Ambulatory blood pressure monitoring in hypertensive patients with high cardiovascular risk: a cross-sectional analysis of a 20 000-patient database in Spain

Non-dipping blood pressure pattern in pediatricians during on-duty

INTRODUCTION

People with a reduced nighttime dip in blood pressure have an increased cardiovascular risk. Our objective was to describe the different patterns in blood pressure (BP) among pediatricians who work in long on-duty shifts in relation with sex, medical rank and sleeping time.

METHODS

Descriptive, cross-sectional, two-center study. On duty pediatric Resident physicians and pediatric Consultants were recruited between January 2018 and December 2021.

RESULTS

Fifty-one physicians were included in the study (78.4% female, 66.7% Resident physicians). Resident physicians had a higher night/day ratio (0.91 vs 0.85; p<0.001) and a shorter nighttime period (3.87 vs 5.41, p<0.001) than Consultants. Physicians sleeping less than 5h had a higher night/day ratio (0.91 vs 0.87, p=0.014). Being a Resident showed a ∼4.5-fold increased risk of having a non-dipping BP pattern compared to Consultants.

CONCLUSION

We found a potential link between both being a Resident and, probably, having shorter sleeping time, and the non-dipping BP pattern in physicians during prolonged shifts.

Effect of air pollutants on ambulatory blood pressure

BACKGROUND AND METHODOLOGY

Air pollutants have a significant impact on public health. The aim of the study was to find out the relationship between ambulatory blood pressure measured by 24-h ambulatory blood pressure monitoring (ABPM) and the atmospheric pollutants that are measured regularly (PM10, PM2.5, NO2 and SO2). An observational study of temporal and geographic measurements of individual patients (case-time series design) was carried out in Primary Care Centres and Hypertension Units in the Barcelona metropolitan area. We included 2888 hypertensive patients≥18 years old, untreated, with a first valid ABPM performed between 2005 and 2014 and with at least one air pollution station within a radius of <3km.

RESULTS AND CONCLUSIONS

The mean age was 54.3 (SD 14.6) years. 50.1% were women and 16.9% of the sample were smokers. Mean 24-h blood pressure (BP) was 128.0 (12.7)/77.4 (9.7) mmHg. After adjusting for mean ambient temperature and different risk factors, a significant association was found between ambulatory diastolic BP (DBP) and PM10 concentrations the day before ABPM. For each increase of 10μg/m3 of PM10, an increase of 1.37mmHg 24-h DBP and 1.48mmHg daytime DBP was observed. No relationship was found between PM2.5, NO2 and SO2 and ambulatory BP, nor between any pollutant and clinical BP. The concentration of PM10 the day before the ABPM is significantly associated with an increase in 24-h DBP and daytime DBP.

Role of ambulatory blood pressure on prediction of cardiovascular disease. A cohort study

Ambulatory blood pressure (BP) is associated with mortality, but it is also interesting to expand its association with cardiovascular morbidity. This study sought to evaluate association with cardiovascular morbidity and cardiovascular mortality. Patients without cardiovascular disease who had a first 24-hour ambulatory BP monitoring were followed-up until the onset of the first event (a combined variable of cardiovascular mortality, coronary heart disease, cerebrovascular disease, peripheral arteriopathy, or hospital admission for heart failure). Changes in antihypertensive treatment couldn't be collected. Cox regression analysis was adjusted for risk factors and office BP. We included 3907 patients (mean age, 58.0, SD 13.8 years), of whom 85.5% were hypertensive. The follow up period was 6.6 (95% CI 5.0-8.5) years. A total of 496 (12.7%) events were recorded. The incidence rate was 19.3 (95% CI 17.7-21.1) cases per 1000 person-years. The patients with an event compared to the rest of patients were mostly men, older, with higher office and ambulatory systolic BP, higher prevalence of diabetes, chronic kidney disease, dyslipidemia, and non-dipper or riser circadian profile. In the fully adjusted model, office BP loses its significant association with the main variable. Ambulatory BP association remained significant with cardiovascular morbidity and mortality, HR 1.494 (1.326-1.685) and 0.767 (0.654-0.899) for 24-hour systolic and diastolic BP, respectively. Nighttime systolic BP also maintained this significant association, 1.270 (1.016-1.587). We conclude that nighttime systolic BP and 24-hour BP are significantly associated with cardiovascular events and cardiovascular mortality in patients without cardiovascular disease attended under conditions of routine clinical practice.

Ambulatory diastolic blood pressure: a marker of comorbidity in elderly fit hypertensive individuals?

BACKGROUND

Masked diastolic hypotension is a new blood pressure (BP) pattern detected by ambulatory blood pressure monitoring (ABPM) in elderly hypertensives. The aim of this study was to relate ABPM and comorbidity in a cohort of fit elderly subjects attending an outpatient hypertension clinic.

METHODS

Comorbidity was assessed by Charlson comorbidity index (CCI) and CHA₂DS₂VASc score. All subjects evaluated with ABPM were aged ≥ 65 years. CCI and CHA₂DS₂VASc score were calculated. Diastolic hypotension was defined as mean ambulatory diastolic BP < 65 mmHg and logistic regression analysis was carried out in order to detect and independent relationship between comorbidity burden and night-time diastolic BP < 65 mmHg.

