Rationale, study design, baseline characteristics and blood pressure at 16 weeks in the HONEST Study

Differences of blood pressure measured at clinic versus at home in the morning and in the evening in Europe and Asia: A systematic review and meta-analysis

Numerous studies have indicated that there might be great differences among different populations in Europe and Asia in terms of home morning and evening blood pressure (BP). Thus, the authors performed a systematic review to determine the quantitative differences of BP measured at clinic versus at home in the morning and in the evening in Europe and Asia. PubMed, Embase, and Scopus databases were searched up to October 2021. Studies that compared clinic BP with home morning and (or) home evening BP in European and Asian populations were included. A random effect model was applied to pool the differences between clinic BP and home morning/evening BP. Thirty‐five studies, for a total of 49 432 patients, were included in this meta‐analysis. Mean clinic systolic blood pressure (SBP) values were significantly higher than home morning SBP values by 3.79 mmHg (95% CI, 2.77–4.80). The differences were much larger in Europe [(6.53 mmHg (95% CI, 4.10–8.97)] than in Asia [(2.70 mmHg (95% CI, 1.74–3.66)], and the region was a significant predictor for the differences. Mean clinic SBP values were also significantly higher than home evening SBP values by 6.59 mmHg (95% CI, 4.98–8.21). The differences were much smaller in Europe [5.85 mmHg (95% CI, 3.24–8.45)] than in Asia [7.13 mmHg (95% CI, 4.92–9.35)], while age and clinic SBP might contribute to it. Our findings showed that the difference between clinic and home morning SBP was much larger in European than Asian populations, whereas the difference between clinic and home evening SBP was the opposite. The differing characteristics of the region, ethnic, age, and clinic BP might explain the diversities.

Comparative Study of Metabolite Changes After Antihypertensive Therapy With Calcium Channel Blockers or Angiotensin Type 1 Receptor Blockers

ABSTRACT

The high prevalence of hypertension contributes to an increased global burden of cardiovascular diseases. Calcium channel blockers (CCBs) and angiotensin type 1 receptor blockers (ARBs) are the most widely used antihypertensive drugs, and the effects of these drugs on serum metabolites remain unknown. Untargeted metabolomics has been proved to be a powerful approach for the detection of biomarkers and new compounds. In this study, we aimed to determine the changes in metabolites after single-drug therapy with a CCB or ARB in patients newly diagnosed with mild to moderate primary hypertension. We enrolled 33 patients and used an untargeted metabolomics approach to measure 625 metabolites associated with the response to a 4-week treatment of antihypertensive drugs. After screening based on P < 0.05, fold change > 1.2 or fold change < 0.83, and variable importance in projection > 1, 63 differential metabolites were collected. Four metabolic pathways-cysteine and methionine metabolism, phenylalanine metabolism, taurine and hypotaurine metabolism, and tyrosine metabolism-were identified in participants treated with ARBs. Only taurine and hypotaurine metabolism were identified in participants treated with CCBs. Furthermore, homocitrulline and glucosamine-6-phosphate were relevant to whether the blood pressure reduction achieved the target blood pressure (P < 0.05). Our study provides some evidence that changes in certain metabolites may be a potential marker for the dynamic monitoring of the protective effects and side effects of antihypertensive drugs.

Morning Home Blood Pressure and Cardiovascular Events in Japanese Hypertensive Patients

SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated the benefit of achieving strict blood pressure control with a lower target blood pressure level in high-risk patients with hypertension. The aim of this post hoc analysis was to investigate the relationship between the 2-year average on-treatment home blood pressure and cardiovascular disease risk in subgroups stratified by risk status using data from the HONEST study (Home Blood Pressure Measurement With Olmesartan Naive Patients to Establish Standard Target Blood Pressure). Participants in the HONEST study (n=21 591) were stratified according to risk level as follows: SPRINT population (n=5823)-patients (≥50 years of age) without diabetes mellitus or prior stroke, with SPRINT-defined cardiovascular risk and systolic blood pressure (SBP) of ≥130 mm Hg; SPRINT-excluded high-risk population (n=5481)-patients with diabetes mellitus or prior stroke; and non-SPRINT low-risk population-all other patients in the HONEST study (n=10 287). Cardiovascular disease event risk was 6.32 events per 1000 person-years in the SPRINT population, which was higher than in the non-SPRINT low-risk (3.39; P<0.001) and lower than the SPRINT-excluded high-risk (12.41; P<0.001) populations. In the SPRINT and the SPRINT-excluded high-risk populations, a lower home SBP achieved was associated with lower cardiovascular disease risk, with the lowest risk in patients with a home SBP <125 mm Hg. The non-SPRINT low-risk population showed a J-curve association between on-treatment home SBP and cardiovascular disease risk with the lowest risk at a home SBP of 135 to <145 mm Hg. Intensive therapy targeting home SBP of <125 mm Hg would be beneficial for high-risk hypertensive patients. Clinical Trial Registration- URL: http://www.umin.ac.jp/ctr/index.htm . UMIN Clinical Trials Registry, trial no.: UMIN000002567.

