Novel Pulse Waveform Index by Ambulatory Blood Pressure Monitoring and Cardiac Function: A Pilot Study

Background

A simple ambulatory measure of cardiac function could be helpful for monitoring heart failure patients.

Objectives

The purpose of this paper was to determine whether a novel pulse waveform analysis using data obtained by our developed multisensor-ambulatory blood pressure monitoring (ABPM) device, the 'Sf/Am' ratio, is associated with echocardiographic left ventricular ejection fraction (LVEF).

Methods

Multisensor-ABPM was conducted twice at baseline in 20 heart failure (HF) patients with HF-reduced LVEF or HF-preserved LVEF (median age 66 years, male 65%) and over a 6- to 12-month follow-up after patient-tailored treatment. We assessed the changes in the pulse waveform index Sf/Am and LVEF that occurred between the baseline and follow-up. The Sf/Am consists of the area of the ejection part in the square forward wave (Sf) and the amplitude of the measured wave (Am). We divided the patients into the recovered (n = 11) and not-recovered (n = 9) groups defined by a ≥10% increase in LVEF.

Results

Although the ambulatory BP levels and variabilities did not change in either group, the Sf/Am increased significantly in the recovered group (baseline 21.4 ± 4.5; follow-up, 25.6 ± 3.7, P = 0.004). The not-recovered group showed no difference between the baseline and follow-up. The follow-up/baseline Sf/Am ratio was significantly associated with the LVEF ratio (r = 0.469, P = 0.037). The Sf/Am was significantly correlated with the LVEF in overall measurements (n = 40, r = 0.491, P = 0.001).

Conclusions

These results demonstrated that a novel noninvasive pulse waveform index, the Sf/Am measured by multisensor-ABPM is associated with LVEF. The Sf/Am may be useful for estimating cardiac function.

Associations of Diabetic Retinopathy Severity With High Ambulatory Blood Pressure and Suppressed Serum Renin Levels

CONTEXT

The relationships between serum renin levels, severity of diabetic retinopathy (DR), and 24-hour blood pressure (BP) have not been previously reported.

OBJECTIVE

To explore causes for DR and the relationships of 24-hour ambulatory BP, and hormone levels with the severity of DR.

METHODS

The diabetic patients were classified as having no DR, simple DR, or severe DR (preproliferative DR plus proliferative DR) based on funduscopic examination, and we measured 24-hour BP, serum active renin (ARC), aldosterone (SAC), adrenocorticotropic hormone, and cortisol levels in each group.

RESULTS

Compared to those with no DR or simple DR, patients with severe DR showed significantly higher 24-hour BPs, including daytime and nighttime systolic and diastolic BP levels, independent of diabetic duration and HbA1c levels. The variability of nighttime systolic BP was greater in patients with severe DR than in those with nonsevere DR, although nocturnal BP reduction was similar between the groups. The ambulatory BPs were significantly inversely associated with ARC. The ARC was significantly lower in severe DR patients than in those with no DR or simple DR (3.2 [1.5-13.6] vs 9.8 [4.6-18.0] pg/mL, P < .05), but there were no differences in SAC in patients taking calcium channel blockers and/or α-blockers. No associations were found between DR severity and other hormone levels.

CONCLUSION

Severe DR was associated with higher 24-hour BPs and suppressed ARC. These findings suggest that mineralocorticoid receptor overactivation may play a role in higher BP levels and severe DR in diabetic patients.

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

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

Rules of Heliogeomagnetics Diversely Coordinating Biological Rhythms and Promoting Human Health

This investigation reviews how geomagnetic activity affects the circadian variation in blood pressure (BP) and heart rate (HR) and their variabilities of clinically healthy individuals. A small study in Alta, Norway (latitude of 70.0° N), serves to illustrate the methodology used to outline rules of procedure in exploring heliogeomagnetic effects on human physiology. Volunteers in the Alta study were monitored for at least 2 days between 18 March 2002 and 9 January 2005. Estimates of the circadian characteristics of BP and HR by cosinor and the Maximum Entropy Method (MEM) indicate an increase in the circadian amplitude of systolic (S) BP on geomagnetic-disturbance days compared to quiet days (p = 0.0236). Geomagnetic stimulation was found to be circadian-phase dependent, with stimulation in the evening inducing a 49.2% increase in the circadian amplitude of SBP (p = 0.0003), not observed in relation to stimulation in the morning. In two participants monitored for 7 days, the circadian amplitude of SBP decreased by 23.4% on an extremely disturbed day but increased by 50.3% on moderately disturbed days (p = 0.0044), suggesting a biphasic (hormetic) reaction of the circadian SBP rhythm to geomagnetics. These results indicate a possible role of geomagnetic fluctuations in modulating the circadian system.

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

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

Carotid Artery Revascularization Improves Cardiac Sympathetic Nerve Activity in Patients With Carotid Artery Stenosis

BACKGROUND

The carotid sinus baroreceptor reflex controls the neural regulation of blood pressure. Baroreceptor disorders due to carotid sinus atherosclerosis have detrimental cardiovascular effects. This study investigated the medium-term effects of carotid artery revascularization (CAR) on sympathetic and cardiac function and systemic blood pressure variability in patients with carotid artery stenosis.

METHODS

This study included 21 consecutive patients (median age 70 years, 18 men) with carotid artery stenosis scheduled for CAR. ¹²³I metaiodobenzylguanidine (MIBG) scintigraphy, echocardiography, brain natriuretic peptide levels, 24-h Holter electrocardiography (ECG), and ambulatory blood pressure monitoring assessed approximately 3 months postoperatively were compared to preoperative data.

RESULTS

All 21 enrolled patients underwent CAR. Carotid artery stenting was done in three patients with cardiovascular risk or anatomical difficult for carotid endarterectomy. The mean common carotid artery end-diastolic velocity improved significantly (P < 0.01) by 1.6-fold, from 10.8 ± 3.2 to 16.1 ± 7.1 cm/s. In ¹²³I-MIBG scintigraphy, the heart-to-mediastinum (H/M) count ratio was significantly higher than preoperatively (from 2.66 ± 0.48 to 2.86 ± 0.56, P = 0.03). Holter ECG analysis revealed a significant decrease in the low-frequency/high-frequency (LF/HF) ratio compared to preoperatively (from 2.17 ± 1.20 to 1.62 ± 0.68, P = 0.04). These findings suggest decreased myocardial sympathetic activation. In echocardiography, the tissue Doppler-derived e' increased, and E/e' decreased significantly (P < 0.05) from 11.7 ± 5.1 to 10.1 ± 4.0, suggesting an improved left ventricular diastolic capacity. The mean 24-h and nighttime blood pressures were unchanged.

CONCLUSIONS

CAR in patients with carotid stenosis may provide medium-term improvement in cardiac sympathetic nerve activity and left ventricular diastolic dysfunction.

