Ethnic Differences in the Degree of Morning Blood Pressure Surge and in Its Determinants Between Japanese and European Hypertensive Subjects

Ambulatory blood pressure monitoring. Current status and future perspectives

Ambulatory Blood Pressure Monitoring (ABPM) is considered the best method for obtaining a reliable estimation of the true blood pressure. Average values obtained during the whole 24-hour period, or during daytime and nighttime periods are better correlated with the risk of mortality and cardiovascular disease compared to clinic or office blood pressure. Indeed, nighttime blood pressure, a measure only obtained through ABPM, is the most powerful risk predictor. ABPM is complementary to clinic blood pressure measurement and allows the definition of blood pressure phenotypes, such as "white-coat or masked hypertension, when clinic and ABPM measurements show discrepancy in normal values. Additional potentially relevant features include blood pressure variability, such as nocturnal blood pressure decline, morning surge or short-term variability, as determined by standard deviation or the coefficient of variation.

A blunted nocturnal blood pressure decline is associated with all-cause and cardiovascular mortality

OBJECTIVE

It has been suggested that a blunted nocturnal blood pressure (BP) decline is associated with a poor prognosis. Nevertheless, it remains unclear if an abnormal dipping is deleterious per se or it merely reflects an elevated BP during sleep. We aimed to assess the prognostic value of nocturnal BP decline, with or without concomitant elevated nocturnal BP.

METHODS

Vital status and cause of death were obtained from death certificates in 59 124 patients, enrolled in the Spanish ABPM Registry between 2004 and 2014 (median follow-up: 10 years). The association between night-to-day ratio (NDR) and dipping patterns (extreme dippers, dippers, reduced dippers, and risers) with all-cause and cardiovascular mortality were evaluated by Cox-proportional models adjusted for clinical confounders and 24 h blood pressure.

RESULTS

NDR was associated with all-cause mortality [hazard ratio for 1SD change: 1.15; 95% confidence interval (CI) 1.13-1.17]. Reduced dippers (1.13; 1.06-1.20) and risers (1.41; 1.32-1.51) were associated with an increased risk of all-cause death, whereas extreme dippers (0.90; 0.79-1.02) were not. Elevated NDR (≥0.9) in the absence of elevated night SBP (<120 mmHg) was associated with an increased risk of death (1.13; 1.04-1.22), as well as elevated night SBP but normal NDR (1.38; 1.26-1.50), and the combination of both abnormalities (1.56; 1.46-1.66). Similar results were obtained for cardiovascular mortality.

CONCLUSION

Abnormalities in the circadian pattern are associated with an increased risk of all-cause and cardiovascular mortality. This is maintained even in the absence of nocturnal BP elevation.

Clinical studies on pharmacological treatment of hypertension in Japan

Differences in the epidemiology and phenotypes of hypertension in Japan compared with Western countries mean that optimal approaches to the pharmacological management of hypertension should be based on local data. Fortunately, there is a large body of evidence from studies conducted in Japanese populations to inform guidelines and treatment decisions. This article highlights treatment recommendations and BP targets for Japanese patients with hypertension, and summarizes key literature supporting these recommendations. The latest version of the Japanese Society of Hypertension (JSH) guidelines is consistent with US and European guidelines in recommending that the general BP target should be <130/80 mmHg for office blood pressure (BP) and <125/75 mmHg for home BP. There is good local evidence to support these targets. The JSH guidelines also strongly recommend that antihypertensive therapy is managed and monitored based on home BP, due to the closer association of this parameter with cardiovascular risk compared with office BP. Japan is a leader in out-of-office BP research, meaning that there is good evidence for the Japanese recommendations. Key features of antihypertensive agents for use in Japanese patients with hypertension include the ability to reduce stroke risk provide antihypertensive efficacy throughout the 24-h dosing period. Calcium channel blockers appear to be particularly effective in Asian populations, and are the most commonly prescribed agents in Japan. Again consistent with international recommendations, antihypertensive therapy should be started with a combination of agents to maximize the chances of achieving target BP.

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.

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.

Management of Hypertension in the Asia-Pacific Region: A Structured Review

This article reviews available evidence regarding hypertension management in the Asia-Pacific region, focussing on five research questions that deal with specific aspects: blood pressure (BP) control, guideline recommendations, role of renin-angiotensin-aldosterone system (RAAS) inhibitors in clinical practice, pharmacological management and real-world adherence to guideline recommendations. A PubMed search identified 2537 articles, of which 94 were considered relevant. Compared with Europeans, Asians have higher systolic/diastolic/mean arterial BP, with a stronger association between BP and stroke. Calcium channel blockers are the most-commonly prescribed monotherapy in Asia, with significant variability between countries in the rates of angiotensin-converting enzyme inhibitors (ACEis)/angiotensin-receptor blockers (ARBs) and single-pill combination (SPC) use. In clinical practice, ARBs are used more commonly than ACEis, despite the absence of recommendation from guidelines and clinical evidence supporting the use of one class of drug over the other. Ideally, antihypertensive treatment should be tailored to the individual patient, but currently there are limited data on the characteristics of hypertension in Asia-Pacific individuals. Large outcome studies assessing RAAS inhibitor efficacy and safety in multi-national Asian populations are lacking. Among treated patients, BP control rates were ~ 35 to 40%; BP control in Asia-Pacific is suboptimal, and disproportionately so compared with Western nations. Strategies to improve the management of hypertension include wider access/availability of affordable treatments, particularly SPCs (which improve adherence), effective public health screening programs targeting patients to drive health-seeking behaviours, an increase in physician/patient awareness and early implementation of lifestyle changes. A unified Asia-Pacific guideline on hypertension management with pragmatic recommendations, particularly in resource-limited settings, is essential.