Home blood pressure and cardiovascular outcomes in very elderly patients receiving antihypertensive drug therapy: a subgroup analysis of Home blood pressure measurement with Olmesartan Naive patients to Establish Standard Target blood pressure (HONEST) study

The appropriate target blood pressure (BP) in elderly patients with hypertension remains uncertain. We investigated the relationship between morning home systolic blood pressure (MHSBP) during follow-up and cardiovascular (CV) risk in outpatients receiving olmesartan-based treatment aged <75 years (n = 16799) and ≥75 years (n = 4792) in the HONEST study. In the follow-up period (mean 2.02 years), the risk for major CV events was significantly higher in patients with MHSBP ≥155 mmHg compared with <125 mmHg in both age groups in Cox proportional hazards model adjusted for other risk factors and there was no significant difference in trend between the two groups (interaction P = 0.9917 for MHSBP). Hazard ratios for CV events for 1-mmHg increase in MHSBP were similar in patients aged <75 years and in patients aged ≥75 years. The incidence of adverse drug reactions related to excessive BP lowering was lower in patients <75 years than in patients ≥75 years (0.73 vs 1.02%, P = 0.0461). In conclusion, the study suggests even in patients ≥75 years antihypertensive treatment targeting the same MHSBP levels in patients <75 years may be beneficial in reducing CV risk when treatment is tolerated.

Increased cardiovascular risk of treated white coat and masked hypertension in patients with diabetes and chronic kidney disease: the HONEST Study

The prognostic implications of treated white coat hypertension (WCH) and masked hypertension (MH) in patients with diabetes mellitus (DM) or chronic kidney disease (CKD) are not well documented. Using data from the HONEST study (n=21 591), we investigated the relationships between morning home systolic blood pressure (MHSBP) or clinic systolic blood pressure (CSBP) and cardiovascular (CV) risk in hypertensive patients with and without DM or CKD receiving olmesartan-based antihypertensive therapy. The study included 4426 DM patients and 4346 CKD patients at baseline who had 101 and 87 major CV events, respectively, during the follow-up. Compared with well-controlled non-DM patients (MHSBP <135 mm Hg; CSBP <140 mm Hg), DM patients with WCH (MHSBP <135 mm Hg; CSBP ⩾140 mm Hg), MH (MHSBP ⩾135 mm Hg; CSBP <140 mm Hg) or poorly controlled hypertension (PCH) (MHSBP ⩾135 mm Hg; CSBP ⩾140 mm Hg) had significantly higher CV risk (hazard ratio (HR), 2.73, 2.77 and 2.81, respectively). CV risk was also significantly increased in CKD patients with WCH, MH and PCH (HR, 2.14, 1.70 and 2.20, respectively) compared with well-controlled non-CKD patients. Furthermore, DM patients had significantly higher incidence rate than non-DM patients of MHSBP ⩾125 to <135 mm Hg (HR, 1.98) and ⩾135 to <145 mm Hg (HR, 2.41). In conclusion, both WCH and MH are associated with increased CV risk, and thus control of both MHSBP and CSBP is important to reduce CV risk in DM or CKD patients. The results also suggest that even lower MHSBP (<125 mm Hg) may be beneficial for DM patients, although this conclusion is limited by the small number of patients.

