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

Management of nocturnal hypertension: An expert consensus document from Chinese Hypertension League

Nocturnal hypertension is highly prevalent among Chinese and Asian populations, which is mainly attributed to high salt intake and high salt sensitivity. Nocturnal hypertension increases the risk of cardiovascular and all-cause mortality, independent of daytime blood pressure (BP). However, it can usually be detected by 24-h ambulatory BP monitoring, rather than routine office or home BP measurement, thus is often underdiagnosed in clinical practice. Currently, no specific guidance is available for the management of nocturnal hypertension in China or worldwide. Experts from the Chinese Hypertension League summarized the epidemiologic and pathophysiologic characteristics and clinical phenotype of nocturnal hypertension and provided consensus recommendations on optimal management of nocturnal hypertension, with the goal of maximally reducing the cardiovascular disease risks. In this consensus document, 24-h ABPM is recommended for screening and diagnosis of nocturnal hypertension, especially in the elderly, patients with diabetes, chronic kidney diseases, obstructive sleep apnea and other conditions prone to high nocturnal BP. Lifestyle modifications including salt intake restriction, exercise, weight loss, sleep improvement, and mental stress relief are recommended. Long-acting antihypertensive medications are preferred for nocturnal and 24-h BP control. Some newly developed agents, renal denervation, and other device-based therapy on nocturnal BP reduction are evaluated.

Isolated Nocturnal Hypertension in Children

Isolated nocturnal hypertension (INH) is attracting attention because it has been shown to correlate with target organ damage as well as cardiovascular events in adults. INH has also been reported in children especially in those with underlying diseases including chronic kidney disease and some studies reported association with markers of early target organ damage. INH occupies the majority of nocturnal hypertension. On the other hand, masked hypertension is largely attributed to INH. INH is usually diagnosed by ambulatory blood pressure monitoring. Recently, it became possible to monitor sleep blood pressure by an automated home blood pressure device feasible also in children. The epidemiology, methodology and reproducibility, pathophysiology, relation to target organ damage, and treatment of INH in children will be reviewed here along with adult data.

Nocturnal Hypertension and Heart Failure: Mechanisms, Evidence, and New Treatments

Heart failure (HF) is a common condition with an increasing prevalence. Despite a variety of evidence-based treatments for patients with HF with reduced ejection fraction, morbidity and mortality rates remain high. Furthermore, there are currently no treatments that have yet been shown to reduce complication and death rates in patients who have HF with preserved ejection fraction. Hypertension is a common comorbidity in patients with HF, contributing to disease development and prognosis. For example, hypertension is closely associated with the development of left ventricular hypertrophy, which an important precursor of HF. In particular, nighttime blood pressure (BP) appears to be an important, modifiable risk factor. Both nighttime BP and an abnormal circadian pattern of nighttime BP dipping have been shown to predict development of HF and the occurrence of cardiovascular events, independent of office BP. Key mechanisms for this association include sodium handling/salt sensitivity and increased sympathetic activation. These pathogenic mechanisms are targeted by several new treatment options, including sodium-glucose cotransporter 2 inhibitors, angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and renal denervation. All of these could form part of antihypertensive strategies designed to control nighttime BP and contribute to the goal of achieving perfect 24-hour BP management. Nevertheless, additional research is needed to determine the effects of reducing nighttime BP and improving the circadian BP profile on the rate of HF, other cardiovascular events, and mortality.

From sleep medicine to medicine during sleep-a clinical perspective

Objective. In this perspective paper, we aim to highlight the potential of sleep as an auspicious time for diagnosis, management and therapy of non-sleep-specific pathologies.Approach. Sleep has a profound influence on the physiology of body systems and biological processes. Molecular studies have shown circadian-regulated shifts in protein expression patterns across human tissues, further emphasizing the unique functional, behavioral and pharmacokinetic landscape of sleep. Thus, many pathological processes are also expected to exhibit sleep-specific manifestations. Modern advances in biosensor technologies have enabled remote, non-invasive recording of a growing number of physiologic parameters and biomarkers promoting the detection and study of such processes.Main results. Here, we introduce key clinical studies in selected medical fields, which leveraged novel technologies and the advantageous period of sleep to diagnose, monitor and treat pathologies. Studies demonstrate that sleep is an ideal time frame for the collection of long and clean physiological time series data which can then be analyzed using data-driven algorithms such as deep learning.Significance.This new paradigm proposes opportunities to further harness modern technologies to explore human health and disease during sleep and to advance the development of novel clinical applications - from sleep medicine to medicine during sleep.

Screening for Hypertension in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Hypertension is a major risk factor for cardiovascular disease and can be modified through lifestyle and pharmacological interventions to reduce cardiovascular events and mortality.

OBJECTIVE

To systematically review the benefits and harms of screening and confirmatory blood pressure measurements in adults, to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, Cochrane Collaboration Central Registry of Controlled Trials, and CINAHL; surveillance through March 26, 2021.