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.

Mediating effect of subclinical inflammation on the process of morning hypertension leading to atrial fibrillation in community-based older adults

BACKGROUND

The impacts and mechanisms of morning hypertension (MHT) on the risk of new-onset atrial fibrillation (AF) in the elderly have not been clarified. We aimed to investigate an association between MHT and new-onset AF and explore a mediating effect of subclinical inflammation on this association.

METHODS

From 2008 to 2010, 1789 older adults aged ≥60 years were recruited in Shandong area, China. Morning blood pressure (BP) was assessed using 24-hour ambulatory BP monitoring. MHT was defined as BP ≥ 135/85 mm Hg during the period from wake time to 0900 a.m. Subclinical inflammation was assessed by hypersensitive C-reactive protein (hsCRP), tumor necrosis factor-alpha (TNF-α), systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and galectin-3. New-onset AF was rated during the follow-up period.

RESULTS

Over an average 129.0 [standard deviation (SD): 21.58] months of follow-up, the hazard ratio of new-onset AF in MHT patients was 1.39 (95% confidence interval: 1.01 to 1.91) compared with non-MHT participants (Padjusted = 0.027). The risk of new-onset AF was 1.17-fold with one-SD increment of morning systolic BP. Subclinical inflammation was significantly associated with new-onset AF. The hazard ratios of new-onset AF were 2.29, 2.04, 2.08, 2.08, 2.03, and 3.25 for one-SD increment in hsCRP, TNF-α, SII, NLR, PLR, and galectin-3, respectively (Padjusted < 0.001). The analysis showed that hsCRP, TNF-α, SII, NLR, PLR, and galectin-3 separately mediated the process of MHT inducing new-onset AF (Padjusted < 0.05).

CONCLUSIONS

MHT is associated with an increased risk of new-onset AF. The subclinical inflammation might play a mediating role in this association.

Associations of blood pressure trajectories in early life with target organ damage in midlife : a 30-year cohort study

Hypertension is a pivotal factor in cardiovascular risk. However, the association of longitudinal blood pressure (BP) trajectories in the early life and cardiovascular risk assessed by target organ damage (TOD) in adulthood is poorly reported. The objective of this study was to identify the association between systolic BP, diastolic BP, and mean atrial pressure (MAP) trajectories early in life with a single or multiple TOD in later life. We identified BP trajectories from 6 to 45 year-old using group-based trajectory models among 2430 individuals in the Hanzhong Adolescent Hypertension Study and examined the relationship between BP trajectories and cardiovascular risk in later life. Four discrete long-term systolic BP, diastolic BP, and MAP trajectories were identified, namely, low stable, moderate stable, high stable (low increasing), and moderate increasing groups, based on the BP levels at baseline and in the 30-year follow-up. The carotid intima-media thickness were higher in persistently high or increasing trajectories in comparison to the low stable group. Individuals with deteriorative trajectories during early life were at an increased risk of suffering from a single TOD, including left ventricular hypertrophy (LVH) and carotid atherosclerosis (CA) in middle age (36-49 years old). Moreover, higher BP trajectories were correlated with the presence of combined TODs load stage which were assessed by CA, LVH, arteriosclerosis and subclinical renal damage (SRD). Higher longitudinal BP trajectories early in life were associated with increased cardiovascular risk in midlife, and identifying BP trajectories in early life can help screen individuals with TOD later. LVH, left Ventricular Hypertrophy; CA, carotid atherosclerosis; SRD, subclinical renal damage; TOD, target organ damage.

A comparative analysis of ambulatory blood pressure characteristics in acute stroke and non-stroke Indian patients

OBJECTIVE

The objective of this study is to identify 24-h blood pressure (BP) characteristics after acute stroke in Indian hospitalized patients.

METHODS

In total, 769 patients [284 women (36.9%)] admitted at a hospital in South India were analyzed. Of these, 364 patients (47.3%) had recently experienced stroke. All patients underwent ambulatory blood pressure measurement (ABPM) so that ABPM patterns and ABPM risk parameters of stroke and non-stroke patients could be compared. Additionally, to investigate the relationship between ABPM parameters and stroke, a stepwise logistic regression analysis was employed.

RESULTS

Stroke patients had significantly higher BP than non-stroke patients (24-h ABP: 145.0 ± 22.1 vs. 133.7 ± 20.5 mmHg, P < 0.001), with similar dipping status. ABPM parameters mostly associated with stroke (all P < 0.001) were: nighttime [odds ratios (OR): 1.587, 95% confidence interval (95% CI): 1.341-1.885], 24-h (1.584, 1.34-1.881), minimum nighttime (1.582, 1.339-1.879), daytime (1.540, 1.304-1.827), and morning SBP (1.517, 1.287-1.797). Non-dipping status was relatively more common in stroke patients (79% vs. 71%, P < 0.05) but dipping percentage did not show a significant linear relationship with stroke.

CONCLUSION

Several ABPM characteristics were strongly associated with stroke in Indian hospitalized patients. Specifically, minimum nighttime and average morning SBP may be considered as important and practical parameters for its relationship with stroke.

