Ambulatory Blood Pressure Values Research Articles

Low Levels of Usual Physical Activity Are Associated with Higher 24 h Blood Pressure in Type 2 Diabetes Mellitus in a Cross-Sectional Study.

The aim of this study is to evaluate the association between usual physical activity and 24 h blood pressure (BP) profile in people with type 2 diabetes mellitus (DM). This is a cross-sectional study of 151 participants with type 2 DM. Usual physical activity was assessed by step counting and self-reported questionnaire. BP was measured in office and by 24 h ambulatory BP monitoring (ABPM; 24 h, daytime and nighttime). Mean participant age was 61.1 ± 8.4 years, 64% was women, and mean duration of diabetes was 14.3 ± 8.5 years. Ninety-two percent of participants had hypertension, and office BP was 138 ± 18/78 ± 10 mmHg. Inverse correlations were observed between step count and 24 h BP (systolic, r = −0.186; p = 0.022), daytime BP (systolic, r = −0.198; p = 0.015), and nighttime BP (pulse pressure, r = −0.190; p = 0.019). People were categorized into tertiles of daily step count, and the 1st tertile had higher 24 h systolic BP, daytime systolic BP, daytime mean BP, and daytime systolic BP load than those in the other tertiles, even after adjusting for age and HbA1c. Participants with type 2 DM and low levels of physical activity exhibit higher 24 h and daytime systolic ambulatory BP values as compared with those who performed more steps per day, even after adjustments for confounding factors.

Comparison of valsartan and amlodipine on ambulatory blood pressure variability in hypertensive patients

ABSTRACTWe tested the hypothesis that calcium channel blockers (CCBs: amlodipine group, n = 38)) are superior to angiotensin receptor blockers (ARBs: valsartan group, n = 38) against ambulatory blood pressure variability (BPV) in untreated Japanese hypertensive patients. Both drugs significantly reduced ambulatory systolic and diastolic BP values. With regard to BPV, standard deviation (SD) in SBP did not change with the administration of either drug, but the ARB significantly increased SD in awake DBP (12 ± 4–14 ± 4 mmHg). The ARB also significantly increased the coefficients of variation (CVs)in awake and 24-h SBP/DBP (all P < 0.05), but amlodipine did not change the CV. CCB significantly reduced the maximum values of awake SBP (193 ± 24–182 ± 27 mmHg, P = 0.02), sleep SBP (156 ± 18–139 ± 14 mmHg, P < 0 .001), and awake and sleep DBP (P < 0.01 in both cases), but the ARB did not change the maximum BP values. In conclusion, a once-daily morning dose of CCB amlodipine was more effective at controlling ambulatory BPV than ARB valsartan, especially in reducing maximum BP levels.

Monitoring and evaluation of out-of-office blood pressure during pregnancy.

Blood pressure (BP) is important to measure during pregnancy because it provides the basis for classifying hypertension, which has several etiologies. Similarly, monitoring home and ambulatory BP can provide useful information outside a medical setting for adults who are not pregnant. Office BP is higher during early pregnancy in primiparous women than in multiparous women, whereas out-of-office BP does not differ between them. White-coat hypertension might be benign compared with hypertension determined from ambulatory BP values that might be associated with a high risk for preeclampsia. Although reference values have been proposed on the basis of the distribution of BP among normotensive pregnant women, prognosis-based reference values are also required.

The Importance of Home Versus 24-Hour Ambulatory Blood Pressure Monitoring and Assessment of Blood Pressure Variability in Hypertension

