Effects of alcohol consumption and restriction on home blood pressure in hypertensive patients: serial changes in the morning and evening records

Very-light alcohol consumption suppresses breast tumor progression in a mouse model

The relationship between alcohol consumption and cancer has no consistent results both in epidemiological studies and animal models. The inaccuracy of alcohol consumption dosage in the experimental design maybe leads to inconsistent results and makes the researchers ignore the effect of very-light alcohol consumption on cancer. To determine the effects of very-light alcohol consumption on cancer, in this study, the manner of gavage was used to control the alcohol consumption accurately. The impacts of age and time of drinking on cancer progression were also evaluated in this study. Here, we find that a certain range of alcohol consumption (from 0.5% w/v to 2.0% w/v) can suppress tumor development in the breast metastasis mouse model by controlling the alcohol consumption dosage accurately. RNA sequencing analyses were performed in primary tumors and related metastases from the NC group and 1.0% w/v group. The results of primary tumors and related metastases indicated that chronic very-light alcohol consumption downregulates breast tumor-associated oncogenes in primary tumors and regulates the immune system and metabolic system in metastatic carcinoma. To provide the public with drinking recommendations, eight commercial alcohol types were investigated at a dosage of 1.0% w/v. Two types of commercial alcohol, red wine (made in France, brand 1) and baijiu (made in China, brand 1), exerted excellent primary tumor and metastasis inhibitory effects. The untargeted metabolomic analysis of commercial alcohol by liquid chromatography-tandem mass spectrometry indicated that baijiu (brand 1) and baijiu (brand 2) exhibited a difference in compositions that can lead to their different anti-cancer effects. These results indicated that a certain range of very light alcohol dosages might have a potential human-cancer inhibition effect.

Effect of alcohol on blood pressure

BACKGROUND

Alcohol is consumed by over 2 billion people worldwide. It is a common substance of abuse and its use can lead to more than 200 disorders including hypertension. Alcohol has both acute and chronic effects on blood pressure. This review aimed to quantify the acute effects of different doses of alcohol over time on blood pressure and heart rate in an adult population.

OBJECTIVES

Primary objective To determine short-term dose-related effects of alcohol versus placebo on systolic blood pressure and diastolic blood pressure in healthy and hypertensive adults over 18 years of age. Secondary objective To determine short-term dose-related effects of alcohol versus placebo on heart rate in healthy and hypertensive adults over 18 years of age.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to March 2019: the Cochrane Hypertension Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2), in the Cochrane Library; MEDLINE (from 1946); Embase (from 1974); the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. We also contacted authors of relevant articles regarding further published and unpublished work. These searches had no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing effects of a single dose of alcohol versus placebo on blood pressure (BP) or heart rate (HR) in adults (≥ 18 years of age).

