Masked hypertension: different blood pressure measurement methodology and risk factors in a working population

Accuracy of screening strategies for masked hypertension: a large-scale nationwide study based on home blood pressure monitoring

This study compared the ability of guideline-proposed office blood pressure (OBP) screening thresholds [European Society of Hypertension (ESH) guidelines: 130/85 mmHg for individuals with an OBP < 140/90 mmHg; American College of Cardiology/American Heart Association (ACC/AHA) guidelines: 120/75 mmHg for individuals with an OBP < 130/80 mmHg] and novel screening scores to identify normotensive individuals at high risk of having masked hypertension (MH) in an office setting. We cross-sectionally evaluated untreated participants with an OBP < 140/90 mmHg (n = 22,266) and an OBP < 130/80 mmHg (n = 10,005) who underwent home blood pressure monitoring (HBPM) (derivation cohort) from 686 Brazilian sites. MH was defined according to criteria suggested by the ESH (OBP < 140/90 mmHg; HBPM ≥ 135/85 mmHg), Brazilian Society of Cardiology (BSC) (OBP < 140/90 mmHg; HBPM ≥ 130/80 mmHg) and ACC/AHA (OBP < 130/80 mmHg; HBPM ≥ 130/80 mmHg). Scores were generated from multivariable logistic regression coefficients between MH and clinical variables (OBP, age, sex, and BMI). Considering the ESH, BSC, and ACC/AHA criteria, 17.2%, 38.5%, and 21.2% of the participants had MH, respectively. Guideline-proposed OBP screening thresholds yielded area under curve (AUC) values of 0.640 (for ESH criteria), 0.641 (for BSC criteria), and 0.619 (for ACC/AHA criteria) for predicting MH, while scores presented as continuous variables or quartiles yielded AUC values of 0.700 and 0.688 (for ESH criteria), 0.720 and 0.709 (for BSC criteria), and 0.671 and 0.661 (for ACC/AHA criteria), respectively. Further analyses performed with alternative untreated participants (validation cohort; n = 2807 with an OBP < 140/90 mmHg; n = 1269 with an OBP < 130/80 mmHg) yielded similar AUC values. In conclusion, the accuracy of guideline-proposed OBP screening thresholds in identifying individuals at high risk of having MH in an office setting is limited and is inferior to that yielded by scores derived from simple clinical variables.

Alcohol Intake and Arterial Hypertension: Retelling of a Multifaceted Story

Alcoholic beverages are common components of diets worldwide and understanding their effects on humans' health is crucial. Because hypertension is the leading risk factor for cardiovascular diseases and all-cause mortality, the relationship of alcohol consumption with blood pressure (BP) has been the subject of extensive investigation. For the purpose of this review, we searched the terms "alcohol", "ethanol", and "arterial hypertension" on Pubmed MeSH and selected the most relevant studies. Short-term studies showed a biphasic BP response after ingestion of high doses of alcohol, and sustained alcohol consumption above 30 g/day, significantly, and dose-dependently, increased the risk for hypertension. These untoward effects of alcoholic beverages on BP can be mediated by a multiplicity of neurohormonal mechanisms. In addition to the effects on BP, excess alcohol intake might contribute to cardiac and renal hypertensive organ damage, although some studies suggest possible benefits of moderate alcohol consumption on additional cardiovascular risk factors, such as diabetes and lipoprotein(a). Some intervention studies and cumulative analyses support the evidence of a benefit of the reduction/withdrawal of alcohol consumption on BP and cardiovascular outcomes. This is why guidelines of scientific societies recommend avoidance or limitation of alcohol intake below one unit/day for women and two units/day for men. This narrative article overviews all these topics, providing an update of the current knowledge on the relationship between alcohol and BP.

Occupational Health and Well-being Questionnaire (OHWQ): an instrument to assess psychosocial risk and protective factors in the workplace

OBJECTIVES

Psychosocial stressors at work have been identified as significant risk factors for several mental and physical health problems. These stressors must be compensated by psychosocial resources to prevent or reduce adverse effects on health. Questionnaires measuring these stressors and resources already exist, but none integrate digital stress, ethical culture, and psychosocial safety climate; factors that are increasingly linked to workers' health. This study aims to develop and establish the psychometric properties of one of the most comprehensive instruments measuring the psychosocial work environment to date: the Occupational Health and Well-being Questionnaire (OHWQ).

STUDY DESIGN

A cross-sectional validation study is proposed to develop the OHWQ and document its psychometric properties.

METHODS

The OHWQ was developed from validated instruments to which new items were added. The questionnaire includes psychosocial dimensions, along with indicators of psychological distress, musculoskeletal disorders, and well-being. It was administered to a sample of 2770 participants from a population working in the academic field. Exploratory and confirmatory factor analyses and the calculation of Cronbach's α coefficient were used to identify the variables, items, and, dimensions of the OHWQ and to document its main psychometric properties.

RESULTS

The acceptability of the measurement model was evaluated by the reliability of the items, internal consistency between the items, and the convergent and discriminant validity. Construct validity was assessed using exploratory and confirmatory factor analyses. Using factor analyses and cut-off rules, the new instrument has 124 items grouped into 22 dimensions. The OHWQ demonstrated satisfactory reliability and validity, as well as reasonable fit indices. The internal consistency of the scales was also good (Cronbach's α = 0.68-0.96, median = 0.85).