RESULTS

We studied 174 hypertensive elderly patients aged 72.1 ± 5.2 years, men were 93 (53.4%). Mean CCI was 0.91 ± 1.14 and mean CHA₂DS₂VASc score of 2.68 ± 1.22. Subjects with night-time mean diastolic values < 65 mmHg were higher in females [54.7% vs. 45.3%, P = 0.048; odds ratio (OR) = 1.914, 95% CI: 1.047-3.500]. Logistic regression analysis showed that only CHA₂DS₂VASc score was independently associated with night-time mean diastolic values < 65 mmHg (OR = 1.518, 95% CI: 1.161-1.985; P = 0.002), but CCI was not.

CONCLUSIONS

ABPM and comorbidity evaluation appear associated in elderly fit subjects with masked hypotension. Comorbid women appear to have higher risk for low ambulatory BP.

Valsartan-mediated chronotherapy in spontaneously hypertensive rats via targeting clock gene expression in vascular smooth muscle cells

OBJECTIVE

This study was to investigate the underlying mechanisms of valsartan chronotherapy in regulating blood pressure variability.

METHODS

RT-PCR was used to assay clock genes expression rhythm in the hypothalamus, aortic vessels, and target organs after valsartan chronotherapy. WB was used to measure Period 1 (Per1), Period 2 (Per2) protein expression in aortic vessels, as well as to measure phosphorylation of 20-kDa regulatory myosin light chain (MLC₂₀) in VSMCs.

RESULTS

Specific clock genes in the hypothalamus, and Per1 and Per2 in aorta abdominalis, exhibited disordered circadian expression in vivo. Valsartan asleep time administration (VSA) restored circadian clock gene expression in a tissue- and gene-specific manner. In vitro, VSA was more efficient in blocking angiotensin II relative to VWA, which led to differential circadian rhythms of Per1 and Per2, ultimately corrected MLC₂₀ phosphorylation.

CONCLUSION

VSA may be efficacious in regulating circadian clock genes rhythm, then concomitantly correct circadian blood pressure rhythms.

Circadian Rhythm, Clock Genes, and Hypertension: Recent Advances in Hypertension

Accumulating evidence suggests that the molecular circadian clock is crucial in blood pressure (BP) control. Circadian rhythms are controlled by the central clock, which resides in the suprachiasmatic nucleus of the hypothalamus and peripheral clocks throughout the body. Both light and food cues entrain these clocks but whether these cues are important for the circadian rhythm of BP is a growing area of interest. The peripheral clocks in the smooth muscle, perivascular adipose tissue, liver, adrenal gland, and kidney have been recently implicated in the regulation of BP rhythm. Dysregulation of the circadian rhythm of BP is associated with adverse cardiorenal outcomes and increased risk of cardiovascular mortality. In this review, we summarize the most recent advances in peripheral clocks as BP regulators, highlight the adverse outcomes of disrupted circadian BP rhythm in hypertension, and provide insight into potential future work in areas exploring the circadian clock in BP control and chronotherapy. A better understanding of peripheral clock function in regulating the circadian rhythm of BP will help pave the way for targeted therapeutics in the treatment of circadian BP dysregulation and hypertension.

Cardiovascular Risk Assessment in Hypertensive Patients

Hypertension is a highly prevalent and causal risk factor for cardiovascular disease (CVD). Quantitative cardiovascular (CV) risk assessment is a new paradigm for stratifying hypertensive patients into actionable groups for clinical management and prevention of CVD. The large heterogeneity in hypertensive patients makes this evaluation complex, but recent advances have made CV risk assessment more feasible. In this review, we first describe the prognostic significance of various levels and temporal patterns of blood pressure (BP). We then discuss CV risk prediction equations and the rationale of taking global risk into account in hypertensive patients. Finally, we review several adjunctive biomarkers that may refine risk assessment in certain patients. We observe that, beyond individual cross-sectional measurements, both short-term and long-term BP patterns are associated with incident CVD; that current CV risk prediction performs well, and its incorporation into hypertension management is associated with potential population benefit; and that adjunctive biomarkers of target organ damage show the most promise in sequential screening strategies that target biomarker measurement to patients in whom the results are most likely to change clinical management. Implementation of quantitative risk assessment for CVD has been facilitated by tools and direct electronic health record integrations that make risk estimates accessible for counseling and shared decision making for CVD prevention. However, it should be noted that treatment does not return an individual to the risk of someone who never develops hypertension, underscoring the need for primordial prevention in addition to continued innovation in risk assessment.

[Improved office blood pressure control by automatic delayed-reading oscillometric device]

INTRODUCTION

Office blood pressure (BP) measurement is a recommended procedure, although the out-of-office BP measurements are increasingly used.

OBJECTIVE

To know the degree of BP control by clinical measurement.

MATERIAL AND METHODS

During November 2019 demographic and clinical data, office attended systolic BP (SBP) and diastolic BP (DBP) measured with an automatic device with delayed reading and, if performed, data from ambulatory BP monitoring (ABPM) were collected.

