Uncontrolled Ambulatory Blood Pressure Research Articles

The role of wearable home blood pressure monitoring in detecting out-of-office control status

Ambulatory blood pressure (ABP) and home blood pressure (HBP) monitoring is currently recommended for management of hypertension. Nonetheless, traditional HBP protocols could overlook diurnal fluctuations, which could also be linked with adverse cardiovascular outcomes. In this observational study, we studied among a group of treated hypertensive patients (N = 62, age: 52.4 ± 10.4 years) by using out-of-office ABP and wearable HBP. They received one session of 24-h ABP measurement with an oscillometric upper-arm monitor, and totally three sessions of 7-day/6-time-daily wearable HBP measurement separated in each month with HeartGuide. Controlled hypertension is defined as an average BP <130/80 mmHg for both daytime ABP and HBP. There was substantial reliability (intraclass correlation coefficient, ICC 0.883–0.911) and good reproducibility (Cohen’s kappa = 0.600) for wearable HBP measurement, especially before breakfast and after dinner. Among all patients, 27.4% had both uncontrolled HBP and ABP, 30.6% had uncontrolled HBP only, while 6.5% had uncontrolled ABP only. Female gender and increased numbers of anti-hypertensive agents are correlated with controlled hypertension. Patients with uncontrolled hypertension had a significantly higher maximal daytime blood pressure, which was previously signified as an imperial marker for cardiovascular risk. In conclusion, wearable HBP monitoring in accordance with a dedicated daily-living schedule results in good reliability and reproducibility. Patients with an uncontrolled wearable HBP should benefit from repeated HBP or ABP measurement for risk stratification.

Association of Home and Ambulatory Blood Pressure With Cardiovascular Prognosis in Practice Hypertensive Outpatients.

Although international guidelines for hypertension management recommend home and ambulatory blood pressure (BP) monitoring, few studies have assessed which is more useful in predicting cardiovascular incidence in hypertensive outpatients. We analyzed the association of home and ambulatory BP with cardiovascular prognosis in 1336 practice outpatients with hypertension who underwent both home and ambulatory BP measurements in the J-HOP study (Japan Morning Surge-Home Blood Pressure). During the median 6.9 years of follow-up, 111 cardiovascular events occurred. Both home and ambulatory systolic BP (SBP) were associated with cardiovascular risk independent of office SBP (hazard ratio [95% CI] per 20 mm Hg of average morning and evening home SBP, 1.46 [1.11-1.93]; 24-hour ambulatory SBP, 1.41 [1.02-1.94]). Moreover, average morning and evening home SBP was also associated with cardiovascular risk even adjusted by 24-hour ambulatory SBP (hazard ratio [95%CI] per 20 mm Hg, 1.38 [1.01-1.87]), but 24-hour ambulatory SBP was not associated with cardiovascular risk adjusted by average morning and evening home SBP. Regarding this relationship, the model-fit was significantly improved by using the analysis of likelihood ratio, but that was not significant in the analysis using C statistics. Additionally, even in patients with well-controlled 24-hour ambulatory BP, uncontrolled morning home BP was associated with cardiovascular risks (hazard ratio [95% CI], 2.15 [1.02-4.50]). In patients with well-controlled average morning and evening home BP, uncontrolled ambulatory BP was not associated with cardiovascular risks. This study demonstrated the prognostic values of home and ambulatory BP in practice hypertensive outpatients. Our findings indicated the modest superiority of home BP compared to ambulatory BP to predict cardiovascular prognosis.

Dipping Status, Ambulatory Blood Pressure Control, Cardiovascular Disease, and Kidney Disease Progression: A Multicenter Cohort Study of CKD

