An Update on Masked Hypertension

When and how to use ambulatory blood pressure monitoring and home blood pressure monitoring for managing hypertension

Many individuals have different blood pressure (BP) values in the office setting compared to that outside the office setting. Therefore, confirming hypertension based on office BP (OBP) measurement alone can lead to misdiagnosis and mistreatment. The limitations of OBP measurement have led to the complementary use of out-of-office BP measurements, including 24-hour ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). This review aims to describe when and how ABPM or HBPM can be used to accurately diagnose and treat hypertension. Both methods should be performed using validated automated oscillometric devices. To minimize user errors, ABPM should be performed using standard techniques, whereas HBPM requires patient education regarding proper BP measurements. ABPM provides short-term comprehensive information on BP, including daytime, nighttime, morning, and 24-h BP. Therefore, ABPM is recommended for the initial diagnosis of hypertension, assessment of BP phenotypes and circadian patterns, and detection of nocturnal hypertension, Furthermore, ABPM plays a critical role in confirming true resistant hypertension thereby excluding pseudo-resistant hypertension. However, it is not suitable for long-term follow-up of patients with hypertension. In contrast, HBPM involves multiple BP readings taken at specific times during the day and evening over a long period. Therefore, HBPM is recommended for diagnosing hypertension and assessing BP phenotypes. However, this method has limitations in measuring nocturnal BP and circadian BP patterns. HBPM is preferred over ABPM for the long-term follow-up of patients with hypertension. This approach improves patient adherence to treatment and ultimately enhances the rate of control of hypertension. Additionally, both methods play an important role in diagnosing and treating white coat hypertension during pregnancy. Consequently, out-of-office BP measurement is essential to prevent the misdiagnosis and mistreatment of hypertension. However, these two methods offer different information regarding the BP status of an individual, and they indeed show discrepancies in the diagnosis of hypertensive phenotypes. Therefore, it is crucial to understand the advantages and limitations of both ABPM and HBPM to ensure their appropriate use in clinical practice.

[May Measurement Month 2019: Screening Analysis In Spanish Community Pharmacies and Detection of Masked Hypertension]

Aim

To know within the scope of the May Measurement Month (MMM) project, the blood pressure (BP) situation in the Spanish population, disseminate the importance of its periodic measurement and estimate the prevalence of masked hypertension (MH).

Methods

Transversal descriptive study in Spanish community pharmacies during May 2019.

Variables

Systolic blood pressure (SBP), diastolic blood pressure (DBP) in millimetres of mercury (mmHg), heart rate (HR) in beats per minute (bpm).Subjects with BP ≥130/85 and <149/90 were offered the possibility of home blood pressure monitor- ing (HBPM) to confirm MH.

Results

A total of 3402 valid records performed by 491 pharmacists. In all 61.9% women, mean age 56.6 years. A total of 143 (4.2%) had never measured BP and 918 (27.0%) had not measured BP in the last year; 1047 were taking anti-hypertensives, of whom 45.7% had high BP.A total of 780 (22.9%) subjects had high BP values; both, 252 (7.4%). mSBP and mDBP was 125.0 mmHg and 76.5 mmHg, respectively; higher in men (P<0.001). mHR was 72.6 bpm..A direct relationship was detected between SBP and DBP and BMI (P<0.0001). mSBP and mHR were higher in smokers (P<0.0001). In diabetic patients, SBP, DBP and HR were greater.A total of 61 subjects with suspected MH agreed to undergo HBPM. A total of 25 (40.1%) resulted in BP ≥135/85 mmHg.

Conclusions

Almost a quarter of subjects had BP ≥140/90 mmHg. The risk factors most closely related to high BP were overweight, diabetes and age; 40% of suspected cases of MH were confirmed by means of HBPM.

Masked Hypertension in Healthy Children and Adolescents: Who Should Be Screened?

PURPOSE OF REVIEW

The goal is to review masked hypertension (MH) as a relatively new phenomenon when patients have normal office BP but elevated out-of-office BP. Firstly, it was described in children in 2004. It has received increased attention in the past decade.

RECENT FINDINGS

The prevalence of MH in different pediatric populations differs widely between 0 and 60% based on the population studied, definition of MH, or method of out-of-office BP measurement. The highest prevalence of MH has been demonstrated in children with chronic kidney disease (CKD), obesity, diabetes, and after heart transplantation. In healthy children but with risk factors for hypertension such as prematurity, overweight/obesity, diabetes, chronic kidney disease, or positive family history of hypertension, the prevalence of MH is 9%. In healthy children without risk factors for hypertension, the prevalence of MH is very low ranging 0-3%. In healthy children, only patients with the following clinical conditions should be screened for MH: high-normal/elevated office BP, positive family history of hypertension, and those referred for suspected hypertension who have normal office BP in the secondary/tertiary center.

Masked hypertension in a middle-aged population and its relation to manifestations of vascular disease

BACKGROUND

Masked hypertension is associated with cardiovascular disease (CVD). However, previous large studies have not used the same device to measure office and home blood pressure (BP) and adhered to current home BP measurement recommendations of the European Society of Hypertension. We aimed to characterize masked hypertension and explore its relation to manifestations of CVD.

