Uncontrolled Office Blood Pressure Research Articles

Nocturnal blood pressure dipping and left ventricular hypertrophy among hypertensive outpatients in a Ghanaian hospital.

To investigate the association between the extent of nocturnal systolic blood pressure decline and left ventricular hypertrophy in patients with primary hypertension who were receiving antihypertensive drug therapy. This was a cross-sectional hospital-based study from November 2020 to March 2021. The study was conducted at the Polyclinic of Korle Bu Teaching Hospital, Ghana. Outpatients ≥18 years old with primary hypertension who were receiving antihypertensive drug therapy. Each participant underwent a 24-hour ambulatory blood pressure monitoring and a transthoracic echocardiogram. Left ventricular hypertrophy and the extent of mean systolic blood pressure decline during sleep. 180 participants were recruited, comprising 110 (61.1%) females. The participants' mean (±SD) age was 57.6 ± 11.0 years. 80% had a non-dipping blood pressure pattern, and 43.9% had left ventricular hypertrophy. Uncontrolled office blood pressure was an independent predictor of left ventricular hypertrophy in these patients (AOR 2.010, 95% CI 1.048-3.855, p=0.036); however, a non-dipping nocturnal systolic blood pressure status was not (AOR 1.849, 95% CI 0.850-4.022, p=0.121). 61.1% had abnormal left ventricular geometry, with concentric hypertrophy being the predominant geometric pattern. Left ventricular hypertrophy and non-dipping nocturnal blood pressure were common in these hypertensive Ghanaian patients on antihypertensive therapy. Left ventricular hypertrophy was associated with uncontrolled office blood pressure but not the extent of nocturnal systolic blood pressure declines during a single 24-hour ambulatory blood pressure recording. None declared.

P075 IS OFFICE BLOOD PRESSURE MEASUREMENT SUFFICIENT FOR DIAGNOSING HYPERTENSION IN PRIMARY HEALTH CARE?

Background and Objective: Recent guidelines have recommended out-of-office blood pressure (BP) measurement to improve the accuracy of the diagnosis of hypertension (HTN) but there are few studies evaluating its use in the scope of primary care. Our objective is to assess the degree of agreement between office BP and HBPM, evaluating their use in a young population assisted in primary care. Methods: This is a cross-sectional population study with adults between 20-50 years old registered in the Family Health Strategy. Sociodemographic, anthropometric data and CV risk factors were recorded. Office BP was the mean of 2 measurements and HBPM followed the 7-day protocol. HBPM < 135 x 85 mmHg and office BP < 140 x 90 mmHg were considered normal, identifying the 4 phenotypes: Normotension (controlled office BP and HBPM); white-coat HTN (uncontrolled office BP and controlled HBPM); masked HTN (controlled office BP and uncontrolled HBPM) and sustained HTN (uncontrolled office BP and HBPM). Results: 475 individuals were included (male sex: 38%; mean age: 37.6 years ± 8.8 years, of which 93 (20%) had their diagnosis modified after HBPM (43 with white-coat and 47 with masked HTN). In multiple logistics regression, male gender (OR 3.87: 95%CI 1.70-8.82) was independently correlated with white-coat HTN, while obesity and prehypertension increased the risk of masked HTN by 2 and 5.5 times, respectively. Uncontrolled office BP has high specificity (89%) and low sensitivity (49%) for detecting sustained HTN, with a low concordance in the diagnosis of HTN (kappa=0.388) Among men with uncontrolled office BP, 55.6% had a diagnosis of white-coat HTN and among women, 37.1%. Conclusion: Office BP was not a sufficient measurement to diagnose hypertension. HBPM was a useful procedure in this young and apparently healthy population in primary care, especially in those with uncontrolled office BP to identify white-coat HTN and in those with high normal office BP, especially if they are male or obese for early diagnosis of masked HTN.

Resistant hypertension and the risk of major adverse cardiac and cerebrovascular events in outpatients

Objective: To investigate the prevalence and associated risk of cardiovascular event of resistant hypertension in treated outpatients. Methods: This study was a nationwide multi-center prospective cohort study. The participants were treated outpatients enrolled in the China Nationwide Ambulatory and Home Blood Pressure Registry study of 42 hospitals in 19 provinces across the country from August 2009 to October 2017. Apparent resistant hypertension was defined as uncontrolled office blood pressure (≥140/90 mmHg, 1 mmHg=0.133 kPa) in spite of the use of three antihypertensive drugs or controlled office blood pressure (<140/90 mmHg) with four antihypertensive drugs or more. Subjects diagnosed with uncontrolled office blood pressure were further subdivided as pseudo-resistant hypertension and true resistant hypertension based on 24 h ambulatory blood pressure monitoring. The primary endpoint was fatal and non-fatal cardiovascular and cerebrovascular events, which was a composite endpoint consisting of cardiovascular and cerebrovascular death, ischemic and hemorrhagic stroke, myocardial infarction, coronary artery revascularization, unstable angina, heart failure, and coronary artery stenosis≥50% confirmed by coronary angiography. Secondary outcomes included fatal and non-fatal stroke or cardiac events. Patients with controlled office blood pressure after taking only 1 or 2 antihypertensive drugs were included as control. Kaplan-Meier survival curves, log-rank test, and Cox proportional risk model were used to evaluate the risk of apparent refractory hypertension in relation to cardiovascular and cerebrovascular prognosis. Results: A total of 2 782 treated hypertensive patients, aged (58.1±12.3) years were enrolled, including 1 403 (50.4%) men. The prevalence of apparent and true resistant hypertension was 15.1% (420/2 782) and 10.5% (293/2 782), respectively. Among patients with apparent resistant hypertension, during a median of 5 years follow-up, the cumulative incidence rate was 28.2, 11.2 and 19.1 per 1 000 person-years for fatal and non-fatal cardiovascular events (n=58), stroke (n=24) and cardiac events (n=40), respectively. The Kaplan-Meier curve and log-rank test showed that those patients with true resistant hypertension, had the highest cumulative incidence rate of fatal and non-fatal cardiovascular events, stroke, and cardiac events. Multivariable Cox regression analyses showed that true resistant hypertension was associated with a significantly higher risk of fatal and non-fatal cardiovascular events (HR=1.73, 95%CI 1.17-2.56, P=0.006) and stroke (HR=2.81, 95%CI 1.53-5.17, P=0.001). Conclusion: Resistant hypertension, especially true resistant hypertension, is associated with a higher risk of fatal and non-fatal cardiac and cerebrovascular events.

