Seated Clinic Blood Pressure Research Articles

The Association of Orthostatic Hypotension With Ambulatory Blood Pressure Phenotypes in SPRINT.

Clinic blood pressure (BP) when measured in the seated position, can miss meaningful BP phenotypes, including low ambulatory BP (white coat effects [WCE]) or high supine BP (nocturnal non-dipping). Orthostatic hypotension (OH) measured using both seated (or supine) and standing BP, could identify phenotypes poorly captured by seated clinic BP alone. We examined the association of OH with WCE and night-to-daytime systolic BP (SBP) in a subpopulation of SPRINT, a randomized trial testing the effects of intensive or standard (<120 vs. <140 mm Hg) SBP treatment strategies in adults at increased risk of cardiovascular disease. OH was assessed during follow-up (6, 12, and 24 months) and defined as a decrease in mean seated SBP ≥20 or diastolic BP ≥10 mm Hg after 1 min of standing. WCE, based on 24-hour ambulatory BP monitoring performed at 27 months, was defined as the difference between 27-month seated clinic and daytime ambulatory BP ≥20/≥10 mm Hg. Reverse dipping was defined as a ratio of night-to-daytime SBP >1. Of 897 adults (mean age 71.5±9.5 years, 29% female, 28% black), 128 had OH at least once. Among those with OH, 15% had WCE (vs. 7% without OH). Moreover, 25% of those with OH demonstrated a non-dipping pattern (vs. 14% without OH). OH was positively associated with both WCE (OR=2.24; 95%CI: 1.28, 4.27) and reverse dipping (OR=2.29; 95% CI: 1.31, 3.99). The identification of OH in clinic was associated with two BP phenotypes often missed with traditional seated BP assessments. Further studies on mechanisms of these relationships are needed. Trial Number NCT03569020.

Exaggerated blood pressure response at mild exertional intensity is associated with lower exercise capacity and worsening of cardiac structural and functional profile

Abstract Even with normal blood pressure (BP) measured at rest, some individuals may experience excessive BP elevation with exercise, termed as an “exaggerated BP response to exercise” (ExBPR). The most common definition of ExBPR is SBP ≥210 mm Hg in men and ≥190 mm Hg in women at peak exercise intensity (ExBPR-PI). However, evidence exists that increase in SBP ≥150 mm Hg at an early stage of exercise stress test (i.e. at mild exercise intensity, ExBPR-MI) can effectively identify hypertension not diagnosed by conventional methods. No studies exploring the pathophysiological significance of ExBPR-MI have been undertaken to date. Aim To investigate the association of ExBPR-MI with exercise capacity and cardiac morpho-functional characteristics. Methods A group of 109 subjects (mean age 52±13 yrs) with and without a pre-established diagnosis of hypertension, having clinical indications for an exercise stress test, with seated clinic BP &amp;lt;140/90 mm Hg, underwent resting echocardiographic imagining and cardiopulmonary exercise testing using a ramped Bruce protocol. Results Based on the BP response at 3 minutes of exercise, the population was divided into two subsets: ExBPR-MI+ and ExBPR-MI− (SBP ≥ and &amp;lt;150 mmHg, respectively). The ExBPR-MI+ group was characterized by lower peak oxygen uptake, higher LV mass and left atrial size, and more impaired LV diastolic function (lower E/A and e', and higher E/e'). When the study cohort was stratified using peak BP response, significant differences indicating an adverse impact of ExBPR-PI were demonstrated only for LV diastolic parameters but not for peak VO2 and cardiac morphology indices (Table 1). Conclusions ExBPR-MI predisposes to reduced exercise capacity and detrimental alterations in cardiac morphology and function. As mild exercise intensity is more frequently present during routine daily activities than peak exercise intensity, ExBPR-MI may be a more important pathophysiological contributor to target organ damage than peak BP response, and may represent a potential new target for preventive and therapeutic measures. Table 1 Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Science Centre Poland

Effects of Sodium-Glucose Cotransporter 2 Inhibitors on 24-Hour Ambulatory Blood Pressure: A Systematic Review and Meta-Analysis.

BackgroundSodium‐glucose cotransporter 2 (SGLT2) inhibitors are a novel class of antihyperglycemic agents that improve glycemic control by increasing glycosuria. Additional benefits beyond glucose lowering include significant improvements in seated clinic blood pressure (BP), partly attributed to their diuretic‐like actions. Less known are the effects of this class on 24‐hour ambulatory BP, which is a better predictor of cardiovascular risk than seated clinic BP.Methods and ResultsWe performed a meta‐analysis of randomized, double‐blind, placebo‐controlled trials to investigate the effects of SGLT2 inhibitors on 24‐hour ambulatory BP. We searched all studies published before August 17, 2016, which reported 24‐hour ambulatory BP data. Mean differences in 24‐hour BP, daytime BP, and nighttime BP were calculated by a random‐effects model. SGLT2 inhibitors significantly reduce 24‐hour ambulatory systolic and diastolic BP by −3.76 mm Hg (95% CI, −4.23 to −2.34; I2=0.99) and −1.83 mm Hg (95% CI, −2.35 to −1.31; I2=0.76), respectively. Significant reductions in daytime and nighttime systolic and diastolic BP were also found. No association between baseline BP or change in body weight were observed.ConclusionsThis meta‐analysis shows that the reduction in 24‐hour ambulatory BP observed with SGLT2 inhibitors is a class effect. The diurnal effect of SGLT2 inhibitors on 24‐hour ambulatory BP may contribute to their favorable effects on cardiovascular outcomes.

