Diurnal blood pressure changes

Self-measured home blood pressure highlights cardiovascular risk in women: the HOMED-BP study

No studies examined sex differences in relation to the prognostic significance of self-measured home blood pressure (HBP). We compared the predictive power for the risk of cardiovascular events in 1547 women and 1516 men with hypertension using HBP captured at treatment-free baseline and during on-treatment follow-up, based on the Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) study. To express the change in risk for the composite cardiovascular endpoint associated with a 1-SD increase in HBP at baseline or on treatment, we derived multivariable-adjusted hazard ratios (HR) based on a Cox regression model. Over a median follow-up of 7.3 years, 100 composite events occurred, including 40 events in women. In women, systolic HBP both at baseline and on-treatment showed significant risk increment (at baseline: HR per 1-SD increment, 1.62; 95% confidence interval [CI], 1.17-2.24. on-treatment: HR, 1.74; 95% CI, 1.32-2.29). However, systolic HBP at baseline did not predict cardiovascular events in men (P = 0.25). On-treatment HBP was significantly associated with cardiovascular risk (P ≤ 0.012) irrespective of sex. Nevertheless, the point estimate of HR for systolic HBP in men (1.33) was less than that in women (1.74), and the interaction of sex with 1 SD-increase in systolic HBP in cardiovascular risk was significant irrespective of baseline (P = 0.039) or follow-up (P = 0.040) measurement when they were mutually adjusted. The increase in cardiovascular risk with the systolic HBP was steeper in women than in men for both baseline and on-treatment. The current findings unveil the importance of the control of systolic HBP, especially in women. Clinical Trial Registration: UMIN Clinical Trial Registry ( http://www.umin.ac.jp/ctr ), Unique identifier: C000000137.

Role of basal autonomic functions in patients with increased morning blood pressure surge

BACKGROUND

Morning blood pressure (BP) surge (MS) is associated with cardiovascular events. The autonomic nervous system plays an active role in the regulation of BP and its function can be evaluated by heart rate variability (HRV) analysis. This study aimed to evaluate autonomic nervous system functions in patients with increased MS.

METHODS

Patients who underwent ambulatory BP monitoring (ABPM) and 24-h rhythm Holter in our hospital during the same period between 2017 and 2022 were evaluated. HRV parameters were obtained from 24-h rhythm Holter recordings. MS values of the patients were calculated from ABPM records and patients were divided into four groups according to the MS quartiles. HRV parameters and other parameters were compared between the groups.

RESULTS

A total of 129 patients were included in the study. The mean age of the patients was 57.2 ± 18.2 years, and 63 (48.8%) were male. HF, the square root of the mean squared differences of successive normal-to-normal intervals (rMSSD), and the proportion of adjacent RR intervals differing by >50 ms in the 24-h recording (pNN50) were statistically significant between the groups ( P  = 0.039, P  = 0.013, P  = 0.011, respectively). In univariate regression analysis, low-frequency/high-frequency ratio was positively associated with MS and HF, SDNNi, rMSSD, and pNN50 were negatively associated ( β  = 0.207, P  = 0.019; β  = -0.272, P  = 0.002; β  = -0.201, P  = 0.022; β  = -0.265, P  = 0.002; β  = -0.278, P  = 0.001, respectively). Multiple linear regression analysis showed an independent association between HF, low-frequency/high-frequency ratio, rMSSD, pNN50, and MS ( β  = -0.247, P  = 0.005; β=0.206, P  = 0.017; β  = -0.209, P  = 0.005; β  = -0.227, P  = 0.008, respectively).

CONCLUSION

We found an independent association between HRV parameters associated with vagal tone and MS. The findings of our study suggest that the increased sympathetic activity detected in patients with high MS in previous studies may be due to a decrease in basal vagal tone.

