Blood Pressure Measurement and Treatment Decisions

Masked phenomenon: renal and cardiovascular complications; review and updates

BACKGROUND

In the in-clinic blood pressure (BP) recording setting, a sizable number of individuals with normal BP and approximately 30% of patients with chronic renal disease (CKD) exhibit elevated outpatient BP records. These individuals are known as masked hypertension (MHTN), and when they are on antihypertensive medications, but their BP is not controlled, they are called masked uncontrolled hypertension (MUHTN). The masked phenomenon (MP) (MHTN and MUHTN) increases susceptibility to end-organ damage (a two-fold greater risk for cardiovascular events and kidney dysfunction). The potential extension of the observed benefits of MP therapy, including a reduction in end-organ damage, remains questionable.

AIM AND METHODS

This review aims to study the diagnostic methodology, epidemiology, pathophysiology, and significance of MP management in end-organs, especially the kidneys, cardiovascular system, and outcomes. To achieve the purposes of this non-systematic comprehensive review, PubMed, Google, and Google Scholar were searched using keywords, texts, and phrases such as masked phenomenon, CKD and HTN, HTN types, HTN definition, CKD progression, masked HTN, MHTN, masked uncontrolled HTN, CKD onset, and cardiovascular system and MHTN. We restricted the search process to the last ten years to search for the latest updates.

CONCLUSION

MHTN is a variant of HTN that can be missed if medical professionals are unaware of it. Early detection by ambulatory or home BP recording in susceptible individuals reduces end-organ damage and progresses to sustained HTN. Adherence to the available recommendations when dealing with masked phenomena is justifiable; however, further studies and recommendation updates are required.

Unique characteristics of Asians with hypertension: what is known and what can be done?

Hypertension remains the leading modifiable risk factor for cardiovascular disease worldwide. Over the past 30 years, the prevalence of hypertension has been increasing in East and Southeast Asia to a greater extent as compared with other Western countries. Asians with hypertension have unique characteristics. This can be attributed to increased impact of obesity on Asians with hypertension, excessive salt intake and increased salt sensitivity, loss of diurnal rhythm in blood pressure and primary aldosteronism. The impact of hypertension on cardiovascular (particularly strokes) and chronic kidney disease is greater in Asians. These unique characteristics underpinned by the diverse socioeconomic backgrounds pose its own challenges in the diagnosis and management of hypertension in Asia.

Factors influencing the efficacy and safety of esaxerenone in hypertensive patients: a pooled analysis of five clinical studies on different comorbidities

This study aimed to identify factors associated with a strong home blood pressure (BP)-lowering effect of esaxerenone and the incidence of elevated serum potassium levels in hypertensive patients treated with esaxerenone. A pooled analysis of five multicenter, prospective, open-label single-arm studies was conducted, including 479 patients in the full analysis set (FAS) and 492 patients in the safety analysis set. Multivariate linear regression analysis of morning home systolic BP (SBP) and diastolic BP (DBP) changes from baseline to Week 12 in the FAS (primary endpoint) showed that male sex (estimated change 4.37 mmHg), office pulse rate ≥100 beats/min (25.10 mmHg), and calcium channel blocker (CCB) use as a basal antihypertensive agent (4.53 mmHg) were significantly associated with a positive estimated change (weaker BP-lowering effect) in morning home SBP. CCB use (3.70 mmHg) was associated with a positive estimated change in morning home DBP. Urine albumin-to-creatinine ratio 30 to <300 mg/gCr (-4.13 mmHg) was significantly associated with a negative estimated change (stronger BP-lowering effect) in morning home SBP. Based on multivariate logistic regression analysis, elevated baseline serum potassium level (≥4.5 vs < 4.5 mEq/L, odds ratio 13.502) was significantly associated with a high incidence of serum potassium level ≥5.5 mEq/L after esaxerenone treatment. In conclusion, factors associated with a strong BP-lowering effect of esaxerenone were female sex and use of renin-angiotensin system inhibitors as a basal antihypertensive drug. Patients with baseline serum potassium levels ≥4.5 mEq/L had an increased risk of developing elevated serum potassium levels (≥5.5 mEq/L) after esaxerenone treatment.

Efficacy of antihypertensive treatment for target organ protection in patients with masked hypertension (ANTI-MASK): a multicentre, double-blind, placebo-controlled trial

Background

Masked hypertension is associated with target organ damage (TOD) and adverse health outcomes, but whether antihypertensive treatment improves TOD in patients with masked hypertension is unproven.

Methods

In this multicentre, randomised, double-blind, placebo-controlled trial at 15 Chinese hospitals, untreated outpatients aged 30-70 years with an office blood pressure (BP) of <140/<90 mm Hg and 24-h, daytime or nighttime ambulatory BP of ≥130/≥80, ≥135/≥85, or ≥120/≥70 mm Hg were enrolled. Patients had ≥1 sign of TOD: electrocardiographic left ventricular hypertrophy (LVH), brachial-ankle pulse wave velocity (baPWV) ≥1400 cm/s, or urinary albumin-to-creatinine ratio (ACR) ≥3.5 mg/mmol in women and ≥2.5 mg/mmol in men. Exclusion criteria included secondary hypertension, diabetic nephropathy, serum creatinine ≥176.8 μmol/L, and cardiovascular disease within 6 months of screening. After stratification for centre, sex and the presence of nighttime hypertension, eligible patients were randomly assigned (1:1) to receive antihypertensive treatment or placebo. Patients and investigators were masked to group assignment. Active treatment consisted of allisartan starting at 80 mg/day, to be increased to 160 mg/day at month 2, and to be combined with amlodipine 2.5 mg/day at month 4, if the ambulatory BP remained uncontrolled. Matching placebos were used likewise in the control group. The primary endpoint was the improvement of TOD, defined as normalisation of baPWV, ACR or LVH or a ≥20% reduction in baPWV or ACR over the 48-week follow-up. The intention-to-treat analysis included all randomised patients, the per-protocol analysis patients who fully adhered to the protocol, and the safety analysis all patients who received at least one dose of the study medication. This study is registered with ClinicalTrials.gov, NCT02893358.

Findings

Between February 14, 2017, and October 31, 2020, 320 patients (43.1% women; mean age ± SD 53.7 ± 9.7 years) were enrolled. Baseline office and 24-h BP averaged 130 ± 6.0/81 ± 5.9 mm Hg and 136 ± 8.6/84 ± 6.1 mm Hg, and the prevalence of elevated baPWV, ACR and LVH were 97.5%, 12.5%, and 7.8%, respectively. The 24-h BP decreased on average (±SE) by 10.1 ± 0.9/6.4 ± 0.5 mm Hg in 153 patients on active treatment and by 1.3 ± 0.9/1.0 ± 0.5 mm Hg in 167 patients on placebo. Improvement of TOD occurred in 79 patients randomised to active treatment and in 49 patients on placebo: 51.6% (95% CI 43.7%, 59.5%) versus 29.3% (22.1, 36.5%; p < 0.0001). Per-protocol and subgroup analyses were confirmatory. Adverse events were generally mild and occurred in 38 (25.3%) and 43 (26.4%) patients randomised to active treatment and placebo, respectively (p = 0.83).

Interpretation

Our results suggest that antihypertensive treatment improves TOD in patients with masked hypertension, highlighting the need of treatment. However, the long-term benefit in preventing cardiovascular complications still needs to be established.

Funding

Salubris China.

Anthocyanins as natural bioactives with anti-hypertensive and atherosclerotic potential: Health benefits and recent advances

BACKGROUND

Hypertension is a highly prevalent chronic metabolic illness affecting individuals of all age groups. Furthermore, it is a significant risk factor for the development of atherosclerosis (AS), as a correlation between hypertension and AS has been observed. However, the effective treatments for either of these disorders appear to be uncommon.

METHODS

A systematic search of articles published in PubMed, Web of Science, ScienceDirect, Scopus, and Google Scholar databases over the last decade was performed using the following keywords: hypertension, AS, anthocyanins, antioxidants, gut microbes, health benefits, and bioactivity.