STUDY SELECTION

Randomized clinical trials (RCTs) and nonrandomized controlled intervention studies for effectiveness of screening; accuracy studies for screening and confirmatory measurements (ambulatory blood pressure monitoring as the reference standard); RCTs and nonrandomized controlled intervention studies and observational studies for harms of screening and confirmation.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction; meta-analyses and qualitative syntheses.

MAIN OUTCOMES AND MEASURES

Mortality; cardiovascular events; quality of life; sensitivity, specificity, positive and negative predictive values; harms of screening.

RESULTS

A total of 52 studies (N = 215 534) were identified in this systematic review. One cluster RCT (n = 140 642) of a multicomponent intervention including hypertension screening reported fewer annual cardiovascular-related hospital admissions for cardiovascular disease in the intervention group compared with the control group (difference, 3.02 per 1000 people; rate ratio, 0.91 [95% CI, 0.86-0.97]). Meta-analysis of 15 studies (n = 11 309) of initial office-based blood pressure screening showed a pooled sensitivity of 0.54 (95% CI, 0.37-0.70) and specificity of 0.90 (95% CI, 0.84-0.95), with considerable clinical and statistical heterogeneity. Eighteen studies (n = 57 128) of various confirmatory blood pressure measurement modalities were heterogeneous. Meta-analysis of 8 office-based confirmation studies (n = 53 183) showed a pooled sensitivity of 0.80 (95% CI, 0.68-0.88) and specificity of 0.55 (95% CI, 0.42-0.66). Meta-analysis of 4 home-based confirmation studies (n = 1001) showed a pooled sensitivity of 0.84 (95% CI, 0.76-0.90) and a specificity of 0.60 (95% CI, 0.48-0.71). Thirteen studies (n = 5150) suggested that screening was associated with no decrement in quality of life or psychological distress; evidence on absenteeism was mixed. Ambulatory blood pressure measurement was associated with temporary sleep disturbance and bruising.

CONCLUSIONS AND RELEVANCE

Screening using office-based blood pressure measurement had major accuracy limitations, including misdiagnosis; however, direct harms of measurement were minimal. Research is needed to determine optimal screening and confirmatory algorithms for clinical practice.

Different effects of morning and nocturnal hypertension on target organ damage in chronic kidney disease

Both morning hypertension (MH) and nocturnal hypertension (NH) are associated with severe target organ damage in patients with chronic kidney disease (CKD). However, the isolated or combined effects of MH and NH on target organ damage are less well‐defined. A cross‐sectional study was conducted among 2386 non‐dialysis CKD patients with ambulatory blood pressure monitoring. The authors categorized patients into four groups based on the presence or absence of MH and NH. Multivariate logistic analyses were used to evaluate the correlation between hypertension subtypes and target organ damage, including left ventricular hypertrophy (LVH), abnormal carotid intima‐media thickness (CIMT), low estimated glomerular filtration rate (eGFR), and albuminuria. The percentages of isolated MH, isolated NH, and combined MH and NH were 2.3%, 24.0%, and 49.3%, respectively. Compared to patients without MH and NH, isolated MH was only related to low eGFR (2.26 [95% confidence interval: 1.00–5.09]) and albuminuria (2.17 [95% CI: 1.03–4.54]). Meanwhile, combined MH and NH group compared to the group without MH and NH had a higher risk of LVH (2.87 [95% CI: 2.01–4.09]), abnormal CIMT (2.01 [95% CI: 1.47–2.75]), low eGFR (3.18 [95% CI: 2.23–4.54]), and albuminuria (1.79 [95% CI: 1.33–2.40]), even in patients without daytime hypertension. The risk of cardiovascular and renal damage was also observed in the isolated NH group. In conclusion, morning hypertension is associated with kidney dysfunction and has combined effects with nocturnal hypertension on cardiovascular damage in chronic kidney disease patients.

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.

Prevalence of isolated nocturnal hypertension according to 2018 European Society of Cardiology and European Society of Hypertension office blood pressure categories

OBJECTIVES

To estimate the prevalence of isolated nocturnal hypertension (INH) and its relationships with office blood pressure (BP) categories defined by 2018 ESC/ESH guidelines.

METHODS

We conducted a prospective cohort study in consecutive patients referred to perform an ambulatory blood pressure monitoring (ABPM) for diagnosis or therapeutic purposes. Office BP measurements and ABPM were performed in the same visit. The cohort was divided according to office BP in optimal, normal, high-normal and hypertension. The prevalence and adjusted risk for combined daytime and nocturnal hypertension and INH were estimated for each category.