METHODS

A randomly selected cohort of 5057 participants aged 50-64 years from the Swedish CardioPulmonary BioImage Study (SCAPIS) was evaluated with office and home BP using the semi-automatic Omron M10-IT oscillometric device. Additional analyses included pulse wave velocity (PWV) and coronary artery calcium score (CACS).

RESULTS

Of participants, 4122 did not have current antihypertensive treatment, and were thus included in our analyses. Of these, 2634 (63.9%) had sustained normotension, and 172 (4.2%) had masked hypertension. Participants with masked hypertension vs. sustained normotension were more often men (66.9 vs. 46.2%, P  < 0.001). Those with masked hypertension had higher mean PWV [9.3 (95% confidence interval, 95% CI 9.1-9.5) vs. 8.3 (95% CI 8.2-8.4) m/s, P  < 0.001] and odds ratio for CACS at least 100 [1.65 (95% CI 1.02-2.68), P  = 0.040]. These associations were similar in a posthoc analysis of masked hypertension and sustained normotension, matched for age, sex and systolic office BP.

CONCLUSION

Masked hypertension was associated with markers of CVD. This suggests that home BP is a better predictor of risk, even when the recordings are performed with the same measurement device, in a population-based setting with randomized recruitment.

Latest Knowledge on the Role of Vitamin D in Hypertension

Hypertension is the third leading cause of the global disease burden, and while populations live longer, adopt more sedentary lifestyles, and become less economically concerned, the prevalence of hypertension is expected to increase. Pathologically elevated blood pressure (BP) is the strongest risk factor for cardiovascular disease (CVD) and related disability, thus making it imperative to treat this disease. Effective standard pharmacological treatments, i.e., diuretics, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blocker (ARBs), beta-adrenergic receptor blockers (BARBs), and calcium channel blockers (CCBs), are available. Vitamin D (vitD) is known best for its role in bone and mineral homeostasis. Studies with vitamin D receptor (VDR) knockout mice show an increased renin-angiotensin-aldosterone system (RAAS) activity and increased hypertension, suggesting a key role for vitD as a potential antihypertensive agent. Similar studies in humans displayed ambiguous and mixed results. No direct antihypertensive effect was shown, nor a significant impact on the human RAAS. Interestingly, human studies supplementing vitD with other antihypertensive agents reported more promising results. VitD is considered a safe supplement, proposing its great potential as antihypertensive supplement. The aim of this review is to examine the current knowledge about vitD and its role in the treatment of hypertension.

Association of the magnitude of the difference in blood pressure between office and ambulatory measurements with blood pressure variability in untreated individuals

OBJECTIVES

We evaluated the association between cardiovascular risk factors and the magnitude of the difference in systolic blood pressure (SBP) between office and ambulatory measurements (masked effect) in untreated individuals without apparent hypertension-mediated organ damage (HMOD).

METHODS

The inclusion criteria were 1) age ≥ 20 years, 2) blood pressure ≥ 140/90 mmHg at the outpatient clinic, and 3) not receiving antihypertensive medications. The difference between office and ambulatory SBP was calculated by subtracting the ambulatory daytime SBP from the office SBP. The association between the masked effect and SBP variability was analyzed in individuals without HMOD (no electrocardiographic left ventricular hypertrophy, spot urine albumin-to-creatinine ratio < 30 mg/g, and estimated glomerular filtration rate ≥ 60 mL/min/1.73 m², n = 296).

RESULTS

Among the cardiovascular risk factors, ambulatory BP variability was significantly correlated with the SBP difference. The standard deviation (SD) and coefficient of variation (cv) of 24-h SBP exhibited a significant negative linear association with the SBP difference in univariate and multivariate analyses adjusted for age, sex, presence of diabetes, and 24-h ambulatory SBP. A significant association was observed in patients with ambulatory daytime hypertension. In the multivariate analysis, individuals with a negative SBP difference > -5 mmHg exhibited a higher SD and cv of 24-h SBP than those with a negative SBP difference ≤ -5 mmHg or a positive SBP difference.

CONCLUSIONS

The results of our study suggest that the magnitude of the negative difference in office and ambulatory SBP may be a potential risk factor, even in individuals without apparent HMOD.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov ( NCT03855605 ).

Cost-Effectiveness of Masked Hypertension Screening and Treatment in US Adults With Suspected Masked Hypertension: A Simulation Study

BACKGROUND

Recent US blood pressure (BP) guidelines recommend using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to screen adults for masked hypertension. However, limited evidence exists of the expected long-term effects of screening for and treating masked hypertension.

METHODS

We estimated the lifetime health and economic outcomes of screening for and treating masked hypertension using the Cardiovascular Disease (CVD) Policy Model, a validated microsimulation model. We simulated a cohort of 100,000 US adults aged ≥20 years with suspected masked hypertension (i.e., office BP 120-129/<80 mm Hg, not taking antihypertensive medications, without CVD history). We compared usual care only (i.e., no screening), usual care plus ABPM, and usual care plus HBPM. We projected total direct healthcare costs (2021 USD), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Future costs and QALYs were discounted 3% annually. Secondary outcomes included CVD events and serious adverse events.