DATA COLLECTION AND ANALYSIS

Two review authors (ST and CT) independently extracted data and assessed the quality of included studies. We also contacted trial authors for missing or unclear information. Mean difference (MD) from placebo with 95% confidence interval (CI) was the outcome measure, and a fixed-effect model was used to combine effect sizes across studies.  MAIN RESULTS: We included 32 RCTs involving 767 participants. Most of the study participants were male (N = 642) and were healthy. The mean age of participants was 33 years, and mean body weight was 78 kilograms. Low-dose alcohol (< 14 g) within six hours (2 RCTs, N = 28) did not affect BP but did increase HR by 5.1 bpm (95% CI 1.9 to 8.2) (moderate-certainty evidence). Medium-dose alcohol (14 to 28 g) within six hours (10 RCTs, N = 149) decreased systolic blood pressure (SBP) by 5.6 mmHg (95% CI -8.3 to -3.0) and diastolic blood pressure (DBP) by 4.0 mmHg (95% CI -6.0 to -2.0) and increased HR by 4.6 bpm (95% CI 3.1 to 6.1) (moderate-certainty evidence for all).  Medium-dose alcohol within 7 to 12 hours (4 RCTs, N = 54) did not affect BP or HR. Medium-dose alcohol > 13 hours after consumption (4 RCTs, N = 66) did not affect BP or HR. High-dose alcohol (> 30 g) within six hours (16 RCTs, N = 418) decreased SBP by 3.5 mmHg (95% CI -6.0 to -1.0), decreased DBP by 1.9 mmHg (95% CI-3.9 to 0.04), and increased HR by 5.8 bpm (95% CI 4.0 to 7.5). The certainty of evidence was moderate for SBP and HR, and was low for DBP. High-dose alcohol within 7 to 12 hours of consumption (3 RCTs, N = 54) decreased SBP by 3.7 mmHg (95% CI -7.0 to -0.5) and DBP by 1.7 mmHg (95% CI -4.6 to 1.8) and increased HR by 6.2 bpm (95% CI 3.0 to 9.3). The certainty of evidence was moderate for SBP and HR, and low for DBP. High-dose alcohol ≥ 13 hours after consumption (4 RCTs, N = 154) increased SBP by 3.7 mmHg (95% CI 2.3 to 5.1), DBP by 2.4 mmHg (95% CI 0.2 to 4.5), and HR by 2.7 bpm (95% CI 0.8 to 4.6) (moderate-certainty evidence for all).  AUTHORS' CONCLUSIONS: High-dose alcohol has a biphasic effect on BP; it decreases BP up to 12 hours after consumption and increases BP > 13 hours after consumption. High-dose alcohol increases HR at all times up to 24 hours. Findings of this review are relevant mainly to healthy males, as only small numbers of women were included in the included trials.

Morning and Evening Blood Pressures Are Associated With Intima-Media Thickness in a General Population - The Hisayama Study

BACKGROUND

The association of morning and evening home blood pressures (HBPs) with carotid atherosclerosis has been uncertain in general populations, so we aimed to investigate it in a general Japanese population.Methods and Results:We performed a cross-sectional survey of 2,856 community-dwelling individuals aged ≥40 years to examine the association of morning and evening HBPs with carotid mean intima-media thickness (IMT). The age- and sex-adjusted geometric averages of carotid mean IMT increased significantly with increasing morning HBP (optimal: 0.67 mm; normal: 0.69 mm; high normal: 0.72 mm; grade 1 hypertension: 0.74 mm; and grade 2+3 hypertension: 0.76 mm) and with increasing evening HBP (0.68 mm, 0.71 mm, 0.73 mm, 0.76 mm, and 0.78 mm, respectively) (both P for trend <0.001). These associations remained significant even after adjusting for potential confounding factors. Likewise, both isolated morning hypertension (morning HBP ≥135/85 mmHg and evening HBP <135/85 mmHg) and isolated evening hypertension (evening HBP ≥135/85 mmHg and morning HBP <135/85 mmHg) as well as sustained hypertension (both morning and evening HBP ≥135/85 mmHg) were significantly associated with thicker mean IMT.

CONCLUSIONS

Our findings suggested that both morning and evening HBPs were significantly associated with carotid atherosclerosis in this general Japanese population.

Progression from prehypertension to hypertension and risk of cardiovascular disease

BACKGROUND

Subjects with prehypertension (pre-HT; 120/80 to 139/89 mm Hg) have an increased risk of cardiovascular disease (CVD); however, whether the risk of pre-HT can be seen at the pre-HT status or only after progression to a hypertensive (HT; ≥140/90 mm Hg) state during the follow-up period is unknown.

METHODS

The Jichi Medical Cohort study enrolled 12,490 subjects recruited from a Japanese general population. Of those, 2227 subjects whose BP data at baseline and at the middle of follow-up and tracking of CVD events were available (median follow-up period: 11.8 years). We evaluated the risk of HT in those with normal BP or pre-HT at baseline whose BP progressed to HT at the middle of follow-up compared with those whose BP remained at normal or pre-HT levels.