Home blood pressure-centered approach - from digital health to medical practice: HOPE Asia Network consensus statement 2023

Recent innovations in digital technology have enabled the simultaneous accumulation, and the linking and analysis of time-series big data relating to several factors that influence blood pressure (BP), including biological indicators, physical activity, and environmental information. Various approaches can be used to monitor BP: in the office/clinic; at home; 24-h ambulatory recording; or with wearable and cuffless devices. Of these, home BP monitoring is a reliable and convenient method, and is recommended for hypertension management by current national and international guidelines. This recommendation is based on evidence showing that home BP is an important predictor of cardiovascular, cerebrovascular and kidney disease in patients with hypertension. In addition, lifetime personalized health record (PHR)-based home BP with telemonitoring combined with co-interventions has been shown to lower BP more effectively than the traditional approach based on office BP. Thus, home BP represents a key metric for personalized anticipation medicine, from digital healthcare to digital medicine. This paper summarizes the latest evidence on home BP monitoring and proposes a Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network consensus on a home BP-centered approach to the management of hypertension.

Association between Morning Surge and Left Ventricular Hypertrophy in Obese Hypertensive Patients

BACKGROUND

Weight gain can trigger mechanisms that increase blood pressure. Nevertheless, obesity causes structural changes in the myocardium, including increased ventricular mass, atrial dilatation, and diastolic and systolic dysfunction. Additionally, blood pressure variations, like morning surge (MS) in obese hypertensive patients may have clinical relevance in cardiovascular events. Although morning blood pressure surge is a physiological phenomenon, excess MS can be considered an independent risk factor for cardiovascular events.

OBJECTIVE

To evaluate MS values and their association with left ventricular hypertrophy (LVH) and nocturnal dipping (ND) in obese and non-obese hypertensive patients.

METHODS

A cross-sectional study that evaluated BP measurements by ambulatory blood pressure monitoring (ABPM) and the presence of LVH by echocardiography in 203 hypertensive outpatients, divided into two groups: 109 non-obese and 94 obese hypertensives patients. The significance level was set at 0.05 in two-tailed tests.

RESULTS

A MS above 20 mmHg by ABPM was detected in 59.2% of patients in the non-obese group and 40.6% in the obese group. LVH was found in 18.1% and 39.3% of patients in the non-obese and obese groups, respectively, p<0.001. In the "obese group", it was observed that a MS>16 mmHg was associated with LVH, [prevalence ratio: 2.80; 95%CI (1.12-6.98), p=0.03]. For the non-obese group, the cut-off point of MS for this association was >22 mmHg.

CONCLUSION

High MS was positively associated with LVH, with a particular behavior in the hypertensive obese group.

Blood Pressure Variability as a Risk Factor for Cardiovascular Disease: Which Antihypertensive Agents Are More Effective?

Blood pressure oscillations during different time scales, known as blood pressure variability (BPV), have become a focus of growing scientific interest. BPV can be measured at long-term (seasonal variability or visit-to-visit), at mid-term (differences in consecutive days or weeks) or at short-term (day-night differences or changes induced by other daily activities and conditions). An increased BPV, either at long, mid or short-term is associated with a poor cardiovascular prognosis independently of the amount of blood pressure elevation. There is scarce evidence on the effect of different antihypertensive treatments on BPV, but some observational and interventional studies suggest that calcium channel blockers in general, and particularly amlodipine, either in monotherapy or combined with renin-angiotensin system blockers, can reduce BPV more efficiently than other antihypertensive drugs or combinations. Nevertheless, there are several aspects of the relationship between BPV, antihypertensive treatment, and clinical outcomes that are still unknown, and more work should be performed before considering BPV as a therapeutical target in clinical practice.

Controversies in Hypertension III: Dipping, Nocturnal Hypertension, and the Morning Surge

A comprehensive approach to hypertension requires out-of-office determinations by home and/or ambulatory monitoring. The 4 phenotypes comparing office and out-of-office pressures in treated and untreated patients include normotension, hypertension, white-coat phenomena, and masked phenomena. Components of out-of-office pressure may be equally as important as mean values. Nighttime pressures are normally 10 - 20% lower than daytime (normal "dipping"). Abnormalities include dipping more than 20% (extreme dippers), less than 10 % (non-dippers), or rising above daytime (risers) and have been associated with elevated cardiovascular risk. Nighttime pressure may be elevated (nocturnal hypertension) in isolation or together with daytime hypertension. Isolated nocturnal hypertension theoretically changes white-coat hypertension to true hypertension and normotension to masked hypertension. Pressure normally peaks in the morning hours ("morning surge") when cardiovascular events are most common. Morning hypertension may result from residual nocturnal hypertension or an exaggerated surge and has been associated with enhanced cardiovascular risk, especially in Asian populations. Randomized trials are needed to determine whether altering therapy based solely on either abnormal dipping, isolated nocturnal hypertension, and/or an abnormal surge is justified.

Inconsistent Control Status of Office, Home, and Ambulatory Blood Pressure All Taken Using the Same Device: The HI-JAMP Study Baseline Data

BACKGROUND

Inconsistencies between the office and out-of-office blood pressure (BP) values (described as white-coat hypertension or masked hypertension) may be attributable in part to differences in the BP monitoring devices used.

METHODS

We studied consistency in the classification of BP control (well-controlled BP vs. uncontrolled BP) among office, home, and ambulatory BPs by using a validated "all-in-one" BP monitoring device. In the nationwide, general practitioner-based multicenter HI-JAMP study, 2,322 hypertensive patients treated with antihypertensive drugs underwent office BP measurements and 24-hour ambulatory BP monitoring (ABPM), consecutively followed by 5-day home BP monitoring (HBPM), for a total of seven BP measurement days.

