Cardiovascular Risk Associated With White-Coat Hypertension

Childhood occasional hypertension and its association with size at birth and early growth: a population-based retrospective cohort study from China

BACKGROUND

Hypertension has recently shown a rapid rise in prevalence among children and adolescents. It can track into adulthood and tend to manifest at an earlier age. It should be prevented urgently and efficiently.

METHODS

This study assesses the prevalence of occasional hypertension (OHTN) at 5 ~ 6 years old and evaluates its association with size at birth and BMI at 2 and 5 ~ 6 years old in full-term children. We conducted a population-based cohort study of 12,564 children from 66 kindergartens in Tianjin, China. Information on birth weight, body mass index (BMI) at 2 and 5 ~ 6 years old, and blood pressure at 5 ~ 6 years old was retrospectively collected.

RESULTS

The prevalence of childhood OHTN (SBP or DBP ≥ P95 percentile for sex, age, and height) was 17.0%. At birth, SGA has a high risk of OHTN (AOR 1.36, 95%CI 1.10-1.68). In the SGA subgroup, although children are of normal weight at 5 ~ 6 years old, excessive catch-up growth (BMI ≥75th at 2 years old) was still attributed to OHTN (OR 1.51, 95%CI 1.03-2.24). Obesity (BMI ≥2SD at 5 ~ 6 years old) was a vital risk factor for OHTN (AOR 2.93, 95%CI 2.56-3.36) unregarding with birthweight (OR 95%CI: SGA 3.23(1.66 ~ 6.27), AGA 2.83 (2.42-3.31), LGA 3.52 (2.65-4.68)). The co-presence of moderate or excessive catch-up growth before 2 years old and obesity at 5 ~ 6 years old significantly increased the risk of childhood OHTN (OR from 2.74 (1.65-4.54) to 6.53 (2.68-15.90)).

CONCLUSIONS

Preschool obesity, low birth weight, and excessive catch-up growth increased the risk of OHTN in childhood.

Team-Based Approach in Hypertension Management: A Quality Improvement Project

BACKGROUND/LOCAL PROBLEM

Hypertension is a major risk factor for heart diseases and stroke among Americans; only 25% have this under control nationwide.

METHODS

This quality improvement project evaluated the outcomes of team-based care in hypertension control by registered nurses and certified nurse practitioners in a primary care setting. Pre/post-data analysis of blood pressure (BP) control, and BP knowledge, was done.

INTERVENTION

The team provided education and counseling based on knowledge assessment during visits and used unattended automated blood pressure measurement (uAOBPM) techniques to measure BP.

RESULTS

There was a significant reduction in systolic and diastolic BP control ( P < .001). There was a statistically significant increase in disease knowledge score pre- and postintervention ( P < .001).

CONCLUSION

The team-based care approach improved patients' BP control and knowledge of the disease. The uAOBPM technique could be incorporated into clinical settings for accurate BP measurements.

Angiotensin-converting enzyme gene (ACE) polymorphisms are associated with dysregulation of biochemical parameters in hypertensive patients

INTRODUCTION

The genetic component, including genes and their variants, plays a significant role in the pathophysiology of arterial hypertension (AH). Thus, clinical, epidemiological and genetic studies have been carried out to improve the understanding of disease mechanisms, improve diagnostic quality and contribute to prevention.

OBJECTIVE

To determine the association of risk factors, biochemical parameters and different ACE gene polymorphisms with AH.

METHOD

The case-control study was carried out in the population of Ouro Preto, Brazil. The subjects answered a questionnaire containing clinical and sociodemographic data. The ACE gene polymorphisms rs4291, rs4363 and rs4335 were evaluated by real time-polymerase chain reaction (real-time PCR) in 310 people (155 hypertensive and 155 normotensive patients), in addition to biochemical parameters. A multivariate logistic regression model was used to identify factors associated with AH. Analysis of continuous variables was performed using the Kruskal-Wallis test to assess significance between groups and Dunn's post-test for multiple comparisons.

RESULTS

The results showed that AH was associated with age, education, smoking, obesity and high levels of triglycerides, sodium, glucose and uric acid. Regarding the biochemical parameters, in hypertensive patients, the rs4363 and rs4335 polymorphisms were associated with high levels of triglycerides, urea and glucose; the rs4291 polymorphism was associated with elevated urea and glucose levels. No association was detected between SNPs and HA.

