Controlling evening BP as well as morning BP is important in hypertensive patients with prediabetes/diabetes: the JMS-1 study

Peak blood pressure-guided monitoring may serve as an effective approach for blood pressure control in the out-of-office setting

We aimed to explore whether diurnal blood pressure (BP) peak characteristics have a significant influence on the association between left ventricular damage with the two BP components (morning BP vs. afternoon peak BP) in untreated hypertensives. This cross-sectional study included 1084 hypertensives who underwent echocardiography and 24-h ambulatory BP monitoring. Participants were stratified according to the relationship between morning systolic BP (MSBP; average SBP within 2 h of waking up) and afternoon peak systolic BP (ASBP; average SBP between 16:00 and 18:00). Afternoon and morning hypertension was defined as ≥ 135/85 mm Hg. The morning and afternoon peak BPs occurred at around 7:00 and 17:00, respectively. In general hypertensives, morning BP and afternoon peak BP are significantly different in absolute values (for binary SBP, McNemar's χ²  = 6.42; p = .014). ASBP was more pronounced than MSBP in 602 patients (55.5%), in whom 24-h SBP showed higher consistency with ASBP than with MSBP (Kappa value: 0.767 vs 0.646, both p < .01). In subjects with ASBP ≥ MSBP, ASBP was associated with left ventricular hypertrophy independent of MSBP (logistic regression analysis odds ratio: 1.046, p < .01), and left ventricular mass index was more strongly correlated with ASBP than with MSBP (multiple regression coefficient β: 0.453, p < .01), in which the relationships held true independently of 24-h SBP. The opposite results were obtained in subjects with MSBP > ASBP. Peak BP-guided monitoring may serve as an effective approach to out-of-office hypertension monitoring and control, providing the best consistency with 24-h average SBP and highest discrimination performance for target organ damage, independently of 24-h SBP.

The disadvantage of morning blood pressure management in hypertensive patients

To investigate whether the control of morning blood pressure (MBP) reflects the control of blood pressure (BP) in other periods (daytime, nighttime and 24-hour) and to assess whether morning BP displays a closer association with subclinical target organ damage (TOD) than the BP measured in other periods.One thousand one hundred forty patients with primary hypertension who completed subclinical TOD detection and 24-hour ambulatory BP monitoring were included in the analysis. Pearson correlation analysis, Kappa consistency test, multiple linear regression analysis, and area under the receiver operating curve were used to analyze the data.Morning BP and daytime BP displayed good agreement, but not 24-hour BP , particularly the nighttime BP (all P < .001). Approximately 39.4% of the hypertensive patients receiving drug treatment who had achieved control of the morning BP presented masked nocturnal hypertension, which was associated with worse subclinical TOD. The BP measured in all periods correlated with subclinical TOD, and the correlation was more obvious in the treatment subgroup. However, morning BP did not independently affect subclinical TOD. Morning BP appeared to exhibit less discriminatory power than nighttime BP, particularly with respect to the urinary albumin to creatinine ratio.The use of morning BP for monitoring during hypertension management may not be enough. Masked uncontrolled nocturnal hypertension should be screened when morning BP is controlled.

A New Proposal for the Target Value for Home BP in Type 2 Diabetes Patients: The J-HOP Study

OBJECTIVE

The target levels of home-monitored blood pressure (BP) in patients with type 2 diabetes mellitus (T2DM) have not yet been established. We sought to examine the appropriate target home BP level in T2DM.

METHODS

This is a subanalysis of the Japan Morning Surge-Home Blood Pressure (J-HOP) study. We enrolled 4,310 patients who had at least 1 cardiovascular risk factor, and clinic and home BP monitoring was performed. The urinary albumin-to-creatinine ratio (UACR) was measured as a marker of microvascular disease. Quadratic equations of the relationship between clinic/home systolic BP (SBP) and log-transformed UACR were used to determine the home BP value. Home BP levels corresponding to clinic SBP/diastolic BP (DBP) level using the UACR values were calculated separately by the presence/absence of diabetes.

RESULTS

The mean age of the patients was 64.9±10.9 years; 47.0% were males. Of the 4,310 subjects enrolled, 1,057 (24.5%) had T2DM (the DM group) and 3,253 (75.5%) did not (non-DM group). The home BP levels equivalent to clinic BP 140/90 mm Hg were 135/84 and 135/83 mm Hg in the DM and non-DM groups, respectively. The home SBP levels equivalent to clinic SBP 130/80 mm Hg were 122/79 mm Hg in the non-DM group and 129/78 mm Hg in the DM group.

CONCLUSIONS

Regardless of diabetic status, the home BP level that corresponds to the clinic SBP 140/90 mm Hg was 135/85 mm Hg. In patients with T2DM, the home SBP level equivalent to clinic SBP 130/80 mm Hg was 129/78 mm Hg with regard to the extent of microvascular disease.

