Status of Home Blood Pressure Measured in Morning and Evening: Evaluation in Normotensives and Hypertensives in Japanese Urban Population

Arterial stiffening is a crucial factor for left ventricular diastolic dysfunction in a community-based normotensive population

BACKGROUND

Left ventricular (LV) diastolic dysfunction is an important underlying hemodynamic mechanism for heart failure. Hypertension reportedly increases aortic stiffness with histological changes in the aorta assessed using aortic pulse wave velocity (PWV) that is associated with LV diastolic dysfunction. The role of hypertension per se in the relationship between aortic stiffness and LV diastolic dysfunction has not been clarified; therefore, we investigated whether this relation works for normotensive subjects.

METHODS

Of the 502 subjects who underwent both echocardiography and PWV measurement in a medical check-up conducted in Arita, Japan, we enrolled 262 consecutive normotensive subjects (age 52 ± 13 years). LV diastolic dysfunction was defined as abnormal relaxation and pseudonormal or restrictive patterns determined with both transmitral flow velocity and mitral annular velocity. Aortic stiffness was assessed via non-invasive brachial-ankle PWV measurement.

RESULTS

LV diastolic dysfunction was detected in 67 of the 262 (26%) normotensive subjects, and PWV was higher in subjects with LV diastolic dysfunction (15.4 ± 3.6 vs. 13.0 ± 2.7 m/s, p < 0.01). Multivariate logistic regression analyses revealed that PWV was independently associated with LV diastolic dysfunction (p = 0.02) after the adjustment for age; body mass index; blood pressure; eGFR; blood levels of BNP, glucose, and HDL cholesterol; LV mass index; and LA dimension.

CONCLUSIONS

Both aortic stiffness and LV diastolic function are mutually related even in normotensive subjects, independent of the potential confounding factors. The increase in aortic stiffness may be a risk factor for LV diastolic dysfunction, irrespective of blood pressure.

Morning and Evening Blood Pressures Are Associated With Intima-Media Thickness in a General Population - The Hisayama Study

BACKGROUND

The association of morning and evening home blood pressures (HBPs) with carotid atherosclerosis has been uncertain in general populations, so we aimed to investigate it in a general Japanese population.Methods and Results:We performed a cross-sectional survey of 2,856 community-dwelling individuals aged ≥40 years to examine the association of morning and evening HBPs with carotid mean intima-media thickness (IMT). The age- and sex-adjusted geometric averages of carotid mean IMT increased significantly with increasing morning HBP (optimal: 0.67 mm; normal: 0.69 mm; high normal: 0.72 mm; grade 1 hypertension: 0.74 mm; and grade 2+3 hypertension: 0.76 mm) and with increasing evening HBP (0.68 mm, 0.71 mm, 0.73 mm, 0.76 mm, and 0.78 mm, respectively) (both P for trend <0.001). These associations remained significant even after adjusting for potential confounding factors. Likewise, both isolated morning hypertension (morning HBP ≥135/85 mmHg and evening HBP <135/85 mmHg) and isolated evening hypertension (evening HBP ≥135/85 mmHg and morning HBP <135/85 mmHg) as well as sustained hypertension (both morning and evening HBP ≥135/85 mmHg) were significantly associated with thicker mean IMT.

CONCLUSIONS

Our findings suggested that both morning and evening HBPs were significantly associated with carotid atherosclerosis in this general Japanese population.

Determinants of the Morning-Evening Home Blood Pressure Difference in Treated Hypertensives: The HIBA-Home Study

Background. The morning home blood pressure (BP) rise is a significant asymptomatic target organ damage predictor in hypertensives. Our aim was to evaluate determinants of home-based morning-evening difference (MEdiff) in Argentine patients. Methods. Treated hypertensive patients aged ≥18 years participated in a cross-sectional study, after performing home morning and evening BP measurement. MEdiff was morning minus evening home average results. Variables identified as relevant predictors were entered into a multivariable linear regression analysis model. Results. Three hundred sixty-seven medicated hypertensives were included. Mean age was 66.2 (14.5), BMI 28.1 (4.5), total cholesterol 4.89 (1.0) mmol/L, 65.9% women, 11.7% smokers, and 10.6% diabetics. Mean MEdiff was 1.1 (12.5) mmHg systolic and 2.3 (6.1) mmHg diastolic, respectively. Mean self-recorded BP was 131.5 (14.1) mmHg systolic and 73.8 (7.6) mmHg diastolic, respectively. Mean morning and evening home BPs were 133.1 (16.5) versus 132 (15.7) systolic and 75.8 (8.4) versus 73.5 (8.2) diastolic, respectively. Significant beta-coefficient values were found in systolic MEdiff for age and smoking and in diastolic MEdiff for age, smoking, total cholesterol, and calcium-channel blockers. Conclusions. In a cohort of Argentine medicated patients, older age, smoking, total cholesterol, and use of calcium channel blockers were independent determinants of home-based MEdiff.

