antihypertensive treatment. Ambulatory blood pressure (ABP) was measured in 284 participants in the Hypertension in the Very Elderly Trial (HYVET), a double-blind randomized trial of indapamide sustained release 1.5 mg±perindopril 2 to 4 mg versus matching placebo in hypertensive subjects (systolic blood pressure 160–199 mm Hg) aged &gt;80 years. ABP recordings (Diasys Integra II) were obtained in 112 participants at baseline and 186 after an average follow-up of 13 months. At baseline, clinic blood pressure (CBP) exceeded the morning ABP by 32/10 mm Hg. Fifty percent of participants fulfilled the established criteria for white coat hypertension. The highest ABP readings were in the morning (average 140/80 mm Hg), the average night-time pressure was low at 124/72 mm Hg, and the average 24-hour blood pressure was 133/77 mm Hg. During follow-up, the systolic/diastolic blood pressure placebo-active differences averaged 6/5 mm Hg for morning ABP, 8/5 mm Hg for 24-hour ABP, and 13/5 mm Hg for CBP. The lowering of blood pressure over 24 hours supports the reduction in blood pressure with indapamide sustained release±perindopril as the explanation for the reduction in total mortality and cardiovascular events observed in the main HYVET study. Because we estimate that 50% had white coat hypertension in the main study, this condition may benefit from treatment in the very elderly.

The effects of telmisartan alone or with hydrochlorothiazide on morning and 24-h ambulatory BP control: results from a practice-based study (SURGE 2)

Observational studies have shown that 24-h and morning ambulatory blood pressure (BP) control is low. This large-scale, practice-based study evaluated the effects of telmisartan 40 or 80 mg alone or in combination with hydrochlorothiazide (HCTZ) 12.5 mg on these BP parameters over 8 weeks; treatment was adjusted if clinic BP remained ≥140/90 mm Hg. A total of 863 patients were evaluated (baseline mean clinic BP, morning and 24-h ambulatory BP: 155±15/93±10 mm Hg, 137±15/83±11 mm Hg, 133±14/79±10 mm Hg, respectively; 68% were previously treated at baseline). Telmisartan with/without HCTZ significantly reduced the mean morning ambulatory BP (-8.2/-4.9 mm Hg), daytime ambulatory BP (-8.0/-4.7 mm Hg), 24-h ambulatory BP (-7.9/-4.7 mm Hg) and clinic BP (-22.3/-13.2 mm Hg) (all P<0.001) in previously untreated and in treated patients who switched to telmisartan and telmisartan/HCTZ. After treatment with telmisartan with/without HCTZ, the morning ambulatory BP control increased from 36.5 to 64.4%; daytime ambulatory BP control increased from 40.8 to 67.6%; 53.0% of patients achieved 24-h ambulatory BP <125/80 mm Hg and 62% achieved <130/80 mm Hg targets. Only 0.8% (7/863) reported an adverse event. In summary, telmisartan and telmisartan/HCTZ increased smooth 24-h BP control in daily management of hypertension.

Automated office versus home measurement of blood pressure in the assessment of morning hypertension

To compare the quality and accuracy of morning blood pressure (BP) readings as taken by automated office BP (AOBP) and morning home BP (mHBP) techniques using morning ambulatory BP (mABP) measurements as the gold standard. A total of 139 individuals were included, 70 men and 69 women, mean age 53±13 years. The average AOBP readings as measured using a Microlife Watch BP office device taking triplicate automated simultaneous readings of both arms were compared with mHBP monitored on 6 routine days, using a validated automated electronic device. Both modalities were also compared with the ambulatory readings of the 3 h of waking (mABP3h). The AOBP values were slightly higher than the mABP3h (mean difference 8.2 mmHg, 95% limits of agreement, -18.8 to 35.2 mmHg for the systolic BP and mean difference 4.3 mmHg, 95% limits of agreement, -15.3 to 23.9 mmHg for the diastolic BP). Systolic and diastolic AOBP readings correlated with mABP3h (r=0.66, P=0.001 and r=0.64, P=0.001, respectively). Agreement was fair between AOBP and mHBP in the detection of morning hypertensive patients (agreement 70%, κ=0.32) as compared with AOBP and mABP3h (agreement 67%, κ=0.32) and mHBP and mABP3h (agreement 65%, κ=0.31). The AOBP technique could replace mHBP monitoring in the assessment of morning BP, as it provides comparable data in relation to the awake ambulatory BP. Given the simplicity of this method, it could be more readily applied in a larger number of individuals.