Uncontrolled early morning blood pressure in medicated patients: the ACAMPA study. Analysis of the Control of Blood Pressure using Abulatory Blood Pressure Monitoring

The association between morning blood pressure and subclinical target organ damage in the normotensive population

OBJECTIVE

To investigate whether isolatedly elevated morning blood pressure (BP) is associated with subclinical target organ damage in normotensive individuals.

METHODS

In all, 287 normotensive individuals were included in this cross-sectional study. Each participant underwent anthropometric measurements, serum biochemistry evaluation, 24-h ambulatory BP monitoring, echocardiography, and carotid ultrasonography. The morning BP and morning surge were defined as: the average BP within 2 h after waking up, and the difference between the mean systolic BP (SBP) within 2 h after waking up and the mean SBP during the hour that included the lowest BP reading during sleep, respectively.

RESULTS

The prevalence of elevated morning BP was 37.3%. Individuals with elevated morning BP had higher left ventricular mass index and morning surge, and also mean 24-h, daytime, and night-time SBP and diastolic BP, BP variability (all P < 0.05). Left ventricular mass index was correlated with 24-h, daytime, night-time, and morning SBP, and morning surge (Pearson's correlation coefficients: 0.271, 0.262, 0.215, 0.368, and 0.415, respectively; all P < 0.05); and standard deviations of 24-h, daytime, and night-time SBP (Pearson's correlation coefficient: 0.303, 0.234, and 0.309, respectively), and coefficient of variations of 24-h and night-time SBP (Pearson's correlation coefficients: 0.253 and 0.271, respectively). Morning surge had the strongest correlation with left ventricular mass index in multiple regression analysis. Only daytime and morning SBP could discriminate elevated morning surge (≥35 mmHg), with an area under the curve of 0.744 and 0.864, respectively (both P < 0.01), and an optimal threshold of 121.5 mmHg for morning SBP.

CONCLUSION

Our findings suggest that isolated elevation of morning BP in normotensive individuals is associated with left ventricular hypertrophy. Home monitoring of morning BP may be suitable for detecting abnormal morning surge.

Effects of spironolactone on dialysis patients with refractory hypertension: a randomized controlled study

The purpose of this study was to evaluate the effects of spironolactone on dialysis patients with refractory hypertension and possible adverse effects. This was a 12-week prospective, randomized, double-blind trial of 82 patients randomly assigned to 12-week treatment with 25 mg/d spironolactone or placebo as add-on therapy. Visits were scheduled at the start of treatment and after 12 weeks. Measurements of 24-hour ambulatory blood pressure (BP) monitoring and morning BP were performed. After 12 weeks, spironolactone significantly improved refractory hypertension. Average placebo-corrected morning BP was reduced by 16.7/7.6 mm Hg. Mean 24-hour ambulatory BP was reduced by 10.9/5.8 mm Hg. In contrast, serum aldosterone levels in the spironolactone group slightly increased and serum potassium levels insignificantly increased. This study has demonstrated that spironolactone (50 mg) safely and effectively reduces BP in patients with refractory hypertension undergoing dialysis.

European Society of Hypertension position paper on ambulatory blood pressure monitoring

Ambulatory blood pressure monitoring (ABPM) is being used increasingly in both clinical practice and hypertension research. Although there are many guidelines that emphasize the indications for ABPM, there is no comprehensive guideline dealing with all aspects of the technique. It was agreed at a consensus meeting on ABPM in Milan in 2011 that the 34 attendees should prepare a comprehensive position paper on the scientific evidence for ABPM.This position paper considers the historical background, the advantages and limitations of ABPM, the threshold levels for practice, and the cost-effectiveness of the technique. It examines the need for selecting an appropriate device, the accuracy of devices, the additional information and indices that ABPM devices may provide, and the software requirements.At a practical level, the paper details the requirements for using ABPM in clinical practice, editing considerations, the number of measurements required, and the circumstances, such as obesity and arrhythmias, when particular care needs to be taken when using ABPM.The clinical indications for ABPM, among which white-coat phenomena, masked hypertension, and nocturnal hypertension appear to be prominent, are outlined in detail along with special considerations that apply in certain clinical circumstances, such as childhood, the elderly and pregnancy, and in cardiovascular illness, examples being stroke and chronic renal disease, and the place of home measurement of blood pressure in relation to ABPM is appraised.The role of ABPM in research circumstances, such as pharmacological trials and in the prediction of outcome in epidemiological studies is examined and finally the implementation of ABPM in practice is considered in relation to the issue of reimbursement in different countries, the provision of the technique by primary care practices, hospital clinics and pharmacies, and the growing role of registries of ABPM in many countries.