Cuff-Less Blood Pressure Prediction Based on Photoplethysmography and Modified ResNet

Cardiovascular disease (CVD) has become a common health problem of mankind, and the prevalence and mortality of CVD are rising on a year-to-year basis. Blood pressure (BP) is an important physiological parameter of the human body and also an important physiological indicator for the prevention and treatment of CVD. Existing intermittent measurement methods do not fully indicate the real BP status of the human body and cannot get rid of the restraining feeling of a cuff. Accordingly, this study proposed a deep learning network based on the ResNet34 framework for continuous prediction of BP using only the promising PPG signal. The high-quality PPG signals were first passed through a multi-scale feature extraction module after a series of pre-processing to expand the perceptive field and enhance the perception ability on features. Subsequently, useful feature information was then extracted by stacking multiple residual modules with channel attention to increase the accuracy of the model. Lastly, in the training stage, the Huber loss function was adopted to stabilize the iterative process and obtain the optimal solution of the model. On a subset of the MIMIC dataset, the errors of both SBP and DBP predicted by the model met the AAMI standards, while the accuracy of DBP reached Grade A of the BHS standard, and the accuracy of SBP almost reached Grade A of the BHS standard. The proposed method verifies the potential and feasibility of PPG signals combined with deep neural networks in the field of continuous BP monitoring. Furthermore, the method is easy to deploy in portable devices, and it is more consistent with the future trend of wearable blood-pressure-monitoring devices (e.g., smartphones and smartwatches).

Association between lung function and hypertension and home hypertension in a Japanese population: the Tohoku Medical Megabank Community-Based Cohort Study

BACKGROUND

Although several studies have shown an inverse association between lung function and hypertension, few studies have examined the association between lung function and hypertension among never-smokers, and no study has investigated the association between lung function and home hypertension. We investigated the associations between lung function and hypertension in a Japanese population.

INDIVIDUALS AND METHODS

We conducted a cross-sectional study of 3728 men and 8795 women aged 20 years or older living in Miyagi Prefecture, Japan. Lung function was assessed using forced expiratory volume at 1 s (FEV 1 ) and forced vital capacity (FVC), measured by spirometry. Hypertension was defined as a casual blood pressure at least 140/90 mmHg and/or self-reported treatment for hypertension. Home hypertension was defined as morning home blood pressure at least 135/85 mmHg and/or self-reported treatment for hypertension. Multivariate logistic regression models adjusted for potential confounders were used to assess the association between lung function and hypertension.

RESULTS

The mean ages (±SD) of men and women were 60.1 (±14.0) years and 56.2 (±13.4) years, respectively, and 1994 (53.5%) men and 2992 (34.0%) women had hypertension. In the multivariable models, FEV 1 and FVC were inversely associated with hypertension. Inverse associations between lung function and hypertension were observed even among never-smokers. Furthermore, reduced lung function was associated with higher prevalence of home hypertension in men and women.

CONCLUSION

Reduced lung function was associated with higher prevalence of hypertension, independent of smoking status. Assessment of the lung function or blood pressure may be required in individuals with reduced lung function or hypertension.

Advances in Cuffless Continuous Blood Pressure Monitoring Technology Based on PPG Signals

Objective. To review the progress of research on photoplethysmography- (PPG-) based cuffless continuous blood pressure monitoring technologies and prospect the challenges that need to be addressed in the future. Methods. Using Web of Science and PubMed as search engines, the literature on cuffless continuous blood pressure studies using PPG signals in the recent five years were searched. Results. Based on the retrieved literature, this paper describes the available open datasets, commonly used signal preprocessing methods, and model evaluation criteria. Early researches employed multisite PPG signals to calculate pulse wave velocity or time and predicted blood pressure by a simple linear equation. Later, extensive researches were dedicated to mine the features of PPG signals related to blood pressure and regressed blood pressure by machine learning models. Most recently, many researches have emerged to experiment with complex deep learning models for blood pressure prediction with the raw PPG signal as input. Conclusion. This paper summarized the methods in the retrieved literature, provided insight into the artificial intelligence algorithms employed in the literature, and concluded with a discussion of the challenges and opportunities for the development of cuffless continuous blood pressure monitoring technologies.

