Mean Nighttime Blood Pressure Research Articles

Masked uncontrolled hypertension among elderly black sub-saharan africans compared to younger adults: a cross-sectional in-hospital study

BackgroundAlthough aging and being of African descent are well-known risk factors for masked uncontrolled hypertension (MUCH), data on MUCH among elderly black sub-Saharan Africans (BSSA) are limited. Furthermore, it is unclear whether the determinants of MUCH in younger individuals differ from those in the elderly.ObjectiveThis study aimed to determine the prevalence and risk factors associated with MUCH in both elderly and younger BSSA individuals.MethodsIn this study, 168 patients with treated hypertension were assessed for medical history, clinical examination, fundoscopy, echocardiography, and laboratory data. All patients underwent ambulatory blood pressure (BP) monitoring for 24 h. MUCH was diagnosed if the average 24-h mean BP ≥ 130/80 mmHg, the daytime mean BP ≥ 135/85 mmHg, and/or the nighttime mean BP ≥ 120/70 mmHg, despite controlled clinic BP (≤ 140/90 mmHg). Logistic regression analysis was performed to assess independent factors associated with MUCH, including elderly and younger adults separately. P-values < 0.05 were used to indicate statistical significance.ResultsOf the 168 patients aged 53.6 ± 11.6 years, 92 (54.8%) were men, with a sex ratio of 1.2, and, 66 (39%) were aged ≥ 60 years. The proportion of patients with MUCH (27.4% for all patients) was significantly higher (p = 0.002) among elderly patients than among younger patients (45.5% vs. 15.7%). Diabetes mellitus (adjusted odds ratio [aOR], 2.44; 95% confidence interval [CI], 1.27–4.46; p = 0.043), anemia (aOR, 3.18; 95% CI, 1.07–5.81; p = 0.043), hypertensive retinopathy (aOR, 4.50; 95% CI, 1.57–5.4; p = 0.043), and left ventricular hypertrophy (aOR, 4.48; 95% CI, 2.26–8.35; p = 0.043) were independently associated with MUCH in the elderly. In younger individuals, male gender (aOR, 2.16; 95% CI, (1.33–4.80); p = 0.029), obesity (aOR, 3.02; 95% CI, (1.26–5.32); p = 0.001), and left ventricular hypertrophy (LVH) (aOR, 3.08; 95% CI, (2.14–6.24); p = 0.019) were independently associated with MUCH were independently associated with MUCH.ConclusionMUCH is more prevalent among elderly than among younger BSSA individuals. Determinants of MUCH vary by age. MUCH prevention and management strategies should be age-specific.

Changes in blood pressure after catheter-based renal denervation in South Africa.

Renal denervation (RDN) is an interventional treatment for patients with uncontrolled hypertension. The Global SYMPLICITY Registry (GSR) is a prospective, all-comer, world-wide registry designed to assess the safety and efficacy of RDN. We evaluated the outcomes in South African patients in the GSR over 12 months. Eligible patients with hypertension had a daytime mean blood pressure (BP) > 135/85 mmHg or night-time mean BP > 120/70 mmHg. Office and 24-hour ambulatory systolic BP reduction and adverse events over 12 months were evaluated. South African patients (n = 36) in the GSR had a mean age of 54.4 ± 9.9 years with a median of four prescribed antihypertensive medication classes. At 12 months, mean changes in office and 24-hour ambulatory systolic BP were -16.9 ± 24.2 and -15.3 ± 18.5 mmHg, respectively, with only one adverse event recorded. RDN safety and efficacy in South African patients were consistent with world-wide GSR results.

