Nighttime Blood Pressure Research Articles

High prevalence of non-dipping patterns among Black Africans with uncontrolled hypertension: a secondary analysis of the CREOLE trial

BackgroundDipping of blood pressure (BP) at night is a normal physiological phenomenon. However, a non-dipping pattern is associated with hypertension mediated organ damage, secondary forms of hypertension and poorer long-term outcome. Identifying a non-dipping pattern may be useful in assessing risk, aiding the decision to investigate for secondary causes, initiating treatment, assisting decisions on choice and timing of antihypertensive therapy, and intensifying salt restriction.ObjectivesTo estimate the prevalence and factors associated with non-dipping pattern and determine the effect of 6 months of three antihypertensive regimens on the dipping pattern among Black African hypertensive patients.MethodsThis was a secondary analysis of the CREOLE Study which was a randomized, single blind, three-group trial conducted in 10 sites in 6 Sub-Saharan African countries. The participants were 721 Black African patients, aged between 30 and 79 years, with uncontrolled hypertension and a baseline 24-h ambulatory blood pressure monitoring (ABPM). Dipping was calculated from the average day and average night systolic blood pressure measures.ResultsThe prevalence of non-dipping pattern was 78% (564 of 721). Factors that were independently associated with non-dipping were: serum sodium > 140 mmol/l (OR = 1.72, 95% CI 1.17–2.51, p-value 0.005), a higher office systolic BP (OR = 1.03, 95% CI 1.01–1.05, p-value 0.003) and a lower office diastolic BP (OR = 0.97, 95% CI 0.95–0.99, p-value 0.03). Treatment allocation did not change dipping status at 6 months (McNemar’s Chi2 0.71, p-value 0.40).ConclusionThere was a high prevalence of non-dipping among Black Africans with uncontrolled hypertension. ABPM should be considered more routinely in Black Africans with uncontrolled hypertension, if resources permit, to help personalise therapy. Further research is needed to understand the mechanisms and causes of non-dipping pattern and if targeting night-time BP improves clinical outcomes.Trial registration ClinicalTrials.gov (NCT02742467).

Dipper pattern in arterial hypertension: is there a correlation with ageing?

Abstract Funding Acknowledgements Type of funding sources: None. Dipper pattern in arterial hypertension is there a correlation with aging? Background Systemic arterial hypertension is an important cardiovascular risk factor. Non-dipper hypertension is associated with increased cardiovascular morbidity and mortality. Purpose Study the effect of aging in the dipper pattern, in patients submitted at 24-Hour Ambulatory Blood Pressure Monitoring. Methods Retrospective study based on patients submitted at 24-Hour Ambulatory Blood Pressure Monitoring on the first trimester of 2020. Patients were divided into categories based on percentage of nighttime blood pressure drop: 0% Reverse Dipper, 0-10% Non-Dipper, 10-20% Dipper e >20% Extreme Dipper. The sample was dived into two groups: group A (GA) with age between 18- and 60-years vs group B (GB) with age between 60- and 90-years. Results This study included 91 hypertensive patients, whom 46.2% were male and with a mean age of 56 ± 15 years. GA represented 60.4% of study sample, whom 43.6% were male and with a mean age of 46 ± 10 years. In the group B, 50% were male with a mean age of 71 ± 6 years. GB patients had more history of diabetes (7.8% vs 26.5%, p = 0.022). No significant difference was found between the two groups in history of kidney chronic disease, obesity or sleep apnea syndrome. In terms of medical treatment, GB had more prescription of loop diuretics (3.9% vs 22.9%, p = 0.010) and angiotensin-converting enzyme (ACE) inhibitors (58.8% vs 88.6%, p = 0.028). No significant differences were found in the prescription of other hypertension therapies or the use of drug combinations. No significant difference was found in the number of Dippers in both groups (63.6% vs 58.3%, p = 0.386). GB had more reverse dippers (1.8% vs 16.7%, p = 0.014). GA had more extreme dippers (12.7% vs 2.8%, p = 0.024). Conclusion There is no difference in the rate of dipper pattern accordingly to age. The prevalence of reverse dippers in older patients was superior, leading to increased risk of cardiovascular events in this group. The younger group had more prevalence of extreme dippers, which, by some authors, can lead to increased risk of a silent cerebrovascular event.

Main Factors Related with the White Coat Effect Level in Patients with Arterial Hypertension and Bronchial Asthma