Comparative effects of telmisartan and valsartan as add-on agents for hypertensive patients with morning blood pressure insufficiently controlled by amlodipine monotherapy

The aim of this study was to determine the efficacies of valsartan and telmisartan as add-on agents for the control of morning blood pressure (BP) in patients already on amlodipine monotherapy. A total of 414 hypertensive patients were prospectively enrolled in a 4-week run-in period when they were treated with amlodipine (5 mg/day), and home BP was measured in the morning and evening. Patients with home systolic BP (SBP) being 135-159 mm Hg in the morning at the end of the run-in period were randomized to additional treatment with valsartan (80 mg/day) or with telmisartan (40 mg/day) for 8 weeks. The primary endpoint was the change in morning home BP, and secondary endpoints included variability of morning home BP. Of the 282 patients randomized, 262 patients (n=131, in each treatment) completed the protocols. Demographic parameters and baseline morning SBP/diastolic BP (DBP) (146.3±7.1/84.8±9.3 vs. 146.0±7.1/84.2±9.1 mm Hg) were comparable in the valsartan group and telmisartan group, and changes in SBP/DBP after 8-week treatment were not significantly different between the two groups (-7.4±10.6/-3.9±6.1 vs. -8.3±9.9/-5.0±5.9 mm Hg). Valsartan significantly increased individual standard deviation and variation coefficient of morning SBP, but telmisartan did not change either of these indices of SBP variation. In subgroups with baseline SBP being above the median (145.2 mm Hg), change in DBP was significantly larger by telmisartan than by valsartan (-6.3±5.6 vs. -3.9±6.7 mm Hg, P<0.05). These results suggest that telmisartan is more useful than valsartan as an add-on agent for reducing the level and variability of morning BP in patients on amlodipine monotherapy.

The effects of telmisartan alone or with hydrochlorothiazide on morning and 24-h ambulatory BP control: results from a practice-based study (SURGE 2)

Observational studies have shown that 24-h and morning ambulatory blood pressure (BP) control is low. This large-scale, practice-based study evaluated the effects of telmisartan 40 or 80 mg alone or in combination with hydrochlorothiazide (HCTZ) 12.5 mg on these BP parameters over 8 weeks; treatment was adjusted if clinic BP remained ≥140/90 mm Hg. A total of 863 patients were evaluated (baseline mean clinic BP, morning and 24-h ambulatory BP: 155±15/93±10 mm Hg, 137±15/83±11 mm Hg, 133±14/79±10 mm Hg, respectively; 68% were previously treated at baseline). Telmisartan with/without HCTZ significantly reduced the mean morning ambulatory BP (-8.2/-4.9 mm Hg), daytime ambulatory BP (-8.0/-4.7 mm Hg), 24-h ambulatory BP (-7.9/-4.7 mm Hg) and clinic BP (-22.3/-13.2 mm Hg) (all P<0.001) in previously untreated and in treated patients who switched to telmisartan and telmisartan/HCTZ. After treatment with telmisartan with/without HCTZ, the morning ambulatory BP control increased from 36.5 to 64.4%; daytime ambulatory BP control increased from 40.8 to 67.6%; 53.0% of patients achieved 24-h ambulatory BP <125/80 mm Hg and 62% achieved <130/80 mm Hg targets. Only 0.8% (7/863) reported an adverse event. In summary, telmisartan and telmisartan/HCTZ increased smooth 24-h BP control in daily management of hypertension.

Home blood pressure control is low during the critical morning hours in patients with hypertension: the SURGE observational study

BACKGROUND

The morning blood pressure (BP) surge is associated with a peak increase in vascular events.

OBJECTIVE

The aim of this observational study was to evaluate morning BP control in treated hypertensive patients using home BP (HBP) monitoring and to compare these findings with clinic BP control.

METHODS

Clinic BP was measured twice during a 2-week period, prior to medication. Seated HBP was measured, using a BHS-validated device, three times per day over a 2-week period. Assessments included morning (06:00-11:59), lunch time (12:00-14:00) and evening (18:00-22:00) HBP control (all <135/85 mmHg) and clinic BP (<140/90 mmHg) control.

RESULTS

A total of 15618 patients were assessed. At baseline (Day 1 and Week 1), clinic BP control (<140/90 mmHg) and morning HBP control (<135/85 mmHg) were low: 23.6% and 21.9%, respectively. The percentage of patients with both clinic BP and morning HBP control was extremely low (8.5%). Similar values were obtained at lunch time (11.3%) and evening (9.9%). There was a slight improvement at the end of the second week, but values remained low. At final visit (Day 4 and Week 2), morning, lunch time and evening HBP control was observed in 31.8%, 42.2% and 36.4% of patients, respectively. Clinic BP control was observed in 41.7%.

CONCLUSION

Morning HBP control was low in this large hypertensive population. The improvement in BP control observed may be associated with inclusion in a study; this could indicate low medication compliance in general practices but may also be attributable to the use of agents that cannot sustain 24-hour BP control.