Association of ambulatory blood pressure with aortic valve and coronary artery calcification

OBJECTIVE

We aimed to investigate the effect of ambulatory blood pressure (BP) on aortic valve calcification (AVC) and coronary artery calcification (CAC), which are subclinical atherosclerotic diseases.

METHODS

In this population-based, cross-sectional study, we assessed office BP, mean ambulatory BP (24-h, awake, and asleep), and variability of ambulatory BP, as determined by the coefficient of variation (awake and asleep). AVC and CAC were quantified using an Agatston score (>0) based on computed tomography scanning. We calculated relative risks (RRs) and 95% confidence intervals (CIs) with a 1-standard deviation increment in each BP index for the presence of AVC and CAC using a multivariate-adjusted Poisson regression with robust error variance.

RESULTS

Of 483 participants (mean age: 66.8 years), 154 (31.9%) and 310 (64.2%) had AVC and CAC, respectively. The presence of AVC was associated with office systolic BP (SBP; RR, 1.15; 95% CI, 1.03-1.28), awake diastolic BP (DBP) variability (RR, 1.12; 95% CI, 1.01-1.25), and asleep SBP variability (RR, 1.14; 95% CI, 1.03-1.27). The presence of CAC was associated with office SBP (RR, 1.08; 95% CI, 1.01-1.15), mean 24-h SBP (RR, 1.10; 95% CI, 1.04-1.16), mean awake SBP (RR, 1.11; 95% CI, 1.04-1.17), mean asleep SBP (RR, 1.07; 95% CI, 1.01-1.13), and asleep SBP variability (RR, 1.07; 95% CI, 1.01-1.13).

CONCLUSION

These findings highlight the association of ambulatory BP indices with both AVC and CAC, but with different effects on their presences.

Impact of COVID-19 on Ambulatory Blood Pressure in Young Adults: A Cross-sectional Analysis Investigating Time Since Diagnosis

Previous studies have reported detrimental effects of COVID-19 on the peripheral vasculature. However, reports on blood pressure (BP) are inconsistent, and measurements are made only in the laboratory setting. To date, no studies have measured ambulatory BP. In addition, in previous studies, time since COVID-19 diagnosis among participants varied across a wide range, potentially contributing to the inconsistent BP results. Thus, we aimed to perform a comprehensive assessment of BP and BP variability using ambulatory and laboratory (brachial and central) measurements in young adults who had COVID-19. We hypothesized that ambulatory BP would be elevated post-COVID-19 and that measures of BP would be inversely related with time since diagnosis. Twenty-eight young adults who had COVID-19 [11 ± 6 (range 3–22) wk since diagnosis] and 10 controls were studied. Ambulatory daytime, nighttime, and 24-h systolic BP, diastolic BP, and mean BP were not different between the control and COVID groups (e.g., daytime systolic BP: control, 122 ± 12 mmHg; COVID, 122 ± 10 mmHg; P = 0.937). Similar results were observed for laboratory BPs (all P > 0.05). However, ambulatory daytime, nighttime, and 24-h BPs as well as laboratory brachial BPs were inversely correlated with time since COVID-19 diagnosis (e.g., daytime systolic BP: r = −0.444; P = 0.044, nighttime systolic BP: r = −0.518; P = 0.016). Ambulatory and laboratory-measured BP variability were not different between groups nor correlated with time since diagnosis. Collectively, these data suggest that adverse effects of COVID-19 on BP in young adults are minimal and likely transient.

NEW & NOTEWORTHY We report for the first time that ambulatory daytime, nighttime, and 24-h blood pressure (BP), as well as laboratory BP, were not different between control and COVID participants. However, a significant inverse relationship with time since COVID-19 diagnosis was found (i.e., greater BP with more recent infection). Ambulatory and laboratory BP variability were unaffected and not related with diagnosis time. These findings suggest that COVID-19 may exert only short-lasting effects on BP in young adults.

24-Hour Blood Pressure Control with Amlodipine: A Review of the Current Scenario

Introduction Hypertension is the leading cause of cardiovascular diseases and premature death worldwide. Antihypertensive therapy using calcium channel blockers (CCBs) is one of the preferred choices to treat blood pressure (BP) and control blood pressure variability (BPV). In contrast to clinic BP, 24-hour ambulatory BP monitoring (ABPM) has evolved into an accurate and reproducible tool for the assessment and management of hypertension. Amlodipine, a longer acting dihydropyridine CCB is effective for 24 hours BP control and also minimizing BPV. The present article is the comprehensive review highlighting the efficacy of amlodipine in controlling 24-hour BP and minimizing BPV from the review of recent studies.

Materials and Methods The literature search was done using PubMed, Google Scholar, and MEDLINE databases. The studies to be included for review, were identified through the keywords: “amlodipine,” “ambulatory BP monitoring (ABPM),”“blood pressure variability (BPV),” “CCBs,” and filtering articles published in English language only.

Results Pharmacological evidence suggests that amlodipine has the ability to block all the subtypes of CCBs such as L-, N-, P-, Q-, R-, and T-type. Various clinical studies reported that amlodipine is a powerful, well-tolerated, and safe antihypertensive agent which is widely used either alone or as a key component of combination therapy for control of 24 hours BP.

Conclusion Overall, amlodipine is a proven and effective antihypertensive drug and helpful in controlling 24-hour BP, minimizing BP variability and hence reducing the risk of cardiovascular complications.

Very short-term beat-by-beat blood pressure variability in the supine position at rest correlates well with the nocturnal blood pressure variability assessed by ambulatory blood pressure monitoring

Blood pressure variability (BPV) is an important indicator in risk stratification for hypertension. Among the daily BPVs assessed using a 24-h ambulatory blood pressure (BP) monitor nocturnal systolic BPV has been suggested to predict cardiovascular risks. We hypothesized that very short-term BPV at rest would correlate with nocturnal BPV because of the shared autonomic BP regulatory system under no daily exertion. Thirty untreated normotensive and hypertensive adults underwent 30-min continuous beat-by-beat BP recordings in the supine position, followed by 24-h ambulatory blood pressure monitoring (ABPM). The relationship between very short-term BPV (standard deviation (SD), coefficient of variation (CV)) and daytime and nocturnal BPV (SD, CV, average real variability (ARV), and standardized ARV (CV-ARV)) was assessed with Pearson's correlation coefficients. Very short-term BPV correlated significantly with nocturnal BPV (ARV, r = 0.604, p < 0.001) but not with daytime BPV. These trends were more pronounced with the increasing data length of continuous beat-by-beat BP recording. Using a data segment from the last 10 min of a 30-min continuous beat-by-beat BP recording resulted in a stronger correlation between very short-term BPV and nocturnal BPV than using earlier segments. The findings of this study suggest that very short-term BPV in the supine position at rest may predict nocturnal BPV. Since the burden of ABPM for patients has hindered clinical dissemination, very short-term BPV has the potential to develop a novel index of BPV.