RESULTS

We evaluated 1344 individuals, 59.3% women (51 ± 14 years old) and 40.7% men (52 ± 15 years old). 61.5% of the individuals had nocturnal hypertension, 12.9% INH and 48.7% combined daytime and nocturnal hypertension. Prevalence of combined daytime and nocturnal hypertension increased through office BP categories (P < 0.001). Conversely, prevalence of INH was lower in individuals with hypertension than in normotensives (7.4 vs. 17.2%, P < 0.001) and similar between nonhypertensive office BP categories, 16.6, 15 and 19.4% for optimal, normal and high-normal BP, respectively (P < 0.399). In individuals with office BP values less than 140/90 mmHg, the prevalence of masked hypertension phenotypes were 8.6, 17.2 and 30.2% for daytime, INH and combined daytime and nocturnal hypertension, respectively. Adjusted risk for combined daytime and nocturnal hypertension increased significantly through office BP categories; conversely, the risk for INH was similar in all nonhypertensive office BP categories.

CONCLUSION

Nocturnal hypertension was the more prevalent phenotype of masked hypertension and more than one-third of the individuals with nocturnal hypertension had INH. The risk for INH was not related to nonhypertensive office BP categories.

The Role of Nocturnal Blood Pressure and Sleep Quality in Hypertension Management

The accurate measurement, prediction and treatment of high blood pressure (BP) are essential to the management of hypertension and the prevention of its associated cardiovascular (CV) risks. However, even if BP is optimally controlled during the day, nocturnal high blood pressure may still increase the risk of CV events. The pattern of circadian rhythm of BP can be evaluated by ambulatory BP monitoring (ABPM). Night-time ABPM is more closely associated with fatal and nonfatal CV events than daytime ambulatory BP. However, the use of ABPM is limited by low availability and the fact that it can cause sleep disturbance, therefore may not provide realistic nocturnal measurements. Home blood pressure monitoring (HBPM) offers an inexpensive alternative to ABPM, is preferred by patients and provides a more realistic assessment of BP during an individual’s daily life. However, until recently, HBPM did not offer the possibility to measure nocturnal (sleep time) BP. The development and validation of new BP devices, such as the NightView (OMRON Healthcare, HEM9601T-E3) HBPM device, could overcome these limitations, offering the possibility of daytime and night-time BP measurements with minimal sleep disturbance.

Isolated nocturnal and isolated daytime hypertension associate with altered cardiovascular morphology and function in children with chronic kidney disease: findings from the Cardiovascular Comorbidity in Children with Chronic Kidney Disease study

INTRODUCTION

Prevalence of isolated nocturnal hypertension (INH) and isolated daytime hypertension (IDH) is around 10% in adults. Data in children, especially in chronic kidney disease (CKD), are lacking. The aim of this cross-sectional multicenter cohort study was to define the prevalence of INH and IDH and its association with cardiovascular morphology and function, that is, pulse wave velocity (PWV), carotid intima-media thickness (cIMT), or left ventricular mass index (LVMI) in children with CKD.

METHODS

Ambulatory blood pressure (BP) monitoring profiles were analyzed in 456 children with CKD stages III-V participating in the Cardiovascular Comorbidity in Children with Chronic Kidney Disease Study (64.3% males, 71.3% congenital anomaly of the kidney and urinary tract, age 12.5 ± 3.2 years, estimated glomerular filtration rate 29 ± 12 ml/min per 1.73 m). Baseline PWV, cIMT, and LVMI were compared in normotension, INH, IDH, or sustained 24-h hypertension.

RESULTS

Prevalence of sustained hypertension was 18.4%, of INH 13.4%, and of IDH 3.7%. PWV SDS (SD score) and cIMT SDS were significantly higher in sustained hypertension and INH, and PWV SDS was significantly higher in IDH, compared with normotension. LVMI was significantly increased in sustained hypertension, but not in INH or IDH. Determinants of INH were smallness for gestational age, older age, higher height SDS and parathyroid hormone, and shorter duration of CKD. In logistic regression analysis, day/night-time hypertension or ambulatory BP monitoring pattern (normal, INH, IDH, sustained hypertension) were independently associated with cardiovascular outcome measures: elevated night-time BP was associated with increased cIMT, PWV, and left ventricular hypertrophy; INH was associated with cIMT.

CONCLUSION

INH is present in almost one out of seven children with predialysis CKD; INH and nocturnal hypertension in general are associated with alterations of arterial morphology and function.

Isolated Nocturnal Hypertension: What Do We Know and What Can We Do?

Nocturnal hypertension has been recognized as a significant risk factor for cardio- and cerebrovascular diseases. Blood pressure (BP) monitoring significantly increased our awareness of nocturnal hypertension and studies revealed its influence on target organ damage. Nocturnal hypertension is associated with nonphysiological 24-h BP patterns, which consider inadequate drop or even increment of nighttime BP in comparison with daytime BP (nondipping and reverse dipping). Nevertheless, investigations showed that nocturnal hypertension was a predictor of adverse outcome independently of circadian BP pattern. There are still many uncertainties regarding diagnosis, mechanisms and treatment of nocturnal hypertension. There is a small difference between American and European guidelines in cutoff values defining nocturnal hypertension. Pathophysiology is also not clear because many conditions such as diabetes, metabolic syndrome, obesity, sleep apnea syndrome, and renal diseases are related to nocturnal hypertension and nonphysiological circadian BP pattern, but mechanisms of nocturnal hypertension still remain speculative. Therapeutic approach is another important issue and chronotherapy provided the best results so far. There are studies which showed that some groups of antihypertensive medications are more effective in regulation of nocturnal BP, but it seems that the timing of drug administration has a crucial role in the reduction of nighttime BP and conversion of circadian patterns from nonphysiologic to physiologic. Follow-up studies are necessary to define clinical benefits of nocturnal BP reduction and restoring unfavorable 24-h BP variations to physiological variant.