Short-term reproducibility of ambulatory blood pressure monitoring in autosomal dominant polycystic kidney disease

BACKGROUND AND OBJECTIVES

Nondipping, defined as a less than 10% decline in Night:Day (N:D) ratio of blood pressure using 24 h ambulatory blood pressure monitoring, is associated with poor cardiovascular outcomes. However, its reproducibility has been questioned in autosomal dominant polycystic kidney disease.

MATERIALS AND METHODS

Twenty-five of 29 recruited hypertensive or prehypertensive patients with autosomal dominant polycystic kidney disease completed ambulatory blood pressure monitoring on two occasions, 7-15 days apart, on a stable antihypertensive regimen. Daytime and night-time were defined as 6:00-21:59 h and 22:00-5:59 h, respectively. Correlation and concordance coefficients for systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate were determined based on N:D and Asleep:Awake (A:A) ratios. Consistency of dipping was assessed by using Cohen's Kappa statistics.

RESULTS

Mean (±standard deviation) for age, estimated glomerular filtration rate, differences in daytime and night-time SBP and DBP were 43.12 years (8.55 years), 63.1 ml/min (20.5 ml/min), 11.74 mmHg (8.2 mmHg), and 10.82 mmHg (6.4 mmHg), respectively. Seventeen of 25 (68%) and 18 of 25 (72%) participants maintained the same dipping category based on D:N or A:A separation. Cohen's Kappa was 0.34 for D:N ratio and 0.38 for A:A ratio. Correlation and concordance coefficients were 0.89 and 0.88 for daytime SBP, 0.91 and 0.91 for daytime DBP, 0.79 and 0.78 for night-time SBP, 0.81 and 0.80 for night-time DBP, 0.58 and 0.56 for N:D ratio of SBP, and 0.56 and 0.53 for N:D ratio of DBP. Coefficients for A:A ratio were almost identical to N:D values except for A:A ratios of SBP (0.69 and 0.67) and DBP (0.48 and 0.45).

CONCLUSION

Repeated measures of SBP and DBP, 7-15 days apart, are highly correlative and concordant in the studied population, but nondipping, even though predominant, was found to be modestly reproducible.

24-Hour ambulatory blood pressure control with triple-therapy amlodipine, valsartan and hydrochlorothiazide in patients with moderate to severe hypertension

To determine the effectiveness and safety of once-daily combination therapy with amlodipine, valsartan and hydrochlorothiazide for reducing ambulatory blood pressure (ABP) in patients with moderate to severe hypertension, a multicenter, double-blind study was performed (N=2271) that included ABP monitoring in a 283-patient subset. After a single-blind, placebo run-in period, patients were randomized to receive amlodipine/valsartan/hydrochlorothiazide (10/320/25 mg), valsartan/hydrochlorothiazide (320/25 mg), amlodipine/valsartan (10/320 mg) or amlodipine/hydrochlorothiazide (10/25 mg) each morning for 8 weeks. Efficacy assessments included change from baseline in 24-h, daytime and night time mean ambulatory systolic BP (SBP) and diastolic BP (DBP). Statistically significant and clinically relevant reductions from baseline in all these parameters occurred in all treatment groups (P<0.0001, all comparisons versus baseline). At week 8, least squares mean reductions from baseline in 24-h, daytime and night time mean ambulatory SBP/DBP were 30.3/19.7, 31.2/20.5 and 28.0/17.8 mm Hg, respectively, with amlodipine/valsartan/hydrochlorothiazide; corresponding reductions with dual therapies ranged from 18.8–24.1/11.7–15.5, 19.0–25.1/12.0–16.0 and 18.3–22.6/11.1–14.3 mm Hg (P⩽0.01, all comparisons of triple versus dual therapy). Treatment with amlodipine/valsartan/hydrochlorothiazide maintained full 24-h effectiveness, including during the morning hours; all hourly mean ambulatory SBP and mean ambulatory DBP measurements were ⩽130/85 mm Hg at end point. Amlodipine/valsartan/hydrochlorothiazide combination therapy was well tolerated. Once-daily treatment with amlodipine/valsartan/hydrochlorothiazide (10/320/25 mg) reduces ABP to a significantly greater extent than component-based dual therapy and maintains its effectiveness over the entire 24-h dosing period.

