Does Antihypertensive Drug Class Affect Day-to-Day Variability of Self-Measured Home Blood Pressure? The HOMED-BP Study

Proposal of reference value for day-to-day blood pressure variability based on two outcomes: the Ohasama study

BACKGROUND

This study aimed to propose reference values for day-to-day home blood pressure (BP) variability that align with the established hypertension threshold of home BP for the risk of two different outcomes: cardiovascular mortality and cognitive decline.

METHODS

This prospective study was conducted in Ohasama town, Japan, with 1212 participants assessed for cardiovascular mortality risk (age: 64.7 years, 33.6% men). Additionally, 678 participants (age: 62.7 years, 31.1% men) were assessed for cognitive decline risk (Mini-Mental Scale Examination score <24). The within-individual coefficient of variation (CV) of home morning SBP (HSBP) was used as the index of day-to-day BP variability (%). Adjusted Cox regression models were used to estimate the HSBP-CV values, which provided the 10-year outcome risk at an HSBP of 135 mmHg.

RESULTS

A total of 114 cardiovascular deaths and 85 events of cognitive decline (mean follow-up:13.9 and 9.6 years, respectively) were identified. HSBP and HSBP-CV were associated with increased risks for both outcomes, with adjusted hazard ratios per 1-standard deviation increase of at least 1.25 for cardiovascular mortality and at least 1.30 for cognitive decline, respectively. The adjusted 10-year risks for cardiovascular mortality and cognitive decline were 1.67 and 8.83%, respectively, for an HSBP of 135 mmHg. These risk values were observed when the HSBP-CV was 8.44% and 8.53%, respectively.

CONCLUSION

The HSBP-CV values indicating the 10-year risk of cardiovascular mortality or cognitive decline at an HSBP of 135 mmHg were consistent, at approximately 8.5%. This reference value will be useful for risk stratification in clinical practice.

Assessment of blood pressure variability: characteristics and comparison of blood pressure measurement methods

Previous studies have reported that blood pressure variability (BPV) is associated with the risk of cardiovascular events independent of blood pressure (BP) levels. While there is little evidence from intervention trials examining whether suppressing BPV is useful in preventing cardiovascular disease, it is suggested that detection of abnormally elevated BPV may be useful in reducing cardiovascular events adding by complementing management of appropriate BP levels. Cuffless BP devices can assess beat-to-beat BPV. Although cuffless BP monitoring devices have measurement accuracy issues that need to be resolved, this is an area of research where the evidence is accumulating rapidly, with many publications on beat-to-beat BPV over several decades. Ambulatory BP monitoring (ABPM) can assess 24-hour BPV and nocturnal dipping patterns. Day-to-day BPV and visit-to-visit BPV are assessed by self-measured BP monitoring at home and office BP measurement, respectively. 24 h, day-to-day, and visit-to-visit BPV have been reported to be associated with cardiovascular prognosis. Although there have been several studies comparing whether ABPM and self-measured BP monitoring at home is the superior measurement method of BPV, no strong evidence has been accumulated that indicates whether ABPM or self-measured home BP is superior. ABPM and self-measured BP monitoring have their own advantages and complement each other in the assessment of BPV.

Self-measured home blood pressure highlights cardiovascular risk in women: the HOMED-BP study

No studies examined sex differences in relation to the prognostic significance of self-measured home blood pressure (HBP). We compared the predictive power for the risk of cardiovascular events in 1547 women and 1516 men with hypertension using HBP captured at treatment-free baseline and during on-treatment follow-up, based on the Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP) study. To express the change in risk for the composite cardiovascular endpoint associated with a 1-SD increase in HBP at baseline or on treatment, we derived multivariable-adjusted hazard ratios (HR) based on a Cox regression model. Over a median follow-up of 7.3 years, 100 composite events occurred, including 40 events in women. In women, systolic HBP both at baseline and on-treatment showed significant risk increment (at baseline: HR per 1-SD increment, 1.62; 95% confidence interval [CI], 1.17-2.24. on-treatment: HR, 1.74; 95% CI, 1.32-2.29). However, systolic HBP at baseline did not predict cardiovascular events in men (P = 0.25). On-treatment HBP was significantly associated with cardiovascular risk (P ≤ 0.012) irrespective of sex. Nevertheless, the point estimate of HR for systolic HBP in men (1.33) was less than that in women (1.74), and the interaction of sex with 1 SD-increase in systolic HBP in cardiovascular risk was significant irrespective of baseline (P = 0.039) or follow-up (P = 0.040) measurement when they were mutually adjusted. The increase in cardiovascular risk with the systolic HBP was steeper in women than in men for both baseline and on-treatment. The current findings unveil the importance of the control of systolic HBP, especially in women. Clinical Trial Registration: UMIN Clinical Trial Registry ( http://www.umin.ac.jp/ctr ), Unique identifier: C000000137.