Blood Pressure Management in Patients with Type 2 Diabetes

In patients with type 2 diabetes (T2DM), the coexistence of hypertension enhances the cardiovascular risk, and the prevention of future cardiovascular disease is an important component of T2DM management. Antihypertensive therapy has been shown to be an effective method of reducing the micro- and macrovascular complications of T2DM, however, the optimal target blood pressure (BP) levels are still under debate. Most of the international guidelines have raised the target clinic BP from 130/80 to 140/90 mmHg, however, the Japanese Society of Hypertension 2014 guidelines kept the target BP level at 130/80 mmHg. However, individualized BP-lowering treatments should be considered in patients with T2DM, especially in high-risk individuals such as those with a history of stroke or retinopathy, and aggressive antihypertensive therapy below 130 mmHg should be initiated even when the initial systolic BP level is <140 mmHg. The authors performed two studies concerning the BP target levels of home BP. In the first study, the authors found that a home BP target <125/75 mmHg was effective in improving the measures of vascular stiffness and kidney damage. In the second study, when the clinic BP target was set at 130/80 mmHg, the home BP could be approximately 130/80 mmHg. More data are needed to individualize the target BP levels of T2DM patients.

Clinical significance of home blood pressure measurements for the prevention and management of high blood pressure

1. Ambulatory blood pressure (ABP) monitoring (M) provides BP information at many points on any particular day during unrestricted routine daily activities, whereas home blood pressure (HBP) monitoring provides a lot of BP information obtained under fixed times and conditions over a long period of time, thus mean values of HBP provide high reproducibility, and thus an overall superiority compared with ABP.  2. HBP is at least equally or better able than ABP to predict hypertensive target organ damage and prognosis of cardiovascular disease.  3. HBPM allows for ongoing disease monitoring by patients, improves adherence to antihypertensive treatment, and can provide health-care providers with timely clinical data and direct and immediate feedback regarding diagnosis and treatment of hypertension.  4. HBPM provides BP information in relation to time; that is, BP in the morning, in the evening and at night during sleep, and it is an essential tool for the diagnosis of white-coat and masked hypertension.  5. HBPM yields minimal alerting affects and no or minimal placebo effect, and can therefore distinguish small, but significant, serial changes in BP. It is thus the most practical method for monitoring BP in the day-to-day management of hypertension. 6. The superiority of HBPM over ABPM and clinic BPM is apparent from almost all practical and clinical research perspectives.

Association of morning and evening blood pressure at home with asymptomatic organ damage in the J-HOP Study

BACKGROUND

Several guidelines recommend that home blood pressure (HBP) be measured both in the morning and in the evening. However, there have been fewer reports about the clinical significance of morning HBP than about the clinical significance of evening HBP.

METHODS

Our study included 4,310 patients recruited for the Japan Morning Surge Home Blood Pressure Study who had one or more cardiovascular risk factors. We measured morning and evening HBP, urinary albumin-creatinine ratio (UACR), left ventricular mass index (LVMI), brachial-ankle pulse wave velocity (baPWV), maximum carotid intima media thickness (IMT), N-terminal pro-brain-type natriuretic peptide (NT-proBNP), and high-sensitivity cardiac troponin T (Hs-cTnT).

RESULTS

The correlation coefficients for the associations between morning systolic BP (SBP) and log-transformed baPWV, NT-proBNP, or Hs-cTnT were significantly greater than the corresponding relationships for evening SBP (all P < 0.01). The goodness-of-fit of the associations between morning home SBP and UACR (P < 0.05) or baPWV (P < 0.01) was improved by adding evening home SBP to the SBP measurement. In contrast, the goodness-of-fit values of the associations between evening SBP and UACR (P < 0.001), LVMI (P < 0.05), baPWV (P < 0.001), NT-proBNP (P < 0.001), and Hs-cTnT (P < 0.001) were improved by adding morning home SBP to the SBP measurement.

CONCLUSIONS

Morning BP and evening BP provide equally useful information for subclinical target organ damage, yet multivariate modeling highlighted the stand-alone predictive ability of morning BP.

Thresholds of ambulatory blood pressure associated with chronic complications in type 2 diabetes

BACKGROUND

Diagnostic cut-off values for ambulatory blood pressure monitoring (ABPM) in diabetic patients are not established. The aim was to investigate associations between office and ambulatory blood pressures (BPs) and diabetic chronic complications and to establish optimal threshold ambulatory BP values regarding the likehood of having microvascular complications in type 2 diabetes.

METHODS

In a cross-sectional design, clinical, laboratory, and 24-h ABPM data were obtained in 550 type 2 diabetic patients. Multivariate logistic regression assessed the associations between office and ambulatory BPs and diabetic micro and macrovascular complications. Optimal threshold values for ambulatory BPs (daytime, night-time, and 24 h) were established by examining the best combination of systolic (SBP) and diastolic BP (DBP) that maximized the odds ratios (ORs) of having each microvascular complication.

RESULTS

After multivariate adjustment for all potential confounders, ambulatory SBPs were more strongly associated with diabetic complications than office BPs, except for retinopathy and nephropathy, in which both were equivalent. In general, night-time BPs were stronger correlates than daytime BPs. The optimal threshold ambulatory BP values were 125/75 mm Hg for daytime, 110/65 mm Hg for night-time, and 120/75 mm Hg for the 24-h period, with odds ranging from 1.7- to 2.3-fold of having each microvascular complication.

CONCLUSIONS

Except for retinopathy and advanced nephropathy, ambulatory BPs are better correlates of chronic complications than office BPs in type 2 diabetes. The association of microvascular complications with lower ambulatory BP levels than those reported as normal for nondiabetic patients may indicate that lower cut-off values for ambulatory BPs might be considered in type 2 diabetic patients.