RESULTS

Using the thresholds of the JSH2019 and ESC2018 guidelines, the patients with consistent classification of well-controlled status in the office (<140 mmHg) and home systolic BP (SBP) (<135 mmHg) (n = 970) also tended to have well-controlled 24-hour SBP (<130 mmHg) (n = 808, 83.3%). The patients with the consistent classification of uncontrolled status in office and home SBP (n = 579) also tended to have uncontrolled 24-hour SBP (n = 444, 80.9%). Among the patients with inconsistent classifications of office and home BP control (n = 803), 46.1% had inconsistent ABPM-vs.-HBPM out-of-office BP control status. When the 2017 ACC/AHA thresholds were applied as an alternative, the results were essentially the same.

CONCLUSIONS

The combined assessment of the office and home BP is useful in clinical practice. Especially for patients whose office BP classification and home BP classification conflict, the complementary clinical use of both HBPM and ABPM might be recommended.

Concept, study design, and baseline blood pressure control status of the nationwide prospective HI-JAMP study using multisensor ABPM

The Home-Activity Information and Communication Technology (ICT)-based Japan Ambulatory Blood Pressure Monitoring Prospective (HI-JAMP) study is a nationwide general practitioner-based cohort of medicated hypertensive patients that began in 2017. The primary objective of this study is to clarify which blood pressure (BP) measure is the best predictor of cardiovascular disease: office, home, or ambulatory BP. To this end, we used a newly developed ICT-based multisensor ambulatory BP monitoring (IMS-ABPM) device (TM-2441; A&D Company), which can also be used for home BP monitoring and is equipped with a high-sensitivity actigraph, a thermometer, and a barometer. This is the first study to evaluate three hemodynamic properties under resting home and active ambulatory conditions using the same device: (1) BP variability; (2) trigger-specific BP sensitivity to physical activity, temperature, and atmospheric pressure; and (3) central hemodynamics. A total of 2754 patients were enrolled, and 2731 patients with the required number of ambulatory BP readings (at least 6 daytime and 3 nighttime readings) were included in the final analysis. The overall patient group showed worse control of morning and nighttime BPs compared to office and daytime BPs, and the control rate was also poor among patients with a higher number of antihypertensive drugs. In conclusion, the baseline data of the HI-JAMP study demonstrated that morning home and nighttime BP remain difficult to control even among patients taking two or more hypertensive agents. By simultaneously considering office, home, and ambulatory BPs, the HI-JAMP study will contribute to the development of hypertension management strategies and new BP indices.

Position of 24-hour ambulatory blood pressure monitoring in modern practice

Currently, 24-hour ambulatory blood pressure (BP) monitoring (ABPM) is the gold standard for diagnosing hypertension (HTN) and evaluating the effectiveness of antihypertensive therapy. The method provides information about some BP parameters that cannot be obtained in any other way. ABPM is reasonable in any patient with a documented increase in BP, especially if specific BP phenotypes are suspected: white coat HTN and masked HTN. Antihypertensive therapy under the ABPM, on average, is more economical and is not associated with overprescribing of drugs and their combinations. Based on the ABPM data, calculating a number of additional indicators of the 24-hour BP profile is possible, but their scope is still limited to the research field. In the conclusion on ABPM data, the results of office BP measurement and antihypertensive therapy should be indicated.

Diagnostic agreement of masked uncontrolled hypertension detected by ambulatory blood pressure and home blood pressure measured by an all-in-one BP monitoring device: The HI-JAMP study

Masked hypertension is defined by office blood pressure (BP) in the controlled-BP range while out-of-office BP measured by ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) is in the uncontrolled range. However, diagnosis of masked hypertension may differ if assessed by different out-of-office BP indices. This study aims to investigate the diagnostic agreement of masked uncontrolled hypertension (MUHT) detected by ABPM indices (ABPM-MUHT) and HBPM indices (HBPM-MUHT) using the same all-in-one device (TM2441; A&D Company). The present study enrolled a total of 2322 treated hypertensive patients (males 53.2%, average age 69.2 ± 11.5 years) from the Home-Activity ICT-based Japan Ambulatory Blood Pressure Monitoring Prospective (HI-JAMP) Study, who consecutively underwent office BP monitoring, 24-h ABPM (at 30-min intervals), and 5-day HBPM (twice each morning and evening) using the same device. When out-of-office BP control status was assessed only by 24-h average SBP or by the average of morning and evening SBP, the diagnostic agreement of MUHT detected by ABPM and HBPM was 29.7% among the 445 patients with any type of MUHT. When out-of-office BP indices in each time-window were simultaneously assessed, the diagnostic agreement increased to 40-45.7%. Our results indicated the importance of assessing BPs at various times of day, especially morning hours, for perfect hypertension management. Diagnosis of masked hypertension only by an averaged BP index, without considering specific time-windows, might underestimate cardiovascular risk.

The HOPE Asia network 2022 up-date consensus statement on morning hypertension management

Morning hypertension is an important clinical target in the management of hypertension for perfect 24-h blood pressure (BP) control. Morning hypertension is generally categorized into two types: "morning surge" type and "sustained nocturnal and morning hypertension" type. The "morning surge" type is characterized by an exaggerated morning blood pressure surge (MBPS), and the "sustained nocturnal and morning hypertension" type with continuous hypertension from nighttime to morning (non-dipper/riser type). They can be detected by home and ambulatory blood pressure measurements (HBPM and ABPM). These two forms of morning hypertension both increase the risk of cardiovascular and renal diseases, but may occur via different pathogenic mechanisms and are associated with different conditions. Morning hypertension should be treated to achieve a morning BP level of < 135/85 mmHg, regardless of the office BP. The second target morning BP levels is < 125/75 mmHg for high-risk patients with morning hypertension and concomitant diseases. Morning hypertension is more frequently found in Asians, than in Westerners. Thus, the management of morning hypertension is especially important in Asia. The detection of morning hypertension and the individual home BP-guided treatment approach targeting morning BP in combination with ABPM, and the optimal treatment of morning hypertension would reduce cardiovascular events in Asia.