CONCLUSION

AH was associated with socioeconomic status, lifestyle habits and biochemical parameters. ACE polymorphisms may have influenced the levels of triglycerides, urea and glucose in hypertensive patients.

Prediction of white-coat hypertension and white-coat uncontrolled hypertension using machine learning algorithm

Aims

The detection of white-coat hypertension/white-coat uncontrolled hypertension (WCH/WUCH) with out-of-office blood pressure (BP) monitoring is time- and resource-consuming. We aim to develop a machine learning (ML)-derived prediction model based on the characteristics of patients from a single outpatient visit.

Methods and results

Data from two cohorts in Taiwan were used. Cohort one (970 patients) was used for development and internal validation, and cohort two (464 patients) was used for external validation. WCH/WUCH was defined as an office BP of ≥140/90 mmHg and daytime ambulatory BP of <135/85 mmHg in treatment-naïve or treated individuals. Logistic regression, random forest (RF), eXtreme Gradient Boosting, and artificial neural network models were trained using 26 patient parameters. We used SHapley Additive exPlanations values to provide explanations for the risk factors. All models achieved great area under the receiver operating characteristic curve (AUROC), specificity, and negative predictive value in both validations (AUROC = 0.754-0.891; specificity = 0.682-0.910; negative predictive value = 0.831-0.968). The RF model was the best performing (AUROC = 0.884; sensitivity = 0.619; specificity = 0.887; negative predictive value = 0.872; accuracy = 0.819). The five most influential features of the RF model were office diastolic BP, office systolic BP, current smoker, estimated glomerular filtration rate, and fasting glucose level.

Conclusion

Our prediction models achieved good performance, underlining the feasibility of applying ML models to outpatient populations for the diagnosis of WCH and WUCH. Further validation with other prospective data sets should be considered in the future.

Stress-induced arterial hypertension

Stress is considered as one of the factors associated with the development of many diseases, including the cardiovascular system. The history of studying stress as a risk factor for hypertension began in the first half of the 20th century and continued after the introduction of 24-hour blood pressure monitoring (ABPM) into clinical practice. Then it turned out that there is normotension, stable hypertension and latent hypertension: masked (when clinical BP is within the normal range, and arterial hypertension is recorded according to ABPM and/or self-monitoring of BP) and white coat hypertension (increased BP during a visit to the doctor when normal values of blood pressure according to ABPM or self-monitoring of BP). Currently, both variants of latent hypertension are classified as stress-induced arterial hypertension. Several models have been proposed for the study of stress, but two of them are more common in clinical studies: the Karasek model (based on an imbalance between job demands and job decision latitude) and the Siegrist model (based on an imbalance of effort and reward). There are only few studies in where attempts have been made to link the increase in BP with the parameters of stress response (for example, with hormonal levels) or genetic predisposition. The review discusses the most significant studies of stress-induced arterial hypertension published to date.

White Coat Hypertension Persistence in Children and Adolescents: The Pediatric Nephrology Research Consortium Study

OBJECTIVES

To determine whether youth with white coat hypertension on initial ambulatory blood pressure monitoring (ABPM) continue to demonstrate the same pattern on repeat ABPM.

STUDY DESIGN

Retrospective longitudinal cohort study of patients referred for high blood pressure (BP) and diagnosed with white coat hypertension by ABPM who had follow-up ABPM 0.5-4.6 years later at 11 centers in the Pediatric Nephrology Research Consortium. We classified ABPM phenotype using the American Heart Association guidelines. At baseline, we classified those with hypertensive BP in the clinic as "stable white coat hypertension," and those with normal BP as "intermittent white coat hypertension." We used multivariable generalized linear mixed effect models to estimate the association of baseline characteristics with abnormal ABPM phenotype progression.

RESULTS

Eighty-nine patients met the inclusion criteria (median age, 13.9 years; 78% male). Median interval time between ABPM measurements was 14 months. On follow-up ABPM, 61% progressed to an abnormal ABPM phenotype (23% ambulatory hypertension, 38% ambulatory prehypertension). Individuals age 12-17 years and those with stable white coat hypertension had greater proportions progressing to either prehypertension or ambulatory hypertension. In the multivariable models, baseline wake systolic BP index ≥0.9 was significantly associated with higher odds of progressing to ambulatory hypertension (OR 3.07, 95% CI 1.02-9.23).