Ambulatory blood pressure (BP) monitoring allows concurrent evaluation of BP control and nocturnal BP dipping status, both related to adverse outcomes. However, few studies have assessed the prognostic role of combining information on dipping status and achieved ambulatory BP in patients with chronic kidney disease (CKD). Prospective observational cohort study. 906 patients with hypertension and CKD attending 1 of 3 Italian nephrology clinics. Four groups were defined by simultaneously classifying systolic ambulatory BP levels as being at goal (daytime SBP<135 and nighttime SBP<120 mm Hg) or above goal, and the presence or absence of nocturnal dipping (nighttime to daytime SBP ratio of<0.9 versus≥0.9). The composite of time to initiation of maintenance dialysis or estimated glomerular filtration rate (eGFR) decline≥50%, and the composite of fatal and nonfatal cardiovascular events. Multivariable Cox proportional hazards models were used to estimate risks of kidney disease progression and cardiovascular disease in the 4 exposure groups where nocturnal dipping with systolic ambulatory BP at goal was the reference group. The mean patient age was 63.8 years, 61% were male, and 26.4% had diabetes; eGFR was 41.1 ± 20.8 mL/min/1.73 m2. The dipping prevalence in each of the 4 groups was as follows: nocturnal dipping with ambulatory BP at goal, 18.6%; no nocturnal dipping with ambulatory BP at goal, 20.5%; nocturnal dipping with ambulatory BP above goal, 11.8%; and no nocturnal dipping with ambulatory BP above goal, 49.1%. Among patients with ambulatory BP above goal, the risk of cardiovascular events was greater in the absence (HR, 2.79 [95% CI, 1.64-4.75]) and presence (HR, 2.05 [95% CI, 1.10-3.84]) of nocturnal dipping. The same held true for risk of kidney disease progression (HRs of 2.40 [95% CI, 1.58-3.65] and 2.11 [95% CI, 1.28-3.48] in the absence and presence of nocturnal dipping, respectively). Patients at the ambulatory BP goal but who did not experience nocturnal dipping had an increased risk of the cardiovascular end point (HR, 2.06 [95% CI, 1.15-3.68]) and the kidney disease progression outcome (HR, 1.82 [95% CI, 1.17-2.82]). Lack of a diverse cohort (all those enrolled were White). Residual uncontrolled confounding. Systolic ambulatory BP above goal or the absence of nocturnal dipping, regardless of ambulatory BP, is associated with higher risks of cardiovascular disease and kidney disease progression among patients with CKD. Among patients with chronic kidney disease (CKD), ambulatory blood pressure (BP) monitoring improves the identification of individuals at high risk of clinical disease outcomes. Those with uncontrolled ambulatory BP are known to have a higher risk of developing cardiovascular disease and kidney disease progression, particularly when their ambulatory BP does not decline by at least 10% at night. Whether this is also true for patients with presence of optimal ambulatory BP levels but a BP pattern of no nighttime decline is largely unknown. We measured ambulatory BP in 900 Italian patients with CKD and followed them for several years. We found that, independent of ambulatory BP level, the absence of nighttime reductions in BP was associated with worsening of CKD and more frequent cardiovascular events. The absence of nighttime declines in BP is an independent risk factor for adverse events among patients with CKD. Future studies are needed to examine whether treating the absence of nighttime declines in BP improves clinical outcomes.

HIGHER PREVALENCE OF MASKED UNCONTROLLED HYPERTENSION WITH NEW EUROPEAN BLOOD PRESSURE TARGETS IN AN ELDERLY PRIMARY CARE POPULATION