Comparing effect of definition of diurnal periods by diary, fixed periods, and actigraphy on ambulatory blood pressure parameters in a Chinese population

BACKGROUND

Reliable measurement of daytime and night-time blood pressure (BP), and degree of BP dipping during sleep during ambulatory blood pressure monitoring (ABPM) requires an accurate definition of sleep time (diurnal definition). However, superiority of any diurnal definition on ABPM remains unclear. The present study compared mean daytime and night-time SBP and DBP using different methods for diurnal definition: patient's diary, wide-defined and narrow-defined fixed periods, and actigraphy, in a Chinese population with diagnosed essential hypertension. We hypothesize that BP values from actigraphy are different from BP obtained by other methods and associated with end-organ damage (i.e. impaired renal function, proteinuria, left ventricular hypertrophy).

METHODS

From April 2017 to October 2019, 203 Chinese patients diagnosed with hypertension were recruited prospectively from Lek Yuen Clinic and 179 completed a 48-h ABPM study, wearing a validated actigraph and completed a sleep diary. Presence of end-organ damage was retrieved from the computerized clinical management system. The differences in the mean BP values provided by different diurnal definition were compared using paired t tests and Bland-Altman plots. The prevalence of elevated BP, dipping status categories, overall percentage agreement and the Kappa statistic were calculated by pairwise comparisons between different diurnal definitions. The reproducibility was also estimated and logistic regression was used to examine the relationship between BP values from different diurnal definitions and end-organ damage.

RESULTS

Mean daytime and night-time BP values were similar regardless of the definition used (mean difference <2 mmHg). Kappa statistics and overall percentage agreement found excellent agreement between different definitions to diagnose elevated daytime BP (Kappa ranged from 0.80 to 0.91) and night-time BP (Kappa ranged from 0.74 to 0.89). Good agreement to diagnose nondipping was also detected (Kappa ranged from 0.65 to 0.78). Furthermore, ABPM values were most reproducible when diurnal periods were defined by patient's diary (intra-class correlation coefficient = 0.82-0.93). Daytime and night-time BP values obtained using different diurnal definitions did not differ in their association to end-organ damage.

CONCLUSION

Differing definitions of diurnal periods provide similar mean BP values among a Chinese hypertensive population and have good agreement for diagnosis of elevated BP and dipping status. In individual patients, clinicians should be aware that different definitions of diurnal periods can lead to a 3-5 mmHg difference in patient's BP values and may affect the diagnosis of elevated BP in patients with BP close to diagnostic thresholds. The current study supports using the patient's diary to define diurnal periods, which provided the best reproducibility.

2022 Malaysian Working Group Consensus Statement on Renal Denervation for management of arterial hypertension

Hypertension is highly prevalent and a major contributor to cardiovascular mortality and morbidity. In spite of the availability of efficacious, safe and affordable anti-hypertensive drugs, hypertension remains poorly controlled in the majority of hypertensive patients. Various reasons including non-adherence to the anti-hypertensive drugs, account for the poor control. Resistant hypertension is also one of the reasons for poor control of blood pressure (BP). The sympathetic nervous system (SNS) has long been recognized as one of the determinants in the pathophysiology of a raised BP. Overactivity of the SNS is a contributor to sustained arterial hypertension. Renal denervation (RDN) is increasingly recognized as a safe and effective adjunctive therapy to control BP with or without pharmacotherapy. Hence for patients who remain uncontrolled despite all efforts, renal denervation (RDN) is a novel treatment that can potentially improve BP control, hence reducing the major adverse cardiovascular events (MACE). More recent randomized, sham control trials of RDN have shown that RDN produces a sustained lowering of BP. To date, this lowering of BP through RDN is maintained for at least 3 years. Furthermore, this procedure has been found to be safe. Hence this consensus summarises the science behind RDN and the available clinical data to support the use of this therapy. It is hoped that this consensus will offer guidance on the importance of identifying patients who will benefit most from this therapy. A multidisciplinary team approach in the management of the patient undergoing RDN is recommended.

Differences of blood pressure measured at clinic versus at home in the morning and in the evening in Europe and Asia: A systematic review and meta-analysis

Numerous studies have indicated that there might be great differences among different populations in Europe and Asia in terms of home morning and evening blood pressure (BP). Thus, the authors performed a systematic review to determine the quantitative differences of BP measured at clinic versus at home in the morning and in the evening in Europe and Asia. PubMed, Embase, and Scopus databases were searched up to October 2021. Studies that compared clinic BP with home morning and (or) home evening BP in European and Asian populations were included. A random effect model was applied to pool the differences between clinic BP and home morning/evening BP. Thirty‐five studies, for a total of 49 432 patients, were included in this meta‐analysis. Mean clinic systolic blood pressure (SBP) values were significantly higher than home morning SBP values by 3.79 mmHg (95% CI, 2.77–4.80). The differences were much larger in Europe [(6.53 mmHg (95% CI, 4.10–8.97)] than in Asia [(2.70 mmHg (95% CI, 1.74–3.66)], and the region was a significant predictor for the differences. Mean clinic SBP values were also significantly higher than home evening SBP values by 6.59 mmHg (95% CI, 4.98–8.21). The differences were much smaller in Europe [5.85 mmHg (95% CI, 3.24–8.45)] than in Asia [7.13 mmHg (95% CI, 4.92–9.35)], while age and clinic SBP might contribute to it. Our findings showed that the difference between clinic and home morning SBP was much larger in European than Asian populations, whereas the difference between clinic and home evening SBP was the opposite. The differing characteristics of the region, ethnic, age, and clinic BP might explain the diversities.

