Effect of Intensive Versus Standard Clinic-Based Hypertension Management on Ambulatory Blood Pressure: Results From the SPRINT (Systolic Blood Pressure Intervention Trial) Ambulatory Blood Pressure Study

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.

Associations of Ambulatory Blood Pressure Measurements With High-Sensitivity Troponin and Natriuretic Peptide Levels in SPRINT

BACKGROUND

Nighttime blood pressure (BP) has greater prognostic importance for cardiovascular disease (CVD) than daytime BP, but less is known about nighttime and daytime BP associations with measures of subclinical CVD.

METHODS

Among 897 Systolic Blood Pressure Intervention Trial Study (SPRINT) participants with 24-hour ambulatory BP monitoring obtained near the 27-month study visit, 849 (95%) had N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) measured at the 24-month study visit. Multivariable linear regression analyses were performed to evaluate the associations of nighttime and daytime BP with cardiac biomarker levels.

RESULTS

The mean age was 69 ± 12 years, 28% were African American, and mean nighttime and daytime SBP were 121 ± 16 mm Hg and 132 ± 14 mm Hg, respectively. In multivariable models, compared with the lowest tertile of nighttime systolic BP, the highest tertile was associated with 48% higher NT-proBNP levels (adjusted geometric mean ratio [GMR] = 1.48, 95% CI: 1.22, 1.79), and 19% higher hs-cTnT levels (adjusted GMR = 1.19, 95% CI: 1.07, 1.32). In contrast, the highest vs. lowest tertile of daytime systolic BP was not associated with NT-proBNP (adjusted GMR = 1.09, 95% CI: 0.88, 1.34), but was associated with 16% higher hs-cTnT levels (adjusted GMR = 1.16, 95% CI: 1.04, 1.30). Similar results were observed using diastolic BP.

CONCLUSIONS

In SPRINT, both higher nighttime and daytime BP were independently associated with higher hs-cTnT levels, but only higher nighttime BP was associated with higher NT-proBNP levels.

Design and rationale of the Comprehensive intelligent Hypertension managEment SyStem (CHESS) evaluation study: A cluster randomized controlled trial for hypertension management in primary care

BACKGROUND

Hypertension management in China is suboptimal with high prevalence and low control rate due to various barriers, including lack of self-management awareness of patients and inadequate capacity of physicians. Digital therapeutic interventions including mobile health and computational device algorithms such as clinical decision support systems (CDSS) are scalable with the potential to improve blood pressure (BP) management and strengthen the healthcare system in resource-constrained areas, yet their effectiveness remains to be tested. The aim of this report is to describe the protocol of the Comprehensive intelligent Hypertension managEment SyStem (CHESS) evaluation study assessing the effect of a multifaceted hypertension management system for supporting patients and physicians on BP lowering in primary care settings.

MATERIALS AND METHODS

The CHESS evaluation study is a parallel-group, cluster-randomized controlled trial conducted in primary care settings in China. Forty-one primary care sites from 3 counties of China are randomly assigned to either the usual care or the intervention group with the implementation of the CHESS system, more than 1,600 patients aged 35 to 80 years with uncontrolled hypertension and access to a smartphone by themselves or relatives are recruited into the study and followed up for 12 months. In the intervention group, participants receive patient-tailored reminders and alerts via messages or intelligent voice calls triggered by uploaded home blood pressure monitoring data and participants' characteristics, while physicians receive guideline-based prescription instructions according to updated individual data from each visit, and administrators receive auto-renewed feedback of hypertension management performance from the data analysis platform. The multiple components of the CHESS system can work synergistically and have undergone rigorous development and pilot evaluation using a theory-informed approach. The primary outcome is the mean change in 24-hour ambulatory systolic BP from baseline to 12 months.

DISCUSSION

The CHESS trial will provide evidence and novel insight into the effectiveness and feasibility of an implementation strategy using a comprehensive digital BP management system for reducing hypertension burden in primary care settings.

TRIAL REGISTRATION

https://www.

CLINICALTRIALS

gov, NCT05605418.

Intelligent Assist Office Blood Pressures (IOBP) versus awake ambulatory monitoring and conventional auscultatory office readings in Chinese primary medical institutions

To practice standardized office blood pressure (OBP) measurement guidelines pragmatically, we developed an intelligent assisted OBP (IOBP) measurement system in the Chinese community, which can automatically obtain two or three BP values after a 5-min rest before the patients visit the doctor and transfer values to the community medical network in real time. We conducted a comparative study to investigate the agreement among IOBP, awake ambulatory BP (ABP), and conventional auscultatory OBP at different BP levels. Participants were divided into three groups according to BP, with 120/80 mmHg and 160/100 mmHg as the cut-off points. Attended IOBP, unattended IOBP, and auscultatory OBP were randomly measured before ABP monitoring. In total, 245 participants were included in the analysis. The mean systolic attended/unattended IOBP, auscultatory OBP, and awake ABP were 135.0, 136.7, 135.6, and 136.2 mmHg, respectively. Bland-Altman analysis revealed a bias of -1.1 and 0.5 mmHg for systolic attended/unattended IOBP compared with awake ABP in the overall sample. For auscultatory OBP, the bias was -0.4 (attended) and 1.2 mmHg (unattended). The discrepancy between the systolic attended/unattended IOBP and awake ABP was inconsistent at different BP levels. In Group 1 the values were -8.4 and -6.9 mmHg, whereas in Group 3, the values were 9.4 and 10.0 mmHg. BP measured using the IOBP measurement system was in accordance with awake ABP and conventional OBP, and can be a good choice in the Chinese community.

Prevalence of masked hypertension in attended versus unattended office blood pressure measurement

There is a controversial debate regarding whether unattended blood pressure (BP) measurement should be regarded as the new gold standard of office BP measurement. Unattended BP measurement eliminates the white-coat effect and reduces external influences on the patient. On the other hand, it might underestimate real-life BP. The present study compares the prevalence of masked hypertension using attended versus unattended office BP measurements. We performed a cross-sectional study on 213 patients in a general practitioner's outpatient clinic and compared attended and unattended office BP with 24h-ambulatory BP monitoring (24h-ABPM). Masked hypertension was defined as pressure ≥135/85 mmHg in daytime ABPM with office systolic BP < 140/90 mmHg. Median attended and unattended office BPs were 140/86 and 134/80 mmHg with a median 24h-BP of 129/79 mmHg and daytime ABP of 133/82 mmHg. The number of patients with masked hypertension was 45/213 (21.2%) using unattended and 23/213 (10.8%) using attended office BP measurements (p < .0001). Bland-Altman analysis revealed a 7.4 mmHg systolic and 6.2 mmHg diastolic bias between the attended versus unattended office BP, and two systolic and -1.7 mmHg diastolic biases between the unattended office BP and daytime ambulatory BP. In linear regression analysis, an unattended office BP of 134 mmHg corresponded to 140 mmHg in attended BP measurement. Using a cut-off of 135/85 mmHg instead of 140/90 mmHg in unattended office BP measurement, the rate of masked hypertension was 26/213 (12.2%). Thus, unattended office BP measurement results in a substantial increase in the prevalence of masked hypertension using the traditional definition of hypertension. The present findings suggest that it might be reasonable to use a definition of 135/85 mmHg.

Framework for Research in Equitable Synthetic Control Arms

Randomized Clinical Trials (RCTs) measure an intervention's efficacy, but they may not be generalizable to a desired target population if the RCT is not equitable. Thus, representativeness of RCTs has become a national priority. Synthetic Controls (SCs) that incorporate observational data into RCTs have shown great potential to produce more efficient studies, but their equity is rarely considered. Here, we examine how to improve treatment effect estimation and equity of a trial by augmenting "on-trial" concurrent controls with SCs to form a Hybrid Control Arm (HCA). We introduce FRESCA - a framework to evaluate HCA construction methods using RCT simulations. FRESCA shows that doing propensity and equity adjustment when constructing the HCA leads to accurate population treatment effect estimates while meeting equity goals with potentially less "on-trial" patients. This work represents the first investigation of equity in HCA design that provides definitions, metrics, compelling questions, and resources for future work.

24-Hour Blood Pressure Variability Via Ambulatory Monitoring and Risk for Probable Dementia in the SPRINT Trial

BACKGROUND

Blood pressure variability is an emerging risk factor for dementia, independent and oftentimes beyond mean blood pressure levels. Recent evidence from interventional cohorts with rigorously controlled mean blood pressure levels suggest blood pressure variability over months to years remains a risk for dementia, but no prior studies have investigated relationships with blood pressure variability over shorter time periods.