2020 Consensus summary on the management of hypertension in Asia from the HOPE Asia Network

Hypertension professionals from Asia have been meeting together for the last decade to discuss how to improve the management of hypertension. Based on these education and research activities, the Hypertension, brain, cardiovascular and renal Outcome Prevention and Evidence in Asia (HOPE Asia) Network was officially established in June 2018 and includes experts from 12 countries/regions across Asia. Among the numerous research and review papers published by members of the HOPE Asia Network since 2017, publications in three key areas provide important guidance on the management of hypertension in Asia. This article highlights key consensus documents, which relate to the Asian characteristics of hypertension, home blood pressure monitoring (HBPM), and ambulatory blood pressure monitoring (ABPM). Hypertension and hypertension-related diseases are common in Asia, and their characteristics differ from those in other populations. It is essential that these are taken into consideration to provide the best opportunity for achieving "perfect 24-hour blood pressure control", guided by out-of-office (home and ambulatory) blood pressure monitoring. These region-specific consensus documents should contribute to optimizing individual and population-based hypertension management strategies in Asian country. In addition, the HOPE Asia Network model provides a good example of the local interpretation, modification, and dissemination of international best practice to benefit specific populations.

Blood Pressure Measurement and Treatment Decisions

White-coat and masked hypertension are important hypertension phenotypes. Out-of-office blood pressure measurement is essential for the accurate diagnosis and monitoring of these conditions. This review summarizes literature related to the detection and diagnosis, prevalence, epidemiology, prognosis, and treatment of white-coat and masked hypertension. Cardiovascular risk in white-coat hypertension appears to be dependent on the presence of coexisting risk factors, whereas patients with masked hypertension are at increased risk of target organ damage and cardiovascular events. There is an unmet need for robust data to support recommendations around the use of antihypertensive treatment for the management of white-coat and masked hypertension.

Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: The HOPE Asia Network

Hypertension is an important public health issue because of its association with a number of significant diseases and adverse outcomes. However, there are important ethnic differences in the pathogenesis and cardio-/cerebrovascular consequences of hypertension. Given the large populations and rapidly aging demographic in Asian regions, optimal strategies to diagnose and manage hypertension are of high importance. Ambulatory blood pressure monitoring (ABPM) is an important out-of-office blood pressure (BP) measurement tool that should play a central role in hypertension detection and management. The use of ABPM is particularly important in Asia due to the specific features of hypertension in Asian patients, including a high prevalence of masked hypertension, disrupted BP variability with marked morning BP surge, and nocturnal hypertension. This HOPE Asia Network document summarizes region-specific literature on the relationship between ABPM parameters and cardiovascular risk and target organ damage, providing a rationale for consensus-based recommendations on the use of ABPM in Asia. The aim of these recommendations is to guide and improve clinical practice to facilitate optimal BP monitoring with the goal of optimizing patient management and expediting the efficient allocation of treatment and health care resources. This should contribute to the HOPE Asia Network mission of improving the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia.

When Office Blood Pressure Is Not Enough: The Case of Masked Hypertension

An increasing attention has been devoted in the last two decades to masked hypertension (MH), a condition characterized by the fact that classification of a normal blood pressure (BP) status by office measurements is not confirmed by home and/or ambulatory BP monitoring (ABPM). MH definition (i.e., normal office BP, but high out-of-office BP) should be restricted to untreated subjects (true MH) whereas masked uncontrolled hypertension (MUCH) reserved to treated patients previously classified as hypertensives, presenting normal office BP and high ABPM or home values. Both MH and MUCH are associated with metabolic alterations, comorbidities, and hypertension-mediated organ damage (HMOD). Furthermore, the risk of cardiovascular events related to these conditions has been shown to be close or greater than that of sustained hypertension. This review discusses available evidence about MH and MUCH by focusing on its prevalence, clinical correlates, association with HMOD, prognostic significance, and their therapeutic implications.