Aim. To study the main relationships of the white coat effect (WCE) levels in patients with arterial hypertension (AH) with bronchial asthma (BA) who treated with AH and BA drugs in routine clinical practice.Material and Methods. We analyzed the prospective cohort study data of AH patients, some of them had BA without exacerbation. We have formed two groups of patients:1 - control group, patients with AH without BA, the second - with AH + BA. The study consisted of three visits (first visit, 6 months and 12 months visits) and data collection period (30.1±7.6 months of follow-up). The following procedures were performed at the first and 12 month visits: clinical blood pressure (BP) measurements (sitting and standing), 24-hour monitoring ambulatory (ABPM), spirometry, clinical and biochemical blood tests, BA control questionnaires (ACQ) and quality of life (QL) questionnaire (GWBQ), at the second visit clinical BP measurement was performed and, if necessary, the drug dose was corrected.Results. The study included 125 patients, 28 men, 97 women. The first group of AH patients without BA included 85 people, the second (AH + BA) - 40. In AH patients without BA with ischemic heart disease, arterial revascularization, regular alcohol intake and smoking we identified the association with the lower WCE levels. In AH+BA patients with diabetes mellitus, gastrointestinal diseases, higher education was identified WCE decrease. In AH patients without asthma we found inverse relationships WCE levels with respiratory function parameters, the nighttime BP decrease, heart rate and the difference between standing and sitting BP levels, and correlations with the EchoCG variables (the left ventricular hypertrophy (LVH) indices), with age, AH duration and body mass index (BMI). In patients with AH + BA we found inverse correlations between WCE levels and some EchoCG variables, the difference between standing and sitting BP levels, and correlations with body weight, BMI.Conclusion. Thereby, in AH patients without BA with ischemic heart disease, revascularization, regular alcohol intake, smoking we identified the association with the lower WCE levels. This patients WCE indices had inverse correlations with height, respiratory function parameters, the BP nighttime decrease, the difference between standing and sitting BP levels and direct relationships with EchoCG variables of LVH, age, AH duration and BMI. In AH + BA patients with diabetes, gastrointestinal diseases, higher education we found relationships with lesser WCE manifestation. WCE levels in this group had inverse correlations with some EchoCG indicators, the standing and sitting BP difference and direct relations with weight and BMI.

Dichotomous effects of smooth muscle TRPV4 channels on vascular contractility

Ca2+ signaling mechanisms in smooth muscle cells (SMCs) determine vascular contractility. Transient receptor potential vanilloid 4 (TRPV4) ion channels have been described as a crucial Ca2+ influx pathway in SMCs from small, resistance-sized arteries. However, the impact of SMC TRPV4 (TRPV4SMC) channel activity on blood pressure remains unknown, mostly due to the lack of studies in SMC-specific knockout mice. We hypothesized that TRPV4SMC channels control the resting blood pressure. Radiotelemetric blood pressure recordings showed reduced daytime and nighttime blood pressures in the inducible, SMC-specific TRPV4 knockout (TRPV4SMC-/-) mice compared to the control mice. The effect of TRPV4SMC-/- on vascular contractility was assessed using two endogenous vasoconstrictor mechanisms- 1) SMC α1 adrenergic receptor (α1AR) stimulation and 2) increased intraluminal pressure. Phenylephrine (α1AR agonist)-induced constriction of pressurized mesenteric arteries (MAs, 80 mm Hg, 1 nM-10 mM phenylephrine) and blood pressure elevation (10 mg/kg phenylephrine, i.p.) were blunted in TRPV4SMC-/- mice, identifying a central role of TRPV4SMC channels in α1AR-induced vasoconstriction and blood pressure elevation. Individual Ca2+ influx signals through TRPV4SMC channels (TRPV4SMC sparklets) were recorded using spinning disk confocal imaging in fluo-4-loaded MAs pressurized to 80 mm Hg. Phenylephrine (1 mM) activated TRPV4SMC sparklets, an effect abolished by protein kinase C (PKC) inhibitor (Go6976, 1 mM). These results indicated that PKC-TRPV4SMC channel signaling is a major contributor to α1AR-induced vasoconstriction. In direct contrast with PE-induced constriction, intraluminal pressure-induced constriction was higher in MAs from TRPV4SMC-/- mice, suggesting that SMC TRPV4 channels limit pressure-induced vasoconstriction. Previous studies have shown that TRPV4SMC channels can activate large-conductance, Ca2+-sensitive K+ (BK) channels, thereby decreasing pressure-induced vasoconstriction. Consistent with these findings, vasoconstriction in response to BK channel inhibitor (paxilline, 1 mM) was reduced in MAs from TRPV4SMC-/- mice, supporting a dilatory TRPV4SMC channel-BK channel signaling under resting conditions. In situ proximity ligation assay revealed co-localization of TRPV4SMC channels with both α1ARs and BK channels. Overall, TRPV4SMC channels increase the resting blood pressure but have divergent effects on vascular contractility. TRPV4SMC channels contribute to α1AR-induced vasoconstriction but limit pressure-induced vasoconstriction. Therefore, selective vasoactive stimulus-TRPV4SMC channel coupling may determine the impact of TRPV4SMC channels on vascular resistance.

Nighttime Home Blood Pressure in Children: Association with Ambulatory Blood Pressure and Preclinical Organ Damage.

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High versus Low-Moderate Intensity Exercise Training Program as an Adjunct to Antihypertensive Medication: A Pilot Clinical Study.