CONCLUSION

The OHWQ demonstrated good psychometric properties. It could be useful for both research purposes and for workplaces interested in developing concrete action plans aimed at improving the balance between psychosocial work stressors and resources.

Options for the diagnosis of high blood pressure in primary care: a systematic review and economic model

The 2011 NICE hypertension guideline (CG127) undertook a systematic review of the diagnostic accuracy of different blood pressure (BP) assessment methods to confirm the diagnosis of hypertension. The guideline also undertook a cost-utility analysis exploring the cost-effectiveness of the monitoring methods. A new systematic review was undertaken as part of the 2019 NICE hypertension guideline update (NG136). BP monitoring methods compared included Ambulatory BP, Clinic BP and Home BP. Ambulatory BP was the reference standard. The economic model from the 2011 guideline was updated with this new accuracy data. Home BP was more sensitive and specific than Clinic BP. Specificity improved more than sensitivity since the 2011 review. A higher specificity translates into fewer people requiring unnecessary treatment. A key interest was to compare Home BP and Ambulatory BP, and whether any improvement in Home BP accuracy would change the model results. Ambulatory BP remained the most cost-effective option in all age and sex subgroups. In all subgroups, Ambulatory BP was associated with lower costs than Clinic BP and Home BP. In all except one subgroup (females aged 40), Ambulatory BP was dominant. However, Ambulatory BP remained the most cost-effective option in 40-year-old females as the incremental cost-effectiveness ratio for Home BP versus Ambulatory BP was above the NICE £20,000 threshold. The new systematic review showed that the accuracy of both Clinic BP and Home BP has increased. However, Ambulatory BP remains the most cost-effective option to confirm a diagnosis of hypertension in all subgroups evaluated.

Diagnostic performance of clinic and home blood pressure measurements compared with ambulatory blood pressure: a systematic review and meta-analysis

BACKGROUND

Clinic blood pressure measurement (CBPM) is currently the most commonly used form of screening for hypertension, however it might have a problem detecting white coat hypertension (WCHT) and masked hypertension (MHT). Home blood pressure measurement (HBPM) may be an alternative, but its diagnostic performance is inconclusive relative to CBPM. Therefore, this systematic review aimed to estimate the performance of CBPM and HBPM compared with ambulatory blood pressure measurement(ABPM) and to pool prevalence of WCHT and MHT.

METHODS

Medline, Scopus, Cochrane Central Register of Controlled Trials and WHO's International Clinical Trials Registry Platform databases were searched up to 23rd January 2020. Studies having diagnostic tests as CBPM or HBPM with reference standard as ABPM, reporting sensitivity and specificity of both tests and/or proportion of WCHT or MHT were eligible. Diagnostic performance of CBPM and HBPM were pooled using bivariate mixed-effect regression model. Random effect model was applied to pool prevalence of WCHT and MHT.

RESULTS

Fifty-eight studies were eligible. Pooled sensitivity, specificity, and diagnostic odds ratio (DOR) of CBPM, when using 24-h ABPM as the reference standard, were 74% (95% CI: 65-82%), 79% (95% CI: 69%, 87%), and 11.11 (95% CI: 6.82, 14.20), respectively. Pooled prevalence of WCHT and MHT were 0.24 (95% CI 0.19, 0.29) and 0.29 (95% CI 0.20, 0.38). Pooled sensitivity, specificity, and DOR of HBPM were 71% (95% CI 61%, 80%), 82% (95% CI 77%, 87%), and 11.60 (95% CI 8.98, 15.13), respectively.

CONCLUSIONS

Diagnostic performances of HBPM were slightly higher than CBPM. However, the prevalence of MHT was high in negative CBPM and some persons with normal HBPM had elevated BP from 24-h ABPM. Therefore, ABPM is still necessary for confirming the diagnosis of HT.

Long Working Hours and the Prevalence of Masked and Sustained Hypertension

Previous studies on the effect of long working hours on blood pressure have shown inconsistent results. Mixed findings could be attributable to limitations related to blood pressure measurement and the lack of consideration of masked hypertension. The objective was to determine whether individuals who work long hours have a higher prevalence of masked and sustained hypertension. Data were collected at 3-time points over 5 years from 3547 white-collar workers. Long working hours were self-reported, and blood pressure was measured using Spacelabs 90207. Workplace clinic blood pressure was defined as the mean of the first 3readings taken at rest at the workplace. Ambulatory blood pressure was defined as the mean of the next readings recorded every 15 minutes during daytime working hours. Masked hypertension was defined as clinic blood pressure < 140/90 mm Hg and ambulatory blood pressure ≥135/85 mm Hg. Sustained hypertension was defined as clinic blood pressure ≥140/90 mm Hg and ambulatory blood pressure ≥135/85 mm Hg or being treated hypertension. Long working hours were associated with the prevalence of masked hypertension (prevalence ratio 49+ =1.70 [95% CI, 1.09–2.64]), after adjustment for sociodemographics, lifestyle-related risk factors, diabetes mellitus, family history of cardiovascular disease, and job strain. The association with sustained hypertension was of a comparable magnitude (prevalence ratio 49+ =1.66 [95% CI, 1.15–2.50]). Results suggest that long working hours are an independent risk factor for masked and sustained hypertension. Workplace strategies targeting long working hours could be effective in reducing the clinical and public health burden of hypertension.

