Surge-Home Blood Pressure Study Research Articles

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

Background: The relationship between notched P-wave characteristics on digital electrocardiogram (ECG) and long-term cardiovascular events remains unclear. Methods: We enrolled 810 subjects from the Japan Morning Surge Home Blood Pressure study who had one or more cardiovascular risk factors. Twelve-lead electrocardiography was conducted, and the peak-to-peak distance in the M shape was calculated automatically using a 12-lead ECG analysis system. We compared two definitions: P-waves were defined as “notched” if the peak-to-peak distance in the M shape was ≥20 ms or ≥40 ms in lead II. We assessed the left atrial diameter and left ventricular mass index (LVMI) by echocardiography. The primary endpoint was defined as a composite endpoint that combines fatal events (stroke, heart failure, coronary artery disease, and sudden death) and nonfatal events (acute myocardial infarction, angina, congestive heart failure, stroke, and aortic dissection). Results: The mean follow-up period was 101 ± 34 months, during which 85 cardiovascular events occurred. When we defined a notched P-wave as ≥20 ms in the M shape (n = 92), a notched P-wave was a significant predictor of cardiovascular events after adjustment for age, gender, and comorbidity (hazard ratio: 1.83; 95% confidence interval: 1.01–3.31, p = 0.045). When we defined a notched P-wave as ≥40 ms in the M shape (n = 25), the hazard ratio of cardiovascular events in the notched P-wave group was not significant after adjustment for covariates (hazard ratio: 1.52; 95% confidence interval: 0.51–4.53, p = 0.455). The left atrial diameter and LVMI in the patients in the notched P-wave group (peak-to-peak distance of ≥20 ms in the M shape) were significantly higher than those in the control group (left atrial diameter: 38.8 ± 5.9 vs. 36.8 ± 5.0 mm, p = 0.001; LVMI: 103.9 ± 27.7 vs. 96.3 ± 25.7 g/m2, p = 0.010). Conclusions: The notched P-wave by digital ECG analysis was associated with cardiovascular events and left atrial enlargement.

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

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

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

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

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

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

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

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

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

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

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

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

Association of Morning and Evening Blood Pressure at Home With Asymptomatic Organ Damage in the J-HOP Study

Several guidelines recommend that home blood pressure (HBP) be measured both in the morning and in the evening. However, there have been fewer reports about the clinical significance of morning HBP than about the clinical significance of evening HBP. Our study included 4,310 patients recruited for the Japan Morning Surge Home Blood Pressure Study who had one or more cardiovascular risk factors. We measured morning and evening HBP, urinary albumin-creatinine ratio (UACR), left ventricular mass index (LVMI), brachial-ankle pulse wave velocity (baPWV), maximum carotid intima media thickness (IMT), N-terminal pro-brain-type natriuretic peptide (NT-proBNP), and high-sensitivity cardiac troponin T (Hs-cTnT). The correlation coefficients for the associations between morning systolic BP (SBP) and log-transformed baPWV, NT-proBNP, or Hs-cTnT were significantly greater than the corresponding relationships for evening SBP (all P < 0.01). The goodness-of-fit of the associations between morning home SBP and UACR (P < 0.05) or baPWV (P < 0.01) was improved by adding evening home SBP to the SBP measurement. In contrast, the goodness-of-fit values of the associations between evening SBP and UACR (P < 0.001), LVMI (P < 0.05), baPWV (P < 0.001), NT-proBNP (P < 0.001), and Hs-cTnT (P < 0.001) were improved by adding morning home SBP to the SBP measurement. Morning BP and evening BP provide equally useful information for subclinical target organ damage, yet multivariate modeling highlighted the stand-alone predictive ability of morning BP.