CONCLUSIONS

The majority of the patients with white coat hypertension progressed to an abnormal ABPM phenotype. This study supports the 2017 American Academy of Pediatrics Clinical Practice Guideline's recommendation for follow-up of ABPM in patients with white coat hypertension.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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The quality of patients' self-blood pressure measurements: a cross-sectional study

BACKGROUND

The accurate and independent measurement of blood pressure (BP) by patients is essential for home BP monitoring (HBPM) and determining the quality of hypertension (HTN) control. This study aimed to evaluate the BP self-measurement techniques of hypertensive patients and their accuracy in accordance with established guidelines. We sought to identify the common errors that patients make and suggest improvements that can be implemented in the primary healthcare setting to increase the reliability of HBPM conducted by hypertensive patients.

METHODS

One hundred patients diagnosed with HTN completed a questionnaire inquiring about their health and demographic data and BP monitoring practices. Patients were then observed and filmed while measuring their BP on their own devices in five primary healthcare centres in Kraków, Poland. The correctness of their techniques was assessed in accordance with the European Society of Hypertension guidelines on HBPM.

RESULTS

Only 3% of patients measured their BP without error; 60% made three or more errors. The most frequent error, made by 76% of subjects, was incorrect sphygmomanometer cuff placement (above or below heart level, or/and the indicator mark was not aligned with the brachial artery). Regarding patients' previous instruction for the correct use of their devices, 36% of patients referred to their monitor's user manual, 22% did not receive any prior assistance, and only 29% were adequately counselled by physicians on how to measure their BP correctly.

CONCLUSIONS

Our findings suggest that primary healthcare physicians and their personnel often do not adequately instruct patients on how to measure their BP correctly. Therefore, healthcare systems must provide patients with more adequate training and reference materials on the best practices of BP monitoring.

White-Coat Hypertension: Pathophysiological and Clinical Aspects: Excellence Award for Hypertension Research 2020

Few issues of modern cardiovascular medicine have been as controversial as the relationship between white-coat hypertension (WCH), that is, a common condition in which office blood pressure is elevated while out-of-office blood pressure (ambulatory blood pressure or home blood pressure) is normal. While earlier studies showed no increased risk of cardiovascular events in WCH compared with the normotensive state, more recent studies have changed this conclusion by showing that an increased cardiovascular risk represents a trait of this hypertensive phenotype. The present article will review a number of issues related to WCH, that is, its definition, pathophysiological background, clinical alterations, and prognostic significance. This will be done by considering the available evidence published during the last decades, with special focus on the data collected in PAMELA (Pressioni Arteriose Monitorate e Loro Associazioni)-a research project performed with a cross-sectional and longitudinal design, which has provided a series of novel clinical information on WCH throughout the years. The final part of the article will discuss the therapeutic implications of the abovementioned evidence, as well as some controversial or still undefined issues related to WCH, whose investigation will be an important goal to pursue by future research.

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

OBJECTIVE

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

DESIGN

A multicentre observational study.

SETTING

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

SUBJECTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

The pressioni arteriose monitorate e loro associazioni (PAMELA) research project: a 25-year long journey

INTRODUCTION

Among the observational studies performed in the area of blood pressure measurements in the population the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) investigation represents an unique research for a number of reasons.

EVIDENCE ACQUISITION AND SYNTHESIS

The PAMELA study combines clinic, home and 24-hour blood pressure measurements in all partiicipants, which were representative of the general population. Examination included metabolic variables, allowing us to determine the interrelationships between bood pressure and metabolic profile. The protocol also included evaluation of organ damage, such as left ventricular hypertrophy, left ventricular diastolic dysfunction, left atrial dimensions and aortic root diameters. Finally, PAMELA represents one of the few studies with a prolonged follow-up, the last survey being completed three years ago and data collected are actually under analysis. This will allow to update the information related to cardiovascular morbidity and mortality in the study cohort.

CONCLUSIONS

The present paper will provide an overview of the various scientific contributions of the PAMELA study to the epidemiology, pathophysiology and clinical aspects of hypertension and hypertension related cardiovascular risk.