Piezoelectric Dynamics of Arterial Pulse for Wearable Continuous Blood Pressure Monitoring

Piezoelectric arterial pulse wave dynamics are traditionally considered to be similar to those of typical blood pressure waves. However, achieving accurate continuous blood pressure wave monitoring based on arterial pulse waves remains challenging, because the correlation between piezoelectric pulse waves and their related blood pressure waves is unclear. To address this, the correlation between piezoelectric pulse waves and blood pressure waves is first elucidated via theoretical, simulation, and experimental analysis of these dynamics. Based on this correlation, the authors develop a wireless wearable continuous blood pressure monitoring system, with better portability than conventional systems that are based on the pulse wave velocity between multiple sensors. They explore the feasibility of achieving wearable continuous blood pressure monitoring without motion artifacts, using a single piezoelectric sensor. These findings eliminate the controversy over the arterial pulse wave piezoelectric response, and can potentially be used to develop a portable wearable continuous blood pressure monitoring device for the early prevention and daily control of hypertension.

A Data-Driven Model with Feedback Calibration Embedded Blood Pressure Estimator Using Reflective Photoplethysmography

Ambulatory blood pressure (BP) monitoring (ABPM) is vital for screening cardiovascular activity. The American College of Cardiology/American Heart Association guideline for the prevention, detection, evaluation, and management of BP in adults recommends measuring BP outside the office setting using daytime ABPM. The recommendation to use night-day BP measurements to confirm hypertension is consistent with the recommendation of several other guidelines. In recent studies, ABPM was used to measure BP at regular intervals, and it reduces the effect of the environment on BP. Out-of-office measurements are highly recommended by almost all hypertension organizations. However, traditional ABPM devices based on the oscillometric technique usually interrupt sleep. For all-day ABPM purposes, a photoplethysmography (PPG)-based wrist-type device has been developed as a convenient tool. This optical, noninvasive device estimates BP using morphological characteristics from PPG waveforms. As measurement can be affected by multiple variables, calibration is necessary to ensure that the calculated BP values are accurate. However, few studies focused on adaptive calibration. A novel adaptive calibration model, which is data-driven and embedded in a wearable device, was proposed. The features from a 15 s PPG waveform and personal information were input for estimation of BP values and our data-driven calibration model. The model had a feedback calibration process using the exponential Gaussian process regression method to calibrate BP values and avoid inter- and intra-subject variability, ensuring accuracy in long-term ABPM. The estimation error of BP (ΔBP = actual BP-estimated BP) of systolic BP was -0.1776 ± 4.7361 mmHg; ≤15 mmHg, 99.225%, and of diastolic BP was -0.3846 ± 6.3688 mmHg; ≤15 mmHg, 98.191%. The success rate was improved, and the results corresponded to the Association for the Advancement of Medical Instrumentation standard and British Hypertension Society Grading criteria for medical regulation. Using machine learning with a feedback calibration model could be used to assess ABPM for clinical purposes.

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

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

Updates on the Diagnosis and Treatment of Peripheral Autonomic Neuropathies

PURPOSE OF REVIEW

Autonomic neuropathies are a complex group of disorders and result in diverse clinical manifestations that affect the cardiovascular, gastrointestinal, urogenital, and sudomotor systems. We focus this review on the diagnosis and treatment of peripheral autonomic neuropathies. We summarize the diagnostic tools and current treatment options that will help the clinician care for individuals with peripheral autonomic neuropathies.

RECENT FINDINGS

Autonomic neuropathies occur often in conjunction with somatic neuropathies but they can also occur in isolation. The autonomic reflex screen is a validated tool to assess sympathetic postganglionic sudomotor, cardiovascular sympathetic noradrenergic, and cardiac parasympathetic (i.e., cardiovagal) function. Initial laboratory evaluation for autonomic neuropathies includes fasting glucose or oral glucose tolerance test, thyroid function tests, kidney function tests, vitamin-B12, serum, and urine protein electrophoresis with immunofixation. Other laboratory tests should be guided by the clinical context. Reduced intraepidermal nerve density on skin biopsy is a finding, not a diagnosis. Skin biopsy can be helpful in selected individuals for the diagnosis of disorders affecting small nerve fibers; however, we strongly discourage the use of skin biopsy without clinical-physiological correlation. Ambulatory blood pressure monitoring may lead to early identification of patients with cardiovascular autonomic neuropathy in the primary care setting. Disease-modifying therapies should be used when available in combination with nonpharmacological management and symptomatic pharmacologic therapies. Autonomic function testing can guide the therapeutic decisions and document improvement with treatment. A systematic approach guided by the autonomic history and standardized autonomic function testing may help clinicians when identifying and/or counseling patients with autonomic neuropathies. Treatment should be individualized and disease-modifying therapies should be used when available.

Framework for selecting and benchmarking mobile devices in psychophysiological research

Commercially available consumer electronics in (smartwatches and wearable biosensors) are increasingly enabling acquisition of peripheral physiological and physical activity data inside and outside of laboratory settings. However, there is scant literature available for selecting and assessing the suitability of these novel devices for scientific use. To overcome this limitation, the current paper offers a framework to aid researchers in choosing and evaluating wearable technologies for use in empirical research. Our seven-step framework includes: (1) identifying signals of interest; (2) characterizing intended use cases; (3) identifying study-specific pragmatic needs; (4) selecting devices for evaluation; (5) establishing an assessment procedure; (6) performing qualitative and quantitative analyses on resulting data; and, if desired, (7) conducting power analyses to determine sample size needed to more rigorously compare performance across devices. We illustrate the application of the framework by comparing electrodermal, cardiovascular, and accelerometry data from a variety of commercial wireless sensors (Affectiva Q, Empatica E3, Empatica E4, Actiwave Cardio, Shimmer) relative to a well-validated, wired MindWare laboratory system. Our evaluations are performed in two studies (N = 10, N = 11) involving psychometrically sound, standardized tasks that include physical activity and affect induction. After applying our framework to this data, we conclude that only some commercially available consumer devices for physiological measurement are capable of wirelessly measuring peripheral physiological and physical activity data of sufficient quality for scientific use cases. Thus, the framework appears to be beneficial at suggesting steps for conducting more systematic, transparent, and rigorous evaluations of mobile physiological devices prior to deployment in studies.