Effects of continuous positive airway pressure on very short-term blood pressure variability associated with sleep-disordered breathing by pulse transit time-based blood pressure measurements

BACKGROUND

Blood pressure (BP) variability (BPV) is a predictor of cardiovascular outcomes independently of BP absolute values. We previously reported that pulse transit time (PTT) enables monitoring beat-to-beat BP, identifying a strong relationship between the extent of very short-term BPV and the severity of sleep-disordered breathing (SDB). Here, we investigated the effects of continuous positive airway pressure (CPAP) on very short-term BPV.

METHODS

We studied 66 patients (mean age 62 years old, 73% male) with newly diagnosed SDB who underwent full polysomnography on two consecutive days for diagnosis (baseline) and CPAP, together with PTT-driven BP continuous recording. PTT index was defined as the average number of acute transient rises in BP (≥12 mmHg) within 30 s/h.

RESULTS

CPAP treatment effectively improved SDB parameters, and attenuated PTT-based BP absolute values during the night-time. Very short-term BPV that includes PTT index and standard deviation (SD) of systolic PTT-BP was significantly reduced by CPAP therapy. The changes in PTT index from baseline to CPAP were positively correlated with the changes in apnea-hypopnea index, obstructive apnea index (OAI), oxygen desaturation index, minimal SpO 2 , and mean SpO 2 . Multivariate regression analysis revealed that changes in OAI and minimal SpO 2 , as well as heart failure, were the independent factors in determining the reduction of PTT index following CPAP.

CONCLUSION

PTT-driven BP monitoring discovered the favorable effects of CPAP on very short-term BPV associated with SDB events. Targeting very short-term BPV may be a novel approach to identifying individuals who experience greater benefits from CPAP.

Blood pressure variability: methodological aspects, clinical relevance and practical indications for management - a European Society of Hypertension position paper ∗

Blood pressure is not a static parameter, but rather undergoes continuous fluctuations over time, as a result of the interaction between environmental and behavioural factors on one side and intrinsic cardiovascular regulatory mechanisms on the other side. Increased blood pressure variability (BPV) may indicate an impaired cardiovascular regulation and may represent a cardiovascular risk factor itself, having been associated with increased all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia incidence. Nonetheless, BPV was considered only a research issue in previous hypertension management guidelines, because the available evidence on its clinical relevance presents several gaps and is based on heterogeneous studies with limited standardization of methods for BPV assessment. The aim of this position paper, with contributions from members of the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability and from a number of international experts, is to summarize the available evidence in the field of BPV assessment methodology and clinical applications and to provide practical indications on how to measure and interpret BPV in research and clinical settings based on currently available data. Pending issues and clinical and methodological recommendations supported by available evidence are also reported. The information provided by this paper should contribute to a better standardization of future studies on BPV, but should also provide clinicians with some indications on how BPV can be managed based on currently available data.

Therapeutic target and clinical impact of day-to-day blood pressure variability in hypertensive patients with covid-19

Blood pressure variability (BPV) is essential in hypertensive patients and is frequently associated with organ damage. As of today, hypertension is still the most common comorbidity in COVID-19, but the impact of BPV and the therapeutic target of BPV on outcomes in COVID-19 patients with hypertension remain unclear. Therefore, this study investigated the relationship between BPV and severity of COVID-19, in-hospital mortality, hypertensive status, and efficacy of antihypertensives in suppressing hypertensive covid-19 patient BPV. This cohort retrospective study enrolled 351 patients hospitalized with COVID-19. Subjects were classified according to the severity of COVID-19, the presence of hypertension, and their BPV status. During hospitalization, mean arterial pressure (MAP) was measured at 6 a.m. and 6 p.m., and BPV was calculated as the coefficient of variation of MAP (MAPCV). MAPCV values above the median were defined as high BPV. In addition, we compared the hypertensive status, COVID-19 severity, in-hospital mortality, and antihypertensive agents between the BPV groups. The mean age was 53.85 ± 18.84 years old. Hypertension was significantly associated with high BPV with prevalence ratio (PR) = 1.38 (95% CI = 1.13-1.70; p = 0.003) or severe COVID-19 (PR = 1.39; 95% CI = 1.09-1.76; p = 0.005). In laboratory findings, high BPV group had lower Albumin, higher WBC, serum Cr, CRP, and creatinine to albumin ratio. High BPV status also significantly increased risk of mortality (HR = 2.30; 95% CI = 1.73-3.86; p < 0.001). Patients with a combination of severe COVID-19 status, hypertension, and high BPV status had the highest risk of in-hospital mortality (HR = 3.51; 95% CI = 2.32-4.97; p < 0.001) compared to other combination status groups. In COVID-19 patients with hypertension, combination therapy with calcium channel blockers (CCB) as well as CCB monotherapy significantly develop low BPV (PR = 2.002; 95 CI% = 1.33-3.07; p = 0.004) and low mortality (HR = 0.17; 95% CI = 0.05-0.56; p = 0.004). Hypertensive status and severe COVID-19 were significantly associated with high BPV, and these factors increased in-hospital mortality. CCBs might be antihypertensive agents that potentially effectively suppressing BPV and mortality in COVID-19 patients.