Objective: In this pilot clinical study we investigated the effect on blood pressure (BP) of two community-based exercise training programs of high (HIT) vs. low-moderate intensity (LMIT) in hypertensive individuals receiving at least one antihypertensive drug. Methods: The study included two phases of physical exercises based on 1-h session, 3 days/week for 12 and 16 weeks, respectively, separately by a 7-week resting period. Each phase was preceded by a four-week conditioning training period. According to the average maximal heart rate at baseline, participants were randomized to HIT (80–90%), LMIT (50–70%) or no-exercise (control). Heart rate was monitored during workout and BP profiles were registered by ambulatory BP monitoring at the beginning and end of each phase. Results: Of 60 individuals randomized, 44 completed the study (HIT, n = 10; LMIT, n = 16; controls, n = 18). BP levels were significantly reduced after the second phase for both LMIT (SBP −3.1 mmHg, DBP −2.4 mmHg) and HIT (SBP −10.8 mmHg, DBP −8.3 mmHg). Similar levels of improvement were also found in daytime and night-time BP. Mean attendance of the prescribed training sessions was 87.4 ± 6.2% for HIT and 87.4 ± 5.3% for LMIT during the first phase and 84.1 ± 5.0% and 85.2 ± 5.9% during the second phase, respectively (p = 0.047). Conclusion: Both HIT and LMIT exercise training programs reduced BP but the HIT modality showed a lower rate of compliance with proposed training schedule. Intensity of training should be individually prescribed to improve tolerance to more high intensity exercises.

DIRECT COMPARISON OF HOME VERSUS AMBULATORY DEFINED NOCTURNAL HYPERTENSION FOR PREDICTING CARDIOVASCULAR EVENTS: THE J-HOP STUDY

Objective: The home blood pressure monitoring (HBPM) method that measures blood pressure during sleep hours was reported to be comparable to ambulatory blood pressure monitoring (ABPM) in measuring night-time blood pressure and detecting nocturnal hypertension. The aim of this study was to directly compare the prognostic power of nocturnal hypertension detected by HBPM versus ABPM for predicting future cardiovascular events. Design and method: We analyzed night-time blood pressure (measured by HBPM and ABPM) data of 1005 participants who were included in the Japan Morning Surge-Home Blood Pressure (J-HOP) study. Results: During a follow-up period of 7.6 ± 3.4 years, 80 cardiovascular disease events occurred. The majority (91.8%) of our study population were hypertensive and 80.7% participants were using antihypertensive medication. Night-time home systolic blood pressure (SBP) was higher compared to night-time ambulatory SBP (123.0 ± 14.6 versus 120.3 ± 14.4, p < 0.001). Nocturnal hypertension was defined as night-time home or ambulatory SBP of 120 mmHg or more. The number of participants with nocturnal hypertension defined by HBPM and ABPM was 564 (56.1%) and 469 (46.7%), respectively. Nocturnal hypertension defined by HBPM was associated with increased risk of future cardiovascular events; total cardiovascular events (coronary artery disease and stroke events) [1.83 (1.00; 3.37)] and stroke [2.87 (1.17; 7.03)], independent of office SBP and night-time ambulatory SBP. These results were absent with nocturnal hypertension defined by ABPM. Conclusions: This is the first comparison prospective study illustrating that uncontrolled nocturnal hypertension defined by HBPM (independent of office SBP and night-time ambulatory SBP) is a predictor of future cardiovascular events.

EFFECT OF MINERALOCORTICOID RECEPTOR BLOCKER, ESAXERENONE, ON NOCTURNAL HYPERTENSION: A POST HOC ANALYSIS OF ESAX-HTN STUDY

Objective: Nocturnal hypertension is an important phenotype of abnormal diurnal blood pressure variability and a known risk marker for target organ damage and cardiovascular events. Esaxerenone is a novel, first non-steroidal mineralocorticoid receptor blocker (MRB) with a dose-dependent antihypertensive effect. We investigated the efficacy of esaxerenone on nocturnal hypertension in Japanese hypertensive patients. Design and method: The ‘Esaxerenone compared to Eplerenone in Patients with Essential Hypertension (ESAX-HTN)’ study was a phase 3, multicenter, randomized, controlled, double-blind, and parallel-group clinical study conducted in Japan. Patients were eligible for enrolment in the study if they had trough systolic BP (SBP) > = 140 and < 180 mmHg, trough diastolic BP (DBP) > = 90 and < 110 mmHg, 24-hour mean BP (ABPM) > = 130/80 mmHg. This post hoc analysis used ABPM data to evaluate the effects of esaxerenone and eplerenone on nocturnal blood pressure in patients with essential hypertension. Results: Patients (n = 1001) were randomized to esaxerenone 2.5 mg/day (n = 331) or 5 mg/day (n = 338), or eplerenone 50 mg/day (n = 332). Esaxerenone significantly lowered blood pressure from baseline throughout the 24-hour dosing interval; reductions in nighttime systolic blood pressure (95% confidence interval [CI]) were significantly greater with 2.5 and 5 mg/day esaxerenone versus eplerenone (-2.6 mmHg [-5.0, -0.2] and -6.4 mmHg [-8.8, -4.0], respectively). Esaxerenone 2.5 and 5 mg/day significantly reduced nighttime blood pressure from baseline compared with eplerenone in non-dipper patients (-4.4 mmHg [-8.6, -0.2] and -10.8 mmHg [-15.0, -6.7], respectively). In addition, esaxerenone did not markedly alter nighttime blood pressure in extreme dipper patients. In the esaxerenone 5 mg/day group, esaxerenone-induced decreases in nighttime blood pressure were greater than eplerenone-induced decreases in older patients. Conclusions: Esaxerenone may be an effective treatment option for nocturnal hypertension, especially in older patients and those with non-dipping patterns of nocturnal blood pressure.