RESULTS

Among the 707 normotensive patients at baseline, 34.1% and 6.6% of subjects progressed to pre-HT and HT, respectively, by the middle of follow-up. Among 702 subjects with pre-HT at baseline, 26.1% progressed to HT. During the follow-up period, there were 11 CVD events in normotensive patients and 16 CVD events in pre-HT patients at baseline. The subjects who progressed from pre-HT to HT had 2.95 times higher risk of CVD than those who remained at normal BP or pre-HT in a multivariable-adjusted Cox hazard model.

CONCLUSION

This relatively long-term prospective cohort study indicated that the CVD risk with pre-HT might increase after progression to HT; however, the number of CVD events was small. Therefore, the results need to be confirmed in a larger cohort.

Chronic Alcohol Consumption in Rats Leads to Desynchrony in Diurnal Rhythms and Molecular Clocks

BACKGROUND

Circadian rhythms are essential for adapting to the environment. Chronic alcohol consumption often leads to sleep and circadian disruptions, which may impair the life quality of individuals with alcohol use disorders and contribute to the morbidity associated with alcoholism.

METHODS

We used a pair-feeding liquid diet alcohol exposure protocol (6 weeks duration) in PER1::LUC transgenic rats to examine the effects of chronic alcohol exposure on: (i) diurnal rhythms of core body temperature and locomotor activity, (ii) plasma corticosterone (CORT) concentrations, and (iii) rhythms of ex vivo Period1 (Per1) expression in the suprachiasmatic nucleus (SCN), pituitary, and adrenal glands. We followed multiple circadian outputs not only to examine individual components, but also to assess the relative phase relationships among rhythms.

RESULTS

We found that chronic alcohol consumption: (i) reduced 24-hour body temperature and locomotor activity counts in the dark period, (ii) advanced the acrophase of diurnal rhythms of body temperature and locomotor activity, (iii) abolished the phase difference between temperature and activity rhythms, (iv) blunted and advanced the diurnal CORT rhythm, and (v) advanced Per1 expression in the adrenal and pituitary glands but not in the SCN. We found that chronic alcohol altered the phase relationships among diurnal rhythms and between the central (SCN) and peripheral (adrenal and pituitary) molecular clocks.

CONCLUSIONS

Our findings suggest that desynchrony among internal rhythms is an important and overlooked aspect of alcohol-induced circadian disruptions. The misalignment of phases among rhythms may compromise normal physiological functions and put individuals with chronic alcohol use at greater risk for developing other physical and mental health issues. How this desynchrony occurs and the extent to which it participates in alcohol-related pathologies requires further investigation.

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.

Diurnal blood pressure variation and related behavioral factors

Blood pressure (BP) varies according to many internal and external factors, and behavioral factors have an important role in diurnal BP variation. BP rises sharply on waking in the morning and falls during sleep at night, although it varies throughout the day and night. These changes in BP are closely related to mental and physical activities, and the sympathetic nervous system mainly contributes to the diurnal variation in BP. Other behavioral factors, such as food consumption and obesity, dietary intake of sodium, drinking and smoking habits, consumption of coffee and tea, and bathing, also affect the diurnal variation in BP. Alterations in diurnal BP variation due to behavioral factors are frequently seen in patients with hypertension and can be classified as morning hypertension, daytime hypertension and nighttime hypertension. Appropriate lifestyle modifications may normalize or improve both the level and rhythm of BP in these patients.

