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

Cuff-based blood pressure measurement: challenges and solutions

OBJECTIVE

Accurate measurement of arterial blood pressure (BP) is crucial for the diagnosis, monitoring, and treatment of hypertension. This narrative review highlights the challenges associated with conventional (cuff-based) BP measurement and potential solutions. This work covers each method of cuff-based BP measurement, as well as cuffless alternatives, but is primarily focused on ambulatory BP monitoring.

RESULTS

Manual BP measurement requires stringent training and standardized protocols which are often difficult to ensure in stressful and time-restricted clinical office blood pressure monitoring (OBPM) scenarios. Home Blood pressure monitoring (HBPM) can identify white-coat and masked hypertension but strongly depends on patient adherence to measurement techniques and procedure. The widespread use of nonvalidated automated HBPM devices raises further concerns about measurement accuracy. Ambulatory blood pressure measurement (ABPM) may be used in addition to OBPM. It is recommended to diagnose white-coat and masked hypertension as well as nocturnal BP and dipping, which are the BP values most predictive for major adverse cardiac events. Nonetheless, ABPM is limited by its non-continuous nature and susceptibility to measurement artefacts. This leads to poor overall reproducibility of ABPM results, especially regarding clinical parameters such as BP variability or dipping patterns.

CONCLUSIONS

Cuff-based BP measurement, despite some limitations, is vital for cardiovascular health assessment in clinical practice. Given the wide range of methodological limitations, the paradigm's potential for improvement is not yet fully realized. There are impactful and easily incorporated opportunities for innovation regarding the enhancement of measurement accuracy and reliability as well as the clinical interpretation of the retrieved data. There is a clear need for continued research and technological advancement to improve BP measurement as the premier tool for cardiovascular disease detection and management.

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.

When blood pressure refuses to budge: exploring the complexity of resistant hypertension

Resistant hypertension, defined as blood pressure that remains above goal despite using three or more antihypertensive medications, including a diuretic, affects a significant proportion of the hypertensive population and is associated with increased cardiovascular morbidity and mortality. Despite the availability of a wide range of pharmacological therapies, achieving optimal blood pressure control in patients with resistant hypertension remains a significant challenge. However, recent advances in the field have identified several promising treatment options, including spironolactone, mineralocorticoid receptor antagonists, and renal denervation. In addition, personalized management approaches based on genetic and other biomarkers may offer new opportunities to tailor therapy and improve outcomes. This review aims to provide an overview of the current state of knowledge regarding managing resistant hypertension, including the epidemiology, pathophysiology, and clinical implications of the condition, as well as the latest developments in therapeutic strategies and future prospects.

Hypertension as Cardiovascular Risk Factor in Chronic Kidney Disease

Hypertension is the leading modifiable cause of premature death and hence one of the global targets of World Health Organization for prevention. Hypertension also affects the great majority of patients with chronic kidney disease (CKD). Both hypertension and CKD are intrinsically related, as hypertension is a strong determinant of worse renal and cardiovascular outcomes and renal function decline aggravates hypertension. This bidirectional relationship is well documented by the high prevalence of hypertension across CKD stages and the dual benefits of effective antihypertensive treatments on renal and cardiovascular risk reduction. Achieving an optimal blood pressure (BP) target is mandatory and requires several pharmacological and lifestyle measures. However, it also requires a correct diagnosis based on reliable BP measurements (eg, 24-hour ambulatory BP monitoring, home BP), especially for populations like patients with CKD where reduced or reverse dipping patterns or masked and resistant hypertension are frequent and associated with a poor cardiovascular and renal prognosis. Even after achieving BP targets, which remain debated in CKD, the residual cardiovascular risk remains high. Current antihypertensive options have been enriched with novel agents that enable to lower the existing renal and cardiovascular risks, such as SGLT2 (sodium-glucose cotransporter-2) inhibitors and novel nonsteroidal mineralocorticoid receptor antagonists. Although their beneficial effects may be driven mostly from actions beyond BP control, recent evidence underline potential improvements on abnormal 24-hour BP phenotypes such as nondipping. Other promising novelties are still to come for the management of hypertension in CKD. In the present review, we shall discuss the existing evidence of hypertension as a cardiovascular risk factor in CKD, the importance of identifying hypertension phenotypes among patients with CKD, and the traditional and novel aspects of the management of hypertensives with CKD.

Liuzijue training improves hypertension and modulates gut microbiota profile

Background

Liuzijue training (LZJ) is a traditional exercise integrating breathing meditation and physical exercise, which could prevent and improve hypertension symptoms.

Purpose

We aimed to evaluate the therapeutic effect of LZJ on hypertensive patients from the perspectives of blood pressure (BP), vascular endothelial function, immune homeostasis, and gut microbiota.

Methods

We conducted a randomized, controlled, single-blind experiment to assess the effect of 12 weeks LZJ in hypertensive patients. We measured the blood pressure level, vascular endothelial function, serum inflammatory factor concentration, and fecal microbial composition of hypertension patients.

Results

Compared with aerobic training, LZJ has a more significant effect on serum inflammatory factors (IL-6 and IL-10) and gut microbiota. PCoA analysis showed that LZJ tended to transform the gut microbiota structure of hypertensive subjects into that of healthy people. This process involves significant changes in Bacteroides, Clostridium_sensu_stricto_1, Escherichia-Shigella, Haemophilus, Megamonas, and Parabacteroides. In particular, Bacteroides and Escherichia-Shigella, these bacteria were closely related to the improvement of BP in hypertensive patients.

Conclusion

In conclusion, our results confirm that LZJ could be used as an adjuvant treatment for hypertensive patients, which could effectively reduce BP, improve the immune homeostasis and gut microbiota structure in patients, and provide a theoretical reference for the use of LZJ in the clinic.

Clinical trial registration

http://www.chictr.org.cn/listbycreater.aspx, identifier: ChiCTR2200066269.

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.

Pseudo and resistant hypertension: A chaotic perspective

Systemic blood pressure (BP) may oscillate for homeostatic needs (equilibrium by constancy) or just as shifts in other intrinsic and extrinsic variables known as allostatic changes. This transitory pressure often rises alerts physicians to out‐of‐control hypertension or even hypertensive crisis. There is a very complex theory underlying these stochastic phenomena, which physicists and mathematicians translate into a single word: chaos. These changes happen according to a stochastic probabilistic pattern that presumes chaotic but somewhat predictable and nonlinear modeling of BP‐related dynamics as a mathematical approach. Based on the chaos theory, small changes at the initial BP (baseline overtime) values could disturb the homeostasis leading to extreme BP chaotic shifts. These almost insignificant oscillations may also affect other variables and systems, leading to the misdiagnosis of hypertension, “out‐of‐control” BP levels, and resistant hypertension (RHT). Thus, these unpredictable and transient increases in BP values may be improperly diagnosed as the white coat and masked or resistant hypertension. Indeed, the interference of the chaos in any phenotype of (true or false) hard to control BP is not considered in clinical settings. This review provides some basic concepts on chaos theory and BP regulation. Besides pseudoresistant hypertension (lack of adherence, circadian variations, and others (white‐coat, masked, early morning effects or hypertension), chaotic changes can be responsible for out‐of‐control hypertension.