Objective: The aim of this study was to examine the distribution and clinical characteristics of hypertension phenotypes among patients aged 65 years or older, in a primary care setting, applying the new lower blood pressure targets, of 140/80 mmHg for office blood pressure measurement and 130/75 for ambulatory measurement, proposed by the European Society of Hypertension in 2018. Design and method: This is a cross-sectional analysis of 77 subjects previously diagnosed with hypertension who used at least one antihypertensive drug in a primary care setting in south-east Sweden. Data was collected between May 2012 and May 2016. All subjects were examined regarding general clinical characteristics, office blood pressure and ambulatory blood pressure (Spacelabs ABP monitor 90217). The participants were grouped based on office blood pressure target achievement. Furthermore, subjects were categorized in four groups based on hypertension phenotype. These groups were defined based on office- and ambulatory blood pressure target achievement; Sustained controlled hypertension i.e. concordant goal achievement, Sustained uncontrolled hypertension i.e. non-achievement, Masked uncontrolled hypertension i.e. controlled office blood pressure with uncontrolled ambulatory blood pressure and White coat uncontrolled hypertension i.e. uncontrolled office blood pressure with controlled ambulatory blood pressure. Lastly, shifts in the distribution of hypertension phenotypes using current and previous blood pressure targets respectively were examined. Results: Obesity related parameters (i.e. BMI and waist circumference) were significantly lower in the group with controlled hypertension based solely on current office blood pressure targets, with BMI (kg/m2) of 25.5 ± 3.9 vs. 28.8 ± 4.9 (p &lt; 0.01) and waist circumference (cm) of 91.0 ± 12.1 vs. 100.3 ± 12.7 (p &lt; 0.01). Among subjects with controlled office blood pressure, the prevalence of masked uncontrolled hypertension was higher (14/29 or 48%) when new office- and ambulatory blood pressure targets were applied than when older targets were applied (14/43 or 33%). Conclusions: The main finding of this observational study was that the prevalence of masked uncontrolled hypertension among subjects with controlled office blood pressure was higher applying new instead of old blood pressure targets. We believe that regular ambulatory blood pressure monitoring can facilitate optimized antihypertensive treatment.

PROGNOSTIC OF PATIENTS WITH REFRACTORY HYPERTENSION IN A COHORT OF RESISTANT HYPERTENSIVES

Objective: To determine prognostic value of true refractory hypertension diagnosis in a large cohort of resistant hypertensives Design and method: Prospective cohort study enrolled 835 patients of a large historical cohort of RHTN. After at least 6 months of follow-up, 147 (17.6%) patients remained refractory to treatment in ABPM despite the use of 5 or more drugs, including a thiazide-like diuretic and spironolactone. All of them were submitted to a standard protocol including laboratory tests, ABPM, echocardiography, and pulse wave velocity (PWV). Primary outcomes were total mortality, cardiovascular mortality, and fatal and non-fatal cardiovascular events. Secondary outcomes were major cardiovascular events separately (coronary artery disease, cerebrovascular disease, chronic kidney disease with substitutive therapy, peripheral arterial disease). Person-time rates for interest outcomes were calculated to find correlations of Kaplan-Meier survival curves using Cox regression multivariate models, after adjustments for several risk factors. Follow-up remained until December 2021 Results: The median follow-up was 162 months [IQR 115–196]. When compared to resistant hypertensives, patients with RfHTN were younger and more obese. Regarding subclinical lesions, refractories presented less aortic stiffness (13 vs 21%, p = 0.02) and stage 3 chronic kidney diseases (26 vs 34%, p = 0.03) with albuminuria and LVMI similar to those of resistant hypertension despite uncontrolled ambulatory blood pressure. There were 232 all causes deaths (21.1 vs 29.2%), of which 122 from CV causes (12.9% vs 15%), and 253 total CV events (44.1% vs 49%). The diagnosis of RfHTN was associated with a significantly lower risk of all-cause mortality when adjusted by sex and age. It also presented a tendency to be a protective factor of cardiovascular death, chronic kidney disease with substitutive therapy and peripheral arterial disease, although without statistical significance. Risk ratio ranged from 0.62 to 0,94 for every analysis/adjustment, except incidence of stroke (IC95%:1.22(0.70–2.17) after every adjustment in RfHTN. Conclusions: Despite uncontrolled ABPM, refractory hypertensive patients presented lower overall and cardiovascular morbimortality at long-term when compared to non-refractory ones, except stroke, which seems to be at least partially influenced by spironolactone use.

Prevalence and prognosis of refractory hypertension diagnosed using ambulatory blood pressure measurements