A New Baroreceptor Sensitivity-Restoring Ca-Channel Blocker Diminishes Age-Related Morning Blood Pressure Increase in Hypertensive Patients: Open-Label Monitoring of Azelnidipine Treatment for Hypertension in the Early Morning (At-HOME) Study

Background: Morning blood pressure (BP) surge, which exhibits an age-related increase, is a risk factor for stroke in elderly hypertensive patients, independently of the 24-h BP level. We studied the effect of the new baroreceptor sensitivity (BRS)-restoring Ca-channel blocker (CCB) azelnidipine (AZ) on this age-related morning BP increase. Methods: We conducted a 16-week prospective study to clarify the effect of morning dosing of AZ on home BPs measured in the morning and in the evening in 2,546 hypertensive patients (mean age, 65.1 years; female, 53.6%). Results: At baseline, ME-Dif (morning systolic BP [SBP]–evening SBP) increased with age, independently of ME-Ave (average of the morning and evening SBPs). This age-related increase of ME-Dif was exaggerated by regular alcohol drinking and beta-blocker use. After AZ treatment (14.3 ± 3.6 mg/day), ME-AV and ME-Dif were significantly reduced independently of each other, with reductions of –18.1 ± 15.6 and –2.5 ± 13.2 mmHg, respectively (both p < 0.001). AZ treatment decreased age-related increase in ME-Dif particularly in patients who were regular consumers of alcohol and in beta-blocker users. Conclusions: The new BRS-restoring CCB AZ significantly reduced age-related increase in morning BP and had some potential benefit on cardiovascular protection in hypertension, particularly in elderly patients and/or consumers of alcohol.

Uncontrolled hypertension based on morning and evening home blood pressure measurements from the J-HOME study

We evaluated the control condition of morning and evening home blood pressure (BP) and compared patients who had isolated uncontrolled morning hypertension and those who had sustained uncontrolled (morning and evening) hypertension using data from the Japan Home versus Office Blood Pressure Measurement Evaluation study. We evaluated 3303 treated hypertensive patients (mean age, 66.2+/-10.5 years; men, 44.7%) in Japan. We classified patients into controlled hypertension, isolated uncontrolled evening hypertension, isolated uncontrolled morning hypertension and sustained uncontrolled hypertension, based on the cutoff value of 135/85 mm Hg for both morning and evening home BP. Of the 3303 patients evaluated, 24.6% had isolated uncontrolled morning hypertension, and 42.0% had sustained uncontrolled hypertension. Factors associated with isolated uncontrolled morning hypertension included taking evening BP measurement after drinking alcohol or bathing. Factors associated with sustained uncontrolled hypertension were male gender, diabetes mellitus and renal disease. The regimen of antihypertensive medication was more complex in patients with uncontrolled morning hypertension than in controlled hypertension. Determinants of the difference between patients with isolated uncontrolled morning hypertension and those with sustained uncontrolled hypertension were diabetes mellitus, renal disease and lower prevalence in measuring evening BP after drinking alcohol or bathing. More than a half of the treated patients were classified into uncontrolled morning hypertension, which were associated with poorer prognosis. Classification of morning hypertensive patients into groups with or without evening hypertension may be useful for evaluating patients' total cardiovascular disease risk. Physicians should also consider evening BP measuring condition for adequate evaluation of evening BP values.

Effects of Nighttime Alcohol Intake on Evening and Next Morning Home Blood Pressure in Japanese Normotensives

Home blood pressure (HBP) is usually measured in the morning and evening, but the evening HBP tends to be influenced by an individual's behavior pattern, such as bathing and drinking, which are often seen in the Japanese. In this study, in order to elucidate the influence of nighttime drinking on the evening and next morning HBP and heart rate (HR), HBP measurement was performed in Japanese normotensives under conditions in which the influence of bathing was minimized. Among 700 registered volunteers, 245 normotensives (189 male, 56 female, mean age; 35.8 +/- 0.5 years old) whose data consisted of a combination of drinking and non-drinking on workdays were selected. A semi-automatic device was lent to all participants, and they were asked to perform triplicate morning and evening measurements on seven consecutive days between October 16, 2002, and November 13, 2002. The differences in evening HBP and HR between the drinking and non-drinking days were calculated, as were the differences in the next morning HBP and HR. Only data of evening HBP measured at least 30 min after bathing were accepted. Evening SBP and DBP on drinking days were significantly lower (2.5 +/- 0.5 mmHg, 3.1 +/- 0.5 mmHg) than those on non-drinking days. On the other hand, evening HR on drinking days was significantly higher (7.7 +/- 0.8 b.p.m.) than that on non-drinking days. Although there was no difference in morning SBP after days with and without drinking, morning DBP the day after drinking was slightly (0.8 +/- 0.3 mmHg) but significantly lower than that the day after non-drinking. Morning HR the day after drinking was significantly higher (2.4 +/- 0.4 b.p.m.) than that after non-drinking. Because nighttime drinking influenced the evening HBP even in normotensives, it was suggested that morning HBP could give more stable values than evening HBP in Japanese people.

