Morning surge in blood pressure and blood pressure variability in Asia: Evidence and statement from the HOPE Asia Network

The control rate of hypertension across months of year and hours of day in a large real-world database

We investigated the control rate of hypertension across months of year and hours of day in a real-world database. The study participants were hypertensive patients from 142 community health centers across 16 districts in Shanghai, China, who measured their blood pressure with an automatic office blood pressure measurement platform between 2018 and 2023. The 343,400 hypertensive patients included 53.7% of women, and had average age of 70.2 (±8.1) years (range 50-90 years). For months of year, the control rate of hypertension was lowest in February and highest in August (51.9% vs 71.8%). For hours of day, the control rate of hypertension was lowest at 7:00 AM and highest at 12:00 PM (52.1% vs 76.0%). When the months of year and hour of day were considered together, the control rate was lowest at 7 AM in February (42.1%), and highest at 12 PM in July (86.8%). In 8516 patients who had uncontrolled blood pressure in the early morning and had their blood pressure also measured around noon, 45.7% had masked uncontrolled morning hypertension, with higher rates in spring and summer, and in women, those aged 50-69 years, and non-diabetic patients. The control rate of hypertension varies greatly across months of year and hours of day, suggesting that the evaluation of blood pressure control has to take into full consideration the measurement time in terms of months and hours.

The Option of Chronotherapy of Hypertension

The aim of the present paper is to explore the option of chronotherapy of hypertension and its effectiveness in blood pressure (BP) lowering compared with its standard daily treatment. The treatment of BP has gone through many different schemes over the years. From no treatment in the early 1930s, to step care, to multiple drug combinations, or to single daily drug combinations with 2-3 drugs, still BP is not well controlled in a significant number of patients. Recently, the role of the circadian rhythm in the treatment of hypertension has been tested by several studies comparing the evening versus the morning drug administration with no clear evidence of superiority of either mode of drug administration. However, in cases of morning surge of BP, nocturnal hypertension, and renal disease, the evening drug administration has been more effective than the morning drug administration, and thus, more preferable. In order to get a better perspective on this approach of hypertension treatment, a Medline search of the English literature was contacted between 2010 and 2023 using the terms BP control, circadian rhythm, morning drug administration, evening drug administration, and 38 pertinent papers were selected for analysis. Careful review of the selected papers showed that chronotherapy of hypertension is effective. However, the overall effectiveness of evening drug administration compared with the morning administration is not significantly more effective compared to the morning administration and more work is needed in this field.

Morning blood pressure surge and intracranial atherosclerotic plaque characteristics: a high-resolution magnetic resonance vessel wall imaging study

OBJECTIVE

To investigate the relationship between morning blood pressure surge (MBPS) and intracranial atherosclerotic plaque burden and vulnerability.

METHODS

A total of 267 ischaemic stroke patients were retrospectively analysed. Sleep-trough and prewaking MBPS were calculated from ambulatory blood pressure monitoring (ABPM). Plaque characteristics, including intraplaque haemorrhage (IPH), maximum wall thickness (max WT), and stenosis degree, were obtained from high-resolution MR vessel wall imaging (HR-vwMRI). Linear and logistic regression were used to detect the association.

RESULTS

Subjects with the top tertile of sleep-trough MBPS (≥15.1 mmHg) had a lower prevalence (9.1% vs. 19.6%, P = .029) of severe stenosis (≥70%) than others. Subjects within the top tertile of prewaking MBPS (≥7.6 mmHg) had a lower percentage of IPH (27.3% vs. 40.4%, P = .035) than others. After adjusting for stroke risk factors (age, sex, diabetes, hyperlipidaemia, hyperhomocysteinaemia, smoking, and family stroke history) and 24-h mean systolic blood pressure, 10 mmHg sleep-trough MBPS increment was associated with 0.07mm max WT reduction, and the top tertile MBPS group was associated with a lower chance of severe stenosis (odd ratio = 0.407, 95% CI, 0.175-0.950). Additionally, an increased prewaking MBPS is associated with a lower incidence of IPH, with OR = 0.531 (95% CI, 0.296-0.952). Subgroup analysis demonstrated that the positive findings could only be seen in non-diabetic subjects.

CONCLUSION

Increment of MBPS is negatively associated with intracranial atherosclerotic plaque burden and vulnerability, and this relationship remains significant in the non-diabetic subgroup.

ADVANCES IN KNOWLEDGE

This study provided evidence that MBPS was associated with the intracranial atherosclerotic plaque burden and vulnerability on HR-vwMRI.

Agreement Between Guideline Thresholds Using an "All-in-One" Device to Measure Office, Home, and Ambulatory Blood Pressures

BACKGROUND

Blood pressure (BP) thresholds for diagnosing and managing hypertension vary for office, home, and ambulatory readings, and between guideline documents. This analysis determined corresponding office, home, and ambulatory BP thresholds using baseline data from the HI-JAMP (Home-Activity Information and Communication Technology-Based Japan Ambulatory Blood Pressure Monitoring Prospective) study, which used a validated "all-in-one" BP monitoring device.