Clinical significance of home blood pressure measurements for the prevention and management of high blood pressure

1. Ambulatory blood pressure (ABP) monitoring (M) provides BP information at many points on any particular day during unrestricted routine daily activities, whereas home blood pressure (HBP) monitoring provides a lot of BP information obtained under fixed times and conditions over a long period of time, thus mean values of HBP provide high reproducibility, and thus an overall superiority compared with ABP.  2. HBP is at least equally or better able than ABP to predict hypertensive target organ damage and prognosis of cardiovascular disease.  3. HBPM allows for ongoing disease monitoring by patients, improves adherence to antihypertensive treatment, and can provide health-care providers with timely clinical data and direct and immediate feedback regarding diagnosis and treatment of hypertension.  4. HBPM provides BP information in relation to time; that is, BP in the morning, in the evening and at night during sleep, and it is an essential tool for the diagnosis of white-coat and masked hypertension.  5. HBPM yields minimal alerting affects and no or minimal placebo effect, and can therefore distinguish small, but significant, serial changes in BP. It is thus the most practical method for monitoring BP in the day-to-day management of hypertension. 6. The superiority of HBPM over ABPM and clinic BPM is apparent from almost all practical and clinical research perspectives.

Effect of the angiotensin II receptor antagonist olmesartan on morning home blood pressure in hypertension: HONEST study at 16 weeks

Morning home blood pressure (BP) levels are more closely associated with cardiovascular risk than clinic BP levels. However, control of morning home BP has been worse than that of clinic BP in clinical practice. We examined the effects of olmesartan-based treatment using data (n=21 341) from the first 16 weeks of the Home BP measurement with Olmesartan Naive patients to Establish Standard Target blood pressure (HONEST) study, a prospective observational study for olmesartan-naive patients with essential hypertension. After 16-week olmesartan-based treatment, the clinic and morning home systolic BP (SBP) lowered from 151.6±16.4 and 153.6±19.0 mm Hg to 135.0±13.7 and 135.5±13.7 mm Hg, respectively (P<0.0001). The achievement percentage of target morning home SBP (<135 mm Hg) in all patients, those with diabetes mellitus (DM), and those with chronic kidney disease (CKD) increased from 13.5, 16.4 and 17.2% to 50.8, 47.9 and 48.8%, respectively, and the proportion of patients with well-controlled hypertension (clinic SBP<140 mm Hg and morning home SBP<135 mm Hg) increased from 7.9, 9.2 and 10.2% to 38.9, 34.5 and 36.3%, respectively. After 16-week olmesartan-based treatment, the proportion of patients with masked and white coat hypertension changed from 11.8 to 24.2% and 5.6 to 11.9%. In conclusion, both clinic and morning home BP in all, DM and CKD patients improved with 16-week olmesartan-based treatment in the ‘real world', and the results showed a sustained 24-hour BP-lowering effect of olmesartan. Decrease in clinic and home BP resulted in an increased rate of masked and white coat hypertension, and further management is needed in those patients.

Adult mortality attributable to preventable risk factors for non-communicable diseases and injuries in Japan: a comparative risk assessment

BACKGROUND

The population of Japan has achieved the longest life expectancy in the world. To further improve population health, consistent and comparative evidence on mortality attributable to preventable risk factors is necessary for setting priorities for health policies and programs. Although several past studies have quantified the impact of individual risk factors in Japan, to our knowledge no study has assessed and compared the effects of multiple modifiable risk factors for non-communicable diseases and injuries using a standard framework. We estimated the effects of 16 risk factors on cause-specific deaths and life expectancy in Japan.