Blood pressure goal in chronic kidney disease: what is the evidence?

Most guidelines recommend that seated clinic blood pressure (BP) be targeted to less than 130/80 mmHg in patients with chronic kidney disease (CKD). The evidence underlying these recommendations is the subject of this review. The best evidence to target a certain level of BP in patients with CKD comes from randomized trials. Only three trials have prospectively examined the level to which BP should be lowered. These trials conducted exclusively among patients with CKD have demonstrated that compared to a less aggressive BP goal, a BP goal of less than 130/80 mmHg neither saves lives nor protects the kidney or the cardiovascular system. It is reasonable to achieve a goal of less than 140/90 mmHg in most patients with CKD. More aggressive lowering is not firmly supported by current data. Since BP control is important, hypertension therapy should be individualized. Individualization through home BP measurements to diagnose, monitor and treat hypertension appears to be an attractive option.

Dose-related effects of flavanol-rich cocoa on blood pressure

Consumption of flavanol-containing cocoa products has been shown to lower blood pressure (BP), but the minimum dose required to reduce BP is not known. This study aimed to examine the effect of three different doses of cocoa flavanols (CF) on 24-h mean arterial BP. Twenty four hour ambulatory BP (24-ABP) monitoring was performed in 32 men and 20 postmenopausal women with untreated mild hypertension (seated clinic BP >130/85 and <160/100 mm Hg). Participants were randomized and instructed to consume daily a reconstituted cocoa beverage containing 33, 372, 712 or 1052 mg day(-1) of CF for 6 weeks in a double-blind, parallel comparison. Seated clinic BP and 24-h ABP were measured at 0, 3 and 6 weeks. Seated clinic BP did not change during the study period. There were significant reductions in 24-h systolic (5.3+/-5.1 mm Hg; P=0.001), diastolic (3+/-3.2 mm Hg; P=0.002) and mean arterial BP (3.8+/-3.2 mm Hg; P=0.0004) at the 1052 mg day(-1) CF only. No reduction in BP was seen at any other dose. No evidence of dose-response was seen in this experiment. The highest dose of 1052 mg CF per day was found to significantly lower BP. These results support previous evidence for CF to lower BP, however more research is needed to establish the most effective dose and food matrix.

Orthostatic Hypertension A Measure of Blood Pressure Variation for Predicting Cardiovascular Risk

Orthostatic hypertension, a measure of blood pressure (BP) variability, is a clinically important pathologic condition associated with the progression of target organ damage and subsequent cardiovascular risk. Orthostatic hypertension precedes hypertension and could be considered as prehypertension if a patient has seated clinic BP <140/90 mmHg. The simple examination of orthostatic BP changes using a self-measured home BP monitoring, through which abnormal pathological conditions can be detected with high reproducibility without the white-coat effect. Orthostatic hypertension is associated with morning hypertension and increased neurohumoral activation; however, the precise mechanism of orthostatic hypertension remains unclear, and accumulation of further clinical evidence is necessary.

Effects of the angiotensin II receptor blockers telmisartan versus valsartan in combination with hydrochlorothiazide: a large, confirmatory trial

In 2004-2005, the antihypertensive effects of telmisartan 80 mg versus valsartan 160 mg combined with hydrochlorothiazide 25 mg were assessed in a large placebo-controlled trial in patients with stages 1 and 2 hypertension and demonstrated that both agents were highly effective in lowering blood pressure (BP) compared with placebo and that telmisartan lowered BP significantly greater than valsartan. To confirm this finding according to Food and Drug Administration guidelines, we performed a second large trial using the same design in an entirely separate patient population. The trial was double-blind with a 4 : 4 : 1 randomization scheme to compare once daily telmisartan 80 mg plus hydrochlorothiazide 25 mg versus once daily valsartan 160 mg plus hydrochlorothiazide 25 mg versus once daily placebo on reductions in seated clinic BP in patients with stages 1 and 2 hypertension. The primary endpoints were the changes from baseline in seated diastolic and systolic BP at the end of the 8-week treatment period. Safety endpoints included adverse events, changes in laboratory parameters and pulse rate. In total, 1185 patients were randomized (of which 1181 were treated and included in the primary analysis: 528 in the telmisartan-hydrochlorothiazide group, 523 in the valsartan-hydrochlorothiazide group, and 130 in the placebo group), changes from baseline in BP following telmisartan-hydrochlorothiazide (-24.6/-18.2 mmHg) were significantly greater than both placebo (-4.1/-6.1 mmHg) and valsartan-hydrochlorothiazide (-22.5/-17.0 mmHg) (versus placebo, P<0.0001 for systolic and diastolic BP; versus valsartan-hydrochlorothiazide, P=0.017 for systolic BP and P=0.025 for diastolic BP). The total number of patients with at least one adverse event reported was similar among the three treatment groups (placebo, 42%, telmisartan-hydrochlorothiazide, 36%, and valsartan-hydrochlorothiazide, 37%). Thus, this large, second trial confirms that telmisartan-hydrochlorothiazide at doses of 80/25 mg lowered both systolic and diastolic BP to a greater extent than valsartan-hydrochlorothiazide at doses of 160/25 mg in stages 1-2 hypertension. Although these are not the highest doses of these agents at present, at the time that the studies were conducted, they were the maximally approved dosages. Both studies support the strategy of using angiotensin receptor blockers with a higher dose of a thazide diuretic (25 mg) for enhancing the control of hypertension.