PS-R02-7: PAROXYSMAL ATRIAL FIBRILLATION IN A PATIENT WITH HYPERTENSION: A CASE REPORT

Objective: To present the association between arterial hypertension and concomitant arrhythmias. Summary: The report examines a case of a 74-year-old female patient with known arterial hypertension. She presented with wide blood pressure (BP) fluctuations, with surges of very high BP during the last three months. She also experienced palpitations, dyspnea and chest pain. BP measurements ranged from 116/67 mmHg in the office to 235/103 mmHg at home. She had been taking telmisartan 40 mg once-daily (OD), lercanidipine 10 mg OD and bisoprolol 5 mg OD regularly for several years and her BP was previously well controlled. Considering the discrepancy between BP measurements in the office and at home, we decided against changing her regular therapy. Therefore, the patient was advised to continue current antihypertensive treatment and additionally take captopril 25 mg and/or sublingual nitroglycerin when systolic BP was above 150 mmHg. Further diagnostics was performed. Transthoracic echocardiogram was normal, except for moderately enlarged left atrium. Pulmonary embolism and obstructive coronary artery disease were excluded. 24-hour Holter ECG revealed that the patient had symptomatic paroxysmal AF with rapid ventricular response (Figure 1a). There were also some sinus pauses and short periods of sinus bradycardia immediately after the cessation of AF paroxysm (Figure 1b). To reduce AF-related symptoms and improve the quality of life, the patient was referred to catheter ablation. Pulmonary vein isolation was successfully achieved with no periprocedural complications. Due to borderline sinus bradycardia, bisoprolol was temporarily discontinued and later reintroduced in a lower dose. After the procedure, she was regularly taking telmisartan 40 mg OD, lercanidipine 10 mg OD, bisoprolol 1.25 mg OD, a direct oral anticoagulant and a statin. 24-hour ambulatory blood pressure monitoring was performed. A 24-hour mean BP was 112/66 mmHg, mean day-time BP was 115/69 and mean night-time BP was 108/62 mm Hg (Figure 1c). There was no excessive fluctuation in BP. Furthermore, no increases in HR were noted that would suggest recurrence of AF paroxysms. Conclusion: The patient, who was referred to our outpatient hypertension clinic due to uncontrolled hypertension, was diagnosed with symptomatic paroxysmal AF. By means of a successful AF catheter ablation, we eliminated the excessive BP fluctuations. AF and hypertension are closely related, and the appearance of AF can lead to poor BP control. An appropriate treatment for AF in patients with hypertension contributes to better control of the hypertension itself.

PS-BPR02-7: SACUBITRIL VALSARTAN FOR REFRACTORY HYPERTENSION CAUSED BY PRIMARY ALDOSTERONISM: A CASE SERIES

Introduction: Primary aldosteronism (PA) is the disease characterized by inappropriately elevated autonomous adrenal aldosterone secretion, leading to the development of refractory hypertension. Patients with PA show higher nighttime blood pressure (BP) and lower nocturnal BP decline than those with essential hypertension. Angiotensin receptor neprilysin inhibitors (ARNIs) are a new class of cardiovascular agents characterized by their dual action on the renin angiotensin system and the natriuretic peptide system. Atrial natriuretic peptide has been shown to inhibit basal aldosterone secretion from adrenal cells in vitro. Case Presentation: A man in his 50 s was referred to our hospital due to vision loss and diagnosed with hypertensive retinopathy. His serum potassium level was below 3.5 mEq/L. A captopril test confirmed the diagnosis of PA, though a CT image revealed no adrenal adenoma. According to his discretion, medical treatment including a mineralocorticoid receptor antagonist, a calcium channel blocker, an angiotensin receptor blocker (ARB), an angiotensin converting enzyme inhibitor (ACEI), an alpha blocker and a beta blocker, were commenced. However, the result of ambulatory bloop pressure monitoring (ABPM) revealed his mean BP of 143/91 mmHg and his mean nighttime BP of 148/89 mmHg, indicating riser pattern. Switching from an ACEI, imidapril (10 mg per day), and an ARB, azilsartan (40 mg per day), to sacubitril/valsartan (200 mg per day) decreased his mean BP to 138/89 mmHg. Furthermore, his mean nighttime BP decreased to 122/79 mmHg, indicating that his nocturnal hypertension was improved by sacubitril/valsartan. Similar favorable effects of Sacubitril/valsartan on BP were found in three other patients with refractory hypertension caused by PA. Discussion: ARNIs are an appropriate treatment option for refractory hypertension caused by PA.