Impact of home blood pressure variability on cardiovascular outcome in patients with arterial stiffness: Results of the J-HOP study

This study sought to investigate whether the relation between increased blood pressure (BP) variability and increased arterial stiffness confers a risk for cardiovascular disease (CVD) events. We analyzed 2648 patients from a practitioner‐based population (mean ± SD age 64.9 ± 11.4 years: 75.8% taking antihypertensive medication) with at least one cardiovascular risk factor who underwent home BP monitoring in the Japan Morning Surge‐Home Blood Pressure Study. The standard deviation (SD_SBP), coefficient of variation (CV_SBP), and average real variability (ARV_SBP) were assessed as indexes of day‐by‐day home systolic BP (SBP) variability. The authors assessed arterial stiffness by brachial‐ankle pulse wave velocity (baPWV) and divided patients into lower (< 1800 cm/s, n = 1837) and higher (≥1800 cm/s, n = 811) baPWV groups. During a mean follow‐up of 4.4 years, 95 cardiovascular events occurred (8.1 per 1000 person‐years). In Cox proportional hazard models adjusted for traditional cardiovascular risk factors including average home SBP, the highest quartiles of SD_SBP (hazard ratio [HR], 2.30; 95% confidence interval [CI], 1.23‐4.32), CV_SBP (HR, 2.89; 95%CI, 1.59‐5.26) and ARV_SBP (HR, 2.55; 95%CI, 1.37‐4.75) were predictive of CVD events compared to the other quartiles in the higher baPWV group. Moreover, 1SD increases in SD_SBP (HR, 1.44; 95%CI, 1.13‐1.82), CV_SBP (HR, 1.49; 95%CI, 1.16‐1.90) and ARV_SBP (HR, 1.37; 95%CI, 1.09‐1.73) were also predictive of CVD events. These associations remained even after N‐terminal pro‐brain natriuretic peptide was added to the models. However, these associations were not observed in the lower baPWV group. We conclude that arterial stiffness contributes to the association between home BP variability and CVD incidence.

Antihypertensive drug effects according to the pretreatment self-measured home blood pressure: the HOMED-BP study

OBJECTIVES

To clarify whether or not the antihypertensive drug effect is proportional to the baseline pretreatment self-measured home blood pressure (HBP) in accordance with the law of initial value (Wilder's law).

DESIGN

A post-hoc analysis of a multicentre clinical trial.

SETTING

Outpatients across Japan with mild-to-moderate essential hypertension.

PARTICIPANTS

Among 3518 randomised participants, 2423 who self-measured HBP during the pretreatment drug-free period (10-28 days after starting fixed-dose antihypertensive monotherapy) with a mean 7.0 years follow-up were eligible.

MAIN OUTCOME MEASURES

We analysed individual HBP readings during pretreatment and monotherapy.

RESULTS

The day-to-day HBP during both the pretreatment period and monotherapy period remains almost the same throughout each period; the results were consistent, regardless of the pretreatment HBP. Following monotherapy, the reduction in the HBP increased by 2.2 mm Hg (95% CI: 1.8 to 2.5 mm Hg) per 10 mm Hg pretreatment HBP increase, up to 11.0 mm Hg (95% CI: 9.9 to 12.0 mm Hg) among patients with an HBP ≥165 mm Hg during pretreatment. Among the 1005 patients receiving low-dose monotherapy (defined daily dose: 0.5 units), the reduction peaked at 8.9-9.1 mm Hg in those with pretreatment HBP 155-164 mm Hg and ≥165 mm Hg (p=0.88).