New standards in hypertension and cardiovascular risk management: focus on telmisartan

Blockade of the renin–angiotensin system is an important approach in managing high blood pressure, and has increasingly been shown to affect cardiovascular disease processes mediated by angiotensin II throughout the cardiovascular and renal continua. Telmisartan is an angiotensin II receptor blocker (ARB) displaying unique pharmacologic properties, including a longer half life than any other ARB, that result in large and sustained reductions of blood pressure. In patients with mild-to-moderate hypertension, telmisartan has proved superior to other antihypertensive agents (valsartan, losartan, ramipril, perindopril, and atenolol) in controlling blood pressure particularly towards the end of the dosing interval. There is also clinical evidence that telmisartan reduces left ventricular hypertrophy, reduces arterial stiffness and the recurrence of atrial fibrillation, and confers renoprotection. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET^®) study has demonstrated that telmisartan has similar cardiovascular protective effects to ramipril in a large, high-risk patient population but was better tolerated. The powerful and sustained blood pressure control apparent in clinical trials, together with cardiovascular protection and tolerability demonstrated in ONTARGET^® means that telmisartan may be a preferred option for patients with hypertension.

Antihypertensive efficacy of telmisartan vs ramipril over the 24-h dosing period, including the critical early morning hours: a pooled analysis of the PRISMA I and II randomized trials

Cardiovascular risk is subject to circadian variation, with peak morning incidence of myocardial infarction and stroke correlating with the early morning blood pressure (BP) surge (EMBPS). Ideally, antihypertensive therapy should maintain control of BP throughout the 24-h dosing cycle. In two sister studies, Prospective, Randomized Investigation of the Safety and efficacy of Micardis vs Ramipril Using ABPM (ambulatory BP monitoring) (PRISMA) I and II, BP control was compared in patients with essential hypertension (24-h mean baseline ambulatory BP approximately 148/93 mm Hg) randomized to the angiotensin receptor blocker, telmisartan (80 mg; n=802), or the angiotensin-converting enzyme inhibitor, ramipril (5 or 10 mg; n=811), both dosed in the morning. The primary end point was the change from baseline in mean ambulatory systolic BP (SBP) and diastolic BP (DBP) during the final 6 h of the 24-h dosing cycle. The adjusted mean treatment differences in the last 6-h mean ambulatory SBP/DBP were -5.8/-4.2 mm Hg after 8 weeks and -4.1/-3.0 mm Hg after 14 weeks, in favour of telmisartan (P<0.0001 for all four comparisons). Secondary end point results, including the mean 24-h ambulatory BP monitoring, day- and night-time BP and 24-h BP load, also significantly favoured telmisartan (P<0.0001). Both treatments were well tolerated; adverse events, including cough, were less common with telmisartan. These findings suggest that telmisartan is more effective than ramipril throughout the 24-h period and during the EMBPS; this may be attributable to telmisartan's long duration of effect, which is sustained throughout the 24-h dosing period.

Magnitude of the early morning blood pressure surge in untreated hypertensive patients: a pooled analysis

OBJECTIVES

A post hoc analysis was performed to assess the magnitude of the early morning blood pressure surge (EMBPS), which is associated with peak cardiovascular risk, in untreated hypertensive patients enrolled in two sister studies (Prospective, Randomised Investigation of the Safety and efficacy of MICARDIS vs. ramipril using ambulatory blood pressure monitoring I and II) with identical design.

METHODS

In adults with a mild-to-moderate primary hypertension and no significant comorbidities, 24-h ambulatory blood pressure monitoring was conducted after a 2- to 4-week placebo run-in period and before treatment initiation. Individual blood pressure measurements at 20-min intervals were analysed.

RESULTS

In 1419 hypertensive patients with normal sleeping times, blood pressure displayed a typical circadian rhythm, with a mean EMBPS of 29/24 mmHg. An EMBPS of >or= 25 mmHg was observed in around 60% of patients. The surge was significantly increased with smoking, alcohol consumption, longer sleep, later waking times, and increased blood pressure variability during waking and sleeping. The magnitude of the EMBPS was significantly reduced in Black vs. White patients. The surge was not affected by gender, body mass index or duration of hypertension. Further analysis showed that ethnicity, alcohol consumption and smoking were all found to have a significant impact on surge around waking and age, sleep duration and sleep blood pressure variability were all found to have an effect on the prewake surge.

CONCLUSIONS

In untreated hypertensive patients, the magnitude of the EMBPS is significant when compared with the 24-h mean and is affected by individual patient characteristics. In light of these findings, physicians should understand the importance of 24-h blood pressure control and the modification of certain lifestyle factors as ways of reducing the EMBPS.

Post- to pre-overnight sleep systolic blood pressures are associated with sleep respiratory disturbance, pro-inflammatory state and metabolic situation in patients with sleep-disordered breathing

OBJECTIVE

The aim of the current study was to investigate whether changes in post- to pre-overnight sleep systolic blood pressure (SSBP) are associated with sleep respiratory disturbance, pro-inflammatory state, and metabolic situation in patients with sleep-disordered breathing (SDB).

METHODS

Anthropometry, sleep polysomnography, biochemical markers, and pre- and post-overnight sleep BP were measured from 263 SDB patients. All SDB patients were further subgrouped into MORNING SURGE (% changes from post- to pre-overnight SSBP >+1SD of this cohort), MORNING DROP (% changes <-1SD), CONSTANT HIGH (% changes within+/-1SD, averaged SSBP>130mmHg) and CONSTANT LOW (% changes within+/-1SD, averaged SSBP<130mmHg).