Kidney subclinical lesions in hypertension phenotypes defined by Home Blood Pressure Monitoring among young adults enrolled in a Family Health Strategy unit

Abstract Introduction The association between kidney lesion, hypertension (HTN) and cardiovascular risk (CV) is well established. Asymptomatic patients with decreased glomerular filtration rate (GFR) and/or increased albuminuria seem to have increased CV risk. The refinement of HTN diagnosis using Home Blood Pressure Monitoring (HBPM) allows to identify individuals with different phenotypes: normotension, sustained HTN (SHT), masked HTN (MHT) and white-coat HTN (WHT), increasing diagnostic accuracy. Objective To assess kidney subclinical lesions among different hypertension (HTN) phenotypes identified by Home Blood Pressure Monitoring (HBPM) in an adult population enrolled in a Family Health Strategy unit. Design and Methods: Cross-sectional, populational study with adults between 20-50 years old enrolled in a Family Health Strategy unit in a metropolis. Sociodemographic, anthropometric and CV risk factors were registered. Office blood pressure (BP) was the average of two consecutive measurements, and HBPM followed a 7-day protocol. HBPM &amp;lt; 135x85 mmHg and office BP &amp;lt; 140x90mmHg were considered normal, identifying four phenotypes: normotension (controlled office BP and HBPM); white-coat hypertension (uncontrolled office BP and controlled HBPM); masked hypertension (controlled office BP and uncontrolled HBPM) and sustained hypertension (uncontrolled office BP and HBPM). Albuminuria was dosed in an isolated urine sample whereas glomerular filtration rate was calculated by CKD Epi formula using serum creatinine. Results A total of 483 individuals were evaluated (39% male; mean age: 37.6 ± 8.8 years). More often, individuals with white-coat hypertension (9.3%) are male, with greater neck circumference and higher prevalence of metabolic syndrome. Individuals with masked hypertension (10%) are more obese, with increased neck and waist circumferences whereas those who present sustained hypertension are predominantly male, more obese, with increased neck and waist circumferences and higher prevalence of diabetes and metabolic syndrome. Analyzing four phenotypes, a progressive albuminuria increase was observed among normotensive patients: white-coat hypertension 4.0 ± 2.2; masked hypertension 5.3 ± 3.4 and sustained hypertension 7.1 ± 1.4 mg/g creatinine. We also observed an increased serum creatinine and decreased GFR: white-coat hypertension 0.74 ± 0.16/132 ± 34; masked hypertension 0.79 ± 0.17/123 ± 28; sustained hypertension 0.81 ± 0.32/120 ± 59, respectively, although without statistical significance. Conclusion The performance of HBPM refined HTN diagnosis and was able to early identify a progressive worsening of kidney function parameters in the different phenotypes.

Proceedings of the 2022 IDACO/IDHOCO/IDCARS/UPRIGHT-HTM Consortium Meeting, 1-3 December 2022, Lamot Congress and Heritage Centre, Mechelen, Belgium Meeting Chairpersons: Kei Asayama and Jan A. Staessen.

Background: Home blood pressure telemonitoring (HTM) is recommended by several guidelines in the management of hypertension with its benefits widely documented. HTM enables patients’ active participation in their management and also assists in the diagnoses of white coat and masked hypertension. The feasibility of HTM in poor resource settings such as in Nigeria is unknown. Aim: To determine the feasibility of HTM in Nigeria Methods: We evaluated HTM among Nigerians recruited under the framework of Urinary Proteomics combined with Home Blood Pressure Telemonitoring for Health Care Reforms trial (UPRIGHT-HTM), a multi-centre global clinical trial involving three centres in Nigeria. Eligible patients, aged 55-75 years old with ≥5 cardiovascular diseases risk factors but asymptomatic were trained to collect HTM data using Bluetooth-enabled automated blood pressure (BP) monitors aided with web-based applications that run on android smartphones. Results: Of the 171 patients screened over a 17-month period (May 2021 to September 2022), 1 (0.6%) withdrew consent, 8 (4.8%) without android smart phones, 3 (1.8%) inconsistent with BP measurement over a 5-week run-in period, and 23 (11.3%) who did not meet the inclusion criteria were excluded from this analysis. Of the 136 subjects randomised, 75 (54.4%) were women, 68 (50.0) were obese and 66 (48.5%) had uncontrolled office BP. The time taken to train subjects on HTM averaged at 8.1±3.4 minutes. So far, 44, 236 BP measurements were taken. Overall, the median annual number of BP measurements in the first and second year were 36 and 127 respectively, with monthly median measurements ranging from 12 in August of the first year to 49 measurements in November of the same year. More than 50% of the subjects measured their BP at least 2 times weekly in all but the first quarter of the first year. The average monthly systolic and diastolic BP in each of the 18 months were less than 135mmHg and 85 mmHg respectively. Conclusion: HTM is feasible in clinical trial settings and thus can be integrated into the routine clinical practice in Nigeria.