Autonomic dysregulation and phenobarbital in patients with masked primary hypertension

Introduction

Primary hypertension can be masked and be responsible of a severe impact on the target bodies. The purpose of this study was to see if Phenobarbital at low dose is able to decrease the sympathetic hyperactivity assessed by cardiovascular autonomic reflexes in patients with masked hypertension.

Materials and methods

This prospective study was conducted on a total of 91 patients with masked hypertension (average age 52.1 ± 10.3 years old). The cardiovascular autonomic tests performed in this group, before and after 3 months of daily oral administration of Phenobarbital, included deep breathing, hand-grip, mental stress and orthostatic tests. Statistical analysis was done using the Student's t-test, Univariate and Multivariate logistic regression analysis; p is significant if < 0.05.

Results

Cardiovascular autonomic reflexes responses before and after 3 months of Phenobarbital oral administration were as follows: Vagal response (XDB) obtained on deep breathing test was of 32.6 ± 5.4% VS 30.4 ± 6.1%, (p = 0.08), alpha peripheral sympathetic response (alpha SP) obtained on hand grip test was of 35.6 ± 8.7% VS 12.0 ± 2.5%, (p < 0.001), alpha central sympathetic response (alpha SC), beta central sympathetic response (beta SC) obtained during mental stress were of respectively 29.3 ± 9.2% VS 11.8 ± 2.4%, (p < 0.001) and 11.0 ± 5.3% VS 10.4 ± 6.1%, (p = 0.2), alpha peripheral adrenergic sympathetic (alpha PAS) obtained during orthostatic test was of 25.3 ± 6.0% VS 13.0 ± 3.4%, (p < 0.001).

Conclusion

These results demonstrated that Phenobarbital at low dose may have an anti-sympathetic effect in patients with masked hypertension.

Sex differences in masked hypertension: the Coronary Artery Risk Development in Young Adults study

OBJECTIVE

To evaluate the association of sex with masked hypertension, defined by out-of-clinic hypertension based on ambulatory blood pressure monitoring (ABPM) among adults without hypertension based on blood pressure (BP) measured in the clinic, after adjusting for potential confounders.

METHODS

We evaluated sex differences in the prevalence of masked hypertension and the difference between awake, or alternatively 24-h, ambulatory BP and clinic BP using multivariable adjusted models among 658 participants who underwent 24-h ABPM and had clinic SBP/DBP less than 140/90 mmHg during the Year 30 Exam of the Coronary Artery Risk Development in Young Adults study.

RESULTS

The mean age ± standard deviation (SD) of the participants was 54.8 ± 3.7 years, 58.4% were women, and 58.2% were black. The prevalence of any masked hypertension was 37.5% among women and 60.6% among men. In a model including adjustment for demographics, cardiovascular risk factors, antihypertensive medication, and clinic BP, the prevalence ratios (95% confidence intervals) comparing men versus women were 1.39 (1.18-1.63) for any masked hypertension, and 1.60 (1.28-1.99), 1.71 (1.36-2.15), and 1.40 (1.13-1.73) for masked awake, 24-h and asleep hypertension, respectively. In a fully adjusted model, the differences between mean awake ambulatory BP and clinic BP were 2.75 [standard error (SE) 0.92] mmHg higher for SBP and 3.61 (SE 0.58) mmHg higher for DBP among men compared with women.

CONCLUSION

The prevalence of masked hypertension on ABPM was high in both men and women. Male sex was an independent predictor of masked hypertension.

Reproducibility of masked uncontrolled hypertension detected through home blood pressure monitoring

Masked uncontrolled hypertension (MUCH) is an entity described in treated hypertensive subjects, where office blood pressure (BP) is well controlled and out-of-office BP is elevated. It has been related to a higher cardiovascular risk. However, the reproducibility of MUCH has been scarcely studied. In this study, we aimed to determine the reproducibility of MUCH detected through home blood pressure monitoring (HBPM). Two sets of measurements were performed in hypertensive adults under stable treatment with a 1-week interval. Each set of measurements included three office BP readings and a 4-day HBPM with duplicate readings in the morning, afternoon, and evening (the same validated oscillometric device was employed in both settings). We determined the percentage of agreement regarding the presence of MUCH in the two sets of measurements and quantified such agreement through the Cohen's kappa coefficient (κ), its 95% confidence interval, and P value. We included 105 patients (median age 58.6 [IQR 45.6-67.2] years old, 53.4% men). MUCH prevalence on at least one occasion was 22.3% (95% CI: 15.2-31.5). The reproducibility of MUCH was scant: κ = 0.19 (95% CI: 0.0002-0.38), P = 0.02, due to the poor reproducibility of the office BP component of MUCH in comparison with the home BP component: κ = 0.21 (95% CI: 0.03-0.39), P = 0.01 vs κ = 0.48 (95% CI 0.29-0.67), P < 0.001, respectively. In conclusion, the reproducibility of MUCH detected through HBPM is minimal, mainly due to the poor reproducibility of office BP measurements. An HBPM-based strategy for the management of patients with MUCH may be more adequate in terms of cardiovascular morbidity and mortality.