RESULTS

BMI, neck circumference, waistline circumference, respiratory disturbance index, arousal index, lowest oxygen saturation, duration of SaO(2)<90%, blood glucose, hs-CRP, and metabolic syndrome score in MORNING SURGE and CONSTANT HIGH were significantly greater than those in CONSTANT LOW. Except metabolic syndrome score, all other parameters in MORNING DROP were similar to those in CONSTANT LOW.

CONCLUSION

Patients with SDB whose post- to pre-overnight SSBPs were elevated or maintained a constant high have more sleep respiratory disturbance, more pro-inflammatory state, and higher metabolic syndrome indices than the rest. Without subdividing into CONSTANT LOW, MORNING DROP, CONSTANT HIGH, and MORNING SURGE, the important pathophysiologic points of SDB patients will possibly be missed.

24-hour powerful blood pressure-lowering: is there a clinical need?

Attenuation of 24-hour blood pressure (BP) fluctuation, and control of the early morning BP surge, may help to improve cardiovascular outcomes in hypertensive patients. However, studies show that early morning BP is generally poorly controlled even in patients with well-controlled clinic BP. Few antihypertensives are sufficiently long-acting to sustain adequate BP-lowering for the full 24 hours between once-daily doses, and indeed many are at their lowest efficacy during the risky early morning period. The angiotensin receptor blocker (ARB) telmisartan has the longest plasma half-life, highest lipophilicity, highest receptor binding affinity, and slowest dissociation of any ARB, making it particularly suitable for sustained 24-hour BP control. In clinical studies, telmisartan provides 24-hour BP control superior to that of the ARBs losartan and valsartan, the calcium-channel blocker amlodipine, and the angiotensin-converting enzyme (ACE) inhibitor ramipril. This agent is particularly effective during the last 6 hours of the dosing interval when the other antihypertensives tend to go down in effectiveness. Telmisartan is, therefore, a highly appropriate antihypertensive for sustained 24-hour BP control, especially during the risky early morning hours.

Morning rise of blood pressure and subcutaneous small resistance artery structure

OBJECTIVES

It has been previously demonstrated that the morning rise (MoR) of blood pressure (BP) may predict major cardiovascular events in hypertensive patients. Structural alterations of small resistance arteries, as evaluated by the tunica media to internal lumen ratio (M/L) of subcutaneous small resistance arteries, may also predict cardiovascular events. Because an increased M/L may amplify the effect of hypertensive stimuli, the present study aimed to evaluate the possible relationships between MoR and M/L in a population of hypertensive patients.

METHODS

Sixty-four patients with essential hypertension were included in the present study. All patients were submitted to a biopsy of subcutaneous fat. Small resistance arteries were dissected and mounted on an isometric myograph, and the M/L was measured. In addition, MoR was calculated from ambulatory blood pressure monitoring (ABPM) according to four previously published different methods (MoR1 to MoR4).

RESULTS

A statistically significant correlation was observed between M/L and MoR1 (r = 0.52, P < 0.001), MoR2 (r = 0.32, P < 0.01), MoR3 (r = 0.25, P < 0.05) and MoR4 (r = 0.27, P < 0.05), as well as between internal diameter of subcutaneous small arteries and MoR1 (r = -0.45, P < 0.001) and MoR2 (r = -0.28, P < 0.05).

CONCLUSION

Our results indicate that subcutaneous small artery structure is related to MoR, possibly because an altered vascular structure may amplify BP changes or, vice versa, because a greater MoR may further damage peripheral vasculature.

Importance of aggressive blood pressure lowering when it may matter most

Variation in blood pressure levels follows a reproducible circadian pattern, characterized by low levels during sleep and a rapid increase during the early-morning period. The incidence of cardiovascular events displays a similar circadian variation, with peak occurrence coinciding with the early-morning blood pressure surge. Numerous prospective studies have shown that blood pressure measured over a 24-hour period is superior to clinic blood pressure in predicting future cardiovascular events. Thus, the use of ambulatory blood pressure monitoring (ABPM) to identify patients at risk of cardiovascular events could improve the management of the patient with hypertension. ABPM has also become widely adopted to evaluate antihypertensive therapeutic options that might provide blood pressure reduction throughout the 24-hour dosing interval. Recently, community-based trials have shown that it is feasible to perform ABPM-oriented research in nonresearch environments. This allows us to better understand the efficacy of antihypertensive therapies in a "real-world" setting. Studies of this nature can even assess blood pressure control in the early-morning period by sequestering data before and after awakening.