The prognosis of refractory hypertension is largely unknown due to its low prevalence. This study aimed to investigate the prognosis of refractory hypertension and compare it with those of resistant and nonresistant hypertension. We retrospectively analyzed the data of 16,284 participants with hypertension who underwent ambulatory blood pressure (BP) monitoring between 2012 and 2019 at a tertiary center. Uncontrolled BP was defined as a 24-h BP ≥ 130/80 mmHg as assessed by ambulatory BP monitoring. Resistant hypertension was defined as uncontrolled BP despite the use of three antihypertensive medications, including a diuretic or the use of ≥4 drugs regardless of BP control. Refractory hypertension was defined as uncontrolled BP despite the use of ≥5 antihypertensive medications. Among 16,284 patients with hypertension (mean age 59.2 ± 15.5 years, 52.7% men), 1501 (9.2%) and 150 (0.9%) patients had resistant and refractory hypertension, respectively. The prevalence of chronic kidney disease, end-stage renal disease, heart failure, previous stroke, left ventricular hypertrophy, and the riser/nondipper patterns of circadian BP rhythm progressively increased from patients with nonresistant hypertension to patients with resistant hypertension to patients with refractory hypertension. During a median follow-up of 3.9 years, the risk of cardiovascular mortality progressively increased from patients with nonresistant hypertension to patients with resistant hypertension (hazard ratio 1.62, 95% confidence interval 1.16-2.26) to patients with refractory hypertension (hazard ratio 5.22, 95% confidence interval 3.04-8.96). In conclusion, refractory hypertension, defined as uncontrolled ambulatory BP levels, was associated with a higher risk of all-cause and cardiovascular mortality than nonresistant or resistant hypertension.

Prognostic Importance of On-Treatment Clinic and Ambulatory Blood Pressures in Resistant Hypertension: A Cohort Study.

The prognostic importances of on-treatment clinic and ambulatory blood pressure (BP) levels have never been investigated in individuals with resistant hypertension. We aimed to evaluate them for the occurrence of incident cardiovascular and mortality outcomes in a prospective cohort of 1726 patients with resistant hypertension. Clinic and ambulatory BPs were measured at baseline and serially during follow-up (analyzed as time-varying and as mean cumulative BPs) and also categorized as controlled/uncontrolled as defined by the traditional and new 2017 American College of Cardiology/American Heart Association criteria. Multivariate Cox analyses examined the associations between BP parameters and the occurrence of total cardiovascular events, major adverse cardiovascular events, and cardiovascular and all-cause mortalities. C statistics and the integrated discrimination improvement indexes evaluated the improvement in risk discrimination. Over a median follow-up of 8.3 years, 417 total cardiovascular events occurred (358 major adverse cardiovascular events) and 391 individuals died (233 cardiovascular deaths). All single systolic BP (SBP) parameters significantly predicted all outcomes, but the associations were stronger for ambulatory SBPs than for clinic SBPs and for on-treatment SBPs (particularly for mean cumulative) than for baseline SBPs, and both improved risk discrimination (with increases in C statistic of up to 0.021 and integrated discrimination improvements of up to 19.7%). These findings were consistent for diastolic BPs. Uncontrolled ambulatory BPs were associated with higher risks for all outcomes, whereas uncontrolled clinic BPs were not. In conclusion, mean cumulative ambulatory BPs during follow-up were the best prognostic markers of adverse cardiovascular outcomes and mortality in patients with resistant hypertension. Serial ambulatory BP monitoring shall be more widely used in resistant hypertension management.

Ambulatory blood pressure monitoring and management of hypertension at a cardiac clinic in Kumasi Metropolis, Ghana.

Ambulatory blood pressure monitoring (ABPM) is considered a good intervention strategy to avoid misdiagnosis of hypertension and allow for targeted treatment of patients with hypertension. This study sought to assess the contribution of ABPM to blood pressure (BP) control and antihypertensive therapy at a cardiac clinic in Ghana. Medical records of 97 patients, aged 18-85years (mean 55), were reviewed. Among patients with clinic BP (CBP) and ambulatory BP recorded on the same day, we assessed for the different hypertension phenotypes, CBP control 6months following ABPM, and changes to antihypertensive therapy after review of the ABPM records in patients with controlled and uncontrolled ambulatory BP. From the clinic and ambulatory BP records measured at baseline, the proportion of patients with white-coat uncontrolled hypertension (WUCH) was 19.5% (17/87) and those with masked uncontrolled hypertension (MUCH) was 16.1% (n=14). A significant reduction in average systolic CBP in the overall cohort (-6.2mm Hg, P<.01) and in the uncontrolled subgroup (-8.8mm Hg, P<.001) at follow-up was observed. After review of the ABPM records, 51.7% of the patients on treatment had changes made in their antihypertensive therapy. Antihypertensive therapy was deintensified or left unchanged in majority of the patients with WUCH and sustained controlled hypertension. In patients with MUCH and true uncontrolled hypertension (TUCH), therapy was intensified. In conclusion, ABPM improved clinical decision-making for antihypertensive therapy and BP control. ABPM should therefore be used more often in hypertension and cardiac clinics in low/middle-income countries for optimal care.