Therapeutic concordance improves blood pressure control in patients with resistant hypertension

IntroductionAn empathetic approach may be particularly useful in patients with therapy-resistant hypertension (TRH), defined as the failure to achieve target blood pressure (BP) despite a maximal doses of 3 antihypertensive drugs including a diuretic. However, the effects of therapeutic concordance have not been determined in hypertensive patients. MethodsWe designed a study to explore the impact of therapeutic concordance in patients with TRH, who were included in an intervention arm based on a protocol in which trained personnel periodically verified the pharmacological regimen of these patients. ResultsFrom a cohort of 5331 hypertensive patients followed-up for 77.64 ± 34.44 months, 886 subjects were found to have TRH; of these, 322 had apparent TRH (aTRH: uncontrolled office BP but optimal home BP) and 285 refused to participate in a second follow-up study, yielding a population of 279 patients with true TRH (tTRH). These tTRH patients were followed according to the therapeutic concordance protocol for 91.91 ± 54.7 months, revealing that 210 patients (75.27%) remained with uncontrolled BP (uncontrolled tTRH, Group I) while 69 patients (24.73%) reached an optimal BP control (average BP <140/90 mmHg in at least 50% of follow-up visits, Group II). Strikingly, at the end of the second follow-up, the percentage of patients displaying a decline in kidney function was significantly smaller in Group II than in Group I (8.5% vs 23.4%, p < 0.012). ConclusionsTaken together, our findings indicate for the first time that therapeutic concordance significantly improves the outcome of antihypertensive treatment in a population of patients with TRH.

Abstract 15741: Is Home Blood Pressure Monitoring Useful in Diagnosing Hypertension in Young Adults in Primary Care?

Introduction: Recent guidelines have recommended out-of-office blood pressure (BP) measurement to improve the accuracy of the diagnosis of hypertension (HTN) but there are few studies evaluating its use in the younger population and in the scope of primary care. Objective: To assess the degree of agreement between office BP and Home Blood Pressure Monitoring (HBPM), evaluating their use in a young population assisted in primary care. Methods: This is a cross-sectional population study with adults between 20-50 years old registered in the Family Health Strategy. Sociodemographic, anthropometric data and cardiovascular risk factors were recorded. Office BP was the mean of 2 measurements and HBPM followed the 7-day protocol. HBPM &lt; 135 x 85 mmHg and office BP &lt; 140 x 90 mmHg were considered normal while dentifying the 4 phenotypes: Normotension (controlled office BP and HBPM); white-coat HTN (uncontrolled office BP and controlled HBPM); masked HTN (controlled office BP and uncontrolled HBPM) and sustained HTN (uncontrolled office BP and HBPM). Results: 475 individuals were included (male sex: 38%; mean age: 37.6 years ± 8.8 years) of which 93 (20%) had their diagnosis modified after HBPM (43 with white-coat and 47 with masked HTN). Through multiple logistics regression, male gender (OR 3.87: 95%CI 1.70-8.82) was independently correlated with white-coat HTN, while obesity and prehypertension increased the risk of masked HTN by 2 and 5.5 times respectively. Uncontrolled office BP had high specificity (89%) and low sensitivity (49%) for detecting sustained HTN, with a low concordance in the diagnosis of HTN (kappa=0.388). Among men with uncontrolled office BP, 55.6% had a diagnosis of white-coat HTN and among women, 37.1%. Conclusion: HBPM was a useful tool in the diagnosis of hypertension in a young and apparently healthy population in primary care, especially in those with uncontrolled office BP to identify white-coat HTN, and in those with high normal office BP, especially if they were male or obese, for early diagnosis of masked HTN.

KIDNEY SUBCLINICAL LESIONS IN HYPERTENSION PHENOTYPES DEFINED BY HOME BLOOD PRESSURE MONITORING AMONG YOUNG ADULTS ENROLLED IN A FAMILY HEALTH STRATEGY UNIT