RESULTS

102 patients (67 men) were included, with a mean age of 64.9 years, 30% diabetic and 34% with cardiovascular complications. 70% had a controlled hypertesion (<140/90 mmHg) by office BP, the mean SBP was 131 ± 16.5 mmHg and the DBP was 73 ± 9.5 mmHg. Old age and diabetes were associated with uncontrolled hypertension. Thirty three patients had ABPM data, which allowed them to be classified according to the 24-hour BP into: 30% true normotension, 9% white-coat hypertension, 15% sustained hypertension, and 45% masked hypertension.

CONCLUSION

The use of automatic devices reduces the white-coat phenomenon, improving the % of patients with office BP controlled. However, this is not confirmed outside the clinic, showing the importance of ABPM in the evaluation of hypertension control. Office BP measurement is useful in patients initial assessment and also provides educational aspects, although the methodology must be optimized to define its clinical role.

Nicotine and vascular dysfunction

Cigarette smoking is the single most important risk factor for the development of cardiovascular diseases (CVDs). However, the role of nicotine, the addictive component of all tobacco products, in the development of CVD is incompletely understood. Although increased public awareness of the harms of cigarette smoking has successfully led to a decline in its prevalence, the use of electronic cigarettes (e-cig) or electronic nicotine delivery system has increased dramatically in recent years because of the perception that these products are safe. This review summarizes our current knowledge of the expression and function of the nicotinic acetylcholine receptors in the cardiovascular system and the impact of nicotine exposure on cardiovascular health, with a focus on nicotine-induced vascular dysfunction. Nicotine alters vasoreactivity through endothelium-dependent and/or endothelium-independent mechanisms, leading to clinical manifestations in both cigarette smokers and e-cig users. In addition, nicotine induces vascular remodelling through its effects on proliferation, migration and matrix production of both vascular endothelial and vascular smooth muscle cells. The purpose of this review is to identify critical knowledge gaps regarding the effects of nicotine on the vasculature and to stimulate continued nicotine research.

How do ultrafine particles in urban air affect ambulatory blood pressure?

INTRODUCTION

Air in urban areas is usually contaminated with particle matter. High concentrations lead to a rise in the risk of cardiovascular and respiratory diseases. Some studies have reported that ultrafine particles (UFP) play a greater role in cardiovascular diseases than other particle matter, particularly regarding hypertensive crises and DBP, although in the latter such effects were described concerning clinical blood pressure (BP). In this study, we evaluate the relationship between 24-h ambulatory BP monitoring (ABPM) and atmospheric UFP concentrations in Barcelona.

METHODS

An observational study of individual patients' temporal and geographical characteristics attended in Primary Care Centres and Hypertensive Units during 2009-2014 was performed.

RESULTS

The participants were 521 hypertensive patients, mean age 56.8 years (SD 14.5), 52.4% were women. Mean BMI was 28.0 kg/m and the most prominent cardiovascular risk factors were diabetes (N = 66, 12.7%) and smoking (N = 79, 15.2%). We describe UFP effects at short-term and up to 1 week (from lag 0 to 7). For every 10 000 particle/cm UFP increase measured at an urban background site, a corresponding statistically significant increase of 2.7 mmHg [95% confidence interval = (0.5-4.8)] in 24-h DBP with ABPM for the following day was observed (lag 1).

CONCLUSION

We have observed that a rise in UFP concentrations during the day prior to ABPM is significantly associated with an increase in 24 h and diurnal DBP. It has been increasingly demonstrated that UFP play a key role in cardiovascular risk factors and, as we have demonstrated, in good BP control.

Reproducibility study of nocturnal blood pressure dipping in patients with high cardiovascular risk

It has been shown that in most people there is a physiological reduction in blood pressure during nighttime sleep, it falling by approximately 10% compared to daytime values (dippers). On the other hand, in some people, there is no nighttime reduction (non‐dippers). Various studies have found an association between being a non‐dipper and a higher risk of cardiovascular disease, but few have assessed whether the nocturnal pattern is maintained over time. From the database of the TAHPS study, data were available on 225 patients, each of whom underwent 24‐hour ambulatory blood pressure monitoring (ABPM) on four occasions over a period of 5 months. We studied the reproducibility of the nocturnal BP dipping pattern with mixed linear analysis and also calculated the concordance in the classification of patients as dippers or non‐dippers. The intraclass correlation coefficients between the different ABPM recordings were 0.482 and 0.467 for systolic and diastolic blood pressure, respectively. Two‐thirds (67%) and 70% of the patients classified, respectively, as dippers or non‐dippers based on systolic and diastolic blood pressure readings in the first ABPM recording were found to have the same classification based on the subsequent recordings. We conclude that the reproducibility of nocturnal dipping patterns and concordance of dipper vs non‐dipper status in individual patients is modest and therefore that we should be cautious about recommending treatments or interventions based on these patterns.