Analysis of ambulatory blood pressure monitoring data in patients with ankylosing spondylitis without clinically evident cardiovascular disease

Ankylosing spondylitis (AS) is associated with an increased risk of cardiovascular morbidity and mortality. Parameters, such as non-dipper, average real variability (ARV), pulse pressure index (PPI), and ambulatory arterial stiffness index (AASI) obtained from ambulatory blood pressure monitoring (ABPM), provide information about adverse cardiovascular outcomes. In this study, these indexes were evaluated in patients with AS. Sixty-five patients with AS and 65 control subjects were included in this study. Non-dipper pattern, ARV, PPI, and AASI parameters were assessed using 24-h ABPM recordings. Twenty-four-hour systolic, diastolic, mean standard deviation, PPI, ARV, and AASI were higher in patients with AS (p < 0.05 all parameters). Non-dipper (43.1% vs. 21.5%, p = 0.007) and reverse dipper (10.8% vs. 0%, p = 0.013) patterns were more common in patients with AS. In addition, disease duration was moderately correlated with AASI and ARV (r = 0.36, p = 0.003; r = 0.31, p = 0.012, respectively). This study showed that PPI, AASI, ARV, and dipper pattern were impaired in patients with AS evaluated with ABPM.

Digital therapeutics for essential hypertension using a smartphone application: A randomized, open-label, multicenter pilot study

Hypertension is the most considerable but treatable risk factor for cardiovascular disease. Although physicians prescribe multiple antihypertensive drugs and promote lifestyle modifications, the real-world blood pressure (BP) control rate remains poor. To improve BP target achievement, we developed a novel digital therapeutic-the HERB software system -to manage hypertension. Here, we performed a randomized pilot study to assess the safety and efficacy of the HERB system for hypertension. We recruited 146 patients with essential hypertension from March 2018 to March 2019. We allocated eligible patients to the intervention group (HERB system + standard lifestyle modification) or control group (standard lifestyle modification alone). The primary outcome was the mean change from baseline to 24 weeks in 24-hour systolic BP (SBP) measured by ambulatory blood pressure monitoring (ABPM). The baseline characteristics in each group were well balanced; the mean age was approx. 57 years, and 67% were male. In the primary end point at 24 weeks, HERB intervention did not lower the mean change of 24-hour SBP by ABPM compared with the controls (adjusted difference: -0.66 mmHg; p = .78). In an exploratory analysis focusing on antihypertensive drug-naïve patients aged <65, the effects of the HERB intervention were significantly greater than the control for reducing 24-hour SBP by ABPM at 16 weeks (adjusted difference: -7.6 mmHg; p = .013; and morning home SBP at 24 weeks (adjusted difference - 6.0 mmHg; p = .012). Thus, the HERB intervention did not achieve a primary efficacy end point. However, we observed that antihypertensive drug-naïve adult hypertensive patients aged <65 years could be a potential HERB system-effective target for further investigations of the efficacy of the system.

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

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

Reproducibility study of nocturnal blood pressure dipping in patients with high cardiovascular risk

It has been shown that in most people there is a physiological reduction in blood pressure during nighttime sleep, it falling by approximately 10% compared to daytime values (dippers). On the other hand, in some people, there is no nighttime reduction (non‐dippers). Various studies have found an association between being a non‐dipper and a higher risk of cardiovascular disease, but few have assessed whether the nocturnal pattern is maintained over time. From the database of the TAHPS study, data were available on 225 patients, each of whom underwent 24‐hour ambulatory blood pressure monitoring (ABPM) on four occasions over a period of 5 months. We studied the reproducibility of the nocturnal BP dipping pattern with mixed linear analysis and also calculated the concordance in the classification of patients as dippers or non‐dippers. The intraclass correlation coefficients between the different ABPM recordings were 0.482 and 0.467 for systolic and diastolic blood pressure, respectively. Two‐thirds (67%) and 70% of the patients classified, respectively, as dippers or non‐dippers based on systolic and diastolic blood pressure readings in the first ABPM recording were found to have the same classification based on the subsequent recordings. We conclude that the reproducibility of nocturnal dipping patterns and concordance of dipper vs non‐dipper status in individual patients is modest and therefore that we should be cautious about recommending treatments or interventions based on these patterns.

Changes in blood pressure during treatment with the tyrosine kinase inhibitor lenvatinib

Background

Within the class of tyrosine kinase inhibitors (TKIs), which are used for the treatment of numerous advanced cancers, lenvatinib is associated with a higher prevalence of hypertension (HT) compared with other TKIs. In this study, we investigated the effect of lenvatinib on blood pressure (BP) and associated factors.

Methods

This single-centre, retrospective observational study included 25 consecutive patients treated with lenvatinib for unresectable hepatocellular carcinoma from April 2018 to December 2018 at the study institution. We assessed changes in BP using ambulatory BP monitoring, urinary sodium excretion, kidney function, use of antihypertensive agents and diuretics, and fluid retention following treatment initiation with lenvatinib.

Results

At 1 week after treatment initiation, the mean BP and the percentage of patients with riser pattern significantly increased compared with those at the baseline. Although there were no significant changes at 1 week, urinary sodium excretion (153.4 ± 51.7 and 112.5 ± 65.0 mEq/day at 1 and 3 weeks, respectively, P < 0.05) and estimated glomerular filtration rate significantly decreased and the number of patients with fluid retention increased at 3 weeks. Furthermore, patients with fluid retention had significantly higher BP or required more intensive BP treatment compared with those without fluid retention.

Conclusions

Lenvatinib might lead to HT without fluid retention soon after the initiation of treatment, subsequently leading to a reduction in urinary sodium excretion, thereby contributing to a rise in BP by fluid retention.

A multicenter clinical trial to assess the efficacy of the digital therapeutics for essential hypertension: Rationale and design of the HERB-DH1 trial

Digital therapeutics is a new approach to treat hypertension via using software programs such as smartphone apps and/or device algorithms. We develop a HERB system-new interactive smartphone app (HERB Mobile) with web-based patient management console (HERB Console)-to lower blood pressure (BP) based on an algorithm that helps users to promote lifestyle modifications in conjunction with medically validated non-pharmacological interventions. The app can assess the personalities, behavior characteristics, and hypertension determinants of each patient with hypertension to provide adequate guidance. To demonstrate the efficacy of the system, we designed a randomized, controlled, multicenter, open-label trial "HERB-DH1 (HERB digital hypertension 1)" to assess the efficacy of HERB system in patients with essential hypertension. The authors allocate patients to the intervention group (HERB system + standard lifestyle modification) or to the control group (standard lifestyle modification alone). In the intervention group, we provide the HERB Mobile for patients and the HERB Console for their primary physicians for 24 weeks. Both groups are instructed for standard lifestyle modifications based on the current recommendations in the Japanese Society of Hypertension 2019 guideline. The primary outcome is the mean change from baseline to 12 weeks in 24-hour systolic BP measured by ambulatory BP monitoring. We started this study in December of 2019, and the trial results will be expected in early 2021. We believe that this trial enables us to verify the efficacy of the HERB system in patients with essential hypertension.

Circadian rhythms of blood pressure and rate pressure product in children with postural tachycardia syndrome

OBJECTIVE

To investigate circadian rhythms of blood pressure (BP) and rate pressure product (RPP) in children with postural tachycardia syndrome (POTS) by performing 24-hour ambulatory blood pressure monitoring (24-h ABPM).