Objective: To assess kidney subclinical lesions among different hypertension (HTN) phenotypes identified by Home Blood Pressure Monitoring (HBPM) in an adult population enrolled in a Family Health Strategy unit Design and method: Cross-sectional, populational study with adults between 20–50 years old enrolled in a Family Health Strategy unit in a metropolis. Sociodemographic, anthropometric and CV risk factors were registered. Office blood pressure (BP) was the average of two consecutive measurements, and HBPM followed a 7-day protocol. HBPM &lt; 135x85 mmHg and office BP &lt; 140x90mmHg were considered normal, identifying four phenotypes: normotension (controlled office BP and HBPM); white-coat hypertension (uncontrolled office BP and controlled HBPM); masked hypertension (controlled office BP and uncontrolled HBPM) and sustained hypertension (uncontrolled office BP and HBPM). Albuminuria was dosed in an isolated urine sample whereas glomerular filtration rate was calculated by CKD Epi formula using serum creatinine. Results: A total of 483 individuals were evaluated (39% male; mean age: 37.6 ± 8.8 years). More often, individuals with white-coat hypertension (9.3%) are male, with greater neck circumference and higher prevalence of metabolic syndrome. Individuals with masked hypertension (10%) are more obese, with increased neck and waist circumferences whereas those who present sustained hypertension are predominantly male, more obese, with increased neck and waist circumferences and higher prevalence of diabetes and metabolic syndrome. Analyzing four phenotypes, a progressive albuminuria increase was observed among normotensive patients: white-coat hypertension 4.0 ± 2.2; masked hypertension 5.3 ± 3.4 and sustained hypertension 7.1 ± 1.4 mg/g creatinine. We also observed an increased serum creatinine and decreased GFR: white-coat hypertension 0.74 ± 0.16/132 ± 34; masked hypertension 0.79 ± 0.17/123 ± 28; sustained hypertension 0.81 ± 0.32/120 ± 59, respectively, although without statistical significance. Conclusions: The performance of HBPM refined HTN diagnosis and was able to early identify a progressive worsening of kidney function parameters in the different phenotypes.

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.

A Study Comparing Office Blood Pressure with Ambulatory Blood Pressure in Successful Adult Kidney-Transplant Recipients at a Tertiary Care Center in North India

Introduction: Hypertension is common following successful renal transplantation and has adverse effects on cardio-vascular and graft health. Blood pressure (BP) readings obtained during clinical visits can be misleading and ambulatory blood pressure monitoring (ABPM) is a more reliable and accurate non-invasive method of BP monitoring. Aims and Objectives: To compare office BP with ambulatory BP recordings in successful adult kidney transplant recipients (KTRs). Material and Methods: Office BP (OBP) was measured with mercury sphygmomanometer according to standardized procedure as the mean of two readings taken 1 minute apart; thereafter, 24 hour ABPM was done using automated oscillometric device (Meditech device) in 56 KTRs. Results: OBP missed hypertension in 68% of KTRs who had normal OBP (masked phenomenon) and OBP overestimated hypertension in 11% of KTRs with uncontrolled OBP (white coat phenomenon). Thirty-four percent of patients were normal dippers, 32% non-dippers, 25% reverse dippers and 9% were extreme dippers. Conclusions: ABPM is a valuable tool in detecting dipping status, white coat and masked phenomena which are frequent problems among KTRs and should be considered as part of routine management of hypertension in KTRs.

THERAPEUTIC APPROACH FOR HYPERTENSION MANAGEMENT AND CONTROL IN PATIENTS RECEIVING OLMESARTAN-BASED TREATMENT: THE “FAMILY” NON-INTERVENTIONAL STUDY IN PRIMARY CARE IN GREECE

Objective: To evaluate the characteristics, office blood pressure (OBP) levels and usual treatment strategies of hypertensive patients receiving olmesartan-based therapy in general practice. Design and method: A nationwide non-interventional survey was performed by primary-care doctors who assessed consecutive hypertensives on stable (&gt; = 4 weeks) olmesartan-based therapy. Patients’ characteristics, OBP levels and treatment changes were reported. Results: A total of 4,883 hypertensives on olmesartan-based therapy (age 66.5 ± 11.2 years, men 54%, diabetics 26%, smokers 23%) were assessed by 491 doctors (48% cardiologists, 39% internists, 12% general practitioners, 1% others). Average OBP was 137.6 ± 16.0/82.4 ± 9.8 mmHg (systolic/diastolic) and 56% had controlled OBP (&lt;140/90 mmHg). Participants were receiving 2.2 ± 0.8 antihypertensive drugs (olmesartan monotherapy 21%; 2 drugs 44%; 3 drugs 30%; &gt; = 4 drugs 5%). Of subjects on olmesartan combinations (79%), 89% used fixed-dose pills (37% olmesartan-amlodipine; 28% olmesartan-hydrochlorothiazide; 35% olmesartan-amlodipine-hydrochlorothiazide). Cardiologists prescribed fixed-dose combinations more frequently than general practitioners or internists (77/75/72% respectively, p &lt; 0.01). 13% of patients reported missing at least one dose per week, with most common reported cause the complexity of treatment regimen (75%). OBP control was (i) higher in nondiabetics than diabetics (58% vs. 52%, p &lt; 0.01), despite using fewer drugs (2.2 ± 0.8 vs. 2.4 ± 0.8 drugs, p &lt; 0.01), (ii) lower in patients on monotherapy compared to 2, 3 or &gt; = 4 drugs (53/56/59/57% respectively, p &lt; 0.05) and (iii) higher in patients on fixed-dose than free combinations (58% vs. 53%, p &lt; 0.01). In cases with uncontrolled OBP the following actions were decided: dose increase 18%; drug addition 17%; drug substitution 3%; treatment simplification using fixed-dose combination 7%; no change 55%. Conclusions: Combination therapy and particularly fixed-dose combinations are widely prescribed in primary care. However, uncontrolled OBP is common, even in patients on monotherapy, and is worse in diabetics. Physicians’ inertia and complexity of regimen are major barriers in achieving optimal control. More intense and simpler therapy, with wider use of triple fixed-dose combinations and second-line drugs, are necessary to improve the control of hypertension in primary care.