Renal denervation in resistant hypertension: a review of clinical trials and future perspectives

A previous report using the National Health and Nutrition Examination Survey demonstrated an increase in the prevalence of resistant hypertension, which does not respond to traditional therapy and medication. Studies using various animal hypertensive models have demonstrated significant blood pressure (BP) reduction following renal artery denervation (RDN). Catheter-based RDN became available in clinical trials as a possible treatment option for resistant hypertension. Although first clinical trials of RDN have demonstrated the efficacy and safety of this treatment mortality for lowering BP in patients with resistant hypertension, the role of RDN has been questioned since the results of the Symplicity HTN-3 trial. Considering the ethnic differences demonstrated in the Symplicity HTN-Japan and Global Symplicity registry, by contrast, RDN might be an effective for resistant hypertension in Asian population. Here, we discuss RDN applications and technology, the old and new clinical evidence of RDN, patients' selection of RDN responder, and optimization of RDN procedure in this review. The available evidence demonstrates that RDN could be effective in carefully selected patients with resistant hypertension, paving the way for future research in this area.

Seven-action approaches for the management of hypertension in Asia - The HOPE Asia network

Asia is a large continent and there is significant diversity between countries and regions. Over the last 30 years, absolute blood pressure (BP) levels in Asia have increased to a greater extent than those in other regions. In diverse Asia‐Pacific populations, for choosing an Asia‐specific approach to hypertension management is important to prevent target organ damage and cardiovascular diseases. In this consensus document of HOPE Asia Network, we introduce seven action approaches for management of hypertension in Asia.

Catheter-based ultrasound renal denervation in patients with resistant hypertension: the randomized, controlled REQUIRE trial

Renal denervation is a promising new non-pharmacological treatment for resistant hypertension. However, there is a lack of data from Asian patients. The REQUIRE trial investigated the blood pressure-lowering efficacy of renal denervation in treated patients with resistant hypertension from Japan and South Korea. Adults with resistant hypertension (seated office blood pressure ≥150/90 mmHg and 24-hour ambulatory systolic blood pressure ≥140 mmHg) with suitable renal artery anatomy were randomized to ultrasound renal denervation or a sham procedure. The primary endpoint was change from baseline in 24-hour ambulatory systolic blood pressure at 3 months. A total of 143 patients were included (72 renal denervation, 71 sham control). Reduction from baseline in 24-hour ambulatory systolic blood pressure at 3 months was not significantly different between the renal denervation (-6.6 mmHg) and sham control (-6.5 mmHg) groups (difference: -0.1, 95% confidence interval -5.5, 5.3; p = 0.971). Reductions from baseline in home and office systolic blood pressure (differences: -1.8 mmHg [p = 0.488] and -2.0 mmHg [p = 0.511], respectively), and medication load, did not differ significantly between the two groups. The procedure-/device-related major adverse events was not seen. This study did not show a significant difference in ambulatory blood pressure reductions between renal denervation and a sham procedure in treated patients with resistant hypertension. Although blood pressure reduction after renal denervation was similar to other sham-controlled studies, the sham group in this study showed much greater reduction. This unexpected blood pressure reduction in the sham control group highlights study design issues that will be addressed in a new trial. CLINICAL TRIAL REGISTRATION: NCT02918305 ( http://www.clinicaltrials.gov ).

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.

Circadian variations in the occurrence of first-ever intracerebral hemorrhage from different sources of income: a hospital-based cross-sectional study

BACKGROUND

The onset time of intracerebral hemorrhage (ICH) may be closely related to the working style and living habits of people, which are determined by different income sources in China. Therefore, the purpose of our study was to investigate the Circadian Variations in the occurrence of ICH from different sources of income.

METHODS

This retrospective study enrolled 4,327 patients with first-ever ICH. Based on the time of day at which the patients developed symptoms, the classifiable onset time was assigned to one of eight three-hour intervals. And based on different income sources, they were categorized into three groups: Farmers, Wage-earners, and Freelancers. Demographic and risk factors of patients were then summarized, and the circadian variation of the 3 groups of patients' known time of onset and those stratified by sex and age were analyzed.

RESULTS

The frequency of ICH onset exhibited significant circadian variation among the 3 income groups, demonstrating a bimodal distribution in the daytime, with a nadir during the night (all P < 0.001). Three groups showed a significant initial peak between 06:01 and 09:00, and the same peak was observed in their subgroups of sex and age. In the 3 income source groups, there was a smaller second peak that between 15:01 and 18:00 for Farmers and Wage-earners and 18:01 and 21:00 for Freelancers. After stratification by sex and age, the second peak was between 18:01 and 21:00 for female in Farmers, female in Freelancers, under 65 years of age in Wage-earners and 65 years or older in Freelancers, while 15:01 and 18:00 for the other groups.

CONCLUSIONS

Different circadian variations of ICH onset time are found in patients with different income sources in southwest China's Chongqing Municipality cohort. Moreover, the frequency and distribution pattern of peak hours may be closely related to the working style and living habits of people with different income sources.