METHODS AND FINDINGS

We obtained data on risk factor exposures from the National Health and Nutrition Survey and epidemiological studies, data on the number of cause-specific deaths from vital records adjusted for ill-defined codes, and data on relative risks from epidemiological studies and meta-analyses. We applied a comparative risk assessment framework to estimate effects of excess risks on deaths and life expectancy at age 40 y. In 2007, tobacco smoking and high blood pressure accounted for 129,000 deaths (95% CI: 115,000-154,000) and 104,000 deaths (95% CI: 86,000-119,000), respectively, followed by physical inactivity (52,000 deaths, 95% CI: 47,000-58,000), high blood glucose (34,000 deaths, 95% CI: 26,000-43,000), high dietary salt intake (34,000 deaths, 95% CI: 27,000-39,000), and alcohol use (31,000 deaths, 95% CI: 28,000-35,000). In recent decades, cancer mortality attributable to tobacco smoking has increased in the elderly, while stroke mortality attributable to high blood pressure has declined. Life expectancy at age 40 y in 2007 would have been extended by 1.4 y for both sexes (men, 95% CI: 1.3-1.6; women, 95% CI: 1.2-1.7) if exposures to multiple cardiovascular risk factors had been reduced to their optimal levels as determined by a theoretical-minimum-risk exposure distribution.

CONCLUSIONS

Tobacco smoking and high blood pressure are the two major risk factors for adult mortality from non-communicable diseases and injuries in Japan. There is a large potential population health gain if multiple risk factors are jointly controlled.

Home and Office Blood Pressure Control among Treated Hypertensive Patients in Japan: Findings from the Japan Home versus Office Blood Pressure Measurement Evaluation (J-HOME) Study

Appropriate control of blood pressure (BP) is essential for prevention of future cardiovascular events. However, BP control among treated hypertensive patients has been insufficient. Recently, the usefulness of self-measured BP at home (home BP measurement) for the management of hypertension has been reported in many studies. We evaluated BP control both at home and in the office among treated hypertensive patients in primary care settings in Japan (the J-HOME study). We found poor control of home and office BPs and clarified some factors affecting control. We also examined factors associated with the magnitude of the white-coat effect, the morning–evening BP difference, and home heart rate in this J-HOME study.

Uncontrolled hypertension based on morning and evening home blood pressure measurements from the J-HOME study

We evaluated the control condition of morning and evening home blood pressure (BP) and compared patients who had isolated uncontrolled morning hypertension and those who had sustained uncontrolled (morning and evening) hypertension using data from the Japan Home versus Office Blood Pressure Measurement Evaluation study. We evaluated 3303 treated hypertensive patients (mean age, 66.2+/-10.5 years; men, 44.7%) in Japan. We classified patients into controlled hypertension, isolated uncontrolled evening hypertension, isolated uncontrolled morning hypertension and sustained uncontrolled hypertension, based on the cutoff value of 135/85 mm Hg for both morning and evening home BP. Of the 3303 patients evaluated, 24.6% had isolated uncontrolled morning hypertension, and 42.0% had sustained uncontrolled hypertension. Factors associated with isolated uncontrolled morning hypertension included taking evening BP measurement after drinking alcohol or bathing. Factors associated with sustained uncontrolled hypertension were male gender, diabetes mellitus and renal disease. The regimen of antihypertensive medication was more complex in patients with uncontrolled morning hypertension than in controlled hypertension. Determinants of the difference between patients with isolated uncontrolled morning hypertension and those with sustained uncontrolled hypertension were diabetes mellitus, renal disease and lower prevalence in measuring evening BP after drinking alcohol or bathing. More than a half of the treated patients were classified into uncontrolled morning hypertension, which were associated with poorer prognosis. Classification of morning hypertensive patients into groups with or without evening hypertension may be useful for evaluating patients' total cardiovascular disease risk. Physicians should also consider evening BP measuring condition for adequate evaluation of evening BP values.

[Clinical investigation of morning hypertension]

AIM

The aim of this study was to investigate morning hypertension and self measurement of blood pressure (BP) at home.