Reproducibility of masked hypertension determined from morning and evening home blood pressure measurements over a 6-month period

Recently, the existence of so-called masked hypertension has attracted attention. In this study, the reproducibility of masked hypertension determined from morning and evening home blood pressure measurements was examined over a 6-month period. Home blood pressure measurements were taken consecutively for 7 days in volunteers at a company in 2002 and again in 2003. The 503 Japanese subjects (329 male, 174 female, mean age: 39.4 years), who were not taking antihypertensive drugs, were asked to measure their home blood pressure three times every morning and three times every evening. We defined casual blood pressure > or =140 (systolic) or > or =90 (diastolic) mmHg and home blood pressure > or =135 or > or =85 mmHg as hypertension. We also defined normotension as <140 and <90 mmHg in casual blood pressure and <135 and <85 mmHg in home blood pressure. We examined the reproducibility of four blood pressure categories (normotension, hypertension, white-coat hypertension, and masked hypertension) over a 6-month period. When measured in morning home blood pressure, the reproducibility of masked hypertension (59.1%) was significantly higher than that of white-coat hypertension (25.0%) and similar to that of hypertension (67.6%). However, the reproducibility of masked hypertension (23.5%) was similar to that of white-coat hypertension (32.0%) and significantly lower than that of hypertension (66.7%) when determined using evening home blood pressure. The concordances in the four blood pressure categories between the two periods were 0.582 (kappa coefficient) and 0.463 when determined using morning and evening home blood pressure data, respectively. In conclusion, the reproducibility of masked hypertension over a 6-month period was moderate in an urban Japanese population when evaluated by morning home blood pressure.

Influence of nighttime bathing on evening home blood pressure measurements: how long should the interval be after bathing?

The Japanese Society of Hypertension has recommended that evening home blood pressure measurement be taken just before bedtime. In this study, to elucidate the influence of nighttime bathing on evening home blood pressure and heart rate, measurements were performed for 7 days using volunteers who were employees of a single company and who had no alcohol intake during the study period. We used data obtained from 158 subjects (78 males and 80 females; mean age, 41.6 years) whose evening data consisted of a combination of pre-bathing and post-bathing measurements. We divided the subjects into four groups according to the time interval from bathing: blood pressure was measured at 30 min after bathing in group I (n=40), at 31-60 min after bathing in group II (n=89), at 61-120 min after bathing in group III (n=74) and at more than 121 min after bathing in group IV (n=53). We evaluated the changes after bathing in each group. For all subjects combined, the evening home blood pressure measured after bathing (114.0+/-17.1/69.4+/-10.9 mmHg) was significantly lower than the value before bathing (116.3+/-17.1/70.7+/-11.2 mmHg). However, there was no difference in heart rate. Both systolic and diastolic blood pressure after bathing in group I (109.1+/-15.2/66.3+/-10.8 mmHg) and II (112.0+/-15.2/66.5+/-10.1 mmHg) were significantly lower than those before bathing (group I: 113.2+/-15.8/70.2+/-10.6 mmHg; group II: 115.2+/-15.8/69.3+/-10.3 mmHg), but these differences disappeared in group III and IV. On the other hand, there was no difference in heart rate after bathing in group I, II, or III, but group IV showed a slight but significant decrease after bathing (67.7+/-10.0 --> 65.8+/-10.7 beats/min). In conclusion, if evening home blood pressure is to be measured after bathing, subjects should be instructed to wait more than 60 min after bathing before performing the measurement in order to eliminate the depressor effect of bathing.