Clinical Significance and Therapeutic Implication of Nocturnal Hypertension: Relationship between Nighttime Blood Pressure and Quality of Sleep

Recent global hypertension guidelines recommend an early, strict and 24-hour blood pressure (BP) control for the prevention of target organ damage and cardiovascular events. Out-of-office BP measurement such as ambulatory BP monitoring and home BP monitoring is now widely utilized to rule out white-coat hypertension, to detect masked hypertension, to evaluate the effects of antihypertensive medication, to analyze diurnal BP variation, and to increase drug adherence. Nocturnal hypertension has been neglected in the management of hypertension despite of its clinical significance. Nighttime BP and non-dipping patterns of BP are stronger risk predictors for the future cardiovascular mortality and morbidity than clinic or daytime BP. In addition to ambulatory or home daytime BP and 24-hour mean BP, nocturnal BP should be a new therapeutic target for the optimal treatment of hypertension to improve prognosis in hypertensive patients. This review will provide an overview of epidemiology, characteristics, and pathophysiology of nocturnal hypertension and clinical significance, therapeutic implication and future perspectives of nocturnal hypertension will be discussed.

Understanding short-term blood-pressure-variability phenotypes: from concept to clinical practice

Clinic blood pressure (BP) is recognized as the gold standard for the screening, diagnosis, and management of hypertension. However, optimal diagnosis and successful management of hypertension cannot be achieved exclusively by a handful of conventionally acquired BP readings. It is critical to estimate the magnitude of BP variability by estimating and quantifying each individual patient's specific BP variations. Short-term BP variability or exaggerated circadian BP variations that occur within a day are associated with increased cardiovascular events, mortality and target-organ damage. Popular concepts of BP variability, including "white-coat hypertension" and "masked hypertension", are well recognized in clinical practice. However, nocturnal hypertension, morning surge, and morning hypertension are also important phenotypes of short-term BP variability that warrant attention, especially in the primary-care setting. In this review, we try to theorize and explain these phenotypes to ensure they are better understood and recognized in day-to-day clinical practice.

Perfect 24-h management of hypertension: clinical relevance and perspectives

Out-of-office blood pressure (BP) measured by home BP monitoring, or ambulatory BP monitoring, was demonstrated to be superior to office BP for the prediction of cardiovascular events. The J-HOP study of a nationwide Japanese cohort demonstrated that morning home BP is the best stroke predictor. In the prospective HONEST study of >21 000 hypertensives, on-treatment morning home BP was shown to be a strong predictor both of future coronary artery disease and stroke events. In subjects whose office BP was maintained at ⩾150 mm Hg, there was no increase in cardiovascular events when their morning systolic BP was well-controlled at <125 mm Hg. Since Asians show greater morning BP surges, it is particularly important for Asians to achieve 'perfect 24-hr BP control,' that is, the 24-h BP level, nocturnal BP dipping and BP variability including morning surge. The morning BP surge and the extremes of disrupted circadian rhythm (riser and extreme dipper patterns) are independent risks for stroke in hypertensives. A morning BP-guided approach is thus the first step toward perfect 24-h BP control, followed by the control of nocturnal hypertension. In the resonance hypothesis, the synergistic resonance of BP variability phenotypes would produce an extraordinary large 'dynamic BP surge' that can trigger a cardiovascular event, especially in high-risk patients with systemic hemodynamic atherothrombotic syndrome, a vicious cycle of exaggerated BP variability and vascular disease. In the future, information and communications technology and artificial intelligence technology with the innovation of wearable continuous surge BP monitoring will contribute to 'anticipation medicine' with the goal of zero cardiovascular events.

Does masked hypertension impact left ventricular deformation?

Our aim was to compare left ventricular (LV) deformation in subjects with masked hypertension (MH) to normotensive and sustained hypertensive patients. This cross-sectional study included 185 untreated subjects who underwent 24-hour ambulatory blood pressure (BP) monitoring and complete two-dimensional echocardiographic (2DE) examination including multilayer strain analysis. MH was diagnosed if clinic BP was normal (<140/90 mm Hg), and 24-hour BP was increased (≥130/80 mm Hg). 2DE LV longitudinal and circumferential strains gradually and significantly decreased from normotensive controls across MH individuals to sustained hypertensive patients. 2DE radial strain was not different between groups. 2DE longitudinal and circumferential endocardial and midmyocardial layer strains progressively decreased from normotensive control to sustained hypertensive individuals. Longitudinal and circumferential epicardial layer strains were lower in sustained hypertensive patients than in normotensive controls. Clinic and 24-hour systolic BP were associated with 2DE LV longitudinal endocardial strain, midmyocardial strain, and 2DE circumferential endocardial strain in the whole-study population independent of LV structure and diastolic function. MH significantly affect LV deformation assessed by 2DE traditional strain and 2DE multilayer strain. Clinic and 24-hour systolic BP were associated with LV mechanics evaluated with comprehensive 2DE strain analysis independent of LV structure and diastolic function.