METHODS

Ninety-six patients out of 260 hypertensive (HT) out patients with antihypertensive medication measured their BP at home and data were collected from 60 patients (21 men, 39 women: mean age 74.8 years). The relation between out patient clinic BP and home BP was evaluated in the 60 HT patients. They were requested to measure home blood pressure at morning and evening time.

RESULTS

Mean out patient clinic BP, mean morning BP at home, and mean evening BP at home were 136.4/71.1, 133.9/74.7, and 131.7/72.2 mmHg, respectively. As far as systolic BP is concerned, well-controlled BP (out patient clinic systolic BP <140 mmHg and morning home BP <135 mmHg) was observed in 21 patients (34.4%). The rate of masked HT and white coat HT were 24.6% and 16.4%, respectively.

CONCLUSION

It was shown that self measurement of BP at home contributes to the management of BP control in hypertensive patients.

Does short sleep duration in daily life affect morning home blood pressure? Evaluation in Japanese people

A short sleep duration is expected to elevate blood pressure the next morning, but no report has evaluated this in detail using home blood pressure measurement. In this study, the relation between sleep duration and morning and evening home blood pressure and heart rate during seven consecutive days was evaluated. From 630 volunteers not receiving antihypertensive agents, we selected 478 subjects (318 male, 160 female; mean age: 39.0 years) whose 2-7 days of data consisted of 7-8 hours sleep duration (proper sleep period phase; mean sleep duration: 7.3 +/- 0.3 hours) and less than 7 hours (short sleep period phase; 5.7 +/- 4.9 hours). In the morning, systolic blood pressure and heart rate in the short sleep period phase (117.7 +/- 14.9 mmHg, 67.3 +/- 9.6/min) were significantly (p < 0.01) higher than those in the proper sleep period phase (116.9 +/- 14.9 mmHg, 66.5 +/- 9.1/min). However, there was no difference in morning diastolic blood pressure. Although the difference in morning systolic blood pressure had disappeared by the time of measurement before going to bed, the difference in heart rate was maintained (proper sleep period phase: 70.4 +/- 10.2/min, short sleep period phase: 71.7 +/- 10.7/min, p < 0.01). In conclusion, days with sleep duration of less than 7 hours showed higher morning systolic blood pressure and heart rate compared with days with sleep duration between 7 and 8 hours, but no difference was found in diastolic blood pressure. Moreover, although the difference in morning systolic blood pressure had disappeared at night, the difference in heart rate was still maintained.

Reproducibility of masked hypertension determined from morning and evening home blood pressure measurements over a 6-month period

Recently, the existence of so-called masked hypertension has attracted attention. In this study, the reproducibility of masked hypertension determined from morning and evening home blood pressure measurements was examined over a 6-month period. Home blood pressure measurements were taken consecutively for 7 days in volunteers at a company in 2002 and again in 2003. The 503 Japanese subjects (329 male, 174 female, mean age: 39.4 years), who were not taking antihypertensive drugs, were asked to measure their home blood pressure three times every morning and three times every evening. We defined casual blood pressure > or =140 (systolic) or > or =90 (diastolic) mmHg and home blood pressure > or =135 or > or =85 mmHg as hypertension. We also defined normotension as <140 and <90 mmHg in casual blood pressure and <135 and <85 mmHg in home blood pressure. We examined the reproducibility of four blood pressure categories (normotension, hypertension, white-coat hypertension, and masked hypertension) over a 6-month period. When measured in morning home blood pressure, the reproducibility of masked hypertension (59.1%) was significantly higher than that of white-coat hypertension (25.0%) and similar to that of hypertension (67.6%). However, the reproducibility of masked hypertension (23.5%) was similar to that of white-coat hypertension (32.0%) and significantly lower than that of hypertension (66.7%) when determined using evening home blood pressure. The concordances in the four blood pressure categories between the two periods were 0.582 (kappa coefficient) and 0.463 when determined using morning and evening home blood pressure data, respectively. In conclusion, the reproducibility of masked hypertension over a 6-month period was moderate in an urban Japanese population when evaluated by morning home blood pressure.