METHODS AND RESULTS

Data from 2322 treated patients with hypertension who underwent office BP measurement, then 24-hour ambulatory BP monitoring, then home BP monitoring for 5 days were analyzed. Corresponding BP thresholds for office, home, and ambulatory measurements were determined using Deming regression. Values equivalent to office systolic BP (SBP) of 120 and 140 mm Hg were as follows: 115.9 and 127.7 mm Hg for 24-hour ambulatory SBP; 120.8 and 134.0 mm Hg for daytime ambulatory SBP; 104.9 and 117.9 mm Hg for nighttime ambulatory SBP; and 122.0 and 134.2 mm Hg for morning-evening average home SBP. Deming regression showed that morning-evening average home SBP and daytime ambulatory SBP were almost the same (home SBP=0.99×daytime ambulatory SBP+0.27 mm Hg; r=0.627). Morning-evening average home SBP values of 120 and 135 mm Hg were equivalent to daytime ambulatory SBP values of 119.1 and 133.9 mm Hg, respectively. A home SBP threshold of 130 mm Hg corresponded to 24-hour and nighttime ambulatory SBP values of 123.5 and 113.6 mm Hg, whereas a home SBP threshold of 135 mm Hg corresponded to 24-hour and nighttime ambulatory SBP values of 128.0 and 119.2 mm Hg.

CONCLUSIONS

Ambulatory and home BP thresholds in this analysis were similar to those proposed by existing guidelines. The similarity between the home BP and daytime ambulatory BP thresholds was a clinically relevant finding.

The Role of the Circadian Rhythm in Dyslipidaemia and Vascular Inflammation Leading to Atherosclerosis

Cardiovascular diseases (CVD) are among the leading causes of death worldwide. Many lines of evidence suggest that the disturbances in circadian rhythm are responsible for the development of CVDs; however, circadian misalignment is not yet a treatable trait in clinical practice. The circadian rhythm is controlled by the central clock located in the suprachiasmatic nucleus and clock genes (molecular clock) located in all cells. Dyslipidaemia and vascular inflammation are two hallmarks of atherosclerosis and numerous experimental studies conclude that they are under direct influence by both central and molecular clocks. This review will summarise the results of experimental studies on lipid metabolism, vascular inflammation and circadian rhythm, and translate them into the pathophysiology of atherosclerosis and cardiovascular disease. We discuss the effect of time-respected administration of medications in cardiovascular medicine. We review the evidence on the effect of bright light and melatonin on cardiovascular health, lipid metabolism and vascular inflammation. Finally, we suggest an agenda for future research and recommend on clinical practice.

Prevalence of hypertension among travelers and stability of blood pressure control during travel: a cross-sectional descriptive study and prospective cohort study

BACKGROUND

Hypertension is a common and important risk factor for cardiovascular disease which is the leading cause of death among the general population and travelers. Data on hypertension among travelers are very limited due to the scarcity of research reports in this specific population. Therefore, this study aimed to determine the prevalence of hypertension among adult travelers and the stability of blood pressure control during international trips using a mobile automated blood pressure device.

METHODS

This was a cross-sectional descriptive study conducted at the Thai travel clinic, Hospital for Tropical Diseases in Bangkok, Thailand. All adult travelers completed a questionnaire which included demographic data, medical history, medication use, trip characteristics and hypertension awareness and knowledge. Standard two time blood pressure measurements were performed at the clinic to detect possible undiagnosed hypertension. Travelers with pre-existing hypertension were also invited to monitor their blood pressure level before and during their trip for a total of 14 days by using an automated blood pressure device and reporting the readings back to the study team.

RESULT

During July and October 2022, a total of 1,359 adult travelers visited the Thai Travel Clinic before their international trip. The overall prevalence of hypertension was 28.8%, including those with pre-existing hypertension (6.7%) and those with newly diagnosed hypertension (22.2%). Travelers with newly diagnosed hypertension were significantly younger than travelers with pre-existing hypertension (38.5 years vs. 55.6 years, p < 0.001). Eleven travelers agreed to monitor their blood pressure, Most (90.9%, 10/11) had stable blood pressure control during their trip. One participant had > 10 mmHg higher blood pressure during the trip, however this was not clinically significant. All participants remained well, and acute symptoms secondary to hypertension were not reported.

CONCLUSION

Up to 28.8% of adult travelers seen in pre-travel consultations had hypertension. Most of them were unaware of their blood pressure condition. Vital signs including blood pressure should be evaluated in all pre-travel visits in order to prevent undiagnosed severe hypertension that might lead to hypertensive crisis.

The relationship between vitamin D and short-term blood pressure variability

OBJECTIVES

This study aimed to evaluate the relationships between serum levels of 25-hydroxyvitamin D (25(OH)D) and short-term blood pressure variability (BPV) in newly diagnosed hypertensive patients.