Home blood pressure and cardiovascular risk in treated hypertensive patients: the prognostic value of the first and second measurements and the difference between them in the HONEST study

Hypertension guidelines recommend using the average of two home blood pressure (HBP) measurements obtained on one occasion to monitor blood pressure. We studied the prognostic value of the first and second measurements or their average value during the follow-up period, as well as the relationships among the difference between the first and second HBP measurements and the prognosis using data from the HONEST (HBP measurement with Olmesartan-Naive patients to Establish Standard Target blood pressure) study. During the mean 2.02 years follow-up, 280 patients had cardiovascular events. Hazard ratios (HRs) for cardiovascular events for each 1 mm Hg increase in the first, second and averaged morning home systolic blood pressure (MHSBP) were similar. Hazards were significantly higher in patients with a large difference between the first and second MHSBP (ΔMHSBP) of <-5 mm Hg (HR: 2.12) or ⩾5 mm Hg (HR: 1.44) compared with those with a small ΔMHSBP of ⩾-5 to <5 mm Hg using the Cox proportional hazards model adjusted for the averaged MHSBP during the follow-up and other risk factors. Hazards in patients with an averaged MHSBP ⩾145 mmHg and a small ΔMHSBP (HR: 3.11), those with an averaged MHSBP ⩾125 to <145 mm Hg and a large ΔMHSBP (HR: 1.91) and those with an averaged MHSBP ⩾145 mm Hg and a large ΔMHSBP (HR: 4.63) were higher compared with those with an averaged MHSBP <125 mm Hg and a small ΔMHSBP. In conclusion, the first, second and averaged MHSBP measurements have similar prognostic values. Prognosis is worse for patients with a large ΔMHSBP. In clinical practice, it would be prudent to measure the HBP two times and use the average HBP of two measurements obtained on one occasion with particular attention to patients with a large ΔMHSBP.

Persistent olmesartan-based blood pressure-lowering effects on morning hypertension in Asians: the HONEST study

Using data from the large-scale HONEST (Home blood pressure measurement with Olmesartan Naive patients to Establish Standard Target blood pressure) study, we investigated the characteristics of the effects of olmesartan-based treatment on morning hypertension in Asian hypertensive patients. Specifically, we investigated the relationship between baseline blood pressure (BP) and BP reduction after 16 weeks by linear regression analyses; determinants of BP reduction were also investigated. For both morning home BP (MHBP) and clinic BP (CBP), reduced systolic BP (SBP) after 16 weeks was associated with baseline SBP (P<0.001). The slope of the regression lines was similar for morning home SBP (MHSBP) (-0.744) and clinic SBP (-0.735). Although sex, concomitant diabetes mellitus and concomitant hepatic disease significantly influence the relationship between BP reduction and baseline BP for MHSBP, none were deemed clinically relevant. In conclusion, olmesartan-based treatment robustly reduced baseline high MHBP, similar to CBP, and the effect was associated with baseline BP but unaffected by patient background factors.

Differences between clinic blood pressure and morning home blood pressure, as shown by Bland-Altman plots, in a large observational study (HONEST study)

When interpreting home blood pressure (BP) measurements in hypertensive patients, differences between clinic and home BP should be noted. To investigate the differences between clinic and morning home BP in hypertensive patients, we analyzed clinic systolic BP (CSBP) and morning home systolic BP (MHSBP) data from the large-scale observational HONEST (Home BP measurement with Olmesartan Naive patients to Establish Standard Target blood pressure) study (n=21 340), using BP measurements obtained before starting olmesartan administration. We generated Bland-Altman plots, with the horizontal axis representing mean CSBP and MHSBP ([CSBP+MHSBP]/2) and the vertical axis representing the difference between CSBP and MHSBP (CSBP-MHSBP). We also did simulation experiments to explore factors affecting the results of the Bland-Altman plots. The difference between CSBP and MHSBP increased as the mean of the two values increased, and when the mean of CSBP and MHSBP was close to 140 mm Hg, the difference was theoretically 0 in average, although large interindividual BP variability existed in this BP range. Results were unaffected by factors such as previous antihypertensive treatment, age and concomitant diabetes or chronic kidney disease. Bland-Altman plots generated from simulated data of normal distribution showed that the slope of the regression line sloped upward, consistent with the results of the HONEST study, when the interindividual BP variability of MHSBP was less than that of CSBP. In conclusion, differences between mean CSBP and MHSBP may be caused by large interindividual variability in CSBP. Therefore, the differences between MHSBP and CSBP may vary between patient groups, which should be noted in the management of hypertension.