Alcohol consumption and the body's biological clock

This review summarizes new findings on the bidirectional interactions between alcohol and the clock genes, underlying the generation of circadian rhythmicity. At the behavioral level, both adult and perinatal ethanol treatments after the free-running period and light response of the circadian clock in rodents; genetic ethanol preference in alcohol-preferring rat lines is also associated with alterations in circadian pacemaker function. At the neuronal level, it has been shown that ethanol consumption alters the circadian expression patterns of period (per) genes in various brain regions, including the suprachiasmatic nucleus. Notably, circadian functions of beta-endorphin-containing neurons that participate in the control of alcohol reinforcement become disturbed after chronic alcohol intake. In turn, per2 gene activity regulates alcohol intake through its effects on the glutamatergic system through glutamate reuptake mechanisms and thereby may affect a variety of physiological processes that are governed by our internal clock. In summary, a new pathologic chain has been identified that contributes to the negative health consequences of chronic alcohol intake. Thus, chronic alcohol intake alters the expression of per genes, and as a consequence, a variety of neurochemical and neuroendocrine functions become disturbed. Further steps in this pathologic chain are alterations in physiological and immune functions that are under circadian control, and, as a final consequence, addictive behavior might be triggered or sustained by this cascade.

Regular Alcohol Drinking Is a Determinant of Masked Morning Hypertension Detected by Home Blood Pressure Monitoring in Medicated Hypertensive Patients with Well-Controlled Clinic Blood Pressure: The Jichi Morning Hypertension Research (J-MORE) Study

Morning blood pressure (BP) level may play an important role in the pathogenesis of cardiovascular events; however, morning BP detected by home BP monitoring may remain uncontrolled in medicated hypertensive patients even when clinic BP is well controlled (masked morning hypertension: MMHT). We studied the determinants of MMHT in stably medicated hypertensive outpatients. In the Jichi Morning Hypertension Research (J-MORE) study, 969 consecutive hypertensive outpatients were recruited by 43 doctors in 32 different institutes. They had been under stable antihypertensive medication status at least for 3 months. Clinic BP was measured on 2 different days and self-measured BP monitoring was conducted twice consecutively in the morning and evening for 3 days. Four-hundred and five patients had well-controlled clinic BP (systolic BP [SBP]<140 mmHg and diastolic BP [DBP]<90 mmHg). Among them, 246 patients (60.7%) had MMHT (morning SBP > or =135 mmHg and/or DBP > or =85 mmHg). Compared with the patients with normal clinic BP and morning BP, the patients with MMHT had a significantly higher prevalence of regular alcohol drinkers (35.0% vs. 23.3%, p=0.012), a significantly higher number of antihypertensive drug classes (1.83 +/- 0.82 vs. 1.66 +/- 0.84, p = 0.04) and a significantly higher clinic BP level (SBP: 130.4 +/- 7.6 mmHg vs. 127.8 +/- 8.4 mmHg, p = 0.001; DBP: 75.5 +/- 7.6 mmHg vs. 73.6 +/- 7.6 mmHg, p = 0.013). In logistic regression analysis, independent determinants for MMHT were regular alcohol drinking (odds ratio [OR]: 1.76; 95% confidence interval [CI]: 0.99-3.12; p = 0.05) and higher-normal clinic BP (130/85 mmHg < clinic SBP/DBP < 140/90 mmHg) (OR: 1.60; 95% CI: 1.05-2.44; p = 0.03) after adjustment for confounding factors. The patients who both drank alcohol regularly and had a higher-normal clinic BP had 2.71 times higher risk for MMHT than those who did not drink alcohol regularly and had a relatively lower-normal clinic BP (<130/85 mmHg) (p < 0.01). In conclusion, regular alcohol drinking is an independent determinant for MMHT detected by home BP monitoring in medicated hypertensive patients with well-controlled clinic BP.