Prevention of stroke in patients with hypertension

Despite the substantial evidence of the benefits of lowering blood pressure, conventional treatment does not normalize the burden of major cardiovascular events in patients with hypertension. Data now suggest that the nature of the antihypertensive agent used may have an important impact on long-term cardiovascular outcomes, including stroke. Optimal treatment should provide powerful 24-hour blood pressure control, including during the early morning hours when the risk of stroke is highest. In addition, antihypertensive therapies selected should have positive blood pressure-independent effects on stroke risk. In contrast to angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers (ARBs) provide consistent benefits in stroke protection beyond blood pressure lowering. The ARB telmisartan has a particularly interesting profile for stroke management. Selective angiotensin II type 1 receptor blockade and 24-hour blood pressure control with telmisartan provide the potential for improved stroke prevention. This will be investigated in the Prevention Regimen for Effectively Avoiding Second Strokes (PROFESS) study.

Blood pressure variability: its measurement and significance in hypertension

Blood pressure (BP) fluctuations over time physiologically result from the complex interaction between environmental stimulation, genetic factors, and cardiovascular control mechanisms. Ambulatory BP-monitoring techniques, in particular systems providing beat-by-beat BP recording, have allowed a detailed description of the different components contributing to overall BP variability (BPV) over 24 hours, including short-lasting and more sustained BP changes. In hypertension, BPV increases with increasing BP levels, and evidence is available that its magnitude correlates closely with target-organ damage and with the incidence of cardiovascular events, independent of absolute BP levels. It has been suggested that drugs capable of providing smooth 24-hour BP control, reducing BPV, may confer additional target-organ protection. Mathematic indices, such as the trough-to-peak ratio and the smoothness index, represent useful measures of the homogeneity of the antihypertensive effect over 24 hours. Further studies are still needed to confirm that, in humans, interventions that can reduce BPV can also reduce the rate of cardiovascular events.

A review of telmisartan in the treatment of hypertension: blood pressure control in the early morning hours

Measurement of blood pressure in the clinic may provide a false impression of blood pressure control. Ambulatory blood pressure monitoring (ABPM) allows the automatic recording of the circadian variation in blood pressure and evaluation of the efficacy of antihypertensive medication throughout the dosing interval. Ambulatory blood pressure provides more effective prediction of cardiovascular risk; blood pressure control at the time of heightened risk in the early morning after waking and before taking the next dose of medication is becoming important in order to improve long-term prognosis. To achieve blood pressure control in the early morning, a long-acting antihypertensive agent is essential. Telmisartan, an angiotensin II receptor blocker, as well as having a terminal elimination half-life of 24 h, has a large volume of distribution due to its high lipophilicity. The efficacy of telmisartan 80 mg monotherapy has been demonstrated using ABPM, with superior reduction in mean values for the last 6 h of the dosing interval compared with ramipril 10 mg and valsartan 80 mg. In addition, telmisartan 80 mg provides superior blood pressure control after a missed dose compared with valsartan 160mg. When combined with hydrochlorothiazide (HCTZ) 12.5 mg, telmisartan 40mg and 80mg is more effective than losartan/HCTZ (50/12.5 mg) at the end of the dosing interval. Furthermore, greater reductions in last 6 h mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) are achieved with telmisartan/HCTZ (80/12.5 mg) than with valsartan/HCTZ (160/12.5 mg) in obese patients with type 2 diabetes and hypertension. Recent data from a large group of patients show that telmisartan 80 mg controls the early morning blood pressure surge more effectively than ramipril 5-10 mg and, thus, may have a greater beneficial effect on long-term cardiovascular risk. This supposition is being tested in the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) programme.

Effectiveness of Blood Pressure Control Outside the Medical Setting

We studied the effectiveness of blood pressure (BP) control outside the clinic by using ambulatory BP monitoring (ABPM) among a large number of hypertensive subjects treated in primary care centers across Spain. The sample consisted of 12 897 treated hypertensive subjects who had indications for ABPM. Office-based BP was calculated as the average of 2 readings. Twenty-four–hour ABPM was then performed using a SpaceLabs 90207 monitor under standardized conditions. A total of 3047 patients (23.6%) had their office BP controlled, and 6657 (51.6%) were controlled according to daytime ABPM. The proportion of office resistance or underestimation of patients’ BP control by physicians in the office (office BP ≥140/90 mm Hg and average daytime ambulatory BP <135/85 mm Hg) was 33.4%, and the proportion of isolated office control or overestimation of control (office BP <140/90 mm Hg and average daytime ambulatory BP ≥135/85 mm Hg) was 5.4%. BP control was more frequently underestimated in patients who were older, female, obese, or with morning BP determination than in their counterparts. BP control was more frequently overestimated in those who were younger, male, nonobese, smokers, or with evening BP determination. Ambulatory-based hypertension control was far better than office-based hypertension control. This conveys an encouraging message to clinicians, namely that they are actually doing better than is evidenced by office-based data. However, the burden of underestimation and overestimation of BP control at the office is still remarkable. Physicians should be aware that the likelihood of misestimating BP control is higher in some hypertensive subjects.