RESULTS

Relative to usual care, adding masked hypertension screening and treatment with ABPM and HBPM was projected to prevent 14.3 and 20.5 CVD events per 100,000 person-years, increase the proportion experiencing any treatment-related serious adverse events by 2.7 and 5.1 percentage points, and increase mean total costs by $1,076 and $1,046, respectively. Compared with usual care, adding ABPM was estimated to cost $85,164/QALY gained. HBPM resulted in lower QALYs than usual care due to increased treatment-related adverse events and pill-taking disutility.

CONCLUSIONS

The results from our simulation study suggest screening with ABPM and treating masked hypertension is cost-effective in US adults with suspected masked hypertension.

Correlation between masked hypertension and endothelial dysfunction measured by flow-mediated dilation: a protocol of systematic review and meta-analysis

INTRODUCTION

A surrogate marker to evaluate artery endothelial response when stimulated by reactive hyperaemia, known as brachial flow-mediated dilation (FMD), has prognostic value in predicting hypertensive organ damage and cardiovascular disease events. However, the degree of correlation between brachial FMD and masked hypertension (MH) outcomes is still unclear. Therefore, the purpose of this study is to pool data regarding FMD with respect to MH.

METHODS AND ANALYSIS

Electronic databases MEDLINE, EMBASE, China National Knowledge Infrastructure and Cochrane Library will be searched for the following keywords: endothelial dysfunction, flow-mediated dilation, and masked hypertension, masked uncontrolled hypertension (MUCH) and prehypertension. The following are the eligibility criteria: population-adults (18 years old or older) without hypertension at baseline, with suspected endothelial dysfunction, or from MH/MUCH populations (office blood pressure <140/90 mm Hg and home blood pressure ≥135 mm Hg and/or 85 mm Hg) and from controlled clinical trials, cohort studies, or randomised and controlled trials; exposures-any metrics for FMD; comparisons-participants without MH or MUCH; and outcome-change in FMD between the case group and the control group. Two authors will be engaged in screening and collecting data independently; disagreements will be resolved through discussion. Data extraction will include primary data designated as HR, OR, correlations and regression coefficients. Comprehensive Meta-Analysis V.2.0 will be used to conduct related subgroup and sensitivity analyses and publication bias.

ETHICS AND DISSEMINATION

This study does not require ethics approval. It will be submitted to a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020208362.

Relationship Between Masked Hypertension Measured by Ambulatory Blood Pressure Monitoring and Left Ventricular Global Longitudinal Strain: A Retrospective Study

Purpose

Masked hypertension (MHT), as an independent clinical entity, the cardiac dysfunction caused by it can be early detected through left ventricular global longitudinal strain (GLS), yet the quantitative relation between MHT and GLS is still unclear. Therefore, we tried to conduct a community-based retrospective study to define this relationship.

Patients and Methods

A total of 308 enrolled participants from Dongguan, China, were divided into non-hypertension (NHT) and MHT groups. Baseline characteristics were recorded, and echocardiography and 24-hour ambulatory blood pressure monitoring were performed. Linear regression analysis and receiver-operating characteristic (ROC) curve analysis were used to assess the associations between MHT and GLS in univariate and multivariate models, and the dose–response curve was plotted to demonstrate their relationship.

Results

The mean age of the NHT and MHT groups was 57 and 60 years, respectively. Signs of left ventricular diastolic function, E/A was reduced and E/e’ was increased in the MHT group while those of the NHT group were nearly normal. The MHT group also showed a significantly lower (“worse”) GLS than NHT (−15.2% vs −19.9%, P < 0.001) while left ventricular ejection fraction (LVEF) did not differ between the groups. Worse GLS was independently and significantly associated with MHT both in univariate (odds ratio [OR]: 1.97, P < 0.001) and stepwise multivariate regression analysis (OR: 1.99, P < 0.001). Comparison of ROC curve results showed that area under curve of GLS was larger than that of E/e’ both in unadjusted (0.8673 vs 0.6831) and adjusted model (0.9178 vs 0.8284). Further analysis showed adjusted nonlinear correlation between MHT and GLS.

Conclusion

Based on the relationship between MHT and GLS, in clinical practice, GLS measurement could facilitate diagnosis for suspected MHT patients and could define the extent of left ventricular dysfunction for diagnosed MHT patients.

Blood pressure phenotypes based on ambulatory monitoring in a general middle-aged population

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) is increasingly recommended for clinical use, but more knowledge about the prevalence and variability in ABPM-derived phenotypes in the general population is needed. We describe these parameters in the community-based Swedish CArdioPulmonary bioImage Study (SCAPIS) cohort.

METHODS

We examined 5881 men and women aged 50-64 with 24-hour ABPM recordings using validated monitors. ABPM phenotypes were defined according to European guidelines. White coat hypertension was defined as elevated office BP (≥140/90 mmHg) with normal mean ambulatory BP (<135/85 mmHg in day-time, <120/70 mmHg in night-time, <130/80 mmHg over 24-h); and masked hypertension as normal office BP (<140/90 mmHg) with elevated mean ambulatory BP (≥135/85 mmHg in day-time, ≥120/70 mmHg in night-time, ≥130/80 mmHg over 24-h). Blood pressure variability was assessed using the coefficient of variation (CV), standard deviation (SD), and average real variability.