Effects of Chronic Nicotine Inhalation on Systemic and Pulmonary Blood Pressure and Right Ventricular Remodeling in Mice

Cigarette smoking is the single most important risk factor for the development of cardiovascular and pulmonary diseases; however, the role of nicotine in the pathogenesis of these diseases is incompletely understood. The purpose of this study was to examine the effects of chronic nicotine inhalation on the development of cardiovascular and pulmonary disease with a focus on blood pressure and cardiac remodeling. Male C57BL6/J mice were exposed to air (control) or nicotine vapor (daily, 12 hour on/12 hour off) for 8 weeks. Systemic blood pressure was recorded weekly by radio-telemetry, and cardiac remodeling was monitored by echocardiography. At the end of the 8 weeks, mice were subjected to right heart catheterization to measure right ventricular systolic pressure. Nicotine-exposed mice exhibited elevated systemic blood pressure from weeks 1 to 3, which then returned to baseline from weeks 4 to 8, indicating development of tolerance to nicotine. At 8 weeks, significantly increased right ventricular systolic pressure was detected in nicotine-exposed mice compared with the air controls. Echocardiography showed that 8-week nicotine inhalation resulted in right ventricular (RV) hypertrophy with increased RV free wall thickness and a trend of increase in RV internal diameter. In contrast, there were no significant structural or functional changes in the left ventricle following nicotine exposure. Mechanistically, we observed increased expression of angiotensin-converting enzyme and enhanced activation of mitogen-activated protein kinase pathways in the RV but not in the left ventricle. We conclude that chronic nicotine inhalation alters both systemic and pulmonary blood pressure with the latter accompanied by RV remodeling, possibly leading to progressive and persistent pulmonary hypertension.

[Position statement on ambulatory blood pressure monitoring (ABPM) by the Spanish Society of Hypertension (2019)]

Conventional blood pressure (BP) measurement in clinical practice is the most used procedure for the diagnosis and treatment of hypertension (HT), but is subject to considerable inaccuracies due to, on the one hand, the inherent variability of the BP itself and, on the other hand biases arising from the measurement technique and conditions, Some studies have demonstrated the prognosis superiority in the development of cardiovascular disease using ambulatory blood pressure monitoring (ABPM). It can also detect "white coat" hypertension, avoiding over-diagnosis and over-treatment in many cases, as well detecting of masked hypertension, avoiding under-detection and under-treatment. ABPM is recognised in the diagnosis and management of HT in most of international guidelines on hypertension. The present document, taking the recommendations of the European Society of Hypertension as a reference, aims to review the more recent evidence on ABPM, and to serve as guidelines for health professionals in their clinical practice and to encourage ABPM use in the diagnosis and follow-up of hypertensive subjects. Requirements, procedure, and clinical indications for using ABPM are provided. An analysis is also made of the main contributions of ABPM in the diagnosis of "white coat" and masked HT phenotypes, short term BP variability patterns, its use in high risk and resistant hypertension, as well as its the role in special population groups like children, pregnancy and elderly. Finally, some aspects about the current situation of the Spanish ABPM Registry and future perspectives in research and potential ABPM generalisation in clinical practice are also discussed.

A Novel Diabetic Mouse Model for Real-Time Monitoring of Clock Gene Oscillation and Blood Pressure Circadian Rhythm

Diabetic patients have an increased prevalence of blood pressure (BP) circadian rhythm disruption, which is associated with an increased risk of target organ damage and detrimental cardiovascular events. Limited information is available regarding the role of clock genes in the disruption of BP circadian rhythm in diabetes due to the lack of a diabetic animal model that allows real-time monitoring of clock gene oscillation. Here, we generated a novel diabetic db/db-mPer2^Luc mouse model by crossing type 2 diabetic db/db mice with mPer2^Luc knock-in mice. The daily rhythms of BP, heart rate, locomotor activity, and food and water intake were acquired by radiotelemetry or using metabolic chambers. The daily oscillation of mPer2 bioluminescence was recorded by LumiCycle in real-time in tissue explants and using the IVIS system in vivo. Our results show that db/db-mPer2^Luc mice are obese, diabetic, and glucose intolerant. The db/db-mPer2^Luc mice displayed a compromised BP daily rhythm, which was associated with disrupted daily rhythms in baroreflex sensitivity, locomotor activity, and metabolism, but not heart rate or food and water intake. The phase of the mPer2 daily oscillation was advanced to different extents in the explanted peripheral tissues from db/db-mPer2^Luc mice relative to control mice. In contrast, no phase shift was detected in mPer2 daily oscillations in the explanted SCN. Moreover, advanced phase shift of the mPer2 daily oscillation was detected in the liver, kidney and submandibular gland in vivo of db/db-mPer2^Luc mice. In conclusion, the diabetic db/db-mPer2^Luc mouse is a novel animal model that allows real-time monitoring of mPer2 circadian rhythms ex vivo and in vivo. The results from db/db-mPer2^Luc mice suggest that the desynchrony of mPer2 daily oscillation in peripheral tissues contributes to the loss of BP daily oscillation in diabetes.

Blood Pressure Control in Hypertensive Patients, Cardiovascular Risk Profile and the Prevalence of Masked Uncontrolled Hypertension (MUCH)

Introduction:

The term masked hypertension (MH) should be used for untreated individuals who have normal office blood pressure but elevated ambulatory blood pressure. For treated patients, this condition should be termed masked uncontrolled hypertension (MUCH).