Characteristics of hypertension in obstructive sleep apnea: An Asian experience

Obstructive sleep apnea (OSA) is a risk of hypertension and is associated with cardiovascular disease (CVD) incidence. In Asian countries, the prevalence of OSA is high, as in Western countries. When blood pressure (BP) is evaluated in OSA individuals using ambulatory BP monitoring (ABPM), the BP phenotype often indicates abnormal BP variability, such as increased nighttime BP or abnormal diurnal BP variation, that is, non‐dipper pattern, riser pattern, and morning BP surge, and all these conditions have been associated with increased CVD events. Asians have a higher prevalence of increased nighttime BP or morning BP surge than Westerners. Therefore, this review paper focused on OSA and hypertension from an Asian perspective to investigate the importance of the association between OSA and hypertension in the Asian population. Such abnormal BP variability has been shown to be associated with progression of arterial stiffness, and this association could provoke a vicious cycle between abnormal BP phenotypes and arterial stiffness, a phenomenon recognized as systemic hemodynamic atherothrombotic syndrome (SHATS). OSA may be one of the background factors that augment SHATS. An oxygen‐triggered nocturnal oscillometric BP measurement device combined with a pulse oximeter for continuous SpO₂ monitoring could detect BP variability caused by OSA. In addition to treating the OSA, accurate and reliable detection and treatment of any residual BP elevation and BP variability caused by OSA would be necessary to prevent CVD events. However, more detailed detection of BP variability, such as beat‐by‐beat BP monitoring, would further help to reduce CV events.

Guidance on ambulatory blood pressure monitoring: A statement from the HOPE Asia Network

Hypertension is an important public health issue due to its association with a number of serious diseases, including cardiovascular disease and stroke. The importance of evaluating hypertension taking into account different blood pressure (BP) profiles and BP variability (BPV) is increasingly being recognized, and is particularly relevant in Asian populations given the specific features of hypertension in the region (including greater salt sensitivity and a high rate of nocturnal hypertension). Ambulatory BP monitoring (ABPM) is the gold standard for diagnosing hypertension and assessing 24-hour BP and provides data on several important parameters that cannot be obtained using any other form of BP measurement. In addition, ABPM parameters provide better information on cardio- and cerebrovascular risk than office BP. ABPM should be used in all patients with elevated BP, particularly those with unstable office or home BP, or who are suspected to have white-coat or masked hypertension. ABPM is also an important part of hypertension diagnosis and monitoring in high-risk patients. ABPM needs to be performed using a validated device and good practice techniques, and has a role both in hypertension diagnosis and in monitoring the response to antihypertensive therapy to ensure strict BP control throughout the 24-hour period. Use of ABPM in clinical practice may be limited by cost and accessibility, and practical education of physicians and patients is essential. The ABPM evidence and practice points in this document are based on the Hypertension Cardiovascular Outcome Prevention and Evidence (HOPE) Asia Network expert panel consensus recommendations for ABPM in Asia.

Differences in ambulatory blood pressure profiles between Japanese and Thai patients with hypertension /suspected hypertension

Ethnic differences in the profiles of hypertension and cardiovascular risk have been reported between Asians and Westerners. However, blood pressure (BP) profiles and the risk factors for cardiovascular disease might differ even among different Asian populations because of the diversity of cultures, foods, and environments. We retrospectively examined differences in 24-h BP profiles between 1051 Japanese (mean age, 62.5 ± 12.4 years; medicated hypertension, 75.7%) and 804 Thai (mean age, 56.9 ± 18.5 years; medicated hypertension, 65.6%) by using the Japanese and Thai ambulatory BP monitoring (ABPM) databases, in order to check the BP control status in treated hypertensives and to inform the clinical diagnosis of hypertension. The two populations had similar office systolic BP (SBP) (142.7 ± 20.0 vs 142.3 ± 20.6 mm Hg, p = .679). However, the Japanese population had higher 24-hr average and daytime SBP, and the Thai population had higher nighttime SBP even after adjusting for cardiovascular risk factors (all p < .05). Greater morning BP surge was observed in Japanese (31.2 vs 22.8 mm Hg, p < .001). Regarding nocturnal BP dipping status, the prevalence of riser status (higher nighttime than daytime SBP) was higher in the Thai population (30.5% vs 10.9%). These findings suggest that a substantial difference in 24-hr BP profiles exists between even neighboring countries in Asia.

Night-time systolic blood pressure and subclinical cerebrovascular disease: the Cardiovascular Abnormalities and Brain Lesions (CABL) study

AIMS

Although ambulatory blood pressure (BP) is a better predictor of cardiovascular outcomes than office BP, its association with subclinical cerebrovascular disease is not clarified. We investigated the associations of office and ambulatory BP values with subclinical cerebrovascular disease in a population based, predominantly elderly cohort without prior stroke.

METHODS AND RESULTS

Eight hundred and twenty-eight participants underwent 24-h ambulatory BP monitoring (ABPM), 2D echocardiography and brain magnetic resonance imaging in the Cardiac Abnormalities and Brain Lesion (CABL) study. Daytime, night-time, and 24-h BPs, nocturnal dipping pattern, morning surge (MS), and 24-h variability were assessed. Subclinical cerebrovascular disease was defined as silent brain infarcts (SBIs) and white matter hyperintensity volume (WMHV). The association of BP measures with the presence of SBI and upper quartile of log-WMHV (log-WMHV4) was analysed. SBIs were detected in 111 patients (13.4%). Mean log-WMHV was -0.99 ± 0.94. In multivariable analysis, only night-time systolic BP (SBP) was significantly associated with SBI [odds ratio (OR) 1.15 per 10 mmHg, P = 0.042], independent of cardiovascular risk factors, and pertinent echocardiographic parameters. Although daytime, night-time, 24-h BPs, and non-dipping pattern were all significantly associated with log-WMHV4 (all P < 0.05), night-time SBP showed the strongest association (OR 1.21 per 10 mmHg, P = 0.003) and was the sole independent predictor when tested against the other BP parameters. Office BP measures, MS, and BP variability were not associated with subclinical cerebrovascular disease in adjusted analyses.

