Morning surge in blood pressure: a phenotype of systemic hemodynamic atherothrombotic syndrome

The HOPE Asia Network activity for "zero" cardiovascular events in Asia: Overview 2020

The impact of hypertension-related cardiovascular disease and target organ damage, and therefore the benefits of blood pressure (BP) control, is greater in Asian than in Western countries. Asia-specific features of hypertension and its effective management are important and active areas of research. The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was formed in 2016 and is now a member of the World Hypertension League. The main goal of the HOPE Asia Network is to improve the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia. Considerable work has already been done on the journey to achieving this goal. We have shown that BP control status in Asia differs between countries, and even between regions within the same country. Several expert panel consensus recommendations and clinical guidance papers are available to support the use of home and ambulatory BP monitoring in the region. In addition, the AsiaBP@Home study prospectively investigated home BP control status across 15 specialist centers using the same validated device and measurement schedule. We have also proposed the concept of systemic hemodynamic atherothrombotic syndrome (SHATS), a vicious cycle of BP variability and vascular disease on cardiovascular events and organ damage, and suggested a SHATS score for risk stratification for clinical practice. This special issue of the journal collates Asia-specific resources and data, contributing to advances in hypertension management and cardiovascular disease prevention in the region.

Rationale, design, and baseline characteristics of the Cardiovascular Prognostic COUPLING Study in Japan (the COUPLING Registry)

Vascular biomarkers, including the cardio-ankle vascular index (CAVI), are increasingly being recognized as important indicators of cardiovascular risk. CAVI has been shown to have good discriminative ability for detecting new-onset hypertension, but results of studies investigating cardiovascular risk prediction are inconsistent. Furthermore, there is a lack of data on the prognostic value of changes in CAVI over time. The Cardiovascular Prognostic Coupling study was designed to determine the impact of baseline CAVI and changes in CAVI on cardiovascular events in a Japanese cohort. The design of the ongoing, multicenter, prospective, observational registry and baseline characteristics of the enrolled population are reported. Eligible consecutive patients were aged ≥30 years, had ≥1 cardiovascular risk factor, and were being treated according to relevant Japanese guidelines. The primary outcome is time to onset of a major cardiovascular event (a composite of cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage, stroke of unknown etiology, myocardial infarction, cardiovascular intervention for angina pectoris, and sudden death). Screening and enrollment occurred over a period of 3 years, followed by ≥7 years of follow-up, with CAVI determined annually. A total of 5279 patients were registered, of whom 5109 had baseline data available and will be included in future analyses. Mean CAVI at baseline was 8.8 ± 1.4. The proportion of patients with CAVI of <8, 8-10 or >10 was 25.3%, 57.0%, and 17.7%, respectively. Data from this registry should provide information on the significance of baseline CAVI and change in CAVI as indicators of cardiovascular prognosis in a representative patient population.

Time to First Cigarette and Self-Reported Health Among US Adult Smokers

Background:

Numerous studies have reported that shorter time to first cigarette (TTFC) is linked to elevated risk for smoking-related morbidity. However, little is known about the influence of early TTFC on self-reported health among current smokers. Hence, the objective of this study was to examine the association between TTFC and self-reported health among US adult smokers.

Methods:

Data came from the 2012-2013 National Adult Tobacco Survey (NATS). Current smokers aged 18 years and older (N = 3323) were categorized into 2 groups based on TTFC: ≤ 5 minutes (n = 1066) and >5 minutes (n = 2257). Propensity score matching (PSM) was used to control selection bias.

Results:

After adjusting for sociodemographic and smoking behavior factors, current smokers with early TTFC had higher odds for poor health in comparison with current smokers with late TTFC in the prematching (adjusted odds ratio [AOR] = 1.65; 95% confidence interval [CI] = 1.31-2.08) and postmatching (AOR = 1.60; 95% CI = 1.22-2.09) samples.

Conclusions:

In conclusion, smokers with early TTFC were associated with increased risk of poor health in the United States. To reduce early TTFC, elaborate efforts are needed to educate people about harms of early TTFC and benefits of stopping early TTFC.

An operational definition of SHATS (Systemic Hemodynamic Atherosclerotic Syndrome): Role of arterial stiffness and blood pressure variability in elderly hypertensive subjects

BACKGROUND

CV risk exponentially increases as the number of damaged organs increases The Systemic Hemodynamic Atherosclerotic Syndrome (SHATS) represents a novel conceptualization of the CV continuum focusing on simultaneous multi-organ alteration. This is the first study operationally defining SHATS and aimed at identifying its determinants.