Masked hypertension in diabetes mellitus: a potential risk

The prevalence and clinical significance of masked hypertension (MHT) in diabetics have infrequently been described. The authors assessed the association of MHT (defined using a clinic blood pressure [BP] <140/90 mm Hg and daytime ambulatory BP > or = 135/85 mm Hg) with microvascular and macrovascular end organ damage in 81 clinically normotensive Japanese diabetic persons. The prevalence of silent cerebral infarcts (SCIs), increased left ventricular mass, and albuminuria were evaluated. Of 81 patients, 38 (46.9%) were classified as having MHT and showed significantly more SCIs (mean +/- SE: 2.5+/-0.5 vs 1.1+/-0.2; P=.017), and more albuminuria (39% vs 16%; P=.025), but no increase in left ventricular mass index, than the normotensive persons in office and on ambulatory BP monitoring group. The prevalence of MHT in this diabetic population was high (47%). Diabetic patients with MHT showed evidence of brain and kidney damage. Hence, out-of-office monitoring of BP may be indicated in diabetics whose BP is normal in the clinic.

Which measurement of home blood pressure should be used for clinical evaluation when multiple measurements are made?

OBJECTIVE

We evaluated which home blood pressure (BP) measurement was most useful in clinical evaluation when we measured it three times per sitting.

METHODS

Home BP measurements in the morning and evening were performed for 7 days in 572 volunteers (384 men, 188 women, mean age 41.2 years) in 2002 (period 1) and 2003 (period 2). Five sets of measurements were analyzed: A, mean of the first; B, mean of the second; C, mean of the first and second; D, mean of the second and third; and E, mean of all measurements. By analyzing BP in five sets in both periods, their reproducibility was examined.

RESULTS

For all five sets of measurements, little difference was found when BP readings were compared between both periods [the differences were -0.6 +/- 6.7 to -0.4 +/- 7.0 mmHg for morning systolic BP (SBP), 0 +/- 4.9 to 0.3 +/- 5.0 mmHg for morning diastolic BP (DBP), -0.1 +/- 7.1 to 0.1 +/- 7.0 mmHg for evening SBP, and 0.1 +/- 5.3 to 0.4 +/- 5.4 mmHg for evening DBP]. Furthermore, BP readings between both periods correlated well; the correlation coefficients were 0.90-0.92 for morning BP and 0.86-0.89 for evening BP. In addition, the concordance rates of three BP categories (normotension, borderline and hypertension) were excellent using morning home BP (kappa coefficient 0.64-0.68) in all five sets, and higher than those using evening home BP (0.52-0.57).

CONCLUSIONS

This study has shown that even one measurement on each occasion is as useful as several measurements when 7 consecutive days of home BP measurements are used for clinical evaluation.

Masked Nocturnal Hypertension and Target Organ Damage in Hypertensives with Well-Controlled Self-Measured Home Blood Pressure

It has been reported that masked hypertension, a state in which patients show normal clinic blood pressure (BP) but elevated out-of-clinic BP by self-measured home BP, is a predictor of cardiovascular morbidity much like sustained hypertension. In addition, nocturnal BP is closely associated with cardiovascular disease. This might mean that ambulatory and self-measured home BP monitoring each provide independent information. We performed ambulatory BP monitoring, self-measured home BP monitoring, echocardiography and carotid ultrasonography in 165 community-dwelling subjects. We subclassified the patients according to the ambulatory and self-measured home BP levels as follows: in the masked nocturnal hypertension group, the self-measured home BP level was <135/85 mmHg and the ambulatory nocturnal BP level was >or=120/75 mmHg; in the normotensive group, the self-measured home BP level was <135/85 mmHg and the ambulatory nocturnal BP level was <120/75 mmHg. The intima-media thickness (IMT) and relative wall thickness (RWT) were greater in the masked nocturnal hypertension group than in the normotensive group (IMT: 0.76+/-0.20 vs. 0.64+/-0.14 mm, p<0.05; RWT: 0.50+/-0.14 vs. 0.41+/-0.10, p<0.05). Even in hypertensives with well-controlled self-measured home BP, elevated ambulatory nocturnal BP might promote target organ damage. We must rule out masked hypertension using self-measured home BP monitoring, and we might also need to rule out nocturnal masked hypertension using ambulatory BP monitoring.