STATIN THERAPY IS ASSOCIATED WITH BETTER 24-HOUR AND NIGHT-TIME BLOOD PRESSURE CONTROL IN HYPERTENSIVE PATIENTS

Objective: Hypertension and dyslipidemia often coexist. Statin therapy was associated with lower blood pressure (BP) in some but not all studies. Aim: to evaluate the association between statin therapy and 24-hour BP in a large hypertensive population, using propensity score matching analysis. Design and method: Retrospective study on 1827 consecutive essential hypertensives evaluated with 24 h ambulatory BP monitoring. Anti-hypertensive treatment intensity (ATI) was calculated to compare different drug associations. We used a propensity score matching to compare two equally-sized cohorts of patients (369 patients in each group) with similar characteristics according to statin therapy (age, sex, body mass index, smoking habit, diabetes mellitus, total cholesterol, high-density lipoprotein cholesterol, triglycerides, low-density lipoprotein cholesterol, estimated glomerular filtration rate, glycaemia, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, calcium channel blocker, diuretic, mineralocorticoid receptor antagonist, beta-blocker, alfa-blocker, ATI, 24 h pulse pressure). Matching was performed on log-transformed propensity score in a 1:1 fashion with a caliper of 0.1, in order to account for the different baseline characteristics between statins and non-statins groups. Results: Mean age: 58.1 ± 13.8 years; male sex: 55%. Patients on statin therapy: 402 (22%). The different statins were taken as follows: atorvastatin (39.8%), simvastatin (35.8%), rosuvastatin (15.7%), pravastatin (5.6%), lovastatin (2.3%) and fluvastatin (0.8%). Patients on statins showed lower 24 h BP (-2.8/-7.1 mmHg), daytime (-3.3/-7.6 mmHg) and night-time BP (-2.5/-6.0 mmHg, all p < 0.001). They also showed better ambulatory BP control, even after adjustment for confounders. The analyses on the groups derived from the propensity score matching (369 patients in each group) confirmed these results (OR 1.8 for 24 h BP control; OR = 1.6 for daytime BP control; OR = 1.7 for night-time BP control, all p < 0.001). Conclusions: Conclusions: Statin therapy is associated with lower ABPM values in hypertensive patients. This result is not affected by the anti-hypertensive treatment intensity or by the several cofactors analyzed, but may depend on greater adherence to prescribed drug therapies as suggested by the assumption of a nocebo-tainted drug class. The cardiovascular benefit of statins is due to the reduction of blood cholesterol and effects on blood pressure may be just indirect.

SEASONAL VARIATION OF MASKED UNCONTROLLED NOCTURNAL HYPERTENSION MEASURED BY NIGHTIME HOME BLOOD PRESSURE: THE J-HOP NOCTURNAL BLOOD PRESSURE STUDY

Objective: Usual daytime (morning and evening) home blood pressure (BP) monitoring can not detect nighttime hypertension. Masked uncontrolled nocturnal hypertension is defined as uncontrolled nighttime BP nonetheless controlled usual daytime home BP (HBP). Although previous studies have reported seasonal variation of nighttime BP evaluated by ambulatory BP monitoring is higher in summer than winter, seasonal variation in prevalence of masked uncontrolled nocturnal hypertension evaluated by nighttime HBP measurements remains unclear. Hence, we assessed the seasonal variation in nighttime HBP and the prevalence of masked uncontrolled nocturnal hypertension using a dataset of the Japan Morning Home-Surge BP (J-HOP) Nocturnal BP study. Design and method: This is a cross-sectional, post-hoc analysis using the dataset of the J-HOP Nocturnal BP study, which recruited patients with a history of or risk factors of cardiovascular disease. Participants underwent consecutive 14-day HBP measurements (morning and evening) and nighttime HBP measurements (a.m. 2, 3, and 4). We divided participants into four groups in each season. Masked uncontrolled nocturnal hypertension was defined as controlled daytime HBP (mean of morning and evening home systolic BP [SBP] < 135 mmHg and diastolic BP [DBP] < 85 mmHg) and uncontrolled nocturnal HBP (mean nighttime home SBP >= 120 or DBP >= 70 mmHg). Results: Among 2545 participants (age, 63.3 ± 10.3 yrs; 49% of male; antihypertensive medication use, 82.6%), 629, 596, 719, and 601 participants were enrolled in spring, summer, autumn, and winter, respectively. Nighttime home SBP/DBP were higher in summer than winter (SBP/DBP in summer, 123.3 ± 14.6/70.4 ± 8.9 mmHg; vs. in winter, 119.3 ± 14.0/69.1 ± 8.4 mmHg, p < 0.05). In 1490 participants with controlled daytime HBP, moreover, the prevalence of masked uncontrolled nocturnal hypertension was higher in summer than other seasons (summer, 55.7% vs. spring, 41.8%; vs. autumn, 42.9%; vs. winter, 39.7%, all p < 0.01). These relationships were also observed in multivariate logistic regression analysis (Table). Conclusions: In the present study, we revealed the prevalence of masked uncontrolled nocturnal hypertension was higher in summer than other seasons.