PS-C07-5: ASSOCIATION OF OVERNIGHT URINARY INDICATORS AND BMI WITH NIGHT TIME AND DAYTIME BLOOD PRESSURE IN ELDERLY

Reportedly, the mean nighttime blood pressure (BP) is the sensitive predictor of cardiovascular diseases and the associated mortality. In this study, we investigated the effect of overnight urinary indicators (levels of sodium, potassium, and sodium to potassium ratio) on daytime and nighttime BP. A total of 108 volunteers (56 males, 52 females) aged between 51 and 76 years (mean age: 65.7 ± 4.9 years) who were not taking any antihypertensive medication participated in the study. Their 24-hour (24-h) BP was measured every 30 minutes with an ambulatory BP monitoring, four times (spring, summer, autumn, and winter) in a year. Overnight urine samples (after the last urination before sleeping and until the first urination on waking up the next day) were easily collected at home using a proportional urine-sampling device, Urine mate P. The ion electrode method was used to measure the sodium and potassium levels excreted in urine. The average values of daytime and nighttime BP were calculated. Multiple regression and simple linear regression analyses were used to evaluate the association of daytime and nighttime BP with the above-mentioned overnight urinary indicators, age, sex, and BMI. There were a total of 353 participants over the four seasons. The average values of daytime SBP and DBP were 130.4 ± 20.2 and 83.4 ± 12.7 mmHg, respectively; nighttime SBP and DBP were 113.7 ± 15.8 and 69.8 ± 9.4 mmHg, respectively. Multiple regression analysis of the six factors revealed that none of the variables were linearly combined. For nighttime SBP, the adjusted standard regression coefficients was 0.219 (p &lt; 0.01) for the urinary Na/K ratio, 0.142 (p &lt; 0.05) for age, and 0.119 (p &lt; 0.05) for BMI. However, for daytime SBP it was 0.124 (p &lt; .0.05) for age, -0.232(p &lt; 0.01) for sex, and 0.175 (p &lt; 0.01) for BMI. Simple linear regular regression analysis showed that nighttime SBP was significantly related to the Na/K ratio, Na, age, and BMI; daytime SBP to sex, BMI, and age. This demonstrates that overnight urinary Na/K ratio has greater effect on nighttime SBP than BMI and age; therefore, its optimal level should be achieved to control nighttime SBP in the elderly.

Dietary Approaches to Stop Hypertension (DASH)-Style Dietary Pattern and 24-Hour Ambulatory Blood Pressure in Elderly Chinese with or without Hypertension

ABSTRACTBackgroundIt is unknown whether the Dietary Approaches to Stop Hypertension (DASH) dietary pattern is associated with other blood pressure (BP) variables, beyond mean systolic blood pressure (SBP) and diastolic blood pressure (DBP).ObjectivesThe study aimed to study the associations between the DASH dietary pattern and daytime and nighttime mean BPs and BP variance independent of the mean (VIM).MethodsA sample of 324 Chinese adults aged ≥ 60 y who were not on BP-lowering medications were included in the analysis. The DASH score was calculated using data collected by a validated FFQ. The 24-h ambulatory BP was measured and the mean and VIM SBP and DBP were calculated for both the daytime (06:00–21:59) and nighttime periods (22:00–05:59). Multivariable linear models were constructed to assess associations between the DASH dietary pattern and daytime and nighttime BP outcomes, adjusting for sociodemographic factors, lifestyle, BMI, and hypertension (clinic SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg), and sleep parameters (only for nighttime BP outcomes). An interaction term between DASH score and hypertension status was added to explore the potential differential association in normotensive and hypertensive individuals.ResultsEvery 1-unit increase in the DASH score was associated with a 0.18-unit (95% CI: −0.34, −0.01 unit) and a 0.22-unit (95% CI: −0.36, −0.09 unit) decrease in nighttime VIM SBP and nighttime VIM DBP, respectively. DASH score was not associated with any daytime BP outcomes, nighttime mean SBP, or nighttime mean DBP. A significant interaction (DASH score × hypertension status) was detected for VIM SBP (P-interaction = 0.04), indicating a differential association between DASH score and nighttime VIM SBP by hypertension status.ConclusionsIndependently of sleep parameters and other factors, the DASH dietary pattern is associated with lower nighttime BP variability in elderly adults.

Effect of CPAP treatment on BP in resistant hypertensive patients according to the BP dipping pattern and the presence of nocturnal hypertension.

High heterogeneity in the blood pressure (BP) response to continuous positive airway pressure (CPAP) exists in patients with resistant hypertension (RH). Only nondipper normotensive and hypertensive patients exhibited BP reductions when treated with CPAP; the baseline BP dipping pattern has been proposed as a predictor of BP response to CPAP but has never been explored in patients with RH. This study aimed to assess the effect of CPAP on BP in subjects with RH with respect to BP dipping pattern or nocturnal hypertension. This is an ancillary study of the SARAH study. RH subjects with an apnea/hypopnea index (AHI) ≥ 15/h and who received CPAP treatment for 1 year were included. Subjects underwent a sleep study and ambulatory BP monitoring (ABPM) at baseline and at the 1-year follow-up. Eighty-nine RH subjects were included. The subjects were mainly male (77.5%) and obese, with a mean age of 66 years (25th-75th percentile; 59.0; 70.0) and an AHI of 32.7/h (25th-75th percentile; 25.0; 54.7). A total of 68.5% of participants were nondippers, and 71.9% had nocturnal hypertension. After 1 year of CPAP, no significant differences in ABPM parameters were observed between dippers and nondippers. According to nighttime BP, subjects with nocturnal normotension did not show significant changes in ABPM parameters, while nocturnal hypertensive subjects achieved a significant reduction in mean nighttime BP of -4.38 mmHg (-7.10 to -1.66). The adjusted difference between groups was 3.04 (-2.25 to 8.34), which was not significant. This study shows that the BP response to CPAP in patients with RH does not differ according to the BP dipping pattern (dipper and nondipper) and suggests a differential response according to the presence of nocturnal hypertension (ClinicalTrials.gov: NCT03002558).