Prediction of stroke by home "morning" versus "evening" blood pressure values: the Ohasama study

Predictive power of self-measured blood pressure at home (home BP) for cardiovascular disease risk has been reported to be higher than casual-screening BP. However, the differential prognostic significance of home BP in the morning (morning BP) and in the evening (evening BP), respectively, has not been elucidated. In the Ohasama study, 1766 subjects (>or=40 years) were followed up for an average of 11 years. The predictive power for stroke incidence of evening BP was compared with that of morning BP as continuous variables. The Cox regression model demonstrated that evening BP and morning BP predicted future stroke risk equally. Subjects were also assigned to 1 of 4 categories based on home BP. In this analysis, stroke risk in morning hypertension ([HT] morning BP >or=135/85 mm Hg and evening BP <135/85 mm Hg; relative hazard (RH): 2.66; 95% CI:1.64 to 4.33) and that in sustained HT(morning BP and evening BP >or=135/85 mm Hg; RH: 2.38; 95% CI: 1.65 to 3.45) was significantly higher than that in normotension (morning BP and evening BP <135/85 mm Hg). The risk in morning HT was more remarkable in subjects taking antihypertensive medication (RH: 3.55; 95% CI: 1.70 to 7.38). Although the risk in evening HT (morning BP <135/85 mm Hg and evening BP >or=135/85 mm Hg) was higher than that in normotension, the differences were not significant. In conclusion, morning BP and evening BP provide equally useful information for stroke risk, whereas morning HT, which indicates HT specifically observed in the morning, might be a good predictor of stroke, particularly among individuals using anti-HT medication.

Influence of nighttime bathing on evening home blood pressure measurements: how long should the interval be after bathing?

The Japanese Society of Hypertension has recommended that evening home blood pressure measurement be taken just before bedtime. In this study, to elucidate the influence of nighttime bathing on evening home blood pressure and heart rate, measurements were performed for 7 days using volunteers who were employees of a single company and who had no alcohol intake during the study period. We used data obtained from 158 subjects (78 males and 80 females; mean age, 41.6 years) whose evening data consisted of a combination of pre-bathing and post-bathing measurements. We divided the subjects into four groups according to the time interval from bathing: blood pressure was measured at 30 min after bathing in group I (n=40), at 31-60 min after bathing in group II (n=89), at 61-120 min after bathing in group III (n=74) and at more than 121 min after bathing in group IV (n=53). We evaluated the changes after bathing in each group. For all subjects combined, the evening home blood pressure measured after bathing (114.0+/-17.1/69.4+/-10.9 mmHg) was significantly lower than the value before bathing (116.3+/-17.1/70.7+/-11.2 mmHg). However, there was no difference in heart rate. Both systolic and diastolic blood pressure after bathing in group I (109.1+/-15.2/66.3+/-10.8 mmHg) and II (112.0+/-15.2/66.5+/-10.1 mmHg) were significantly lower than those before bathing (group I: 113.2+/-15.8/70.2+/-10.6 mmHg; group II: 115.2+/-15.8/69.3+/-10.3 mmHg), but these differences disappeared in group III and IV. On the other hand, there was no difference in heart rate after bathing in group I, II, or III, but group IV showed a slight but significant decrease after bathing (67.7+/-10.0 --> 65.8+/-10.7 beats/min). In conclusion, if evening home blood pressure is to be measured after bathing, subjects should be instructed to wait more than 60 min after bathing before performing the measurement in order to eliminate the depressor effect of bathing.