When Office Blood Pressure Is Not Enough: The Case of Masked Hypertension

An increasing attention has been devoted in the last two decades to masked hypertension (MH), a condition characterized by the fact that classification of a normal blood pressure (BP) status by office measurements is not confirmed by home and/or ambulatory BP monitoring (ABPM). MH definition (i.e., normal office BP, but high out-of-office BP) should be restricted to untreated subjects (true MH) whereas masked uncontrolled hypertension (MUCH) reserved to treated patients previously classified as hypertensives, presenting normal office BP and high ABPM or home values. Both MH and MUCH are associated with metabolic alterations, comorbidities, and hypertension-mediated organ damage (HMOD). Furthermore, the risk of cardiovascular events related to these conditions has been shown to be close or greater than that of sustained hypertension. This review discusses available evidence about MH and MUCH by focusing on its prevalence, clinical correlates, association with HMOD, prognostic significance, and their therapeutic implications.

Masked hypertension incidence and risk factors in a prospective cohort study

Aims

Masked hypertension may affect up to 30% of the general population and is associated with a high cardiovascular disease risk. No previous study has examined the incidence of masked hypertension and its risk factors. The study aim was to determine the incidence of masked hypertension and to examine its related risk factors.

Methods

This is a cohort study including 1836 initially normotensive participants followed up on average for 2.9 years. Blood pressure was measured using Spacelabs 90207. Manual blood pressure was defined as the mean of the first three readings taken at rest. Ambulatory blood pressure was defined as the mean of the next readings recorded every 15 minutes during daytime working hours. Masked hypertension incidence at follow-up was defined as manual blood pressure less than 140 and less than 90 mmHg and ambulatory blood pressure at least 135 or at least 85 mmHg. Generalised estimating equations were used.

Results

The cumulative incidence of masked hypertension was 10.3% and was associated with male gender (relative risk (RR) 1.51, 95% confidence interval (CI) 1.18–1.94), older age (RR40–49 years 1.56, 95% CI 1.16–2.11, RR≥50 years 1.50, 95% CI 1.06–2.10), higher education (RRcollege 1.31, 95% CI 1.03–1.65), body mass index (RR≥27 1.43, 95% CI 1.11–1.85), smoking (RR 1.51, 95% CI 1.09–2.010) and alcohol intake (RR≥6/week 1.65, 95% CI 1.13–2.03).

Conclusion

The present study is the first to identify risk factors for the incidence of masked hypertension. Current guidelines for hypertension detection recommend ambulatory blood pressure in patients with an elevated blood pressure reading at the clinic. As it is impractical to measure ambulatory blood pressure in all normotensive patients, factors identified in the present study should be considered for the screening of at-risk individuals and for primary prevention of masked hypertension.

Masked hypertension and effort-reward imbalance at work among 2369 white-collar workers

Hypertension is an important risk factor of cardiovascular diseases, the leading cause of death worldwide. Adverse effects of psychosocial factors at work might increase the risk of masked hypertension, but evidences are still scarce. The objective of this study is then to determine whether adverse psychosocial work factors from the effort-reward imbalance (ERI) model are associated with the prevalence of masked hypertension in a population of white-collar workers. White-collar workers were recruited from three public organizations. Blood pressure was measured at the workplace for manually operated measurements (mean of the first three readings taken by a trained assistant) followed by ambulatory measurements (mean of all subsequent readings taken during the working day). Masked hypertension was defined as manually operated BP<140/90 mm Hg and ambulatory BP ⩾135/85 mm Hg. ERI exposure at work was measured using Siegrist's validated questionnaire. Blood pressure readings were obtained from 2369 workers (participation proportion: 85%). ERI exposure (OR: 1.53 (95% CI: 1.16-2.02) and high efforts at work (OR: 1.61 (95% CI: 1.13-1.29) were associated with masked hypertension, after adjusting for sociodemographic and cardiovascular risk factors. Workers exposed to an imbalance between efforts spent at work and reward had a higher prevalence of masked hypertension. High efforts at work might be of particular importance in explaining this association. Future studies should be designed to investigate how clinicians can include questions on psychosocial work factors to screen for masked hypertension and how workplace interventions can decrease adverse psychosocial exposures to lower BP.

Prevalence of Masked Hypertension: a Population-Based Survey in a Large City by Using 24-Hour Ambulatory Blood Pressure Monitoring

Background and Objectives

We estimated the prevalence of hypertension and hypertension subtypes in a large semi-urban city in Korea, using 24-hour ambulatory blood pressure monitoring (ABPM) in a randomly selected sample population.

Subjects and Methods

A random sample (aged 20-65 years) from a city with an adult population of approximately 600000 was selected by using a list-assisted random digit dialing method. The 24-hour ABPM and conventional blood pressure measurement (CBPM) of these individuals were obtained.