Abstract Background: A number of studies reveal that home blood pressure variability is associated with cardiovascular risk factors. However, we do not have a consensus regarding the variability index and the frequency of measurements. Objective: The aim of the study was to assess home blood pressure variability for a period of 7 consecutive days and 24-hour ambulatory blood pressure variability using the average real variability index and to test whether home blood pressure variability represents a suitable parameter for long-term monitoring of the hypertensive patients. Material and methods: A number of 31 hypertensive patients were included in the study, 8 male, 23 female, mean age 60.19±7.35 years. At the inclusion ambulatory blood pressure monitoring was performed, home blood pressure monitoring was carried out for 7 consecutive days with 2 measurements daily. We compared ambulatory blood pressure values, variability using paired t-test. We were looking for correlations between HBP values and cardiovascular risk factors. Results: Ambulatory versus home blood pressure derived mean blood pressure was 131.38±15.2 versus 131.93±8.25, p=0.81. Ambulatory derived variability was 10.65±2.05 versus home variability 10.56±4.83, p=0.91. Home versus ambulatory pulse pressure was 51.8± 9.06 mmHg vs. 54.9±11.9 mmHg, p=0.046. We found positive correlation between HBPV and home BP values, p=0.027, r2=0.1577, (CI: 0.04967 to 0.6588). Home, as well as ambulatory derived variability were positively correlated to age p=0.043, r2=0.1377 (CI: 0.01234 to 0.6451) versus p&lt;0.0001, CI: 0.3870 to 0.8220, r2=0.4302. Conclusion: Assessment of home blood pressure monitoring and variability could represent a well-tolerated alternative for long-term follow-up of hypertension management.

Effects of the Antihypertensive Fixed-Dose Combinations on an Early Marker of Hypertensive Cardiac Damage in Subjects at Low Cardiovascular Risk.

In hypertensive subjects (HTs), isolated left ventricular diastolic dysfunction (LVDD) is an early marker of cardiac damage and is associated with poor prognosis. However, few intervention trials investigated the effects of antihypertensive therapy on isolated LVDD regression. This study investigates the blood pressure (BP)-lowering efficacy and the effect on LVDD of antihypertensive drugs administered as fixed-dose combinations in untreated HTs with isolated LVDD. A total of 168 HTs (23% of them having impaired fasting glucose (IFG)) aged 48±4.2 years were randomized to receive open-label once-daily oral treatment of beta-blocker + diuretic, angiotensin-converting enzyme inhibitor (ACEI) + diuretic, angiotensin II receptor blocker (ARB) + diuretic, ARB + calcium channel blocker (CCB), or ACEI + CCB. Clinic and 24-hour ambulatory BP values were measured before randomization and at the follow-up. Regression of LVDD was defined as normalization of both the E/A (ratio of early-to-late ventricular filling wave velocity) and E/E' (mitral velocity to early diastolic velocity of the mitral annulus) ratios. Comparisons were made between categorical variables using the χ(2) test and between continuous variables by gender using analysis of variance for repeated measures. BP reduction did not differ between groups. LVDD regression was significantly more prevalent in the ARB + CCB or ACEI + CCB groups than with other combinations; in HTs with IFG, it was most prevalent (46%) with ACEI + CCB. Independently of BP reduction, the fixed-dose combinations ARB + CCB and ACEI + CCB led to regression of isolated LVDD. In those with an IFG, ACEI + CCB was most effective.

Anxiety and sleep as potential mechanisms underlying heightened sympathetic tone in patients with refractory hypertension

(p1⁄40.003). Adolescents with HABP showed significant higher values than normotensives in the AASI, these values were: 0.483 0.3 vs. 0.390 0.2 (p<0.0.04). Spearman Correlation shows a statistically significant correlation between HABP and AASI (r1⁄40.2197, P<0.02) In conclusion, there is a very high prevalence of HABP in adolescent population. In this age group, the AASI is associated with the presence of high ambulatory BP. This condition, associated with arterial stiffness, should be assessed in adolescents with high values of ambulatory blood pressure, because they should be in high cardiovascular risk.

