Characteristics of blood pressure measured at home in the morning and in the evening: the Ohasama study

Difference between morning and evening blood pressure at home and nocturnal hypoxia in the general practitioner-based J-HOP study

The aim of this study was to determine the independent association of nocturnal hypoxia with morning minus evening home blood pressure (MEdif) in a cohort of outpatients with at least one cardiovascular risk. A total of 1053 participants underwent home blood pressure (BP) portable pulse oximetry measurements, and 147 (14%) had an MEdif ≥20 mmHg, where MEdif was defined as the difference between morning and evening home systolic BP. When participants were divided into quartiles according to the lowest oxygen saturation (SpO₂) during the nighttime, those in the lowest quartile (range, 54-79%) were significantly more likely to have MEdif ≥20 mmHg than those in the top quartile (range, 89-97%) (adjusted odds ratio, 1.98; 95% confidence interval, 1.13-3.49). The present study revealed an association between lowest SpO₂ during the nighttime and increased MEdif in a cohort of outpatients with at least one cardiovascular risk.

A personal history of research on hypertension From an encounter with hypertension to the development of hypertension practice based on out-of-clinic blood pressure measurements

In the 1970s, many people had severe hypertension and related cardiovascular and cerebrovascular diseases; however, antihypertensive treatments were not available at the time. The author encountered such conditions during the initial exposure to medicine. The author subsequently entered the field of hypertension medicine to prevent such conditions and engaged in hypertension research for more than 50 years. The author's central interest was the physiological and clinical aspects of blood pressure (BP) variability. Out-of-clinic BP measurements were the focus of clinical research. It was anticipated that self-measurement of BP at home (HBP) would improve medical practice surrounding hypertension. To establish evidence-based hypertension medicine, the Ohasama study (an epidemiology based on HBP) was conducted. The study provided firm evidence of the clinical significance of HBP and diagnostic criteria for hypertension and normotension. To establish target HBP levels for antihypertensive therapy, the Hypertension Objective treatment based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) study (a prospective intervention study) was also conducted. Application of HBP measurements expanded to obstetric, clinical pharmacology, pathophysiology, and genetic studies. During these studies, crucial information on the clinical significance of BP variability (such as circadian and day-by-day variation of BP, nocturnal BP, white-coat hypertension, and masked hypertension) was established. Finally, the author described the priority of HBP over clinic-measured BP for the diagnosis of hypertension in the 2014 Japanese Society of Hypertension Guidelines. In this article, the author's history of hypertension research, from the first encounter with hypertension to the construction of guidelines on hypertension, is reviewed.

Predictive power of home blood pressure in the evening compared with home blood pressure in the morning and office blood pressure before treatment and in the on-treatment follow-up period: a post hoc analysis of the HOMED-BP study

The predictive power of home blood pressure (BP) in the evening compared with home BP in the morning and office BP has been controversial. The predictive power of evening BP was compared to that of morning BP and office BP. The likelihood ratio test between one model containing a single BP index with traditional risk factors and a similar model further containing another BP index was used to assess whether the additional BP index significantly improved the adequacy of the model. Of 3266 patients with mild-to-moderate hypertension who were on antihypertensive medications (men 50.6%, age 59.5 ± 10.0 years), 58 experienced a major adverse cardiovascular event during a median follow-up of 7.1 years. The hazard ratios for a one standard deviation increment of evening home systolic/diastolic BP were 1.26 (0.98-1.62)/1.43 (1.09-1.88) in the baseline untreated period and 1.46 (1.17-1.81)/1.63 (1.26-2.11) during the on-treatment follow-up period. When evening BP at baseline and that during follow-up were included in the same model, only the latter significantly improved the prediction models (P = 0.006/0.005 for systolic/diastolic BP). Then, evening home BP vs. morning BP during follow-up was tested. The former did not improve the prediction models (P > 0.2), but the latter significantly improved the models (P ≤ 0.048). Similarly, when evening home BP and office BP during follow-up were analyzed, only the former significantly improved the prediction models (P ≤ 0.015). In conclusion, evening BP could be a more potent predictor than office BP, but it was inferior compared to morning BP in the treatment of mild-to-moderate hypertensive patients.

Association between urinary sodium-to-potassium ratio and home blood pressure and ambulatory blood pressure: the Ohasama study

OBJECTIVE

No studies have demonstrated the association between urinary sodium-to-potassium (Na/K) ratio and all out-of-office blood pressure (BP) [home morning and evening BP (self-measured at home), and 24-h, daytime, and night-time ambulatory BP] in the same cohort. We aimed to assess, which type of out-of-office BP is more strongly associated with urinary Na/K ratio in the general population.

METHODS

This cross-sectional study was conducted in the general population of Ohasama, Japan. Home and ambulatory BP levels were measured, and 24-h urine samples were obtained from 875 participants (men, 25.5%; mean age, 60.1 years). The urinary Na/K ratio in the 24-h urine samples was calculated.