Long-Term Risk of Progression to Sustained Hypertension in White-Coat Hypertension with Normal Night-Time Blood Pressure Values

Background

The long-term prognosis and transition towards sustained ambulatory hypertension (SHT) of white-coat hypertension (WCHT) remain uncertain particularly in those with both normal nighttime and daytime blood pressure (BP) values. Different classification criteria and the use of antihypertensive drugs may contribute to conflicting results. Patients and Methods. We prospectively evaluated for a 7.1 year transition to SHT in 899 nondiabetic subjects free from cardiovascular (CV) events: normotensive (NT) (n = 344; 52, 9% female; ageing 48 ± 14 years); untreated WCHT (UnWCHT n = 399; 50, 1% female; ageing 51 ± 14 years); and treated WCHT with antihypertensive drugs after baseline (TxWCHT n = 156; 54, 4% female; ageing 51 ± 15 years). All underwent 24 h ambulatory BP monitoring (24 h-ABPM) at baseline, at 30 to 60 months, and at 70 to 120 months thereafter. WCHT was at baseline (with no treatment) as office BP ≥ 140/or 90 mm·Hg, daytime BP < 135/85 mm·Hg, and nighttime BP < 120/70 mm·Hg. Development of SHT was considered if daytime BP ≥ 135/or 85 mm Hg and/or nighttime BP ≥ 120/or 70 mm·Hg.

Results

Baseline metabolic parameters did not differ among groups. At 30–60 months and at the end of follow-up, development of SHT occurred, respectively, in NT (3.8% (n = 13) and 9.6% (n = 33)) and in UnWCHT (10.1% (n = 40) and 16.5% (n = 66)) (p < 0.009). The mean annual increase of average 24 h-systolic BP was 0.48 + 0.93 in NT and 0.73 + 1.06 in UnWCHT, whereas annual SBP in office increased in NT by 1.2 + 0.95 but decreased in UnWCHT by 1.36 + 1.35 mm Hg (p < 0.01).

Conclusion

Untreated WCHT patients exhibit a faster and a higher risk of developing SHT compared to NT with TxWCHT assuming an intermediate position between them.

Twenty-four-hour versus clinic blood pressure levels as predictors of long-term cardiovascular and renal disease outcomes among African Americans

In Caucasian and Asian populations, evidence suggests that 24-h blood pressures (BP) are more predictive of long-term cardiovascular events than clinic BP. However, few long-term studies have evaluated the predictive value of 24-h BP phenotypes (24-h, daytime, nighttime) among African Americans (AA). The purpose of this study is to evaluate the added value of 24-h BP phenotypes compared to clinic BP in predicting the subsequent fatal and non-fatal cardiovascular/renal disease events in AA subjects. AA subjects (n = 270) were initially studied between 1994 and 2006 and standardized clinic BP measurements were obtained during screening procedures for a 3-day inpatient clinical study during which 24-h BP measurements were obtained. To assess the subsequent incidence of cardiovascular and renal disease events, follow-up information was obtained and confirmed by review of paper and electronic medical records between 2015 and 2017. During a mean follow-up of 14 ± 4 years, 50 subjects had one or more fatal or non-fatal cardiovascular/renal disease events. After adjustment for covariates, clinic systolic and diastolic BP were strongly associated with cardiovascular/renal disease events and all-cause mortality (p < 0.0001). Twenty-four-hour BP phenotypes conferred a small incremental advantage over clinic BP in predicting cardiovascular/renal events, which was limited to making a difference of one predicted event in 250-1,000 predictions depending on the 24-h BP phenotype. Nocturnal BP was no more predictive than the other 24-h BP phenotypes. In AA, 24-h BP monitoring provides limited added value as a predictor of cardiovascular/renal disease events. Larger studies are needed in AA to confirm these findings.

Central hemodynamic characteristics of young adults with isolated systolic hypertension: an ambulatory blood pressure monitoring-based study of real-world clinical patients