RESULTS

The available research indicates that anthocyanin consumption can achieve antioxidant effects by inducing the activation of intracellular nuclear factor erythroid 2-related factor (Nrf2) and the expression of antioxidant genes. Moreover, previous reports showed that anthocyanins can enhance the human body's ability to fight against inflammation and cancer through the inhibition of inflammatory factors and the regulation of related signaling pathways. They can also protect the blood vessels and nervous system by regulating the production and function of endothelial nitric oxide synthase (eNOS). Gut microorganisms play an important role in various chronic diseases. Our research has also investigated the role of anthocyanins in the metabolism of the gut microbiota, leading to significant breakthroughs. This study not only presents a unique strategy for reducing the risk of cardiovascular diseases (CVDs) without the need for medicine but also provides insights into the development and utilization of intestinal probiotic dietary supplements.

CONCLUSION

In this review, different in vitro and in vivo studies have shown that anthocyanins slow down the onset and progression of hypertension and AS through different mechanisms. In addition, gut microbial metabolites also play a crucial role in diseases through the gut-liver axis.

Prevalence of Obesity-Related Disease in a Danish Population - The Results of an Algorithm-Based Screening Program

Purpose

The prevalence of obesity continues to rise. People with obesity are at increased risk of several diseases. We tested an algorithm-based screening program for people with a BMI above 30 kg/m2 and present data on the prevalence of previously undiagnosed obesity-related diseases.

Patients and Methods

Seven hundred and sixty-nine persons with BMI > 30 kg/m2 and age 18-60 years were screened for diabetes (assessed by glycosylated hemoglobin and oral glucose tolerance test at HbA1c 43-48 mmol/mol), sleep apnea (screened by questionnaires and assessed by cardiorespiratory monitoring at indication of sleep disorder), liver steatosis or liver fibrosis (assessed by biochemistry and fibroscan) and arterial hypertension (assessed by both office and 24-hour blood pressure measurement). A reference group of people with a BMI of 18.5-29.9 kg/m2 was established.

Results

Of those referred, 73.0% were women. We identified new diabetes in 4.2%, prediabetes in 9.1%, moderate-to-severe sleep apnea in 25.1%, increased liver fat and increased liver stiffness in 68.1% and 17.4%, respectively, and hypertension or masked hypertension in 19.0%. The prevalence of diseases was much higher among men and increased with BMI. Except for hypertension, we found few participants with undiagnosed disease in the reference group.

Conclusion

An algorithm-based screening program is feasible and reveals undiagnosed obesity-related disease in a large proportion of the participants. The disproportional referral pattern calls for a tailored approach aiming to include more men with obesity.

Trial Registration

Inclusion of the non-obese group was approved by the Scientific Ethics Committee of The Region of Southern Denmark (project identification number: S-20210091), and the study was reported at clinicaltrials.gov (NCT05176132).

Ambulatory blood pressure monitoring profiles in Asia

High blood pressure (BP) remains a major health problem globally, with a proportion of hypertension-mediated organ damage (HMOD) increasing worldwide including in Asia region. Cardiovascular (CV), cerebral and kidney diseases related to hypertension were reported to be closely associated with morning surge and nocturnal hypertension-a subset of BP variability-which can be detected by out-of-office BP measurement. Ambulatory BP monitoring (ABPM) and Home BP monitoring (HBPM) have been recommended by major guidelines to be used in the evaluation of BP variability and outcomes' prediction of hypertension patients. However, an interesting profile of ABPM in Asia has been reported and hypothesized to correlate with different outcomes. This review will focus on the current recommendation of ABPM use by the guidelines, the major different profiles of ABPM in Asia as compared to Western countries according to clinical indications, and the challenges in implementing optimal use of ABPM in Asian countries based on available evidence.

Neighborhood Deprivation, Perceived Stress, and Pregnancy-Related Hypertension Phenotypes a Decade Following Pregnancy

BACKGROUND

Hypertensive disorders in pregnancy and other adverse pregnancy outcomes (APOs) increase the risk of developing chronic hypertension and cardiovascular disease. Perceptions of stress and neighborhood context also influence blood pressure (BP) fluctuations. We examined if APOs, higher perceived stress, and neighborhood deprivation were associated with hypertension phenotypes a decade after pregnancy in untreated individuals.

METHODS

Participants were 360 individuals who gave birth between 2008 and 2009 and participated in a research study 8-10 years following pregnancy. Standardized office and home BP readings were obtained, and we applied the AHA/ACC 2017 guidelines to identify sustained, white coat, and masked hypertension phenotypes. We measured personal stress with the perceived stress scale and neighborhood deprivation with the CDC Social Vulnerability Index.

RESULTS

Of the 38.3% (138/360) with any hypertension, 26.1% (36/138) reported a diagnosis of hypertension but were currently untreated. Sustained hypertension was the most common (17.8%), followed by masked and white coat hypertension, both 10.3%. Hypertensive disorders in pregnancy were associated with sustained (odds ratio [OR] 5.54 [95% confidence interval, CI 2.46, 12.46] and white coat phenotypes (OR 4.20 [1.66, 10.60], but not masked hypertension (OR 1.74 [0.62, 4.90]). Giving birth to a small for gestational age infant was also associated with sustained hypertension. In covariate adjusted models, perceived stress, but not neighborhood deprivation, was significantly associated with masked hypertension.

CONCLUSIONS

A decade after delivery, APOs were associated with sustained and white coat hypertension, but not masked hypertension. Exploration of the mechanisms underlying, and clinical implications of, these associations is warranted.

Digital Health Interventions for Hypertension Management in US Populations Experiencing Health Disparities: A Systematic Review and Meta-Analysis

Importance

Hypertension remains a leading factor associated with cardiovascular disease, and demographic and socioeconomic disparities in blood pressure (BP) control persist. While advances in digital health technologies have increased individuals' access to care for hypertension, few studies have analyzed the use of digital health interventions in vulnerable populations.

Objective

To assess the association between digital health interventions and changes in BP and to characterize tailored strategies for populations experiencing health disparities.

Data Sources

In this systematic review and meta-analysis, a systematic search identified studies evaluating digital health interventions for BP management in the Cochrane Library, Ovid Embase, Google Scholar, Ovid MEDLINE, PubMed, Scopus, and Web of Science databases from inception until October 30, 2023.

Study Selection

Included studies were randomized clinical trials or cohort studies that investigated digital health interventions for managing hypertension in adults; presented change in systolic BP (SBP) or baseline and follow-up SBP levels; and emphasized social determinants of health and/or health disparities, including a focus on marginalized populations that have historically been underserved or digital health interventions that were culturally or linguistically tailored to a population with health disparities. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

Data Extraction and Synthesis

Two reviewers extracted and verified data. Mean differences in BP between treatment and control groups were analyzed using a random-effects model.

Main Outcomes and Measures

Primary outcomes included mean differences (95% CIs) in SBP and diastolic BP (DBP) from baseline to 6 and 12 months of follow-up between digital health intervention and control groups. Shorter- and longer-term follow-up durations were also assessed, and sensitivity analyses accounted for baseline BP levels.

Results

A total of 28 studies (representing 8257 participants) were included (overall mean participant age, 57.4 years [range, 46-71 years]; 4962 [60.1%], female). Most studies examined multicomponent digital health interventions incorporating remote BP monitoring (18 [64.3%]), community health workers or skilled nurses (13 [46.4%]), and/or cultural tailoring (21 [75.0%]). Sociodemographic characteristics were similar between intervention and control groups. Between the intervention and control groups, there were statistically significant mean differences in SBP at 6 months (-4.24 mm Hg; 95% CI, -7.33 to -1.14 mm Hg; P = .01) and SBP changes at 12 months (-4.30 mm Hg; 95% CI, -8.38 to -0.23 mm Hg; P = .04). Few studies (4 [14.3%]) reported BP changes and hypertension control beyond 1 year.

Conclusions and Relevance

In this systematic review and meta-analysis of digital health interventions for hypertension management in populations experiencing health disparities, BP reductions were greater in the intervention groups compared with the standard care groups. The findings suggest that tailored initiatives that leverage digital health may have the potential to advance equity in hypertension outcomes.