TREATMENT OF MASKED HYPERTENSION WITH A CHINESE HERBAL FORMULA: A RANDOMIZED, PLACEBO‐CONTROLLED, SINGLE‐BLIND TRIAL

Objective: Masked hypertension is associated with adverse cardiovascular outcomes. Nonetheless, no randomized controlled trials exist in the treatment of masked hypertension. The aim of this randomized, placebo-controlled trial was to investigate the efficacy and safety of blood pressure (BP) lowering treatment with a Chinese herbal formula, gastrodia-uncaria granules (GUG), in patients with masked hypertension. Design and method: Patients with an office BP of < 140/90 mmHg and daytime ambulatory BP of 135–150 mmHg systolic and/or 85–95 mmHg diastolic were randomized 1:1 to the treatment of GUG or placebo 5–10 grams twice daily for 4 weeks. The primary efficacy variable was the change in daytime ambulatory BP. Results: At baseline, office and daytime BP of the 251 participants (mean age 50.4 years, 53.4% men, mean body mass index 24.5 kg/m2, and 2.8%, 1.6%, and 30.7% with cardiovascular disease, diabetes mellitus, and smoking, respectively) averaged 129/82 and 135/89 mmHg, respectively. In the intention-to-treat analysis, daytime systolic/diastolic BP was reduced by 5.44 /3.39 and 2.91/1.60 mmHg in the GUG and placebo groups, respectively. The between-group difference in BP reductions was significant for the daytime (2.52/1.79 mmHg, P?0.025) and 24-h BP (2.33/1.49 mmHg, P?0.012), but not for the clinic and nighttime BPs (P?0.162). The per-protocol analysis in 229 patients produced similar results. Only one adverse event (sleepiness during the day) was reported and no serious adverse event occurred. Conclusions: BP lowering treatment with Chinese traditional medicine GUG is efficacious for patients with masked hypertension.

LEFT VENTRICULAR HYPERTROPHY REGRESSION DURING ANTIHYPERTENSIVE TREATMENT IN RESISTANT HYPERTENSION PATIENTS

Objective: Objective: to determine the predictors of regression of left ventricular hypertrophy (LVH) in treated resistant hypertensive (RH) patients after 2.1 ± 0.1 years of follow-up. Design and method: We studied 51 patients with RH confirmed by the office and ambulatory blood pressure (BP) monitoring despite the use of 3 antihypertensive medications for at least 3 months. During 2 years-period patients had been treated to 12-week rotations of oral daily treatment with spironolactone, nebivolol, torsemide, eplerenone, moxonidine in addition to their baseline triple-combination. Then participants continued to receive the personal most effective fourth-line agent. Patients were divided into 2 groups: 17 patients had LV mass index (LVMI) which was increased or stayed stable after 2 years (1st group), 34 patients with a reduction of LVMI in 2 years (2nd group). Results: Initially there were no significant differences in sex, duration of hypertension, body mass index, office and average 24-h ambulatory BP between the 2 groups. Compared with the 1st group patients from the 2nd group had a higher prevalence of non-dippers (24.3 vs 65 %, P < 0.001, respectively) and larger baseline LVMI (127.3 ± 4.1 vs 147.8 ± 6.5 g/m2, P < 0.01, respectively). Patients with persistent LVH included more subjects with coronary artery disease, chronic kidney disease and had less baseline active renin concentration (all P < 0.05). After 2 years in both groups office and average 24-h BP levels have been reduced, but goal rates were achieved at 28.6 % patients of the 1st group and 44.1 % patients of the 2nd group (P < 0.05). Reduction in nighttime BP was greater in the 2nd group. Initial higher LVMI (β = 0.655; P < 0.0001), baseline 24-h urinary albumin excretion (β = - 0.475; P < 0.0001), active renin concentration (β = 0.442; P = 0.005) were predictors of δ LVMI in multivariate modeling. Conclusions: Regression of LVH is possible in patients with RH in case of BP control, especially at night. Baseline higher LVMI, an increase of active renin concentration, decline of urinary albumin excretion are factors that determine reversibility LVH.