CONCORDANCE BETWEEN THE DIAGNOSIS OF HYPERTENSION BY OFFICE BLOOD PRESSURE AND HOME BLOOD PRESSURE MONITORING IN A FAMILY HEALTH CARE UNIT- LAPARC COHORT STUDY

Objective: To evaluate concordance between diagnosis of hypertension by Office Blood Pressure (OBP) and Home Blood Pressure Monitoring (HBPM) in a young adult population. Design and method: A cross-sectional population study enrolled adults between 20 and 50 years registered in a primary healthcare unit in the city of Rio de Janeiro, Brazil. Socio-demographic and anthropometric characteristics were registered at the entrance of the study. Also, the presence of CV risk factors was evaluated. OBP was determined by calculating the mean value of 2 consecutive measurements (Omron-705CP) while the HBPM followed a 7-day protocol with 2 measurements in the morning and 2 in the evening (28 measurements). Measurements of the first day were discarded and the average of the other 6 days was calculated. It was considered normal a Home BP &lt; 135 x 85 mmHg and OBP &lt; 140 x 90 mmHg. Patients were classified into 4 groups: normotension (controlled OBP and HBPM); white coat hypertension (uncontrolled OBP and controlled HBPM); masked hypertension (controlled OBP and uncontrolled HBPM) and sustained hypertension (uncontrolled OBP and HBPM). Results: A total of 462 individuals were evaluated [37.7% males with mean age 37.4 ± 8.8 years]. Sedentary lifestyle (43%), dyslipidemia (38%) and obesity (28%) were the main CV risk factors. By OBP, the prevalence of hypertension was 13.4% while by HBPM was 18.6%. Kappa coefficient demonstrated a low concordance between the two diagnostic methods (kappa = 0.472). After HBPM, 68 individuals (16.9%) changed the diagnosis, being 21 (5.6%) with white coat hypertension and 45 (11.3%) with masked hypertension. The variables that were independently associated with hypertension diagnosed by OBP were male gender (OR 1.83, CI95%, 1.01–3.33, p = 0.04) and increased neck circumference (OR 3.77, CI95%:1.59–8.93, p = 0.003). Hypertension diagnosed by HBPM was associated with obesity (OR 2.18, CI95%, 1.27–3.76, p = 0.005) and increased neck circumference (OR 2.37, CI95%, 1.05–5.33, p = 0.04). Conclusions: Concordance between office BP and HBPM was low in this young adult population. Thus, If the diagnosis was based only in the office BP values, 17.5% of the subjects would have an erroneous diagnosis of hypertension.

Impact of hospitalization for checking medication adherence due to resistant and refractory hypertension suspicious on short and mid-term blood pressure control

Abstract Background Resistant (HR) and refractory hypertension (HRef) are associated with increased cardiovascular events and target-organ damage. However, appropriate HR and HRef diagnosis require good drug adherence. In this context, the “gold standard” method for assessing adherence is supervised medication intake. However, it is not clear the real utility of supervised medication intake in clinical practice. Purpose To evaluate whether hospitalization for confirming anti-hypertensive adherence in patients with HR and HRef may impact blood pressure (BP) control after hospital discharge in patients with HR or HRef suspicious at a tertiary outpatient clinic. Methods We recruited consecutive patients with HR or HRef suspicious admitted to the Hospital for confirming treatment adherence. HR was defined as uncontrolled office BP (≥140 and/or ≥90mmHg) despite using ≥3 classes at optimal doses (one of them being diuretic) or controlled BP using ≥4 classes. HRef was defined as no BP control despite using ≥5 antihypertensive drugs. Patients with suspected HRef who did not meet the criteria but full field the HR definition were named HRNoRef. During hospitalization, all patients used low sodium diet and had supervised taking of prescribed drugs by the medical team aiming BP control. We defined not only the rate of adherence and HF/HRef status but also BP and number of antihypertensive drugs at hospital discharge and in the two first return outpatient's visits. Results We studied a total of 83 patients with suspected HR/HRef (age 53±14 years; 76% females; pre-hospitalization systolic and diastolic BP: 177±28 and 106±21mmHg, respectively). Of these, 68.7% (57 patients) had suspected HRef in the outpatient clinic. The average number of antihypertensive drugs on admission was 5.3±1.3 classes. After hospitalization, the overall frequency of HR fell to 80% (66 patients). The average number of antihypertensive drugs at hospital discharge as well as systolic and diastolic BP was 4.5±1.3 classes, 131±17mmHg and 80±12mmHg, respectively (p&amp;lt;0.001 vs. pre-hospitalization for all comparisons). Among the HR types, HRef was confirmed in only 27 patients (32.5%). During the outpatient follow-up, the patients remained with lower number of antihypertensive drugs as well as lower systolic and diastolic BP at first outpatient visit (mean returned time: 2.1±1.7months) and second outpatient visit post-discharge (mean returned time 7.1±2.6months) as compared to pre-hospitalization data: First visit: 4.3±1.2 classes, systolic: 152±24mmHg, diastolic BP: 89±17mmHg; second visit: 4.5±1.3 classes, systolic: 150±26mmHg, diastolic BP: 89±15mmHg; (p&amp;lt;0.001 vs. pre-hospitalization for all comparisons). Conclusion Supervised medication intake during hospitalization may help not only to define the HR and HRef status but also to have impact on the number of antihypertensive drugs and lower BP values at short and mid-term follow-up. Funding Acknowledgement Type of funding source: None

Effects of Intensive Versus Standard Office-Based Hypertension Treatment Strategy on White-Coat Effect and Masked Uncontrolled Hypertension: From the SPRINT ABPM Ancillary Study.