Resistant Hypertension: Diagnosis and Management.

Resistant hypertension is defined as high blood pressure requiring 3 or more medications for adequate control or controlled blood pressure requiring 4 or more medications. Considering the growing prevalence of hypertension and the strong link with cardiovascular disease, it is vital to understand the causes and treatment of resistant hypertension. This review article starts with an overview of the prevalence and little-known pathophysiology of resistant hypertension. Afterward, we discuss the evaluation and management of suspected secondary resistant hypertension in 2 broad categories: pseudoresistant hypertension and true resistant hypertension. Strategies for the identification and management of pseudoresistant hypertension are addressed. In addition, causes of true resistant hypertension, such as obstructive sleep apnea, primary aldosteronism, and renal artery stenosis, are examined along with their respective treatments. Finally, treatment of resistant hypertension is reviewed including pharmacologic treatments and novel procedural interventions for resistant hypertension. Overall, the review hopes to provide practitioners with a cohesive approach for the diagnosis and treatment of resistant hypertension.

PP.18.15] EFFECT OF LONG-TERM USE OF CONTINUOUS POSITIVE AIRWAY PRESSURE TREATMENT ON BLOOD PRESSURE IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA AND RESISTANT HYPERTENSION

Objective: To evaluate the impact of a long-term use of CPAP on clinic and ambulatory blood pressure (BP) in patients with resistant hypertension (RHT) and obstructive sleep apnea (OSA) Design and method: An observational prospective study was performed in 66 patients with RHT and moderate/severe OSA (AHI > 15/hour), using CPAP for at least 12 months. Clinic BP and 24-hour BP were obtained before and after follow-up. Primary outcomes were changes in clinic and ambulatory BPs, and BP control. The differences of BP from the beginning to the end of the study were evaluated with a paired t test, adjusted by baseline BP. A per-protocol analysis was performed limited to patients with uncontrolled ambulatory BP levels at baseline. Results: 66 patients [64% females, mean (SD) age: 62 (8) years] were followed-up for a median of 20 [15–35] months. They used a median of 5 [3–8] antihypertensive drugs and had mean (SD) clinic BPs of 151 (26)/86 (17) mm Hg and ambulatory 24-hour BPs of 128 (17)/75 (11) mmHg; 61% of them had uncontrolled ambulatory BP levels at baseline. The average use of CPAP treatment was 5 (1.9) hours per night, with 78% using it at least 4 hours per night. A significant reduction of 24-hour (−3.7 [−7.7 to + 0.2] mmHg, p = 0.04) and daytime (−5.6 [−10.1 to – 1.1] mm Hg, p = 0.02) systolic ambulatory BP was found. Controlled ambulatory BP increased from 39% to 57%. In a per-protocol analysis, 48 patients with baseline uncontrolled ABPM were evaluated. They achieved a significant decrease in clinic systolic BP (−7.4 [−11.4 to + 3.2] mmHg, p = 0.04) and in systolic and diastolic ambulatory BP in all periods: 24-hour (14.6 [−21.0 to – 8.2]/−7.4 [−10.8 to −2.8]) mmHg, daytime (−17.3 [−10.8 to – 3.8]/−7.7[−11.3 to −4.3] mmHg) and nighttime (−8.6 [−15.2 to - 1.9) / −4.1 [−7.1 to – 1.0]) mmHg. Conclusions: The treatment of OSA with long-term use of CPAP significantly reduces blood pressure in patients with resistant hypertension, especially in those with uncontrolled ambulatory BP at baseline.