METHODS

Left Ventricular Hypertrophy (echocardiography), Common Carotid Artery plaque and increased thickness (ultrasound), and Chronic Kidney Disease (estimated Glomerular Filtration Rate) indexed selective target organ damage. SHATS was operationally defined as their simultaneous presence in a patient. PWV was measured by Sphygmocor® and BP variability by 24 h ABPM.

RESULTS

SHATS affected 19.9% of the 367 studied subjects. Subjects with SHATS had a similar prevalence in diabetes mellitus, but a greater prevalence of very stiff artery (84.9 vs 64.3%, p < 0.01) and use of antihypertensive medications. In the presence of similar office BP, SHATS was associated with higher 24 h SBP and lower 24 h DBP (a greater pulsatile pressure!), reduced nighttime SBP fall, and a twofold greater prevalence of reverse dipper status (48.2 vs 20.2%, p < 0.001). BMI (positive correlation) and DBP (negative correlation) were the only traditional CV risk factors significantly associated with the odds of having SHATS. Very stiff artery and BP variability were significant independent determinants of SHATS, with highly predictive accuracy.

CONCLUSION

SHATS, the simultaneous damage of multiple target organs, may easily operationally defined. Very stiff artery and BP variability represent key factors for SHATS. The present results support the hypothesis of SHATS as a systemic condition, needing further characterization.

Morning blood pressure surge: pathophysiology, clinical relevance and therapeutic aspects

Morning hours are the period of the day characterized by the highest incidence of major cardiovascular events including myocardial infarction, sudden death or stroke. They are also characterized by important neurohormonal changes, in particular, the activation of sympathetic nervous system which usually leads to a rapid increase in blood pressure (BP), known as morning blood pressure surge (MBPS). It was hypothesized that excessive MBPS may be causally involved in the pathogenesis of cardiovascular events occurring in the morning by inducing hemodynamic stress. A number of studies support an independent relationship of MBPS with organ damage, cerebrovascular complications and mortality, although some heterogeneity exists in the available evidence. This may be due to ethnic differences, methodological issues and the confounding relationship of MBPS with other features of 24-hour BP profile, such as nocturnal dipping or BP variability. Several studies are also available dealing with treatment effects on MBPS and indicating the importance of long-acting antihypertensive drugs in this regard. This paper provides an overview of pathophysiologic, methodological, prognostic and therapeutic aspects related to MBPS.

Morning blood pressure monitoring in the management of hypertension

: The aim of the current article is to review the current evidence on the role of morning blood pressure (BP) in the management of hypertension. Morning BP surge had been and will continue to be a hot topic of hypertension research. However, more evidence is needed to prove its clinical usefulness in the management of hypertension. Masked morning hypertension, as the other forms of masked hypertension, requires more research. The concept of morning BP monitoring could be clinically relevant in the therapeutic management of hypertension and in the prevention of cardiovascular complications by defining and treating morning hypertension. Antihypertensive medication is usually taken in the morning. The presence of uncontrolled morning BP during trough effect hours could be a hallmark of inadequate antihypertensive regimen, such as, for instance, the use of short-acting or intermediate-acting drugs, under dosing of drugs, or no or low use of combination therapy. To improve the management of hypertension in general and morning hypertension in particular, long-acting antihypertensive drugs should be used in appropriate often full dosages and in proper combinations. The clinical usefulness of antihypertensive drugs of specific mechanisms against morning BP or split or timed dosing of long-acting drugs in controlling morning BP remains under investigation. In conclusion, there is some evidence that morning BP is critical in the incidence of cardiovascular complications. However, proving its clinical usefulness in the management of hypertension requires further research.

Dispositional self-control: relationships with aerobic capacity and morning surge in blood pressure

The psychological, behavioral and psychosocial implications of self-control are well established, but relatively little is known about its implications for physical health. This study examined the association between self-control and two important indicators of cardiovascular risk: morning blood pressure surge (MBPS) and maximum oxygen consumption (VO_2max). Undergraduate students (N = 78) completed a measure of dispositional self-control (Brief Self-Control Scale), participated in a 24-h ambulatory assessment of heart rate (HR) and blood pressure (BP), and completed the YMCA Cycle Ergometer Submaximal Test. Regression analyzes yielded a significant positive relationship between self-control and VO_2max. Results also indicated a significant negative association between self-control and MBPS, independent of average 24-h blood pressure and VO_2max scores. These findings expand our understanding of the relationship between dispositional self-control and MBPS. Study limitations and directions for future research are discussed.