RESULTS

The median (interquartile range) urinary Na/K ratio was 4.19 (3.36-5.26). Significant positive trends of home morning, home evening, 24-h, and daytime SBP were observed across quartiles of urinary Na/K ratio (trend P ≤ 0.041; adjusted mean values between Q1 and Q4 of urinary Na/K ratio: 121.0-125.5 mmHg for home morning, 120.1-123.8 mmHg for home evening, 121.6-123.4 mmHg for 24-h, 127.5-129.5 mmHg for daytime). Urinary Na/K ratio was not significantly associated with office or night-time SBP and nocturnal BP fall (trend P ≥ 0.13). In the model with both home morning or evening SBP and daytime SBP, only home SBP was significantly associated with urinary Na/K ratio (P ≤ 0.048 for home SBP).

CONCLUSION

These findings suggest that urinary Na/K ratio might be more strongly associated with home BP than with 24-h and daytime BP but was not associated with night-time BP.

Difference between morning and evening home blood pressure and cardiovascular events: the J-HOP Study (Japan Morning Surge-Home Blood Pressure)

Little is known about the relationship of the difference between morning and evening systolic blood pressure (BP) (MEdif) in home BP with cardiovascular disease (CVD) incidence. To assess this relationship, we used data from the nationwide practice-based J-HOP (Japan Morning Surge-Home BP) study, which recruited 4258 cardiovascular risk participants (mean age 64.9 years; 46.8% men; 79.2% using antihypertensive medications) who underwent morning and evening home BP monitoring using a validated, automated device for 14 consecutive days. During a mean ± SD follow-up of 6.2 ± 3.8 years (26,295 person-years), 269 CVD events occurred. Adjusted Cox models suggested that higher MEdif (≥20 mmHg) was associated with higher CVD risks than was medium MEdif (0-20 mmHg) independent of the average morning and evening (MEave) home systolic BP (SBP) (adjusted hazard ratio [HR]: 1.40; 95% confidence interval [CI] 1.02-1.91). We also divided participants into four BP phenotype groups as follows: "both non-elevated" (MEdif < 20 mmHg and MEave SBP < 135 mmHg), "elevated-MEdif" (MEdif ≥ 20 mmHg and MEave SBP < 135 mmHg), "elevated-MEave" (MEdif < 20 mmHg and MEave SBP ≥ 135 mmHg), and "both elevated" (MEdif ≥ 20 mmHg and MEave SBP ≥ 135 mmHg). The cumulative incidence of CVD events was higher in patients with the "elevated-MEdif," "elevated-MEave," and "both elevated" phenotypes than in those with the "both non-elevated" phenotype. After adjusting for covariates, the "both elevated" phenotype was associated with higher CVD risk than the "both non-elevated" phenotype (adjusted HR: 1.64; 95% CI: 1.09-2.46). This is the first study demonstrating a direct correlation between CVD outcomes and the difference between morning and evening home SBP.

Day-to-Day Home Blood Pressure Variability is Associated with Cerebral Small Vessel Disease Burden in a Memory Clinic Population

BACKGROUND

High visit-to-visit blood pressure variability (BPV) has been associated with cognitive decline and cerebral small vessel disease (cSVD), in particular cerebrovascular lesions. Whether day-to-day BPV also relates to cSVD has not been investigated.

OBJECTIVE

To investigate the cross-sectional association between day-to-day BPV and total cSVD MRI burden in older memory clinic patients.

METHODS

We included outpatients referred to our memory clinic, who underwent cerebral MRI as part of their diagnostic assessment. We determined the validated total cSVD score (ranging from 0-4) by combining four markers of cSVD that were visually rated. Home blood pressure (BP) measurements were performed for one week, twice a day, according to international guidelines. BPV was defined as the within-subject coefficient of variation (CV; standard deviation/mean BP*100). We used multivariable ordinal logistic regression analyses adjusted for age, sex, smoking, diabetes, antihypertensive medication, history of cardiovascular disease, and mean BP.

RESULTS

For 82 patients (aged 71.2±7.9 years), mean home BP was 140/79±15/9 mmHg. Dementia and mild cognitive impairment were diagnosed in 46% and 34%, respectively. 78% had one or more markers of cSVD. Systolic CV was associated with cSVD burden (adjusted odds ratio per point increase in CV = 1.29, 95% confidence interval = 1.04-1.60, p = 0.022). There were no differences in diastolic CV and mean BP between the cSVD groups. When we differentiated between morning and evening BP, only evening BPV remained significantly associated with total cSVD burden.

CONCLUSION

Day-to-day systolic BPV is associated with cSVD burden in memory clinic patients. Future research should indicate whether lowering BPV should be included in BP management in older people with memory complaints.

Novel Indices of Home Blood Pressure Variability and Hypertension-Mediated Organ Damage in Treated Hypertensive Patients

INTRODUCTION

Although multiple home blood pressure variability (HBPV) indices have been proposed, the superiority of one over another is not clear in treated hypertensives.

AIM

We evaluated the correlation between different indices of HBPV and hypertension-mediated organ damage (HMOD) in this population and determined predictors of greater HBPV.

METHODS

We included adult treated hypertensives who performed an HBP monitoring (duplicate sitting BP readings in the morning, afternoon, and evening for 4 days, Omron HEM-705CP-II), laboratory measurements, transthoracic echocardiogram and carotid-femoral pulse wave velocity. We selected HBPV indices from three different calculation approaches: coefficient of variation (CoV), difference between maximum and minimum BP (MMD), and morning BP increase (MI), and evaluated their correlation with left ventricular mass index, relative wall thickness (RWT), ejection fraction, arterial stiffness and estimated glomerular filtration rate through a correlation matrix. For those variability indices significantly associated with HMOD, we constructed multiple linear regression models to determine independent predictors of HBPV.