Guidelines recommend using out-of-office blood pressure (BP) measurements to confirm the diagnoses of hypertension and in the titration of antihypertensive medication. The prevalence of out-of-office BP phenotypes for an office systolic/diastolic BP goal <140/90 mm Hg has been reported. However, the prevalence of these phenotypes when targeting an office systolic/diastolic BP goal <120/80 is unknown. The SPRINT (Systolic Blood Pressure Intervention Trial) Ambulatory BP Ancillary study evaluated out-of-office BP using ambulatory BP monitoring in 897 participants 27 months after randomization to intensive versus standard BP targets (office systolic BP <120 versus <140 mm Hg). We used office and daytime BP to assess the proportion of participants with white-coat effect (standard target: office BP ≥140/90 mm Hg and daytime BP <135/85 mm Hg versus intensive target: office BP ≥120/80 mm Hg and daytime BP <120/80 mm Hg) and masked uncontrolled hypertension (standard target: office BP <140/90 mm Hg and daytime BP ≥135/85 mm Hg versus intensive target: office BP <120/80 mm Hg and daytime BP ≥120/80 mm Hg) in each treatment arm. The prevalence of white-coat effect and masked uncontrolled hypertension was 9% and 34%, in both treatment groups. Among participants with uncontrolled office BP, white-coat effect was present in 20% and 23% in the intensive and standard groups, respectively. Among participants with controlled office BP, masked uncontrolled hypertension was present in 62% and 56% in the intensive and standard groups, respectively. In conclusion, a more intensive BP target resulted in a similar proportion of patients with white-coat effect and masked uncontrolled hypertension compared with a standard target.

P0153IS THERE ANY VALUE FOR HOSPITALIZATION FOR CHECKING MEDICATION ADHERENCE DUE TO RESISTANT AND REFRACTORY HYPERTENSION SUSPICIOUS? IMPLICATIONS FOR MID-TERM FOR BLOOD PRESSURE CONTROL

Abstract Background and Aims Resistant hypertension (RH) and refractory hypertension (RefH, an extreme phenotype of RH) are associated with increased cardiovascular events and target-organ damage. However, appropriate RH and RefH diagnosis require good drug adherence. In this context, the “gold standard” method for assessing adherence is supervised medication intake. However, it is not clear the real utility of supervised medication intake during a hospital stay. Therefore, this study was aimed to evaluate whether hospitalization for confirming antihypertensive adherence in patients with RH and RefH may impact blood pressure (BP) values and BP control after hospital discharge in patients with RH or RefH suspicious at a tertiary outpatient clinic. Method From June 2015 to June 2017, we recruited consecutive patients with RH or RefH suspicious admitted to the Hospital for confirming treatment adherence and the respective diagnosis. We excluded patients with secondary forms of hypertension. RH was defined as uncontrolled office BP (≥140 and/or ≥90mmHg) despite using ≥3 classes at optimal doses (one of them being diuretic) or controlled BP using ≥4 classes. RefH was defined as no BP control despite using ≥5 antihypertensive drugs. During hospitalization, all patients used low sodium diet (∼3grs of salt/day) and had supervised taking of prescribed drugs by the medical team aiming BP control. We defined not only the rate of adherence and RH/RefH status but also BP and number of antihypertensive drugs at hospital discharge and in the two first outpatients visits returns. Results We studied a total of 83 patients with suspected RH/RefH (age 53±14 years; 76% female gender; body mass index 28.8±6.2 Kg/m2; pre-hospitalization systolic 177±28mmHg and diastolic BP 106±21mmHg). Of these, 68.7% (57 patients) had suspected RefH in the outpatient clinic. The average number of antihypertensive drugs on admission was 5.3±1.3 classes. After hospitalization, the overall frequency of RH fell to 80% (66 patients). The average number of antihypertensive drugs at hospital discharge as well as systolic and diastolic BP was 4.5±1.3 classes, 131±17mmHg and 80±12mmHg, respectively (p&amp;lt;0.001 vs. pre-hospitalization for all comparisons). Among the RH types, RefH was confirmed in only 27 patients (32.5%). As compared to pre-hospitalization data, we noticed consistent lower number of antihypertensive drugs and lower levels of systolic and diastolic BP both at first outpatient visit post-discharge (mean returned time 2.1±1.7 months) and second outpatient visit post-discharge (mean returned time 7.1±2.6 months): First visit: 4.3±1.2 classes, systolic BP: 152±24 mmHg, diastolic BP: 89±17 mmHg; second visit: 4.5±1.3 classes, systolic BP: 150±26 mmHg, diastolic BP: 89±15 mmHg; (p&amp;lt;0.001 vs. pre-hospitalization for all comparisons). As a consequence, the rate of patients that reached at least 140x90mmHg increased from 0% to 35% (first visit post-discharge) and 38.5% (second visit post-discharge). Conclusion Supervised medication intake with controlled salt diet during hospitalization may help not only to define the RH and RefH status in uncontrolled hypertensive outpatients but also to have impact on the number of antihypertensive drugs and lower BP values in the mid-term follow-up.