Results

Among the 496 participants, valid 24-hour ABPM and CBPM were obtained from 462 (93%) individuals. The estimated prevalence of hypertension in Goyang was 17.54% by CBPM and 32.70% by 24-hour ABPM (p<0.01). In the age stratified analysis, both CBPM and 24-hour ABPM showed increased prevalence of hypertension with age. The estimated prevalence of masked hypertension was 16.22% and that of white-coat hypertension was 1.08%. Men had a higher prevalence of masked hypertension than women (20.79% vs. 11.86%, p=0.0295). The estimated prevalence of masked hypertension was 17.5%, 20.58%, 24.34%, and 13.29% in the age categories of 30s, 40s, 50s, and 60s, respectively. The estimated prevalence of masked uncontrolled hypertension was 26.79% in patients with hypertension who were taking antihypertensive medications.

Conclusion

The estimated prevalence of hypertension by 24-hour ABPM was higher than that by CBPM, revealing high prevalence of masked hypertension. The high prevalence of masked hypertension supports the adoption of ABPM in the national population survey and clinical practice to improve public health and reduce health care costs.

Hypertension Prevalence, Awareness, Treatment, and Control: Should 24-Hour Ambulatory Blood Pressure Monitoring be the Tool of Choice?

We aimed to examine hypertension prevalence, awareness, treatment and control in a community sample and investigate the impact of using 24 hour ABPM. Office blood pressure (BP) was taken from the electronic health record. Study BP was measured by standardised methods. Participants were invited to undergo ABPM. Hypertension was defined by accepted thresholds or anti-hypertensive use. Standardised questions assessed awareness and treatment. Control was defined as anti-hypertensive use with BP below normal threshold. There were 931 (45%) participants with office BP, study BP and ABPM. By study BP, hypertension prevalence was 60%, awareness 59%, 60% were treated and 46% controlled. By daytime ABPM threshold, prevalence was 61%, awareness 59%, 59% were treated and 54% controlled. ABPM reclassified 13.5% from normotensive to hypertensive and 14.5% from hypertensive to normotensive. ABPM may not hugely impact population hypertension prevalence but at an individual level it reduces misclassification and facilitates more appropriate management.

Masked Hypertension in Low-Income South African Adults

While South Africa has one of the highest hypertension rates globally, there are few data on masked hypertension (MHT) and white-coat hypertension (WCHT). This study measured the frequency of MHT and WCHT in low-income (<$500 US per month) South African adults, evaluating cardiovascular risk by arterial stiffness. Participants (n=101, 50% male; mean age 39.4±9.7 years) were recruited from a large North-West Province employer. Clinic and 24-hour blood pressure (BP) and pulse wave analysis were recorded. Clinic BP identified 18% of patients as hypertensive, while 24-hour BP showed that 63% of patients were hypertensive. The frequency of MHT was high (33 of 81, 41%) with only one case of WCHT. In comparison to those with normal clinic and 24-hour BP, augmentation index and pulse wave velocity were significantly higher in those with hypertensive 24-hour BP irrespective of clinic BP, indicating that, in this group, masked and sustained hypertension carry a similar elevated cardiovascular risk.

SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014

This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.

Epidemiology of masked and white-coat hypertension: the family-based SKIPOGH study

Objective

We investigated factors associated with masked and white-coat hypertension in a Swiss population-based sample.

Methods

The Swiss Kidney Project on Genes in Hypertension is a family-based cross-sectional study. Office and 24-hour ambulatory blood pressure were measured using validated devices. Masked hypertension was defined as office blood pressure<140/90 mmHg and daytime ambulatory blood pressure≥135/85 mmHg. White-coat hypertension was defined as office blood pressure≥140/90 mmHg and daytime ambulatory blood pressure<135/85 mmHg. Mixed-effect logistic regression was used to examine the relationship of masked and white-coat hypertension with associated factors, while taking familial correlations into account. High-normal office blood pressure was defined as systolic/diastolic blood pressure within the 130–139/85–89 mmHg range.

Results

Among the 652 participants included in this analysis, 51% were female. Mean age (±SD) was 48 (±18) years. The proportion of participants with masked and white coat hypertension was respectively 15.8% and 2.6%. Masked hypertension was associated with age (odds ratio (OR) = 1.02, p = 0.012), high-normal office blood pressure (OR = 6.68, p<0.001), and obesity (OR = 3.63, p = 0.001). White-coat hypertension was significantly associated with age (OR = 1.07, p<0.001) but not with education, family history of hypertension, or physical activity.

Conclusions

Our findings suggest that physicians should consider ambulatory blood pressure monitoring for older individuals with high-normal office blood pressure and/or who are obese.

Persistence and progression of masked hypertension: a 5-year prospective study

Objectives. To examine masked hypertension persistence over 5 years. Methods. White-collar workers were recruited from three public organizations. Blood pressure (BP) was measured using Spacelabs 90207. Manually operated BP was defined as the mean of the first three readings taken at rest. Ambulatory BP was defined as the mean of the next readings taken every 15 minutes and recorded during working hours. BP was assessed three times over 5 years. Masked hypertension was defined as manually operated BP less than 140 and less than 90 mmHg and ambulatory BP at least 135 or at least 85 mmHg. Sustained hypertension was defined as manually operated BP at least 140 or at least 90 mmHg and ambulatory BP at least 135 or at least 85 mmHg or being treated for hypertension. Results. BP measurements were obtained from 1669 participants from whom 232 had masked hypertension at baseline. Persistence of masked hypertension was 38% and 18.5%, after 3 and 5 years, respectively. Progression to sustained hypertension was 26% and 37%, after 3 and 5 years, respectively. Conclusion. Among baseline masked hypertensives, one-third progressed to sustained hypertension and about one out of five remained masked after 5 years, potentially delaying diagnosis and treatment.