Twenty four hour ambulatory blood pressure monitoring: a new tool for determining cardiovascular prognosis

Twenty four hour ambulatory blood pressure monitoring (24-H ABPM) plays an important part in the management of subjects with suspected and confirmed disorders of blood pressure regulation. This article reviews the prognostic significance of various aspects of the 24-H ABPM and describes the authors experience in Chesterfield. Over the course of 12 month period from 1 August 2002, 1264 subjects had 24-ABPM. A total of 1187 (93.91%) subjects were included in this study, with mean age of 59.30 years and male:female ratio was 46%: 54 %. Fifty two (4.38%) of the subjects had all of the seven features associated with an adverse prognosis. Only 82 (6.90%) subjects had none of the seven adverse prognostic features with the remainder having one or more adverse prognostic features.

Prospects for the prevention of stroke

We are currently fighting a battle against a stroke epidemic. Implementation of new treatment strategies could save many patients in the future. The control of blood pressure is a major objective; however, choosing specific antihypertensive therapy (e.g. an agent blocking the renin-angiotensin system) is also important. The Losartan Intervention For Endpoint reduction in hypertension (LIFE) study demonstrates potential benefits beyond blood pressure reduction of prescribing an angiotensin II receptor blocker (ARB) compared with more established therapy in patients with left ventricular hypertrophy (LVH). Losartan-based therapy brought about regression of LVH and reduced incidences of fatal and non-fatal stroke by 25%, new-onset diabetes by 25% and atrial fibrillation by 30% more than atenolol-based therapy for a similar blood pressure control and better tolerability. The Study on COgnition and Prognosis in the Elderly (SCOPE) study, although difficult to interpret, does not contradict an ARB benefit beyond blood pressure lowering in primary prevention linked to targeting the angiotensin type 1 receptor. The findings of the MOrbidity and mortality after Stroke, Eprosartan compared with nitrendipine in Secondary prevention (MOSES) trial suggest clear-cut ARB benefits independent of blood pressure lowering in secondary stroke prevention. Experimental findings and other clinical evidence further support the benefits of ARBs in stroke prevention. Telmisartan is an ARB with a particularly interesting profile for stroke; given the 24-hour efficacy with more pronounced protection against the morning blood pressure surge and peroxisome proliferator-activated receptor-gamma activity at clinical doses. The unique properties of telmisartan for secondary stroke prevention are being tested in the Prevention Regimen For Effectively avoiding Second Strokes (PRoFESS) study.

Circadian rhythm of blood pressure and the relation to cardiovascular events

Incidences of potentially life-threatening cardiovascular events display a diurnal pattern, tending to be higher in the morning than at other times of day. The recording of blood pressure at pre-defined intervals under everyday circumstances is facilitated by ambulatory blood pressure monitoring (ABPM). This technique shows that systolic and diastolic blood pressures display a circadian rhythm in most individuals. Typically, at the end of the night on arousal, blood pressure surges. This surge coincides with increased cardiovascular events. A recent prospective study conducted in Japan, where the incidence of stroke is high, provides further evidence for the link between cardiovascular events and morning blood pressure surge. Prevalence of both silent ischaemic events and multiple cerebrovascular infarcts was highest among the elderly subjects studied, with the largest increase in blood pressure on awakening. An increased risk of cardiovascular morbidity and mortality is also seen in 'non-dippers' (i.e. individuals in whom the normal nocturnal fall in blood pressure is absent or blunted). ABPM is superior to clinic blood pressure in predicting cardiovascular morbidity and mortality, and this suggests that 24-h blood pressure control may be necessary to gain complete benefit from blood pressure-lowering therapy. Antihypertensive agents with a long duration of action have the potential to provide blood pressure control throughout the dosing interval and thus cover the critical early morning period when the blood pressure surges. Clinical studies that have compared telmisartan with shorter-acting angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors demonstrate that telmisartan has a sustained duration of action, with proven efficacy over the entire 24-h period between doses, including the critical early morning period.