Clinical Practice of Two Measurements of Home Blood Pressure on Each Occasion in Patients with Chronic Kidney Disease

BACKGROUND/AIMS

Although several guidelines propose two or three measurements of home blood pressure (HBP) on each occasion, the actual status of multiple measurements is not clear in the practical management of hypertension. We surveyed the details regarding two measurements of HBP in patients with chronic kidney disease (CKD).

METHODS

HBP was measured twice every morning and evening over 7 consecutive days in 175 CKD patients. The distribution of the differences between two BP values (2nd - 1st BP) and their association with BP parameters were evaluated.

RESULTS

The 2nd - 1st morning systolic BP (SBP) and diastolic BP (DBP) differences were -2.3 ± 4.1 and -0.4 ± 2.6 mm Hg, respectively. The proportion of 2nd - 1st morning SBP differences >0 mm Hg was 31.7% in a total of 1,195 measurements. Eighty patients (45.7%) had days with a difference ≤-5 mm Hg and days with a difference ≥5 mm Hg in morning SBP during 7 days. The multivariate regression analysis of the SD values of 2nd - 1st morning SBP as a dependent variable showed that the SD value of the 1st morning SBP (β = 0.65, p < 0.001) was a significant determinant.

CONCLUSION

Although the 2nd SBP was 2-3 mm Hg lower than the 1st SBP in the population as a whole, various differences were found for each subject during 7 days. 2nd - 1st BP variability might be associated with day-by-day 1st BP variability.

Effect of Olmesartan-Based Therapies on Therapeutic Indicators Obtained Through Out-of-Office Blood Pressure

Ambulatory blood pressure (BP) correlates more significantly with hypertension-associated cardiovascular mortality and morbidity than BP obtained in the doctor's office. Assessing ambulatory BP, either through 24-h monitoring or through protocolized self-measurement at home, is essential in diagnosing and monitoring patients with hypertension. Several ambulatory BP-derived indicators are related with cardiovascular prognosis. These include 24-h, daytime and nighttime BP measurements, BP measurements obtained through home self-measurement, dipping status, morning surge, and BP variability. The objective of this article was to review the effect of olmesartan-based antihypertensive therapy on the main risk variables obtained when assessing ambulatory BP.

Effectiveness of olmesartan-based treatment on home and clinic blood pressure in elderly patients with masked and white coat hypertension

Few large-scale studies have evaluated the effectiveness of angiotensin receptor blockers in patients with masked hypertension (MH) and white coat hypertension (WCH) based on age using real-world blood pressure (BP) data. We used data from the Home BP measurement with Olmesartan Naive patients to Establish Standard Target BP (HONEST) study to investigate the effectiveness of olmesartan-based treatment by patient age (<65 years of age, n=9817; 65–74 years of age, n=6792; ⩾75 years of age, n=4732), focusing on morning home BP (strongly associated with cardiovascular disease and useful for MH and WCH diagnosis). Sixteen weeks of treatment changed morning home BP (mean systolic/diastolic) by −18.1/−9.7, −15.9/−7.4 and −14.2/−6.4 mm Hg and clinic BP by −20.1/−11.3, −17.3/−8.7 and −15.4/−7.2 mm Hg, in these age groups, respectively (P<0.0001). Pulse pressure decreased (−7.8 to −8.8 mm Hg, P<0.0001). Patients aged ⩾80 years experienced similar BP and pulse pressure changes. In patients aged ⩾75 years, mean morning and clinic BP after 16 weeks was 137.5/74.8 and 129.7/70.4 mm Hg, respectively, in MH patients and 132.3/72.2 and 139.7/72.7 mm Hg, respectively, in WCH patients. Regardless of age, only elevated clinic or home BP values decreased to target ranges. The incidence of adverse effects associated with excessive BP lowering was low in all of the age groups. In conclusion, our study suggests that olmesartan-based treatment was safe and useful for managing MH, WCH and sustained hypertension in elderly patients. The lack of a placebo group was a limitation of the study.