METHODS

One hundred newly diagnosed patients with stage one essential hypertension were included and divided into two groups, the deficient and non-deficient groups, according to their 25(OH)D level. The blood pressure was recorded automatically by a portable ambulatory blood pressure monitor for 24 h.

RESULTS

In the present study, there was no significant relationship between vitamin D levels and short-term BPV or other parameters derived from ambulatory blood pressure monitoring (ABPM) (P > 0.05). Age (r = 0.260, P = 0.009), serum phosphorus (r = 0.271, P = 0.007), and cholesterol levels (r = 0.310, P = 0.011) were positively correlated with 25(OH)D levels, while glomerular filtration rate (r = -0.232, P = 0.021) negatively correlated with vitamin D levels. There was no crude or adjusted relationship between the levels of 25(OH)D and any parameters of ABPM in multiple linear regression analysis.

CONCLUSION

Although the relationship between vitamin D levels and cardiovascular diseases has been confirmed, vitamin D deficiency does not cause an increase in cardiovascular risk by influencing the short-term BPV or other parameters derived from ABPM.

Standardized home blood pressure monitoring: Rationale behind the 722 protocol

Home blood pressure (HBP) has been recognized as a prognostic predictor for cardiovascular events, and integrated into the diagnosis and management of hypertension. With increasing accessibility of oscillometric blood pressure devices, HBP monitoring is easy to perform, more likely to obtain reliable estimation of blood pressures, and feasible to document long-term blood pressure variations, compared to office and ambulatory blood pressures. To obtain reliable HBP estimates, a standardized HBP monitoring protocol is essential. A consensus regarding the optimal duration and frequency of HBP monitoring is yet to be established. Based on the current evidence, the "722" protocol, which stands for two measurements on one occasion, two occasions a day (morning and evening), and over a consecutive of 7 days, is most commonly used in clinical studies and recommended in relevant guidelines and consensus documents. HBP monitoring based on the "722" protocol fulfills the minimal requirement of blood pressure measurements to achieve agreement of blood pressure classifications defined by office blood pressures and to predict cardiovascular risks. In the Taiwan HBP consensus, the frequency of repeating the "722" protocol of HBP monitoring according to different scenarios of hypertension management, from every 2 weeks to 3 months, is recommended. It is reasonable to conclude that the "722" protocol for HBP monitoring is clinically justified and can serve as a basis for standardized HBP monitoring.

Identification of sodium homeostasis genes in Camelus bactrianus by whole transcriptome sequencing

Salt dietary intake is tightly coupled to human health, and excessive sodium can cause strokes and cardiovascular diseases. Research into the renal medulla of camels exhibiting high salt resistance may aid identification of the mechanisms governing resistance to high salinity. In this study, we used RNA sequencing (RNA‐seq) to show that in the renal medulla of camels under salt stress, 22 mRNAs, 2 long noncoding RNAs (lncRNAs), and 31 microRNAs (miRNAs) exhibited differential expression compared with the free salt‐intake diet group. Using fluorescence in situ hybridization and dual‐luciferase reporter assays, we demonstrated that the lncRNA LNC003834 can bind miRNA‐34a and thereby relieve suppression of the salt‐absorption‐inhibiting SLC14A1 mRNA from miRNA‐34a, suggesting that the above lncRNA‐miRNA‐mRNA act as competing endogenous RNAs (ceRNAs). We subsequently performed short hairpin RNA and small RNA interference and reactive oxygen species (ROS) detection assays to show that SLC6A1, PCBP2, and PEX5L can improve the antioxidation capacity of renal medulla cells of camel by decreasing ROS levels. Our data suggest that camels achieve sodium homeostasis through regulating the expression of salt‐reabsorption‐related genes in the renal medulla, and this involves ceRNAs (SLC14A1 mRNA, LNC003834, and miRNA‐34a) and antioxidant genes (SLC6A1, PCBP2, and PEX5L). These data may assist in the development of treatments for diseases induced by high salt diets.

Effects of isometric leg training on ambulatory blood pressure and morning blood pressure surge in young normotensive men and women