Prediction of atrial fibrillation in patients with hypertension: A comprehensive comparison of office and ambulatory blood pressure measurements

Hypertension is associated with the development of atrial fibrillation (AF). Evidence has shown that reverse dipping pattern, an abnormal increase of night-time blood pressure (BP) comparing to daytime BP, is associated with cardiovascular events. However, the relationship between diurnal changes in BP and AF has not been sufficiently explored. This paper aims to cross-sectionally explore the relationship between AF and ambulatory BP parameters, especially reverse dippers to the others, and further longitudinally analyze how BP patterns are associated to the risk of developing new-onset AF. Between February 2012 and March 2021, five out of 412 patients were identified of AF at baseline; four were reverse dippers (3.7%) and one was from the others (.3%). Cross-sectionally, the multivariate logistic regression analysis showed that reverse dippers were significantly more likely to have AF (odds ratio: 12.39, p = .030). After excluding patients with baseline AF, during the mean follow-up of 4.6 ± 3.0 years, seven patients developed AF. Longitudinally, the multivariate Cox regression analysis revealed that 24-h systolic BP (hazard ratio per 10 mmHg: 2.12, p = .015), night-time systolic BP (hazard ratio per 10 mmHg: 2.27, p = .002), and presentation of reverse dipping (hazard ratio: 5.25, p = .042) were independently associated with new-onset AF. None of the office BP measurements were associated with new-onset AF. While ambulatory BP measurements were better predictors for the incidence of AF, careful management is necessary for reverse dippers as they are at high risk of developing AF.

Genetic variants of GRK4 influence circadian rhythm of blood pressure and response to candesartan in hypertensive patients

Background: Genetic variants of coding genes related to blood pressure regulation participate in the pathogenesis of hypertension and determines the response to specific antihypertensive drugs. G protein-coupled receptor kinase 4 (GRK4) and its variants are of great importance in pathogenesis of hypertension. However, little is known about role of GRK4 variants in determine circadian rhythm of blood pressure and response to candesartan in hypertension. The aim of this study was to analyze the correlation of GRK4 variants and circadian rhythm of blood pressure, and to explore their effect on antihypertensive efficiency of candestartan.Methods: In this study, a total of 1239 cases were eligible, completed ambulatory blood pressure monitoring (ABPm) observation and exon sequencing of G protein-coupled receptor kinase 4 (GRK4). ABPm was obtained before and after 4-week treatment of candesartan. Diurnal variation of systolic blood pressure and antihypertensive effect of candesartan were then assessed.Results: Compared to GRK4 wild type (GRK4-WT), patients with GRK4 variants were more likely to be non-dippers (odds ratio (OR) 6.672, 95% confidence interval (CI) 5.124-8.688, P < .001), with GRK4 A142V (OR 5.888, 95% CI 4.332-8.003, P < .001), A486V (OR 7.102, 95% CI 5.334-9.455, P < .001) and GRK4 R65L (OR 3.273, 95% CI 2.271-4.718, P < .001), respectively. Correlation analysis revealed that non-dippers rhythm of blood pressure were associated with GRK4 variants (r = .420, P < .001), with GRK4 A142V (r = .416, P < .001), A486V (r = .465, P < .001) and GRK4 R65L (r = .266, P < .001), respectively. When given 4-week candesartan, patients with GRK4 variants showed better antihypertensive effect as to drop in blood pressure (24 h mSBP, 21.21 ± 4.99 vs 12.34 ± 4.78 mmHg, P < .001) and morning peak (MP-SBP, 16.54 ± 4.37 vs 11.52 ± 4.14 mmHg, P < .001), as well as greater increase in trough to peak ratio (SBP-T/P, .71 ± .07 vs .58 ± .07, P < .001) and smoothness index (SBP-SI, 1.44 ± .16 vs 1.17 ± .11, P < .001) than those with GRK4 WT.Conclusion: This study indicates that hypertensive patients with GRK4 variants are more likely to be non-dippers. What's more, patients with GRK4 variants possess a significantly better antihypertensive response to candesartan than those with GRK4 WT.

Impacts of the urinary sodium-to-potassium ratio, sleep efficiency, and conventional risk factors on home hypertension in a general Japanese population