Real-World Evaluation of an Automated Algorithm to Detect Patients With Potentially Undiagnosed Hypertension Among Patients With Routine Care in Hawai'i

BACKGROUND

This real-world evaluation considers an algorithm designed to detect patients with potentially undiagnosed hypertension, receiving routine care, in a large health system in Hawai'i. It quantifies patients identified as potentially undiagnosed with hypertension; summarizes the individual, clinical, and health system factors associated with undiagnosed hypertension; and examines if the COVID-19 pandemic affected detection.

METHODS AND RESULTS

We analyzed the electronic health records of patients treated across 6 clinics from 2018 to 2021. We calculated total patients with potentially undiagnosed hypertension and compared patients flagged for undiagnosed hypertension to those with diagnosed hypertension and to the full patient panel across individual characteristics, clinical and health system factors (eg, clinic of care), and timing. Modified Poisson regression was used to calculate crude and adjusted risk ratios. Among the eligible patients (N=13 364), 52.6% had been diagnosed with hypertension, 2.7% were flagged as potentially undiagnosed, and 44.6% had no evidence of hypertension. Factors associated with a higher risk of potentially undiagnosed hypertension included individual characteristics (ages 40-84 compared with 18-39 years), clinical (lack of diabetes diagnosis) and health system factors (clinic site and being a Medicaid versus a Medicare beneficiary), and timing (readings obtained after the COVID-19 Stay-At-Home Order in Hawai'i).

CONCLUSIONS

This evaluation provided evidence that a clinical algorithm implemented within a large health system's electronic health records could detect patients in need of follow-up to determine hypertension status, and it identified key individual characteristics, clinical and health system factors, and timing considerations that may contribute to undiagnosed hypertension among patients receiving routine care.

Digital hypertension towards to the anticipation medicine

"Digital Hypertension" is a new research field proposed by the Japanese Society of Hypertension that integrates digital technology into hypertension management and proactively promotes research activities. This novel approach includes the development of new technologies for better BP management, such as sensors for detecting environmental factors that affect BP, information processing, and machine learning. To facilitate "Digital Hypertension," a more sophisticated BP monitoring system capable of measuring an individual's BP more frequently in various situations would be required. With the use of these technologies, hypertension management could shift from the current "dots" management based on office BP readings during clinic visits to a "line" management system based on seamless home BP or individual BP data taken by a wearable BP monitoring device. DTx is the innovation to change hypertension management from "dots" to "line", completely achieved by wearable BP.

A new method of continuous blood pressure monitoring using multichannel sensing signals on the wrist

Hypertension is a worldwide health problem and a primary risk factor for cardiovascular disease. Continuous monitoring of blood pressure has important clinical value for the early diagnosis and prevention of cardiovascular disease. However, existing technologies for wearable continuous blood pressure monitoring are usually inaccurate, rely on subject-specific calibration and have poor generalization across individuals, which limit their practical applications. Here, we report a new blood pressure measurement method and develop an associated wearable device to implement continuous blood pressure monitoring for new subjects. The wearable device detects cardiac output and pulse waveform features through dual photoplethysmography (PPG) sensors worn on the palmar and dorsal sides of the wrist, incorporating custom-made interface sensors to detect the wearing contact pressure and skin temperature. The detected multichannel signals are fused using a machine-learning algorithm to estimate continuous blood pressure in real time. This dual PPG sensing method effectively eliminates the personal differences in PPG signals caused by different people and different wearing conditions. The proposed wearable device enables continuous blood pressure monitoring with good generalizability across individuals and demonstrates promising potential in personal health care applications.

Tutorial review for peptide assays: An ounce of pre-analytics is worth a pound of cure

The recent increase in peptidomimetic-based medications and the growing interest in peptide hormones has brought new attention to the quantification of peptides for diagnostic purposes. Indeed, the circulating concentrations of peptide hormones in the blood provide a snapshot of the state of the body and could eventually lead to detecting a particular health condition. Although extremely useful, the quantification of such molecules, preferably by liquid chromatography coupled to mass spectrometry, might be quite tricky. First, peptides are subjected to hydrolysis, oxidation, and other post-translational modifications, and, most importantly, they are substrates of specific and nonspecific proteases in biological matrixes. All these events might continue after sampling, changing the peptide hormone concentrations. Second, because they include positively and negatively charged groups and hydrophilic and hydrophobic residues, they interact with their environment; these interactions might lead to a local change in the measured concentrations. A phenomenon such as nonspecific adsorption to lab glassware or materials has often a tremendous effect on the concentration and needs to be controlled with particular care. Finally, the circulating levels of peptides might be low (pico- or femtomolar range), increasing the impact of the aforementioned effects and inducing the need for highly sensitive instruments and well-optimized methods. Thus, despite the extreme diversity of these peptides and their matrixes, there is a common challenge for all the assays: the need to keep concentrations unchanged from sampling to analysis. While significant efforts are often placed on optimizing the analysis, few studies consider in depth the impact of pre-analytical steps on the results. By working through practical examples, this solution-oriented tutorial review addresses typical pre-analytical challenges encountered during the development of a peptide assay from the standpoint of a clinical laboratory. We provide tips and tricks to avoid pitfalls as well as strategies to guide all new developments. Our ultimate goal is to increase pre-analytical awareness to ensure that newly developed peptide assays produce robust and accurate results.

Health football beats them all: subgroup analysis of the 3F (Fit&Fun with Football) study on white-coat hypertension, sustained hypertension, dippers, nondippers, and on pharmacologically un(treated) arterial hypertension

BACKGROUND

The 3F study (Fit&Fun with Football) demonstrated a significant reduction in blood pressure, antihypertensive medication, body weight, stress and depression through health football. Health football could be a popular tool to unleash the full preventive potential of physical activity. This work analyses the effect of health football on hypertensive subgroups: dipper, nondipper, white-coat hypertension (WCH), sustained hypertension, (un)treated hypertensive patients (UH, TH).

METHODS

A prospective interventional study with 1-year follow-up. Football group (FG): n  = 103, 'health'-football training (1×/week, 90 min) led by licensed football coaches. Physical inactive, hypertensive patients older than 45 years were compared with a control group (CG) ( n  = 105). Subgroups were divided by ambulatory blood pressure monitoring (ABPM), casual blood pressure (CBP), medication schedule and compared by blood pressure (BP), laboratory results and weight.

RESULTS

In all three subgroups (WCH vs. sustained hypertension, TH vs. UH, D vs. ND), health football reduced BP and weight significantly compared with the CG, and compared with the admission. An even greater effect in CBP was found in people with WCH than in sustained hypertension (FG: WCH: 141-127 mmHg, sustained Hypertension (SH): 142-132 mmHg; CG: WCH: 141-143 mmHg, SH: 140-141 mmHg). In contrast, the significant reduction in CBP and ABPM was comparable in treated and untreated patients, although antihypertensive drugs were reduced significantly more frequently in FG than in CG. BP reduction in nondippers and dippers was also comparable. In the nondipper group, nocturnal BP was significantly reduced in the FB (122.0-111.5 mmHg), but not in the CG or the dippers.

CONCLUSION

All evaluated football subgroups achieved a significant BP reduction (compared with CG). This applied to dipper, nondipper, (un)treated hypertension, WCH and SH. All mentioned subgroups displayed a clear benefit. The even greater reduction in BP in WCH demonstrates the importance of physical activity before the additional prescription of antihypertensive medications, underscoring the recommendations of the ESC and ISH in WCH.

What did we learn from the International Databases on Ambulatory and Home Blood Pressure in Relation to Cardiovascular Outcome?