Despite the reported association between diurnal variations in ambulatory blood pressure (BP) and elevated cardiovascular disease risk, little is known regarding the effects of isometric resistance training (IRT), a practical BP-lowering intervention, on ambulatory BP and morning BP surge (MBPS). Thus, we investigated whether (i) IRT causes reductions in ambulatory BP and MBPS, in young normotensives, and (ii) if there are any sex differences in these changes. Twenty normotensive individuals (mean 24-h SBP = 121 ± 7, DBP = 67 ± 6 mmHg) undertook 10-weeks of bilateral-leg IRT (4 × 2-min/2-min rest, at 20% maximum voluntary contraction (MVC) 3 days/week). Ambulatory BP and MBPS (mean systolic BP (SBP) 2 h after waking minus the lowest sleeping 1 h mean SBP) was measures pre- and post-training. There were significant reductions in 24-h ambulatory SBP in men (− 4 ± 2 mmHg, P = 0.0001) and women (− 4 ± 2 mmHg, P = 0.0001) following IRT. Significant reductions were also observed in MBPS (− 6 ± 8 mmHg, p = 0.044; − 6 ± 7 mmHg, P = 0.019), yet there were no significant differences between men and women in these changes, and 24-h ambulatory diastolic BP remained unchanged. Furthermore, a significant correlation was identified between the magnitude of the change in MBPS and the magnitude of changes in the mean 2-h SBP after waking for both men and women (men, r = 0.89, P = 0.001; women, r = 0.74, P = 0.014). These findings add further support to the idea that IRT, as practical lifestyle intervention, is effective in significantly lowering ambulatory SBP and MBPS and might reduce the incidence of adverse cardiovascular events that often occur in the morning.

The Correlation Between ABPM Parameters and Left Ventricular Hypertrophy in Pediatric Essential Hypertension

OBJECTIVE

To explore the association of dipping pattern and blood pressure load with left ventricular hypertrophy (LVH) in pediatric essential hypertension.

MATERIALS AND METHODS

Through an echocardiography monitor and an ambulatory blood pressure monitor of 425 children and adolescents diagnosed with essential hypertension with no treatment received, we identified 140 cases of LVH. Grouping patients according to LVH (LVH, N = 140; n-LVH, N = 285), we further evaluated their ambulatory blood pressure monitoring (ABPM) parameters by comparing dipping patterns between groups. A multivariable logistic regression analysis was used to determine the effect of blood pressure load on LVH.

RESULTS

No significant difference was found in systolic or diastolic blood pressure dipping patterns between groups (P = 0.161, P = 0.139). However, compared to the n-LVH group, the LVH group presented significant elevated nighttime systolic blood pressure (SBP) (P < 0.05), while nighttime DBP remained stable (P = 0.391), resulting in higher daytime and nighttime SBP loads, higher nighttime DBP load, and higher 24-h SBP load (P < 0.05). Notably, our multivariable logistic regression has shown that this trend of 24-h SBP load acts independently as a critical risk factor for LVH.

CONCLUSION

Collectively, we observed a correlation between BP load and LVH in pediatric hypertension. Our data demonstrated that SBP load has a more significant weight in LVH progression, and 24-h SBP load, in particular, acts as a critical early prognostic parameter for LVH in pediatric hypertension.

Association of morning blood pressure surge with chronic kidney disease progression in patients with chronic kidney disease and hypertension

Blood pressure (BP) usually rise from being asleep to awake, which is named the morning blood pressure surge (MBPS). Researches have reported that elevated MBPS was related with CV events, incident CKD in hypertensive patients. However, there have been no studies that have investigated the association between MBPS and renal or heart outcomes in patients with CKD and hypertension, in these patients, the MBPS is much lower because of high prevalence of night hypertension and reduced BP dipping. In this prospective two-center observational study, we enrolled patients with CKD and hypertension and the 24 h ambulatory blood pressure monitoring (ABPM) was conducted in all patients. Time to total mortality, CKD progression and CV events was recorded; Finally, a total of 304 patients were enrolled and 94 (30.9%) of them had elevated MBPS. After a follow-up for median 30 months, 23 (7.6%), 34 (11.2%), and 95 (31.3%) patients occurred death, CKD progression and new-onset CV events, respectively. The Cox regression analysis suggested the elevated MBPS was a strong predictor of CKD progression (HR 2.35, 95%CI 1.2 -4.63, p = .013), independent of morning BP, while no associations were found between elevated MBPS and CV events (HR 1.02, 95%CI 0.66 -1.57), as well as death (HR 1.08, 95%CI 0.46 -2.55). In conclusion, we provided the first evidence that elevated MBPS was an important risk factor of CKD progression in patients with CKD and hypertension. Appropriate evaluation and management of MBPS may be helpful to postpone CKD progression.

Differential Effect of the Morning Blood Pressure Surge on Prognoses Between Heart Failure With Reduced and Preserved Ejection Fractions

BACKGROUND

Rising blood pressure (BP) in the morning, known as the morning BP surge (MBPS), is known to pose a risk for cardiovascular events in hypertensive individuals. It was not known whether the MBPS was associated with a worse prognosis in patients with heart failure (HF) with a reduced (HFrEF) or preserved (HFpEF) ejection fraction.Methods and Results:We performed a prospective, observational cohort study of hospitalized HF patients who underwent ambulatory BP monitoring (ABPM). The MBPS was calculated by subtracting the mean systolic BP (SBP) during the 1 h that included the lowest sleep BP from the mean SBP during the 2 h after waking. The MBPS group was defined as the top decile of MBPS (>40 mmHg). In all, 456 hospitalized HF patients (mean [±SD] age 68±13 years, 63.9% male) were followed-up for a median of 1.67 years. There were 90 events (16.3 per 100 person-years) of the composite outcome (all-cause mortality and worsening HF) in the HFrEF group, compared with 53 events (19.6 per 100 person-years) in the HFpEF group. Multivariate Cox regression analysis showed that MBPS was a significant predictor of outcome (hazard ratio 2.84, 95% confidence interval 1.58-5.10, P<0.01) in the HFrEF but not HFpEF group.