PROGNOSTIC VALUE OF MASKED UNCONTROLLED HYPERTENSION DEFINED BY DIFFERENT AMBULATORY BLOOD PRESSURE CRITERIA

Objective: Masked uncontrolled hypertension (MUCH), that is, normal clinic but high out-of-office blood pressure (BP) in treated hypertensive patients is at increased cardiovascular risk than controlled hypertension (CH), that is, normal clinic and out-of-office BP. Based on ambulatory BP, MUCH can be defined as daytime and/or nighttime and/or 24-hour BP above threshold values. It is unclear whether different definitions of MUCH show similar prognostic information. This study assessed the prognostic value of MUCH defined by different ambulatory BP criteria. Design and method: The occurrence of a composite end-point was evaluated in 738 treated hypertensive patients with normal clinic BP (<140/90 mmHg) who were selected from 2264 treated subjects. Participants were classified as having daytime MUCH (BP >135/85 mmHg) regardless of nighttime BP (Group 1), nighttime MUCH (BP >120/70 mmHg) regardless of daytime BP (Group 2), 24-hour MUCH (BP >130/80 mmHg) regardless of daytime or nighttime BP (Group 3), daytime MUCH only (Group 4), nighttime MUCH only (Group 5) and daytime + nighttime MUCH (Group 6). Results: There were 215, 357, 275, 42,184 and 173 patients with MUCH from Group 1 to 6, respectively. During the follow-up (10 ± 5 years), 148 events occurred in patients with CH and MUCH. Results of univariate and multivariate Cox regression analyses are reported in the Table. Conclusions: The prognostic impact of MUCH defined according to various ambulatory BP definitions may be different.

NOCTURNAL HOME VERSUS AMBULATORY BLOOD PRESSURE MONITORING IN CHILDREN AND ADOLESCENTS: ASSOCIATION WITH PRECLINICAL TARGET-ORGAN DAMAGE

Abstract Objective: To evaluate the relationship between nighttime blood pressure (BP) assessed by home (HBP) or ambulatory (ABP) monitoring with preclinical damage in children and adolescents. Design and method: Apparently healthy children and adolescents (age 6–18 yeas) referred for elevated BP were subjected to (i) 24 h ABP monitoring (Microlife WatchBP O3), (ii) 7-day HBP monitoring during daytime (duplicate morning and evening measurements) and nighttime (3 nights, 3 readings/night) (Microlife WatchBP Home-N), and measurement of (iii) carotid intima-media thickness (cIMT) and carotid distensibility coefficient (cDC), (iv) carotid-femoral pulse wave velocity (PWV; Complior device), and (v) echocardiographic left ventricular mass index (LVMI). Results: 94 individuals were analyzed (mean age 13.2 ± 2.8 years, 54 males, BMI 24.8 ± 5.2 kg/m2, 18 with 24 h ABP > 95th centile). Daytime HBP was slightly lower than daytime ABP (difference -2.0 ± 6.4/-0.8 ± 5.0 mmHg, systolic/diastolic, p < 0.01/NS), whereas nighttime HBP was slightly higher than nighttime ABP (2.5 ± 7.1/2.1 ± 6.2 mmHg, p < 0.01/ < 0.01). There was a strong association between ABP and HBP (daytime r = 0.83/0.79 and nighttime 0.79/0.60, systolic/diastolic) (all p < 0.05). Nighttime systolic ABP and HBP were associated with all indices of target-organ damage (LVMI r = 0.36/0.30 for ABP/HBP; cIMT 0.47/0.49; cCD -0.31/-0.25; PWV 0.50/0.56 (p = NS for HBP-ABP comparisons). The agreement between nighttime HBP and ABP in identifying: (i) subjects with asleep ABP > 90th percentile was 73% (kappa 0.38, p < 0.01) and (ii) non-dippers 55% (kappa 0.16). Conclusions: These results suggest that in children and adolescents nocturnal HBP monitoring is feasible, is strongly correlated with nighttime ABP and gives similar correlations with preclinical target-organ damage. The agreement between these methods in identifying individuals with nocturnal hypertension is satisfactory, whereas for non-dippers it is moderate.

LEFT VENTRICULAR HYPERTROPHY IN WOMEN AND MEN WITH PRIMARY ALDOSTERONISM

Abstract Objective: Primary aldosteronism (PA) is the leading cause of secondary hypertension and has been associated with higher prevalence of left ventricular hypertrophy (LVH) compared to essential hypertension (EH). In EH, women have higher prevalence of LVH than men. Whether this also applies to PA patients remains unknown. We aimed to compare the prevalence and type of LVH in women and men with PA. Design and method: 109 patients (mean age 57 ± 11 years, 32% women) recently diagnosed with PA according to current guidelines, underwent echocardiography and ambulatory blood pressure monitoring. LVH was identified using guideline recommended sex-specific values. Post saline infusion test (SIT) aldosterone level was considered an indicator of PA-severity. Results: Women had a shorter duration of hypertension than men (9 ± 9 vs. 16 ± 10 years, p < 0.001), lower BMI (28 ± 6 vs. 31 ± 5 kg/m2, p = 0.04) and lower prevalence of diabetes (6 vs. 23%, p = 0.034), while clinical and ambulatory blood pressure and post-SIT aldosterone level did not differ. LVH was more prevalent in men than women (63% vs. 41%, p = 0.04), eccentric hypertrophy was the most common geometric pattern in both sexes. In univariate logistic regression analyses, male sex, higher BMI, night-time blood pressure and co-presence of diabetes were all associated with prevalent LVH, while post-SIT aldosterone level was not. In multivariate analysis, the association of male sex with prevalent LVH became statistically non-significant when adjusted for confounder (Table 1). Conclusions: The higher prevalence of LVH in men than women with PA in our study was fully explained by differences in BMI and nocturnal hypertension, independent of PA-severity.