Impact of miscuffing during home blood pressure measurement on the prevalence of masked hypertension

BACKGROUND

Masked hypertension has been associated with obesity. However, because most studies do not mention the specific cuff size used for home measurements, masked hypertension prevalence may have been overestimated in obese patients because of undersized cuffs. In this prospective, observational study, the effect of miscuffing on hypertension status was evaluated in patients with large arms.

METHODS

Fifty-three patients with an upper-arm circumference >33cm, undergoing treatment for mild-to-moderate hypertension, took 2 sets of home blood pressure (BP) measurements (standard vs. large cuff) using the validated Microlife BP A100 Plus automated device.

RESULTS

Mean BP was 143/85mm Hg at the office using a large cuff, 141/84mm Hg at home using a standard cuff, and 134/80mm Hg at home using a large cuff. Standard vs. large cuff home BP mean differences were 6.9mm Hg (95% confidence interval (CI) = 4.7-9.2; P < 0.0001) for systolic BP and 4.0mm Hg (95% CI = 2.4-5.5; P < 0.0001) for diastolic BP. Hypertension status differed significantly between standard vs. large cuffs: sustained hypertension (56.6% vs. 41.5%, respectively; P = 0.002), controlled hypertension (20.8% vs. 28.3%, respectively; P = 0.04), white coat hypertension (7.5% vs. 22.6%, respectively; P = 0.002), masked hypertension (15.1% vs. 7.5%, respectively; P = 0.04).

CONCLUSIONS

In patients with large arms, use of an appropriately sized large cuff for home BP measurements led to a 2-fold reduction in masked hypertension. Regarding clinical and epidemiological implications, future studies investigating masked hypertension should specify cuff size for home BP measurements. The low market availability and increased cost of large cuffs should also be addressed.

The impact of different anthropometric measures on sustained normotension, white coat hypertension, masked hypertension, and sustained hypertension in patients with type 2 diabetes

BACKGROUND

Many studies have aimed to determine whether body mass index (BMI), waist circumference (WC), or waist to hip ratio (WHR) best predicts hypertension in diabetic patients, with conflicting results. However, no study has examined the specific relationship between these anthropometric parameters with sustained normotension (SNT), white coat hypertension (WCHT), masked hypertension (MHT), and sustained hypertension (SHT) based on office and ambulatory blood pressure (BP) measurements in these patients.

METHODS

Patients with newly diagnosed type 2 diabetes underwent the following procedures: history taking, measurements of anthropometric parameters, office and ambulatory BP measurements, physical examination, laboratory analysis, and random and 24-hour urine analysis.

RESULTS

In total, there were 65 dippers and 37 nondipper patients. None of the anthropometric parameters were different between the dippers and the nondippers. There were 25 patients with SNT, 32 with WCHT, seven with MHT, and 38 with SHT. A comparison of anthropometric parameters between these four groups of patients showed that WC (P=0.016) and WHR (P=0.015) were different among all groups. According to regression analysis, only BMI was independently related with MHT (odds ratio [OR], 1.373, P=0.022), whereas only WC has been associated with SHT (OR, 1.321, P=0.041).

CONCLUSION

Among anthropometric parameters, only WC and WHR were different in SNT, WCHT, MHT, and SHT in newly diagnosed patients with type 2 diabetes.

Predictors of masked hypertension among treated hypertensive patients: an interesting association with orthostatic hypertension

BACKGROUND

Masked hypertension (MH) entails an increased cardiovascular risk. Therefore, it is important to identify those individuals who would benefit the most from out-of-office blood pressure (BP) measurement. We sought to determine the prevalence and identify predictors of MH among adult hypertensive patients under treatment.

METHODS

Treated hypertensive patients aged ≥ 18 years underwent office (duplicate sitting and standing BP in 1 visit) and home BP measurements (duplicate measurements for 4 days in the morning, afternoon, and evening; at least 16 measurements) and completed a questionnaire regarding risk factors and history of cardiovascular disease. MH was defined as normal office BP (<140/90mm Hg) with elevated home BP (≥135/85mm Hg, average of all readings discarding first day measurements). Patients with a systolic BP rise upon standing ≥5mm Hg were considered to have orthostatic hypertension (OHT). Variables indentified as relevant predictors of MH were entered into a multivariable logistic regression analysis model.

RESULTS

Three hundred and four patients were included (mean age = 66.7 ±13.8; 67.4% women). The prevalence of MH in the whole population was 12.4% and was 20.9% among patients with office-controlled hypertension. Factors independently associated with MH were age (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.03-1.14), high-normal office systolic BP (OR = 5.61, 95% CI = 1.39-22.57), history of peripheral artery disease (PAD) (OR = 8.83, 95% CI = 1.5-51.84), moderate alcohol consumption (OR = 0.08, 95% CI = 0.01-0.73), and OHT (OR = 3.65, 95% CI = 1.27 to 10.51).