RESULTS

Based on the ABPM recordings, 36.9% of participants had 24-h hypertension, 40.7% had day-time hypertension, and 37.6% nocturnal hypertension. Among participants treated with anti-hypertensive drugs, one in three had elevated office blood pressures, and more than half had elevated 24-h, day-time or nocturnal blood pressures. Among participants without anti-hypertensive drugs, only one in six had elevated office blood pressures, but one in three had elevated 24-h, day-time or nocturnal blood pressures. Men had higher 24-h blood pressures, more masked hypertension, but less white-coat hypertension than women. The prevalence of white-coat hypertension increased with age, but not the prevalence of masked hypertension. A positive association between blood pressure level and variability was observed, and within-person and between-person SD and CV were of similar magnitude. The variance in ABPM on repeated measurements was substantial.

CONCLUSIONS

In the middle-aged general population, masked hypertension is an underappreciated problem on the population level.

An Evaluation of Biometric Monitoring Technologies for Vital Signs in the Era of COVID-19

The novel coronavirus disease 2019 (COVID-19) global pandemic has shifted how many patients receive outpatient care. Telehealth and remote monitoring have become more prevalent, and measurements taken in a patient's home using biometric monitoring technologies (BioMeTs) offer convenient opportunities to collect vital sign data. Healthcare providers may lack prior experience using BioMeTs in remote patient care, and, therefore, may be unfamiliar with the many versions of BioMeTs, novel data collection protocols, and context of the values collected. To make informed patient care decisions based on the biometric data collected remotely, it is important to understand the engineering solutions embedded in the products, data collection protocols, form factors (physical size and shape), data quality considerations, and availability of validation information. This article provides an overview of BioMeTs available for collecting vital signs (temperature, heart rate, blood pressure, oxygen saturation, and respiratory rate) and discusses the strengths and limitations of continuous monitoring. We provide considerations for remote data collection and sources of validation information to guide BioMeT use in the era of COVID-19 and beyond.

Feasibility of a Clinical Decision Support Tool to Manage Resistant Hypertension: Team-HTN, a Single-arm Pilot Study

INTRODUCTION

Based on defining criteria, hypertension (HTN) affects 31% to 46% of the adult U.S. population and almost 20% of service members. Resistant HTN (rHTN) consumes significant resources, carries substantial morbidity and mortality risk and costs over $350 billion dollars annually. For multiple reasons, only 48.3% of people with HTN are controlled, e.g., undiagnosed secondary HTN, therapeutic or diagnostic inertia, and patient adherence. Our purpose was to determine the feasibility of a web-based clinical decision support tool (CDST) using a renin-aldosterone system (RAS) classification matrix and drug sequencing algorithm to assist providers with the diagnosis and management of uncontrolled HTN (rHTN). Outcomes were blood pressure (BP) rates of control, provider management time, and end-user satisfaction.

METHODS

This two-phase, prospective, non-randomized, single-arm, six-month pilot study was conducted in primary care clinics at a tertiary military medical center. Patients with uncontrolled HTN and primary care providers were recruited. Phase 1 patients checked their BP twice daily (AM and PM), three times weekly using a standardized arm cuff. Patients with rHTN were enrolled in phase 2. Phase 2 patients were managed virtually by providers using the CDST, the RAS classification matrix, and the drug sequencing algorithm which incorporated age, ethnicity, comorbidities, and renin/aldosterone levels. Medications were adjusted every 10 days until BP was at target, using virtual visits.

RESULTS

In total, 54 patients and 16 providers were consented. One transplant patient was disqualified, 29 met phase 2 criteria for rHTN, and 6 providers completed the study. In phase 1, 45% (n = 24) of patients were identified as having apparent uncontrolled HTN using peak diurnal blood pressure (pdBP) home readings. In phase 2 (n = 29), previously undetected RAS abnormalities were identified in 69% (n = 20) of patients. Blood pressure control rates improved from 0% to 23%, 47%, and 58% at 2, 4, and 6 months, respectively. Provider management time was reduced by 17%. Using home pdBP readings identified masked HTN in almost 20% of patients that would have been missed by a single daily AM or PM home BP measurement. Feasibility and satisfaction trends were favorable.

CONCLUSIONS

Despite significant morbidity, mortality, and existing guidelines, over half of hypertensive patients are uncontrolled. Our results suggest that this CDST used with pdBP monitoring is a feasible option to facilitate improved rates of control in rHTN, aid in overcoming therapeutic/diagnostic inertia, improve identification of secondary HTN, and potentially, access. Further research with this tool in a larger population is recommended.