RESULTS

We included 204 patients, mean age 67.2 (± 13.8) years, 64% female. CoV and MMD for systolic BP showed the greatest correlation with HMOD. Factors independently associated both with CoV and MMD were: older age (b = 0.07; 95% CI 0.04-0.07; p < 0.001 and b = 0.4; 95% CI 0.2-0.5; p < 0.001, respectively), history of stroke (b = 3.6; 95% CI 0.9-6.4; p = 0.01 and b = 25.7; 95% CI 10.1-41.2; p = 0.001, respectively), and body mass index [b = - 0.1; 95% CI - 0.2 to (- 0.02); p = 0.01 and b = - 0.5; 95% CI - 0.9 to (- 0.1); p = 0.01, respectively].

CONCLUSION

CoV and MMD showed the greatest association with HMOD in treated hypertensives. Older age, history of stroke and lower body mass index were easy-to-detect predictors.

Associations Between Relative Morning Blood Pressure, Cerebral Blood Flow, and Memory in Older Adults Treated and Controlled for Hypertension

[Figure: see text].

Recent status of self-measured home blood pressure in the Japanese general population: a modern database on self-measured home blood pressure (MDAS)

Despite the clinical usefulness of self-measured home blood pressure (BP), reports on the characteristics of home BP have not been sufficient and have varied due to the measurement conditions in each study. We constructed a database on self-measured home BP, which included five Japanese general populations as subdivided aggregate data that were clustered and meta-analyzed according to sex, age category, and antihypertensive drug treatment at baseline (treated and untreated). The self-measured home BPs were collected after a few minutes of rest in a sitting position: (1) the morning home BP was measured within 1 h of waking, after urination, before breakfast, and before taking antihypertensive medication (if any); and (2) the evening home BP was measured just before going to bed. The pulse rate was simultaneously measured. Eligible data from 2000 onward were obtained. The morning BP was significantly higher in treated participants than in untreated people of the same age category, and the BP difference was more marked in women. Among untreated residents, home systolic/diastolic BPs measured in the morning were higher than those measured in the evening; the differences were 5.7/5.0 mmHg in women (ranges across the cohorts, 5.3-6.8/4.7-5.4 mmHg) and 7.3/7.7 mmHg in men (ranges, 6.4-8.5/7.0-8.7 mmHg). In contrast, the home pulse rate in women and men was 2.4 (range, 1.5-3.7) and 5.6 (range, 4.6-6.6) beats per minute, respectively, higher in the evening than in the morning. We demonstrated the current status of home BP and home pulse rate in relation to sex, age, and antihypertensive treatment status in the Japanese general population. The approach by which fine-clustered aggregate statistics were collected and integrated could address practical issues raised in epidemiological research settings.

Screening for orthostatic hypotension using home blood pressure measurements

OBJECTIVE

Orthostatic hypotension is a common condition associated with adverse cardiovascular and cognitive prognosis. Screening for orthostatic hypotension consists of blood pressure measurements in supine (or sitting) and standing position during clinical consultations. As orthostatic hypotension is a poorly reproducible clinical condition, it is likely that the simple measurement carried out during consultations underestimates the true prevalence of the condition. The objective of this study is, therefore, to determine whether screening for orthostatic hypotension with home blood pressure measurements (HBPM) may improve orthostatic hypotension diagnosis without compromising the quality of the blood pressure readings.

MATERIALS AND METHODS

We asked all patients with indications for HBPM in the hypertension unit and in a general medical practice to perform a series of home blood pressure measurements, ending each series with a measurement in standing position.

RESULTS

We recruited 505 patients of mean age 68 years of which 93% were hypertensive patients. The success rate of HBPM complying with the ESH criteria (12 out of 18 measurements) was 94.5%, which is comparable with previously published series of measurements. Ninety-one percent of patients measured their blood pressure at least once in standing position, and 88% of patients recorded all six standing measurements. Orthostatic hypotension prevalence defined as the presence of one episode of orthostatic hypotension was 37.47%, much higher than orthostatic hypotension prevalence measured in the same cohort in a clinic setting (15%).

CONCLUSION

The measurement of blood pressure in standing position during HBPM is feasible without altering the quality of the blood pressure readings in seated position. Our findings show that orthostatic hypotension is significantly more often detected at home by the patient than at the doctor's office, which may allow quicker initiation of preventive and therapeutic strategies.

Blood Pressure and Left Ventricular Hypertrophy in Patients on Different Peritoneal Dialysis Regimens

Objective

To examine the relation between the results of ambulatory 24-hour blood pressure monitoring (ABPM) and left ventricular mass index (LVMI), then to find the independent determinant for left ventricular hypertrophy (LVH) in peritoneal dialysis (PD) patients. Finally, to evaluate the differences in the clinical and cardiovascular characteristics between patients on continuous ambulatory PD (CAPD) and continuous cyclic PD (CCPD).

Design

An open, nonrandomized, cross-sectional study.