Night-time home versus ambulatory blood pressure in determining target organ damage

This study aimed to evaluate the association of night-time blood pressure (BP) assessed by home blood pressure (HBP) or ambulatory blood pressure (ABP) monitoring with preclinical target organ damage in untreated hypertension. Untreated hypertensive study participants were evaluated with ABP monitoring (24-h) and HBP monitoring during daytime (6 days, duplicate morning and evening measurements) and night-time (automated asleep measurements, three nights, 3-hourly measurements/night). Target organ damage was assessed by echocardiographic left ventricular mass index (LVMI), common carotid intima-media thickness (cIMT), urine albumin excretion (UAE), and ankle-brachial index (ABI). A total of 131 study participants were analysed [mean age 52.1 ± 11.9 (SD) years, BMI 29.9 ± 5.3 kg/m2, men 58%, cardiovascular disease history 6.1%]. Daytime and night-time HBP were slightly higher than the respective ABP values (mean difference for systolic daytime/night-time 3.5 ± 10.6/2.6 ± 9.8 mmHg, P < 0.01 for both comparisons and diastolic -0.3 ± 6.8/1.2 ± 6.2 mmHg, P = NS/0.02, respectively). There was a strong correlation between daytime ABP and HBP (r = 0.71/0.72, systolic/diastolic), as well as between the respective night-time values (r = 0.80/0.79; all P < 0.01). Night-time ABP and HBP presented strong and comparable correlations with all the indices of preclinical target organ damage. In multivariate analyses, both LVMI (R2 = 0.26) and cIMT (R2 = 0.25) were determined by night-time systolic HBP, age and male sex; UAE (R2 = 0.28) by night-time systolic HBP and male sex; ABI (R2 = 0.20) by male sex and night-time home pulse pressure. In untreated hypertensives, night-time BP assessed by home monitoring appears to be as good as night-time ambulatory monitoring in determining preclinical target organ damage.

Orthostatic hypotension and cardiac sympathetic denervation in Parkinson disease patients with REM sleep behavioral disorder

BackgroundRapid eye movement (REM) sleep behavioral disorder (RBD), orthostatic hypotension (OH), and cardiac sympathetic denervation were commonly observed in PD and are related in both the premotor and motor periods. This study is intended to evaluate if the OH and cardiac sympathetic denervation found in PD are associated with RBD. MethodsAmong 94 non-medicated and mild PD patients, 53 had RBD. Orthostatic vital signs and ambulatory 24-hour blood pressure values were recorded. 123I-metaiodobenzylguanidine (MIBG) cardiac scintigraphy as obtained in all patients. The association between orthostatic hypotension, supine hypertension, nocturnal hypertension, non-dipping, myocardial MIBG uptake, and RBD was analyzed. ResultsRBD was associated with orthostatic hypotension. Patients with RBD had higher systolic blood pressure changes during orthostasis and lower myocardial MIBG uptake than patients without RBD and controls. Patients with OH also had lower mean H/M ratios those in the non-OH group. ConclusionThis study showed that RBD was closely associated with OH and cardiac sympathetic denervation in patients with early and mild PD. The result also suggests that impaired cardiac sympathetic innervation could be the mechanism behind OH in PD. This association may be closely correlated with Braak alpha-synuclein pathogenetic sequences, which would account for the clinical spectrum of PD.

White coat hypertension in pediatrics.

The article summarizes current information on blood pressure changes in children during clinic visit. White coat as a general dressing of physicians and health care personnel has been widely accepted at the end of the 19th century. Two problems can be associated with the use of white coat: white coat phenomenon and white coat hypertension. Children often attribute pain and other unpleasant experience to the white coat and refuse afterwards cooperation with examinations. Definition of white coat hypertension in the literature is not uniform. It has been defined as elevated blood pressure in the hospital or clinic with normal blood pressure at home measured during the day by ambulatory blood pressure monitoring system. White coat effect is defined as temporary increase in blood pressure before and during visit in the clinic, regardless what the average daily ambulatory blood pressure values are. Clinical importance of white coat hypertension is mainly because of higher risk for cardiovascular accidents that are dependent on end organ damage (heart, vessels, kidney). Current data do not allow any clear recommendations for the treatment. Pharmacological therapy is usually started in the presence of hypertrophic left ventricle, changes in intimal/medial wall thickness of carotic arteries, microalbuminuria and other cardiovascular risk factors. Nonpharmacological therapy is less controversial and certainly more appropriate. Patients have to change their life style, need to eliminate as much cardiovascular risk factors as possible and sustain a regular blood pressure monitoring.