The central hemodynamic characteristics of young adults with isolated systolic hypertension (ISH) remain controversial, particularly regarding the extent of pulse pressure amplification (PPamp) compared with that of normotensives (NTs). Given the lack of ambulatory blood pressure monitoring (ABPM)-based data, this study evaluated 509 untreated young adults (18-35 years) who had undergone ABPM during the last decade, 109 who had undergone both ABPM and SphygmoCor analysis, and 26 newly recruited NTs. The agreement rate between office BP- and ABPM-based subtype classification was alarmingly low (50.7%). ISH was distinguishable from systolic-diastolic hypertension, the predominant subtype characterized by increased central BPs and stiffened arteries. The central hemodynamic parameters were all similar between patients with ISH and white-coat hypertension (WC). ISH patients had central BPs that were, albeit higher than those of NTs, at an upper-normal level that was comparable to those of WC patients. ISH patients had similar cfPWV but significantly higher PPamp than NTs (p = 0.032). The central hemodynamic parameters of the participants were further analyzed according to central pressure waveform types (A vs. B vs. C). Type C waves were associated with the highest PPamp and lowest cfPWV, whereas type A waves were associated with the lowest PPamp and highest cfPWV. Subjects with type B waves, an intermediate form, also had considerably high PPamps. Waveform composition differed significantly across hypertension subtypes (p < 0.001). ISH patients mostly had type B or C waves (96.7%), with only 3.3% having type A waves. This study based on a refined diagnosis showed that the ambulatory ISH of young adults arises from highly elastic arteries and related robustness of PPamp and shares similar central hemodynamic characteristics with WC patients.

Österreichischer Blutdruckkonsens 2019

Erhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.

Searching for optimal blood pressure targets in type 2 diabetic patients with coronary artery disease

BACKGROUND

Controversies exist regarding the optimal blood pressure (BP) level that is safe and provides cardiovascular protection in patients with type 2 diabetes mellitus (T2DM) and coexistent coronary artery disease. Several new glucose-lowering agents have been found to lower BP as well, making the interaction between BP and T2DM even more complex.

METHODS

With the reference to recent literature, this review article describes the potential mechanisms of increased risk of hypertension in T2DM and outlines the possible optimal BP levels based upon recommendations on the management of hypertension by the current guidelines, in combination with our research findings, for type 2 diabetic patients with coronary artery disease.

RESULTS

The development of hypertension in T2DM involves multiple processes, including enhanced sympathetic output, inappropriate activation of renin-angiotensin- aldosterone system, endothelial dysfunction induced through insulin resistance, and abnormal sodium handling by the kidney. Both AGE-RAGE axis and adipokine dysregulation activate intracellular signaling pathways, increase oxidative stress, and aggravate vascular inflammation. Pancreatic β-cell specific microRNAs are implicated in gene expression and diabetic complications. Non-pharmacological intervention with lifestyle changes improves BP control, and anti-hypertensive medications with ACEI/ARB, calcium antagonists, β-blockers, diuretics and new hypoglycemic agent SGLT2 inhibitors are effective to decrease mortality and prevent major adverse cardiovascular events. For hypertensive patients with T2DM and stable coronary artery disease, control of BP < 130/80 mmHg but not < 120/70 mmHg is reasonable, whereas for those with chronic total occlusion or acute coronary syndromes, an ideal BP target may be somewhat higher (< 140/90 mmHg). Caution is advised with aggressive lowering of diastolic BP to a critical threshold (< 60 mmHg).

CONCLUSIONS

Hypertension and T2DM share certain similar aspects of pathophysiology, and BP control should be individualized to minimize adverse events and maximize benefits especially for patients with T2DM and coronary artery disease.

The Impact of Measurement Methods on Office Blood Pressure and Management of Hypertension in General Practice

INTRODUCTION

The use of unattended automated office blood pressure (uAutoOBP) versus attended automated (aAutoOBP) and manual auscultatory office blood pressure (AuscOBP) measurements is a topic of current controversy.

AIM

To evaluate the differences between OBP measurements methods in the general practice (GP) setting.

METHODS

We first compared aAutoOBP and uAutoOBP in 42 consecutive patients with hypertension (group 1). Secondly, we compared AuscOBP to uAutoOBP measurements in 133 consecutive patients with hypertension (group 2). In addition, we analyzed the achieved OBP targets as recommended in the 2018 European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) guidelines in group 2.

RESULTS

The mean age of patients in group 1 was 71 years (range 34-89 years, 54.8% females). The aAutoOBP and uAutoOBP systolic (131.7 and 131.6 mmHg) and diastolic (83.4 and 82.4 mmHg) mean values were not significantly different. The patient characteristics in group 2 were similar to group 1. We observed a significant difference between AuscOBP and uAutoOBP measurement for both systolic (149.4 versus 129.5 mm Hg) and diastolic (85.4 versus 81.6 mm Hg, p < 0.0001, respectively). Accordingly, 20.3% and 45.9% of patients reached the overall 2018 ESC/ESH systolic and diastolic OBP targets of < 140/80 mmHg according to AuscOBP and uAutoOBP (p < 0.0001).