CONCLUSIONS

According to Wilder's law, the HBP reduction due to fixed-dose monotherapy was proportional to the pretreatment HBP without any regression to the mean phenomenon. With low-dose antihypertensive drugs, however, the HBP reduction peaked in patients with a high pretreatment HBP, indicating the need for such patients to receive a sufficient amount of antihypertensive drug medication at the initial treatment.

TRIAL REGISTRATION

UMIN Clinical Trial Registry (http://www.umin.ac.jp/ctr), Unique identifier: C000000137.

Increased Arterial Stiffness Amplifies the Association Between Home Blood Pressure Variability and Cardiac Overload

Increased blood pressure (BP) variability, an index of hemodynamic stress, leads to cardiac overload and worse cardiovascular prognosis. The association between day-by-day home BP variability and NT-proBNP (N-terminal pro-B-type natriuretic peptide) as an index of cardiac overload may be amplified by increased arterial stiffness as assessed by brachial-ankle pulse wave velocity (baPWV). J-HOP (Japan Morning Surge-Home Blood Pressure) Study participants who were selected from a practitioner-based population with at least one cardiovascular risk factor underwent home BP monitoring, and their BP levels and SD, coefficient of variation, and average real variability as indexes of systolic BP variability were assessed. We analyzed 2115 individuals without prevalent heart failure and divided them into lower (<1800 cm/s, n=1464) and higher (≥1800 cm/s, n=651) baPWV groups. The higher baPWV group had significantly higher SD SBP , CV SBP , ARV SBP values, and NT-proBNP levels than the lower baPWV group (all P <0.001). In the higher baPWV group, a multiple linear regression analysis revealed that the SD SBP was associated with the NT-proBNP level after adjustment for traditional cardiovascular risk factors including the average home systolic BP (coefficient per 1 SD increase, 0.049 [95% CI, 0.018–0.081]; P =0.002). Similar trends were found for CV SBP ( P =0.003) and ARV SBP ( P =0.004). However, these associations were not found in the lower baPWV group. There was an interaction between all indexes of systolic BP variability and the NT-proBNP level according to lower or higher baPWV group (all P <0.05). Arterial stiffness amplified the association between home BP variability and cardiac overload.

Blood Pressure Variability and Therapeutic Implications in Hypertension and Cardiovascular Diseases

Blood pressure (BP) is characterized by continuous dynamic and spontaneous oscillations occurring over lifetime and defining the so-called blood pressure variability (BPV). BPV has been associated with target organ damage, cardiovascular (CV) risk and death, suggesting the use of BPV as a new target in hypertension management in addition to mean BP values lowering. The purpose of the review is to focus on the therapeutic implications of BPV and summarize the effects of different drug classes on various types of BPV. Despite most first-line antihypertensive medications contribute to reduce both short and long term BPV, calcium channel blockers (CCBs) as monotherapy or fixed-combination therapy appear to be the most effective on BPV control. Further randomized interventional trials are needed to investigate which drug combinations are most appropriate according to patient CV risk stratification, in order to improve their CV outcomes.

Effect of Improving Volume Overload on Home Blood Pressure Variability in Hemodialysis Patients

Blood pressure variability is an independent predictor of adverse clinical events in hemodialysis patients. Volume overload is one of the most important factors affecting blood pressure homeostasis. In the present study, we explored the effects of dry weight reduction on home blood pressure variability in volume overload hemodialysis patients. Hemodialysis patients with volume overload had their dry weight gradually decreased under the guidance of bioimpedance methods, which was represented by calf-bioimpedance ratio (Calf-BR). Home blood pressure was measured on waking up and at bedtime for 1 week at baseline and at the end of the two-month study. Coefficient of variation was used to define home blood pressure variability. Thirty-eight hemodialysis patients had their dry weight significantly decreased from 60.7 ± 11.3 to 59.6 ± 10.7 kg (P = 0.003) accompanied with a significant reduction in calf-BR (0.828 ± 0.023 vs. 0.786 ± 0.020, P<0.001). The systolic and diastolic blood pressure decreased significantly. Moreover, the whole-day, morning, and evening systolic blood pressure variability gradually and significantly decreased by the end of the study (5.6 ± 2.1% versus 4.0 ± 1.7%, P<0.001; 7.7 ± 3.5% vs. 6.3 ± 2.7%, P = 0.005; 7.5 ± 2.8% vs. 5.9 ± 2.3%, P = 0.002, respectively). Diastolic blood pressure variability parameters were unchanged. The interdialytic weight gain and the incidence of adverse events were similar throughout the study period. Gradual dry weight reduction by bioimpedance methods improved home blood pressure variability in hemodialysis patients with chronic fluid overload.