C3. A case of extreme discrepancy between office and ambulatory blood pressure: is it true uncontrolled hypertension?

Abstract Background White coat uncontrolled hypertension (WCUH), defined as drug-treated hypertension but with increased blood pressure in the office and normal ambulatory blood pressure, should be assessed in patients with uncontrolled hypertension to prevent overtreatment. We report a case of an extreme WCUH found by ambulatory blood pressure monitoring (ABPM). Case Summary A 66-year-old woman was a regular patient in Cardiology Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto with uncontrolled hypertension, CAD post-PCI, and insulin-dependent type 2 diabetes mellitus. The patient was overweight (BMI was 24.56 kg/m2) with dyslipidemia and uncontrolled blood glucose. Despite aggressive treatment with ARB, CCB, beta-blockers, diuretic, and clonidine, the patient had persistent hypertension with mean office systolic blood pressure &amp;gt;160/90 mmHg. Echocardiography showed concentric left ventricular hypertrophy. ABPM result found extreme variability of blood pressure with the average 24-hour blood pressure of 93.6/59 mmHg (mean daytime blood pressure was 90/55 mmHg and mean night-time blood pressure was 98.7/65.2 mmHg), intermittent hypotension, and reverse dipper pattern. The blood pressure once dropped to the lowest point of 69/44 mmHg, and the highest was 211/186 mmHg. Based on this result, we classified the patient’s condition as WCUH and adjusted the antihypertensive regiment. Discussion This case emphasizes the need to evaluate the presence of WCUH by ABPM in patients with uncontrolled hypertension so antihypertensive drugs could be adjusted accordingly and prevent hypotension.

C3. A case of extreme discrepancy between office and ambulatory blood pressure: is it true uncontrolled hypertension?

Abstract Background White coat uncontrolled hypertension (WCUH), defined as drug-treated hypertension but with increased blood pressure in the office and normal ambulatory blood pressure, should be assessed in patients with uncontrolled hypertension to prevent overtreatment. We report a case of an extreme WCUH found by ambulatory blood pressure monitoring (ABPM). Case Summary A 66-year-old woman was a regular patient in Cardiology Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto with uncontrolled hypertension, CAD post-PCI, and insulin-dependent type 2 diabetes mellitus. The patient was overweight (BMI was 24.56 kg/m2) with dyslipidemia and uncontrolled blood glucose. Despite aggressive treatment with ARB, CCB, beta-blockers, diuretic, and clonidine, the patient had persistent hypertension with mean office systolic blood pressure &amp;gt;160/90 mmHg. Echocardiography showed concentric left ventricular hypertrophy. ABPM result found extreme variability of blood pressure with the average 24-hour blood pressure of 93.6/59 mmHg (mean daytime blood pressure was 90/55 mmHg and mean night-time blood pressure was 98.7/65.2 mmHg), intermittent hypotension, and reverse dipper pattern. The blood pressure once dropped to the lowest point of 69/44 mmHg, and the highest was 211/186 mmHg. Based on this result, we classified the patient’s condition as WCUH and adjusted the antihypertensive regiment. Discussion This case emphasizes the need to evaluate the presence of WCUH by ABPM in patients with uncontrolled hypertension so antihypertensive drugs could be adjusted accordingly and prevent hypotension.

Efficacy &amp; tolerability of bisoprolol in comparison to metoprolol in Indian patients with stage-1 hypertension: multicentre, parallel group, open labelled, randomised noninferiority clinical study