Effect of Intensive Salt-Restriction Education on Clinic, Home, and Ambulatory Blood Pressure Levels in Treated Hypertensive Patients During a 3-Month Education Period.

The authors tested the hypothesis that low-salt diet education by nutritionists would lower blood pressure (BP) levels in treated hypertensive patients. The amount of urinary salt excretion and clinic, home, and ambulatory BP values at baseline and at 3months were measured in 95 patients with hypertension. After randomization to a nutritional education group (E group, n=51) or a control group (C group, n=44), the C group received conventional salt-restriction education and the E group received intensive nutritional education aimed at salt restriction to 6g/d by nutritionists. From baseline to the end of the study, 24-hour urinary sodium excretion was significantly lowered in the E group compared with the C group (6.8±2.9g/24h vs 8.6±3.4g/24h, P<.01). Morning home systolic BP tended to be lowered in the E group (P=.051), and ambulatory 24-hour systolic BP was significantly lowered in the E group (-4.5±1.3mm Hg) compared with the C group (2.8±1.3mm Hg, P<.001). Intensive nutritional education by nutritionists was shown to be effective in lowering BP in treated hypertensive patients.

Forty-two-year-old female patient with resistant hypertension, bilateral renal fibromuscular dysplasia and intracranial aneurysm.

We present a case of a 42-year-old woman with 1-month known history of resistant hypertension. On admission the patient’s blood pressure was 230/123 mm Hg and during the subsequent days ranged from 165/103 to 157/97 mm Hg (24 h ambulatory blood pressure values (ABPM) 151/102 mm Hg) despite taking 4 antihypertensive drugs (nebivolol 5 mg, amlodipine 10 mg, clonidine 375 µg and indapamide 1.5 mg). Physical examination revealed no abnormalities. Malignant hypertension was diagnosed based on grade III fundoscopy. Laboratory data showed normal serum potassium, creatinine and estimated glomerular filtration rate (eGFR), hemoglobin and platelet count. Urine analysis showed no abnormalities. Electrographic (ECG) and echocardiographic examinations were normal. The patient had two complicated pregnancies and one miscarriage. Doppler ultrasonography revealed bilateral, significant renal artery stenosis (RAS) with renal-aortic ratio (RAR) > 6 on the right side and RAR 4 on the left side, confirmed in computed tomography angiography (angio-CT). Invasive angiography revealed typical multifocal fibromuscular dysplasia (FMD) morphology (“string of beads” appearance) with at least 2 significant lesions of the main right renal artery trunk and also multifocal FMD lesions of left renal artery, with a significant lesion in the central region of the trunk (Figures 1 A and B). Multilevel balloon angioplasty of both arteries was performed, with good final flow, without significant residual stenosis (Figures 2 A and B).

Relationship of Office and Ambulatory Blood Pressure With Left Ventricular Global Longitudinal Strain

Left ventricular (LV) global longitudinal strain (GLS) is an early indicator of subclinical cardiac dysfunction, even when LV ejection fraction (LVEF) is normal, and is an independent predictor of cardiovascular events. Ambulatory blood pressure (BP) is a better predictor of cardiovascular events, including heart failure, than office BP. We investigated the association of office and ambulatory BP measurements with subclinical LV systolic dysfunction in a community-based cohort with normal LVEF. Two-dimensional speckle-tracking echocardiography and 24-hour ambulatory BP monitoring were performed in 577 participants (mean age 70±9 years; 60% women) with LVEF ≥50% from the Cardiovascular Abnormalities and Brain Lesions (CABL) study. Univariable and multivariable linear regression analyses were used to assess the associations of BP measures with GLS. Higher ambulatory and office BP values were consistently associated with impaired GLS. After adjustment for pertinent covariates (age, sex, race/ethnicity, body mass index, diabetes mellitus, coronary artery disease, LV mass index, and antihypertensive medication), office diastolic BP and ambulatory systolic and diastolic BPs (24-hour, daytime and nighttime) were independently associated with GLS (P = 0.003 for office DBP, P ≤ 0.001 for all ambulatory BPs). When ambulatory and office BP values were included in the same model, all ambulatory BP measures remained significantly associated with GLS (all P < 0.01), whereas office BP values were not. Ambulatory BP values are significantly associated with impaired GLS and the association is stronger than for office BP. Ambulatory BP monitoring might have a role in the risk stratification of hypertensive patients for early LV dysfunction.