Age-Related Trends in Home Blood Pressure, Home Pulse Rate, and Day-to-Day Blood Pressure and Pulse Rate Variability Based on Longitudinal Cohort Data: The Ohasama Study

Background Home blood pressure is a more accurate prognosticator than office blood pressure and allows the observation of day-to-day blood pressure variability. Information on blood pressure change during the life course links the prediction of blood pressure elevation with age. We prospectively assessed age-related trends in home blood pressure, home pulse rate, and their day-to-day variability evaluated as a coefficient of variation. Methods and Results We examined 1665 participants (men, 36.0%; mean age, 56.2 years) from the general population of Ohasama, Japan. A repeated-measures mixed linear model was used to estimate the age-related trends. In a mean of 15.9 years, we observed 5438 points of measurements including those at baseline. The home systolic blood pressure linearly increased with age and was higher in men than in women aged <70 years. There was an inverse-U-shaped age-related trend in home diastolic blood pressure. The day-to-day home systolic blood pressure linearly increased with age in individuals aged >40 years. However, an U-shaped age-related trend in day-to-day diastolic blood pressure variability with the nadir point at 65 to 69 years of age was observed. No significant sex differences in the day-to-day blood pressure variability were observed (P≥0.22). The average and day-to-day variability of home pulse rate decreased with age but were lower and higher, respectively, in men than in women. Conclusions The current descriptive data are needed to predict future home blood pressure and pulse rate. The data also provide information on the mechanism of day-to-day blood pressure and pulse rate variability.

Effect of stent implantation on blood pressure control in adults with coarctation of the aorta

BACKGROUND

Stenting of coarctation of the aorta (CoA) generally results in good angiographic results and a decrease in transcoarctation pressure gradient. However, effect on blood pressure control is less clear. The goal of the current retrospective analysis was to investigate the effects of CoA stenting on blood pressure control.

METHODS

A retrospective analysis was conducted in consecutive adult patients with a CoA who underwent a percutaneous intervention at one of the three participating hospitals. Measurements included office blood pressure, invasive peak-to-peak systolic pressure over the CoA, diameter of the intima lumen at the narrowest part of the CoA and use of medication. The follow-up data were obtained, based on the most recent examination date.

RESULTS

There were 26 native CoA and 17 recurrent CoAs (total n = 43). Seven of them underwent two procedures. Mean peak-to-peak gradient decreased from 27 mmHg to 3 mmHg (p < 0.001), and minimal diameter increased from a mean of 11 mm to 18 mm (p < 0.001). Mean systolic blood pressure decreased from 151 ± 18 mmHg to 135 ± 19 mmHg at first follow-up of 3.8 ± 1.9 months and 137 ± 22 mmHg at latest follow-up of 19.5 ± 10.9 months (p = 0.001 and p = 0.009, compared to baseline, respectively). The total number of hypertensive patients decreased from 74% to 27% at latest follow-up. No significant change in antihypertensive medication was observed.

CONCLUSION

A clinically significant decrease in systolic blood pressure of approximately 16 mmHg was shown after (re)intervention in CoA patients, which sustained at follow-up. This sustained decrease of blood pressure can be expected to lead to less future adverse cardiovascular events.

Effects of Long- and Intermediate-Acting Dihydropyridine Calcium Channel Blockers in Hypertension: A Systematic Review and Meta-Analysis of 18 Prospective, Randomized, Actively Controlled Trials

BACKGROUND

Dihydropyridine calcium channel blockers are a heterogeneous group of antihypertensive drugs. Long-acting dihydropyridine agent amlodipine is widely used for monotherapy and combination therapy for hypertension in clinical practice, while intermediate-acting dihydropyridine agents have shown inconsistent results in randomized clinical trials (RCTs).