Setting

Divisions of nephrology and cardiology in a medical center.

Patients

Thirty-two uremic patients on maintenance PD therapy (22 patients on CAPD, and 10 on CCPD) without anatomical heart disease or history of receiving long-term hemodialysis.

Interventions

Home blood pressure (BP) and office BP were measured using the Korotkoff sound technique by sphygmomanometer. ABPM was employed for continuous measurement of BP. Echocardiography was performed for measurement of cardiac parameters and calculation of LVMI.

Main Outcome Measures

Multivariate logistic regression analysis was performed for independent determinant of LVH in PD patients. The differences in clinical and cardiovascular characteristics between CAPD and CCPD patients were compared.

Results

Simple regression analysis showed positive correlations between LVMI and the duration of hypertension, ambulatory nighttime BP/BP load/BP load > 30%, serum phosphate, calcium–phosphate product, ultrafiltration (UF) volume, and percentage of UF volume during the nighttime. A negative correlation was noted between LVMI and dipping. In multiple regression analysis, the duration of hypertension was the only variable linked to LVMI. In multivariate logistic regression analysis, only ambulatory nighttime systolic BP load > 30% had an independent association with LVH. There were correlations between office/home BP and ambulatory 24-hour BP. In addition, CCPD patients had higher LVMI, UF volume during the nighttime, and percentage of UF volume during the nighttime than those of CAPD patients.

Conclusions

In this study, ambulatory nighttime systolic BP load > 30% had an independent association with LVH. Office and home BP measurements were correlated with ABPM in PD patients. The result that CCPD patients had a higher LVMI than CAPD patients may be due to a relative volume overload during the daytime in CCPD patients.

Age-Related Trends in Home Blood Pressure, Home Pulse Rate, and Day-to-Day Blood Pressure and Pulse Rate Variability Based on Longitudinal Cohort Data: The Ohasama Study

Background Home blood pressure is a more accurate prognosticator than office blood pressure and allows the observation of day-to-day blood pressure variability. Information on blood pressure change during the life course links the prediction of blood pressure elevation with age. We prospectively assessed age-related trends in home blood pressure, home pulse rate, and their day-to-day variability evaluated as a coefficient of variation. Methods and Results We examined 1665 participants (men, 36.0%; mean age, 56.2 years) from the general population of Ohasama, Japan. A repeated-measures mixed linear model was used to estimate the age-related trends. In a mean of 15.9 years, we observed 5438 points of measurements including those at baseline. The home systolic blood pressure linearly increased with age and was higher in men than in women aged <70 years. There was an inverse-U-shaped age-related trend in home diastolic blood pressure. The day-to-day home systolic blood pressure linearly increased with age in individuals aged >40 years. However, an U-shaped age-related trend in day-to-day diastolic blood pressure variability with the nadir point at 65 to 69 years of age was observed. No significant sex differences in the day-to-day blood pressure variability were observed (P≥0.22). The average and day-to-day variability of home pulse rate decreased with age but were lower and higher, respectively, in men than in women. Conclusions The current descriptive data are needed to predict future home blood pressure and pulse rate. The data also provide information on the mechanism of day-to-day blood pressure and pulse rate variability.

Schedules for Self-monitoring Blood Pressure: A Systematic Review

BACKGROUND

Self-monitoring of blood pressure better predicts prognosis than clinic measurement, is popular with patients, and endorsed in hypertension guidelines. However, there is uncertainty over the optimal self-monitoring schedule. We therefore aimed to determine the optimum schedule to predict future cardiovascular events and determine "true" underlying blood pressure.

METHODS

Six electronic databases were searched from November 2009 (updating a National Institute for Health and Care Excellence [NICE] systematic review) to April 2017. Studies that compared aspects of self-monitoring schedules to either prognosis or reliability/reproducibility in hypertensive adults were included. Data on study and population characteristics, self-monitoring regime, and outcomes were extracted by 2 reviewers independently.

RESULTS

From 5,164 unique articles identified, 25 met the inclusion criteria. Twelve studies were included from the original NICE review, making a total of 37 studies. Increasing the number of days of measurement improved prognostic power: 72%-91% of the theoretical maximum predictive value (asymptotic maximum hazard ratio) was reached by 3 days and 86%-96% by 7 days. Increasing beyond 3 days of measurement did not result in better correlation with ambulatory monitoring. There was no convincing evidence that the timing or number of readings per day had an effect, or that ignoring the first day's measurement was necessary.

CONCLUSIONS

Home blood pressure should be measured for 3 days, increased to 7 only when mean blood pressure is close to a diagnostic or treatment threshold. Other aspects of a monitoring schedule can be flexible to facilitate patient uptake of and adherence with self-monitoring.