Abstract 12021: Ambulatory Blood Pressure Correlates With Chronic Renal Tubulointerstitial Injury in Patients With IgA Nephropathy

Introduction: Hypertension is a major prognostic factor in IgA nephropathy (IgAN), the most common form of primary glomerulonephritis and a major cause of ESRD worldwide. However, there are few studies that assessed the ambulatory blood pressure (ABP) in IgAN patients, which could detect the abnormality in circadian BP and predict long-term renal or cardiovascular outcomes. Hypothesis: Renal histopathological changes established by chronic exposure to injuries may have effects on the abnormal regulation of circadian BP in IgAN patients. Methods: This cross-sectional study included biopsy-proven IgAN patients, in whom both renal biopsy and ABP monitoring were performed during the same hospitalization. The histopathological findings were assessed and analyzed in relation to ABP. Results: A total of 111 IgAN patients were included. The score for interstitial fibrosis and tubular atrophy (IF/TA) was significantly associated with the both values of daytime and nighttime ABP. In contrast, the score for global and segmental glomerulosclerosis, arterial, and arteriole lesions did not show significant associations with these ABP values. These results were almost similar in the subgroup analyses of patients without apparent renal function decline (eGFR&gt;30mL/min/1.73m2) or those without antihypertensive medications. In the multiple linear regression analyses, the severity of IF/TA was associated with the both values of daytime and nighttime ABP, independent of age, gender, renal function, severity of proteinuria, and use of antihypertensive medications. On the other hand, the severity of glomerular lesions was not associated with these ABP values after adjustment (Table). The night to day ratio of mean ABP did not display significant trends according to any renal histopathological lesions. Conclusions: These results suggest that IF/TA is the most relevant renal histopathological finding associated with abnormal regulation of circadian BP in IgAN patients.

Reproducibility of ambulatory blood pressure values and circadian blood pressure patterns in untreated subjects in a 1–11 month interval

ObjectiveTo evaluate in untreated subjects the reproducibility of mean values and four circadian patterns between two ambulatory blood pressure monitoring (ABPM) recordings separated by 1–11 months. MethodsWe performed a retrospective analysis of 481 individuals (59% women) evaluated by ABPM on two occasions, visit 1 (V1) and 2 (V2), separated by 5.5+0.2 months. Four circadian patterns were defined by night/day systolic blood pressure (SBP) ratios: reverse dippers (RD), ratio >1.0; non-dippers (ND), ratio 0.9–1.0; dippers (D), ratio 0.8–<0.9; and extreme dippers (ED), ratio <0.8. Coefficients of correlation and concordance between the ABPM values at V1 and V2 and the reproducibility of the RD, ND, D and ED patterns were calculated by the percentage of the same profile from V1 to V2. ResultsMean 24-h blood pressure (BP) at V1 and V2 was 126.8/75.9±0.5/0.5 vs. 126.5/75.7±0.5/0.4 mmHg (NS). Nighttime SBP fall was 9.8±0.4 (V1) and 9.6±0.3% (V2) (NS). The correlation coefficient of ABPM data at V1 vs. at V2 was 0.41–0.69 (p<0.001) and the concordance coefficient was 0.34–0.57 (p<0.01). At V1, 38 subjects were classified as ED (7.9%); D, n=216 (44.9%), 187 as ND (38.9%) and 40 as RD (8.3%). At V2 only 26.3% of ED, 44.9% of D, 54.5% of ND and 40% of RD maintained the same profile as at V1. ConclusionIn untreated subjects ABPM has high reproducibility for mean values but only modest reproducibility for circadian profiles, thereby challenging the prognostic value of BP dipping patterns.