METHODS

103 POTS children and 84 age- and gender-matched healthy children were enrolled and they got 24-h ABPM under usual routine of diurnal activity and nocturnal sleep.

RESULTS

Although the mean awake systolic BP (SBP), 24-h diastolic BP (DBP), awake DBP, asleep heart rate (HR) did not differ between two groups (P > 0.05), the mean 24-h and asleep SBP, asleep DBP, 24-h and awake HR, 24-h, awake and asleep RPP were significantly higher in POTS children (P < 0.01). Non-dipping BP was more prevalent in POTS children (67.0% vs. 46%, P < 0.001). The RPP of POTS and control children showed 24-h circadian variations with peak roughly occurring approximately 2 h after waking from nocturnal sleep. Compared with controls, the RPP values of POTS children were significantly higher during 2 h before and 3 h after waking (P < 0.05). For the RPP value of 1 h after waking, a cutoff value of 8995.6 bpm·mmHg yielded a sensitivity of 75.8% and a specificity of 65.4% for predicting POTS.

CONCLUSIONS

Abnormal circadian BP regulation is prevalent in POTS children. POTS children present with daily sympathetic hyperactivity, especially during nocturnal sleep and within 3 h after waking. And the excessive morning surge in RPP parallels with the morning surge of orthostatic HR increments and OI symptoms.

Direct Comparison of Home Versus Ambulatory Defined Nocturnal Hypertension for Predicting Cardiovascular Events

The home blood pressure monitoring (HBPM) method that measures blood pressure during sleep hours was reported to be comparable to ambulatory blood pressure monitoring (ABPM) in measuring nighttime blood pressure and detecting nocturnal hypertension. The aim of this study was to directly compare the prognostic power of nocturnal hypertension detected by HBPM versus ABPM for predicting future cardiovascular events. We analyzed nighttime blood pressure (measured by HBPM and ABPM) data of 1005 participants who were included in the J-HOP study (Japan Morning Surge-Home Blood Pressure). During a follow-up period of 7.6±3.4 years, 80 cardiovascular disease events occurred. The majority (91.8%) of our study population were hypertensive, and 80.7% of participants were using antihypertensive medication. Nighttime home systolic blood pressure (SBP) was higher compared to nighttime ambulatory SBP (123.0±14.6 versus 120.3±14.4 mm Hg, P <0.001). Nocturnal hypertension was defined as nighttime home or ambulatory SBP of ≥120 mm Hg. The number of participants with nocturnal hypertension defined by HBPM and ABPM was 564 (56.1%) and 469 (46.7%), respectively. Nocturnal hypertension defined by HBPM was associated with increased risk of future cardiovascular events: total cardiovascular events (coronary artery disease and stroke events; 1.78 [1.00–3.15]) and stroke (2.65 [1.14–6.20]), independent of office SBP. These results were absent with nocturnal hypertension defined by ABPM. This is the first comparison prospective study illustrating that uncontrolled nocturnal hypertension defined by HBPM (independent of office SBP) is a predictor of future cardiovascular events.

Usefulness of Blood Pressure Variability Indices Derived From 24-Hour Ambulatory Blood Pressure Monitoring in Detecting Autonomic Failure

Background Increased blood pressure ( BP ) variability and nondipping status seen on 24-hour ambulatory BP monitoring are often observed in autonomic failure ( ATF ). Methods and Results We assessed BP variability and nocturnal BP dipping in 273 patients undergoing ambulatory BP monitoring at Southwestern Medical Center between 2010 and 2017. SD , average real variability, and variation independent of mean were calculated from ambulatory BP monitoring. Patients were divided into a discovery cohort (n=201) and a validation cohort (n=72). ATF was confirmed by formal autonomic function test. In the discovery cohort, 24-hour and nighttime average real variability, SD , and variation independent of mean did not differ significantly between ATF (n=25) and controls (n=176, all P>0.05). However, daytime SD, daytime coefficient of variation, and daytime variation independent of mean of systolic BP ( SBP ) were all significantly higher in patients with ATF than in controls in both discovery and validation cohorts. Nocturnal BP dipping was more blunted in ATF patients than controls in both cohorts (both P<0.01). Using the threshold of 16 mm Hg, daytime SD SBP yielded a sensitivity of 77% and specificity of 82% in detecting ATF in the validation cohort, whereas nondipping status had a sensitivity of 80% and specificity of 44%. The area under the receiver operator characteristic of daytime SD SBP was greater than the area under the receiver operator characteristic of nocturnal SBP dipping (0.79 [0.66-0.91] versus 0.73 [0.58-0.87], respectively). Conclusions Daytime SD of SBP is a better screening tool than nondipping status in detecting autonomic dysfunction.

Current status of ambulatory blood pressure monitoring in Asian countries: A report from the HOPE Asia Network

Ambulatory blood pressure monitoring (ABPM) can measure 24-hour blood pressure (BP), including nocturnal BP and diurnal variations. This feature of ABPM could be of value in Asian populations for preventing cardiovascular events. However, no study has yet investigated regarding the use of ABPM in actual clinical settings in Asian countries/regions. In this study, 11 experts from 11 countries/regions were asked to answer questionnaires regarding the use of ABPM. We found that its use was very limited in primary care settings and almost exclusively available in referral settings. The indications of ABPM in actual clinical settings were largely similar to those of home BP monitoring (HBPM), that is, diagnosis of white-coat or masked hypertension and more accurate BP measurement for borderline clinic BP. Other interesting indications, such as nighttime BP patterns, including non-dipper BP, morning BP surge, and BP variability, were hardly adopted in daily clinical practice. The use of ABPM as treatment guidance for detecting treated but uncontrolled hypertension in the Asian countries/regions didn't seem to be common. The barrier to the use of ABPM was primarily its availability; in referral centers, patient reluctance owing to discomfort or sleep disturbance was the most frequent barrier. ABPM use was significantly more economical when it was reimbursed by public insurance. To facilitate ABPM use, more simplified indications and protocols to minimize discomfort should be sought. For the time being, HBPM could be a reasonable alternative.

Repeated ambulatory monitoring reveals an evening rise in blood pressure in a Japanese population

Recent studies have revealed 2 peaks in the onset of cardiovascular events, 1 in the morning and another in the evening. We evaluated whether blood pressure (BP) also rises in the morning/evening and identified the determinants of evening BP rise using 24-hour ambulatory BP monitoring for 7 consecutive days. We identified 2 BP peaks, 1 in the morning (0-3 hours after waking) and 1 in the evening (9-12 hours after waking). Subjects were subclassified according to the extent of evening BP rise: those in the top quartile (≥6.45 mm Hg, n = 34; ER group) vs all others. After adjustment for age, sex, and 24-hour systolic BP, evening BP rise was associated with the use of antihypertensive medications [odds ratio (OR), 3.57; 95% confidence interval (CI), 1.46-8.74; P = .01] and estimated glomerular filtration rate (OR, 0.96; 95% CI, 0.93-0.99; P = .04), confirming its association with antihypertensive medication use and renal dysfunction.