Short-Term Reproducibility of Masked Hypertension Among Adults Without Office Hypertension

The 2017 American College of Cardiology/American Heart Association blood pressure (BP) Hypertension Clinical Practice Guidelines recommends ambulatory BP monitoring to detect masked hypertension. Data on the short-term reproducibility of masked hypertension are scarce. The IDH study (Improving the Detection of Hypertension) enrolled 408 adults not taking antihypertensive medication from 2011 to 2013. Office BP and 24-hour ambulatory BP monitoring were performed on 2 occasions, a median of 29 days apart. After excluding participants with office hypertension (mean systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg), the analytical sample included 254 participants. Using the κ statistic, we evaluated the reproducibility of masked awake hypertension (awake systolic/diastolic BP ≥130/80 mm Hg) defined by the 2017 BP guideline thresholds, as well as masked 24-hour (24-hour systolic/diastolic BP ≥125/75 mm Hg), masked asleep (asleep systolic/diastolic BP ≥110/65 mm Hg), and any masked hypertension (high awake, 24-hour, and asleep BP). The mean (SD) age of participants was 38.0 (12.3) years and 65.7% were female. Based on the first and second ambulatory BP recordings, 24.0% and 26.4% of participants, respectively, had masked awake hypertension. The κ statistic (95% CI) was 0.50 (0.38-0.62) for masked awake, 0.57 (0.46-0.69) for masked 24-hour, 0.57 (0.47-0.68) for masked asleep, and 0.58 (0.47-0.68) for any masked hypertension. Clinicians should consider the moderate short-term reproducibility of masked hypertension when interpreting the results from a single ambulatory BP recording.

[Antihypertensives always evenings-absolutely not or sensible?]

The Spanish Hygia study has led to considerable irritation due to the general recommendation to prescribe antihypertensives preferably to be taken in the evening, especially since the lay press as well as medical media made enthusiastic comments. The discussion about the optimal time to take antihypertensive drugs shows once again how dangerous the uncritical handling of study data can be. No possible risks were pointed out. The Hygia study compared 19,084 patients with morning and evening intake of antihypertensive drugs under the control of a 48‑h blood pressure measurement (!). There was a significantly better reduction in blood pressure and the rate of cardiovascular and cerebrovascular events with evening intake. The data are scientifically valuable; however, the conclusions are incomprehensible based on the data, contradict many other studies and are dangerous for certain patient groups. There are also methodological shortcomings. Therefore, a general evening intake is not justified and nonsensical due to the diverse, individually very different pathophysiological findings of the nocturnal blood pressure behavior. Basically, the outpatient 24‑h blood pressure measurement (ABPM) enables a better assessment of the individual cardiovascular and cerebrovascular risks and prevents an incorrect assessment of the blood pressure and thus unnecessary or sufficient treatment. Instead of a general recommendation, the ABPM offers the option of an individually tailored treatment. Taking antihypertensive drugs in the evening should always be preceded by an ABDM in the case of prognostically unfavorable nocturnal hypertension in order to avoid the risk of nocturnal ischemic risks due to excessive drops in blood pressure.

The prevalence of masked hypertension in a group of young healthy soldiers

BACKGROUND

To assess the prevalence of masked hypertension (MH) in young Saudi National Guard soldiers based on 24h ambulatory blood pressure monitoring (ABPM).

METHODS

A prospective study of 196 soldiers, aged between 21-50 years, without a history of hypertension or antihypertensive medication use. Each participant was fitted with a 24h-ABPM. Patients were considered to have MH if the office blood pressure (OBP) was <140/90 mm Hg and the 24h-ABPM average was ≥130/80 mmHg.

RESULTS

The mean age of the MH group was 34.5 years compared to 32.4 years of the normotensive group. By pairing the average OBP with the 24h-ABPM, the prevalence of MH was estimated to be 29/196 (14.8%), with the SBP (systolic blood pressure) and DPB MH (diastolic BP) prevalence 12.8% and 7.7%, respectively. For the systolic BP, the OBP compared with the 24h-ABPM was 120.0±8.1 vs. 134.7±4.5 (P<0.001) and for the diastolic BP, 70.7±7.0 vs. 79.9±4.2 (P<0.001).

CONCLUSIONS

The prevalence of MH among this sample of healthy military soldiers was 14.8%. It is important not to rely solely on the OBP and to consider MH when screening for hypertension in apparently healthy individuals.

Association between retinal arterial narrowing and left ventricular diastolic dysfunction in masked hypertensives

Morphological change in retinal vessel diameters has been reported to be associated with negative cardiovascular outcomes, but its association with left ventricular diastolic dysfunction (LVDD) is not clear. This study aimed to examine the association between echocardiographic markers of LVDD and retinal vascular diameters, in untreated masked hypertension (MH). In this observational study, 105 MH patients without other cardiovascular risks were included (mean age 48.4 ± 5.7, female 72.4%). All individuals underwent extensive clinical and laboratory investigations, including echocardiography, ambulatory blood pressure monitoring, and retinal vascular diameters measured by optical coherence tomography. In the group, LVDD was diagnosed in 36 participants evaluated by left ventricular volume index, E/A and E/e' ratio. Compared to non-LVDD, LVDD subjects displayed narrower retinal arteriolar diameter (139.1 ± 33.8 vs 165.1 ± 29.1; adjusted P = .007) and wider retinal venular diameter (237.9 ± 42.2 vs 214.9 ± 44.8; adjusted P = .045). Significant and independent associations were demonstrated for retinal arteriolar narrowing and E/A ratio (adjusted β = 0.744, P = .031) and for retinal arteriolar diameter and E/e' ratio (adjusted β = -0.158, P = .001) after controlling for age, gender, body mass index, ambulatory systolic blood pressure, low-density lipoprotein cholesterol, and retinal venular diameter. In untreated MH subjects, retinal arteriolar diameter, a marker of microvascular damage, was independently associated with echocardiographic markers of diastolic dysfunction. These findings might underscore the hypothesis that microvascular disease could contribute to cardiac remodeling.