Perfect 24-h management of hypertension: clinical relevance and perspectives

Out-of-office blood pressure (BP) measured by home BP monitoring, or ambulatory BP monitoring, was demonstrated to be superior to office BP for the prediction of cardiovascular events. The J-HOP study of a nationwide Japanese cohort demonstrated that morning home BP is the best stroke predictor. In the prospective HONEST study of >21 000 hypertensives, on-treatment morning home BP was shown to be a strong predictor both of future coronary artery disease and stroke events. In subjects whose office BP was maintained at ⩾150 mm Hg, there was no increase in cardiovascular events when their morning systolic BP was well-controlled at <125 mm Hg. Since Asians show greater morning BP surges, it is particularly important for Asians to achieve 'perfect 24-hr BP control,' that is, the 24-h BP level, nocturnal BP dipping and BP variability including morning surge. The morning BP surge and the extremes of disrupted circadian rhythm (riser and extreme dipper patterns) are independent risks for stroke in hypertensives. A morning BP-guided approach is thus the first step toward perfect 24-h BP control, followed by the control of nocturnal hypertension. In the resonance hypothesis, the synergistic resonance of BP variability phenotypes would produce an extraordinary large 'dynamic BP surge' that can trigger a cardiovascular event, especially in high-risk patients with systemic hemodynamic atherothrombotic syndrome, a vicious cycle of exaggerated BP variability and vascular disease. In the future, information and communications technology and artificial intelligence technology with the innovation of wearable continuous surge BP monitoring will contribute to 'anticipation medicine' with the goal of zero cardiovascular events.

Systemic Hemodynamic Atherothrombotic Syndrome and Resonance Hypothesis of Blood Pressure Variability: Triggering Cardiovascular Events

Blood pressure (BP) exhibits different variabilities and surges with different time phases, from the shortest beat-by-beat to longest yearly changes. We hypothesized that the synergistic resonance of these BP variabilites generates an extraordinarily large dynamic surge in BP and triggers cardiovascular events (the resonance hypothesis). The power of pulses is transmitted to the peripheral sites without attenuation by the large arteries, in individuals with stiffened arteries. Thus, the effect of a BP surge on cardiovascular risk would be especially exaggerated in high-risk patients with vascular disease. Based on this concept, our group recently proposed a new theory of systemic hemodynamic atherothromboltic syndrome (SHATS), a vicious cycle of hemodynamic stress and vascular disease that advances organ damage and triggers cardiovascular disease. Clinical phenotypes of SHATS are large-artery atherothombotic diseases such as stroke, coronary artery disease, and aortic and pheripheral artery disease; small-artery diseases, and microcirculation-related disease such as vascular cognitive dysfunction, heart failure, and chronic kidney disease. The careful consideration of BP variability and vascular diseases such as SHATS, and the early detection and management of SHATS, will achieve more effective individualized cardiovascular protection. In the near future, information and communication technology-based 'anticipation medicine' predicted by the changes of individual BP values could be a promising approach to achieving zero cardiovascular events.

Time to First Cigarette and Hypertension in Korean Male Smokers

Background

Morning blood pressure surge affects to cardiovascular disease risk. Short time to first cigarette (TTFC) after waking can enhance morning blood pressure surge, and accelerate atherosclerosis

Methods

We investigated that the relationship between TTFC and blood pressure. The study subjects included male current smokers (n=211) who had health check-up in Hallym University Sacred Heart Hospital from July to September, 2014. We categorized the subjects into 2 groups according to TTFC; early TTFC (TTFC <30 minutes) and late TTFC (TTFC ≥30 minutes), and the subjects who were taking antihypertensive medications or had a high blood pressure (>140 mm Hg or 90 mm Hg) were defined as hypertensive group. Multivariate logistic regression was performed to estimate the odds ratio and 95% confidence interval to investigate the association between TTFC and hypertensive group.

Results

Compared with late TTFC, early TTFC had higher odds (odds ratio [OR], 3.87; 95% confidence interval [CI], 1.89-7.94) for hypertensive group. After adjusting confounding factors, early TTFC was significantly associated with an increased risk of hypertension (OR, 4.43; 95% CI, 1.84-10.70).

Conclusion

early TTFC after waking is associated with hypertension. It suggests delaying TTFC might help to control of blood pressure among the current smokers who are not ready to immediately quit smoking.