Clinical value of ambulatory blood pressure: Is it time to recommend for all patients with hypertension?

Hypertension is a very common disease, and office measurements of blood pressure are frequently inaccurate. Ambulatory Blood Pressure Monitoring (ABPM) offers a more accurate diagnosis, more detailed readings of average blood pressures, better blood pressure measurement during sleep, fewer false positives by detecting more white-coat hypertension, and fewer false negatives by detecting more masked hypertension. ABPM offers better management of clinical outcomes. For example, based on more accurate measurements of blood pressure variability, ABPM demonstrates that taking antihypertensive medication at night leads to better controlled nocturnal blood pressure, which translates into less end organ damage and fewer clinical complications of hypertension. For these reasons, albeit some shortcomings which were discussed, ABPM should be considered as a first-line tool for diagnosing and managing hypertension.

Prognostic Value of Ambulatory Blood Pressure in the Obese: The Ambulatory Blood Pressure-International Study.

The purpose of this study was to compare the predictive value of ambulatory blood pressure (BP) vs office BP for cardiovascular events during a 5.8-year follow-up period in the obese and nonobese participants of the Ambulatory Blood Pressure-International Study (n=10,817). Both ambulatory BP and office BP considered separately were predictive of cardiovascular events. However, in Cox models including both pressures, only ambulatory BP was associated with outcome. Among obese patients, the hazard ratios for a 10-mm Hg increase in 24-hour and office systolic BPs were 1.37 (95% confidence interval, 1.20-1.53) and 0.91 (95% confidence interval, 0.76-1.07), respectively. Among nonobese patients, the corresponding hazard ratios were 1.39 (95% confidence interval, 1.31-1.47) and 0.94 (95% confidence interval, 0.88-1.00) (P=not significant vs obese). Similar results were obtained for diastolic BP and for daytime and nighttime BPs. Ambulatory BP has similar predictive capacity in obese and nonobese patients, suggesting that ambulatory BP monitoring is a useful diagnostic tool for the assessment of obese individuals.

Ambulatory blood pressure and tubulointerstitial injury in patients with IgA nephropathy.

BackgroundFew studies have been conducted to assess the ambulatory blood pressure (ABP) in IgA nephropathy (IgAN) patients. This study aimed to determine the relationships between ABP and renal histopathological findings assessed using the Oxford classification (OC) and the Japanese classification (JC), which have recently established histopathological criteria for IgAN.MethodsThis cross-sectional study included biopsy-diagnosed IgAN patients, in whom both a renal biopsy and ABP measurement were performed. The histopathological findings were assessed using the OC and the JC and were analyzed in relation to the ABP.ResultsA total of 111 IgAN patients were included. The score of interstitial fibrosis and tubular atrophy (T score) using the OC was a significantly associated factor with both the daytime and nighttime ABP values. In contrast, the other histopathological scores, including mesangial hypercellularity, endocapillary hypercellularity and segmental glomerulosclerosis, did not show significant associations with the ABP. The histological grade (H-grade) using the JC, which was based on the sum of injured glomeruli, was associated with the daytime ABP, but not with the nighttime ABP. The associations between the T score using the OC (%) and the daytime and nighttime ABP values were independent of age, gender, renal function, proteinuria and the use of antihypertensive medications, whereas the H-grade using the JC (%) did not show significant associations after adjusting for these clinical parameters.ConclusionsThese results suggest that the T score using the OC is the most relevant renal histopathological parameter associated with abnormalities of circadian blood pressure in IgAN patients.