To assess in individual-person meta-analyses how out-of-office blood pressure (BP) contributes to risk stratification and the management of hypertension, an international consortium set up the International Databases on Ambulatory (IDACO) and Home (IDHOCO) Blood Pressure in Relation to Cardiovascular Outcome. This review summarizes key findings of recent IDACO/IDHOCO articles. Among various BP indexes derived from office and ambulatory BP recordings, the 24-h and nighttime BP level were the best predictors of adverse health outcomes. Second, using the 10-year cardiovascular risk associated with guideline-endorsed office BP thresholds as reference, corresponding thresholds were derived for home and ambulatory BP. Stratified by the underlying cardiovascular risk, the rate of cardiovascular events in white-coat hypertensive patients and matched normotensive controls were not substantially different. The observation that masked hypertension carries a high cardiovascular risk was replicated in Nigerian Blacks, using home BP monitoring. The thresholds for 24-h mean arterial pressure, i.e., the BP component measured by oscillometric devices, delineating normotension, elevated BP and hypertension were <90, 90 to 92 and ≥92 mmHg. At young age, the absolute risk associated with out-of-office BP was low, but the relative risk was high, whereas with advancing age, the relative risk decreased and the absolute risk increased. Using pulse pressure as an exemplary case, the relative risks of death, cardiovascular endpoints and stroke decreased over 3-fold from 55 to 75 years of age, whereas in contrast absolute risk rose 3-fold. In conclusion, IDACO/IDHOCO forcefully support the notion that the pressing need to curb the hypertension pandemic cannot be met without out-of-the-office BP monitoring.

Role of housing in blood pressure control: a review of evidence from the Smart Wellness Housing survey in Japan

Current countermeasures for preventing hypertension emphasize only improvements to lifestyle. Recently, improving life environment has attracted attention, in parallel with publication of the WHO Housing and health guidelines. We quantitatively evaluated the relationship between housing thermal environment and blood pressure (BP) in a real-world setting. We conducted a nationwide, prospective intervention study-the Smart Wellness Housing survey-in Japan, as a non-randomized controlled trial. The intervention was the retrofitting of thermal insulation in houses. Participant recruitment was done by construction companies in all 47 prefectures of Japan. Measurements of home BP and indoor temperature at 1.0 m above the floor in the living room, changing room, and bedroom were taken for 2 weeks before and after the intervention each winter (November-March) of FY 2014-2019. As of July 2022, over 2500 households and 5000 participants were registered in the database. We found that (1) about 90% of Japanese lived in cold homes (minimum indoor temperature <18 °C), (2) indoor temperature was non-linearly associated with home BP, (3) morning systolic BP (SBP) was more sensitive than evening SBP to changes in indoor temperature, (4) SBP was influenced by indoor temperature change particularly in older participants and women, (5) unstable indoor temperature was associated with large BP variability, and (6) insulation retrofitting intervention significantly reduced home BP, especially in hypertensive patients. We proposed that the BP reduction effect of the life-environment is comparable to that achievable by lifestyle.

Prevalence and Related Factors of White Coat Hypertension and Masked Hypertension in Shunde District, Southern China

Background: White coat hypertension (WCH) and masked hypertension (MH) can increase the risk of target organ damage. Home blood pressure monitoring is an important method for detecting WCH and MH. However, the prevalence and related factors of WCH and MH in China have been rarely reported.

Objective: To explore the prevalence and related factors associated with white coat hypertension (WCH) and masked hypertension (MH) in Shunde District, Southern China.

Methods: This study recruited subjects from the Physical Examination Center in Shunde Hospital, Southern Medical University. Office blood pressure and home blood pressure values were collected using the home blood pressure monitor with telemedicine device and office blood pressure monitor, and the prevalence of WCH and MH was calculated by the values. Multivariate logistic regression was used to explore the related factors for WCH and MH.

Results: Four-hundred and sixty-one participants (61% male), with an average age of 49 years, were included. The prevalence of WCH and MH was 5.1 and 15.2%, respectively. Multivariate logistic regression analysis showed that smoking (OR = 4.71, 95% CI = 1.05–21.15) and family history of coronary heart disease (OR = 4.51, 95% CI = 1.08–18.93) were associated with higher odds of WCH. The associated factors for higher odds of MH were smoking (OR = 2.83, 95% CI = 1.11–7.23), family history of hypertension (OR = 2.17, 95% CI = 1.11–4.26) and family history of coronary heart disease (OR = 2.82, 95% CI = 1.07–7.45).

Conclusion: WCH and MH are highly prevalent in the Physical Examination Center in Shunde Hospital, Southern Medical University. We found smoking and family history of coronary heart disease were related factors for WCH, and smoking, family history of hypertension and coronary heart disease were associated with the odds of MH. Home blood pressure monitoring with a telemedicine device should be recommended to identity abnormal BP phenotype.

Blood Pressure and Chronic Kidney Disease Progression: An Updated Review

Hypertension (HTN) is common in chronic kidney disease (CKD), and it may aggravate CKD progression. The optimal blood pressure (BP) value in CKD patients is not established yet, although systolic BP ≤130 mmHg is acceptable as a target. Continuous BP monitoring is essential to detect the different variants of high BP and monitor the treatment response. Various methods of BP measurement in the clinic office and at home are currently used. One of these methods is ambulatory BP monitoring (ABPM), by which BP can be closely assessed for even diurnal changes.

We conducted a non-systematic literature review to explore and update the association between high BP and the course of CKD and to review various BP monitoring methods to determine the optimal method for BP recording in CKD patients. PubMed, EMBASE, Google, Google Scholar, and Web Science were searched for published reviews and original articles on BP and CKD by using various phrases and keywords such as "hypertension and CKD", "CKD progression and hypertension", "CKD stage and hypertension", "BP control in CKD", "BP measurement methods", "diurnal BP variation effect on CKD progression", and "types of hypertension." We evaluated and discussed published articles relevant to the review objective. Before preparing the final draft of this article, each author was assigned a section of the topic to read, research deeply, and write a summary about the assigned section. Then a summary of each author's contribution was collected and discussed in several group sessions.

Early detection of high BP is essential to prevent CKD development and progression. Although the latest Kidney Disease Improving Global Outcomes (KDIGO) guidelines suggest that a systolic BP ≤120 mmHg is the target toprevent CKD progression, systolic BP ≤130 mmHg is universally recommended.ABPM is a promising method to diagnose and follow up on BP control; however, the high cost of the new devices and patient unfamiliarity with them have proven to be major disadvantages with regard to this method.

Incidental findings in UK healthy volunteers screened for a COVID-19 vaccine trial

The safety of novel therapeutics and vaccines are typically assessed in early phase clinical trials involving "healthy volunteers." Abnormalities in such individuals can be difficult to interpret and may indicate previously unrecognized medical conditions. The frequency of incidental findings (IFs) in healthy volunteers who attend for clinical trial screening is unclear. To assess this, we retrospectively analyzed data for 1838 "healthy volunteers" screened for enrolment in a UK multicenter, phase I/II severe acute respiratory syndrome-coronavirus 2 (SARS-COV-2) vaccine trial. Participants were predominantly White (89.7%, 1640/1828) with a median age of 34 years (interquartile range [IQR] = 27-44). There were 27.7% of participants (510/1838) who had at least one IF detected. The likelihood of identifying evidence of a potential, new blood-borne virus infection was low (1 in 238 participants) compared with identification of an elevated alanine transaminase (ALT; 1 in 17 participants). A large proportion of participants described social habits that could impact negatively on their health; 21% consumed alcohol in excess, 10% were current smokers, 11% described recreational drug use, and only 48% had body weight in the ideal range. Our data demonstrate that screening prior to enrollment in early phase clinical trials identifies a range of IFs, which should inform discussion during the consent process. Greater clarity is needed to ensure an appropriate balance is struck between early identification of medical problems and avoidance of exclusion of volunteers due to spurious or physiological abnormalities. Debate should inform the role of the trial physician in highlighting and advising about unhealthy social habits.

Changes in blood pressure after crossover to ultrasound renal denervation in patients initially treated with sham in the RADIANCE-HTN SOLO trial

BACKGROUND

The multicentre, randomised, sham-controlled RADIANCE-HTN SOLO trial reported the blood pressure (BP)-lowering efficacy and safety of ultrasound renal denervation (RDN) in the absence (2 months) and presence (6 and 12 months) of antihypertensive medications in patients with mild-to-moderate hypertension.

AIMS

The aim of this report was to evaluate patients originally assigned to the sham group who crossed over to RDN.