Prognostic Importance of Ambulatory Blood Pressure Monitoring in Resistant Hypertension: Is It All that Matters?

This article reviews the current knowledge on the prognostic importance of ambulatory blood pressure (BP) monitoring parameters in patients with apparent treatment-resistant hypertension. Although mean 24-h ambulatory BPs have been consistently established as better cardiovascular risk predictors than clinic (office) BPs in several clinical settings, and ambulatory BP monitoring is generally indicated in patients with resistant hypertension; there were only five previous longitudinal prospective studies that specifically evaluated the prognostic importance of ambulatory BP monitoring parameters in resistant hypertensive patients. These studies are carefully reviewed here. In conjunction, they demonstrated that office BP levels have little, if any, prognostic value in resistant hypertensive patients. Otherwise, several ambulatory BP monitoring parameters are strong cardiovascular risk predictors, particularly nighttime sleep BPs and the non-dipping pattern. Most relevant, the ambulatory BP monitoring diagnosis of true resistant hypertension (i.e., patients with uncontrolled ambulatory BPs, either daytime or nighttime) doubled the risk of future occurrence of major cardiovascular events in contrast to patients with white-coat resistant hypertension (i.e., with controlled ambulatory BPs despite uncontrolled office BPs). This review reinforces the pivotal role of serial ambulatory BP monitoring examinations in the clinical management of patients with resistant hypertension.

Hypertension Editors' Picks: Hypertension and Sleep.

Hypertension Editors' Picks: Hypertension and Sleep.

Abstract 15836: Blood Pressure Control and Subclinical Left Ventricular Dysfunction in Treated Hypertensive Subjects

Background: Blood pressure (BP) control in hypertensive patients is crucial to reducing the risk of future cardiovascular events and heart failure. Left ventricular (LV) global longitudinal strain (GLS) can detect early subclinical cardiac dysfunction, even when LV ejection fraction (EF) is normal, and is an important prognostic indicator. It is not known whether poor BP control is associated with subclinical dysfunction by GLS, and whether ambulatory BP (ABP) is superior to office BP measurements in this regard. Methods: Two-dimensional speckle tracking echocardiography and 24-hour ABP monitoring were performed in 394 treated hypertensive subjects (mean age 72 ± 9 years; 63% women) with LVEF ≥50% from the Cardiovascular Abnormalities and Brain Lesions (CABL) study. Uncontrolled office BP was defined as systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg; uncontrolled ABP as mean 24-hour systolic BP ≥130 mmHg and/or diastolic BP ≥80 mmHg. Abnormal GLS was defined as a value above the 95% percentile of healthy normotensive subjects from the CABL cohort. Results: Office BP was uncontrolled in 188 subjects (47.7%), and ABP in 162 (41.1%). Agreement between these two categorization was low [kappa = 0.16, 95% confidence interval (CI), 0.06-0.26; concordant classification in only 58.4% of subjects]. Subjects with uncontrolled ABP showed significantly worse GLS compared to those with controlled ABP (-16.3 ± 3.0% vs -17.7 ± 2.9%, p&lt;0.0001), whereas GLS was not significantly different between those with uncontrolled vs controlled office BP (-16.8 ± 3.1% vs -17.4 ± 3.0%, p=0.07). After adjustment for pertinent covariates (age, sex, race-ethnicity, body mass index, diabetes mellitus, coronary artery disease and LV mass index), uncontrolled ABP was associated with a higher risk of abnormal GLS (odds ratio = 2.32; 95% CI, 1.33-4.03; p=0.003), while uncontrolled office BP was not (odds ratio = 1.30; 95% CI, 0.76-2.22; p=0.35). Conclusions: Uncontrolled 24-hour ABP is strongly associated with LV subclinical dysfunction in hypertensive subjects with normal LVEF. Assessing BP control with ABP monitoring may refine the risk stratification of treated hypertensive patients for early LV dysfunction.