THE IMPORTANCE OF CHRONICK KIDNEY DISEASE IN A PORTUGUESE DIABETIC RESISTANT HYPERTENSION POPULATION

Abstract Objective: Introduction: Resistant hypertension (RH) isn’t well studied with Ambulatory blood pressure monitoring (ABPM). Objective: Study in a RH population obtained in hypertension department to characterize Diabetes Mellitus (DM) patients and identify cardiovascular (CV) outcome predictors. Design and method: ABPM - collected 1999–2018. Identified RH patients according to the ESC Guidelines 2018 and selected DM patients. Sample was characterized and analysed for predictors of CV events (CVe). CVe - ischaemic stroke (IS), acute coronary syndrome (ACS), acute heart failure (if hospitalized - AHF), peripheral arterial disease (PAD). Follow-up finished with event, the last evaluation of the patient or death. Statistical significance was assumed if p < 0.05. Results: Sample - 268 RH patients - 119 DM patients (80 males, 39 females). Age - 62.5 + /- 9.9 years (mean + /- SD), Follow-up - 5.1 + /- 4.6 years. Dyslipidaemia - 79.8%, obesity - 58.0%, Chronic Kidney Disease (CKD) - 36.1%, history of previous CVe – 47.9% (PCVe). CVe observed - 32 (8 IS, 10 ACS, 9 AHF, 5 PAD). 4 death from non-CVe. When the sample was analysed events vs no-event, those with event had higher creatinine, history of PCVe and CKD. In Univariate Cox analysis for the prognosis of future CVe, it was significant: age, PCVe, creatinine and 24 h Diastolic Blood Pressure (24DBP) (Table 1). In a multivariate Cox Analysis with the variables: age, gender, PCVe, glycaemia, creatinine, CKD and its staging, statistical significance was age, creatinine, CKD and its staging. Glycaemia was almost significant (Table 1). In Kaplan-Meier survival curve free of events, PCVe, CKD and CKD staging revealed worst survival prognosis (respectively log rank 7.85, p < 0.05; 7.72, p = 0.000; 49.5, p = 0.000). We analysed the CKD subgroup and verified that those with CKD were older, lower body mass index, less 24DBP and night-time blood pressure. Conclusions: In our diabetic RH population, CKD, elevated creatinine, increasing age and PCVe were independently associated with increasing incidence of CVe. It seems that our action in these patients should aim to stricter control in order to retard the progression of CKD, despite attention in glycaemic control.

PORTUGUESE RESISTANT HYPERTENSION POPULATION: IS IT POSSIBLE A RISK SCORE?

Abstract Objective: Introduction: Resistant hypertension isn’t well studied with Ambulatory blood pressure monitoring (ABPM). Study in a RH population obtained in hypertension department to characterize it and identify cardiovascular (CV) outcome predictors. Design and method: ABPM - collected 1999–2018. Identified RH patients according to the ESC Guidelines 2018. Sample was characterized and analysed for predictors of CV events (CVe). CVe were ischaemic (IS), haemorrhagic stroke (HS), transient ischaemic attack (if hospitalized - TIA), acute coronary syndrome (ACS), acute heart failure (if hospitalized - AHF), peripheral arterial disease (PAD). Follow-up finished with event, the last evaluation of the patient or death. Statistical significance was assumed if p < 0.05. Results: Sample - 268 patients (161 males and 107 females) with RH. Age - 60.4 + /- 11.3 years (mean + /- SD). Follow-up - 5.5 + /- 4.9 years. Diabetes Mellitus (DM) - 44.4%, dyslipidaemia -75.4%, obesity - 45.1%, Chronic Kidney Disease (CKD) - 32.1%, history of previous CVe - 34.7% (PCVe). CVe observed - 55 (18 IS, 3 HS, 1 TIA, 16 ACS, 11 AHF, 6 PAD). 12 death from non-CVe. When the sample was analysed events vs no-event, those who with event, were older, had higher glycaemia, more prevalence of DM, history of PCVe and CKD. In Univariate Cox analysis for the prognosis of future CVe, it was significant: gender, DM, PCVe, age, glycaemia (Table 1). In a multivariate Cox Analysis with all these variables in the same sample, those who stood significant: glycaemia, age, gender, PCVe (Table 1). Even when these variables were adjusted to 24 h systolic blood pressure (24SBP) and night-time blood pressure (NSBP), they remained significant, but the 24SBP and NSBP didn’t (Table 1). In Kaplan-Meier survival curve free of events, being male, history of PCVe revealed worst survival prognosis (respectively log rank 5.74, p < 0.05; 18.50, p = 0.000). Conclusions: In our population of RH, age, glycaemia, male, DM and history of PCVe are associated with markers of worst prognosis independent of blood pressure values. Perhaps in the future in larger samples, these variables can be taken in account for a risk score.