Epidemiological Impact and Clinical Consequences of Masked Hypertension: A Narrative Review

Masked hypertension (MHT) is a clinical condition characterized by normal blood pressure (BP) levels during clinical consultation and above normal out-of-office BP values. MHT is associated to an increased risk of developing hypertension-mediated organ damage (HMOD) and major cardiovascular (CV) outcomes, such as myocardial infarction, stroke, and hospitalizations due to CV causes, as well as to metabolic abnormalities and diabetes, thus further promoting the development and progression of atherosclerotic disease. Previous studies showed contrasting data on prevalence and clinical impact of MHT, due to not uniform diagnostic criteria (including either home or 24-h ambulatory BP measurements, or both) and background antihypertensive treatment. Whatever the case, over the last few years the widespread diffusion of validated devices for home BP monitoring has promoted a better diagnostic assessment and proper identification of individuals with MHT in a setting of clinical practice, thus resulting in increased prevalence of this clinical condition with potential clinical and socio-economic consequences. Several other items, in fact, remain unclear and debated, particularly regarding the therapeutic approach to MHT. The aim of this narrative review is to illustrate the clinical definition of MHT, to analyze the diagnostic algorithm, and to discuss the potential pharmacological approaches to be adopted in this clinical condition, in the light of the recommendations of the recent European hypertension guidelines.

Blood Pressure Measurement and Treatment Decisions

White-coat and masked hypertension are important hypertension phenotypes. Out-of-office blood pressure measurement is essential for the accurate diagnosis and monitoring of these conditions. This review summarizes literature related to the detection and diagnosis, prevalence, epidemiology, prognosis, and treatment of white-coat and masked hypertension. Cardiovascular risk in white-coat hypertension appears to be dependent on the presence of coexisting risk factors, whereas patients with masked hypertension are at increased risk of target organ damage and cardiovascular events. There is an unmet need for robust data to support recommendations around the use of antihypertensive treatment for the management of white-coat and masked hypertension.

Home Blood Pressure Monitoring in Cases of Clinical Uncertainty to Differentiate Appropriate Inaction From Therapeutic Inertia

PURPOSE

Conventional clinic blood pressure (BP) measurements are routinely used for hypertension management and physician performance measures. We aimed to check home BP measurements after elevated conventional clinic BP measurements for which physicians did not intensify treatment, to differentiate therapeutic inertia from appropriate inaction.

METHODS

We conducted a pre and post study of home BP monitoring for patients with uncontrolled hypertension as determined by conventional clinic BP measurements for which physicians did not intensify hypertension management. Physicians were notified of average home BP 2-4 weeks after the initial clinic visit. Outcome measures were the proportion of patients with controlled hypertension using average home BP measurements, changes in hypertension management by physicians, changes in physicians' hypertension metrics, and factors associated with home-clinic BP differences.

RESULTS

Of 90 recruited patients who had elevated conventional clinic BP recordings, 65.6% had average home BP measurements that were <140/90 mm Hg. Physicians changed treatment plans for 61% of patients with average home BP readings of ≥140/90 mm Hg, whereas decisions to not change treatment for the remaining patients were based on contextual factors. Substituting average home BP for conventional clinic BP for 4% of patients from 2 physicians' hypertension registries improved the physicians' hypertension control rates by 3% to 5%. Greater body mass index and increased number of BP medications were associated with home BP measurement ≥140/90 mm Hg. Clinic BP levels did not estimate normal home BP levels.

CONCLUSIONS

Documented home BP in cases of clinical uncertainty helped differentiate therapeutic inertia from appropriate inaction and improved physicians' hypertension metrics.

Blood pressure control and cardiovascular risk profile in hypertensive patients under specialist care in Argentina: Results from the CHARTER study

Worldwide, hypertension control rate is far from ideal. Some studies suggest that patients treated by specialists have a greater chance to achieve control. The authors aimed to determine the BP control rate among treated hypertensive patients under specialist care in Argentina, to characterize patients regarding their cardiovascular risk profile and antihypertensive drug use, and to assess the variables independently associated with adequate BP control. The authors included adult hypertensive patients under stable treatment, managed in 10 specialist centers across Argentina. Office BP was measured thrice with a validated oscillometric device. Adequate BP control was defined as an average of the three readings <140/90 mm Hg (and <150/90 in patients older than 80 years). The authors estimated the proportion of adequate BP control and the variables independently associated with it through a multiple conditional logistic regression model. Among the 1146 included patients, 48.2% were men with a mean age of 63.5 (±13.1) years old. Mean office BP was 135.3 (±14.8)/80.8 (±10) mm Hg, with a 64.8% (95% CI: 62%-67.6%) of adequate control. The mean number of antihypertensive drugs was 2.1 per participant, the commonest being angiotensin receptor blockers and calcium channel blockers. In multivariable analysis, only female sex was a predictor of adequate BP control (OR 1.33 [95% CI 1.02-1.72], P = .04). In conclusion, almost 65% of hypertensive patients treated in specialist centers in Argentina have adequate BP control. The challenge for future research is to define strategies in order to translate this control rate to the primary care level, where most patients are managed.