METHODS AND RESULTS

A meta-analysis of 18 RCTs enrolling a total of 80,483 patients with hypertension followed for a mean of 51.4 months was performed. Amlodipine therapy was associated with 25% higher risk of heart failure (relative risk [RR]: 1.25, 95% confidence interval [CI], 1.05-1.49, P = .019) but 17% lower risk of stroke (RR: 0.83, [95% CI, 0.72-0.97], P = .009) without statistically significant effect on acute myocardial infarction (AMI) compared to major alternative antihypertensive therapy (MAAT), including β-blocker, diuretic, angiotensin-converting enzyme inhibitor, or angiotensin-receptor blocker. Intermediate-acting dihydropyridine calcium channel blocker therapy was associated with 25% higher risk of heart failure (RR: 1.25, [95% CI, 1.06-1.47], 0.005, P = .005) and 26% higher risk of AMI (RR: 1.26, [95% CI, 1.05-1.51], 0.019, P = .019) compared to MAAT. Results of the subgroup analysis suggested that the intermediate-acting dihydropyridine calcium channel blocker was associated with higher risk of heart failure (RR: 1.30, [95% CI, 1.08-1.56], P = .005) and AMI (RR: 1.50, [95% CI, 1.01-2.22], P = .043) compared to renin-angiotensin system blockers and a trend toward higher risk of AMI (RR: 1.17, [95% CI, 0.99-1.38], P = .064) compared to conventional therapy, including β-blockers and diuretics. Meta-regression analyses suggested that long-acting dihydropyridine calcium channel blocker is associated with lower risk of AMI ( B: -0.327, [95% CI, -0.530 to -0.123], P = .002) with a trend toward lower risk of stroke ( B: -0.203, [95% CI, -0.410 to 0.003] P = .054).

CONCLUSIONS

This study suggests that Amlodipine offers greater protection against major complications of hypertension compared to intermediate-acting dihydropyridine calcium channel blockers.

Association Between Amplitude of Seasonal Variation in Self-Measured Home Blood Pressure and Cardiovascular Outcomes: HOMED-BP (Hypertension Objective Treatment Based on Measurement By Electrical Devices of Blood Pressure) Study

Background

The clinical significance of long‐term seasonal variations in self‐measured home blood pressure (BP) has not been elucidated for the cardiovascular disease prevention.

Methods and Results

Eligible 2787 patients were classified into 4 groups according to the magnitude of their seasonal variation in home BP, defined as an average of all increases in home BP from summer (July–August) to winter (January–February) combined with all decreases from winter to summer throughout the follow‐up period, namely inverse‐ (systolic/diastolic, <0/<0 mm Hg), small‐ (0–4.8/0–2.4 mm Hg), middle‐ (4.8–9.1/2.4–4.5 mm Hg), or large‐ (≥9.1/≥4.5 mm Hg) variation groups. The overall cardiovascular risks illustrated U‐shaped relationships across the groups, and hazard ratios for all cardiovascular outcomes compared with the small‐variation group were 3.07 (P=0.004) and 2.02 (P=0.041) in the inverse‐variation group and large‐variation group, respectively, based on systolic BP, and results were confirmatory for major adverse cardiovascular events. Furthermore, when the summer‐winter home BP difference was evaluated among patients who experienced titration and tapering of antihypertensive drugs depending on the season, the difference was significantly smaller in the early (September–November) than in the late (December–February) titration group (3.9/1.2 mm Hg versus 7.3/3.1 mm Hg, P<0.001) as well as in the early (March–May) than in the late (June–August) tapering group (4.4/2.1 mm Hg versus 7.1/3.4 mm Hg, P<0.001).

Conclusions

The small‐to‐middle seasonal variation in home BP (0–9.1/0–4.5 mm Hg), which may be partially attributed to earlier adjustment of antihypertensive medication, were associated with better cardiovascular outcomes.

Effect of Azilsartan on Day-to-Day Variability in Home Blood Pressure: A Prospective Multicenter Clinical Trial

Background

The blood pressure variability (BPV) such as visit-to-visit, day-by-day, and ambulatory BPV has been also shown to be a risk of future cardiovascular events. However, the effects of antihypertensive therapy on BPV remain unclear. The purpose of this study was to evaluate the effect of azilsartan after switching from another angiotensin II receptor blocker (ARB) on day-to-day BPV in home BP monitoring.

Methods

This prospective, multicenter, open-labeled, single-arm study included 28 patients undergoing treatment with an ARB, which was switched to azilsartan after enrollment. The primary outcome was the change in the mean of the standard deviation and the coefficient of variation of morning home BP for 5 consecutive days from baseline to the 24-week follow-up. The secondary outcome was the change in arterial stiffness measured by the cardio-ankle vascular index.