CONCLUSIONS

Easily measurable parameters such as age, office systolic BP, history of PAD, and OHT may help to detect a population at risk of MH that would benefit from home BP monitoring.

Effort-reward imbalance at work and psychological distress: a validation study of post-myocardial infarction patients

OBJECTIVES

To examine whether the psychometric properties of the effort-reward imbalance (ERI) at work scales could be replicated with post-myocardial infarction (post-MI) patients and to measure the criterion validity through its association with psychological distress.

METHODS

A cross-sectional survey was conducted among 814 patients (739 men and 75 women) who had returned to work after their first MI and who were followed up by telephone at an average of 2.2 years after their baseline interview (1998-2000). The psychological demands scale of the Karasek Job Content Questionnaire was used to measure effort. Reward was measured with nine items from the original reward scale by Siegrist plus two proxy items. Exploratory and confirmatory factor analyses were used to test the theoretical structure of ERI. Using log-binomial regression models, we evaluated the association between ERI scales and psychological distress measured with the 14-item Psychiatric Symptom Index.

RESULTS

ERI scales and subscales demonstrated adequate internal consistencies. Exploratory factor analysis using oblique (promax) rotation yielded a three-factor solution with items representative of extrinsic effort (Factor 1) and reward subscales (Factors 2 and 3). Confirmatory factor analysis demonstrated a good fit with the data. The internal consistencies and discriminant validities of the ERI scales were satisfactory. Furthermore, effort, reward, and ERI ratio were significantly associated with psychological distress (adjusted prevalence ratio [PR] = 1.71, 95% confidence interval [CI] = 1.26-2.31; PR = 1.63, 95% CI = 1.16-2.29; and PR = 1.70, 95% CI = 1.17-2.47, respectively).

CONCLUSIONS

The psychometric properties of the ERI scales were generally reproduced among post-MI patients. The associations with psychological distress supported the criterion validity of the ERI scales in this population.

Effort-reward imbalance at work and recurrent coronary heart disease events: a 4-year prospective study of post-myocardial infarction patients

OBJECTIVE

Prospective studies have shown that effort-reward imbalance (ERI) at work is associated with the incidence of a first coronary heart disease (CHD) event. However, it is unknown whether ERI at work increases the risk of recurrent CHD events. The objective of this study was to determine whether ERI at work and its components (effort and reward) increase the risk of recurrent CHD in post-myocardial infarction (post-MI) workers.

METHODS

We carried out a prospective cohort study of 669 men and 69 women who returned to work after a first MI. ERI at work was assessed by telephone interview using validated scales of reward and psychological demands. The outcome was a composite of fatal CHD, nonfatal MI, and unstable angina. CHD risk factors were documented in medical files and by interview. The participants were followed up for a mean period of 4.0 years (1998-2005).

RESULTS

During the follow-up, 96 CHD events were documented. High ERI and low reward were associated with recurrent CHD (respective adjusted hazard ratios [HRs] = 1.75, 95% confidence interval [CI] = 0.99-3.08, and HR = 1.77, 95% CI = 1.16-2.71). There was a gender interaction showing stronger effects among women (respective adjusted HRs for high ERI and low reward: HR = 3.95, 95% CI = 0.93-16.79, and HR = 9.53, 95% CI = 1.15-78.68).

CONCLUSIONS

Post-MI workers holding jobs that involved ERI or low reward had increased risk of recurrent CHD.

Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review

OBJECTIVE

To determine the relative accuracy of clinic measurements and home blood pressure monitoring compared with ambulatory blood pressure monitoring as a reference standard for the diagnosis of hypertension.

DESIGN

Systematic review with meta-analysis with hierarchical summary receiver operating characteristic models. Methodological quality was appraised, including evidence of validation of blood pressure measurement equipment.

DATA SOURCES

Medline (from 1966), Embase (from 1980), Cochrane Database of Systematic Reviews, DARE, Medion, ARIF, and TRIP up to May 2010. Eligibility criteria for selecting studies Eligible studies examined diagnosis of hypertension in adults of all ages using home and/or clinic blood pressure measurement compared with those made using ambulatory monitoring that clearly defined thresholds to diagnose hypertension.

RESULTS

The 20 eligible studies used various thresholds for the diagnosis of hypertension, and only seven studies (clinic) and three studies (home) could be directly compared with ambulatory monitoring. Compared with ambulatory monitoring thresholds of 135/85 mm Hg, clinic measurements over 140/90 mm Hg had mean sensitivity and specificity of 74.6% (95% confidence interval 60.7% to 84.8%) and 74.6% (47.9% to 90.4%), respectively, whereas home measurements over 135/85 mm Hg had mean sensitivity and specificity of 85.7% (78.0% to 91.0%) and 62.4% (48.0% to 75.0%).

CONCLUSIONS

Neither clinic nor home measurement had sufficient sensitivity or specificity to be recommended as a single diagnostic test. If ambulatory monitoring is taken as the reference standard, then treatment decisions based on clinic or home blood pressure alone might result in substantial overdiagnosis. Ambulatory monitoring before the start of lifelong drug treatment might lead to more appropriate targeting of treatment, particularly around the diagnostic threshold.