METHODS

After the primary endpoint was met, patients in the sham arm who remained uncontrolled were allowed to cross over to receive RDN. All patients were unblinded and treated with standard of care medications at the time of crossover. Ambulatory BP was evaluated 2 and 6 months after crossover.

RESULTS

Among 72 subjects of the sham arm, 33 underwent ultrasound RDN after an average follow-up of 23±6 months. Prior to crossover, patients had a daytime ambulatory BP of 144.1±10.1/89.9±8.4 mmHg and received 1.2±0.8 antihypertensive medications. Mean change in daytime ambulatory BP from pre-crossover to 2 and 6 months post RDN was -11.2±13.7/-7.1±8.9 mmHg (n=33; p<0.001; p<0.001) and -10.8±17.3/-7.8±11.6 mmHg (n=27; p=0.002; p<0.001). The number of antihypertensive medications did not change from pre-crossover baseline to 2 and 6 months. Eighteen of 33 (54.5%) patients had their daytime ambulatory BP controlled (<135/85 mmHg) at 2 months and 44.4% (12/27) at 6 months post RDN. No major procedure-related adverse events occurred.

CONCLUSIONS

During unblinded long-term follow-up of the RADIANCE-HTN SOLO study, patients originally assigned to a sham procedure who remained uncontrolled had significant reductions in BP following crossover treatment with ultrasound RDN.

Is relaxation exercise therapy effective in the management of patients with severe arterial hypertension?

Arterial hypertension (AH) is a burning problem in the world. Antihypertensive pharmacological therapy combined by physical exercises is well-studied in patients with mild and moderate AH. However, studies that have investigated relaxation in patients with severe AH in addition to drug therapy are lacking. Optimization of a comprehensive treatment for patients with severe AH, by using a multicomponent rational antihypertensive pharmacotherapy (PT) with subsequent application of relaxation exercise therapy (RET). The study involved 32 male patients with severe AH. Initially, clinical-instrumental and laboratory examination, blood pressure registration and daily arterial blood pressure monitoring were carried out. Suitable PT was selected for all the patients. 3 months after starting PT the patients were divided in 2 groups. The patients of the 1st group were prescribed RET in addition to PT. The 2nd group of patients continued receiving PT alone. 3 months later, average daily blood pressure (ADBP)-syst and ADBP-diast were compared in both groups. Three months after PT both groups demonstrated a significant decrease in ADBP-syst and ADBP diast, but these indicators remained higher than normal and did not reach the target level. Three months after the inclusion of RET in the comprehensive treatment, the 1st group demonstrated a significant decrease in ADBP (systolic and diastolic), not only in comparison with the initial data, but also with the data observed three months after PT. After 6 months, ADBP-syst and ADBP-diast in the 1st group were significantly lower compared with those of patients in the 2nd group. The inclusion of RET in addition to a multicomponent antihypertensive PT is a promising treatment option for severe AH.

Prediction of Masked Hypertension and Masked Uncontrolled Hypertension Using Machine Learning

Objective: This study aimed to develop machine learning-based prediction models to predict masked hypertension and masked uncontrolled hypertension using the clinical characteristics of patients at a single outpatient visit.

Methods: Data were derived from two cohorts in Taiwan. The first cohort included 970 hypertensive patients recruited from six medical centers between 2004 and 2005, which were split into a training set (n = 679), a validation set (n = 146), and a test set (n = 145) for model development and internal validation. The second cohort included 416 hypertensive patients recruited from a single medical center between 2012 and 2020, which was used for external validation. We used 33 clinical characteristics as candidate variables to develop models based on logistic regression (LR), random forest (RF), eXtreme Gradient Boosting (XGboost), and artificial neural network (ANN).

Results: The four models featured high sensitivity and high negative predictive value (NPV) in internal validation (sensitivity = 0.914–1.000; NPV = 0.853–1.000) and external validation (sensitivity = 0.950–1.000; NPV = 0.875–1.000). The RF, XGboost, and ANN models showed much higher area under the receiver operating characteristic curve (AUC) (0.799–0.851 in internal validation, 0.672–0.837 in external validation) than the LR model. Among the models, the RF model, composed of 6 predictor variables, had the best overall performance in both internal and external validation (AUC = 0.851 and 0.837; sensitivity = 1.000 and 1.000; specificity = 0.609 and 0.580; NPV = 1.000 and 1.000; accuracy = 0.766 and 0.721, respectively).

Conclusion: An effective machine learning-based predictive model that requires data from a single clinic visit may help to identify masked hypertension and masked uncontrolled hypertension.

Cardiovascular Prognosis in Drug-Resistant Hypertension Stratified by 24-Hour Ambulatory Blood Pressure: The JAMP Study

[Figure: see text].

White-coat hypertension detected during opportunistic blood pressure screening in a dental healthcare setting

OBJECTIVE

To study white-coat hypertension (WCHT, blood pressure ≥140/90 mmHg in a clinic and normal blood pressure <135/85 mmHg at home), with blood pressure screening of a healthy population during their dental healthcare visit and the associated risk factors.

DESIGN

A multicentre observational study.

SETTING

A healthy general population at four dental clinics in a region in southern Sweden.

SUBJECTS

2025 individuals aged 40-75 years were screened for high blood pressure at their annual regular check-up dental visit.

MAIN OUTCOME MEASURES

Frequencies of normal and elevated blood pressure (BP) in dental clinics, with home BP as a reference. According to BP results, the population was divided into three groups: normotension (NT), WCHT and suspected hypertension (HT). Background and life style factors were measured: sex, age, family history of hypertension, body mass index (BMI kg/m²), education level, tobacco use, and physical activity level.

RESULTS

The overall prevalence of WCHT in the study was 17.7%, and the prevalence was 57.2% among those with clinically high blood pressure. Compared with NT, WCHT was associated with male sex (OR 1.56, CI 1.18-2.06), older age group (OR 2.33, CI 1.66-3.26), family history of hypertension (OR 1.61, CI 1.24-2.10), high BMI kg/m² (OR 2.36, CI 1.80-3.10), daily snuff use (OR 1.74, CI 1.19-2.53). In comparison with WCHT, HT was associated with male sex (OR 2.16, CI 1.44-3.25), older age group (OR 2.85, CI 1.75-4.65), daily smoking (OR 2.10, CI 1.14-3.85), less daily snuff use (OR 0.59, CI 0.34-0.99).

CONCLUSIONS

The prevalence of WCHT in a healthy population was 17.7%. Regarding cardiovascular risk factors, WCHT seems to be in the middle of NT and HT. Individuals with WCHT can be identified and given lifestyle advice in connection with a dental check-up, but follow-up and assessment of their cardiovascular risk should take place in primary care.Key pointsScreening in dental practice can detect white-coat hypertension (WCHT) (17.7%) and suspected hypertension (HT) (12.4%).Individuals with WCHT have more cardiovascular risk factors than normotensive individuals.Individuals with WCHT could be given lifestyle advice in dental clinics according to current guidelines.

Home Blood Pressure Monitoring: Current Status and New Developments

Home blood pressure monitoring (HBPM) is a reliable, convenient, and less costly alternative to ambulatory blood pressure monitoring (ABPM) for the diagnosis and management of hypertension. Recognition and use of HBPM have dramatically increased over the last 20 years and current guidelines make strong recommendations for the use of both HBPM and ABPM in patients with hypertension. The accuracy and reliability of home blood pressure (BP) measurements require use of a validated device and standardized procedures, and good patient information and training. Key HBPM parameters include morning BP, evening BP, and the morning-evening difference. In addition, newer semi-automatic HBPM devices can also measure nighttime BP at fixed intervals during sleep. Advances in technology mean that HBPM devices could provide additional relevant data (e.g., environmental conditions) or determine BP in response to a specific trigger (e.g., hypoxia, increased heart rate). The value of HBPM is highlighted by a growing body of evidence showing that home BP is an important predictor of target organ damage, and cardiovascular disease (CVD)- and stroke-related morbidity and mortality, and provides better prognostic information than office BP. In addition, use of HBPM to monitor antihypertensive therapy can help to optimize reductions in BP, improve BP control, and reduce target organ damage and cardiovascular risk. Overall, HBPM should play a central role in the management of patients with hypertension, with the goal of identifying increased risk and predicting the onset of CVD events, allowing proactive interventions to reduce risk and eliminate adverse outcomes.