Blood pressure variability: its measurement and significance in hypertension

The occurrence of blood pressure fluctuations over time has been documented since the 18th century, but the clinical importance of this phenomenon is only now being recognized. The introduction of ambulatory blood pressure monitoring in the late 1960s represented a major step forward in the study of blood pressure behaviour and helped to characterize the relationship between blood pressure variability and cardiovascular disease. In hypertension, blood pressure variability increases with increasing blood pressure and correlates closely with target-organ damage, independently of absolute blood pressure values. This has important consequences for treatment, which in the past has focused on reducing mean blood pressure values as the main goal. Experimental evidence suggests that drugs capable of buffering or reducing blood pressure variability may confer additional benefits on target-organ protection. Effective target-organ protection could best be afforded by antihypertensive agents that provide efficient 24-h blood pressure control and also stabilize blood pressure variability. Mathematical indices, such as the trough:peak ratio and the smoothness index, provide useful measures of the homogeneity of the antihypertensive effect over 24 h; optimum control is provided by drugs with a trough:peak ratio close to 1 and a smoothness index > 1, as is observed with long-acting drugs such as telmisartan or amlodipine. Recently, a direct relationship was demonstrated between homogeneous blood pressure control and treatment-induced regression of left ventricular hypertrophy, emphasizing the importance of smooth 24-h blood pressure control. In conclusion, the goals of antihypertensive treatment should consider the reduction of both 24-h mean blood pressure and its variability. Long-lasting drugs or drug combinations are preferable to ensure a homogeneous and smooth 24-h blood pressure profile.

Strategies Against High Blood Pressure in the Early Morning

Acute myocardial infarction and cerebrovascular disease reportedly show peak onset in the early morning, when blood pressure increases. The increase of blood pressure, or morning surge, may result from increased sympathetic activity reactive to arousal. The circadian pattern of vascular events is considered to be related to the morning surge in blood pressure, sympathetic activity, and hypercoagulability. Although there is no direct evidence indicating a causal relationship between the morning surge in blood pressure and vascular complications, it may be postulated that morning blood pressure surge is a factor which affects hypertensive complications. There may be two possible approaches to morning blood pressure surge; the pharmacodynamic and pharmacokinetic approach. On the basis of pharmacodynamics, drugs with adrenergic alpha-blocking actions are usually selected. From a pharmacokinetic view, it is essential to maintain blood concentration of a drug at the critical early morning period. On this point, use of long acting agents, changes in drug regimen and the development of a chronobiological system has been studied, with many studies reporting successful results in lowering morning blood pressure. Further study whether such kinds of treatments improve long term outcomes in hypertensive patients are desired.

Transgenic amplification of glucocorticoid action in adipose tissue causes high blood pressure in mice

Obesity is closely associated with the metabolic syndrome, a combination of disorders including insulin resistance, diabetes, dyslipidemia, and hypertension. A role for local glucocorticoid reamplification in obesity and the metabolic syndrome has been suggested. The enzyme 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) regenerates active cortisol from inactive 11-keto forms, and aP2-HSD1 mice with relative transgenic overexpression of this enzyme in fat cells develop visceral obesity with insulin resistance and dyslipidemia. Here we report that aP2-HSD1 mice also have high arterial blood pressure (BP). The mice have increased sensitivity to dietary salt and increased plasma levels of angiotensinogen, angiotensin II, and aldosterone. This hypertension is abolished by selective angiotensin II receptor AT-1 antagonist at a low dose that does not affect BP in non-Tg littermates. These findings suggest that activation of the circulating renin-angiotensin system (RAS) develops in aP2-HSD1 mice. The long-term hypertension is further reflected by an appreciable hypertrophy and hyperplasia of the distal tubule epithelium of the nephron, resembling salt-sensitive or angiotensin II-mediated hypertension. Taken together, our findings suggest that overexpression of 11beta-HSD1 in fat is sufficient to cause salt-sensitive hypertension mediated by an activated RAS. The potential role of adipose 11beta-HSD1 in mediating critical features of the metabolic syndrome extends beyond obesity and metabolic complications to include the most central cardiovascular feature of this disorder.

[Control of arterial hypertension based on self-measurement of blood pressure: APACHE study]

BACKGROUND AND OBJECTIVE

The objective was to analyze the control rates of hypertension in a large group of hypertensives on antihypertensive treatment by means of blood pressure (BP) self-measurements, and to assess if the degree of control at early morning hours differs from that at the rest of the day.

PATIENTS AND METHOD

9,227 subjects [4,398 men, mean age 61.0 (11.4) yr, body mass index 28.4 (4.1) kg/m2] who had hypertension and were on antihypertensive treatment at least during one month before were included. Patients were recruited from primary care physicians. After receiving training, six BP measurements over one day were performed by means of a Braun Precision Sensor BP 2550 monitor, which measures BP at wrist level.

RESULTS

Whole day SBP and DBP averages were 138.4 (16.5) mmHg and 85.4 (8.7) mmHg, respectively. Both SBP and DBP in early morning hours were significantly higher than those observed before lunch or before dinner. The percentage of subjects with BP < 130/80 mmHg was 15.5%; 15.4% had SBP < 130 mmHg but DBP > 80 mmHg, and 2.0% had DBP < 80 mmHg and SBP > 130 mmHg). Control rates were lower at early morning hours and in men.

CONCLUSIONS

By using BP self-measurement, control rates of hypertension are low, especially in early morning hours as compared to the rest of the day. New strategies are needed to further increase the control of hypertension.