Masked hypertension in the elderly: cross-sectional analysis of a population-based sample

BACKGROUND

Masked hypertension (MHT), defined as normal blood pressure (BP) at office associated with high BP at home, has been shown to be associated with an increased risk of vascular events. However, MHT is poorly known in the elderly, although this age segment is at high risk of hypertension-related vascular events. Our objectives were to assess frequency and determinants of MHT in the elderly.

METHODS

We studied MHT in a community-based sample of 1,814 participants aged 75 years or older, whose office BP and home BP measurements (HBPM) were both taken with the same device (Omron M6; Omron Healthcare, Kyoto, Japan).Hypertension was defined as a systolic BP (SBP) ≥ 140 mm Hg and/or a diastolic BP (DBP) ≥ 90 mm Hg for office BP, and SBP ≥ 135 mm Hg and/or DBP ≥ 85 mm Hg for HBPM.

RESULTS

Frequency of MHT was 16% in the overall sample and 41% in participants with a normal office BP. Multivariable analyses revealed that male subjects, >80 years of age, with diabetes, on antihypertensive medication, and with office SBP >120 mm Hg were independently associated with a higher risk of MHT.

CONCLUSION

MHT is frequent in the elderly and is associated with a high vascular profile. These results should encourage a more widespread use of home BP monitoring in this age segment.

Exaggerated blood pressure response to exercise--a new portent of masked hypertension

Masked hypertension (MHT) is a popular entity with increased risk of developing sustained hypertension, heart attack, stroke, and death. Subjects have normal blood pressure (BP) at office but elevated values at night so it is difficult to diagnose. Exaggerated blood pressure response to exercise (EBPR) is also a predictor of future hypertension. To investigate the relationship between these two entities, we evaluated 61 normotensive subjects with EBPR. The subjects underwent 24-h ambulatory blood pressure monitoring (ABPM). The prevalence of masked hypertension among subjects with EBPR was 41%. Body mass index (BMI), non-high density lipoprotein (HDL) cholesterol, diastolic blood pressure (DBP) at peak exercise and recovery, nondipping DBP pattern, and elevated early morning average BPs were associated with masked hypertension. In multivariate logistic regression analysis, the DBP measured at peak exercise was detected as an independent predictor of MHT in subjects with EBPR. Subjects with abnormally elevated BP during exercise are prone to MHT, necessitate medical assessment and close follow-up for hypertension.

Job strain and masked hypertension

OBJECTIVES

To determine whether psychosocial work characteristics are associated with the prevalence of masked hypertension in a population of white collar workers.

METHODS

White-collar workers were recruited from three public organizations. Blood pressure (BP) was measured at the workplace for manual measurements (mean of the first three readings taken by a trained assistant) followed by ambulatory measurements (mean of all subsequent readings taken during the working day). Masked hypertension (MH) was defined as manual BP <140/90 mm Hg, and ambulatory BP ≥135/85 mm Hg. Job strain was evaluated, using the quadrant method for exposure assessment, as well as alternative formulations.

RESULTS

BP measurements were obtained from 2,357 workers (80% participation, 61% women; mean age, 44 years). For men, being in the active group (high psychological demands and high decision latitude) was associated with MH (adjusted odds ratio, 2.07; 95% confidence interval, 1.30-3.31). No significant association with a higher prevalence of MH was observed in women.

CONCLUSION

MH is associated with job strain in men. Workers in "active" job situations may be more likely to have the condition.

Relationship of self-reported alcohol consumption to ambulatory blood pressure in a sample of healthy adults

BACKGROUND

Habitual alcohol consumption has shown positive associations with office blood pressure (BP). Less well established, however, is alcohol consumption's relationship to various measures of ambulatory BP (ABP) in healthy, normotensive persons.

METHODS

We investigated alcohol consumption's relationship to mean ABP, ABP variability, and the ABP arterial stiffness index in a sample of nonsmoking adults who were free of hypertension and cardiovascular disease (CVD; n = 157). Total alcohol consumption, intake of specific alcoholic beverages, and binge drinking were assessed by self-report. ABP was measured every 30 min for 24 h.

RESULTS

In multivariable-adjusted linear regression models, higher levels of total weekly alcohol consumption were associated with higher ABP. For those consuming 0, 1-2, and 3 or more alcoholic drinks per week, mean 24-h systolic ABP values were 112.2, 115.2, and 116.6 mm Hg, respectively (P = 0.05), and mean 24-h diastolic ABP values were 70.6, 71.9, and 74.2 mm Hg, respectively (P = 0.02). Beer and liquor consumption showed stronger positive associations with ABP than did wine consumption. Among nonbinge drinkers and binge drinkers, mean 24-h systolic ABP values were 113.3 and 118.6 mm Hg, respectively (P = 0.04) and mean 24-h diastolic ABP values were 71.3 and 75.0 mm Hg, respectively (P = 0.04). Alcohol consumption was not significantly related to ABP variability or the ABP arterial stiffness index.

CONCLUSION

Total habitual alcohol consumption, consumption of specific alcoholic drinks, and binge drinking are associated with higher mean ABP in healthy, normotensive adults.