Improving the Accuracy in Classification of Blood Pressure from Photoplethysmography Using Continuous Wavelet Transform and Deep Learning

Background

Continuous wavelet transform (CWT) based scalogram can be used for photoplethysmography (PPG) signal transformation to classify blood pressure (BP) with deep learning. We aimed to investigate the determinants that can improve the accuracy of BP classification based on PPG and deep learning and establish a better algorithm for the prediction.

Methods

The dataset from PhysioNet was accessed to extract raw PPG signals for testing and its corresponding BPs as category labels. The BP category of normal or abnormal followed the criteria of the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Hypertension Guidelines. The PPG signals were transformed into 224 ∗ 224 ∗ 3-pixel scalogram via different CWTs and segment units. All of them are fed into different convolutional neural networks (CNN) for training and validation. The receiver-operating characteristic and loss and accuracy curves were used to evaluate and compare the performance of different methods.

Results

Both wavelet type and segment length could affect the accuracy, and Cgau1 wavelet and segment-300 revealed the best performance (accuracy 90%) without obvious overfitting. This method performed better than previously reported MATLAB Morse wavelet transformed scalogram on both of our proposed CNN and CNN-GoogLeNet.

Conclusions

We have established a new algorithm with high accuracy to predict BP classification from PPG via matching of CWT type and segment length, which is a promising solution for rapid prediction of BP classification from real-time processing of PPG signal on a wearable device.

Long-term effect of masked hypertension management on cognitive functions in geriatric age: geriatric MASked hypertension and cognition follow-up study (G-MASH-cog MONITOR)

OBJECTIVES

Masked hypertension, defined as nonelevated clinic blood pressure with elevated out of clinic blood pressure, has been associated with increased cardiovascular events, mortality and cognitive impairment. No evidence exists regarding the effect of treating masked hypertension. In this study, we followed-up the patients in the G-MASH-cog study for 1 year and aimed to examine the effect of the management of masked hypertension on cognitive functions.

METHODS

The G-MASH-cog study participants were followed-up for 1 year. In masked hypertensive individuals, lifestyle modification and antihypertensive treatment (perindopril or amlodipine) were initiated for blood pressure control. Measurements of cognitive tests and ambulatory blood pressure monitoring at baseline and at 1-year follow-up were compared.

RESULTS

A total of 61 patients (30 in masked hypertension group; 31 in normotensive group) were included. Mean age was 72.3 ± 5.1 and 59% of the participants were female. Compared with baseline ambulatory blood pressure measurement results, patients with masked hypertension had significantly lower ambulatory blood pressure measurement results after 1-year follow-up. The quick mild cognitive impairment test (Q-MCI-TR) score increased with antihypertensive treatment (Q-MCI score at baseline = 41(19-66.5), at 1 year = 45.5 (22-70), P = 0.005) in masked hypertensive patients. In the final model of the mixed-effects analysis, when adjusted for covariates, interaction effect of the masked hypertension treatment with time was only significant in influencing the changes in Q-MCI scores over time in patients aged between 65 and 74 years (P = 0.002).

CONCLUSIONS

Treatment of masked hypertension in older adults was associated with improvement in cognitive functions.

Blood pressure phenotypes based on ambulatory monitoring in a general middle-aged population

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) is increasingly recommended for clinical use, but more knowledge about the prevalence and variability in ABPM-derived phenotypes in the general population is needed. We describe these parameters in the community-based Swedish CArdioPulmonary bioImage Study (SCAPIS) cohort.

METHODS

We examined 5881 men and women aged 50-64 with 24-hour ABPM recordings using validated monitors. ABPM phenotypes were defined according to European guidelines. White coat hypertension was defined as elevated office BP (≥140/90 mmHg) with normal mean ambulatory BP (<135/85 mmHg in day-time, <120/70 mmHg in night-time, <130/80 mmHg over 24-h); and masked hypertension as normal office BP (<140/90 mmHg) with elevated mean ambulatory BP (≥135/85 mmHg in day-time, ≥120/70 mmHg in night-time, ≥130/80 mmHg over 24-h). Blood pressure variability was assessed using the coefficient of variation (CV), standard deviation (SD), and average real variability.

RESULTS

Based on the ABPM recordings, 36.9% of participants had 24-h hypertension, 40.7% had day-time hypertension, and 37.6% nocturnal hypertension. Among participants treated with anti-hypertensive drugs, one in three had elevated office blood pressures, and more than half had elevated 24-h, day-time or nocturnal blood pressures. Among participants without anti-hypertensive drugs, only one in six had elevated office blood pressures, but one in three had elevated 24-h, day-time or nocturnal blood pressures. Men had higher 24-h blood pressures, more masked hypertension, but less white-coat hypertension than women. The prevalence of white-coat hypertension increased with age, but not the prevalence of masked hypertension. A positive association between blood pressure level and variability was observed, and within-person and between-person SD and CV were of similar magnitude. The variance in ABPM on repeated measurements was substantial.

CONCLUSIONS

In the middle-aged general population, masked hypertension is an underappreciated problem on the population level.

Blood pressure monitoring in kidney transplantation: a systematic review on hypertension and target organ damage

BACKGROUND

Sparse studies show that ambulatory blood pressure monitoring (ABPM) is superior to office BP (oBP) measurements to predict target organ damage and cardiovascular (CV) events in kidney transplant recipients (KTRs). We performed a systematic review aimed at determining the potential associations between BP recordings by different methods and renal and CV outcomes in this population.

METHODS

Major medical databases were searched for studies enrolling adult KTRs undergoing 24h ABPM compared to office or home BP measurements. Main outcomes were: associations between different BP recordings and renal and CV outcomes. Additionally, any association between the circadian BP pattern (dipping/non-dipping status) and outcomes was assessed.

RESULTS

Twenty-two studies (2078 participants) were reviewed. Amongst 12 studies collecting data on renal endpoints, ten studies found that BP assessed by ABPM was a stronger predictor of renal function decline, assessed by serum creatinine (SCr) and/or creatinine clearance (CrCl) or estimated glomerular filtration rate (eGFR), than traditional office measurements. Twelve studies analyzed the relation between different BP recordings and CV target organ damages and reported robust correlations between echocardiographic abnormalities [i.e. left ventricular mass index (LVM/LVMI)] and 24h ABPM, but not with office BPs. Furthermore, 24h ABPM correlated better than oBP with markers of vascular damage, such as carotid intima-media thickness (IMT), diffuse thickening, and endothelial dysfunction. Additionally, abnormal circadian BP pattern (non-dippers and reverse dippers) identified a group of kidney recipients at risk for kidney function loss and CV abnormalities.

CONCLUSIONS

In our systematic review, ABPM reflected target organ damage more closely than oBP in KTRs. Furthermore, altered circadian BP profile associated with renal and CV target organ damages.

Self-measured worksite blood pressure and its association with organ damage in working adults: Japan Morning Surge Home Blood Pressure (J-HOP) worksite study

The effects of elevations in blood pressure (BP) on worksite stress as an out-of-office BP setting have been evaluated using ambulatory BP monitoring but not by self-measurement. Herein, we determined the profile of self-measured worksite BP in working adults and its association with organ damage in comparison with office BP and home BP measured by the same home BP monitoring device. A total of 103 prefectural government employees (age 45.3 ± 9.0 years, 77.7% male) self-measured their worksite BP at four timepoints (before starting work, before and after a lunch break, and before leaving the workplace) and home BP in the morning, evening, and nighttime (at 2, 3, and 4 a.m.) each day for 14 consecutive days. In the total group, the average worksite systolic BP (SBP) was significantly higher than the morning home SBP (129.1 ± 14.3 vs. 124.4 ± 16.4 mmHg, p = .026). No significant difference was observed among the four worksite SBP values. Although the average worksite BP was higher than the morning home BP in the study participants with office BP < 140/90 mmHg (SBP: 121.4 ± 9.4 vs. 115.1 ± 10.4 mmHg, p < .001, DBP: 76.0 ± 7.7 vs. 72.4 ± 8.4 mmHg, p = .013), this association was not observed in those with office BP ≥ 140/90 mmHg or those using antihypertensive medication. Worksite SBP was significantly correlated with the left ventricular mass index evaluated by echocardiography (r = 0.516, p < .0001). The self-measurement of worksite BP would be useful to unveil the risk of hypertension in working adults who show normal office and home BP.