OBJECTIVES

To investigate the potential effect of ambulatory blood pressure variability on the rate of cognitive outcomes under intensive vs standard blood pressure lowering.

DESIGN

Post hoc analysis of the randomized, controlled, open-label Systolic Blood Pressure Intervention Trial clinical trial.

SETTING

Multisite Systolic Blood Pressure Intervention Trial.

PARTICIPANTS

793 participants at increased risk for cardiovascular disease and without history of dementia at study randomization.

INTERVENTION

Standard (<140 mmHg systolic blood pressure target) vs intensive (<120 mmHg systolic blood pressure target) lowering of mean blood pressure.

MEASUREMENTS

24-hour ambulatory blood pressure monitoring 27 months after treatment randomization (standard vs intensive) and follow-up cognitive testing. Intraindividual blood pressure variability was calculated as the average real variability over 24-hour, daytime, and nighttime periods. Participants were categorized into 3 adjudicated clinical outcomes: no cognitive impairment, mild cognitive impairment, probable dementia. Cox proportional hazards models examined the potential effect of ambulatory blood pressure variability on the rate of cognitive outcomes under intensive vs standard blood pressure lowering. Associations with mean blood pressure were also explored.

RESULTS

Higher systolic 24-hour blood pressure variability was associated with increased risk for probable dementia in the standard group (adjusted hazard ratio [HR]: 2.56 [95% CI 1.16, 5.62], p = 0.019) but not in the intensive group (HR: 0.54 [95% CI 0.24, 1.23], p = 0.141). Similar findings were observed with daytime systolic blood pressure variability but not nighttime blood pressure variability. Mean blood pressure was not associated with cognitive outcomes.

CONCLUSIONS

Higher systolic 24-hour and daytime blood pressure variability via ambulatory monitoring is associated with risk for dementia under standard blood pressure treatment. Findings support prior evidence that blood pressure variability remains a risk for dementia despite strict control of mean blood pressure levels.

Thiazide and thiazide-like diuretics are associated with improved cardiovascular and renal outcomes in patients with chronic kidney disease

Introduction

Hypervolemia is a prevalent comorbidity of chronic kidney disease (CKD) patients. Thiazide diuretics (THZ) are the most common treatment for volume overload and hypertension (HTN). This study examines the association between THZ usage and clinical outcomes among CKD patients in a nationwide cohort.

Method

The total number of patients in the study was 24,312. After matching with one non-user randomly selected from the CKD population, we identified 8501 patients in the THZ and the comparison cohorts. Cox proportional hazards regression analysis was conducted to estimate the associations of THZ on the incidence of all-cause mortality, end-stage renal disease (ESRD), congestive heart failure (CHF), acute myocardial infarction (AMI), peripheral arterial occlusive disease (PAOD), and stroke.

Results

The all-cause mortality rate was significantly lower in THZ users than in non-users (hazard ratio [HR] = 0.65, 95% confidence interval [CI] = 0.60- 0.71). The THZ usage was associated with a lower incidence of ESRD, AMI, PAOD, and stroke (P<0.05). In subgroup analysis, some significant clinical outcomes were related with CKD stages 3 and 4 (P<0.05); however, there were no clinical associations in CKD stage 5. In further THZ subtype analysis, there were clinical associations with fewer deaths, ESRD, AMI, and PAOD accompanying chlorthalidone treatment. Moreover, the indapamide prescription was linked to lower mortality, ESRD, AMI, and PAOD prevalence. However, there were significantly greater incidences of ESRD, CHF, and AMI in the metolazone users.

Conclusion

THZ usage is associated with lower mortality and incidence of ESRD, AMI, PAOD, and stroke s in patients with CKD stages 3 and 4.

The HOPE Asia Network consensus on blood pressure measurements corresponding to office measurements: Automated office, home, and ambulatory blood pressures

For adopting recently introduced hypertension phenotypes categorized using office and out of office blood pressure (BP) for the diagnosis of hypertension and antihypertension drug therapy, it is mandatory to define the corresponding out of office BP with the specific target BP recommended by the major guidelines. Such conditions include white-coat hypertension (WCH), masked hypertension (MH), white-coat uncontrolled hypertension (WUCH), and masked uncontrolled hypertension (MUCH). Here, the authors review the relevant literature and discuss the related issue to facilitate the use of corresponding BPs for proper diagnosis of WCH, MH, WUCH, and MUCH in the setting of standard target BP as well as intensive target BP. The methodology of deriving the corresponding BP has evolved from statistical methods such as standard deviation, percentile value, and regression to an outcome-based approach using pooled international cohort study data and comparative analysis in randomized clinical trials for target BPs such as the SPRINT and STEP studies. Corresponding BPs to 140/90 and 130/80 mm Hg in office BP is important for safe and strict achievement of intensive BP targets. The corresponding home, daytime, and 24-h BPs to 130/80 mm Hg in office BP are 130/80, 130/80, and 125/75 mm Hg, respectively. However, researchers have found some discrepancies among the home corresponding BPs. As tentative criterion for de-escalation of antihypertensive therapy as shown in European guidelines was 120 mm Hg in office BP, corresponding home, daytime, and 24-h systolic BPs to 120 mm Hg in office systolic BP are 120, 120, and 115 mm Hg, respectively.

The link between diabetic retinal and renal microvasculopathy is associated with dyslipidemia and upregulated circulating level of cytokines

Purpose

To investigate the mechanisms underlying the correlations between diabetic retinopathy (DR) and diabetic nephropathy (DKD) and examine whether circulating cytokines and dyslipidemia contribute to both DR and DKD in patients with 2 diabetes mellitus (T2DM).

Methods

A total of 122 patients with T2DM were enrolled and categorized into the DM group (without no DR and DKD), DR group [non-proliferative DR (NPDR), and proliferative DR (PDR)] with no DKD), DR complicated with DKD groups (DR+DKD group). The biochemical profile, including fasting blood glucose (FBG), glycated hemoglobin (HbA1c), and lipid profile were estimated, and plasma inflammatory and angiogenic cytokines [monocyte chemoattractant protein-1 (MCP-1), interleukin (IL)-6, IL-8, vascular endothelial growth factor (VEGF)-A, C, D, and placental growth factor (PlGF)] were analyzed by protein microarrays. The atherogenic plasma index (API) was defined as low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein-cholesterol (HDL-C); atherogenic index (AI) was calculated as [(total cholesterol (TC) -HDL-C)/HDL-C], and atherogenic index of plasma (AIP) was defined as log (TG/HDL-C).

Results

By multivariable disordered regression analysis, after controlling for duration of DM and hypertension, LDL-C (p = 0.019) and VEGF-D (p = 0.029) resulted as independent risk factors for DR. Albumin-to-creatinine ratio (uACR) (p = 0.003) was an independent risk factor for DR with DKD. In DR, NPDR, and PDR groups, grades of A1, A2, and A3 of albuminuria increased with the severity of DR. In A1, A2, and A3 grade groups, the severity of DR (DM, NPDR, and PDR) increased with higher albuminuria grades. Kendall's tau-b correlation coefficient analysis revealed that FBG (p = 0.019), circulating level of PlGF (p = 0.002), and VEGF-D (p = 0.008) were significantly positively correlated with the grades of uACR (p < 0.001), and uACR grades were significantly correlated with DR severity (p < 0.001).

Conclusions

The occurrence and severity of DR are closely correlated with kidney dysfunction. Among the three kidney functional parameters, uACR resulted as the better indicator of DR severity and progression than glomerular filtration (eGFR) and serum creatinine (Scr). Impaired FBG was associated with microalbuminuria, emphasizing that well-controlled FBG is important for both DR and DKD. The link between diabetic retinal and renal microvasculopathy was associated with dyslipidemia and upregulated circulating level of angiogenic cytokines.

Target Blood Pressure Values in Ambulatory Blood Pressure Monitoring

INTRODUCTION

2018 ESC/ESH guidelines have recommended 24-h ambulatory blood pressure monitoring to assess hypotensive therapy in many circumstances. Recommended target blood pressure in office blood pressure measurements is between 120/70 and 130/80 mmHg. Such targets for 24-h ambulatory blood pressure monitoring lacks.

AIM

We aimed to define target values of blood pressure in 24-h ambulatory blood pressure monitoring in hypertensive patients.

METHODS

Office blood pressure measurements and 24-h ambulatory blood pressure monitoring data were collected from 1313 hypertensive patients and sorted following increasing systolic (SBP)/diastolic (DBP) blood pressure in office blood pressure measurements. The corresponding 24-h ambulatory blood pressure monitoring to office blood pressure measurements values were calculated.