Results

The mean BPs in the morning and evening for 5 days did not statistically differ between baseline and 24 weeks. For the morning BP, the means of the standard deviations and coefficient of variation of the systolic BP were significantly decreased from 7.4 ± 3.6 mm Hg to 6.1 ± 3.2 mm Hg and from 5.4±2.7% to 4.6±2.3% (mean ± standard deviation, P = 0.04 and P = 0.04, respectively). For the evening BP, no significant change was observed in the systolic or diastolic BPV. The cardio-ankle vascular index significantly decreased from 8.3 ± 0.8 to 8.1 ± 0.8 (P = 0.03).

Conclusions

Switching from another ARB to azilsartan reduced day-to-day BPV in the morning and improved arterial stiffness.

Observational study and participant-level meta-analysis on antihypertensive drug treatment-related cardiovascular risk

Although antihypertensive therapy reduces cardiovascular risk, individuals who are treated with antihypertensive medication generally have a worse prognosis for cardiovascular disease than untreated people. We recently evaluated the impact of conventional blood pressure level based on two Japanese individual participant databases and found that conventional blood pressure at baseline was not or was weakly associated with cardiovascular events among patients under antihypertensive drug medication. In the general population in Ohasama and the Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressures study, self-measured home blood pressure significantly predicted cardiovascular outcomes in patients under antihypertensive treatment. Hypertension is a chronic disease, and blood pressure must be evaluated with repeated measurements over a long period of time. Therefore, although not proven by a randomized controlled trial, it is likely that the long-term management of hypertension by antihypertensive drug treatment should be based on self-measured home blood pressure. We should also pay careful attention to the residual cardiovascular risk in treated patients.

The effects of increasing calcium channel blocker dose vs. adding a diuretic to treatment regimens for patients with uncontrolled hypertension

In patients with insufficient blood pressure (BP) control, despite using a combination regimen containing an angiotensin receptor blocker and a calcium channel blocker (CCB), whether a greater dose of CCB or adding a diuretic is more effective at lowering BP remains unclear. We conducted a multicenter randomized clinical trial to compare the efficacy of switching from the daily administration of a single-pill fixed-dose combination of irbesartan (100 mg) and amlodipine (5 mg) to irbesartan (100 mg) with an increased dose of amlodipine (10 mg) (HD group, n=62) or irbesartan (100 mg) and amlodipine (5 mg) with 1 mg of indapamide (D group, n=63) in patients with poorly controlled hypertension. BP measured at home was monitored by a physician using a telemonitoring system. Between the HD and D groups, no significant differences were observed in morning home BP changes (mean reduction of systolic/diastolic BP, 1.7/0.9 mmHg; 95% confidence intervals, -2.4 to 5.7/-1.4 to 3.2; P=0.19/0.37), achievement rate of target BP (45.2% vs. 42.9%, P=0.80), BP variability independent of the mean (P⩾0.74), other variability indices (P⩾0.55) and time to stabilization, which was calculated using a fitted analysis (13.1 days vs. 11.4 days, P=0.99). Although a significant increase in serum uric acid was observed in the D group (P<0.0001), neither clinically relevant abnormal laboratory test results nor critical BP changes were observed throughout the trial period. Both antihypertensive drug combination strategies were effective treatment options. Further investigation is required to determine the appropriate use of both therapies based on the various pathologies associated with hypertension.

Outcome-Driven Thresholds for Increased Home Blood Pressure Variability

Increased blood pressure (BP) variability predicts cardiovascular disease, but lack of operational thresholds limits its use in clinical practice. Our aim was to define outcome-driven thresholds for increased day-to-day home BP variability. We studied a population-based sample of 6238 individuals (mean age 60.0±12.9, 56.4% women) from Japan, Greece, and Finland. All participants self-measured their home BP on ≥3 days. We defined home BP variability as the coefficient of variation of the first morning BPs on 3 to 7 days. We assessed the association between systolic/diastolic BP variability (as a continuous variable and in deciles of coefficient of variation) and cardiovascular outcomes using Cox regression models adjusted for cohort and classical cardiovascular risk factors, including BP. During a follow-up of 9.3±3.6 years, 304 cardiovascular deaths and 715 cardiovascular events occurred. A 1 SD increase in systolic/diastolic home BP variability was associated with increased risk of cardiovascular mortality (hazard ratio, 1.17/1.22; 95% confidence interval, 1.06-1.30/1.11-1.34; P=0.003/<0.0001) and cardiovascular events (hazard ratio, 1.13/1.14; 95% confidence interval, 1.05-1.21/1.07-1.23; P=0.0007/0.0002). Compared with the average risk in the whole population, risk of cardiovascular deaths (hazard ratio, 1.66/1.84; 95% confidence interval, 1.27-2.17/1.42-2.37; P=0.0002/<0.0001) and events (hazard ratio, 1.46/1.42; 95% confidence interval, 1.21-1.76/1.17-1.71; P<0.0001/0.0004) was increased in the highest decile of systolic/diastolic BP variability (coefficient of variation>11.0/12.8). Increased home BP variability predicts cardiovascular outcomes in the general population. Individuals with a systolic/diastolic coefficient of variation of day-to-day home BP >11.0/12.8 may have an increased risk of cardiovascular disease. These findings could help physicians identify individuals who are at an increased cardiovascular disease risk.