High prevalence of masked uncontrolled morning hypertension in elderly non-valvular atrial fibrillation patients: Home blood pressure substudy of the ANAFIE Registry

In the ANAFIE Registry home blood pressure subcohort, we evaluated 5204 patients aged ≥75 years with non-valvular atrial fibrillation (NVAF) to assess blood pressure (BP) control, prevalence of masked hypertension, and anticoagulant use. Mean clinic (C) and home (H) systolic/diastolic BP(SBP/DBP) was 128.5/71.3 and 127.7/72.6 mm Hg, respectively. Overall, 77.5% of patients had hypertension; of these, 27.7%, 13.4%, 23.4%, and 35.6% had well-controlled, white coat, masked, and sustained hypertension, respectively. Masked hypertension prevalence increased with diabetes, decreased renal function, age ≥80 years, current smoker status, and chronic obstructive pulmonary disease. By morning/evening average, 59.0% of patients had mean H-SBP ≥ 125 mm Hg; 48.9% had mean C-SBP ≥ 130 mm Hg. Early morning hypertension (morning H-SBP ≥ 125 mm Hg) was found in 65.9% of patients. Although 51.1% of patients had well-controlled C-SBP, 52.5% of these had uncontrolled morning H-SBP. In elderly NVAF patients, morning H-BP was poorly controlled, and masked uncontrolled morning hypertension remains significant.

Comparison between unattended automated office blood pressure and conventional office blood pressure under the environment of health checkup among Japanese general population

Unattended automated office blood pressure (AOBP) measurement has been endorsed as the preferred in-office measurement modality in recent Canadian and American clinical practice guidelines. However, the difference between AOBP and conventional office blood pressure (CBP) under the environment of a health checkup remains unclear. We aimed to identify the clinical significance of AOBP as compared to CBP under the environment of a health checkup. There were 491 participants (333 females, mean age of 62.5 years) who were at least 20 years old, including 179 participants who were previously diagnosed with hypertension. Mean AOBPs were 131.8 ± 20.9/76.6 ± 11.7 mm Hg, and CBPs were 135.6 ± 21.6/77.3 ± 11.5 mm Hg. There was a difference of 3.9 mm Hg in systolic blood pressure (SBP) and 0.8 mm Hg in diastolic BP between AOBP and CBP. In all participants, SBP and pulse pressure, as well as the white coat effect (WCE), increased with age. The cutoff value used was 140/90 mm Hg for CBP and 135/85 mm Hg for AOBP, and the prevalence of WCE and masked hypertension effect (MHE) was 12.4% and 14.1%, respectively. Even in a health checkup environment of the general population, there was a difference between the AOBP and CBP, and the WCE was observed more strongly in the elderly with a history of hypertension, suggesting that a combination of AOBP with CBP may be useful in detecting WCE and MHE in all clinical scenarios including health checkups, and help solve the "hypertension paradox" not only in Japan but in all over the world.

Nighttime Blood Pressure Phenotype and Cardiovascular Prognosis: Practitioner-Based Nationwide JAMP Study

Supplemental Digital Content is available in the text.

Ambulatory and home blood pressure (BP) monitoring parameters are better predictors of cardiovascular events than are office BP monitoring parameters, but there is a lack of robust data and little information on heart failure (HF) risk. The JAMP study (Japan Ambulatory Blood Pressure Monitoring Prospective) used the same ambulatory BP monitoring device, measurement schedule, and diary-based approach to data processing across all study centers and determined the association between both nocturnal hypertension and nighttime BP dipping patterns and the occurrence of cardiovascular events, including HF, in patients with hypertension.

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.

A multicenter clinical trial to assess the efficacy of the digital therapeutics for essential hypertension: Rationale and design of the HERB-DH1 trial

Digital therapeutics is a new approach to treat hypertension via using software programs such as smartphone apps and/or device algorithms. We develop a HERB system-new interactive smartphone app (HERB Mobile) with web-based patient management console (HERB Console)-to lower blood pressure (BP) based on an algorithm that helps users to promote lifestyle modifications in conjunction with medically validated non-pharmacological interventions. The app can assess the personalities, behavior characteristics, and hypertension determinants of each patient with hypertension to provide adequate guidance. To demonstrate the efficacy of the system, we designed a randomized, controlled, multicenter, open-label trial "HERB-DH1 (HERB digital hypertension 1)" to assess the efficacy of HERB system in patients with essential hypertension. The authors allocate patients to the intervention group (HERB system + standard lifestyle modification) or to the control group (standard lifestyle modification alone). In the intervention group, we provide the HERB Mobile for patients and the HERB Console for their primary physicians for 24 weeks. Both groups are instructed for standard lifestyle modifications based on the current recommendations in the Japanese Society of Hypertension 2019 guideline. The primary outcome is the mean change from baseline to 12 weeks in 24-hour systolic BP measured by ambulatory BP monitoring. We started this study in December of 2019, and the trial results will be expected in early 2021. We believe that this trial enables us to verify the efficacy of the HERB system in patients with essential hypertension.

[Antihypertensives always evenings-absolutely not or sensible?]

The Spanish Hygia study has led to considerable irritation due to the general recommendation to prescribe antihypertensives preferably to be taken in the evening, especially since the lay press as well as medical media made enthusiastic comments. The discussion about the optimal time to take antihypertensive drugs shows once again how dangerous the uncritical handling of study data can be. No possible risks were pointed out. The Hygia study compared 19,084 patients with morning and evening intake of antihypertensive drugs under the control of a 48‑h blood pressure measurement (!). There was a significantly better reduction in blood pressure and the rate of cardiovascular and cerebrovascular events with evening intake. The data are scientifically valuable; however, the conclusions are incomprehensible based on the data, contradict many other studies and are dangerous for certain patient groups. There are also methodological shortcomings. Therefore, a general evening intake is not justified and nonsensical due to the diverse, individually very different pathophysiological findings of the nocturnal blood pressure behavior. Basically, the outpatient 24‑h blood pressure measurement (ABPM) enables a better assessment of the individual cardiovascular and cerebrovascular risks and prevents an incorrect assessment of the blood pressure and thus unnecessary or sufficient treatment. Instead of a general recommendation, the ABPM offers the option of an individually tailored treatment. Taking antihypertensive drugs in the evening should always be preceded by an ABDM in the case of prognostically unfavorable nocturnal hypertension in order to avoid the risk of nocturnal ischemic risks due to excessive drops in blood pressure.

Control of 24-hour blood pressure with SGLT2 inhibitors to prevent cardiovascular disease

The presence of hypertension (HTN) in patients with diabetes mellitus (DM) further worsens cardiovascular disease (CVD) prognosis. In addition, masked HTN and abnormal circadian blood pressure (BP) variability are common among patients with DM. Clinical trial data show that sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve CVD prognosis and prevent progression of renal dysfunction in high-risk patients with type 2 DM (T2DM). Consistent reductions in 24-hour, daytime and nocturnal BP have been documented during treatment with SGLT2i in patients with DM and HTN, and these reductions are of a magnitude that is likely to be clinically significant. SGLT2i agents also appear to have beneficial effects on morning, evening and nocturnal home BP. Greater reductions in BP during treatment with SGLT2i have been reported in patient subgroups with higher body mass index, and in those with higher baseline BP. Other documented beneficial effects of SGLT2i include reductions in arterial stiffness and the potential to decrease the apnea-hypopnea index in patients with DM and obstructive sleep apnea. Recent guidelines highlight the important role of SGLT2i as part of the pharmacological management of patients with DM and HTN, and recommend consideration of SGLT2i early in the clinical course to reduce all-cause and CVD mortality in patients with T2DM and CVD. Overall, available data support a role for SGLT2i as effective BP-lowering agents in patients with T2DM and poorly controlled HTN, irrespective of baseline glucose control status. Sustained improvements in 24-hour BP and the 24-hour BP profile are likely to contribute to the CVD benefits of SGLT2i treatment.