Home blood pressure and cardiovascular outcomes in patients during antihypertensive therapy: primary results of HONEST, a large-scale prospective, real-world observational study

This study aimed to investigate the relationship between on-treatment morning home blood pressure (HBP) and incidence of cardiovascular events using data from the Home Blood Pressure Measurement With Olmesartan Naive Patients to Establish Standard Target Blood Pressure (HONEST) study, a prospective observational study of 21 591 outpatients with essential hypertension (mean age, 64.9 years; women, 50.6%) enrolled between 2009 and 2010 at clinics and hospitals in Japan. They received olmesartan-based treatment throughout. The primary end point was major cardiovascular events. After a mean follow-up period of 2.02 years, cardiovascular events occurred in 280 patients (incidence, 6.46/1000 patient-years). The risk for the primary end point was significantly higher in patients with on-treatment morning HBP ≥145 to <155 mm Hg (hazard ratio [HR], 1.83; 95% confidence interval [CI], 1.12-2.99) and ≥155 mm Hg (HR, 5.03; 95% CI, 3.05-8.31) than <125 mm Hg and with on-treatment clinic blood pressure ≥150 to <160 mm Hg (HR, 1.69; 95% CI, 1.10-2.60) and ≥160 mm Hg (HR, 4.38; 95% CI, 2.84-6.75) than <130 mm Hg. Morning HBP associated with minimum risk was 124 mm Hg by spline regression analysis. Cardiovascular risk was increased in patients with morning HBP ≥145 mm Hg and clinic blood pressure <130 mm Hg (HR, 2.47; 95% CI, 1.20-5.08) compared with morning HBP <125 mm Hg and clinic blood pressure <130 mm Hg. In conclusion, it is essential to control morning HBP to <145 mm Hg, even in patients with controlled clinic blood pressure.

CLINICAL TRIAL REGISTRATION URL

http://www.umin.ac.jp/ctr/index.htm. UMIN Clinical Trials Registry, trial No. UMIN000002567.

Effects of olmesartan-based treatment on masked, white-coat, poorly controlled, and well-controlled hypertension: HONEST study

The authors examined the effects of olmesartan‐based treatment on clinic systolic blood pressure (CSBP) and morning home systolic blood pressure (HSBP) in 21,340 patients with masked hypertension (MH), white‐coat hypertension (WCH), poorly controlled hypertension (PCH), and well‐controlled hypertension (CH) using data from the Home Blood Pressure Measurement With Olmesartan Naive Patients to Establish Standard Target Blood Pressure (HONEST) study. MH, WCH, PCH, and CH were defined using CSBP 140 mm Hg and MHSBP 135 mm Hg as cutoff values at baseline. At 16 weeks, the MH, WCH, PCH, and CH groups had changes in CSBP by −1.0, −15.2, −23.1, and 1.8 mm Hg, and changes in morning HSBP by −12.5, 1.0, −20.3, and 2.0 mm Hg, respectively. In conclusion, in “real‐world” clinical practice, olmesartan‐based treatment decreased high morning HBP or CBP without excessive decreases in normal morning HBP or CBP according to patients' BP status.

Difference in the effects of switching from candesartan to olmesartan or telmisartan to olmesartan in hypertensive patients with type 2 diabetes: the COTO study

Purpose

This open-label controlled study compared the therapeutic efficacy of three representative angiotensin II receptor blockers (ARBs) in hypertensive patients with type 2 diabetes attending a hospital outpatient clinic. The primary measure in this study was morning home blood pressure (BP).

Patients and methods

Two studies were done concurrently to investigate the effects of switching from two different ARBs to olmesartan. Patients prescribed candesartan (8 mg once daily in the morning) or telmisartan (40 mg once daily in the morning) for 16 weeks were switched to olmesartan (20 mg once daily in the morning) for 16 weeks. Then, they were switched back to candesartan (CO group) or telmisartan (TO group) for another 16 weeks.