RESULTS

Values 130/80 mmHg in office blood pressure measurements correspond in 24-h ambulatory blood pressure monitoring: night-time SBP/DBP mean: 113.74/66.95 mmHg; daytime SBP/DBP mean: 135.02/81.78 mmHg and 24-h SBP/DBP mean: 130.24/78.73 mmHg. Values 120/70 mmHg in office blood pressure measurements correspond in 24-h ambulatory blood pressure monitoring: night-time SBP/DBP mean: 109.50/63.43 mmHg; daytime SBP/DBP mean: 131.01/78.47 mmHg and 24-h SBP/DBP mean: 126.36/75.31 mmHg.

CONCLUSIONS

The proposed blood pressure target values in 24-h ambulatory blood pressure monitoring complement the therapeutic target indicated in the ESC/ESH recommendations and improves 24-h ambulatory blood pressure monitoring usefulness in clinical practice.

Medication Beliefs, Cognitive Defusion, and Valued Living in Hypertensive Patients with Varying Medication Adherence

BACKGROUND

One of the most severe problems that patients with Hypertension (HPN) face are lack of medication adherence, which is influenced by psychological factors. Thus, the current survey sought to compare medication beliefs, cognitive defusion and valued living in hypertensive patients with varying medication adherence.

METHOD

A cross-sectional study with 162 HPN patients from three clinics at Isfahan University of Medical Sciences was conducted in 2019. Participants completed the BMQ (Beliefs about Medicines Questionnaire), MMAS (Morisky Medication Adherence Scale), CFQ (Cognitive Fusion Questionnaire), and VLQ (Valued Living Questionnaire). The data were analyzed using descriptive statistics, chi-square, and analysis of variance (ANOVA).

RESULTS

Only 22.2% of patients scored high in medication adherence (MA). MA levels increased with age in a significant correlation (P=0.03). ANOVA results revealed that the three MA levels (low, medium, and high) had substantial differences in both VLQ subscales (importance of person-valued living and allotted time for values; P=0.002 and P=0.023). However, no significant differences in MA levels were found in the CFQ (cognitive defusion and cognitive fusion) and BMQ subscales (specific necessity, specific concern, general overuse, and general harm).

CONCLUSIONS

This study discovered that a higher MA is associated with increasing age. In addition, patients with HPN who value living and devote more time to their values have higher MA.

Silent brain infarcts, peripheral vascular disease and the risk of cardiovascular events in patients with hypertension

BACKGROUND AND AIMS

We aimed to study the relationship between cerebral small vessel disease (cSVD) lesions, as markers of subclinical target organ damage (TOD) in the brain, and incident cardiovascular events (CVE).

METHODS

Data from the ISSYS (Investigating Silent Strokes in hYpertensives Study), which is a longitudinal and observational study conducted in patients with hypertension aged 50-70 years, and stroke-free at the inclusion. At the baseline visit, participants underwent a clinical interview, a brain MRI, urine and blood sampling collection and vascular testing studies. Therefore, we obtained markers of TOD from the brain [white matter hyperintensities, silent brain infarcts (SBI), cerebral microbleeds and enlarged perivascular spaces (EPVS)], from kidney (microalbuminuria, glomerular filtration) and regarding large vessels [ankle-to-brachial index (ABI), carotid-femoral pulse wave velocity]. Survival analyses were used to assess the relationship between these predictors and the incidence of cardiovascular events (CVE).

RESULTS

We followed-up 964 individuals within a median time of 5 years (4.7-5), representing 4377.1 persons-year. We found 73 patients presenting incident CVE, which corresponds to a rate of 8.2%. We found ABI less than 0.9 [hazard ratio, 2.2; 95% confidence interval (CI) 1.17-4.13, P value = 0.014] and SBI (hazard ratio, 2.9; 95% CI 1.47-5.58, P value = 0.002) independently associated with higher risk of incident CVE. The inclusion of both variables in a clinical model resulted in an increased discrimination of individuals with new CVE of 4.72%, according to the integrated discrimination index.

CONCLUSION

Assessment of SBI and ABI less than 0.9 may refine the cardiovascular risk stratification in patients with hypertension.

Automated Office Blood Pressure and the Impact of Attendance and Rest on Diagnostic Accuracy

BACKGROUND

Automated office blood pressure (AOBP) using 3-5 measurements taken with an oscillometric device with or without an attendant in the room may decrease "white coat" effect. We evaluated the impact of the presence or absence of the attendant and rest on BP and diagnosis of hypertension.

METHODS

We randomly assigned 133 adults aged 18-85 with high BP at baseline (≥140/90 mm Hg), no hypertensive diagnosis and no antihypertensive medications to either attended AOBP first, unattended second, or unattended AOBP first, attended second. Outcomes included within-person BP difference for attended vs. unattended measurements; 5 vs. 15 minutes of rest; and the diagnostic performance of AOBP compared with daytime automated blood pressure measurement (ABPM).

RESULTS

We found no significant differences between attended and unattended AOBP (mean difference attended - unattended [95% confidence interval, CI], systolic 0.14 mm Hg [-0.78, 1.06]; diastolic 0.16 mm Hg [-0.45, 0.78]) or by rest time (mean difference 15 - 5 minutes [95% CI], systolic -0.45 mm Hg [-1.36, 0.47]; diastolic 0.61 mm Hg [-1.23, 0.003]). AOBP was lower than mean daytime ABPM, regardless of attendance or rest (after 5 minutes rest systolic -3.6 and diastolic -2.55 mm Hg, P = 0.001 for both comparisons). Using daytime ABPM of ≥135/85 mm Hg as the diagnostic threshold, AOBP sensitivity and specificity after 5 minutes of rest were 71.0% and 54.1%, respectively.

CONCLUSIONS

The presence or absence of a clinic attendant during AOBP measurement and the amount of rest time before AOBP measurements had no effects on BP. AOBP measurements have low sensitivity and specificity for making a new diagnosis of hypertension.

Role of ambulatory blood pressure monitoring in elderly hypertensive patients

Background

Arterial hypertension is facing some changes in the last years. Its prevalence is increasing in elderly subjects. This growing prevalence is due to longer survival of the population worldwide, among other factors. On the other hand, recent guidelines have insisted in the relevance of out of office blood pressure measurements, to improve diagnostic and management of hypertension. Therefore, elderly subjects with hypertension could benefit from out of office blood pressure measurements, like ambulatory blood pressure measurements; nevertheless, there are very few or no specific recommendations regarding this.

Aim

In this review, we will gather the most important information about this subject.

Results

As hypertension in the elderly has some specific characteristics related to aging of the cardiovascular system, the most important aspect could be that these characteristics make ambulatory blood pressure measurement suitable for its use in elderly. Among those a higher prevalence of white coat hypertension, white coat phenomenon, and a higher nocturnal blood pressure and higher prevalence of nondipper and riser pattern, represent aspects that should be considered for better diagnostic and an improved management.

Conclusion

As the prevalence of hypertension will grow in the next years, more studies specifically directed to this subject are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-022-00205-6.

A clinical algorithm to determine target blood pressure in the elderly: evidence and limitations from a clinical perspective

As the elderly population is growing rapidly, management of hypertension in South Korea faces major challenges because the proportion of elderly hypertension patients is also increasing. The characteristics of this population are also much more complex than younger patients. Elderly hypertension is characterized by wide variations in (1) fitness or biological age, (2) white-coat effect, (3) poor functional status or frailty, (4) dependency in activities of daily living or institutionalization, (5) orthostatic hypotension, and (6) multiple comorbidities. All of these should be considered when choosing optimal target blood pressure in individual patients. Recent randomized clinical trials have shown that the benefits of intensive blood pressure control for elderly patients is greater than previously thought. For generalization of these results and implementation of the guidelines based on these studies, defining the clinician's role for individualization is critically important. For individualized decisions for target blood pressure (BP) in the elderly with hypertension, four components should first be checked. These consist of (1) the minimum requirement of functional status and capability of activities of daily living, (2) lack of harmful evidence by the target BP, (3) absence of white-coat hypertension, and (4) standing systolic BP ≥ 110 mmHg without orthostatic symptoms. Risk of decreased organ perfusion by arterial stenosis should be screened before starting intensive BP control. When the target BP differs among comorbidities, the lowest target BP should be given preference. After starting intensive BP lowering therapy, tolerability should be monitored, and the titration should be based on the mean level of blood pressure by office supplemented by out-of-office BPs. Applications of the clinical algorithms will be useful to achieve more standardized and simplified applications of target BP in the elderly.