CONCLUSION

The attended versus unattended status of automated OBP measurements had no impact on OBP values in GP. However, significantly higher OBP values and lower rates of achieved target OBP were observed by using AuscOBP measurements by physicians in comparison to automated OBP recordings.

Limited reproducibility of MUCH and WUCH: evidence from the ELSA study

Aims

To evaluate the long-term reproducibility of masked (MUCH) and white-coat uncontrolled hypertension (WUCH), an information crucial for determining the long-term prognostic impact of these conditions.

Methods and results

Reproducibility of MUCH and WUCH was assessed in 1664 hypertensive patients recruited for the European Lacidipine Study on Atherosclerosis and treated with atenolol or lacidipine (±additional drugs) during a 4-year period. Office and 24 h blood pressure (BP) was measured at baseline and every year during treatment, allowing repeated classification of either condition. After 1 year of treatment 21.1% and 17.8% of the patients were classified as MUCH and WUCH, respectively. For both conditions the prevalence was similar in the following years, although with a large change in patients composition because only about 1/3 of patients classified as MUCH or WUCH at one set of office and ambulatory BP measurements maintained the same classification at a subsequent set of measurements. In only 4.5% and 6.2% MUCH and WUCH persisted throughout the treatment period. MUCH and WUCH reproducibility was worse than that of patients showing control or lack of control of both office and ambulatory BP, i.e. controlled and uncontrolled hypertension, respectively.

Conclusion

Both MUCH and WUCH display poor reproducibility over time. This should be taken into account in studies assessing the long-term prognostic value of these conditions based on only one set of BP measurements.

Patient Expectations about Communication in the Perioperative Setting of Elective Knee Surgery - a Questionnaire-based Cross-sectional Study

BACKGROUND

Patient expectations are an issue which is attracting increased interest in outcome research for knee surgery procedures. So far, research into patient expectations has mainly focused on the procedure and postoperative functional improvements. The purpose of this study was to identify patient expectations in the perioperative setting.

MATERIAL AND METHODS

This was a single-center prospective study. A 17-item questionnaire (ordinal answer scale) about patients' perioperative expectations was developed and completed by patients undergoing elective joint-preserving knee surgery. The study covered a period of 3 months and included all patients consecutively undergoing knee surgery. Subgroup analysis was performed for gender, age and type of insurance.

RESULTS

111 consecutive patients completed the questionnaire on admission. Significant preferences for one answer option were found for 13 out of 17 items. Patients considered it "unimportant" whether or not the physician wore a white coat during the consultation and "very important" that the first medical consultation after the patient was discharged from hospital was with the surgeon who had performed their operation. A concise explanation of the surgical procedure using images, talking to the surgeon the day before surgery and immediately after surgery, having their wound personally inspected by the surgeon, and, finally, the availability of the surgeon by phone were regarded as "important". There were no differences in patient responses between the different subgroups.

CONCLUSION

Patients expect a high personal commitment and availability of the surgeon during the entire perioperative setting, starting from the first consultation and continuing during follow-up examinations.

Treatment of hypertension in the elderly in 2017/2018 - what's new?

Introduction: Hypertension is highly prevalent in the elderly and represents a major risk factor for cardiovascular complications such as coronary heart disease, stroke, and cognitive dysfunction. Areas covered: The recently published AHA/ACC and ESC/ESH guidelines for the management of hypertension in adult populations modified their approach towards hypertension in the elderly, particularly in those older than 85 years. The new concepts presented in these guidelines are discussed. They recommend a less conservative threshold and lower blood pressures targets; an emphasis on considering the biological rather than chronological age for patients >85 years, and the use of single-pill combinations to simplify treatment algorithms and increase long-term drug adherence. Expert opinion: Considering the high prevalence of hypertension in the elderly and the negative impact of untreated hypertension, early detection of hypertension in patients over 60 years old is crucial. The screening of hypertension should be reinforced in patient populations using out-of-office BP measurements. The author supports the latest ESC/ESH guidelines, which define a threshold at >140 mmHg for patients aged 65 to 79 years and >160 mmHg for those >85 years and propose a target BP of 130-140 mmHg, while considering patient frailty and the tolerability of the treatment.