Recently, a high urinary sodium-to-potassium (Na/K) ratio and reduced sleep efficiency, in addition to conventional risk factors (obesity and excess alcohol intake), have been identified as risk factors for hypertension. We estimated the population attributable fraction (PAF) for home hypertension due to these risk factors in a general Japanese population. We conducted a cross-sectional study including 1384 participants (393 men and 991 women) to estimate the odds ratio (OR) and 95% confidence interval (CI) for the presence of any of the conventional risk factors using multivariable logistic regression analyses. The models were adjusted for sex, age, smoking status, and log-transformed average daily steps. We also estimated the OR and 95% CI for the presence of any of the overall risk factors. Furthermore, we calculated the PAF due to these risk factors. The results showed that the prevalence of home hypertension was 39.0% (540/1384). The presence of any of the conventional risk factors, as well as any of the overall risk factors, was significantly associated with an increased prevalence of hypertension (OR 2.80, 95% CI 2.15-3.65; OR 2.50, 95% CI 1.93-3.22, respectively). The PAF for hypertension due to the presence of any of the conventional risk factors and the PAF due to the presence of any of the overall risk factors were 30.2% and 39.0%, respectively. In conclusion, the impact of the overall risk factors, including the urinary Na/K ratio and sleep efficiency, on home hypertension was higher than that of conventional risk factors alone. The management of the urinary Na/K ratio and sleep efficiency as well as conventional risk factors might be important in the management of blood pressure.

The dawning of the digital era in the management of hypertension

Awareness, treatment, and control of hypertension are of the utmost importance in conquering stroke and cardiovascular disease. To reduce the global burden of hypertension, the Japanese Society of Hypertension (JSH) established the "JSH Future Plan" based on an increasing need to transform the strategy for combating hypertension. In addition to energizing conventional approaches in basic, translational, and clinical research, the application of rapidly evolving digital health technologies and artificial intelligence to hypertension healthcare and research (digital hypertension) holds promise for providing further insights into the pathophysiology and therapeutic targets and implementing predictive, personalized, and preemptive approaches in clinical practice. With great potential to revolutionize the landscape of hypertension, digital hypertension has some technical, legal, ethical, social, and financial issues to overcome. Given the multidisciplinary framework, digital hypertension requires comprehensive and strategic collaboration among industry, academia, and government to move forward toward the goal of "Future Medicine".

Nocturnal blood pressure measured by home devices: evidence and perspective for clinical application

: Studies using ambulatory blood pressure (BP) monitoring have shown that BP during night-time sleep is a stronger predictor of cardiovascular outcomes than daytime ambulatory or conventional office BP. However, night-time ambulatory BP recordings may interfere with sleep quality because of the device cuff inflation and frequency of measurements. Hence, there is an unmet need for obtaining high quality BP values during sleep. In the last two decades, technological development of home BP devices enabled automated BP measurements during night-time. Preliminary data suggest that nocturnal home BP measurements yield similar BP values and show good agreement in detecting nondippers when compared with ambulatory BP monitoring. Thus, nocturnal home BP measurements might be a reliable and practical alternative to ambulatory BP monitoring to evaluate BP during sleep. As the use of home BP devices is widespread, well accepted by users and has relatively low cost, it may prove to be more feasible and widely available for routine clinical assessment of nocturnal BP. At present, however, data on the prognostic relevance of nocturnal BP measured by home devices, the optimal measurement schedule, and other methodological issues are lacking and await further investigation. This article offers a systematic review of the current evidence on nocturnal home BP, highlights the remaining research questions, and provides preliminary recommendations for application of this novel approach in BP management.

Blood pressure and heart rate variability and baroreflex sensitivity in white-coat, masked, and sustained hypertension

We investigated blood pressure (BP) and heart rate variability and baroreflex sensitivity (BRS) in white-coat, masked and sustained hypertension in untreated patients (n = 645). Normotension and white-coat, masked, and sustained hypertension were defined according to the clinic (cutoff 140/90 mmHg) and 24-h ambulatory (130/80 mmHg) BPs. The Finometer device recorded beat-to-beat finger BP and electrocardiograms in the supine and standing positions for the computation of frequency-domain power-spectral BP and heart rate variability indexes and BRS. In multivariate analysis, BP variability indexes in the supine position differed significantly (P < 0.0001) for both low-frequency (LF) and high-frequency (HF) components and the LF/HF ratio, with the lowest LF and HF power and highest LF/HF ratio in white-coat hypertension (n = 28), the highest LF and HF power and lowest LF/HF ratio in sustained hypertension (n = 198), and intermediate values in normotension (n = 189) and masked hypertension (n = 230). These differences diminished in the standing position, being significant (P < 0.0001) only for the LF component variability. The LF/HF ratio in BP in the supine position decreased with advancing age in normotension and sustained hypertension (P ≤ 0.03) but not white-coat or masked hypertension (P ≥ 0.12). For heart rate variability, a significant difference was observed only for the LF component in the supine position (P = 0.0005), which was lowest in white-coat hypertension. BRS in masked and sustained hypertension was significantly (P ≤ 0.0001) lower than that in normotension in both supine and standing positions and decreased with advancing age (P ≤ 0.0001). In conclusion, masked, but not white-coat, hypertension showed similar patterns of, but slightly less severe, changes in BP and heart rate variability and BRS to sustained hypertension.