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.

Home and ambulatory blood pressure levels below target range and clinical effort to detect this condition: a population-based study in older treated hypertensives

BACKGROUND

With implementation of stricter blood pressure (BP) treatment targets, potential for excessive BP lowering becomes an important issue, especially in older patients.

OBJECTIVES

Assess the magnitude, indicators and detection effort of BP levels below-target-range (BTR-BP) recommended by the European hypertension guidelines in older treated hypertensive patients (130-139/70-79 mmHg).

DESIGN

Cross-sectional, retrospective study (Seniors-ENRICA-2 cohort).

SETTING

General population.

SUBJECTS

1,329 treated hypertensive patients aged ≥65, assessed with three home casual BP measurements and 24-hour ambulatory BP monitoring (ABPM).

METHODS

Based on the European hypertension guidelines and the literature, BTR-BPs were defined as mean BP <130/70, <125/65, <130/70 and <110/55 mmHg, for casual BP, 24-hour BP, daytime BP and nighttime BP, respectively, and hypotension as <110/70, <105/65, <110/70 and <90/55 mmHg, respectively.

RESULTS

Participants' mean age was 72 ± 4.4 (50.3%, women). Based on casual BP, 7.2% of patients were in target range (130-139/70-79 mmHg), 44.3% in BTR-BP (<130/70) and 20.8% hypotensive (<110/70). Some 44.9, 54.9 and 22.0% of patients were in BTR-BP for 24-hour BP, daytime BP and nighttime BP, respectively, and 11.0, 21.1 and 5.6%, respectively, were hypotensive. The number of patients needed for ABPM to detect one case of 24-hour-, daytime-, and nighttime-BTR-BP was 3, 2 and 5, respectively, and 10, 5 and 18, respectively, for detecting one hypotensive case. Cardiovascular disease and female sex were associated with both BTR-BP and hypotension, and the number of antihypertensive drugs was only associated with hypotension.

CONCLUSIONS

BTR-BP levels were common in older treated patients at home and in everyday life, more frequent than many trials report, and daytime ABPM is highly size-efficient for detecting the low ambulatory BP conditions.

Assessment of hypertension in kidney transplantation by ambulatory blood pressure monitoring: a systematic review and meta-analysis

Background

Hypertension (HTN) is common following renal transplantation and it is associated with adverse effects on cardiovascular (CV) and graft health. Ambulatory blood pressure monitoring (ABPM) is the preferred method to characterize blood pressure (BP) status, since HTN misclassification by office BP (OBP) is quite common in this population. We performed a systematic review and meta-analysis aimed at determining the clinical utility of 24-h ABPM and its potential implications for the management of HTN in this population.

Methods

Ovid-MEDLINE and PubMed databases were searched for interventional or observational studies enrolling adult kidney transplant recipients (KTRs) undergoing 24-h ABP readings compared with OBP or home BP. The main outcome was the proportion of KTRs diagnosed with HTN by ABPM, home or OBP recordings. Additionally, day-night BP variability and dipper/non-dipper status were assessed.

Results

Forty-two eligible studies (4115 participants) were reviewed. A cumulative analysis including 27 studies (3481 participants) revealed a prevalence of uncontrolled HTN detected by ABPM of 56% [95% confidence interval (CI) 46-65%]. The pooled prevalence of uncontrolled HTN according to OBP was 47% (95% CI 36-58%) in 25 studies (3261 participants). Very few studies reported on home BP recordings. The average concordance rate between OBP and ABPM measurements in classifying patients as controlled or uncontrolled hypertensive was 66% (95% CI 59-73%). ABPM revealed HTN phenotypes among KTRs. Two pooled analyses of 11 and 10 studies, respectively, revealed an average prevalence of 26% (95% CI 19-33%) for masked HTN (MHT) and 10% (95% CI 6-17%) for white-coat HTN (WCH). The proportion of non-dippers was variable across the 28 studies that analysed dipping status, with an average prevalence of 54% (95% CI 45-63%).

Conclusions

In our systematic review, comparison of OBP versus ABP measurements disclosed a high proportion of MHT, uncontrolled HTN and, to a lesser extent, WCH in KTRs. These results suggest that HTN is not adequately diagnosed and controlled by OBP recordings in this population. Furthermore, the high prevalence of non-dippers confirmed that circadian rhythm is commonly disturbed in KTRs.

Perceived Risk of Heart Attack and Type 2 Diabetes in Hispanic Adults With Overweight and Obesity

BACKGROUND

Individuals with a greater perceived risk of heart attack or type 2 diabetes tend to adopt recommended lifestyle changes to minimize their risks. Despite the rapidly growing Hispanic population in the United States, data regarding their perceived risks are lacking.

OBJECTIVE

This study aimed to examine the perceived risk of suffering a heart attack and/or developing type 2 diabetes and to explore the factors associated with these risk perceptions in Hispanic adults with overweight/obesity.

METHODS

We analyzed 69 Hispanic adults with overweight/obesity who participated in the screening/baseline visit for the Adelgaza study, a weight loss and diabetes prevention trial, using descriptive statistics and logistic regressions. Heart attack or type 2 diabetes risk perception was assessed using a single-item questionnaire.

RESULTS

The mean (SD) values for age and body mass index (BMI) were 43.8 (11.2) years and 31.7 (4.5) kg/m 2 , respectively. Of all participants, 46.4% perceived a low risk for heart attack and 29.0% perceived a low risk for developing type 2 diabetes in their lifetime, whereas only 11.6% reported both risk perceptions. Older age, lower BMI, and longer walking duration (minutes) per day were significantly associated with a lower perceived risk of heart attack ( P &lt; .05). Having no family history of heart attack, lower BMI, and lower fat intake were significant predictors of a lower diabetes-risk perception ( P &lt; .05).

CONCLUSIONS

Hispanic adults with overweight/obesity seem to underestimate their risks of heart attack and type 2 diabetes.

Diagnosis and treatment of arterial hypertension 2021

In the last 4 years, several evidence-based, national, and international guidelines on the management of arterial hypertension have been published, mostly with concordant recommendations, but in some aspects with discordant opinions. This in-depth review takes these guidelines into account but also addresses several new data of interest. Although being somewhat obvious and simple, accurate blood pressure (BP) measurement with validated devices is the cornerstone of the diagnosis of hypertension, but out-of-office BP measurements are of crucial importance as well. Simplified antihypertensive drug treatment such as single-pill combinations enhances the adherence to medication and speeds up the process of getting into the BP target range, a goal not so far adequately respected. Recommended (single-pill) combination therapy includes diuretics as part of the first step of antihypertensive therapy, and updated analysis does not provide evidence to exclude diuretics from this first step because of the recently discussed potential risk of increasing cancer incidence. Target BP goals need to be individualized, according to comorbidities, hypertension-mediated organ damage, coexistence of cardiovascular risk factors (including age), frailty in the elderly, and individual tolerability. There are also concordant recommendations in the guidelines that an office BP between 120 and 140 mm Hg systolic and between 70 and 80 mm Hg diastolic should be achieved. The BP target of Kidney Disease: Improving Global Outcomes for hypertensive patients with chronic kidney disease are not applicable for clinical practice because they heavily rely on 1 study that used a study-specific, nontransferable BP measurement technique and excluded the most common cause of chronic kidney disease, namely, diabetic nephropathy. Actual data even from a prospective trial on chronotherapy have to be disregarded, and antihypertensive medication should not be routinely dosed at bedtime. Rigorously conducted trials justify the revival of renal denervation for treatment of (at least, but not only) uncontrolled and treatment-resistant hypertension.

A New Interprofessional Community-Service Learning Program, HATS (Health Ambassador Teams for Seniors) to Improve Older Adults Attitudes about Telehealth and Functionality

Senior population health often is underrepresented in curricula for medical and allied health students. Furthermore, entrenched and dense curricular schedules preclude interprofessional teams from clinical experiences related to senior population health. Community service learning potentially offers the opportunity to engage interprofessional students with a panel of older adults to assess health promotion metrics over time. To test this educational concept, we created Health Ambassador Teams for Seniors, also known as HATS. Utilizing a telehealth platform, interprofessional student teams were tasked with older adult wellness promotion. The annual Medicare wellness exam served as a template for patient encounters which was enhanced with key elements of geriatric assessment such as gait and balance, cognition, and functional evaluations. The objective was to have dyads of interprofessional students conduct telehealth visits and gather healthcare data to be used for serial patient encounters and track functional trajectories over time. As a proof of concept, pilot telehealth encounters with medical, physical therapy, nursing and occupational therapy students revealed that data on older adult functional performances such as gait speed, Timed Up and Go test (TUG), and Mini-Cog test could be acquired through telehealth. Equally importantly, trainees received diverse feedback from faculty, peers and volunteer patients. A Research Electronic Data Capture (REDCap) data repository allows trainees to track patient trends relative to their health promotion recommendations as well as handoff their patient panel to the next set of trainees. The HATS program promises to strengthen the Geriatric Workforce, especially with senior population health.

Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension

The present paper provides an update of previous recommendations on Home Blood Pressure Monitoring from the European Society of Hypertension (ESH) Working Group on Blood Pressure Monitoring and Cardiovascular Variability sequentially published in years 2000, 2008 and 2010. This update has taken into account new evidence in this field, including a recent statement by the American Heart association, as well as technological developments, which have occurred over the past 20 years. The present document has been developed by the same ESH Working Group with inputs from an international team of experts, and has been endorsed by the ESH.

Blood pressure measurement: Should technique define targets?

Accurate assessment of blood pressure (BP) is the cornerstone of hypertension management. The objectives of this study were to quantify the effect of medical personnel presence during BP measurement by automated oscillometric BP (AOBP) and to compare resting office BP by AOBP to daytime average BP by 24‐h ambulatory BP monitoring (ABPM). This study is a prospective randomized cross‐over trial, conducted in a referral population. Patients underwent measurements of casual and resting office BP by AOBP. Resting BP was measured as either unattended (patient alone in the room during resting and measurements) or as partially attended (nurse present in the room during measurements) immediately prior to and after 24‐h ABPM. The primary outcome was the effect of unattended 5‐min rest preceding AOBP assessment as the difference between casual and resting BP measured by the Omron HEM 907XL. Ninety patients consented and 78 completed the study. The mean difference between the casual and Omron unattended systolic BP was 7.0 mm Hg (95% confidence interval [CI] 4.5, 9.5). There was no significant difference between partially attended and unattended resting office systolic BP. Resting office BP (attended and partially attended) underestimated daytime systolic BP load from 24‐h ABPM. The presence or absence of medical personnel does not impact casual office BP which is higher than resting office AOBP. The requirement for unattended rest may be dropped if logistically challenging. Casual and resting office BP readings by AOBP do not capture the complexity of information provided by the 24‐h ABPM.

Direct comparison of inorganic nitrite and nitrate on vascular dysfunction and oxidative damage in experimental arterial hypertension

Arterial hypertension is one of the major health risk factors leading to coronary artery disease, stroke or peripheral artery disease. Dietary uptake of inorganic nitrite (NO₂^-) and nitrate (NO₃^-) via vegetables leads to enhanced vascular NO bioavailability and provides antihypertensive effects. The present study aims to understand the underlying vasoprotective effects of nutritional NO₂^- and NO₃^- co-therapy in mice with angiotensin-II (AT-II)-induced arterial hypertension. High-dose AT-II (1 mg/kg/d, 1w, s. c.) was used to induce arterial hypertension in male C57BL/6 mice. Additional inorganic nitrite (7.5 mg/kg/d, p. o.) or nitrate (150 mg/kg/d, p. o.) were administered via the drinking water. Blood pressure (tail-cuff method) and endothelial function (isometric tension) were determined. Oxidative stress and inflammation markers were quantified in aorta, heart, kidney and blood. Co-treatment with inorganic nitrite, but not with nitrate, normalized vascular function, oxidative stress markers and inflammatory pathways in AT-II treated mice. Of note, the highly beneficial effects of nitrite on all parameters and the less pronounced protection by nitrate, as seen by improvement of some parameters, were observed despite no significant increase in plasma nitrite levels by both therapies. Methemoglobin levels tended to be higher upon nitrite/nitrate treatment. Nutritional nitric oxide precursors represent a non-pharmacological treatment option for hypertension that could be applied to the general population (e.g. by eating certain vegetables). The more beneficial effects of inorganic nitrite may rely on superior NO bioactivation and stronger blood pressure lowering effects. Future large-scale clinical studies should investigate whether hypertension and cardiovascular outcome in general can be influenced by dietary inorganic nitrite therapy.

The Association of Orthostatic Hypotension With Ambulatory Blood Pressure Phenotypes in SPRINT

BACKGROUND

Clinic blood pressure (BP) when measured in the seated position, can miss meaningful BP phenotypes, including low ambulatory BP (white coat effects [WCE]) or high supine BP (nocturnal non-dipping). Orthostatic hypotension (OH) measured using both seated (or supine) and standing BP, could identify phenotypes poorly captured by seated clinic BP alone.

METHODS

We examined the association of OH with WCE and night-to-daytime systolic BP (SBP) in a subpopulation of SPRINT, a randomized trial testing the effects of intensive or standard (<120 vs. <140 mm Hg) SBP treatment strategies in adults at increased risk of cardiovascular disease. OH was assessed during follow-up (6, 12, and 24 months) and defined as a decrease in mean seated SBP ≥20 or diastolic BP ≥10 mm Hg after 1 min of standing. WCE, based on 24-hour ambulatory BP monitoring performed at 27 months, was defined as the difference between 27-month seated clinic and daytime ambulatory BP ≥20/≥10 mm Hg. Reverse dipping was defined as a ratio of night-to-daytime SBP >1.

RESULTS

Of 897 adults (mean age 71.5±9.5 years, 29% female, 28% black), 128 had OH at least once. Among those with OH, 15% had WCE (vs. 7% without OH). Moreover, 25% of those with OH demonstrated a non-dipping pattern (vs. 14% without OH). OH was positively associated with both WCE (OR=2.24; 95%CI: 1.28, 4.27) and reverse dipping (OR=2.29; 95% CI: 1.31, 3.99).

CONCLUSIONS

The identification of OH in clinic was associated with two BP phenotypes often missed with traditional seated BP assessments. Further studies on mechanisms of these relationships are needed.

CLINICAL TRIALS REGISTRATION

Trial Number NCT03569020.

Hypertension in Chronic Kidney Disease (CKD): Diagnosis, Classification, and Therapeutic Targets

Blood pressure (BP) in the office is often recorded without standardization of the technique of measurement. When office BP measurement is performed with a research-grade methodology, it can inform better therapeutic decisions. The reference-standard method of ambulatory BP monitoring (ABPM) together with the assessment of BP in the office enables the identification of white-coat and masked hypertension, facilitating the stratification of cardiorenal risk. Compared with general population, the prevalence of resistant hypertension is 2- to 3-fold higher among patients with chronic kidney disease (CKD). The use of ABPM is mandatory in order to exclude the white-coat effect, a common cause of pseudoresistance, and confirm the diagnosis of true-resistant hypertension. After the premature termination of Systolic Blood Pressure Intervention Trial due to an impressive cardioprotective benefit of intensive BP-lowering, the 2017 American Heart Association/American College of Cardiology guideline reappraised the definition of hypertension and recommended a tighter BP target of <130/80 mm Hg for the majority of adults with a high cardiovascular risk profile, inclusive of patients with CKD. However, the benefit/risk ratio of intensive BP-lowering in particular subsets of patients with CKD (i.e., those with diabetes or more advanced CKD) continues to be debated. We explore the controversial issue of BP targets in CKD, providing a critical evaluation of the available clinical-trial evidence and guideline recommendations. We argue that the systolic BP target in CKD, if BP is measured correctly, should be <120 mm Hg.

Performance of an automated blood pressure measurement device in a stroke rehabilitation unit

CONTEXT

Valid blood pressure (BP) measurements are needed in post-stroke rehabilitation hospital units for the management of hypertension. Automated devices could be used to improve on usual care BP measurement. However, more information is needed about the performance of these devices in such a context.

METHODS

This prospective nonrandomized study was performed in stroke patients with hypertension hospitalized in a stroke rehabilitation unit. Two in-hospital BP assessment strategies were compared: usual care BP and in-hospital automated office BP (AOBP) standardized measurements. In-office AOBP and ambulatory BP monitoring (ABPM) were also performed on these patients. The main outcome was SBP. Study follow-up was until discharge, up to a maximum of 4 weeks.

RESULTS

Sixty-two patients with stroke hospitalized in a rehabilitation unit were included. Usual care BP was 130 ± 12/79 ± 9 mmHg and differed from an in-hospital AOBP of 117 ± 14/75 ± 12 mmHg (P < 0.001/P < 0.001). In-hospital and in-office AOBP measurements did not differ. Twenty percent of patients reached SBP therapeutic goals according to in-hospital AOBP but not according to usual care BP measurements.