Abstract Introduction Bisoprolol &amp; Metoprolol are selective β1 adrenergic blockers used in treatment of several diseases, including hypertension (HTN). Unlike Metoprolol, the β1-receptor selectivity of Bisoprolol does not change with increasing dose and Bisoprolol also has a longer half-life. The objective was to compare the efficacy &amp; tolerability of Bisoprolol with Metoprolol in Indian patients with Stage-1 HTN. Method Multicentre, parallel group, open labelled, randomised noninferiority trial was conducted at 6 cardiology centres in India (2010 – 2011). The study was approved by the institutional ethics committee at each centre and was performed in accordance with the good clinical practice guidelines and ICH-GCP. Out 218 adult patients screened, 200 patients between the age group of 18 to 65 years, with systolic blood pressure (SBP) 140–159 mm Hg or diastolic blood pressure (DBP) 90–99 mm Hg were randomly assigned to receive either Bisoprolol 5 mg once daily or Metoprolol-SR 50 mg once daily. Primary outcome measure was the responder rate (% of patients achieving BP &amp;lt;140/90 mm Hg throughout 24 hours) at 12 weeks. The secondary outcome measures were the percentage of patients requiring dose titration at 6 weeks, change in the SBP &amp; DBP from baseline at 6 and 12 weeks, change in the mean night-time blood pressure from baseline at 12 weeks &amp; global efficacy and tolerability assessment on a four-point scale. Results 200 patients (100 each in the 2 arms, 74.5% Males, mean age of 49.55 and 53.39 in the bisoprolol and metoprolol arms respectively) were enrolled in the study. Efficacy analysis was done on 165 patients who completed the study. There was a trend towards a better 24 hr BP control rate with Bisoprolol, responder rates were 68.33% for Bisoprolol and 62.9% for Metoprolol as measured by continuous ambulatory blood pressure measurement. Also Bisoprolol was non-inferior to Metoprolol with respect to percentage of patients requiring dose titration (12.3% vs 11.6%), change in SBP (7.7% vs 7.2%) &amp; DBP (9.6% vs 9.1%), change in mean night-time blood pressure (29.1% vs 25.3%) and reduction in heart rate (9.2% vs 6.7%). The two treatments were also similar with respect to efficacy &amp; tolerability on Global Assessment by doctors &amp; patients respectively. Conclusion Bisoprolol is non-inferior to Metoprolol-SR with respect to efficacy &amp; safety in patients of stage-1 HTN, with a trend towards better control of 24 hr BP in this non-inferiority trial. This study was conducted at a time when β-blockers were considered as first-line therapies for the management of hypertension. Our study supports the use of bisoprolol in Indian patients, based on the non-inferiority (as compared to metoprolol) and with the advantageous profile of the molecule. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): The study was supported by a research grant from Merck.

The long-term impact of expansion sphincter pharyngoplasty treatment on blood pressure control and health-related quality of life in patients with obstructive sleep apnea and hypertension

To assess how expansion sphincter pharyngoplasty (ESP) impacts blood pressure (BP) and health-related quality of life (HRQOL) in hypertensive patients with obstructive sleep apnea (OSA). Patients were separated into two groups based upon whether or not they adhered to antihypertensive drug regimens. Patients underwent 24-h ambulatory BP monitoring before and at 6 months post-ESP, while clinical BP measurements and HRQOL questionnaires (SF-36) were conducted over the course of 24 months post-surgery. We enrolled 62 patients, with 25 and 37 in the medicated and non-medicated groups, respectively. Mean 24-h BP differed significantly, with systolic and diastolic BP (SBP and DBP) decreases of 5.3 mmHg and 2.5 mmHg, respectively (P <0.01). Mean 24-h SBP and DBP decreases in the medicated group were 10.2 mmHg and 4.6 mmHg, respectively (P < 0.001), with significant decreases during the daytime of8.6 mmHg, 3.0 mmHg, and nighttime of12.3 mmHg, 7.7 mmHg (P <0.001). In the non-medicated treatment group, 24-h SBP and DBP decreases were 1.9 mmHg and 1.1 mmHg (P < 0.005) with significant decreases in mean nighttime BP values of 3.2 mmHg and 1.9 mmHg (P < 0.001). While pre- and postoperative SF-36 results differed significantly, no differences were observed between the two groups. ESP decreases BP and improves HRQOL in OSA patients with hypertension, particularly in combination with antihypertensive drugs.

Nocturnal hypertension in primary care patients with high office blood pressure: A regional study of the MAPAGE project.

Nocturnal hypertension (NH) is an independent cardiovascular risk factor. We aimed to describe the frequency of NH among primary care hypertensive patients and to analyze NH determinants. This observational, cross-sectional, multicenter study enrolled the patients of 23 general practitioners in Burgundy region, France. We included the first patient of the day with office blood pressure≥140/90mmHg, whatever the reason for consultation. All included patients had 24-hour ambulatory blood pressure monitoring (ABPM). Nocturnal hypertension was considered nighttime mean blood pressure≥120/70mmHg, as per current guidelines. Medical, sociodemographic, and deprivation data were collected. Nocturnal hypertensive and non-hypertensive patients were compared. The determinants of NH were identified using logistic regression models. From July 2015 to November 2018, 447 patients were analyzed. Mean office blood pressure was 158.6/91.5mmHg, and 255 patients (57.0%) were taking at least one antihypertensive drug. Among the 409 (91.5%) valid ABPM, 316 (77.3%) showed NH. In multivariate analyses, male sex (odds ratio [OR]=2.20, 95% confidence interval [CI] 1.29-3.75), first office diastolic blood pressure>100mmHg (OR=5.71, 95% CI 1.53-21.40), and current smoking (OR=5.91, 95% CI 2.11-16.56) were independent predictors of NH. Obesity was associated with a reduced risk of NH (OR=0.43, 95% CI 0.25-0.75). No association was found between deprivation status or sociodemographic factors and NH. To conclude, NH was identified in more than three out of four patients with high office blood pressure. Male smokers with high diastolic blood pressure were most affected by NH. ABPM may improve hypertension management in these patients.