Results

Data from all patients in the CO group (n=165) and the TO group (n=152) were analyzed. Clinic and morning home BP and urinary albumin levels showed a significant decrease from baseline at 16 weeks after switching to olmesartan in both the CO and the TO group (clinic BP, morning home diastolic BP, and urinary albumin, P<0.05; morning home systolic BP, P<0.01). In contrast, clinic BP, morning home BP, and urinary albumin were significantly increased again 16 weeks after switching back to candesartan or telmisartan (clinic BP, morning home diastolic BP, and urinary albumin, P<0.05; morning home systolic BP, P<0.01). No subjects experienced an adverse reaction that required withdrawal from the study. No adverse reactions attributable to the study drugs were observed.

Conclusion

Olmesartan is a promising ARB for BP control in hypertensive type 2 diabetics.

Effect of the angiotensin II receptor antagonist olmesartan on morning home blood pressure in hypertension: HONEST study at 16 weeks

Morning home blood pressure (BP) levels are more closely associated with cardiovascular risk than clinic BP levels. However, control of morning home BP has been worse than that of clinic BP in clinical practice. We examined the effects of olmesartan-based treatment using data (n=21 341) from the first 16 weeks of the Home BP measurement with Olmesartan Naive patients to Establish Standard Target blood pressure (HONEST) study, a prospective observational study for olmesartan-naive patients with essential hypertension. After 16-week olmesartan-based treatment, the clinic and morning home systolic BP (SBP) lowered from 151.6±16.4 and 153.6±19.0 mm Hg to 135.0±13.7 and 135.5±13.7 mm Hg, respectively (P<0.0001). The achievement percentage of target morning home SBP (<135 mm Hg) in all patients, those with diabetes mellitus (DM), and those with chronic kidney disease (CKD) increased from 13.5, 16.4 and 17.2% to 50.8, 47.9 and 48.8%, respectively, and the proportion of patients with well-controlled hypertension (clinic SBP<140 mm Hg and morning home SBP<135 mm Hg) increased from 7.9, 9.2 and 10.2% to 38.9, 34.5 and 36.3%, respectively. After 16-week olmesartan-based treatment, the proportion of patients with masked and white coat hypertension changed from 11.8 to 24.2% and 5.6 to 11.9%. In conclusion, both clinic and morning home BP in all, DM and CKD patients improved with 16-week olmesartan-based treatment in the ‘real world', and the results showed a sustained 24-hour BP-lowering effect of olmesartan. Decrease in clinic and home BP resulted in an increased rate of masked and white coat hypertension, and further management is needed in those patients.

ANGIOTENSIN RECEPTOR ANTAGONISTS: GOING WITH THE TIMES

This literature review focuses on the angiotensin II receptor antagonists as one of the new and promising classes of antihypertensive medications. Apart from their antihypertensive activity, these agents possess a number of other beneficial effects. The results of multiple studies, including large multi-centre clinical trials, are presented for olmesartan, an angiotensin receptor antagonist with additional beneficial properties.

Enhanced blood pressure-lowering effect of olmesartan in hypertensive patients with chronic kidney disease-associated sympathetic hyperactivity: HONEST study

To investigate the blood pressure (BP)–lowering effect of olmesartan in relation to chronic kidney disease (CKD)–associated sympathetic nerve activity, a subanalysis was performed using data from the first 16 weeks of the Home BP Measurement With Olmesartan‐Naive Patients to Establish Standard Target Blood Pressure (HONEST) study, a prospective observational study of hypertensive patients. Essential hypertensive patients who took no antihypertensive agent at baseline were classified based on baseline morning home systolic BP (MHSBP) in quartiles. In each class, patients were further classified based on baseline morning home pulse rate (MHPR). A subgroup analysis in patients with/without chronic kidney disease (CKD) was performed. A total of 5458 patients (mean age, 63.0 years; 51.6% women) were included. In the 4th quartile of baseline MHSBP (≥165 mm Hg), patients with MHPR ≥70 beats per minute had a greater BP reduction (by 3.2 mm Hg) than those with MHPR <70 beats per minute after 16 weeks of olmesartan‐based treatment (P=.0005). An even greater BP reduction (by 6.6 mm Hg) was observed in patients with CKD than in patients without CKD in this group (P=.0084). Olmesartan was more effective in hypertensive patients with high MHSBP and MHPR ≥70 beats per minute, especially in patients with CKD. Olmesartan may have enhanced BP‐lowering effects by improving renal ischemia in hypertensive CKD patients with potential increased sympathetic nerve activity.