CONCLUSION

This study shows that in a post-stroke rehabilitation unit, standardized in-hospital AOBP estimates are on average much lower than the usual care BP correlates and similar to the in-office AOBP estimates. In-hospital AOBP devices in a stroke rehabilitation unit could add important information for the management of hypertension.

Office blood pressure threshold of 130/80 mmHg better predicts uncontrolled out-of-office blood pressure in apparent treatment-resistant hypertension

The objective of this study was to compare the diagnostic accuracy of office blood pressure (BP) threshold of 140/90 and 130/80 mmHg for correctly identifying uncontrolled out‐of‐office BP in apparent treatment‐resistant hypertension (aTRH). We analyzed 468 subjects from a prospectively enrolled cohort of patients with resistant hypertension in South Korea (clinicaltrials.gov: NCT03540992). Resistant hypertension was defined as office BP ≥ 130/80 mmHg with three different classes of antihypertensive medications including thiazide‐type/like diuretics, or treated hypertension with four or more different classes of antihypertensive medications. We conducted different types of BP measurements including office BP, automated office BP (AOBP), home BP, and ambulatory BP. We defined uncontrolled out‐of‐office BP as daytime BP ≥ 135/85 mmHg and/or home BP ≥ 135/85 mmHg. Among subjects with office BP < 140/90 mmHg and subjects with office BP < 130/80 mmHg, 66% and 55% had uncontrolled out‐of‐office BP, respectively. The prevalence of controlled and masked uncontrolled hypertension was lower, and the prevalence of white‐coat and sustained uncontrolled hypertension was higher, with a threshold of 130/80 mmHg than of 140/90 mmHg, for both office BP and AOBP. The office BP threshold of 130/80 mmHg was better able to diagnose uncontrolled out‐of‐office BP than 140/90 mmHg, and the net reclassification improvement (NRI) was 0.255. The AOBP threshold of 130/80 mmHg also revealed better diagnostic accuracy than 140/90 mmHg, with NRI of 0.543. The office BP threshold of 130/80 mmHg showed better than 140/90 mmHg in terms of the correspondence to out‐of‐office BP in subjects with aTRH.

Exercise Reduces Ambulatory Blood Pressure in Patients With Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background Although exercise training reduces office blood pressure (BP), scarcer evidence is available on whether these benefits also apply to ambulatory blood pressure (ABP), which is a stronger predictor of cardiovascular disease and mortality. The present study aims to assess the effects of exercise training on ABP in patients with hypertension based on evidence from randomized controlled trials. Methods and Results A systematic search of randomized controlled trials on the aforementioned topic was conducted in PubMed and Scopus (since inception to April 1, 2020). The mean difference between interventions (along with 95% CI) for systolic BP and diastolic BP was assessed using a random-effects model. Sub-analyses were performed attending to (1) whether participants were taking antihypertensive drugs and (2) exercise modalities. Fifteen studies (including 910 participants with hypertension) met the inclusion criteria. Interventions lasted 8 to 24 weeks (3-5 sessions/week). Exercise significantly reduced 24-hour (systolic BP, -5.4 mm Hg; [95% CI, -9.2 to -1.6]; diastolic BP, -3.0 mm Hg [-5.4 to -0.6]), daytime (systolic BP, -4.5 mm Hg [-6.6 to -2.3]; diastolic BP, -3.2 mm Hg [-4.8 to -1.5]), and nighttime ABP (systolic BP, -4.7 mm Hg [-8.4 to -1.0]; diastolic BP, -3.1 mm Hg [-5.3 to -0.9]). In separate analyses, exercise benefits on all ABP measures were significant for patients taking medication (all P<0.05) but not for untreated patients (although differences between medicated and non-medicated patients were not significant), and only aerobic exercise provided significant benefits (P<0.05). Conclusions Aerobic exercise is an effective coadjuvant treatment for reducing ABP in medicated patients with hypertension.

Concordance Between Blood Pressure in the Systolic Blood Pressure Intervention Trial and in Routine Clinical Practice

IMPORTANCE

There are concerns with translating results from the Systolic Blood Pressure Intervention Trial (SPRINT) into clinical practice because the standardized protocol used to measure blood pressure (BP) may not be consistently applied in routine clinical practice.

OBJECTIVES

To evaluate the concordance between BPs obtained in routine clinical practice and those obtained using the SPRINT protocol and whether concordance varied by target trial BP.

DESIGN, SETTING, AND PARTICIPANTS

This observational prognostic study linking outpatient vital sign information from electronic health records (EHRs) with data from 49 of the 102 SPRINT sites was conducted from November 8, 2010, to August 20, 2015, among 3074 adults 50 years or older with hypertension without diabetes or a history of stroke. Statistical analysis was performed from May 21, 2019, to March 20, 2020.

MAIN OUTCOMES AND MEASURES

Blood pressures measured in routine clinical practice and SPRINT.

RESULTS

Participant-level EHR data was obtained for 3074 participants (2482 men [80.7%]; mean [SD] age, 68.5 [9.1] years) with 3 or more outpatient and trial BP measurements. In the period from the 6-month study visit to the end of the study intervention, the mean systolic BP (SBP) in the intensive treatment group from outpatient BP recorded in the EHR was 7.3 mm Hg higher (95% CI, 7.0-7.6 mm Hg) than BP measured at trial visits; the mean difference between BP recorded in the outpatient EHR and trial SBP was smaller for participants in the standard treatment group (4.6 mm Hg [95% CI, 4.4-4.9 mm Hg]). Bland-Altman analyses demonstrated low agreement between outpatient BP recorded in the EHR and trial BP, with wide agreement intervals ranging from approximately -30 mm Hg to 45 mm Hg in both treatment groups. In addition, the difference between BP recorded in the EHR and trial BP varied widely by site.

CONCLUSIONS AND RELEVANCE

Outpatient BPs measured in routine clinical practice were generally higher than BP measurements taken in SPRINT, with greater mean SBP differences apparent in the intensive treatment group. There was a consistent high degree of heterogeneity between the BPs recorded in the EHR and trial BPs, with significant variability over time, between and within the participants, and across clinic sites. These results highlight the importance of proper BP measurement technique and an inability to apply 1 common correction factor (ie, approximately 10 mm Hg) to approximate research-quality BP estimates when BP is not measured appropriately in routine clinical practice.

TRIAL REGISTRATION

SPRINT ClinicalTrials.gov Identifier: NCT01206062.

Orthostatic Hypertension and Intensive Blood Pressure Control; Post-Hoc Analyses of SPRINT

We evaluated the association between orthostatic hypertension and cardiovascular outcomes and the effect of intensive blood pressure (BP) control on cardiovascular outcomes in patients with orthostatic hypertension. Post hoc analyses of the SPRINT (Systolic Blood Pressure Intervention Trial) data were conducted; orthostatic hypertension was defined as increase in systolic BP≥20 mm Hg or increase in diastolic BP≥10 mm Hg with standing. Of 9329 participants, 1986 (21.2%) had orthostatic hypertension at baseline. Within the intensive treatment group, participants with orthostatic hypertension were at higher risk of developing the composite cardiovascular outcome (hazard ratio, 1.44 [95% CI, 1.1-1.87], P=0.007) compared with participants without orthostatic hypertension. Within the standard treatment group, there were no significant differences in cardiovascular outcome between participants with and without orthostatic hypertension. In participants with orthostatic hypertension, there was no statistically significant difference in risk of the composite cardiovascular outcome between the intensive and the standard BP treatment group (hazard ratio, 1.07 [95% CI, 0.78-1.47], P=0.68). In participants without orthostatic hypertension at baseline, the intensive treatment group was associated with a lower risk of the composite cardiovascular outcome (hazard ratio, 0.67 [95% CI, 0.56-0.79], P<0.0001). Orthostatic hypertension was associated with a higher risk of cardiovascular outcomes in the intensive and not in the standard treatment group; intensive treatment of BP did not reduce the risk of cardiovascular outcomes compared with standard treatment in patients with orthostatic hypertension. These post hoc analyses are hypothesis generating and will need to be confirmed in future studies.

Effect of ambulatory blood pressure monitoring guided antihypertensive treatment on renal progression in patients with chronic kidney disease: a randomized comparative study

OBJECTIVES

Adequate blood pressure (BP) control is pivotal for managing chronic kidney disease (CKD). The optimal approach for monitoring BP to delay CKD progression is not yet clear.