N-Terminal Pro-B-Type Natriuretic Peptide Is Not a Significant Predictor of Stroke Incidence After 5 Years - The Ohasama Study

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) has been used for risk stratification in heart failure or acute coronary syndrome, but the beyond 5-year predictive value of NT-proBNP for stroke remains an unsettled issue in Asian patients. The aim of the present study was to clarify this point.Methods and Results:We followed 1,198 participants (33.4% men; mean age, 60.5±11.1 years old) in the Japanese general population for a median of 13.0 years. A first stroke occurred in 93 participants. Referencing previous reports, we stratified participants according to NT-proBNP 30.0, 55.0, and 125.0 pg/mL. Using the NT-proBNP <30.0 pg/mL group as a reference, adjusted HR for stroke (95% CI) in the NT-proBNP 30.0-54.9-pg/mL, 55.0-124.9-pg/mL, and ≥125.0-pg/mL groups were 1.92 (0.94-3.94), 1.77 (0.85-3.66), and 1.99 (0.86-4.61), respectively. With the maximum follow-up period set at 5 years, the hazard ratio of the NT-proBNP≥125.0-pg/mL group compared with the <30.0-pg/mL group increased significantly (HR, 4.51; 95% CI: 1.03-19.85). On extension of the maximum follow-up period, however, the association between NT-proBNP and stroke risk weakened.

CONCLUSIONS

NT-proBNP was significantly associated with an elevated stroke risk. Given, however, that the predictive power decreased with the number of years after NT-proBNP measurement, NT-proBNP should be re-evaluated periodically in Asian patients.

Home blood pressure predicts stroke incidence among older adults with impaired physical function: the Ohasama study

OBJECTIVE

Several observational studies have found modifying effects of functional status on the association between conventional office blood pressure (BP) and adverse outcomes. We aimed to examine whether the association between higher BP and stroke was attenuated or inverted among older adults with impaired function using self-measured home BP measurements.

METHODS

We followed 501 Japanese community-dwelling adults aged at least 60 years (mean age, 68.6 years) with no history of stroke. Multivariate-adjusted hazard ratios for 1-SD increase in home BP and office BP measurements were calculated by the Cox proportional hazards model. Functional status was assessed by self-reported physical function.

RESULTS

During a median follow-up of 11.5 years, first strokes were observed in 47 participants. Higher home SBP, but not office SBP, was significantly associated with increased risk of stroke among both 349 participants with normal physical function and 152 participants with impaired physical function [hazard ratio (95% confidence interval) per 14.4-mmHg increase: 1.74 (1.12-2.69) and 1.77 (1.06-2.94), respectively], with no significant interaction for physical function (P = 0.56). Higher home DBP, but not office DBP, was also significantly associated with increased risk of stroke (P ≤ 0.029) irrespective of physical function (all P > 0.05 for interaction). Neither home BP nor office BP was significantly associated with all-cause mortality irrespective of physical function.

CONCLUSION

Higher home BP was associated with increased risk of stroke even among those with impaired physical function. Measurements of home BP would be useful for stroke prevention, even after physical function decline.

Difference in evening home blood pressure between before dinner and at bedtime in Japanese elderly hypertensive patients

The authors evaluated the differences between evening home blood pressure (HBP) readings taken before dinner and those taken at bedtime, which were documented in a European and a Japanese guideline, respectively. Forty-eight patients (mean age, 76.4 years) measured their evening HBP twice each day (two measurements both before dinner and at bedtime) for 14 days. The authors defined the at-bedtime (B) minus the before-dinner (D) systolic HBP as the B-D difference. The mean B-D difference was -8.7 mm Hg (P<.001). The depressor effect of bathing was significantly prolonged for 120 minutes. The B-D difference with alcohol consumption was significantly greater than that without alcohol. In the linear mixed model analysis, time after bathing ≤120 minutes and alcohol consumption were significantly associated with the B-D difference after adjustment with covariates. There was a marked difference between evening HBP values. When patients' evening HBP is measured according to the guidelines, their daily activities should be considered.

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.

Outcome-Driven Thresholds for Increased Home Blood Pressure Variability

Increased blood pressure (BP) variability predicts cardiovascular disease, but lack of operational thresholds limits its use in clinical practice. Our aim was to define outcome-driven thresholds for increased day-to-day home BP variability. We studied a population-based sample of 6238 individuals (mean age 60.0±12.9, 56.4% women) from Japan, Greece, and Finland. All participants self-measured their home BP on ≥3 days. We defined home BP variability as the coefficient of variation of the first morning BPs on 3 to 7 days. We assessed the association between systolic/diastolic BP variability (as a continuous variable and in deciles of coefficient of variation) and cardiovascular outcomes using Cox regression models adjusted for cohort and classical cardiovascular risk factors, including BP. During a follow-up of 9.3±3.6 years, 304 cardiovascular deaths and 715 cardiovascular events occurred. A 1 SD increase in systolic/diastolic home BP variability was associated with increased risk of cardiovascular mortality (hazard ratio, 1.17/1.22; 95% confidence interval, 1.06-1.30/1.11-1.34; P=0.003/<0.0001) and cardiovascular events (hazard ratio, 1.13/1.14; 95% confidence interval, 1.05-1.21/1.07-1.23; P=0.0007/0.0002). Compared with the average risk in the whole population, risk of cardiovascular deaths (hazard ratio, 1.66/1.84; 95% confidence interval, 1.27-2.17/1.42-2.37; P=0.0002/<0.0001) and events (hazard ratio, 1.46/1.42; 95% confidence interval, 1.21-1.76/1.17-1.71; P<0.0001/0.0004) was increased in the highest decile of systolic/diastolic BP variability (coefficient of variation>11.0/12.8). Increased home BP variability predicts cardiovascular outcomes in the general population. Individuals with a systolic/diastolic coefficient of variation of day-to-day home BP >11.0/12.8 may have an increased risk of cardiovascular disease. These findings could help physicians identify individuals who are at an increased cardiovascular disease risk.