Clinical Implications

HomeHypertensionVol. 66, No. 3Clinical Implications Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBClinical Implications Originally published1 Sep 2015https://doi.org/10.1161/HYPERTENSIONAHA.115.06168Hypertension. 2015;66:445Pravastatin Treatment for Preeclampsia (p 687)Preeclampsia is a serious complication affecting 5% to 8% of pregnancies. The preeclamptic placenta releases elevated soluble fms-like tyrosine kinase-1 and soluble endoglin into the maternal circulation, leading to widespread endothelial dysfunction and maternal organ injury. There is no medical treatment and preterm delivery is required to stop the disease from progressing. This can lead to perinatal death and disability arising from prematurity. There is an increasing momentum to consider pravastatin as a treatment for preeclampsia. However, most of the evidence supporting this concept has come from mice models. There has been little evidence generated in human tissues. In this issue of Hypertension, Brownfoot et al report studies showing pravastatin reduces key aspects of preeclampsia in primary human tissues. The group found pravastatin reduced soluble fms-like tyrosine kinase-1 and soluble endoglin secretion from preterm preeclamptic human placenta. This effect was mediated through the 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase cholesterol synthesis pathway. Using multiple endothelial dysfunction assays, Brownfoot et al showed that pravastatin reduced key aspects of vascular dysfunction. Finally, the team administered pravastatin to 4 women with preterm preeclampsia. Excitingly, there was some suggestion that the drug might have stabilized the disease in 3 of the participants (Figure). This work supports the contention that pravastatin may be a promising treatment for preeclampsia, but it should not be used until it has been tested in clinical trials.Download figureDownload PowerPointN-Terminal Pro-Brain Natriuretic Peptide Predicts Incident Atherosclerotic Cardiovascular Disease Beyond Ambulatory Blood Pressure (p 681)Improvement of risk prediction for atherosclerotic cardiovascular disease is needed. Both ambulatory blood pressure (ABP) and the biomarkers amino-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein and cystatin C improve risk prediction compared with traditional risk factors, but the additive value of the biomarkers has not been evaluated in relation to ABP. Skoglund et al investigated the predictive value of these biomarkers for incident atherosclerotic cardiovascular disease in a model including traditional risk factors in combination with ABP variables in 907 healthy elderly men from Uppsala, Sweden. The additive value of ABP to a traditional model already including one of these biomarkers was also tested. Results showed that ABP improved discrimination for incident atherosclerotic cardiovascular disease when compared with office BP in a traditional risk factor model and NT-proBNP further improved net reclassification when added to ABP models. ABP improved net reclassification when added to a traditional risk factor model that already included NT-proBNP. NT-proBNP and ABP are widely available and easy to use methods. The results from the study by Skoglund et al indicate that the combination of NT-proBNP and ABP can be used to improve risk prediction for incident atherosclerotic cardiovascular disease in elderly male patients. The application of these methods in tailoring treatment of patients with high blood pressure could be of benefit and may reduce the risk for incident cardiovascular disease.Blood Pressure Variability and Cerebral Small Vessel Disease (p 634)Besides blood pressure (BP) levels, BP variability has been independently associated with the risk of cardiovascular events, including stroke. Because hypertension is a major risk factor for cerebral small vessel disease (CSVD), which is a determinant for future stroke and dementia, it might be worthwhile to evaluate whether short-term BP variability relates to the presence of CSVD (Figure). In addition, the contribution of short-term BP variability metrics and BP levels to the diagnosis of CSVD in asymptomatic individuals is not known. In this issue of Hypertension, Filomena et al reported the results of a cohort study involving 487 asymptomatic individuals who underwent brain magnetic resonance imaging and 24-hour ambulatory BP monitoring. CSVD was identified in 18.9% of the participants and was based on the presence of lacunar infarcts and white matter hyperintensity grades. Among 20 different metrics of short-term BP variability, only 24-hour and nocturnal average real variability of systolic BP were independently associated with the presence of CSVD, together with increasing systolic BP levels at any period. When both systolic BP levels and average real variability were increased over 24 hours, the CSVD prevalence was the highest. Nonetheless, their addition to other clinical parameters related to CSVD, such as age, male sex, diabetes mellitus, or office BP, was associated with a small increase in discrimination of CSVD (5.3%), which was not clinically relevant.Download figureDownload PowerPoint Previous Back to top Next FiguresReferencesRelatedDetails September 2015Vol 66, Issue 3 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.115.06168 Originally publishedSeptember 1, 2015 PDF download Advertisement

Reassessment of Ambulatory Blood Pressure Improves Renal Risk Stratification in Nondialysis Chronic Kidney Disease: Long-Term Cohort Study.