METHODS

Patients with hypertension and CKD stage 3-4 were randomized into ambulatory blood pressure monitoring (ABPM) or office BP groups. All patients had ABPM at baseline and 18 months, and the ABPM group additionally underwent ABPM at 3 and 6 months. Each ABPM result was notified only for the ABPM group. The BP target was daytime ABP less than 135/85 mmHg for the ABPM group and office BP less than 140/90 mmHg for the office BP group. The primary outcome was decrease in estimated glomerular filtration rate (eGFR) during 18 months.

RESULTS

A total of 146 patients were randomized into the ABPM (n = 69) and office BP groups (n = 77). Although office BP was comparable in the two groups at baseline, daytime ABP was higher in the ABPM group (median 140 vs. 132 mmHg). Initial eGFR was 35.7 ± 12.5 ml/min per 1.73 m2 in the ABPM group and 34.6 ± 12.0 ml/min per 1.73 m2 in the office BP group. eGFR change was -5.5 [95% confidence interval (95% CI) -7.7 to  -3.4] ml/min per 1.73 m2 in the ABPM group and -5.0 (95% CI -6.9 to -3.0) ml/min per 1.73 m2 in the office BP group (P = 0.704). Renal events occurred in 10 patients (15.6%) from the ABPM group and five (7.1%) from the office BP group (P = 0.120).

CONCLUSION

The present study did not show a beneficial effect of ABPM for controlling hypertension in CKD compared with conventional office BP monitoring in terms of renal outcomes.

Scope, Influence, and Interdisciplinary Collaboration: The Publication Portfolio of the NIH Clinical and Translational Science Awards (CTSA) Program From 2006 Through 2017

The Clinical and Translational Science Awards (CTSA) program sponsors an array of innovative, collaborative research. This study uses complementary bibliometric approaches to assess the scope, influence, and interdisciplinary collaboration of publications supported by single CTSA hubs and those supported by multiple hubs. Authors identified articles acknowledging CTSA support and assessed the disciplinary scope of research areas represented in that publication portfolio, their citation influence, interdisciplinary overlap among research categories, and characteristics of publications supported by multihub collaborations. Since 2006, CTSA hubs supported 69,436 articles published in 4,927 journals and 189 research areas. The portfolio is well distributed across diverse research areas with above-average citation influence. Most supported publications involved clinical/health sciences, for example, neurology and pediatrics; life sciences, for example, neuroscience and immunology; or a combination of the two. Publications supported by multihub collaborations had distinct content emphasis, stronger citation influence, and greater interdisciplinary overlap. This study characterizes the CTSA consortium's contributions to clinical and translational science, identifies content areas of strength, and provides evidence for the success of multihub collaborations. These methods lay the foundation for future investigation of the best policies and priorities for fostering translational science and allow hubs to understand their progress benchmarked against the larger consortium.

Effects of Intensive Versus Standard Office-Based Hypertension Treatment Strategy on White-Coat Effect and Masked Uncontrolled Hypertension: From the SPRINT ABPM Ancillary Study

Guidelines recommend using out-of-office blood pressure (BP) measurements to confirm the diagnoses of hypertension and in the titration of antihypertensive medication. The prevalence of out-of-office BP phenotypes for an office systolic/diastolic BP goal <140/90 mm Hg has been reported. However, the prevalence of these phenotypes when targeting an office systolic/diastolic BP goal <120/80 is unknown. The SPRINT (Systolic Blood Pressure Intervention Trial) Ambulatory BP Ancillary study evaluated out-of-office BP using ambulatory BP monitoring in 897 participants 27 months after randomization to intensive versus standard BP targets (office systolic BP <120 versus <140 mm Hg). We used office and daytime BP to assess the proportion of participants with white-coat effect (standard target: office BP ≥140/90 mm Hg and daytime BP <135/85 mm Hg versus intensive target: office BP ≥120/80 mm Hg and daytime BP <120/80 mm Hg) and masked uncontrolled hypertension (standard target: office BP <140/90 mm Hg and daytime BP ≥135/85 mm Hg versus intensive target: office BP <120/80 mm Hg and daytime BP ≥120/80 mm Hg) in each treatment arm. The prevalence of white-coat effect and masked uncontrolled hypertension was 9% and 34%, in both treatment groups. Among participants with uncontrolled office BP, white-coat effect was present in 20% and 23% in the intensive and standard groups, respectively. Among participants with controlled office BP, masked uncontrolled hypertension was present in 62% and 56% in the intensive and standard groups, respectively. In conclusion, a more intensive BP target resulted in a similar proportion of patients with white-coat effect and masked uncontrolled hypertension compared with a standard target.

The use of automated sequential blood pressure in hypertension clinics compared with office and ambulatory blood pressure measurements

BACKGROUND

Office blood pressure (OBP) measurement is the most common method of blood pressure measurement. However, it is associated with several pitfalls as white coat effect and masked hypertension. Ambulatory blood pressure monitoring (ABPM) is usually used for diagnosis of hypertension and elimination of white coat effect. This study aimed to assess the correlation and degree of agreement of the automated sequential blood pressure (ASqBP) with OBP and ABPM. Patients presented to hypertension clinic were included. Each patient had his blood pressure recorded by three methods: OBP using a digital sphygmomanometer device, unattended ASqBP using sequential BP devices with recording of the readings over 30 min, and ABPM that was performed within 48 h of office visit using portable BP devices with BP recording over 24 h.

RESULTS

We recruited 64 patients (age 50.0 ± 15.0 years and female gender 53.1%). We found a strong positive correlation between ASqBP and OBP readings (r 0.81 for SBP and 0.83 for DBP, p < 0.001). We also found a strong positive correlation between ASqBP and ABPM readings (r 0.74, p < 0.001). The ASqBP readings were lower than OBP (137.0 ± 16.8/86.4 ± 13.8 vs. 142.7 ± 15.5/88.5 ± 12.3) and close to ABPM readings (average 24 h, 134.0 ± 15.4/88.5 ± 12.3, and daytime, 135.8 ± 15.7/82.1 ± 13.7). For SBP readings, there was moderate agreement between ASqBP and AMBP (both average and daytime). For DBP readings, there was fair agreement between ASqBP and AMBP (both average and daytime).

CONCLUSION

ASqBP measurement has good correlation with OBP and ABPM readings. Unattended automated office pressure has moderate degree of agreement with ABPM for the SBP& fair degree of agreement for the DBP. It can be used in the hypertension clinics to eliminate the problems of white coat effect and marked BP variability.

Non-Invasive Risk Stratification of Hypertension: A Systematic Comparison of Machine Learning Algorithms

One of the most important physiological parameters of the cardiovascular circulatory system is Blood Pressure. Several diseases are related to long-term abnormal blood pressure, i.e., hypertension; therefore, the early detection and assessment of this condition are crucial. The identification of hypertension, and, even more the evaluation of its risk stratification, by using wearable monitoring devices are now more realistic thanks to the advancements in Internet of Things, the improvements of digital sensors that are becoming more and more miniaturized, and the development of new signal processing and machine learning algorithms. In this scenario, a suitable biomedical signal is represented by the PhotoPlethysmoGraphy (PPG) signal. It can be acquired by using a simple, cheap, and wearable device, and can be used to evaluate several aspects of the cardiovascular system, e.g., the detection of abnormal heart rate, respiration rate, blood pressure, oxygen saturation, and so on. In this paper, we take into account the Cuff-Less Blood Pressure Estimation Data Set that contains, among others, PPG signals coming from a set of subjects, as well as the Blood Pressure values of the latter that is the hypertension level. Our aim is to investigate whether or not machine learning methods applied to these PPG signals can provide better results for the non-invasive classification and evaluation of subjects’ hypertension levels. To this aim, we have availed ourselves of a wide set of machine learning algorithms, based on different learning mechanisms, and have compared their results in terms of the effectiveness of the classification obtained.

Optimización del desempeño del observador al medir la presión arterial en el consultorio: declaración de posición de la Comisión Lancet de Hipertensión

La hipertensión arterial es una causa modificable muy prevalente de enfermedades cardiovasculares, accidentes cerebrovasculares y muerte. Medir con exactitud la presión arterial es fundamental, dado que un error de medición de 5 mmHg puede ser motivo para clasificar incorrectamente como hipertensas a 84 millones de personas en todo el mundo. En la presente declaración de posición se resumen los procedimientos para optimizar el desempeño del observador al medir la presión arterial en el consultorio, con atención especial a los entornos de ingresos bajos o medianos, donde esta medición se ve complicada por limitaciones de recursos y tiempo, sobrecarga de trabajo y falta de suministro eléctrico. Es posible reducir al mínimo muchos errores de medición con una preparación adecuada de los pacientes y el uso de técnicas estandarizadas. Para simplificar la medición y prevenir errores del observador, deben usarse tensiómetros semiautomáticos o automáticos de manguito validados, en lugar del método por auscultación. Pueden ayudar también la distribución de tareas, la creación de un área específica de medición y el uso de aparatos semiautomáticos o de carga solar. Es fundamental garantizar la capacitación inicial y periódica de los integrantes del equipo de salud. Debe considerarse la implementación de programas de certificación de bajo costo y fácilmente accesibles con el objetivo de mejorar la medición de la presión arterial.