Hypertension Treatment Guidelines: Practical Implications

The focus of blood pressure (BP) lowering is to prevent or reduce the risk for cardiovascular and renal events. This rationale forms the basis for the recent guideline statements issued by the Seventh Joint National Committee, the American Diabetes Association, the European Society of Hypertension, and the Kidney Disease Outcomes Quality Initiative. The goal BP in the majority of hypertensive patients should be less than 140/90 mm Hg, with a lower goal of less than 130/80 mm Hg in patients with diabetes or kidney disease. Meta-analyses of clinical trials with renal end points make it clear that the presence of 1 gram or more of proteinuria mandates a BP approaching 115 mm Hg to slow the progression of advanced nephropathy adequately. Compelling indications also exist for the use of certain antihypertensive agents in the setting of kidney dysfunction, diabetes, heart failure, and coronary artery disease. Initiation with 2 antihypertensive agents should be considered strongly for patients with a BP of more than 20 mm Hg greater than the systolic BP goal. This means that those with a goal BP of less than 130 mm Hg should be started on 2 antihypertensive medications with complementary actions when the systolic BP is 150 mm Hg or greater. In patients with kidney disease, reaching the BP goal requires multiple agents that should include an appropriate diuretic and an agent that blocks the renin-angiotensin-aldosterone system to slow the progression of kidney disease.

Status of Home Blood Pressure Measured in Morning and Evening: Evaluation in Normotensives and Hypertensives in Japanese Urban Population

To assess home blood pressure status in a Japanese urban population, we analyzed home blood pressure values in normotensive subjects determined by casual blood pressure (< 140/90 mmHg), hypertensive subjects without medication (> or = 140/90 mmHg) and treated hypertensive patients. The subjects (468 male, 232 female; mean age 41 years old) were recruited from a company located in Tokyo. Home blood pressure was measured with a semi-automatic device (Omron HEM-759P). Subjects were instructed to perform triplicate morning and evening measurements on 7 consecutive days. In the treated hypertensive group (n = 70), there was a significant difference between morning (139 +/- 12/88 +/- 9 mmHg) and evening (130 +/- 12/79 +/- 8 mmHg) home blood pressure. In the normotensive group (n = 558), however, only the diastolic blood pressure (DBP) component of the home blood pressure was significantly different between morning (115 +/- 13/72 +/- 9 mmHg) and evening (114 +/- 12/68 +/- 8 mmHg). In the nontreated hypertensive group (n = 72), casual blood pressure (145 +/- 14/92 +/- 9 mmHg) was higher than morning (138 +/- 16/89 +/- 11 mmHg) and evening (134 +/- 16/83 +/- 11 mmHg) home blood pressure, but no difference was seen between morning and evening systolic blood pressure (SBP). According to the reference value of the Japanese Society of Hypertension 2004 (SBP > or = 135 mmHg and/or DBP > or = 85 mmHg), 7.2% (systolic) and 8.7% (diastolic) of subjects in the normotensive group were classified as hypertensive by home blood pressure. Casual blood pressure in the treated hypertensive group was normal in 64.3% for SBP and 70.0% for DBP. However, their morning SBP (32.9%), morning DBP (40.0%), evening SBP (10.0%), and evening DBP (17.1%) were classified as hypertensive by home blood pressure. Furthermore, patients who were taking antihypertensive drug(s) only in the morning (n = 52) showed higher morning SBP (6 mmHg, p = 0.086) and morning DBP (6 mmHg, p = 0.005) than patients taking drug(s) by other administration schedules (n = 18), but no difference in evening home blood pressure was observed. In conclusion, a proportion of the subjects defined as normotensive by casual blood pressure were classified as hypertensive by home blood pressure in the present urban population. Furthermore, morning home blood pressure control in the treated hypertensive group classified as under control by casual blood pressure was insufficient, especially in patients who were taking medication only in the morning.