CONCLUSION

Elevated night-time SBP is strongly associated with subclinical cerebrovascular disease. Night-time SBP by ABPM allows to identify individuals at higher risk of hypertensive brain injury.

Efficacy and safety of a combination antihypertensive drug (olmesartan plus azelnidipine): "Issues with hypertension studies in real-world practice"

Background: This study investigated whether a combination drug containing an angiotensin II receptor blocker (ARB) and a calcium channel blocker (CCB) could provide effective antihypertensive therapy.Methods: A multicenter, prospective, open-label study was conducted at the clinics of Clinical Research Network. The subjects had uncontrolled blood pressure (BP) despite ARB or CCB monotherapy. The effect on both office and home BP was examined after patients switched to a combination drug (REZ: containing 20 mg of olmesartan [OL] and 16 mg of azelnidipine [AZ]).Results: A total of 78 patients were enrolled. After switching to REZ, a significant and sustained reduction of office BP was observed. The proportion of patients who achieved the target for both office and home BP was an increase from 0% to 55%. Switching from amlodipine to REZ resulted in a significant and sustained decrease of office and home BP. There was also a significant decrease of home pulse rate (PR), but office PR was unchanged. To determine the accuracy of the BP and PR values reported by patients, the frequency of each number as the first digit was determined. The frequency of "0" was extremely high for both office and home BP values, and the same was noted for home PR values.Conclusion: The results of this study suggested that switching from a single drug to combination therapy with REZ could achieve a stronger antihypertensive effect. However, concern was raised regarding the methods of BP and PR measurement and recording in this clinical trial involving general practitioners.

Association of Circadian Rhythm of Blood Pressure and Cerebral Small Vessel Disease in Community-Based Elderly Population

BACKGROUND

Although it is accepted that the etiology of cerebral small vessel disease (CSVD) is associated with cardiovascular risk factors, the association between CSVD and the circadian rhythm of blood pressure (BP) is unclear. We aimed to determine if such an association existed in the elderly population.

METHOD

White matter hyperintensities (WMHs), lacunes, microbleeds, nocturnal dipping pattern (NDP), and morning surge in systolic blood pressure (SBP) were assessed in 2,091 participants ≥60 years of age.

RESULTS

During an average of 63 months of follow-up, WMH and the WMH-to-intracranial volume ratio were significantly increased in extreme dippers, nondippers, and reverse dippers than those in dippers (p < .001). For new-incident Fazekas scale ≥2, the hazard ratios were 1.77 (95% confidence interval [CI], 1.09-2.86) for extreme dippers, 2.20 (95% CI, 1.48-3.28) for nondippers, and 2.43 (95% CI, 1.59-3.70) for reverse dippers compared with dippers, and 1.04 (95% CI, 0.81-1.35) for higher morning surge compared with lower morning surge. Nondippers and reverse dippers were associated with higher risks of new-incident lacunes and microbleeds than dippers (p < .05). Higher morning surge was associated with a higher risk of new-incident microbleeds than lower morning surge (p < .05).

CONCLUSION

NDPs in SBP played an important role in CSVD, and the morning surge in SBP was associated with cerebral microbleeds in community-based elderly population beyond the average SBP level.

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.

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.

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.

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.

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.

Association of Extreme Nocturnal Dipping With Cardiovascular Events Strongly Depends on Age

Whether extreme dipping is associated with cardiovascular events (CVE) is unclear. The present study was conducted to test the hypothesis that the prognostic role of extreme dipping varies as a function of age. The analysis was performed in 10 868 participants (53% men) aged 53±15 (mean±SD) years enrolled in 8 prospective studies. Using the ambulatory systolic blood pressure nocturnal decline, we identified 4 groups: dippers (>10%–20%), nondippers (>0%–10%), reverse dippers (≤0%), and extreme dippers (>20%). The association between dipping category and CVE was estimated as a function of age using Cox models adjusted for sex, average 24-hour systolic blood pressure, and traditional risk factors. During a median follow-up of 5.7 years, there were a total of 829 CVE (168 fatal). For extreme dippers, no increase in risk of CVE was observed among the participants <70 years (hazard ratio, 0.99 [95% CI, 0.73–1.34]; P =0.93) compared with dippers. In contrast, among the participants ≥70 years, there was a significant increase in risk (hazard ratio, 1.88 [95% CI, 1.14–3.11]; P =0.013). Among the octogenarians, the hazard ratio (95% CI) for CVE were 2.34 (1.12–4.93) for nondippers ( P =0.024), 3.91 (1.75–8.73) for reverse dippers ( P =0.001), and 4.12 (1.64–10.37) for extreme dippers ( P =0.003) compared with dippers. These data show that extreme dipping is not associated with poorer outcome in people younger than 70 years. A U-shaped relationship between nocturnal blood pressure dipping and adverse outcome is present in subjects older than 70 years. In the octogenarian extreme dippers, the risk of CVEs was 4× higher than in the dippers and similar to that in the reverse dippers.