Optimizing observer performance of clinic blood pressure measurement: a position statement from the Lancet Commission on Hypertension Group

High blood pressure (BP) is a highly prevalent modifiable cause of cardiovascular disease, stroke, and death. Accurate BP measurement is critical, given that a 5-mmHg measurement error may lead to incorrect hypertension status classification in 84 million individuals worldwide. This position statement summarizes procedures for optimizing observer performance in clinic BP measurement, with special attention given to low-to-middle-income settings, where resource limitations, heavy workloads, time constraints, and lack of electrical power make measurement more challenging. Many measurement errors can be minimized by appropriate patient preparation and standardized techniques. Validated semi-automated/automated upper arm cuff devices should be used instead of auscultation to simplify measurement and prevent observer error. Task sharing, creating a dedicated measurement workstation, and using semi-automated or solar-charged devices may help. Ensuring observer training, and periodic re-training, is critical. Low-cost, easily accessible certification programs should be considered to facilitate best BP measurement practice.

Impact of cumulative SBP and serious adverse events on efficacy of intensive blood pressure treatment: a randomized clinical trial

BACKGROUND

Intensive blood pressure lowering is increasingly gaining attention. In addition to higher baseline blood pressure, cumulative SBP, visit-to-visit variability, and treatment-induced serious adverse events (SAEs) could impact treatment efficacy over time. Our aim was to assess the impact of cumulative SBP and SAEs on intensive hypertension treatment efficacy in the Systolic Blood Pressure Intervention Trial (SPRINT) population during follow-up.

METHODS

Secondary analysis of the SPRINT study: a randomized, controlled, open-label trial including 102 clinical sites in the United States. We included 9068 SPRINT participants with 128 139 repeated SBP measurements. Participants were randomly assigned to intensive (target SBP < 120 mmHg) versus standard treatment (target SBP between 135 and 139 mmHg). We used cumulative joint models for longitudinal and survival data analysis. Primary outcome was a composite outcome of myocardial infarction, other acute coronary syndromes, acute decompensated heart failure, stroke, and cardiovascular mortality.

RESULTS

Although intensive treatment decreased the risk for the primary SPRINT outcome at the start of follow-up, its effect lost significance after 3.4 years of follow-up in the total SPRINT population and after 1.3, 1.3, 1.1, 1.8, 2.1, 1.8, and 3.4 years among participants with prevalent chronic kidney disease, prevalent cardiovascular disease, women, black individuals, participants less than 75 years, those with baseline SBP more than 132 mmHg, and individuals who suffered SAEs during follow-up, respectively.

CONCLUSION

The initial beneficial impact of intensive hypertension treatment might be offset by cumulative SBP and development of SAEs during follow-up.

Ambulatory Blood Pressure Levels in the Prediction of Progression of Cerebral Small Vessel Disease

OBJECTIVES

We aimed to study the value of ambulatory blood pressure monitoring (ABPM) in predicting the global progression of cerebral small vessel disease (cSVD).

DESIGN

Longitudinal cohort study.

SETTING

Data from the population-based Investigating Silent Strokes in Hypertensives study.

PARTICIPANTS

Individuals with hypertension who were 50 to 70 years of age and stroke free at baseline. In baseline and follow-up visits, patients underwent magnetic resonance imaging and ABPM.

MEASUREMENTS

Ambulatory systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels were studied as continuous variables and dichotomized according to good or poor control on the basis of 125/75 (24 hours), 130/80 (day), and 110/65 (night) mm Hg cutoff values. Whole cSVD progression was qualitatively scored with 1 point when an incident lesion (incident lacunar infarcts, deep cerebral microbleeds, white matter hyperintensities, and basal ganglia enlarged perivascular spaces) was detected. The score ranged from 0 to 4.

RESULTS

We followed up 233 participants with a median age of 65 years within 4 years. A total of 61 (26.2%) and 23 (9.9%) subjects showed cSVD progression in one and two or more markers, respectively. Baseline ambulatory SBP and DBP and nighttime pulse pressure (PP) values were positively correlated with the number of incident cSVD lesions. Interestingly, patients without incident lesions showed greater differences between office and ambulatory BP, thus suggesting an increased white coat effect. Poor DBP control, nighttime PP, and DBP white coat effect were independently associated with cSVD progression. The inclusion of these metrics in a clinical model resulted in a significant increase in the prediction of incident lesions (integrated discrimination improvement = 9.09%; P value <.001).

CONCLUSION

ABPM may help assess cSVD risk of progression, especially by the identification of poor BP control, masked hypertension, and increased nighttime PP. J Am Geriatr Soc 68:2232-2239, 2020.

The global burden of hypertension exceeds 1.4 billion people: should a systolic blood pressure target below 130 become the universal standard?

: In 2010, 1.4 billion people globally had hypertension, with 14% controlled to systolic blood pressure (SBP, mmHg) below 140, which contributes to 18 million cardiovascular deaths annually. Recent hypertension guidelines endorsed SBP targets below 130 or lower for all or some hypertensive patients to reduce cardiovascular events (CVEs) more than the prior SBP target less than 140. In 2016, the Australian Guideline strongly recommended target SBP below 120 for adults at very high risk for CVE or aged above 75 years. In 2017 and 2018, the Canadian Guideline recommended automated office SBP (AOSBP) below 120 in adults at high risk and aged above 75 years (grade B). In 2017, the US Guideline recommended SBP below 130 for all adults (moderate-to-high risk class I; lower-risk grade IIb). In 2018, the European Guideline recommended SBP below 140 for all adults, and, if tolerated, a SBP range of 120-129 for adults aged below 65 years and 130-139 for adults aged at least 65 years (class I). The guidelines were variably influenced by Systolic blood PRessure INTervention trial and meta-analyses indicating fewer CVE when mean in-trial SBP was below 130 versus above 130. Clinicians considering lower SBP targets should be aware that: AOSBP preceded by 5-min rest is approximately 10-15 mmHg lower than usual office SBP; hypertensive patients with office SBP consistently versus intermittently below 140 have fewer CVE; benefits of mean office SBP or AOSBP below 120 remain unproven and could increase adverse events. Clinicians worldwide will do well to control SBP to below 140 in most hypertensive patients on most visits, which should lead to mean in-clinic SBP of 120-129.

Caring for Women After Hypertensive Pregnancies and Beyond: Implementation and Integration of a Postpartum Transition Clinic

Purpose We developed a postpartum transition clinic to better support women after hypertensive pregnancy. Description Our program goals were (1) early postpartum hypertension medical management, (2) patient and provider education around CVD risk, (3) transition to primary care provider (PCP) and (4) a sustainable clinical model reimbursed by private and public insurances. We focused on women immediately postpartum in this analysis. Assessment Over the course of 5 years, a racially and socioeconomically diverse population of 412 immediately postpartum women received care for one, two or more appointments. Referral diagnoses included antepartum preeclampsia (PET) 51% (210/412), postpartum preeclampsia/hypertension (PP-PET) 22.3% (92/412), preeclampsia superimposed on chronic hypertension (siPET) 10.2% (42/412), chronic hypertension (cHTN) 8.8% (37/412), and gestational hypertension (gHTN) 7.8% (31/412). Almost half of women had 2-3 visits 47.3% (195/412) with no difference by diagnosis (p = 0.18). No show rates were consistently around 25%. Acquisition of home blood pressure monitors increased from 56.8% (44/94) to 93.8% (61/65) over the 5 years (p < 0.0001). Nearly half of patients seen had antihypertensive medication adjustments 48.3% (199/412). Of those patients scheduled, 86.8% (79/91) attended a nutrition consultation. For patients with PCPs within our system, 79.5% (105/132) kept their scheduled follow up PCP appointments. Conclusion We report a postpartum transition clinic after hypertensive pregnancy. In this diverse population, patients attended 2-3 visits, incorporated home blood pressure monitoring, adjusted antihypertensive medications and initiated prevention measures such as nutrition referrals and PCP follow-up. An internist salary was sustained through billings and collections from private and public insurance.