Telemonitoring of 24-Hour Blood Pressure in Local Pharmacies and Blood Pressure Control in the Community: The Templar Project

BACKGROUND

The analysis of ambulatory blood pressure monitorings (ABPMs) performed in 639 Italian pharmacies in the context of a telehealth-based service allowed to evaluate the level of blood pressure (BP) control in the community.

METHODS

Twenty-four-hour ABPMs were performed by a clinically validated, automated, upper-arm BP monitor. Recordings were uploaded on a certified web-based telemedicine platform (www.tholomeus.net) and remote medical reporting provided. In each subject, an automatic BP measurement was obtained in the pharmacy and clinical information collected before starting the ABPM.

RESULTS

A total of 20,773 subjects (mean age 57 ± 15 years; 54% females; 28% receiving antihypertensive medications, 31% with any cardiovascular [CV] risk factor) provided valid ABPMs. BP control was poor, but better in ambulatory conditions (24-hour BP <130/80 mm Hg 54% vs. pharmacy BP < 140/90 mm Hg 43%; P < 0.0001) and in drug-treated subjects. Sustained normotension was reported in only 28% subjects. Isolated nocturnal hypertension (16%; nighttime BP ≥120/70 mm Hg with normal daytime BP) was more common (P < 0.0001) than isolated daytime hypertension (9%; daytime BP ≥ 135/85 mm Hg with normal nighttime BP). Sustained hypertension (43%) was more common in younger males at the lowest CV risk, with daytime hypertension. White-coat hypertension (14%) was more common in females. Masked hypertension was not uncommon (15%) and more often observed in older males with an elevated nocturnal BP.

CONCLUSIONS

A telemedicine-based service provided to community pharmacies may facilitate access to ABPM, thus favoring a more accurate hypertension screening and detection. It may also help describe the occurrence of different 24-hour BP phenotypes and personalize the physician's intervention.

Masked Hypertension in CKD: Increased Prevalence and Risk for Cardiovascular and Renal Events

PURPOSE OF REVIEW

Hypertension and chronic kidney disease (CKD) are inextricably linked. The causal nature of the relationship is bidirectional. This relationship holds when blood pressure is assessed in the clinic and outside the clinic with home and ambulatory blood pressure monitoring. Patients with CKD are more likely to have high-risk hypertension phenotypes, such as masked and sustained hypertension, and are at increased risk for cardiovascular disease. The purpose of this review is to describe the increased prevalence of masked hypertension in patients with CKD and then describe the increased risk for target organ damage and adverse clinical events associated with masked hypertension in patients with CKD.

RECENT FINDINGS

The prevalence of masked hypertension is greater in patients with CKD than that of the general population. Recent studies have demonstrated that masked hypertension is associated with increased risk for target organ damage including left ventricular hypertrophy, elevated pulse wave velocity, proteinuria, and decreased estimated glomerular filtration rate in patients with CKD. Additionally, in patients with CKD, masked hypertension is associated with increased risk for cardiovascular disease, end-stage renal disease, and all-cause mortality. Patients with CKD are at increased risk for masked hypertension. Masked hypertension is associated with increased risk for target organ damage and adverse cardiovascular and renal outcomes in patients with CKD. Further research is necessary to better understand the pathophysiology of masked hypertension, the optimal method for diagnosing masked hypertension, and to determine whether masked hypertension is a modifiable risk factor.

Masked Hypertension: Whom and How to Screen?

PURPOSE OF REVIEW

To review issues regarding the practical implementation of screening strategies for masked hypertension.

RECENT FINDINGS

Masked hypertension has been associated with an increased risk of cardiovascular disease events and all-cause mortality. Recent guidelines have encouraged practitioners to use out-of-clinic monitoring to detect masked hypertension in some situations. However, it is unclear from these guidelines who should be screened or how to best measure out-of-office blood pressure. In this review, challenges to screening strategies for masked hypertension, and factors that should be considered when deciding to screen using ambulatory or home blood pressure monitoring. Masked hypertension is an important clinical phenotype to detect. Future research is needed in order to develop optimal screening strategies, and to understand population level implications of using ambulatory or home blood pressure monitoring on blood pressure control.

White-coat hypertension from a paediatric perspective

AIM

This mini review explored the prevalence of white-coat hypertension (WCH), which is very common in children. It results in elevated office blood pressure (BP) but normal ambulatory BP monitoring (ABPM) readings.

METHODS

WCH can only be identified by analysing and comparing office BP readings and ABPM, which periodically records BP every 20-30 minutes over 24-hour period. This study provides initially the background for WCH in adults, together with a comprehensive overview of the most relevant paediatric data on WCH.