CONCORDANCE BETWEEN THE DIAGNOSIS OF ARTERIAL HYPERTENSION BY OFFICE BLOOD PRESSURE AND HOME BLOOD PRESSURE MONITORING IN A FAMILY HEALTH STRATEGY UNIT - LAPARC STUDY

Objective: To evaluate concordance between diagnosis of hypertension by office blood pressure (OBP) and Home Blood Pressure Monitoring (HBPM) in a population of young adults. Design and method: A cross-sectional population study with adults between 20 and 50 years registered in the Family Health Strategy in the center of the city of Rio de Janeiro. The study was approved by the institution's Ethics and Research Committee. Socio-demographic and anthropometric characteristics were registered at the entrance of the study. The presence of CV risk factors was evaluated. The OBP was determined by calculating the mean value of 2 consecutive measurements (Omron-705CP) while the HBPM followed the 7-day protocol with 2 measurements in the morning and 2 in the evening (28 measurements). The measurements of the first day were discarded and the average of the other 6 days was calculated. It was considered normal an Home BP < 135 x 85 mmHg and OBP < 140 x 90 mmHg. The patients were classified into 4 groups: normotension (controlled OBP and HBPM); white coat hypertension (uncontrolled OBP and controlled HBPM); masked hypertension (controlled OBP and uncontrolled HBPM) and sustained hypertension (uncontrolled OBP and HBPM). Results: A total of 316 individuals were evaluated, 37.3% male with mean age 39.8 ± 8.6 years. Sedentary lifestyle (44%), dyslipidemia (37%) and obesity (26%) were the main CV risk factors. By OBP, the prevalence of hypertension was 24.4% while by HBPM was 17.8%. The Kappa coefficient demonstrated a low concordance between the two diagnostic methods (kappa = 0.385). After HBPM, 65 individuals (20.6%) changed the diagnosis, being 43 (13.6%) with white coat hypertension and 22 (7.0%) with masked hypertension. The variables that were independently associated with the hypertension diagnosed by OBP were increased neck (OR 3.75, CI95%, 1.50–9.34, p = 0.005) and abdominal circumference (OR 3.13, CI95%, 1.40–6.97, p = 0.005) while the hypertension diagnosed by HBPM were only associated with increased neck circumference (OR 2.45, CI95%, 1.05–5.91, p = 0.04). Conclusions: The concordance between office BP and HBPM was low. If the diagnosis was based on only in information provided by office BP, we would make wrong decisions in 21% of the individuals.

Automated office blood pressure measurements in primary care are misleading in more than one third of treated hypertensives: The VALENTINE-Greece Home Blood Pressure Monitoring study

BackgroundThis study assessed the diagnostic reliability of automated office blood pressure (OBP) measurements in treated hypertensive patients in primary care by evaluating the prevalence of white coat hypertension (WCH) and masked uncontrolled hypertension (MUCH) phenomena. MethodsPrimary care physicians, nationwide in Greece, assessed consecutive hypertensive patients on stable treatment using OBP (1 visit, triplicate measurements) and home blood pressure (HBP) measurements (7 days, duplicate morning and evening measurements). All measurements were performed using validated automated devices with bluetooth capacity (Omron M7 Intelli-IT). Uncontrolled OBP was defined as ≥140/90 mmHg, and uncontrolled HBP was defined as ≥135/85 mmHg. ResultsA total of 790 patients recruited by 135 doctors were analyzed (age: 64.5 ± 14.4 years, diabetics: 21.4%, smokers: 20.6%, and average number of antihypertensive drugs: 1.6 ± 0.8). OBP (137.5 ± 9.4/84.3 ± 7.7 mmHg, systolic/diastolic) was higher than HBP (130.6 ± 11.2/79.9 ± 8 mmHg; difference 6.9 ± 11.6/4.4 ± 7.6 mmHg, p < 0.001). WCH phenomenon (high OBP with low HBP) was observed in 22.7% of the patients, MUCH (low OBP with high HBP) in 15.8%, uncontrolled hypertension (high OBP with high HBP) in 29.9%, and controlled hypertension (low OBP with low HBP) in 31.6%. In multivariate logistic regression analysis, WCH was determined by stage-1 systolic hypertension (odds ratio [OR] 8.6, 95% confidence intervals [CI] 5.7, 13.1) and female gender (OR 1.6, 95% CI 1.1, 2.4), whereas MUCH was determined by high-normal systolic OBP (OR 6.2, 95% CI 3.8, 10.1) and male gender (OR 2.0, 95% CI 1.2, 3.1). ConclusionsIn primary care, automated OBP measurements are misleading in approximately 40% of treated hypertensive patients. HBP monitoring is mandatory to avoid overtreatment of subjects with WCH phenomenon and prevent undertreatment and subsequent excess cardiovascular disease in MUCH.