Evidence and Perspectives on the 24-hour Management of Hypertension: Hemodynamic Biomarker-Initiated 'Anticipation Medicine' for Zero Cardiovascular Event

There are notable differences between Asians and Westerners regarding hypertension (HTN) and the relationship between HTN and cardiovascular disease (CVD). Asians show greater morning surges in blood pressure (BP) and a steeper slope illustrating the link between higher BP and the risk of CVD events. It is thus particularly important for Asian hypertensives to achieve 24-h BP control, including morning and night-time control. There are three components of 'perfect 24-h BP control:' the 24-h BP level, nocturnal BP dipping, and BP variability (BPV), such as the morning BP surge that can be assessed by ambulatory BP monitoring. The morning BP-guided approach using home BP monitoring (HBPM) is the first step toward perfect 24-h BP control, followed by the control of nocturnal HTN. We have been developing new HBPM devices that can measure nocturnal BP. BPV includes different time-phase variability from the shortest beat-by-beat, positional, diurnal, day-by-day, visit-to-visit, seasonal, and yearly changes. The synergistic resonance of each type of BPV would produce a great dynamic BP surge (resonance hypothesis), which triggers a CVD event, especially in the high-risk patients with systemic hemodynamic atherothrombotic syndrome (SHATS). In the future, the innovative management of HTN based on the simultaneous assessment of the resonance of all of the BPV phenotypes using a beat by beat wearable 'surge' BP monitoring device (WSP) and an information and communication technology (ICT)-based data analysis system will produce a paradigm shift from 'dots' BP management to 'seamless' ultimate individualized 'anticipation medication' for reaching a zero CVD event rate.

Prehypertension in adolescents with cardiovascular risk: a comparison between type 1 diabetic patients and overweight subjects

BACKGROUND

Adolescents with type 1 diabetes and obesity present higher cardiovascular risk and ambulatory blood pressure measurements (ABPM) has been shown to predict vascular events, especially by identifying the nondipper status. The aim of our observational cross-sectional study conducted in adolescents with type 1 diabetes, overweight subjects and healthy controls was to assess mean blood pressure parameters to identify subclinical cardiovascular risk.

METHODS

The study included adolescents patients with type 1 diabetes followed in our Pediatric Department in University of Catania between January 2011 and 2013. A total of 60 patients were enrolled, and 48 (32 male and 16 female) completed the study. For each subject we performed systolic and diastolic Ambulatory Blood Pressure Measurements (ABPM) during wakefulness and sleep recording blood pressure every 30 min for 24 h with the Tonoport V/2 GE CardioSoft V6.51 device. We compared the data of patients with those of overweight subjects and healthy controls.

RESULTS

ABPM revealed no significant difference between type 1 diabetic patients and overweight subjects in 24 h Systolic, 24 h Diastolic, Day-time Systolic, Night-time systolic and Day-time Diastolic blood pressure values but significantly different values in Night-time Diastolic blood pressure values (p < 0.001). We found significant differences between type 1 diabetic patients and healthy controls in all 24 h Systolic (p < 0.001), 24 h Diastolic (p < 0.01), Day-time Systolic (p < 0.01), Night-time Systolic (p < 0.001), Day-time Diastolic (p < 0.05) and Night-time Diastolic (p < 0.001) blood pressure values. We detected hypertension in 12/48 (25%) type 1 diabetic patients and in 10/48 overweight subjects (p = 0.62; OR 1.2; CI 0.48-3.29), whereas no-one of healthy controls presented hypertension (p < 0.001). We observed nondipper pattern in 40/48 (83.3%) type 1 diabetic patients, in 33/48 (68.8%) overweight subjects (p = 0.094; OR 2.27; CI 0.85-6.01), and in 16/48 (33.3%) of healthy controls (p < 0.001; OR 10; CI 3.79-26.3).

CONCLUSIONS

ABPM studies might help to define a subset of patients at increased risk for the development of hypertension. In evaluating blood pressure in type 1 diabetes and overweight subjects, ABPM should be used since a reduced dipping can indicate incipient hypertension.

Key Points of the Japanese Society of Hypertension Guidelines for the Management of Hypertension in 2014

The Japanese Society of Hypertension (JSH) published the new JSH guidelines for the management of hypertension in 2014, which is the revision of the JSH guidelines of 2009. The primary objective of the guideline is to provide physicians the standard treatment strategy of hypertension to prevent the hypertension-related target organ damage and cardiovascular events. The management of hypertension should be performed in hypertensive patients with a blood pressure of ≥140/90 mm Hg. As Asians have a higher prevalence of stroke than of coronary artery disease and stroke is more steeply associated with the level of blood pressure, the target blood pressure should be lower than 130/80 mm Hg for high-risk patients such as those with diabetes or chronic kidney disease. Because of the increasing prevalence of obesity and the related metabolic syndrome, more salt intake and higher salt sensitivity in the population, lifestyle modifications are necessary in hypertensive patients and subjects with high normal blood pressure. This guideline provides evidence-based recommendations for the management of patients with hypertension with the characteristics of our society.