[Position statement on ambulatory blood pressure monitoring (ABPM) by the Spanish Society of Hypertension (2019)]

Conventional blood pressure (BP) measurement in clinical practice is the most used procedure for the diagnosis and treatment of hypertension (HT), but is subject to considerable inaccuracies due to, on the one hand, the inherent variability of the BP itself and, on the other hand biases arising from the measurement technique and conditions, Some studies have demonstrated the prognosis superiority in the development of cardiovascular disease using ambulatory blood pressure monitoring (ABPM). It can also detect "white coat" hypertension, avoiding over-diagnosis and over-treatment in many cases, as well detecting of masked hypertension, avoiding under-detection and under-treatment. ABPM is recognised in the diagnosis and management of HT in most of international guidelines on hypertension. The present document, taking the recommendations of the European Society of Hypertension as a reference, aims to review the more recent evidence on ABPM, and to serve as guidelines for health professionals in their clinical practice and to encourage ABPM use in the diagnosis and follow-up of hypertensive subjects. Requirements, procedure, and clinical indications for using ABPM are provided. An analysis is also made of the main contributions of ABPM in the diagnosis of "white coat" and masked HT phenotypes, short term BP variability patterns, its use in high risk and resistant hypertension, as well as its the role in special population groups like children, pregnancy and elderly. Finally, some aspects about the current situation of the Spanish ABPM Registry and future perspectives in research and potential ABPM generalisation in clinical practice are also discussed.

Noninvasive Assessment of Myocardial Perfusion in Different Blood Pressure Phenotypes and Its Association With Arterial Stiffness Indices

BACKGROUND

We investigated for the first time whether patients with recent-onset, uncomplicated hypertension and different hypertension phenotypes exhibit altered values of subendocardial viability ratio (SEVR), a surrogate measure of myocardial perfusion that correlates with the ratio of subendocardial to subepicardial blood flow. We additionally explored whether SEVR correlates with arterial stiffness in a population free from the long-term effects of essential hypertension.

METHODS

Nontreated individuals free from any known health problems were classified as true hypertensives (THs), white-coat hypertensives (WCHs), masked hypertensives (MHs), and normotensives. SEVR was noninvasively calculated with applanation tonometry in the radial artery. Carotid-femoral pulse wave velocity, central and peripheral pulse pressure (PP), augmentation index, and central systolic/diastolic blood pressure (BP) were assessed with applanation tonometry. Total arterial compliance index was calculated with impedance cardiography.

RESULTS

In a total of 150 participants, normotensive individuals exhibited the highest values of SEVR (162.9 ± 25.3%), whereas SEVR appeared to be similar in MHs (150.2 ± 22.1%), WCHs (148.1 ± 20.4%), and THs (149.9 ± 24.8%) (P = 0.017). In the univariate analysis, SEVR significantly correlated with central systolic BP, peripheral PP, and total arterial compliance index. The association between SEVR and both central (P = 0.017) and peripheral PP (P = 0.003) remained significant after adjustment for heart rate and other parameters.

CONCLUSIONS

SEVR, an alternative tool to the invasive assessment of microvascular coronary perfusion, presents different values across patients with divergent BP phenotypes and correlated with arterial stiffness, even in the absence of overt cardiovascular disease. Future studies need to address the potential utility of this easily implementable marker as a screening test for myocardial ischemia.

Magnitude of the Difference Between Clinic and Ambulatory Blood Pressures and Risk of Adverse Outcomes in Patients With Chronic Kidney Disease

Background Obtaining 24-hour ambulatory blood pressure ( BP ) is recommended for the detection of masked or white-coat hypertension. Our objective was to determine whether the magnitude of the difference between ambulatory and clinic BP s has prognostic implications. Methods and Results We included 610 participants of the AASK (African American Study of Kidney Disease and Hypertension) Cohort Study who had clinic and ambulatory BPs performed in close proximity in time. We used Cox models to determine the association between the absolute systolic BP ( SBP ) difference between clinic and awake ambulatory BPs (primary predictor) and death and end-stage renal disease. Of 610 AASK Cohort Study participants, 200 (32.8%) died during a median follow-up of 9.9 years; 178 (29.2%) developed end-stage renal disease. There was a U-shaped association between the clinic and ambulatory SBP difference with risk of death, but not end-stage renal disease. A 5- to <10-mm Hg higher clinic versus awake SBP (white-coat effect) was associated with a trend toward higher (adjusted) mortality risk (adjusted hazard ratio, 1.84; 95% CI, 0.94-3.56) compared with a 0- to <5-mm Hg clinic-awake SBP difference (reference group). A ≥10-mm Hg clinic-awake SBP difference was associated with even higher mortality risk (adjusted hazard ratio, 2.31; 95% CI, 1.27-4.22). A ≥-5-mm Hg clinic-awake SBP difference was also associated with higher mortality (adjusted hazard ratio, 1.82; 95% CI, 1.05-3.15) compared with the reference group. Conclusions A U-shaped association exists between the magnitude of the difference between clinic and ambulatory SBP and mortality. Higher clinic versus ambulatory BPs (as in white-coat effect) may be associated with higher risk of death in black patients with chronic kidney disease.