In nondialysis chronic kidney disease, ambulatory blood pressure (ABP) performs better than clinic BP in predicting outcome, but whether repeated assessment of ABP further refines prognosis remains ill-defined. We recruited 182 consecutive hypertensive patients with nondialysis chronic kidney disease who underwent 2 ABPs 12 months apart to evaluate the enhancement in risk stratification provided by a second ABP obtained 1 year after baseline on the risk (hazard ratio and 95% confidence interval) of composite renal end point (death, chronic dialysis, and estimated glomerular filtration rate decline ≥40%). The difference in daytime and nighttime systolic BP between the 2 ABPs (daytime and nighttime bias) was added to a survival model including baseline ABP. Net reclassification improvement was also calculated. Age was 65.6±13.4 years; 36% had diabetes mellitus and 36% had previous cardiovascular event; estimated glomerular filtration rate was 42.2±19.6 mL/min per 1.73 m(2), and clinic BP was 145±18/80±11 mm Hg. Baseline ABP (daytime, 131±16/75±10 and nighttime, 122±18/66±10 mm Hg) and daytime/nighttime BP goals (58.2% and 43.4%) did not change at month 12. Besides baseline ABP values, bias for daytime and nighttime systolic BP linearly associated with renal outcome (1.12, 1.04-1.21 and 1.18, 1.08-1.29 for every 5-mm Hg increase, respectively). Classification of patients at risk improved when considering nighttime systolic level at second ABP (net reclassification improvement, 0.224; 95% confidence interval, 0.005-0.435). Patients with first and second ABPs above target showed greater renal risk (2.15, 1.29-3.59 and 1.71, 1.07-2.72, for daytime and nighttime, respectively). In nondialysis chronic kidney disease, reassessment of ABP at 1 year further refines renal prognosis; such reassessment should specifically be considered in patients with uncontrolled BP at baseline.

Abstract P148: Ambulatory Blood Pressure in Hypertensive Patients Treated with Different 2-Drug and 3-Drug Combinations

An elevated proportion of patients require 2-drug and 3-drug combinations to achieve BP control. There is scarce evidence regarding if there are differences in such BP control among different types of combinations in daily practice. We aimed to assess office and ambulatory BP values achieved, as well as the proportion of controlled patients, depending on the type of drug combination used. From the Spanish ABPM Registry we selected 17187 patients treated with the 6 most common types of 2-drug combinations and 9724 treated with the 6 most common types of 3-drug combination. We looked for differences in achieved office and ambulatory BP, as well as nocturnal dip, and the proportion of controlled patients among types of combinations, after adjusting for confounders (age, gender, BMI, smoking, diabetes, dyslipidemia, and previous CV disease). With respect to the combination of renin angiotensin system (RAS) blockers and diuretics (reference), none of the other combinations achieved lower BP values or better BP control. Ambulatory BP control (including 24-hour, daytime and nighttime) was worse with combinations of RAS blockers/beta blockers (OR: 1.06; 95%CI: 1.01-1.11), with combinations of calcium channel blockers (CCB)/beta blockers (1.1; 1.04-1.16) and with combinations of RAS blockers and CCB (1.38; 1.23-1.55). Nondipping was also more frequent in combinations other than RAS blockers/diuretics. In patients receiving 3-drug combinations, and with respect to RAS blockers/CCB/diuretic combinations (reference), ambulatory BP were higher and non dipping more frequent in other types of combinations. Ambulatory BP control was worse in RAS blockers/CCB/alpha blockers, RAS blockers/diuretics/alpha blockers, and CCB/beta blockers/diuretics combinations. No differences in office BP control were observed among types of 2-drug or 3-drug combinations. We conclude that RAS/diuretic combinations and RAS/diuretic/CCB combinations are associated with better ambulatory BP control and more pronounced dipping in comparison with other types of 2-drug or 3-drug combinations, even with same rates of office BP control. These results can be helpful in deciding the way to combine antihypertensive agents in patients who require combination therapy.