Association of morning and evening blood pressure at home with asymptomatic organ damage in the J-HOP Study

BACKGROUND

Several guidelines recommend that home blood pressure (HBP) be measured both in the morning and in the evening. However, there have been fewer reports about the clinical significance of morning HBP than about the clinical significance of evening HBP.

METHODS

Our study included 4,310 patients recruited for the Japan Morning Surge Home Blood Pressure Study who had one or more cardiovascular risk factors. We measured morning and evening HBP, urinary albumin-creatinine ratio (UACR), left ventricular mass index (LVMI), brachial-ankle pulse wave velocity (baPWV), maximum carotid intima media thickness (IMT), N-terminal pro-brain-type natriuretic peptide (NT-proBNP), and high-sensitivity cardiac troponin T (Hs-cTnT).

RESULTS

The correlation coefficients for the associations between morning systolic BP (SBP) and log-transformed baPWV, NT-proBNP, or Hs-cTnT were significantly greater than the corresponding relationships for evening SBP (all P < 0.01). The goodness-of-fit of the associations between morning home SBP and UACR (P < 0.05) or baPWV (P < 0.01) was improved by adding evening home SBP to the SBP measurement. In contrast, the goodness-of-fit values of the associations between evening SBP and UACR (P < 0.001), LVMI (P < 0.05), baPWV (P < 0.001), NT-proBNP (P < 0.001), and Hs-cTnT (P < 0.001) were improved by adding morning home SBP to the SBP measurement.

CONCLUSIONS

Morning BP and evening BP provide equally useful information for subclinical target organ damage, yet multivariate modeling highlighted the stand-alone predictive ability of morning BP.

Nocturnal blood pressure and cardiovascular disease: a review of recent advances

The accurate measurement, prediction and treatment of high blood pressure (BP) are essential issues in the management of hypertension. Ambulatory blood pressure monitoring (ABPM) has been shown to be superior to clinic BP measurements as ABPM can provide the following important information: (i) the mean BP levels, (ii) the diurnal variation in BP and (iii) the short-term BP variability. Among these parameters, there is increasing evidence that the mean nocturnal BP level is the most sensitive predictor of cardiovascular morbidity and mortality. Furthermore, several studies have shown that less nocturnal BP dipping, defined as less nocturnal BP decline relative to daytime BP, or a high night-day BP ratio was associated with poor prognosis irrespective of the 24-hour BP levels. These findings can be interpreted in at least two ways: namely, high nocturnal BP or less nocturnal BP dipping might be not only a potent risk factor for cardiovascular disease (CVD), but also a marker of pre-existing or concurrent diseases that can lead to nocturnal BP elevation. In this review, we consider the clinical utility of ABPM and in particular focus on the nocturnal BP levels or nocturnal BP dipping as a potent risk factor for CVD. In addition, the clinical management of high nocturnal BP and blunted nocturnal BP dipping with antihypertensive medications is discussed.

Age and the difference between awake ambulatory blood pressure and office blood pressure: a meta-analysis

BACKGROUND

Ambulatory blood pressure (BP) (ABP) is a better predictor of adverse cardiovascular events than office BP (OBP). Owing to the extensive literature on the 'white coat effect', it is widely believed that ABP tends to be lower than OBP, with statements to this effect in Joint National Committee VII. However, recent evidence suggests that the difference varies systematically with age.

METHODS

We searched PubMed to identify population studies, published before April 2009, which assessed OBP and either ABP or home BP (HBP). On account of significant heterogeneity in the outcomes, random effect models were used for the meta-analyses.

RESULTS

OBP increased with age more steeply than awake ABP. OBP became higher than awake systolic/diastolic ABP at the age of 51.3/42.7 years in men (13 studies, N=3562) and 51.9/42.3 years in women (11 studies, N=2585). In the data in which OBP and HBP were measured (eight studies, N=4916), OBP was higher than HBP at all ages. In the data in which OBP, awake ABP, and HBP were all measured (two studies, N=895), awake ABP was higher than HBP at younger ages, becoming similar at the older age.

CONCLUSION

OBP tends to be higher than awake ABP only after the age of 50 years for systolic and after the age of 45 years for diastolic BP, but is lower than ABP at younger ages; in contrast OBP tends to exceed HBP at all ages.

Prognostic value of isolated nocturnal hypertension on ambulatory measurement in 8711 individuals from 10 populations

BACKGROUND

We and other investigators previously reported that isolated nocturnal hypertension on ambulatory measurement (INH) clustered with cardiovascular risk factors and was associated with intermediate target organ damage. We investigated whether INH might also predict hard cardiovascular endpoints.