Hipertensão resistente: abordagem clínica

Hipertensão arterial resistente é definida como a pressão arterial de consultório não controlada, apesar do uso de três ou mais anti-hipertensivos, incluindo, preferencialmente, um diurético. Indivíduos em uso de quatro ou mais medicamentos com controle pressórico também são considerados hipertensos resistentes. Por sua vez, hipertensão refratária é a pressão arterial não controlada, apesar do uso de cinco ou mais drogas, incluindo um tiazídico de ação prolongada e um antagonista da aldosterona. Sua prevalência vem crescendo com o envelhecimento da população e o avanço da obesidade, estando relacionada às altas taxas de morbidade e mortalidade de origem cardiovascular e renal. A abordagem diagnóstica se baseia em quatro pontos: afastar pseudorresistência, identificar o fenômeno do jaleco branco, investigar causas secundárias e identificar lesões subclínicas para estratificação do risco cardiovascular. O objetivo terapêutico é o controle da pressão arterial de 24 horas. Mudanças de estilo de vida devem ser implementadas e as três primeiras drogas devem incluir um diurético adequado, um inibidor do sistema renina-angiotensina-aldosterona e um bloqueador de canais de cálcio. Persistindo o descontrole pressórico, adicionamos a quarta droga: espironolactona. Quanto aos hipertensos refratários, novas modalidades terapêuticas vêm sendo desenvolvidas, como a denervação renal e a estimulação do barorreflexo.

A18207 Effect of nifedipine controlled released tablets (Xinran) on home morning blood pressure in mild-to-moderate hypertension

Objectives: Home blood pressure monitoring (HBPM) is becoming increasingly important in the diagnosis and management of arterial hypertension. The current study aimed to evaluate the effect of nifedipine controlled released tablets (Xinran) was non-inferior to nifedipine Adalat GITs on morning blood pressure (BP) by HBPM using a telemonitoring system. Methods: This multicenter, randomized, double-blind, positive-controlled, Phase IV study recruited 244 patients aged 18–70 years with mild-to-moderate hypertension from December 2014 to December 2017. Baseline office BP had to be 140–179 mmHg systolic and/or 90–109 mmHg diastolic, and home morning BP greater than 135/85 mmHg. Patients were randomly divided into test group (N = 122, nifedipine Xinran) and positive control group (N = 122, nifedipine Adalat GITS) and treated for 8 weeks at a dose of 30 mg/d. The dose was uptitrated to 60 mg/d in case of uncontrolled office BP after 4 weeks. Efficacy assessments included changes from baseline in the average home morning BP, central BP and augmentation index. Results: Of the 244 patients, home morning BP averaged 150.6/93.3 mmHg at baseline, and central BP 138.9/92.7 mmHg. After 8 weeks of treatment, reductions in home morning BP from baseline in patients treated with Xinran were 13.9 ± 11.95 mmHg systolic and 7.3 ± 7.43 mmHg diastolic, being non-inferior (P < 0.00x) to 14.1 ± 11.77 mmHg and 6.9 ± 7.06 mmHg, respectively, in patients treated with nifedipine Adalat GITS. Reductions in central systolic BP from baseline did not differ between the two groups (11.1 ± 15.23 vs. 10.8 ± 12.04 mmHg, P = 0.xx). There was no significant change in central arterial augmentation index (−1.5 ± 9.81% vs. 1.0 ± 8.84%, P = 0.xx) in both groups. Conclusion: Nifedipine controlled released tablets (Xinran) is effective in reducing early morning BP and central arteria

Lowering blood pressure in primary care in Vienna (LOW-BP-VIENNA) : Acluster-randomized trial.

SummaryBackgroundIn Austria only 41% of patients with treated hypertension (HTN) have their blood pressure (BP) controlled. This study investigated a strategy to improve BP control in primary care.MethodsGeneral practitioners (GPs) were randomized to interventional care vs. standard care and included patients with uncontrolled office BP > 140/90 mm Hg. In interventional care, antihypertensive therapy was up-titrated using a single pill combination (olmesartan, amlodipine and/or hydrochlorothiazde) in 4‑week intervals. In standard care, physicians were encouraged to treat according to the 2013 European Society of Cardiology guidelines for the management of arterial hypertension. The primary endpoint was the proportion of patients with controlled office BP < 140/90 mm Hg at 6 months. The main secondary endpoint was the improvement in 24 h ambulatory BP (ABPM, Clinicaltrials.gov NCT02377661).ResultsBetween 2015–2017, 20 GPs contributed to patient recruitment. The trial was discontinued due to slow recruitment after inclusion of 139 eligible patients, 54 of whom were included in the interventional group. A significantly larger proportion of patients in interventional vs. standard care achieved the office BP target (67% ± 26% vs. 39% ± 29%, respectively, mean difference −27.9%, 95% confidence interval CI −54.0%; −1.7%, p = 0.038). The proportion of patients with controlled 24 h ABPM (<130/80 mm Hg) was similar between groups (49% ± 33% vs. 40% ± 34%, respectively, mean difference −8.8%, 95% CI −40.7%; 23.1%, p = 0.57). At baseline, pretreated patients received an average of 1.5 ± 0.8 vs. 1.7 ± 0.9 antihypertensive prescriptions. At 6 months, the respective BP reductions were achieved with 1.2 ± 0.5 prescriptions in interventional vs. 2.0 ± 1.0 in standard care (p < 0.01).ConclusionIn both groups statistically and clinically significant BP reductions were observed after 6 months. In the interventional care group, a larger proportion of patients achieved the office BP target compared to standard care. The 24 h ambulatory blood pressure levels were controlled in 44% of patients at 6 months, without significant differences between groups. The respective BP reductions were achieved with a significantly lower medication burden in interventional care.Electronic supplementary materialThe online version of this article (10.1007/s00508-018-1374-4) contains supplementary material, which is available to authorized users.