Blood pressure variability: assessment, predictive value, and potential as a therapeutic target

A large body of evidence has consistently supported the relationship between blood pressure (BP) levels and the risk of cardiovascular complications. In recent years, several independent studies have also indicated that this risk may not only depend on the magnitude of the blood pressure elevation per se but also on the presence of other associated conditions such as increased blood pressure variability. This concept has been supported by a series of reports, most of which post hoc analyses of clinical trials in hypertension, showing that increasing values of BP variability (BPV) (either in the short term, in the midterm, or in the long term) may predict development, progression, and severity of cardiac, vascular, and renal organ damage, as well as cardiovascular events and mortality. Remarkably, studies conducted in populations at high cardiovascular risk have shown increasing values of BPV in the individual subjects (so-called intra- or within-individual BPV) to be strong predictors of cardiovascular morbidity and mortality, even to a larger extent than average BP values. However, in subjects at low to moderate cardiovascular risk, the contribution of BPV to cardiovascular risk prediction over and beyond average BP values has been shown to be only moderate. The aim of this paper is to critically review the evidence addressing the prognostic relevance of different components of BPV addressing a yet open question, i.e., whether routine assessment of BPV in clinical practice should be regarded as an additional target of antihypertensive treatment to improve cardiovascular protection.

Time points for obtaining representative values of 24-hour blood pressure in chronic kidney disease

BACKGROUND/AIMS

Ambulatory blood pressure (BP) monitoring has been widely recommended for evaluating the status of BP, but is lacking in practicality. Determination of the specific time points for BP measurement that are representative of 24-hour mean BP could be useful and convenient in hypertensive patients with chronic kidney disease (CKD).

METHODS

A total of 1,317 patients for whom 24-hour ambulatory BP monitoring was performed were enrolled in a multicenter study on hypertensive CKD. We analyzed the time points at which systolic blood pressure (SBP) values exhibited the smallest differences from 24-hour mean SBP (mSBP). We included office mSBP and analyzed the relationships between SBPs at the office and the time points with the smallest differences from 24-hour mSBP using several methods.

RESULTS

The time points with the smallest differences from 24-hour mSBP were 7:00 AM, 2:00 PM, and 9:30 PM. In regression analysis, SBPs at 7:00 AM and 9:30 PM were better correlated with 24-hour mSBP than SBPs at 2:00 PM and the office. The proportions of patients with SBPs within 30% of 24-hour mSBP were higher at 7:00 AM and 9:30 PM. The best consistency between the uncontrolled hypertensive groups, defined as ≥ 135 mmHg of 24-hour mSBP and higher values of SBPs corresponding to 135 mmHg of 24-hour mSBP, were observed at the 7:00 AM and 9:30 PM time points.

CONCLUSIONS

The specific time points for SBPs that correlated well with 24-hour mSBP in hypertensive CKD patients were 7:00 AM and 9:30 PM.

Determinants of the Morning-Evening Home Blood Pressure Difference in Treated Hypertensives: The HIBA-Home Study

Background. The morning home blood pressure (BP) rise is a significant asymptomatic target organ damage predictor in hypertensives. Our aim was to evaluate determinants of home-based morning-evening difference (MEdiff) in Argentine patients. Methods. Treated hypertensive patients aged ≥18 years participated in a cross-sectional study, after performing home morning and evening BP measurement. MEdiff was morning minus evening home average results. Variables identified as relevant predictors were entered into a multivariable linear regression analysis model. Results. Three hundred sixty-seven medicated hypertensives were included. Mean age was 66.2 (14.5), BMI 28.1 (4.5), total cholesterol 4.89 (1.0) mmol/L, 65.9% women, 11.7% smokers, and 10.6% diabetics. Mean MEdiff was 1.1 (12.5) mmHg systolic and 2.3 (6.1) mmHg diastolic, respectively. Mean self-recorded BP was 131.5 (14.1) mmHg systolic and 73.8 (7.6) mmHg diastolic, respectively. Mean morning and evening home BPs were 133.1 (16.5) versus 132 (15.7) systolic and 75.8 (8.4) versus 73.5 (8.2) diastolic, respectively. Significant beta-coefficient values were found in systolic MEdiff for age and smoking and in diastolic MEdiff for age, smoking, total cholesterol, and calcium-channel blockers. Conclusions. In a cohort of Argentine medicated patients, older age, smoking, total cholesterol, and use of calcium channel blockers were independent determinants of home-based MEdiff.

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.