Early morning-Best time window of hourly 24-hour ambulatory blood pressure in relation to hypertensive organ damage: The Japan Morning Surge-Home Blood Pressure study

The correlations between organ damage and hourly ambulatory blood pressure (BP) have not been established. The patients were 1464 participants of the Japan Morning Surge-Home Blood Pressure (J-HOP) study participants who underwent ambulatory BP monitoring. The hourly systolic BP (SBP) at x o'clock was defined as the average of SBP values measured at times x - 30 minutes, x, and x + 30 minutes. The mean age was 64.8 ± 11.6 years. The percentage of male participants was 47.8%. The left ventricular mass index (LVMI) was significantly associated with SBP at 6 o'clock (r = 0.166, P < 0.001). The carotid intima-media thickness was significantly associated with SBP at 5 o'clock (r = 0.196, P < 0.001). After adjustment for age, sex, smoking, hyperlipidemia, diabetes mellitus, antihypertensive drug use, clinic SBP, and 24-hour ambulatory SBP, the correlations of the LVMI and hourly SBP at 6 o'clock remained significant (beta coefficient = 0.125, P < 0.01). In conclusion, morning ambulatory systolic BP especially at 5 and 6 o'clock was independently associated with organ damage.

Ambulatory blood pressure variability within the first 24 hours after admission and outcomes of acute ischemic stroke

Our purpose was to evaluate the value of blood pressure variability within the first 24 hours after admission in predicting outcomes of patients with acute ischemic stroke (AIS). A greater variability in systolic blood pressure (adjusted odds ratio [OR] = 1.801, 95% confidence interval [CI] = 1.167-2.779) was associated with poor discharge outcome, especially for nondiabetics (adjusted OR = 1.948, 95% CI = 1.184-3.205) and cardioembolism-related patients with AIS (OR = 7.650, 95% CI = 1.370-42.713). However, this correlation was not observed with a long-term (3-month or 6-month) outcome in patients with AIS. There was no association between diastolic blood pressure variability within the first 24 hours after admission and outcome. In conclusion, systolic blood pressure variability within the first 24 hours after admission is a critical predictor for short-term outcome of patients with AIS.

Evaluation of Criteria to Detect Masked Hypertension

The prevalence of masked hypertension (out-of-clinic daytime systolic/diastolic blood pressure (SBP/DBP) ≥135/85 mm Hg on ambulatory blood pressure monitoring [ABPM] among adults with clinic SBP/DBP <140/90 mm Hg) is high. It is unclear who should be screened for masked hypertension. The authors derived a clinic blood pressure (CBP) index to identify populations for masked hypertension screening. Index cut points corresponding to 75% to 99% sensitivity and prehypertension were evaluated as ABPM testing criterion. In a derivation cohort (n=695), the index was clinic SBP+1.3*clinic DBP. In an external validation cohort (n=675), the sensitivity for masked hypertension using an index ≥190 mm Hg and ≥217 mm Hg and prehypertension status was 98.5%, 71.5%, and 82.5%, respectively. Using National Health and Nutrition Examination Survey data (n=11,778), the authors estimated that these thresholds would refer 118.6, 44.4, and 59.3 million US adults, respectively, to ABPM screening for masked hypertension. In conclusion, the CBP index provides a useful approach to identify candidates for masked hypertension screening using ABPM.

Efficacy of 24-Hour Blood Pressure Monitoring in Evaluating Response to Percutaneous Transluminal Renal Angioplasty

BACKGROUND

Percutaneous transluminal renal angioplasty (PTRA) improves patency in atherosclerotic renal artery stenosis (ARAS), but improvement in clinic blood pressure (BP) is seen in only 20-40% of patients who undergo PTRA. This study investigated the effects of PTRA on BP lowering, assessed on 24-h ambulatory BP monitoring (ABPM), and identified preoperative features predictive of satisfactory BP improvement after PTRA.

METHODS AND RESULTS

Of 1,753 consecutive patients undergoing coronary angiography, 31 patients with angiographically significant ARAS and translesional pressure gradient (TLPG) >20 mmHg underwent PTRA. ABPM was performed before, at 1 month and at 1 year after PTRA; patients with average systolic ABPM-BP decrease >10 mmHg at 1 month from baseline were categorized as responders. There was no obvious relationship between clinic BP and ABPM-BP at baseline. ABPM-BP was significantly higher in responders at baseline (SBP: 148 vs. 126 mmHg, P<0.01) and was improved 1 month after PTRA. This difference persisted until 1 year after PTRA. Night-time BP improved more than daytime BP in responders. Patients with higher baseline ABPM-BP achieved a larger decrease in ABPM-BP, but the severity of stenosis reflected by TLPG; renal duplex findings; and neurohumoral parameters other than baseline renal function, did not differ between the groups.

CONCLUSIONS

Clinic BP does not represent daily hemodynamic status, whereas high ABPM-BP is a potent predictor of satisfactory BP response to PTRA. (Circ J 2016; 80: 1922-1930).

Abnormal Circadian Blood Pressure Profile as a Prognostic Marker in Patients with Nonischemic Dilated Cardiomyopathy

OBJECTIVES

An abnormal circadian blood pressure (BP) profile is considered a risk factor for cardiovascular disease. However, its significance in heart failure patients with nonischemic etiology is unknown. Herein, we investigated the prognostic value of a circadian BP profile in patients with nonischemic dilated cardiomyopathy (NIDCM).

METHODS

We enrolled 114 NIDCM patients (76 males, mean age 53.1 years). The percent nighttime BP fall (%NBPF) was defined using ambulatory BP monitoring as a percent decrease in mean systolic BP in nighttime from daytime. All patients were divided into three groups: dipper (%NBPF ≥10), non-dipper (0 ≤ %NBPF < 10), and riser (%NBPF <0).

RESULTS

Riser patients had the highest serum creatinine levels (dipper, 0.78 ± 0.20 mg/dl; non-dipper, 0.85 ± 0.21 mg/dl; riser, 0.99 ± 0.23 mg/dl; p = 0.006). In survival analysis, riser patients had the highest cumulative cardiac-related deaths (log-rank, p = 0.001), which was an independent predictor of cardiac-related deaths (hazard ratio, 12.6; 95% confidence interval, 1.76-253; p = 0.01). Multivariate analysis revealed that the norepinephrine level at 24-hour collected urine (24 h U-NE) and the serum creatinine level were independent determinants of %NBPF (adjusted R2 = 0.20; 24 h U-NE, p = 0.0001; serum creatinine, p = 0.04).

CONCLUSIONS

The riser profile was associated with poor prognosis of NIDCM, which may reflect impaired sympathetic nervous system activity. Evaluating the circadian BP profile may be useful for risk stratification in NIDCM patients.