Prognostic Value of a Riser Pattern of Nighttime Blood Pressure in Very Elderly Adults of ≥80 Years: A General Practice-Based Prospective SEARCH Study.

We examined our hypothesis that participants with higher mean nighttime blood pressure (BP) levels and/or those with a riser BP pattern, both measured by ambulatory blood pressure (BP) monitoring (ABPM), would show higher risk for cardiovascular disease (CVD) events compared to those with normal nighttime BP levels or a normal dipper BP pattern of circadian BP rhythm, even in very elderly participants in a general practice population. This prospective observational study enrolled 485 very elderly outpatients of ≥80 years (mean age: 83.2 ± 3.3 years; 44.7% male; 89.3% using antihypertensive medications). The prevalences of extreme dipper, dipper, nondipper, and riser status were 15.5%, 38.6%, 32.2%, and 13.8%, respectively. During a mean follow-up of 3.9 years (1,734 person-years), 41 CVD events occurred. The participants with a riser pattern (higher nighttime systolic BP [SBP] than daytime SBP) showed a significantly higher risk for CVD events with adjustment for covariates: hazard ratio (HR), 2.61; 95% confidence interval (CI), 1.03-6.62. Even after adjusting for covariates and mean nighttime SBP level, the CVD risks in participants with a riser pattern remained significant: HR, 3.11; 95% CI, 1.10-8.88. On the other hand, all BP variables showed no significant risks for CVD events. In addition, when we divided study participants into quartiles by their ambulatory BP levels, none of the ambulatory BP variables showed a J- or U-shaped relationship with CVD event risk. In very elderly general practice outpatients, a riser BP pattern was significantly associated with CVD events independently of mean nighttime BP.

Cardiac organ damage in patients with Parkinson's disease and reverse dipping.

Patients with autonomic neuropathy associated with Parkinson's disease often show reverse dipping pattern/nocturnal hypertension at 24-h ambulatory blood pressure (BP) monitoring (24-h ABPM) and diurnal orthostatic hypotension. The aim of the study was to evaluate cardiac alterations in Parkinson's disease patients with reverse dipping, in comparison with non-reverse dippers Parkinson's disease and essential hypertensive patients. A total of 26 consecutive Parkinson's disease patients with reverse dipping at 24-h ABPM and no previous history of hypertension were compared with 26 non-reverse Parkinson's disease patients matched for age, sex and 24-h mean BP, and 26 essential hypertensive patients matched for nighttime mean BP. None of the Parkinson's disease patients suffered from cardiovascular diseases or were treated with antihypertensive or antihypotensive drugs. Reverse dipping was defined by a systolic day-night BP difference less than 0% at 24-h ABPM. Left ventricular (LV) hypertrophy was defined by a LV mass index at least 115 g/m in men and at least 95 g/m in women. LV mass, indexed for BSA, was significantly higher in reverse dipping than non-reverse Parkinson's disease patients (respectively 90.2 ± 25.3 vs. 77.4 ± 13.3 g/m, P = 0.04), and was similar to essential hypertensive patients (91.6 ± 24.8, P = 0.92). LV hypertrophy was detected in five reverse dipping Parkinson's disease patients and four hypertensive patients, but was not present in non-reverse Parkinson's disease patients (P = 0.046). Nocturnal BP values, nocturnal BP load, weighted BP variability and age were found to correlate with the increased LV mass index. Reverse dipping and nocturnal hypertension are related to higher LV mass and increased prevalence of LV hypertrophy in Parkinson's disease patients.

Extreme dipping: More complex than it looks

Information on clinical and prognostic implications of the extreme dipping (ED) pattern is scanty and findings provided by studies are controversial. Increasing evidence suggests than mean night-time blood pressure (BP), a powerful predictor of cardiovascular outcomes, in ED can be markedly different between patients and distributed over a wide range of values ranging from hypotension to hypertension. On the whole, these findings emphasize the need to know that the ED pattern is a heterogeneous phenotype that deserve to be evaluated more in detail in future studies.