Blood pressure variability assessed by home measurements: a systematic review

Accumulating evidence suggests that day-by-day blood pressure (BP) variability assessed using self-measurements by patients at home (HBPV) provides useful information beyond that of average home BP. This systematic review summarizes the current evidence on day-by-day HBPV. A systematic literature search (PubMed) revealed 22 eligible articles. Independent prognostic value of day-by-day HBPV for cardiovascular events and total mortality was demonstrated in two outcome studies, whereas novel indices of variability had minimal or no independent prognostic ability. Although findings are not consistent among the studies, the evidence suggests that HBPV has an independent role in the progression of preclinical cardiac, arterial and renal damage and is affected by age, gender, average BP and heart rate level, antihypertensive treatment, antihypertensive drug class and other factors. However, there is large diversity among the available studies in the home BP monitoring protocols, the indices used to quantify HBPV and the end points selected for evaluation. Overall, these preliminary data largely based on heterogeneous studies indicate an important and independent role of day-by-day HBPV in the pathogenesis of hypertension-induced cardiovascular damage. Yet, fundamental questions remain unanswered, including the optimal variability index, the optimal home monitoring schedule required, the threshold that defines increased HBPV and the impact of treatment-induced variability change on organ damage and cardiovascular events. Until these questions are adequately addressed in future studies, HBPV should largely remain a research issue with limited practical value for individual patients.

Home blood pressure level, blood pressure variability, smoking, and stroke risk in Japanese men: the Ohasama study

BACKGROUND

Hypertension and smoking independently contribute to the risk of stroke. Our objective was to investigate home blood pressure (HBP) levels, day-by-day BP variability, and smoking in the prediction of stroke in Japanese men.

METHODS

In this study, 902 men (mean age, 58.6 years) without a past history of stroke were evaluated. HBP was measured once every morning for 4 weeks. Day-by-day BP variability was defined as within-subject standard deviations (SD) of HBP. Smoking history was obtained from a standardized questionnaire. Hazard ratios (HRs) for stroke were examined by Cox regression model, with adjustment for possible confounders.

RESULTS

During 13.1 years (median) of follow-up, 89 cerebral infarctions, 28 intracranial hemorrhages, and six other strokes occurred. Systolic HBP levels (HR = 1.59 per 14.6 mm Hg increase, P < 0.0001) and variability (HR = 1.26 per 3.1 mm Hg increase, P = 0.03) of +1 between-subject SD were significantly associated with cerebral infarction. The relationship between HBP and cerebral infarction differed with smoking status (interaction P = 0.021 and 0.017 for systolic level and variability, respectively). In analyses stratified according to smoking, systolic level (HR = 1.78, P < 0.0001) and variability (HR = 1.38, P = 0.006) were significantly associated with cerebral infarction in ever smokers (N = 511), but not in never smokers (N = 391; P ≥ 0.6 for both). No significant association was found between smoking and the risk of intracranial hemorrhage.

CONCLUSIONS

In ever smokers, both HBP levels and variability are significantly associated with the risk of cerebral infarction. Our findings further validate the benefit of smoking cessation in preventing cardiovascular disease (CVD), especially cerebral infarction.

Travel-related change of residence leads to a transitory stress reaction in humans

OBJECTIVE

It is well known that animals show a stress response when confronted with a novel environment. The aim of the this study was to investigate whether humans show a similar response by studying the reaction to a travel-related transitory change of residence.

METHOD

Forty-eight individuals (32 women, 16 men, age 40-83 years) traveling to a health resort approximately 120 km from their home town participated in the study. Individuals monitored their blood pressure (BP) twice a day 3 weeks before (baseline) and during the stay and filled out a diary stating their mood and sleep. The change of the variables relative to baseline on the day before departure, the travel day, and the day after arrival as well as 5 days after arrival were determined.

RESULTS

Systolic and diastolic BPs were increased on the day before travel and diastolic BP remained increased on the travel day and the day after arrival. Sleep was poorer during the first night at the new residence. All three variables had returned to baseline level 5 days into the stay. Mood was not affected by the change of residence.

CONCLUSION

The results indicate that not only the change of residence but also its anticipation affects individuals in a transient way. The findings are relevant not only for the basic understanding of the reaction to novel environments but also to travel, tourism as well as rehabilitation, and spa-research.

Optimal schedule for home blood pressure measurement based on prognostic data: the Finn-Home Study

Current guidelines based on cross-sectional statistical parameters derived from reference populations make equivocal recommendations for the optimal schedule of home blood pressure (BP) measurement. The objective of this study was to determine a schedule for home BP measurements in relation to their predictive value for total cardiovascular risk. Home BP was measured twice every morning and evening for 1 week in an unselected nationwide population of 2081 subjects aged 45 to 74 years. The prognostic significance of BP for fatal and nonfatal cardiovascular events was examined using adjusted Cox proportional hazards regression models. A total of 162 cardiovascular events were recorded during a 6.8-year follow-up. The predictive value of home BP increased progressively with the number of measurements, showing the highest predictive value with the average of all measurements (systolic/diastolic hazard ratio per 1-mm Hg increase in BP: 1.021/1.034; systolic/ diastolic 95% CI: 1.012 to 1.030/1.018 to 1.049). However, most of this increase was achieved during the first 3 days of measurement (hazard ratio: 1.017/1.028; 95% CI: 1.009 to 1.026/1.013 to 1.045), and only minimal increase occurred after day 6. No additional benefit was achieved by discarding the values obtained during the first day of measurement. Morning and evening BPs were equally predictive of future cardiovascular events. Novel prognostic data from this study show that measurement of home BP twice in the morning and evening, preferably for a period of 7 days, or for at least 3 days, provides a thorough image of a patient's BP level. This information should be used to prepare a unified international guideline for home BP measurement.