CONCLUSIONS

MBPS was found to be a novel predictor of worsening HF in patients with HFrEF.

Development and validation of a model to estimate the risk of acute ischemic stroke in geriatric patients with primary hypertension

Objectives

This study aimed to construct and validate a prediction model of acute ischemic stroke in geriatric patients with primary hypertension.

Methods

This retrospective file review collected information on 1367 geriatric patients diagnosed with primary hypertension and with and without acute ischemic stroke between October 2018 and May 2020. The study cohort was randomly divided into a training set and a testing set at a ratio of 70 to 30%. A total of 15 clinical indicators were assessed using the chi-square test and then multivariable logistic regression analysis to develop the prediction model. We employed the area under the curve (AUC) and calibration curves to assess the performance of the model and a nomogram for visualization. Internal verification by bootstrap resampling (1000 times) and external verification with the independent testing set determined the accuracy of the model. Finally, this model was compared with four machine learning algorithms to identify the most effective method for predicting the risk of stroke.

Results

The prediction model identified six variables (smoking, alcohol abuse, blood pressure management, stroke history, diabetes, and carotid artery stenosis). The AUC was 0.736 in the training set and 0.730 and 0.725 after resampling and in the external verification, respectively. The calibration curve illustrated a close overlap between the predicted and actual diagnosis of stroke in both the training set and testing validation. The multivariable logistic regression analysis and support vector machine with radial basis function kernel were the best models with an AUC of 0.710.

Conclusion

The prediction model using multiple logistic regression analysis has considerable accuracy and can be visualized in a nomogram, which is convenient for its clinical application.

Can Systemic Immune-Inflammation Index Detect the Presence of Exxaggerated Morning Blood Pressure Surge in Newly Diagnosed Treatment-Naive Hypertensive Patients?

Background: The exaggerated morning blood pressure surge (MS) is associated with target organ damage and cardiovascular events. Systemic immune-inflammation index (SII) has been detected as a useful marker in tumors and cardiovascular diseases. The role of inflammation in the pathogenesis of hypertension is a well-known issue. We aimed to investigate whether there is an association between SII and exaggerated MS in newly diagnosed treatment-naive hypertensive patients.Material and Methods: In total, 343 newly diagnosed in clinical and 24-h ambulatory blood pressure (BP) monitoring treatment-naive hypertensive patients were included in this study. Morning surge was defined as the difference between morning BP, which was the mean of BP during 2 h after wake-up, and the lowest BP, which was the mean of three lowest BP during nighttime. A cutoff value of 52.1 mmHg was used to discriminate the high- and low value MS groups. SII was calculated based on neutrophil, platelet, and lymphocyte counts.Results: Neutrophil, platelet, SII, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) were higher, whereas lymphocyte counts were lower in the high-value MS than the low-value MS. These indices were all independently associated with exaggerated MS and SII was superior to all other indices for detecting the presence of exaggerated MS. SII was moderately correlated with morning BP surge (r: 0.489, p < 0.0001).Conclusion: SII was higher in patients with exaggerated MS and was independently associated with exaggerated MS. Furthermore, SII might be a better indicator than platelet, neutrophil, lymphocyte, NLR, and PLR for the presence of exaggerated MS.

Telmisartan use and risk of dementia in type 2 diabetes patients with hypertension: A population-based cohort study

BACKGROUND

Angiotensin receptor blockers (ARBs) may have protective effects against dementia occurrence in patients with hypertension (HTN). However, whether telmisartan, an ARB with peroxisome proliferator-activated receptor γ (PPAR-γ)-modulating effects, has additional benefits compared to other ARBs remains unclear.