Left ventricular hypertrophy by electrocardiogram as a predictor of success in home blood pressure control: HOMED-BP study

Few studies have focused on the effect of organ damage on achievement of long-term home blood pressure (BP) control. Based on the nationwide home BP-based trial data, we aimed to investigate the factors associated with home BP control, in particular, left ventricular hypertrophy (LVH) using the electrocardiogram in patients who started antihypertensive drug treatment. According to the trial protocol, we defined BP as controlled when systolic home BP reached specified targets (125-134 mm Hg in usual control (UC), n=1261; <125 mm Hg in tight control (TC), n=1288). At baseline, before drug treatment started, the mean Sokolow-Lyon voltage was 2.57±0.87 mV, and the mean Cornell product was 1573±705 mm·ms. The numbers of patients who achieved the target BP level in the UC and TC groups were 892 (70.7%) and 576 (44.7%), respectively. In both the UC and TC groups, systolic home BP at baseline was significantly lower in patients who achieved target levels than in those who did not achieve target levels (P<0.0001). Sokolow-Lyon voltage was significantly lower in patients who achieved target levels than in those who did not (P⩽0.0055). The Cornell product levels in each group were similar (P⩾0.12), although significantly different between patients who did or did not achieve the target level when the UC and TC groups were combined for analysis (P=0.031). Sokolow-Lyon voltage was significantly associated with achievement of home BP control in the multivariable-adjusted model (odds ratio, 1.13; 95% confidence intervals, 1.02-1.26; P=0.015), but Cornell product was not (P=0.13). These results indicate the difficulty of sufficient antihypertensive treatment when untreated patients had target organ damage, that is, LVH diagnosed by Sokolow-Lyon voltage.

Does Antihypertensive Drug Class Affect Day-to-Day Variability of Self-Measured Home Blood Pressure? The HOMED-BP Study

Background

Recent literature suggests that blood pressure variability (BPV) predicts outcome beyond blood pressure level (BPL) and that antihypertensive drug classes differentially influence BPV. We compared calcium channel blockers, angiotensin‐converting enzyme inhibitors, and angiotensin receptor blockade for effects on changes in self‐measured home BPL and BPV and for their prognostic significance in newly treated hypertensive patients.

Methods and Results

We enrolled 2484 patients randomly allocated to first‐line treatment with a calcium channel blocker (n=833), an angiotensin‐converting enzyme inhibitor (n=821), or angiotensin receptor blockade (n=830). Home blood pressures in the morning and evening were measured for 5 days off treatment before randomization and for 5 days after 2 to 4 weeks of randomized drug treatment. We assessed BPL and BPV changes as estimated by variability independent of the mean and compared cardiovascular outcomes. Home BPL response in each group was significant (P≤0.0001) but small in the angiotensin‐converting enzyme inhibitor group (systolic/diastolic: 4.6/2.8 mm Hg) compared with the groups treated with a calcium channel blocker (systolic/diastolic: 8.3/3.9 mm Hg) and angiotensin receptor blockade (systolic/diastolic: 8.2/4.5 mm Hg). In multivariable adjusted analyses, changes in home variability independent of the mean did not differ among the 3 drug classes (P≥0.054). Evening variability independent of the mean before treatment significantly predicted hard cardiovascular events independent of the corresponding home BPL (P≤0.022), whereas BPV did not predict any cardiovascular outcome based on the morning measurement (P≥0.056). Home BPV captured after monotherapy had no predictive power for cardiovascular outcome (P≥0.22).

Conclusions

Self‐measured home evening BPV estimated by variability independent of the mean had prognostic significance, whereas antihypertensive drug classes had no significant impact on BPV changes. Home BPL should remain the primary focus for risk stratification and treatment.

Clinical Trial Registration

URL: http://www.umin.ac.jp/ctr/index.htm. Unique identifier: C000000137.