Research Objectives:

Masked uncontrolled hypertension (MUCH) has gone unrecognized because few studies have used 24-h ABPM to determine the prevalence of suboptimal BP control in seemingly well-treated patients, and there are few such studies in large cohorts of treated patients attending usual clinical practice. This is important because masked hypertension is associated with a high risk of cardiovascular events. This study was conducted to obtain more information about the association between hypertension and other CV risk factors, about office and ambulatory blood pressure (BP) control as well as on cardiovascular (CV) risk profile in treated hypertensive patients, also to define the prevalence and characteristics of masked uncontrolled hypertension (MUCH) among treated hypertensive patients in routine clinical practice.

Patients and methods:

In this study 2514 male and female patients were included during a period of 5 years follow up. All patients have ambulatory blood pressure monitoring (ABPM) for at least 24h. We identified patients with treated and controlled BP according to current international guidelines (clinic BP, 140/90mmHg). Cardiovascular risk assessment was based on personal history, clinic BP values, as well as target organ damage evaluation. Masked uncontrolled hypertension (MUCH) was diagnosed in these patients if despite controlled clinic BP, the mean 24-h ABPM average remained elevated (24-h systolic BP ≥130mmHg and/or 24-h diastolic BP ≥80mmHg).

Results:

Patients had a mean age of 60.2+10 years, and the majority of them (94.6%) were followed by specialist physicians. Average clinic BP was 150.4+16/89.9+12 mmHg. About 70% of patients displayed a very high-risk profile. Ambulatory blood pressure monitoring (ABPM) was performed in all recruited patients for at least 24h. Despite the combined medical treatment (78% of the patients), clinic control (<140/90 mmHg) was achieved in only 26.2% of patients, the corresponding control rate for ambulatory BP (<130/80 mmHg) being 32.7%. From 2514 patients with treated BP, we identified 803 with treated and controlled office BP control (<140/90 mmHg), of whom 258 patients (32.1%) had MUCH according to 24-h ABPM criteria (mean age 57.2 years, 54.7% men). The prevalence of MUCH was slightly higher in males, patients with borderline clinic and office BP (130–139/80–89 mmHg), and patients at high cardiovascular risk (smokers, diabetes, obesity). Masked uncontrolled hypertension (MUCH) was most often due to poor control of nocturnal BP, with the proportion of patients in whom MUCH was solely attributable to an elevated nocturnal BP almost double that solely attributable to daytime BP elevation (22.3 vs. 10.1%, P 0.001).

Conclusion:

The prevalence of masked suboptimal BP control in patients with treated and well-controlled clinic BP is high. The characteristics of patients with MUCH (male, longer duration of hypertension, obesity, smoking history, and diabetes) indicate that this is a higher-risk group with most to gain from improved BP.

Diastolic Function Is Impaired in Patients With Prehypertension: Data From the EPIPorto Study

INTRODUCTION AND OBJECTIVES

Hypertension causes subclinical changes in left ventricular structure and function, namely diastolic dysfunction. Diastolic dysfunction is a predictor of heart failure, being involved in the association between hypertension and heart failure with preserved ejection fraction. We aimed to determine whether patients with prehypertension have early changes in diastolic function in a large community-based cohort of asymptomatic adults.

METHODS

A cross-sectional evaluation was performed of a community-based cohort consisting of 925 adults, aged 45 years or older, without known cardiovascular disease. All participants underwent detailed clinical and echocardiographic examination. The participants were categorized according to the European guidelines for the classification of office blood pressure (BP) levels as optimal, prehypertensive (normal and high-normal categories), and hypertensive. Diastolic function was evaluated by echocardiography using e' velocities and E/e' ratio. Diastolic dysfunction was defined using the 2016 ASE/EACVI Joint Recommendations and a 2017 clinically-oriented algorithm.

RESULTS

In this cohort (61.5 ± 10.5 years; 37% men), prehypertension was present in 30.4% and hypertension in 51.0%. Using optimal BP as the reference, there was a progressive decrease of e' velocity in prehypertensive and hypertensive individuals (12.2 ± 3.5 vs 11.3 ± 3.1 vs 9.6 ± 2.9cm/s, respectively; P for trend < .001). After multivariable adjustment, both BP categories were independent predictors of a lower e' velocity (β = -0.56, P = .035 for prehypertension and β = -1.08, P < .001 for hypertension).

CONCLUSIONS

In this large community-based cohort, adults with prehypertension already showed impaired cardiac relaxation before the onset of hypertension.