METHODS AND FINDINGS

Between 1997 and 2013, 2,166,944 type 2 diabetes mellitus (T2DM) patients were identified from the National Health Insurance Research Database of Taiwan. Patients with HTN using ARBs were included in the study. Patients with a history of stroke, traumatic brain injury, or dementia were excluded. Finally, 65,511 eligible patients were divided into 2 groups: the telmisartan group and the non-telmisartan ARB group. Propensity score matching (1:4) was used to balance the distribution of baseline characteristics and medications. The primary outcome was the diagnosis of dementia. The secondary outcomes included the diagnosis of Alzheimer disease and occurrence of symptomatic ischemic stroke (IS), any IS, and all-cause mortality. The risks between groups were compared using a Cox proportional hazard model. Statistical significance was set at p < 0.05. There were 2,280 and 9,120 patients in the telmisartan and non-telmisartan ARB groups, respectively. Patients in the telmisartan group had a lower risk of dementia diagnosis (telmisartan versus non-telmisartan ARBs: 2.19% versus 3.20%; HR, 0.72; 95% CI, 0.53 to 0.97; p = 0.030). They also had lower risk of dementia diagnosis with IS as a competing risk (subdistribution HR, 0.70; 95% CI, 0.51 to 0.95; p = 0.022) and with all-cause mortality as a competing risk (subdistribution HR, 0.71; 95% CI, 0.53 to 0.97; p = 0.029). In addition, the telmisartan users had a lower risk of any IS (6.84% versus 8.57%; HR, 0.79; 95% CI, 0.67 to 0.94; p = 0.008) during long-term follow-up. Study limitations included potential residual confounding by indication, interpretation of causal effects in an observational study, and bias caused by using diagnostic and medication codes to represent real clinical data.

CONCLUSIONS

The current study suggests that telmisartan use in hypertensive T2DM patients may be associated with a lower risk of dementia and any IS events in an East-Asian population.

Chronotherapy for morning blood pressure surge in hypertensive patients: a systematic review and meta-analysis

BACKGROUND

The morning blood pressure surge (MBPS) is related to an exaggerated risk of cardiovascular diseases and mortality. With increasing attention on circadian change in blood pressure and extensive use of ambulatory blood pressure monitoring (ABPM), chronotherapy that administration of medication according to biological rhythm, is reported to improve cardiovascular outcomes. The aim of this study is to evaluate the influence of chronotherapy of antihypertensive drugs upon MBPS in hypertensive patients.

METHODS

A search strategy was applied in Ovid MEDLINE, EMBASE, Cochrane (Wiley) CENTRAL Register of Controlled Trials, Cochrane Database of Systematic Reviews, and the Chinese Biomedical literature database. No language and date restrictions. Randomized controlled trials (RCT) assessing the efficacy of evening and morning administration of the same medications in adult patients with primary hypertension were included.

RESULTS

A total of ten trials, comprising 1724 participants with a mean age of 61 and 51% female, were included in this study. Combined analysis observed significant reduction of MBPS (- 5.30 mmHg, 95% CI - 8.80 to - 1.80), night-time SBP (- 2.29 mmHg, 95% CI - 4.43 to - 0.15), night-time DBP (- 1.63 mmHg, 95 %CI - 3.23 to - 0.04) and increase in night blood pressure dipping (3.23%, 95% CI 5.37 to 1.10) in evening dosage compared with traditional morning dosage of blood pressure-lowering drugs. No significant difference was found in the incidence of overall adverse effects (RR 0.65, 95% CI 0.30 to 1.41) and withdrawal due to adverse effects (RR 0.95, 95% CI 0.53 to 1.71).

CONCLUSIONS

Our study suggested that evening administration of antihypertensive medications exerted better blood pressure-lowering effect on MBPS compared with conventional morning dosage. Safety assessment also indicated that the evening regimen did not increase the risk of adverse events. However, endpoint studies need to be carried out to confirm the significance and feasibility of this treatment regimen in clinical practice.

Sex-Dependent Association Between Early Morning Ambulatory Blood Pressure Variations and Acute Mountain Sickness

Background

Acute high altitude (HA) exposure elicits blood pressure (BP) responses in most subjects, and some of them suffer from acute mountain sickness (AMS). However, a 24-h ambulatory BP (ABP) change and the correlation with the occurrence of AMS in different sexes are still unclear.

Objectives

This prospective study aimed to investigate HA induced BP responses in males and females and the relationship between AMS and 24-h ABP.

Methods

Forty-six subjects were matched according to demographic parameters by propensity score matching with a ratio of 1:1. All the subjects were monitored by a 24-h ABP device; the measurement was one period of 24 h BP. 2018 Lake Louise questionnaire was used to evaluate AMS.

Results

Both the incidence of AMS (14 [60.9%] vs. 5 [21.7%], P = 0.007) and headache (18 [78.3%] vs. 8 [34.8%], P = 0.003) were higher in females than in males. All subjects showed an elevated BP in the early morning [morning systolic BP (SBP), 114.72 ± 13.57 vs. 120.67 ± 11.10, P = 0.013]. The elevation of morning SBP variation was more significant in females than in males (11.95 ± 13.19 vs. −0.05 ± 14.49, P = 0.005), and a higher morning BP surge increase (4.69 ± 18.09 vs. −9.66 ± 16.96, P = 0.005) was observed after acute HA exposure in the female group. The increase of morning SBP was associated with AMS occurrence (R = 0.662, P < 0.001) and AMS score (R = 0.664, P = 0.001). Among the AMS symptoms, we further revealed that the incidence (R = 0.786, P < 0.001) and the severity of headache (R = 0.864, P < 0.001) are closely correlated to morning SBP.