Characteristics, drug combinations and dosages of primary care patients with uncontrolled ambulatory blood pressure and high medication adherence

Most studies on the prevalence and determinants of resistant hypertension (RH) do not account for white coat hypertension, medication non-adherence, or use of suboptimal treatment dosages. We studied the characteristics, drug combinations, and dosages of patients on at least three antihypertensives of different classes who had uncontrolled blood pressure on 24-hour ambulatory blood pressure monitoring and high medication adherence measured by electronic monitoring. The data were collected as part of the baseline measures of a hypertension control trial. Of 140 monitored primary care patients, all with uncontrolled office blood pressure, 69 (49%) were on at least three antihypertensives of different classes. Of these 69, 15 (22%) were controlled on ambulatory blood pressure monitoring, 20 (29%) were uncontrolled and non-adherent, leaving only 34 (49%) adherent to their medications and having uncontrolled ambulatory hypertension (uncontrolled RH). Thirty-one (91%) of the 34 uncontrolled RH patients were prescribed a diuretic, of which 24 were on hydrochlorothiazide 25 mg. Less than half of the patients on angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or calcium channel blocker were prescribed maximal doses of these agents. Half of the RH can be attributed to white coat effect and poor medication adherence, and all of the remaining patients were on apparently suboptimal drug combinations and/or dosages. Primary care physicians need to be educated regarding the optimal treatment of RH.

Differences Between Office and 24-Hour Blood Pressure Control in Hypertensive Patients With CKD: A 5,693-Patient Cross-sectional Analysis From Spain

Previous studies have examined control rates of office blood pressure (BP) in chronic kidney disease (CKD). However, recent evidence suggests major discrepancies between office and 24-hour BP values in hypertensive populations. This study examined concordance/discordance between office- and ambulatory-based BP control in a large cohort of patients with CKD. Cross-sectional. 5,693 hypertensive individuals with CKD stages 1-5 from the Spanish ABPM (ambulatory BP monitoring) Registry. Thresholds of 140/90 and 130/80 mm Hg for office BP and 24-hour ambulatory BP, respectively. Age, sex, body mass index, waist circumference, hypertension duration, kidney measures, diabetes, dyslipidemia, target-organ damage, and cardiovascular comorbid conditions. Misclassification of BP control as "white-coat" hypertension (office BP ≥140/90 mm Hg, 24-hour BP <130/80 mm Hg) or masked hypertension (office BP <140/90 mm Hg, 24-hour BP ≥130/80 mm Hg). Standardized office-based BP and 24-hour ABPM. Mean age was 61.0 ± 13.9 (SD) years and 52.6% were men. The proportion with white-coat hypertension was 28.8% (36.8% of patients with office BP ≥140/90 mm Hg) and that of masked hypertension was 7.0% (but 32.1% of patients with office BP <140/90 mm Hg). Female sex, aging, obesity, and target-organ damage were associated with white-coat hypertension; aging and obesity were associated with masked hypertension. Only 21.7% and 8.1% of the CKD population had office BP <140/90 and <130/80 mm Hg, respectively. In contrast, 43.5% of individuals had average 24-hour BP <130/80 mm Hg. Cross-sectional design, longitudinal associations cannot be established. Misclassification of BP control at the office was observed in 1 of 3 hypertensive patients with CKD. Ambulatory-based control rates were far better than office-based rates. Nevertheless, the burden of uncontrolled ambulatory BP and misclassification of BP control at the office constitutes a call for wider use of ABPM to evaluate the success of hypertension treatment in patients with CKD.

Resistant hypertension: a practical clinical approach

Resistant hypertension (RH) is defined as an uncontrolled office blood pressure (BP) despite the use of at least three antihypertensive drugs. With an increasing prevalence, RH implies in a very high cardiovascular risk and needs a careful clinical approach, aiming to control BP and to reduce its morbidity and mortality. The initial diagnostic approach involves drug adherence checking and the evaluation of antihypertensive scheme, emphasizing the use of diuretics and adequate combination and dosages of the two other drugs, which preferentially reduces cardiovascular risk and promotes prevention/regression of target organ damages. Because of an exaggerated white-coat effect, ambulatory BP monitoring (ABPM) at baseline is mandatory to classify patients into true RH (uncontrolled ambulatory BPs) and white-coat RH (controlled ambulatory BPs), and define initial therapeutic approach. Ideally, the objective is ambulatory BP control, so the treatment follow-up shall be based on ABPM measurements. The treatment involves lifestyle changes and use of adequate combinations of antihypertensive agents from different classes. In this way, patients with true RH need to intensify antihypertensive treatment by adding aldosterone antagonists as the fourth drug and also changing antihypertensive treatment to bedtime. Otherwise, in patients with controlled ambulatory BP, the therapeutic scheme should be maintained and ABPM or home BP monitoring repeated serially. Despite pharmacological interventions, ambulatory BP control in RH patients remains challenging and new interventional procedures have been recently proposed, as renal denervation and baroreflex activation therapy. Currently, these procedures shall be reserved to true RH patients in whom other alternatives have failed.