Prevalence, Treatment, and Control Rates of Conventional and Ambulatory Hypertension Across 10 Populations in 3 Continents

Hypertension is a major global health problem, but prevalence rates vary widely among regions. To determine prevalence, treatment, and control rates of hypertension, we measured conventional blood pressure (BP) and 24-hour ambulatory BP in 6546 subjects, aged 40 to 79 years, recruited from 10 community-dwelling cohorts on 3 continents. We determined how between-cohort differences in risk factors and socioeconomic factors influence hypertension rates. The overall prevalence was 49.3% (range between cohorts, 40.0%-86.8%) for conventional hypertension (conventional BP ≥140/90 mm Hg) and 48.7% (35.2%-66.5%) for ambulatory hypertension (ambulatory BP ≥130/80 mm Hg). Treatment and control rates for conventional hypertension were 48.0% (33.5%-74.1%) and 38.6% (10.1%-55.3%) respectively. The corresponding rates for ambulatory hypertension were 48.6% (30.5%-71.9%) and 45.6% (18.6%-64.2%). Among 1677 untreated subjects with conventional hypertension, 35.7% had white coat hypertension (23.5%-56.2%). Masked hypertension (conventional BP <140/90 mm Hg and ambulatory BP ≥130/80 mm Hg) occurred in 16.9% (8.8%-30.5%) of 3320 untreated subjects who were normotensive on conventional measurement. Exclusion of participants with diabetes mellitus, obesity, hypercholesterolemia, or history of cardiovascular complications resulted in a <9% reduction in the conventional and 24-hour ambulatory hypertension rates. Higher social and economic development, measured by the Human Development Index, was associated with lower rates of conventional and ambulatory hypertension. In conclusion, high rates of hypertension in all cohorts examined demonstrate the need for improvements in prevention, treatment, and control. Strategies for the management of hypertension should continue to not only focus on preventable and modifiable risk factors but also consider societal issues.

Utility of ambulatory blood pressure monitoring for the management of hypertension

PURPOSE OF REVIEW

Hypertension is a leading cause of cardiovascular morbidity and mortality, affecting nearly 80 million individuals in the United States alone. Accurate measurement of blood pressure (BP) is the crucial first step to reduce the associated cardiovascular risk of hypertension. For decades, clinicians have relied on office BP measurements for the diagnosis and subsequent management of hypertension. However, it has been clearly demonstrated that ambulatory BP measurements are a better predictor of cardiovascular risk and can provide clinicians with important additional information to improve BP control and reduce cardiovascular risk. This article reviews the available data and provides clinical insights into the use of ambulatory BP monitoring for the management of hypertension.

RECENT FINDINGS

Ambulatory BP monitoring is uniquely capable of identifying patients with white-coat hypertension (WCH), masked hypertension and abnormal nocturnal BP profiles. Recently, ambulatory BP data have demonstrated the negative impact of WCH on right ventricular function, a greater prevalence of masked hypertension than previously recognized and the detrimental impact of nocturnal hypertension even in controlled hypertension.

SUMMARY

Ambulatory BP monitoring provides clinicians with the most comprehensive evaluation of hypertension and the ability to define individual BP phenotypes. Hence, these out-of-office measurements can be utilized to improve hypertension control, translating into a reduction of cardiovascular events.

[Combination for initial therapy in hypertension, is it useful?]

Hypertension represents the first cause of mortality worldwide because a leading role in development of cardiovascular and renal diseases. Evidence about the benefits of controlling hypertension is overwhelming, but adequate control of blood pressure is still poor even in high-income countries. At least one of 2 hypertensive patients suffers from uncontrolled blood pressure. Nearly 75% of hypertensive patients do not achieve adequate control with monotherapy. Strategies to improve control include avoiding inertia in initiating pharmacological treatment, prompt shift to combined therapy from monotherapy, initial treatment with a 2-drug combination, and use of fixed-dose combinations in a single pill. This review focuses in benefits of initiating treatment combining antihypertensive drugs.

Associations between cystatin C-based eGFR, ambulatory blood pressure parameters, and in-clinic versus ambulatory blood pressure agreement in older community-living adults

OBJECTIVES

The objective of this study was to determine the relationship between chronic kidney disease [CKD; measured using cystatin C-based estimated glomerular filtration rate (eGFR)] and abnormal ambulatory blood pressure (including nocturnal dipping) in healthy older adults. Further, this study aimed to assess the agreement between clinic and ambulatory blood pressure monitoring.

METHODS

Serum cystatin C levels were measured to calculate eGFR. Participants underwent clinic and 24-h ambulatory blood pressure measurements. Multiple linear regression was performed to examine the association between reduced cystatin C-based eGFR (CKDcys) and blood pressure parameters. Bland-Altman analysis was carried out to evaluate the agreement between clinic and ambulatory measurements.

RESULTS

The average age was 72 years. There were 60 individuals with CKDcys (eGFR<60 ml/min/1.73 m). Compared with those without CKDcys, individuals with CKDcys were older, more likely to have hypertension, and less likely to have normal dipping patterns. On multivariate analysis, the presence of CKDcys was found to be significantly associated with a lower mean ambulatory diastolic blood pressure (-2 mmHg, P=0.048), but not with nocturnal dipping or other blood pressure parameters. Clinic systolic blood pressure (SBP) significantly overestimated the mean wake-time ambulatory SBP; the mean difference was 11 mmHg for those without CKDcys (95% limits of agreement -14 to 35 mmHg) and 14 mmHg for those with CKDcys (95% limits of agreement -13 to 41 mmHg); there was no statistically significant effect modification by CKD status.

CONCLUSION

In older, seemingly healthy adults, mild CKD was associated with lower ambulatory diastolic blood pressure. The presence of CKD did not affect interpretation of clinic versus ambulatory blood pressure monitoring, although the accuracy of clinic SBP was poor.