Photoplethysmographic Prediction of the Ankle-Brachial Pressure Index through a Machine Learning Approach

Cardiovascular disease is a leading cause of death. Several markers have been proposed to predict cardiovascular morbidity. The ankle-brachial index (ABI) marker is defined as the ratio between the ankle and the arm systolic blood pressures, and it is generally assessed through sphygmomanometers. An alternative tool for cardiovascular status assessment is Photoplethysmography (PPG). PPG is a non-invasive optical technique that measures volumetric blood changes induced by pulse pressure propagation within arteries. However, PPG does not provide absolute pressure estimation, making assessment of cardiovascular status less direct. The capability of a multivariate data-driven approach to predict ABI from peculiar PPG features was investigated here. ABI was measured using a commercial instrument (Enverdis Vascular Explorer, VE-ABI), and it was then used for a General Linear Model estimation of ABI from multi-site PPG in a supervised learning framework (PPG-ABI). A Receiver Operating Characteristic (ROC) analysis allowed to investigate the capability of PPG-ABI to discriminate cardiovascular impairment as defined by VE-ABI. Findings suggested that ABI can be estimated form PPG (r = 0.79) and can identify pathological cardiovascular status (AUC = 0.85). The advantages of PPG are simplicity, speed and operator-independency, allowing extensive screening of cardiovascular status and associated cardiovascular risks.

The HOPE Asia Network activity for "zero" cardiovascular events in Asia: Overview 2020

The impact of hypertension-related cardiovascular disease and target organ damage, and therefore the benefits of blood pressure (BP) control, is greater in Asian than in Western countries. Asia-specific features of hypertension and its effective management are important and active areas of research. The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was formed in 2016 and is now a member of the World Hypertension League. The main goal of the HOPE Asia Network is to improve the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia. Considerable work has already been done on the journey to achieving this goal. We have shown that BP control status in Asia differs between countries, and even between regions within the same country. Several expert panel consensus recommendations and clinical guidance papers are available to support the use of home and ambulatory BP monitoring in the region. In addition, the AsiaBP@Home study prospectively investigated home BP control status across 15 specialist centers using the same validated device and measurement schedule. We have also proposed the concept of systemic hemodynamic atherothrombotic syndrome (SHATS), a vicious cycle of BP variability and vascular disease on cardiovascular events and organ damage, and suggested a SHATS score for risk stratification for clinical practice. This special issue of the journal collates Asia-specific resources and data, contributing to advances in hypertension management and cardiovascular disease prevention in the region.

Renal Denervation in Asia: Consensus Statement of the Asia Renal Denervation Consortium

The Asia Renal Denervation Consortium consensus conference of Asian physicians actively performing renal denervation (RDN) was recently convened to share up-to-date information and regional perspectives, with the goal of consensus on RDN in Asia. First- and second-generation trials of RDN have demonstrated the efficacy and safety of this treatment modality for lowering blood pressure in patients with resistant hypertension. Considering the ethnic differences of the hypertension profile and demographics of cardiovascular disease demonstrated in the SYMPLICITY HTN (Renal Denervation in Patients With Uncontrolled Hypertension)-Japan study and Global SYMPLICITY registry data from Korea and Taiwan, RDN might be an effective hypertension management strategy in Asia. Patient preference for device-based therapy should be considered as part of a shared patient-physician decision process. A practical population for RDN treatment could consist of Asian patients with uncontrolled essential hypertension, including resistant hypertension. Opportunities to refine the procedure, expand the therapy to other sympathetically mediated diseases, and explore the specific effects on nocturnal and morning hypertension offer a promising future for RDN. Based on available evidence, RDN should not be considered a therapy of last resort but as an initial therapy option that may be applied alone or as a complementary therapy to antihypertensive medication.

2020 Consensus summary on the management of hypertension in Asia from the HOPE Asia Network

Hypertension professionals from Asia have been meeting together for the last decade to discuss how to improve the management of hypertension. Based on these education and research activities, the Hypertension, brain, cardiovascular and renal Outcome Prevention and Evidence in Asia (HOPE Asia) Network was officially established in June 2018 and includes experts from 12 countries/regions across Asia. Among the numerous research and review papers published by members of the HOPE Asia Network since 2017, publications in three key areas provide important guidance on the management of hypertension in Asia. This article highlights key consensus documents, which relate to the Asian characteristics of hypertension, home blood pressure monitoring (HBPM), and ambulatory blood pressure monitoring (ABPM). Hypertension and hypertension-related diseases are common in Asia, and their characteristics differ from those in other populations. It is essential that these are taken into consideration to provide the best opportunity for achieving "perfect 24-hour blood pressure control", guided by out-of-office (home and ambulatory) blood pressure monitoring. These region-specific consensus documents should contribute to optimizing individual and population-based hypertension management strategies in Asian country. In addition, the HOPE Asia Network model provides a good example of the local interpretation, modification, and dissemination of international best practice to benefit specific populations.

Diversity of and initiatives for hypertension management in Asia-Why we need the HOPE Asia Network

The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was set up to improve the management of hypertension in Asia with the ultimate goal of achieving "zero" cardiovascular events. Asia is a diverse continent, and the prevalence of hypertension has increased over the last 30 years. There are a number of Asia-specific features of hypertension and hypertension-related cardiovascular complications, which means that a region-specific approach is needed. White-coat hypertension will become more of an issue over time as Asian populations age, and masked hypertension is more prevalent in Asian than in Western countries. Identifying and treating masked hypertension is important to reduce cardiovascular risk. Abnormal patterns of blood pressure (BP) variability common in Asia include exaggerated early morning BP surge and nocturnal hypertension. These are also important cardiovascular risk factors that need to be managed. Home blood pressure monitoring (HBPM) is an important tool for detecting white-coat and masked hypertension, and monitoring BP variability, and practices in Asia are variable. Use of HBPM is important given the Asia-specific features of hypertension, and strategies are needed to improve and standardize HBPM usage. Development of HBPM devices capable of measuring nocturnal BP along with other information and communication technology-based strategies are key developments in the widespread implementation of anticipation medicine strategies to detect and prevent cardiovascular events in patients with hypertension. Region-wide differences in hypertension prevalence, control, and management practices in Asia highlight the importance of information sharing to facilitate best practices.

Rationale, design, and baseline characteristics of the Cardiovascular Prognostic COUPLING Study in Japan (the COUPLING Registry)

Vascular biomarkers, including the cardio-ankle vascular index (CAVI), are increasingly being recognized as important indicators of cardiovascular risk. CAVI has been shown to have good discriminative ability for detecting new-onset hypertension, but results of studies investigating cardiovascular risk prediction are inconsistent. Furthermore, there is a lack of data on the prognostic value of changes in CAVI over time. The Cardiovascular Prognostic Coupling study was designed to determine the impact of baseline CAVI and changes in CAVI on cardiovascular events in a Japanese cohort. The design of the ongoing, multicenter, prospective, observational registry and baseline characteristics of the enrolled population are reported. Eligible consecutive patients were aged ≥30 years, had ≥1 cardiovascular risk factor, and were being treated according to relevant Japanese guidelines. The primary outcome is time to onset of a major cardiovascular event (a composite of cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage, stroke of unknown etiology, myocardial infarction, cardiovascular intervention for angina pectoris, and sudden death). Screening and enrollment occurred over a period of 3 years, followed by ≥7 years of follow-up, with CAVI determined annually. A total of 5279 patients were registered, of whom 5109 had baseline data available and will be included in future analyses. Mean CAVI at baseline was 8.8 ± 1.4. The proportion of patients with CAVI of <8, 8-10 or >10 was 25.3%, 57.0%, and 17.7%, respectively. Data from this registry should provide information on the significance of baseline CAVI and change in CAVI as indicators of cardiovascular prognosis in a representative patient population.