How to use ambulatory blood pressure monitoring in resistant hypertension

Resistant hypertension is defined as an uncontrolled office blood pressure (BP) despite the use of at least three antihypertensive drugs, in adequate doses and combinations, preferentially including one diuretic. It is a clinical diagnosis based on office BP measurements. Ambulatory BP monitoring (ABPM) is the cornerstone in the management of patients with resistant hypertension, as it is mandatory for diagnosis, treatment, follow-up and prognosis. In relation to diagnosis, ABPM measurements have classified patients with resistant hypertension into four subgroups: true, white-coat, controlled and masked resistant hypertension. This classification largely defines the therapeutic approach and the follow-up for each group. In this way, the target of antihypertensive treatment is ambulatory BP control and not office BP control. Chronotherapy based on ABPM values might frequently lead to a more rational treatment regimen. In relation to prognosis, uncontrolled ambulatory BP levels at baseline identify a subgroup of patients with a very high cardiovascular risk profile and a significantly worse prognosis. ABPM parameters can provide a better cardiovascular risk stratification than other traditional risk factors and office BPs.

CHRONOTHERAPY WITH A FIXED VALSARTAN/HYDROCHLOROTHIAZIDE COMBINATION: IMPROVED NIGHTTIME BLOOD PRESSURE CONTROL WITH BEDTIME DOSING: PP.5.168

Objectives: We have previously documented a significant change in the dose-response curve, increased proportion of controlled patients, and improved efficacy on nighttime blood pressure (BP) when valsartan was ingested at bedtime, as compared to upon awakening, in subjects with essential hypertension. However, no study has yet investigated the potential differing effects depending of the time of administration of combination therapy. Accordingly, we investigated the administration-time-dependent antihypertensive efficacy of valsartan-hydrochlorothiazide (HCTZ) combination. Methods: We studied 204 hypertensive subjects (95 men), 49.7 ± 11.1 years of age, randomly assigned to receive valsartan (160 mg/day) monotherapy either on awakening or at bedtime for 12 weeks. Due to uncontrolled ambulatory BP, HCTZ (12.5 mg/day) was added to valsartan as a single-pill formulation, maintaining the original circadian time of treatment, for another 12 weeks. BP was measured every 20-min from 07:00 to 23:00 h and every 30-min at night for 48 h before treatment and after each period of 12 weeks of therapy. Results: Combination treatment resulted in a statistically significant reduction of the 24 h BP mean from baseline, similar for both treatment-time groups (P > 0.542). The efficacy of valsartan/HCTZ on the awake BP mean was also similar for the two treatment-groups (P > 0.682). Results, however, reveal a greater efficacy with bedtime dosing in regulating asleep systolic BP (P = 0.015) as well as asleep pulse pressure (PP; P = 0.007 between groups). Accordingly, there was a significant (P < 0.001) increase in sleep-time relative systolic BP decline only when valsartan/HCTZ was consistently ingested at bedtime. The proportion of non-dipping was reduced from 59 to 23% only after bedtime dosing (P < 0.001). Conclusions: In patients not properly controlled with valsartan monotherapy, the addition of 12.5 mg/day HCTZ efficiently reduces BP for the entire 24 h of the day independently of dosing time. Bedtime administration, however, may be preferred, mainly in the elderly and patients with diabetes, due to the associated increase in sleep-time relative systolic BP decline and the decrease in ambulatory PP, both relevant markers of cardiovascular risk.