What is the optimal cut-off threshold in self-home blood pressure measurement?: A cohort study according to STROBE statement

Two aspects arise concerning the use of self-measured blood pressure monitoring to diagnose white-coat hypertension (WCH): the presence of target organ damage (TOD) and the normal cut-off threshold. This study aims to evaluate the cardiovascular risk of WCH according to different self-measured blood pressure normal cut-off thresholds and the influence of TOD at baseline.In all, 678 patients were followed for 6.2 years; 223 normotensive patients, 271 patients with sustained hypertension (HT), and 184 with WCH. TOD was defined as: left ventricular hypertrophy according to ECG, albuminuria, or low estimated glomerular filtration rate. The risk for different cutting points of self-measured blood pressure (<135/85 mm Hg, <130/85 mm Hg, and <130/80 mm Hg) has been determined.The patients with HT experienced an increase in cardiovascular risk and death higher than the normotensive patients (odds ratio [OR] 7.9, 95% confidence interval [CI] 3.8-16.2 for sustained HT; and OR 3.5, 95% CI 1.6-7.4 for WCH). This was observed for all the cut-off thresholds analyzed. In white-coat hypertensive patients (cut-off <135/85 mm Hg) with TOD, the risk was higher than in normotensive patients (OR 4.5; 95% CI 1.9-10.6). Using a self-monitoring blood pressure cut-off threshold of <130/80 mm Hg without TOD at baseline, the WCH cases exhibited no differences in risk to the normotensive patients (OR 2.0, 95% CI 0.5-7.7).The decisions being taken for patients with WCH based on the presence of TOD and a self-administered home monitoring blood pressure measurement cut-off point probably lower than the one that is currently recommended.

White-coat hypertension from a paediatric perspective

AIM

This mini review explored the prevalence of white-coat hypertension (WCH), which is very common in children. It results in elevated office blood pressure (BP) but normal ambulatory BP monitoring (ABPM) readings.

METHODS

WCH can only be identified by analysing and comparing office BP readings and ABPM, which periodically records BP every 20-30 minutes over 24-hour period. This study provides initially the background for WCH in adults, together with a comprehensive overview of the most relevant paediatric data on WCH.

RESULTS

Accurate measurements of BP are very important for the diagnosis and management of hypertension. It is important to acknowledge the clinical relevance of WCH and follow up children who display this BP phenotype by carrying out ABPM, so that clinicians can build up an accurate picture of their BP. It is also important to identify children who have BP issues and are overweight or obese, so that treatment of this modifiable cardiovascular risk factor can be initiated.

CONCLUSION

Using ABPM provides paediatricians with a more precise evaluation of a child's BP readings than office BP readings. It is the gold standard for diagnosing WCH.

2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension

: Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.

Diurnal blood pressure changes

The definition of diurnal blood pressure changes varies widely, which can be confusing. Short-term blood pressure variability during a 24-h period and the dipping status of diurnal blood pressure can be captured by ambulatory blood pressure monitoring, and these metrics are reported to have prognostic significance for cardiovascular complications. Morning blood pressure surge also indicates this risk, but its effect may be limited to populations with specific conditions. Meanwhile, the combined use of conventional office blood pressure and out-of-office blood pressure allows us to identify people with white-coat and masked hypertension. Current home devices can measure nocturnal blood pressure during sleep more conveniently than ambulatory monitoring; however, we should pay attention to blood pressure measurement conditions regardless of whether they are in a home, ambulatory, or office setting. The relatively poor reproducibility of diurnal blood pressure changes, including the nocturnal fall of blood pressure, is another underestimated issue to be addressed. Although information on diurnal blood pressure changes is expected to be used more effectively in the future, we should also keep in mind that blood pressure levels have remained central to the primary and secondary prevention of blood pressure-related cardiovascular diseases in clinical practice.