Effects of white-coat, masked and sustained hypertension on coronary artery stenosis and cardiac arrhythmia

This study aimed to investigate whether hypertension phenotypes such as white-coat hypertension (WCHT), diagnosed with the addition of nighttime blood pressure (BP) criteria, are related to coronary artery stenosis (CAS) and cardiac arrhythmia. In this cross-sectional observational study, 844 participants who did not use antihypertensive, lipid-lowering, and antiplatelet drugs were selected. The subjects were divided into normotensive (NT), WCHT, masked hypertension (MHT), and sustained hypertension (SHT) groups based on the results of clinic BP measurement and ambulatory BP monitoring. Coronary angiography and ambulatory electrocardiography were performed to determine the participants' CAS and cardiac arrhythmia status. Coronary angiography revealed 556 patients with CAS and 288 participants with normal coronary arteries. The chi-squared test showed that the incidence of CAS was higher in the MHT and SHT groups than in the NT group, while no significant change was found in the WCHT group (P = 0.003, P < 0.001, P = 0.119). The logarithm of the Gensini score was used to compare the degree of CAS between the groups. Multiple linear regression analysis showed that the degree of CAS was higher in the WCHT, MHT, and SHT groups than in the NT group (P < 0.05). The incidences of frequent atrial premature beats, atrial tachycardia, and ventricular cardiac arrhythmia were significantly higher in the WCHT and SHT groups than in the NT group, while only ventricular cardiac arrhythmia changes were observed in the MHT group. This study found that hypertension phenotypes such as WCHT were closely associated with CAS and cardiac arrhythmia.

Can High-Sensitivity Troponins Predict Future Hypertension? A Systematic Literature Review

Hypertension (HT) is associated with cardiovascular events and increased mortality, and identification of persons at risk in due time is therefore important. Finding a biomarker to identify those at risk will enable early preventive treatment, and high-sensitivity cardiac troponin (hs-cTn) seems to be a highly relevant candidate. To gather the existing knowledge on the association between hs-cTn and future HT, a systematic literature review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) reporting guidelines and using the PICOS system. Medline was searched until August 2018. Of 45 extracted papers, eleven papers were eligible for the study. None were randomized controlled trials. Three studies assessed hs-cTnI, eight studies assessed hs-cTnT. All studies found statistically significant associations between hs-cTn concentrations and future HT, but the studies included different types of blood pressure (diastolic, systolic, diurnal). Due to differences in troponin assay construction and test capability, a direct comparison of test performance in terms of specificity, sensitivity and predictive values was not possible, and a specific hs-cTn cutoff value for HT prediction could therefore not be defined. Furthermore, a number of conditions known to affect troponin concentrations (e.g. gender, renal function, and co-morbidities) were not sufficiently studied. All retrieved studies found significant associations between hs-cTn concentrations and future HT; although the findings are promising, the studies were too heterogeneous, and many conditions affecting troponin concentrations needs investigation at these low concentrations before hs-cTn can be considered a useful HT predictor.

Reduced sleep efficiency, measured using an objective device, was related to an increased prevalence of home hypertension in Japanese adults