Conclusions

Our study demonstrates that females are more likely to suffer from AMS than males. AMS is closely associated with elevated BP in the early morning period, which may be correlated to higher headache incidence in subjects with higher morning SBP.

Hypertension and stroke in Asia: A comprehensive review from HOPE Asia

Stroke is the primary cause of disability and vascular death worldwide, including Asia. Asian characteristics that differ from the West lead to higher stroke incidence. Stroke epidemiology studies in Asia have shown varying levels of mortality, incidence, prevalence, and burden of disease. Hypertension is the most prevalent risk factor found in Asia. Besides ethnicity that is associated with stroke incidence, both systolic blood pressure, diastolic blood pressure, and blood pressure variability are positively correlated with stroke incidence. Post-stroke cognitive impairment is one of the sequelae that affect one-third of stroke survivors and has become a significant public health concern that is often neglected despite its increasing prevalence. Therefore, it is very important to prevent recurrence by treating stroke optimally and effectively. Increasing awareness and treatment adherence to hypertension, the leading risk factor for stroke, became the main goal in several countries in Asia.

2020 Consensus Statement of the Taiwan Hypertension Society and the Taiwan Society of Cardiology on Home Blood Pressure Monitoring for the Management of Arterial Hypertension

To facilitate the applications of home blood pressure (HBP) monitoring in clinical settings, the Taiwan Hypertension Society and the Taiwan Society of Cardiology jointly put forward the Consensus Statement on HBP monitoring according to up-to-date scientific evidence by convening a series of expert meetings and compiling opinions from the members of these two societies. In this Consensus Statement as well as recent international guidelines for management of arterial hypertension, HBP monitoring has been implemented in diagnostic confirmation of hypertension, identification of hypertension phenotypes, guidance of anti-hypertensive treatment, and detection of hypotensive events. HBP should be obtained by repetitive measurements based on the " 722 " principle, which is referred to duplicate blood pressure readings taken per occasion, twice daily, over seven consecutive days. The " 722" principle of HBP monitoring should be applied in clinical settings, including confirmation of hypertension diagnosis, 2 weeks after adjustment of antihypertensive medications, and at least every 3 months in well-controlled hypertensive patients. A good reproducibility of HBP monitoring could be achieved by individuals carefully following the instructions before and during HBP measurement, by using validated BP devices with an upper arm cuff. Corresponding to office BP thresholds of 140/90 and 130/80 mmHg, the thresholds (or targets) of HBP are 135/85 and 130/80 mmHg, respectively. HBP-based hypertension management strategies including bedtime dosing (for uncontrolled morning hypertension), shifting to drugs with longer-acting antihypertensive effect (for uncontrolled evening hypertension), and adding another antihypertensive drug (for uncontrolled morning and evening hypertension) should be considered. Only with the support from medical caregivers, paramedical team, or tele- monitoring, HBP monitoring could reliably improve the control of hypertension.

Chronobiological patterns of acute aortic dissection in central China

BACKGROUND

Acute aortic dissection (AAD) is a life-threatening emergency with poor clinical outcomes. Understanding the chronological patterns of AAD onset would be helpful for identifying the triggers of AAD and preventing this catastrophic event.

METHODS

We collected data from 2048 patients diagnosed with AAD at Tongji Hospital (Wuhan, China) from 2011 to 2018. The χ2 test was used to determine whether a specific period had significantly different seasonal/weekly distributions from other periods. Fourier models were used to analyse the rhythmicity in monthly/circadian distribution.

RESULTS

The mean age was 53.4±10.9 years, and 1161 patients (56.7%) were under 55 years. One thousand six hundred fifty-seven patients (80.9%) were male, and 935 cases (45.7%) were type A dissections. The proportions of patients with comorbid hypertension/diabetes were 60.3% (1234 cases) and 1.8% (36 cases), respectively. A peak was identified in colder periods (winter/December) and a trough in warmer periods (summer/June). No significant variation was observed in weekly distribution. Fourier analysis showed a statistically significant circadian variation (p<0.001) with a nocturnal trough in 2:00-3:00, a morning peak in 9:00-10:00, and an afternoon peak in 16:00-17:00. Subgroup analyses identified circadian rhythmicity in all subgroups except for the female group and younger group (younger than 55 years).

CONCLUSION

Our results confirmed that the onset of AAD exhibits significant seasonal, monthly and circadian patterns. Patients with AAD with different Stanford-type dissections, sexes, ages and hypertension statuses could present different circadian variations. These findings may provide novel perspectives for identifying the triggers of AAD and better preventing this catastrophic event.