The Japan Morning Surge-1 (JMS-1) Study: Protocol Description

Morning blood pressure is reported to be more closely related to hypertensive organ damages such as left ventricular mass index, microalbuminuria and silent cerebral infarcts, than blood pressure at other times of the day. Morning blood pressure may play an important role in the pathogenesis of hypertensive target organ damage. Increased sympathetic nerve activity is reported to be one of the mechanisms of morning hypertension; however, there are no available data that show whether strict home blood pressure control, especially in the morning period, can reduce target organ damage. The Japan Morning Surge-1 (JMS-1) study includes hypertensive outpatients with elevated morning systolic blood pressure (>or=135 mmHg) as assessed by self-measured blood pressure monitoring at home. All enrolled patients are under stable antihypertensive medication status. Exclusion criteria are arrhythmia, chronic inflammatory disease, and taking alpha-blockers or beta-blockers. The target number of patients to be enrolled in the JMS-1 study is 600, and the aim is to evaluate differences in the markers of hypertensive target organ damage, such as brain natriuretic peptide and the urinary albumin excretion/creatinine ratio. All of the patients are randomized to an experimental group or a control group, with randomization to be carried out by telephone interviews with the patients' physicians. In the experimental group, patients begin taking additional antihypertensive medication just before going to bed. This consists of doxazosin 1 mg/day, which then is increased to 2 mg/day and 4 mg/day, with a beta-blocker added after a 1-month interval until the morning systolic blood pressure is controlled to less than 135 mmHg. Patients in the control group continue the treatment they are receiving at the enrollment for 6 months. Blood pressure levels, adverse effects, and hypertensive target organ damage before and after the study are evaluated. In the JMS-1 study, we will evaluate whether strict morning blood pressure control by sympathetic nervous system blockade using an alpha-blocker, doxazosin, and with the addition of a beta-blocker if needed, can reduce hypertensive target organ damage.

Electrocardiogram Screening for Left High R-Wave Predicts Cardiovascular Death in a Japanese Community-Based Population: NIPPON DATA90

Little is known about the efficacy of left ventricular hypertrophy diagnosed by electrocardiography for predicting cardiovascular disease in a general Japanese population. In a large cohort of participants selected randomly from the overall Japanese population, we attempted to evaluate the usefulness of a high amplitude R-wave (left high R-wave) on the electrocardiogram for predicting cardiovascular death. A total of 6,688 Japanese (mean age, 50.7 years old; 57% women) free of previous cardiovascular disease and use of antihypertensive agents at baseline were followed for 10 years, from 1990 to 2000. Left high R-wave on the electrocardiogram (the Minnesota Code, 3-1 or 3-3) was found in 9.4% of the 6,688 participants, in 14.6% of the 2,413 hypertensives and in 6.4% [corrected] of the 4,275 normotensives. During the follow-up period, 133 [corrected] participants died due to cardiovascular disease. After adjustment for systolic blood pressure and other risk factors, left high R-wave conferred an increased risk of cardiovascular death; the hazard ratio among all the participants was 1.88 (95% confidence interval, 1.22-2.89; p < 0.01), that among hypertensives was 1.97 (1.20-3.24; p = 0.01), and that among normotensives was 1.66 (0.69-3.98; p = 0.26). The population attributable risk percent of left high R-wave for cardiovascular death was 7.6% among all participants, 12.4% among hypertensives and 4.1% among normotensives. Left high R-wave on electrocardiogram, irrespective of the level of systolic blood pressure, was a predictive marker for cardiovascular death among community-dwelling Japanese.

Prevalence of masked uncontrolled and treated white-coat hypertension defined according to the average of morning and evening home blood pressure value: from the Japan Home versus Office Measurement Evaluation Study

OBJECTIVE

To evaluate the prevalence of masked uncontrolled and treated white-coat hypertension defined according to the average of morning and evening home blood pressure values.

METHODS

The study population consisted of 3303 essential hypertensive outpatients receiving antihypertensive treatment in Japan. Information on the characteristics of the patients was collected by a physician's self-administrated questionnaire. The office blood pressure value was calculated as the average of the four readings in two visits. All patients were asked to measure their blood pressure once every morning and once every evening. In the study, we included patients with at least three measurements in the morning and in the evening, respectively. The average of all home blood pressure values was taken as the home blood pressure value.

RESULTS

The mean value of home systolic/diastolic blood pressure was 136.8/79.3 mmHg, and the mean value of office systolic/diastolic blood pressure was 142.8/80.6 mmHg. Of the 3303 patients, 758 (23.0%) had controlled hypertension (home <135/85 mmHg and office <140/90 mmHg), 628 (19.0%) had masked uncontrolled hypertension (home > or =135/85 mmHg and office <140/90 mmHg), 640 (19.4%) had treated white-coat hypertension (home <135/85 mmHg and office > or =140/90 mmHg), and 1277 (38.7%) had uncontrolled hypertension (home > or =135/85 mmHg and office > or =140/90 mmHg).

CONCLUSIONS

Treated white-coat hypertension and masked uncontrolled hypertension were often observed in clinical settings. Physicians need to understand the prevalence of such patients to prevent inadequate diagnosis and treatment in them.