Ambulatory blood pressure monitoring in daily clinical practice - the Spanish ABPM Registry experience

Many patients are hypertensive at the medical settings but show normal blood pressure out of the doctor's office, and are classified as white-coat hypertensives. On the other hand, many patients with controlled hypertension at the clinic show ambulatory blood pressure levels above the thresholds considered for an adequate blood pressure control, known as having masked hypertension. Using data from the Spanish Ambulatory Blood Pressure Monitoring Registry (Spanish ABPM Registry), a national program developed to promote the use of the ambulatory technique for hypertension management in daily practice, we have reviewed the main strengths of this approach, that is the ability to detect discrepancies of blood pressure status with respect to office blood pressure measurement, and to better assess accurate rates of hypertension control. White-coat hypertension within patients with elevated office blood pressure, and masked hypertension within office-controlled patients affected one of three patients in each office status. On the other hand, rates of ambulatory blood pressure control (50%) doubled those of office blood pressure control (25%), still remaining half the patients uncontrolled. We think that a systematic use of ambulatory blood pressure monitoring, and strategies to improve blood pressure control constitute key priorities in hypertension management.

Managing hypertension with ambulatory blood pressure monitoring

There has been a dramatic shift in the manner in which blood pressure (BP) is measured to provide far more comprehensive clinical information than that provided by a single set of office BP readings. Extensive clinical and epidemiological research shows an important role of ambulatory BP monitoring (ABPM) in the management of hypertensive patients. A 24-h BP profile helps to determine the absence of nocturnal dipping status and evaluate BP control in patients on antihypertensive therapy. The ability to detect white-coat or masked hypertension is enhanced by ambulatory BP monitoring. In 2001, the Center for Medicare and Medicaid Services approved ABPM for reimbursement for the identification of patients with white-coat hypertension. In 2011, the National Institute for Health and Clinical Excellence (NICE) in the UK published guidelines that recommended the routine use of ABPM in all patients suspected of having hypertension. The European Society of Hypertension (ESH) 2013 guidelines also support greater use of ABPM in clinical practice. While the advantages of ABPM are apparent from a clinical perspective, its use should be considered in relation to its cost, the complexity of data evaluation, as well as patient inconvenience. In this review, we evaluate the clinical importance of ABPM, highlighting its role in the current management of hypertension.

Effect of Olmesartan-Based Therapies on Therapeutic Indicators Obtained Through Out-of-Office Blood Pressure

Ambulatory blood pressure (BP) correlates more significantly with hypertension-associated cardiovascular mortality and morbidity than BP obtained in the doctor's office. Assessing ambulatory BP, either through 24-h monitoring or through protocolized self-measurement at home, is essential in diagnosing and monitoring patients with hypertension. Several ambulatory BP-derived indicators are related with cardiovascular prognosis. These include 24-h, daytime and nighttime BP measurements, BP measurements obtained through home self-measurement, dipping status, morning surge, and BP variability. The objective of this article was to review the effect of olmesartan-based antihypertensive therapy on the main risk variables obtained when assessing ambulatory BP.

Prevalence of Atherogenic Dyslipidemia in Spanish Hypertensive Patients and Its Relationship With Blood Pressure Control and Silent Organ Damage

INTRODUCTION AND OBJECTIVES

To assess the prevalence of atherogenic dyslipidemia in hypertensive patients and its relationship with risk profile and blood pressure control.

METHODS

The study included 24 351 hypertensive patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. Atherogenic dyslipidemia was defined as the presence of hypertriglyceridemia (> 150mg/dL) and low levels of high-density lipoprotein cholesterol (< 40mg/dL in men and < 46mg/dL in women). Blood pressure control was assessed by office and ambulatory monitoring.

RESULTS

Atherogenic dyslipidemia was present in 2705 patients (11.1%). Of these, 30% had hypertriglyceridemia and 21.7% had low levels of high-density lipoprotein cholesterol. Compared with patients without these risk factors, the former group were more often male (60% vs 52%), younger (57 years vs 59 years), had other risk factors and organ damage (microalbuminuria, reduced estimated glomerular filtration rate, and left ventricular hypertrophy), worse office, diurnal, and nocturnal blood pressure values (odds ratio 1.09, 1.06, and 1.10, respectively), and the lowest nocturnal blood pressure reduction (odds ratio=1.07), despite the greater use of antihypertensive drugs.

CONCLUSIONS

Atherogenic dyslipidemia is present in more than 10% of hypertensive patients and is associated with other risk factors, organ damage, and poorer blood pressure control. Greater therapeutic effort is needed to reduce overall risk in these patients.

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.