Factors associated with day-by-day variability of self-measured blood pressure at home: the Ohasama study

BACKGROUND

We previously reported that high day-by-day blood pressure (BP) variability derived from self-measured BP at home (home BP) predicted cardiovascular mortality over and beyond other risk factors. The objective of this study is to clarify the determinants of the day-by-day home-BP variability.

METHODS

We conducted a cross-sectional community survey in 1,215 inhabitants (female gender 59%, mean age 62 years) of Ohasama, Japan. The subjects measured their BP and heart rate once every morning and once every evening for 4 weeks. The day-by-day BP variability and heart rate variability were defined as within individual standard deviation of all home BP and heart rate, respectively. We also considered coefficient of variation (CV). These parameters in the morning and those in the evening were calculated separately.

RESULTS

The level and standard deviation of home systolic/diastolic BP (SBP/DBP) in the morning were 123.4 +/- 15.1/75.7 +/- 9.0 mm Hg and 8.6 +/- 3.1/5.8 +/- 2.0 mm Hg. Multivariate linear regression analysis demonstrated that older age, female gender, elevated home BP, low home heart rate, and elevated home heart rate variability were significant determinants of elevated home-BP variability. In addition to these factors, alcohol intake and sedentary lifestyle were also determinants of elevated home-BP variability in the evening.

CONCLUSIONS

Day-by-day home-BP variability was associated with home BP, alcohol intake or sedentary lifestyle. Whether modifying these factors would reduce BP variability and whether such reduction would lead to better outcomes needs further study.

Relationship of dysregulation of glucose metabolism with white-coat hypertension: the Ohasama study

Characteristics of glucose metabolism in subjects with white-coat hypertension (WCHT) have not been fully investigated. The purpose of this study was to determine the relationship between glucose metabolism and WCHT on the basis of blood pressure (BP) at home (HBP) in the general population. Participants were from Ohasama, a rural Japanese community, and included 466 residents (mean age, 61.0 years) who had no history of diabetes mellitus. HBP and oral glucose tolerance test values were measured. Participants were classified into four groups on the basis of their HBP and casual-screening BP (CBP) values: normotension (NT) (HBP<135/85 mm Hg, CBP<140/90 mm Hg); WCHT (HBP<135/85 mm Hg, CBP>/=140/90 mm Hg); masked hypertension (HBP>/=135/85 mm Hg, CBP<140/90 mm Hg); or sustained hypertension (SHT) (HBP>/=135/85 mm Hg, CBP>/=140/90 mm Hg). The relationships between glucose metabolism and BP among the four groups were examined using multivariate analysis adjusted for possible confounding factors. Factors in relation to glucose metabolism, such as fasting glucose level, 2-h postchallenge glucose level and homeostasis model assessment-insulin resistance index, were significantly higher in subjects with WCHT and SHT than in those with NT (all P<0.03). When men and women were analyzed separately, these relationships were more pronounced in women. Our results suggest that dysregulation of glucose metabolism in WCHT might contribute to the increase in the long-term cardiovascular risk among the general population.

Stroke risk in treated hypertension based on home blood pressure: the Ohasama study

BACKGROUND

Several observational studies have shown that treated hypertensives are characterized as having worse prognosis than nonhypertensives. However, there is little evidence based on home blood pressure (home BP) measurement. We compare the risk of stroke between untreated individuals and those taking antihypertensive medication based on home BP and casual-screening BP (casual BP) in the general population.

METHODS

The study included 1,690 untreated and 700 treated subjects aged >or=35 years. We measured home BP and casual BP at the beginning of the study. The risk of first stroke was examined by using the Cox proportional hazards model.

RESULTS

During 11.9 years of follow-up, we observed 242 first-time stroke cases. Treated subjects had significantly higher risk for stroke than untreated subjects based on home BP (relative hazard (RH) = 1.48) as well as on casual BP (RH = 1.78), adjusted for systolic BP values and characteristics. When subjects were classified into six categories based on BP (optimal, normal, high normal, and grade 1-3 hypertension), RHs in treated hypertensives linearly increased (trend P < 0.01) based on home BP. However, there was no consistent association for casual BP (trend P: not significant) in treated subjects. Stroke risk was linearly increased regardless of the BP information source in untreated subjects (home BP: trend P < 0.01, casual BP: trend P < 0.01).

CONCLUSION

The results suggest a strong association between elevated home BP and increased risk of stroke. Home BP is a better tool to assess stroke risk, especially in treated hypertensives.

Home and Office Blood Pressure Control among Treated Hypertensive Patients in Japan: Findings from the Japan Home versus Office Blood Pressure Measurement Evaluation (J-HOME) Study

Appropriate control of blood pressure (BP) is essential for prevention of future cardiovascular events. However, BP control among treated hypertensive patients has been insufficient. Recently, the usefulness of self-measured BP at home (home BP measurement) for the management of hypertension has been reported in many studies. We evaluated BP control both at home and in the office among treated hypertensive patients in primary care settings in Japan (the J-HOME study). We found poor control of home and office BPs and clarified some factors affecting control. We also examined factors associated with the magnitude of the white-coat effect, the morning–evening BP difference, and home heart rate in this J-HOME study.

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.