METHODS AND RESULTS

We monitored blood pressure (BP) throughout the day and followed health outcomes in 8711 individuals randomly recruited from 10 populations (mean age 54.8 years, 47.0% women). Of these, 577 untreated individuals had INH (daytime BP <135/85 mmHg and night-time BP ≥120/70 mmHg) and 994 untreated individuals had isolated daytime hypertension on ambulatory measurement (IDH; daytime BP ≥135/85 mmHg and night-time BP <120/70 mmHg). During follow-up (median 10.7 years), 1284 deaths (501 cardiovascular) occurred and 1109 participants experienced a fatal or nonfatal cardiovascular event. In multivariable-adjusted analyses, compared with normotension (n = 3837), INH was associated with a higher risk of total mortality (hazard ratio 1.29, P = 0.045) and all cardiovascular events (hazard ratio 1.38, P = 0.037). IDH was associated with increases in all cardiovascular events (hazard ratio 1.46, P = 0.0019) and cardiac endpoints (hazard ratio 1.53, P = 0.0061). Of 577 patients with INH, 457 were normotensive (<140/90 mmHg) on office BP measurement. Hazard ratios associated with INH with additional adjustment for office BP were 1.31 (P = 0.039) and 1.38 (P = 0.044) for total mortality and all cardiovascular events, respectively. After exclusion of patients with office hypertension, these hazard ratios were 1.17 (P = 0.31) and 1.48 (P = 0.034).

CONCLUSION

INH predicts cardiovascular outcome in patients who are normotensive on office or on ambulatory daytime BP measurement.

Masked hypertension defined by ambulatory blood pressure monitoring is associated with an increased serum glucose level and urinary albumin-creatinine ratio

The authors evaluated the relationship of hypertensive target organ damage to masked hypertension assessed by ambulatory blood pressure (BP) and home blood pressure (HBP) monitoring in 129 participants without taking antihypertensive medication. Masked hypertension was defined as office BP < or =140/90 mm Hg and 24-hour ambulatory BP > or =130/80 mm Hg. The masked hypertensive participants defined by 24-hour ambulatory BP (n=13) had a higher serum glucose level (126 vs 96 mg/dL, P=.001) and urinary albumin-creatinine ratio (38.0 vs 7.5 mg/gCr, P<.001) than the normotensive participants (n=74); however, these relationships were not observed when the authors defined groups using HBP (> or =135/85 mm Hg). Masked hypertension by both 24-hour ambulatory BP and HBP had a higher urinary albumin-creatinine ratio than normotension by both 24-hour ambulatory BP and HBP (62.1 vs 7.4 mg/gCr, P=.001), and than masked hypertension by HBP alone (9.3 mg/gCr, P=.009). Masked hypertension defined by 24-hour ambulatory BP is associated with an increased serum glucose level and urinary albumin-creatinine ratio, but these relationships are not observed in masked hypertension defined by HBP.

Masked hypertension: evaluation, prognosis, and treatment

Blood pressure (BP) may be high during usual daily life in one out of 7-8 individuals with normal BP in the clinic or doctor's office. This condition is usually defined as masked hypertension (MH). Prevalence of MH varied across different studies depending on patient characteristics, populations studied, and different definitions of MH. Self-measured BP and ambulatory BP (ABP) have been widely used to identify subjects with MH. Various factors have been identified as possible determinants of MH. Cigarette smoking, alcohol, physical activity, job, and psychological stress may increase BP out of the clinical environment in otherwise normotensive individuals, leading to MH. In most studies, target organ damage was comparable in subjects with MH and those with sustained hypertension, and greater than in those with true normotension. Subjects with MH showed a 1.5- to 3-fold higher risk of major cardiovascular (CV) disease than those with normotension, and their risk was not different from that of patients with sustained hypertension. In an overview of literature, we found that the risk of major CV disease was higher in subjects with MH than in the normotensive subjects regardless of the definition of MH based on self-measured BP (hazard ratio (HR) 2.13; 95% confidence interval (CI): 1.35-3.35; P = 0.001) or 24-h ABP (HR 2.00; 95% CI: 1.54-2.60; P < 0.001). MH is an insidious and prognostically adverse condition that can be reliably diagnosed by self-measured BP and ABP. MH should be searched for in subjects who appear to be more likely to have this condition. Antihypertensive treatment is envisaged in these subjects, although the associated outcome benefits are still undetermined.

Home blood pressure monitoring in clinical practice: a review

Home blood pressure monitoring is a convenient and inexpensive technique to monitor blood pressure in hypertensive patients. There are convincing data that home blood pressure monitoring is a good predictor of future cardiovascular risk, perhaps better than office blood pressure. Home blood pressure measurement can be standardized using validated instruments and systematic protocols; normative criteria have established home blood pressure >135/85 mm Hg as hypertensive. Home blood pressure monitoring has been shown to improve compliance and blood pressure control, and to reduce health care costs. Ongoing studies are evaluating management of hypertension based on home blood pressure readings compared with traditional office-based readings. Home blood pressure monitoring is particularly useful for evaluation of white coat hypertension and masked hypertension. In this article, we discuss the methodology for measuring blood pressure at home, its comparison to the other measurement techniques, the advantages and disadvantages, cost benefit analyses, and ongoing clinical trials to help define the role of home blood pressure monitoring in the clinical management of hypertension.