Home and ambulatory blood pressure in resistant hypertension

Since their introduction in the clinical setting home and ambulatory blood pressure measurements have gained growing popularity in the diagnosis and treatment of essential hypertension for a number of reasons. These reasons include: 1) the lack of the so-called "white-coat effect", 2) the ability of the two approaches to provide information on blood pressure phenomena of prognostic value, and 3) the close relationship of the derived values with the risk of developing fatal and non-fatal cardiovascular events. These features also apply to resistant hypertension, in which these approaches allow a precise definition of the diagnosis of this clinical condition, by excluding the presence of white-coat hypertension. Assessment of "out-of-office" blood pressure also allows us to define the patterns of blood pressure variability in this clinical condition as well as its relationships with target organ damage. Finally, home as well as ambulatory blood pressure measurements allow us to investigate the effects of therapeutic interventions, including those associated with the radiofrequency ablation of renal nerves. The present paper will provide a critical review of the main features of home and ambulatory blood pressure measurement in resistant hypertension, highlighting their main advantages as compared to office blood pressure. The prognostic significance, relationships with target organ damage and implications for treatment will also be discussed.

The effect of continuous nursing intervention guided by chronotherapeutics on ambulatory blood pressure of older hypertensive patients in the community

AIMS AND OBJECTIVES

To explore the effect of continuous nursing intervention guided by chronotherapeutics so as to provide the easy, noninvasive, effective and acceptable intervention for older hypertensive patients in the community.

BACKGROUND

Many researchers studied the effect of administration at different times on blood pressure control and circadian rhythm. However, the individual administrative time was set ambiguously in previous studies.

DESIGN

A semi-experimental study.

METHODS

In the study, 90 eligible patients were recruited and separated into three groups randomly, which were the control group, intervention group A (behaviour and chronotherapy intervention) and intervention group B (behaviour intervention). At 6 and 12 months after the study, the intervention groups were measured 24-hour ambulatory blood pressure monitoring.

RESULTS

There were significant differences in ambulatory blood pressure monitoring parameters of the two intervention groups at different measurement times, and there were interaction between measurement time and different groups. The number of patients with dipper increased and reverse dipper decreased in group A as the intervention applied. There were statistical differences between two groups. The number of patients with morning surge in group A decreased more, and there were statistical differences between two groups at six months after the intervention.

CONCLUSIONS

The behaviour and chronotherapy intervention based on the patients' ambulatory blood pressure monitoring can control casual blood pressure much better and last longer, which can also improve patients' indexes of ambulatory blood pressure monitoring better than behaviour intervention only. The behaviour and chronotherapy intervention can increase patients' nocturnal blood pressure drop, increase the number of patients with dipper and decrease reverse dipper, and improve blood pressure surge in the morning.

RELEVANCE TO CLINICAL PRACTICE

Nurses can use continuous nursing intervention guided by chronotherapeutics to help improve hypertension of older patients better in the community.

Ambulatory blood pressure monitoring: recent evidence and clinical pharmacy applications

Conventional office blood pressure readings are a well-established surrogate for the prediction of cardiovascular risk. It is assumed that these readings reflect an underlying average level of blood pressure exposure occurring in an individual over a period of time. But because blood pressure is not static, important additional prognostic information about the diurnal blood pressure profile, including within-day and between-day variability, is not easily ascertained from conventional measurements. Ambulatory blood pressure monitoring provides a more thorough depiction of the underlying blood pressure level and predicts cardiovascular risk more robustly than do conventional blood pressure measurements. Although the technology has been available for more than 30 years, there has been an expansion of the research base in the past decade supporting its role in the evaluation and management of patients with hypertension and as an important surrogate in research trials. This review summarizes recent evidence supporting the predictive ability of ambulatory blood pressure monitoring and briefly highlights opportunities for clinical pharmacists to adopt this important clinical and research tool.

Clinical inertia in poorly controlled elderly hypertensive patients: a cross-sectional study in Spanish physicians to ascertain reasons for not intensifying treatment

BACKGROUND

Clinical inertia, the failure of physicians to initiate or intensify therapy when indicated, is a major problem in the management of hypertension and may be more prevalent in elderly patients. Overcoming clinical inertia requires understanding its causes and evaluating certain factors, particularly those related to physicians.

OBJECTIVE

The objective of our study was to determine the rate of clinical inertia and the physician-reported reasons for it.

METHODS

An observational, cross-sectional, multi-center study was carried out in a primary care setting. We included 512 physicians, with a consecutive sampling of 1,499 hypertensive patients with clinical inertia.

MAIN OUTCOME MEASURE

Clinical inertia was defined when physicians did not modify treatment despite knowing that the therapeutic target had not been reached. Clinical inertia was considered to be justified (JCI) when physicians provided an explanation for not intensifying treatment and as not justified (nJCI) when no reasons were given.

RESULTS

JCI was observed in 30.1 % (95 % CI 27.8-32.4) of patients (n = 451) and nJCI in 69.9 % (95 % CI 67.6-72.2) (n = 1,058). JCI was associated with higher blood pressure (BP) values (both systolic and diastolic) and diabetes (p = 0.012) than nJCI. nJCI was associated with patients having an isolated increase of systolic or diastolic or high borderline BP values or cardiovascular disease.

CONCLUSION

Physicians provided reasons for not intensifying treatment in poorly controlled patients in only 30 % of instances. Main reasons for not intensifying treatment were borderline BP values, co-morbidity, suspected white coat effect, or perceived difficulty achieving target. nJCI was associated with high borderline BP values and cardiovascular disease.