Few studies have reported the relationship between reduced sleep efficiency and the prevalence of hypertension independent of sleep duration in Japan. This study aimed to evaluate whether reduced sleep efficiency, measured using an objective device for >1 week, was related to an increased prevalence of hypertension independent of sleep duration in the general Japanese population. We conducted a cross-sectional study of 904 participants aged ≥20 years who lived in Miyagi Prefecture, Japan. Sleep efficiency was measured using a contactless biomotion sleep sensor for 10 continuous days. The participants were classified into two groups according to their sleep efficiency: reduced (<90%) or not reduced (≥90%). Hypertension was defined as morning home blood pressure ≥135/85 mmHg or self-reported treatment for hypertension. Multivariable logistic regression models were used to obtain odds ratios (ORs) and 95% confidence intervals (CIs) to assess the relationship between sleep efficiency and hypertension adjusted for potential confounders. The results showed that two hundred and ninety-four individuals (32.5%) had reduced sleep efficiency, and 331 (36.6%) had hypertension. Individuals with reduced sleep efficiency had a higher body mass index and shorter sleep duration. In the multivariable analysis, reduced sleep efficiency was significantly related to an increased prevalence of hypertension (OR, 1.62; 95% CI, 1.15–2.28). In conclusion, reduced sleep efficiency was significantly related to an increased prevalence of hypertension in Japanese adults. Improvements in sleep efficiency may be important to reduce blood pressure in Japanese adults.

Comparison of blood pressure values-self-measured at home, measured at an unattended office, and measured at a conventional attended office

Self-measured blood pressure (BP) at home (HBP) has been commonly used in clinical practice. Although the unattended office BP (UBP), in which a patient is left alone before and during the measurement, has been investigated, the advantages of UBP over HBP or conventionally measured attended office BP obtained using automated devices (CBP) remain unclear. We performed a multicenter clinical study in Japan to compare the UBP, CBP, and HBP among 308 patients with hypertension at 3 clinics (women, 57.8%; mean age 71.8 years; under antihypertensive drug therapy, 96.4%). The patients measured HBP twice in the morning and twice in the evening for 5 days according to the Japanese Society of Hypertension guidelines. Using the Omron HEM-907 cuff-oscillometric device, the UBP and CBP were measured in line with the protocol in the Systolic blood PRessure INtervention Trial (SPRINT) and in accordance with the guidelines, respectively. Correlation coefficients were ≤0.16 for the comparison of UBP versus morning and evening HBP for the systolic measurement, whereas they were approximately 0.5 (P < 0.001) for the diastolic measurement. The difference between UBP minus HBP was small on average but varied among individuals (mean ± SD for UBP minus morning HBP: 0.9 ± 17.8/-4.5 ± 10.5 mmHg; UBP minus evening HBP: 5.7 ± 17.8/-0.1 ± 11.3 mmHg). In contrast, the measurement values of CBP and UBP were highly correlated (r ≥ 0.72), but the difference between CBP minus UBP was 10.4 ± 12.0/4.2 ± 6.5 mmHg. Based on the low correlations and wide range of differences, UBP cannot be used as an alternative to HBP.

Kidney volume, kidney function, and ambulatory blood pressure in children born extremely preterm with and without nephrocalcinosis

BACKGROUND

Reduced kidney volume (KV) following prematurity is a proxy for reduced nephron number and is associated with the development of hypertension and end-stage renal disease in adults. We investigated whether extreme prematurity affects KV, function, and blood pressure in school-aged children and if nephrocalcinosis (NC) developed during the neonatal period had additional effects.

METHODS

We investigated 60 children at a mean age of 7.7 years: 20 born extremely preterm (EPT < 28 weeks gestational age with NC (NC+)), 20 born EPT without NC (NC-), and 19 born as full-term infants (control). We measured KV by ultrasound, collected blood and urine samples to evaluate renal function, and measured office and 24-h ambulatory blood pressure (ABPM).

RESULTS

Children born EPT had significantly smaller kidneys (EPT (NC+ NC-) vs control (estimated difference, 11.8 (CI - 21.51 to - 2.09 ml), p = 0.018) and lower but normal cystatin C-based glomerular filtration rate compared with control (estimated difference, - 10.11 (CI - 0.69 to - 19.5), p = 0.035). KV and function were not different between NC+ and NC- groups. Change in KV in relation to BSA (KV/BSA) from the neonatal period to school age showed significantly more EPT children with neonatal NC having a negative evolution of KV (p = 0.01). Blood pressure was normal and not different between the 3 groups. Fifty percent of EPT had a less than 10% day-to-night decline in ABPM.

CONCLUSIONS

Kidney growth and volume is affected by EPT birth with NC being a potential aggravating factor. Circadian blood pressure regulation seems abnormal in EPT-born children.