Increasing incidence of macular edema in excessive morning blood pressure surge in patients with retinal vein occlusion

Morning blood pressure surge (MBPS) had been known to be associated with hypertensive target organ injury and vascular events. Retinal vein occlusion (RVO) is also known to be related with underlying cardiovascular risk factors. This study investigated the effect of MBPS on patients with RVO. In total, 76 patients with RVO who had undergone systemic cardiovascular examination including a 24-hour ambulatory blood pressure monitoring, carotid artery intima media thickness, and pulse wave velocity were evaluated between January 2015 and February 2019. The MBPS was calculated as follows: mean systolic blood pressure measured over two hours after awakening minus mean systolic blood pressure measured during the one hour that included the lowest sleep blood pressure. Macular edema was significantly more prevalent in the MBPS group compared with the non-MBPS group. After adjusting for confounding factors, multivariate regression analyses revealed that MBPS independently predicted macular edema in patients with RVO [Odds ratio 4.75, 95% confidence interval 1.136–16.6, p = 0.015]. In conclusion, evaluating blood pressure patterns, especially MBPS, using 24-hour ambulatory blood pressure monitoring may be useful for assessing and predicting ophthalmologic outcome and may facilitate better blood pressure control in patients with RVO.

Current status of ambulatory blood pressure monitoring in Asian countries: A report from the HOPE Asia Network

Ambulatory blood pressure monitoring (ABPM) can measure 24-hour blood pressure (BP), including nocturnal BP and diurnal variations. This feature of ABPM could be of value in Asian populations for preventing cardiovascular events. However, no study has yet investigated regarding the use of ABPM in actual clinical settings in Asian countries/regions. In this study, 11 experts from 11 countries/regions were asked to answer questionnaires regarding the use of ABPM. We found that its use was very limited in primary care settings and almost exclusively available in referral settings. The indications of ABPM in actual clinical settings were largely similar to those of home BP monitoring (HBPM), that is, diagnosis of white-coat or masked hypertension and more accurate BP measurement for borderline clinic BP. Other interesting indications, such as nighttime BP patterns, including non-dipper BP, morning BP surge, and BP variability, were hardly adopted in daily clinical practice. The use of ABPM as treatment guidance for detecting treated but uncontrolled hypertension in the Asian countries/regions didn't seem to be common. The barrier to the use of ABPM was primarily its availability; in referral centers, patient reluctance owing to discomfort or sleep disturbance was the most frequent barrier. ABPM use was significantly more economical when it was reimbursed by public insurance. To facilitate ABPM use, more simplified indications and protocols to minimize discomfort should be sought. For the time being, HBPM could be a reasonable alternative.

Target blood pressure and control status in Asia

It is widely accepted that hypertension constitutes a significant cardiovascular risk factor and that treating high blood pressure (BP) effectively reduces cardiovascular risk. An important issue in Asia is not just the high prevalence of hypertension, particularly in some countries, but also the low level of awareness and treatment rates in many regions. The 2017 update of the American College of Cardiology/American Heart Association hypertension guidelines raised the question about which BP threshold should be used to diagnose and treat hypertension. Although there is a theoretical rationale for a stricter BP criterion in Asia given the ethnic-specific features of hypertension in the region, the majority of countries in Asia have retained a diagnostic BP threshold of ≥140/90 mm Hg. Although lowering thresholds might make theoretical sense, this would increase the prevalence of hypertension and also markedly reduce BP control rates. In addition, there are currently no data from robust randomized clinical trials of the benefits of the lower targets in preventing cardiovascular disease and reducing cardiovascular risk, particularly in high-risk patients and especially for Asian populations. There is also no defined home BP treatment target level for an office BP treatment target of 130/80 mm Hg. However, in this regard, in the interim, lifestyle modifications, including reducing body weight and salt intake, should form an important part of hypertension management strategies in Asia, while studies on treating at lower BP threshold level in Asians and getting to lower BP targets will be helpful to inform and optimize the management of hypertension in the region.

Key Points of the 2019 Japanese Society of Hypertension Guidelines for the Management of Hypertension

The new 2019 Japanese Society of Hypertension (JSH) guidelines for the management of hypertension are now available; these update the previous guidelines published in 2014. The primary objective of the guideline is to provide all healthcare professionals with a standard management strategy and appropriate antihypertensive treatments to prevent hypertension-related target organ damage and cardiovascular events. The major changes in the new guideline relate to the definition of normal blood pressure (BP) and target BP. The terms 'normal BP' and 'high normal BP' used in the JSH 2014 guidelines are replaced with terms 'high normal BP' and 'elevated BP,' respectively. There was no change to the office BP diagnostic threshold for hypertension (140/90 mmHg). Recommended target office and home BP values for patients with hypertension aged <75 years and/or high-risk patients are <130/80 mmHg and <125/75 mmHg, respectively. Corresponding targets for elderly patients with hypertension (age≥75 years) are 140/90 and 135/85 mmHg, respectively. The goal is that these changes will contribute to reducing cardiovascular events, especially stroke and heart failure, in Japan. The dissemination of the JSH 2019 guidelines and implementation of a home BP-based approach by all general practitioners in Japan might be facilitated by digital hypertension management using health information technology.