REPRODUCIBILITY AND DETERMINANTS OF DAYTIME AND NIGHTTIME BLOOD PRESSURE VARIABILITIES

Objective: Night-time blood pressure variability (BPV) has shown to have a greater predictive capacity than daytime BPV for adverse outcome. This has been attributed to a better reproducibility of BPV during sleep than during waking hours but studies comparing the two subperiods are lacking. Design and method: To compare the reproducibility of daytime and night-time short term BPV (Standard Deviation) and to identify the determinants of BPV we recorded 24-hour blood pressure (BP) twice 3 months apart in 1051 hypertensive subjects participating in the HARVEST study. BP was measured every 10 minutes during daytime and 30 minutes during night-time. Correlations were performed with Pearson test. Consistency was obtained by calculating the difference between baseline and repeat recording, disregarding the sign of the difference. Repeatability was defined as twice the standard deviation of the changes between the two repeated recordings. Results: Systolic BPV (mean of the 2 recordings) was higher during daytime (12.9 ± 3.2 mmHg) than during night-time (10.9 ± 3.2 mmHg). Independent predictors of daytime systolic BPV were smoking, mean daytime BP, pulse pressure, BP reaction to standing, nocturnal BP fall, white-coat effect, and physical activity habits (negative). Independent predictors of night-time systolic BPV were young age, smoking, mean night-time BP, pulse pressure, BP reaction to standing, nocturnal BP fall, and male gender. Small mean changes in systolic BPV were observed at repeat recording for both daytime and night-time BPV (−0.11 ± 3.8 mmHg and 0.3 ± 4.4 mmHg, respectively). A higher correlation was found between baseline and repeat measurement for daytime BPV than night-time BPV (0.47 vs 0.36, p = 0.002). Consistency was also better for daytime than night-time BPV (2.6 ± 2.8 vs 2.9 ± 3.3 mmHg, p = 0.007) as was repeatability (7.6 vs 8.8 mmHg, respectively). Similar results were obtained for diastolic BPV. Conclusions: Contrary to what is currently thought BPV, measured twice over a 3-month period, is more reproducible during waking hours than during sleep. Smoking, mean BP level, pulse pressure, BP reaction to standing, and nocturnal BP fall, are main determinants of both daytime and night-time BPVs. In addition, BP reactivity to stress is another strong contributor to daytime BPV.

Twenty-four-hour ambulatory blood pressure changes in older patients with essential hypertension receiving monotherapy or dual combination antihypertensive drug therapy.

ObjectiveTo evaluate the differences in 24-hour ambulatory blood pressure (BP) in older patients with hypertension treated with the five major classes of antihypertensive drugs, as monotherapy or dual combination therapy, to improve daytime and nighttime BP control.MethodsWe enrolled 1920 Chinese community-dwelling outpatients aged ≥ 60 years and compared ambulatory BP values and ambulatory BP control (24-hour BP < 130/80 mmHg; daytime mean BP < 135/85 mmHg; and nighttime mean BP < 120/70 mmHg), as well as nighttime BP dip patterns for monotherapy and dual combination therapy groups.ResultsPatients' mean age was 71 years, and 59.5% of patients were women. Calcium channel blockers (CCBs) constituted the most common (60.3% of patients) monotherapy, and renin–angiotensin system (RAS) blockers combined with CCBs was the most common (56.5% of patients) dual combination therapy. Monotherapy with beta-blockers (BB) provided the best daytime BP control. The probabilities of having a nighttime dip pattern and nighttime BP control were higher in patients receiving diuretics compared with CCBs (OR = 0.52, P = 0.05 and OR = 0.41, P = 0.007, respectively). Patients receiving RAS/diuretic combination therapy had a higher probability of having controlled nighttime BP compared with those receiving RAS/CCB (OR = 0.45, P = 0.004). Compared with RAS/diuretic therapy, BB/CCB therapy had a higher probability of achieving daytime BP control (OR = 1.27, P = 0.45).ConclusionsAntihypertensive monotherapy and dual combination drug therapy provided different ambulatory BP control and nighttime BP dip patterns. BB-based regimens provided lower daytime BP, whereas diuretic-based therapies provided lower nighttime BP, compared with other antihypertensive regimens.

Nocturnal blood pressure changes in Parkinson's disease: correlation with autonomic dysfunction and vitamin D levels.