Obstructive Sleep Apnea as Possible Causal Factor for Visit-to-Visit Blood Pressure Variability

BACKGROUND

Recent studies have shown that visit-to-visit blood pressure variability (BPV) is an independent risk factor for cardiovascular disease. However, it has not been clarified whether obstructive sleep apnea (OSA) is associated with visit-to-visit BPV.

METHODS AND RESULTS

The 56 subjects with OSA and 26 control subjects without OSA were examined. Office BP was measured on 5 separate consecutive occasions prior to a polysomnography examination. The visit-to-visit BPV was expressed as the standard deviation and the coefficient of variation of the 5 systolic BP measurements. In subjects with an apnea-hypopnea index (AHI) of more than 20 episodes per hour, the visit-to-visit BPV was also measured after the start of continuous positive airway pressure (CPAP) therapy. Overall, the AHI positively correlated with the standard deviation and the coefficient of variation of systolic BP. In a multivariate analysis, the plasma noradrenaline level and the AHI were independently and positively correlated with the standard deviation and the coefficient of variation of the systolic BP. Among the patients who underwent CPAP therapy, good adherence with CPAP therapy significantly reduced the visit-to-visit BPV.

CONCLUSIONS

OSA is associated with abnormal visit-to-visit BPV and sympathetic activation seems to be related in some way. (Circ J 2016; 80: 1787-1794).

Blood Pressure Response to Losartan and Continuous Positive Airway Pressure in Hypertension and Obstructive Sleep Apnea

RATIONALE

Obstructive sleep apnea (OSA) is common in people with hypertension, particularly resistant hypertension. Treatment with an antihypertensive agent alone is often insufficient to control hypertension in patients with OSA.

OBJECTIVES

To determine whether continuous positive airway pressure (CPAP) added to treatment with an antihypertensive agent has an impact on blood pressure (BP) levels.

METHODS

During the initial 6-week, two-center, open, prospective, case-control, parallel-design study (2:1; OSA/no-OSA), all patients began treatment with an angiotensin II receptor antagonist, losartan, 50 mg daily. In the second 6-week, sex-stratified, open, randomized, parallel-design study of the OSA group, all subjects continued to receive losartan and were randomly assigned to either nightly CPAP as add-on therapy or no CPAP.

MEASUREMENTS AND MAIN RESULTS

Twenty-four-hour BP monitoring included assessment every 15 minutes during daytime hours and every 20 minutes during the night. Ninety-one patients with untreated hypertension underwent a home sleep study (55 were found to have OSA; 36 were not). Losartan significantly reduced systolic, diastolic, and mean arterial BP in both groups (without OSA: 12.6, 7.2, and 9.0 mm Hg; with OSA: 9.8, 5.7, and 6.1 mm Hg). Add-on CPAP treatment had no significant changes in 24-hour BP values but did reduce nighttime systolic BP by 4.7 mm Hg. All 24-hour BP values were reduced significantly in the 13 patients with OSA who used CPAP at least 4 hours per night.

CONCLUSIONS

Losartan reduced BP in OSA, but the reductions were less than in no-OSA. Add-on CPAP therapy resulted in no significant changes in 24-hour BP measures except in patients using CPAP efficiently. Clinical trial registered with www.clinicaltrials.gov (NCT00701428).​

Ambulatory Blood Pressure Monitoring: Five Decades of More Light and Less Shadows

Casual blood pressure measurements have been extensively questioned over the last five decades. A significant percentage of patients have different blood pressure readings when examined in the office or outside it. For this reason, a change in the paradigm of the best manner to assess blood pressure has been observed. The method that has been most widely used is the Ambulatory Blood Pressure Monitoring - ABPM. The method allows recording blood pressure measures in 24 hours and evaluating various parameters such as mean BP, pressure loads, areas under the curve, variations between daytime and nighttime, pulse pressure variability etc. Blood pressure measurements obtained by ABPM are better correlated, for example, with the risks of hypertension. The main indications for ABPM are: suspected white coat hypertension and masked hypertension, evaluation of the efficacy of the antihypertensive therapy in 24 hours, and evaluation of symptoms. There is increasing evidence that the use of ABPM has contributed to the assessment of blood pressure behaviors, establishment of diagnoses, prognosis and the efficacy of antihypertensive therapy. There is no doubt that the study of 24-hour blood pressure behavior and its variations by ABPM has brought more light and less darkness to the field, which justifies the title of this review.

Chronotherapy in practice: the perspective of the community pharmacist

BACKGROUND

Optimising the time of drug administration in alignment with circadian rhythms to enhance the clinical effect or minimise/avoid adverse effects is referred to as chronotherapy. Pharmacists have a key role in providing medicine related information, including counselling about the optimal time for medication administration. Where applicable, the principles of chronotherapy should underlie this aspect of medication counselling. Despite significant developments in the science of chronotherapy for specific pharmacological treatments, the perspective of pharmacists about their understanding and application of these principles in practice has not been explored.

OBJECTIVE

To explore community pharmacist's viewpoints about and experience with the application of chronotherapy principles in practice.

SETTING

Community pharmacies within metropolitan Sydney in New South Wales, Australia.

METHODS

Semi-structured, face to face interviews with a convenience sample of community pharmacists were conducted. All interviews were audio-recorded, transcribed verbatim and thematically analyzed using a 'grounded theory' approach, given the novelty of this area. Main outcome measure Community pharmacists' awareness, current practice and future practice support requirements about the principles of chronotherapy.

RESULTS

Twenty-five semi-structured interviews were conducted. Most participants reported encountering cases where clinical decision making about suggesting appropriate times of drug administration to patients was needed. Their approach was mainly pragmatic rather than based on theoretical principles of circadian variation in drug disposition or on current or emerging evidence; thus there was an evidence practice chasm in some cases. However, most participants believed they have an important role to play in counselling patients about optimal administration times and were willing to enact such roles or acquire skills/competence in this area.

CONCLUSION

Community pharmacists contribute to the safe and effective use of medications in providing the patients with information on optimal timing of drug administration during counselling. Further education, practical training and access to information may help pharmacists in translating principles of chronotherapy into the practice.

Clinical value of ambulatory blood pressure: Is it time to recommend for all patients with hypertension?

Hypertension is a very common disease, and office measurements of blood pressure are frequently inaccurate. Ambulatory Blood Pressure Monitoring (ABPM) offers a more accurate diagnosis, more detailed readings of average blood pressures, better blood pressure measurement during sleep, fewer false positives by detecting more white-coat hypertension, and fewer false negatives by detecting more masked hypertension. ABPM offers better management of clinical outcomes. For example, based on more accurate measurements of blood pressure variability, ABPM demonstrates that taking antihypertensive medication at night leads to better controlled nocturnal blood pressure, which translates into less end organ damage and fewer clinical complications of hypertension. For these reasons, albeit some shortcomings which were discussed, ABPM should be considered as a first-line tool for diagnosing and managing hypertension.