BILATERAL RENAL ARTERY EMBOLIZATION IN END-STAGE RENAL DISEASE AND RESISTANT HYPERTENSION

Objective: Some patients with end-stage renal disease present with resistant or refractory arterial hypertension despite dialysis and use of multiple antihypertensive drugs. Renal artery embolization is a rarely used minimally invasive interventional procedure which may provide improved blood pressure (BP) control in chronic renal parenchymal disease by eliminating renal function while avoiding the morbidity and mortality of a nephrectomy. Design and method: A 44-year old white male with chronic glomerulonephritis and stage 5 chronic kidney disease undergoing regular dialysis treatment was referred for refractory arterial hypertension. Despite treatment by 7 antihypertensive drugs and good therapeutic adherence his office and ambulatory BP remained very high. Plasma renin was markedly elevated and CT angiography found diffuse atherosclerotic changes of renal arteries. Sequential catheter-based renal artery embolization with application of a tissue glue was indicated. Results: In September 2019, catheter based embolization of right renal artery was performed in analgosedation, followed by the embolization of the left renal artery two weeks later. Because of the rapid antihypertensive effect of the procedure, antihypertensive medications were reduced at the time of the left-sided procedure (from 9 to 6 defined daily doses). One month after the renal artery embolization, despite reduced medication, office BP decreased from baseline 170/106 mmHg by 57/22 mmHg. Mean 24-hour, day-time and night-time ambulatory BP was reduced by 15/11 mmHg, 14/11 and 34/15 mmHg, respectively. The patient reported prolonged flank pain lasting approximately one week after the embolization, which responded well to conventional analgesics. Conclusions: Renal artery embolization lead to a marked improvement of BP control in a patient with end-stage renal disease, refractory arterial hypertension and high plasma renin. Further studies are warranted to assess the efficacy and safety of renal artery embolization in such patients.

LONG-TERM EFFICACY AND SAFETY OF SPIRONOLACTONE IN THE TREATMENT OF RESISTANT ARTERIAL HYPERTENSION

Objective: Spironolactone is recommended as a fourth line antihypertensive drug by current hypertension guidelines. However, data about its long-term efficacy and safety is limited. Design and method: We prospectively followed 274 patients with resistant arterial hypertension who started treatment with spironolactone between September 2007 and December 2016. Change of office and ambulatory blood pressure (BP) between baseline and the last clinical examination was recorded, as well as the duration of spironolactone use, its dose, changes of other antihypertensive medications, laboratory parameters and the incidence of adverse events. Results: Patients were followed for an average of 35 (± 29) months, the mean daily dose of spironolactone was 27.5 mg. Mean office BP decreased during follow-up from 149/87 mmHg to 136/80 mmHg by a mean 13/7 mmHg (P < 0.001 for both). Mean 24-hour, day-time and night-time ambulatory BP decreased by 12/6 mmHg, 11/6 mmHg and 14/9 mmHg respectively (P < 0.001 for all). Adverse effects occurred in 72 patients (26.3%) and in 61 (22.2%) lead to discontinuation of spironolactone. Adverse events occurred more frequently in patients using angiotensin receptor blockers (hazard ratio – HR 1.65, P = 0.040), in the elderly (HR 1.38, P = 0.007) and patients with higher baseline serum creatinine (HR 1.12, P = 0.035). Conclusions: Our data confirm good long-term antihypertensive efficacy of spironolactone in patients who tolerate it. However, in more than a quarter of patients the use of spironolactone leads to side effects, which usually necessitate its discontinuation.

HOW TO MAXIMIZE POST-EXERCISE HYPOTENSION? IS A BOUT OF HIGH INTENSITY EXERCISE BETTER THAN A BOUT OF MODERATE CONTINUOUS EXERCISE?

Objective: Post-exercise hypotension (PEH) is an important tool in the daily management of patients with hypertension. Varying the exercise parameters is likely to change the blood pressure (BP) response following a bout of exercise. In recent years, high-intensity interval exercise (HIIE) has gained significant popularity in exercise-based prevention and rehabilitation of clinical populations. Yet, to date, it is not known whether a single session of HIIE maximizes PEH more than a bout of moderate-intensity continuous exercise (MICE). We aimed to compare the effect of HIIE vs. MICE on PEH by means of a systematic review and meta-analysis. Design and method: A systematic search in the electronic databases MEDLINE, Embase, and SPORTDiscus was conducted from the earliest date available until February 24, 2020. Randomized clinical trials comparing the transient effect of a single bout of HIIE to MICE on office and/or ambulatory BP in humans (> 18 years) were included. Data were pooled using random-effects models with summary data reported as weighted means and 95% confidence interval (CIs). Results: Data from 14 trials were included, involving 18 comparisons between HIIE and MICE and 276 (193 males) participants. The immediate effects, measured as office BP at 30- and 60-minutes post-exercise, were similar for a bout of HIIE and MICE (p > 0.05 for systolic and diastolic BP). However, HIIE elicited a more pronounced BP reduction than MICE [(-5.3 mmHg (-7.3 to -3.3)/ -1.63 mmHg (-3.00 to -0.26)] during the subsequent hours of ambulatory daytime monitoring. No differences were observed for ambulatory nighttime BP (p > 0.05). Conclusions: HIIE promoted a larger PEH than MICE on ambulatory daytime BP. However, the number of studies was small, patients were mostly young to middle-aged individuals and only a few studies included patients with hypertension. Therefore, there is a need for studies that involve older individuals with hypertension and use ambulatory BP monitoring to confirm HIIE's superiority as a safe BP lowering intervention in today's clinical practice.