Nocturnal blood pressure (BP) changes are an indicator of autonomic dysfunction. We aim to investigate the correlation between nocturnal blood pressure (BP) variability, vitamin D levels and Parkinson's disease severity (PD) in this study. Thirty-five patients with PD participated in the study. Disease severity was evaluated by United Parkinson's Disease Rating Scale (UPDRS) and Hoehn and Yahr Scale (HYS). Equivalent levodopa dose was calculated and 25-hydroxyvitamin D levels were measured. The Non-Motor Symptom Questionnaire (NMSQ) was applied to all patients. Ambulatory BP monitoring for 24h was established. Patients were divided into three groups according to nocturnal BP results: dippers (normal finding-a decline in mean nighttime BP of more than 10%); non-dippers (pathological-a decline in mean nighttime BP of less than 10%); reverse dippers (pathological-an increase in mean nighttime BP) .The mean score of the NMSQ was higher in the group with HYS > 2 (p = 0.050). Four patients were dipper, 17 patients were non-dipper and 16 patients were reverse dipper. There was no significant difference between the three groups in terms of age, gender, disease duration, age of the disease onset, disease stage, disease duration, dopamine agonist usage, levodopa equivalent dose, vitamin D level and NMSQ scores. NMSQ scores are high in advanced PD. Ambulatory BP monitoring is useful in detecting autonomic dysfunction. The number of patients with non-dipping and reverse dipping is high in PD, independent from PD severity, drug dose, vitamin D and the other NMS symptoms.

Diagnosing Masked Hypertension Using Ambulatory Blood Pressure Monitoring, Home Blood Pressure Monitoring, or Both?

Guidelines recommend measuring out-of-clinic blood pressure (BP) to identify masked hypertension (MHT) defined by out-of-clinic BP in the hypertensive range among individuals with clinic-measured BP not in the hypertensive range. The aim of this study was to determine the overlap between ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) for the detection of MHT. We analyzed data from 333 community-dwelling adults not taking antihypertensive medication with clinic BP <140/90 mm Hg in the IDH study (Improving the Detection of Hypertension). Any MHT was defined by the presence of daytime MHT (mean daytime BP ≥135/85 mm Hg), 24-hour MHT (mean 24-hour BP ≥130/80 mm Hg), or nighttime MHT (mean nighttime BP ≥120/70 mm Hg). Home MHT was defined as mean BP ≥135/85 mm Hg on HBPM. The prevalence of MHT was 25.8% for any MHT and 11.1% for home MHT. Among participants with MHT on either ABPM or HBPM, 29.5% had MHT on both ABPM and HBPM; 61.1% had MHT only on ABPM; and 9.4% of participants had MHT only on HBPM. After multivariable adjustment and compared with participants without MHT on ABPM and HBPM, those with MHT on both ABPM and HBPM and only on ABPM had a higher left ventricular mass index (mean difference [SE], 12.7 [2.9] g/m2, P<0.001; and 4.9 [2.1] g/m2, P=0.022, respectively), whereas participants with MHT only on HBPM did not have an increased left ventricular mass index (mean difference [SE], -1.9 [4.8] g/m2, P=0.693). These data suggest that conducting ABPM will detect many individuals with MHT who have an increased cardiovascular disease risk.

Abstract P317: Nocturnal Blood Pressure Variability is associated with hs-CRP in Hypertensive Patients

Background: 24-hr Blood pressure (BP) variability and high sensitivity C-reactive protein (hs-CRP) have been found to be independently associated with increased cardiovascular diseases (CVD). Studies have shown a positive association between hs-CRP and BP variability in hypertensive population. In particular, nocturnal BP variability is associated with increased risk for CVD. However, the relationship between inflammation and nocturnal BP variability has not been examined in hypertensive patients. Methods: In this prospective study, 237 hypertensive patients were recruited from University of Alabama at Birmingham Hypertension clinic. As part of the study protocol, hs-CRP and 24-hr ambulatory blood pressure monitoring (ABPM) was performed at same visit. Patients with chronic kidney disease and those who did not have complete ABPM and hs-CRP values were excluded. Nocturnal BP variability was assessed using standard deviation. Results: Out of 202 patients who were included, 49.0% were women and 55.9% were African American. The mean age was 58.2 ± 10.9 years, mean nighttime BP (Systolic BP 132.4 ± 22.9 mmHg and diastolic BP 71.9 ± 14.0 mmHg), mean nighttime BP variability (systolic BP 13.4 ± 5.3 and diastolic BP 9.9 ± 4.2) and mean hs-CRP was 5.9 ± 7.0 mg/L. Regression analysis showed significant positive association (p-value = 0.033) between nocturnal BP variability and hs-CRP. Conclusion: In this study, we demonstrated that hs-CRP is strongly correlated with nocturnal BP variability in hypertensive patients, suggesting a likely mechanistic role of inflammation in the pathogenesis of nocturnal BP variability and a possible additive role in adverse cardiovascular outcomes.