RESULTS

Accurate measurements of BP are very important for the diagnosis and management of hypertension. It is important to acknowledge the clinical relevance of WCH and follow up children who display this BP phenotype by carrying out ABPM, so that clinicians can build up an accurate picture of their BP. It is also important to identify children who have BP issues and are overweight or obese, so that treatment of this modifiable cardiovascular risk factor can be initiated.

CONCLUSION

Using ABPM provides paediatricians with a more precise evaluation of a child's BP readings than office BP readings. It is the gold standard for diagnosing WCH.

Ambulatory blood pressure monitoring in clinical practice

Being one of the most widely prevalent diseases throughout the world, hypertension has emerged as one of the leading causes of global premature morbidity and mortality. Hence, blood pressure (BP) measurements are essential for physicians in the diagnosis and management of hypertension. Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend initiating antihypertensive medications on the basis of office BP readings. However, office BP readings provide a snapshot evaluation of the patient's BP, which might not reflect patient's true BP, with the possibility of being falsely elevated or falsely low. Recently, there is ample evidence to show that ambulatory blood pressure monitoring (ABPM) is a better predictor of major cardiovascular events than BP measurements at clinic settings. ABPM helps in reducing the number of possible false readings, along with the added benefit of understanding the dynamic variability of BP. This article will focus on the significance of ambulatory BP, its advantages and limitations compared with the standard office BP measurement and a brief outlook on its use and interpretation to diagnose and treat hypertension.

Diagnosing Masked Hypertension Using Ambulatory Blood Pressure Monitoring, Home Blood Pressure Monitoring, or Both?

Guidelines recommend measuring out-of-clinic blood pressure (BP) to identify masked hypertension (MHT) defined by out-of-clinic BP in the hypertensive range among individuals with clinic-measured BP not in the hypertensive range. The aim of this study was to determine the overlap between ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) for the detection of MHT. We analyzed data from 333 community-dwelling adults not taking antihypertensive medication with clinic BP <140/90 mm Hg in the IDH study (Improving the Detection of Hypertension). Any MHT was defined by the presence of daytime MHT (mean daytime BP ≥135/85 mm Hg), 24-hour MHT (mean 24-hour BP ≥130/80 mm Hg), or nighttime MHT (mean nighttime BP ≥120/70 mm Hg). Home MHT was defined as mean BP ≥135/85 mm Hg on HBPM. The prevalence of MHT was 25.8% for any MHT and 11.1% for home MHT. Among participants with MHT on either ABPM or HBPM, 29.5% had MHT on both ABPM and HBPM; 61.1% had MHT only on ABPM; and 9.4% of participants had MHT only on HBPM. After multivariable adjustment and compared with participants without MHT on ABPM and HBPM, those with MHT on both ABPM and HBPM and only on ABPM had a higher left ventricular mass index (mean difference [SE], 12.7 [2.9] g/m2, P<0.001; and 4.9 [2.1] g/m2, P=0.022, respectively), whereas participants with MHT only on HBPM did not have an increased left ventricular mass index (mean difference [SE], -1.9 [4.8] g/m2, P=0.693). These data suggest that conducting ABPM will detect many individuals with MHT who have an increased cardiovascular disease risk.

Out of Office Blood Pressure Measurement in Pregnancy and the Postpartum Period

PURPOSE

Hypertensive disorders of pregnancy are increasing in prevalence and associated with significant maternal and perinatal morbidity and mortality.

RECENT FINDINGS

Increased emphasis has been placed recently on the use of out-of-office (i.e., home and ambulatory) blood pressure (BP) monitoring to diagnose and manage hypertension in the general population. Current guidelines offer limited recommendations on the use of out-of-office BP monitoring during pregnancy and postpartum. This review will discuss the recent literature on BP measurement outside of the office and its use for screening, diagnosis, and treatment in pregnancy and postpartum, and will illuminate areas for future research.

Patient Barriers and Facilitators to Ambulatory and Home Blood Pressure Monitoring: A Qualitative Study

BACKGROUND

Guidelines recommend that patients with newly elevated office blood pressure undergo ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to rule-out white coat hypertension before being diagnosed with hypertension. We explored patients' perspectives of the barriers and facilitators to undergoing ABPM or HBPM.

METHODS

Focus groups were conducted with twenty English- and Spanish-speaking individuals from underserved communities in New York City. Two researchers analyzed transcripts using a conventional content analysis to identify barriers and facilitators to participation in ABPM and HBPM.

RESULTS

Participants described favorable attitudes toward testing including readily understanding white coat hypertension, agreeing with the rationale for out-of-office testing, and believing that testing would benefit patients. Regarding ABPM, participants expressed concerns over the representativeness of the day the test was performed and the intrusiveness of the frequent readings. Regarding HBPM, participants expressed concerns over the validity of the monitoring method and the reliability of home blood pressure devices. For both tests, participants noted that out-of-pocket costs may deter patient participation and felt that patients would require detailed information about the test itself before deciding to participate. Participants overwhelmingly believed that out-of-office testing benefits outweighed testing barriers, were confident that they could successfully complete either testing if recommended by their provider, and described the rationale for their testing preference.

CONCLUSIONS

Participants identified dominant barriers and facilitators to ABPM and HBPM testing, articulated testing preferences, and believed that they could successfully complete out-of-office testing if recommended by their provider.