Prognostic Significance of Neuroadrenergic Dysfunction for Cardiovascular Events in Patients With Acute Myocardial Infarction

BACKGROUND

The dysregulation of systemic blood pressure (BP) variation or cardiac neuroadrenergic dysfunction is associated with adverse cardiovascular events. We aimed to clarify the prognostic significance of neuroadrenergic dysfunction for cardiovascular events in patients with acute myocardial infarction (AMI).

METHODS AND RESULTS

We enrolled 63 AMI patients (mean age, 67±12 years) underwent ambulatory BP monitoring (ABPM) and cardiac iodine-(123)metaiodobenzylguanidine (MIBG) imaging within 4 weeks after AMI onset. We analyzed the circadian BP pattern and heart-to-mediastinum (H/M) MIBG uptake ratio. All the patients were followed for 2 years. The study endpoint was a composite of major adverse cardiovascular events, including all-cause death, MI, coronary revascularization except for the MI culprit lesion, and stroke. Patients with a non-dipper pattern (n=29) or an H/M ratio <1.96 (n=28) had a worse prognosis than those with either a dipper pattern (n=34) or an H/M ratio ≥1.96 (n=35; log-rank, P=0.013 and 0.010, respectively). Patients with both a non-dipper pattern and an H/M ratio <1.96 (n=12) had a significantly worse prognosis than did the other patients (P=0.0020).

CONCLUSIONS

Dysregulation of BP variation and cardiac MIBG uptake were associated with cardiovascular events following AMI. Examining ABPM with MIBG imaging may potentially improve risk stratification in these patients.

Noninvasive effects measurements for air pollution human studies: methods, analysis, and implications

Human exposure studies, compared with cell and animal models, are heavily relied upon to study the associations between health effects in humans and air pollutant inhalation. Human studies vary in exposure methodology, with some work conducted in controlled settings, whereas other studies are conducted in ambient environments. Human studies can also vary in the health metrics explored, as there exists a myriad of health effect end points commonly measured. In this review, we compiled mini reviews of the most commonly used noninvasive health effect end points that are suitable for panel studies of air pollution, broken into cardiovascular end points, respiratory end points, and biomarkers of effect from biological specimens. Pertinent information regarding each health end point and the suggested methods for mobile collection in the field are assessed. In addition, the clinical implications for each health end point are summarized, along with the factors identified that can modify each measurement. Finally, the important research findings regarding each health end point and air pollutant exposures were reviewed. It appeared that most of the adverse health effects end points explored were found to positively correlate with pollutant levels, although differences in study design, pollutants measured, and study population were found to influence the magnitude of these effects. Thus, this review is intended to act as a guide for researchers interested in conducting human exposure studies of air pollutants while in the field, although there can be a wider application for using these end points in many epidemiological study designs.

Inverse association of des-acyl ghrelin with worksite blood pressure in overweight/obese male workers

BACKGROUND

Job strain, defined as a combination of high job demands and low job control, has been reported to elevate blood pressure (BP) during work. Meanwhile, a recent experimental study showed that ghrelin blunted the BP response to such mental stress. In the present study, we examined the hypothesis that des-acyl ghrelin may have some beneficial effects on worksite BP through modulating the BP response to work-related mental stress, i.e., job strain.

METHODS

Subjects were 34 overweight/obese male day-shift workers (mean age 41.7 ± 6.7 years). No subjects had received any anti-hypertensive medication. A 24-h ambulatory BP monitoring was recorded every 30 min on a regular working day. The average BP was calculated for Work BP, Morning BP, and Home BP. Job strain was assessed using the short version of the Japanese Job Content Questionnaire.

RESULTS

Des-acyl ghrelin showed significant inverse correlations with almost all BPs except Morning SBP, Morning DBP, and Home DBP. In multiple regression analysis, des-acyl ghrelin inversely correlated with Work SBP after adjusting for confounding factors. Des-acyl ghrelin was also negatively associated with BP changes from Sleep to Morning, Sleep to Work, and Sleep to Home.

CONCLUSIONS

Des-acyl ghrelin was inversely associated with Worksite BP, suggesting a unique beneficial effect of des-acyl ghrelin on Worksite BP in overweight/obese male day-shift workers.

Hyperbaric area index calculated from ABPM elucidates the condition of CKD patients: the CKD-JAC study

BACKGROUND

High prevalence of masked hypertension as well as persistent hypertension was observed in the Chronic Kidney Disease Japan Cohort (CKD-JAC) study. We proposed a novel indicator of blood pressure (BP) load, hyperbaric area index (HBI), calculated from ambulatory blood pressure monitoring (ABPM) data. The characteristic of this index and its relationship with kidney function were also evaluated.

METHODS

The CKD-JAC study, enrolled 2,977 patients, is a prospective observational study started in September 2007. ABPM was conducted in a sub-group from September 2007 to April 2010 and baseline ABPM data of 1,075 subjects (63.4 % male, 60.7 years old) were analyzed.

RESULTS

Mean systolic HBI of male and female patients were 242.3 and 176.5 mmHg×h, respectively. HBI sensitively reflected sex (54.7 mmHg×h higher in males than in females), seasonal effects (51.6 mmHg×h higher in winter than in summer), and advancing CKD stage [(16.5 mmHg×h higher) per -10 mL/min/1.73 m(2) in eGFR]. The HBI was a significant factor to associate with reduced kidney function, after adjusting with nocturnal BP change (NBPC), sex, and other variables (p value <0.001).

CONCLUSIONS

Our findings suggested that HBI might be a novel sensitive indicator for the reduction of kidney function, independent of patterns of NBPC.

Ambulatory blood pressure monitoring in clinical practice: a review

Ambulatory blood pressure monitoring offers the ability to collect blood pressure readings several times an hour across a 24-hour period. Ambulatory blood pressure monitoring facilitates the identification of white-coat hypertension, the phenomenon whereby certain individuals who are not taking antihypertensive medication show elevated blood pressure in a clinical setting but show nonelevated blood pressure averages when assessed by ambulatory blood pressure monitoring. In addition, readings can be segmented into time windows of particular interest, for example, mean daytime and nighttime values. During sleep, blood pressure typically decreases, or dips, such that mean sleep blood pressure is lower than mean awake blood pressure. A nondipping pattern and nocturnal hypertension are strongly associated with increased cardiovascular morbidity and mortality. Approximately 70% of individuals have blood pressure dips of ≥10% at night, whereas 30% have nondipping patterns, when blood pressure remains similar to daytime average or occasionally increases above daytime average. The various blood pressure categorizations afforded by ambulatory blood pressure monitoring are valuable for clinical management of high blood pressure because they increase the accuracy for diagnosis and the prediction of cardiovascular risk.