Masked hypertension in diabetes mellitus: a potential risk

Design and validation of dual-point time-differentiated photoplethysmogram (2PPG) wearable for cuffless blood pressure estimation

BACKGROUND & OBJECTIVES

Measurement of blood pressure (BP) in ambulatory patients is crucial for at high-risk cardiovascular patients. A non-obtrusive, non-occluding device that continuously measures BP via photoplethysmography will enable long-term ambulatory assessment of BP. The aim of this study is to validate the metasense 2PPG cuffless wearable design for continuous BP estimation without ECG.

METHODS

A customized high-speed electronic optical sensor architecture with laterally spaced reflectance pulse oximetry was designed into a simple unobtrusive low-power wearable in the form of a watch. 78 volunteers with a mean age of 32.72 ± 7.4 years (21 to 64), 51% male, 49% female were recruited with ECG-2PPG signals acquired. The fiducial features of the 2PPG morphologies were then attributed to the estimator. A 9-1 K-fold cross-validation was applied in the ML.

RESULTS

The correlation for PTT-SBP was 0.971 and for PTT-DBP was 0.954. The mean absolute error was 3.167±1.636 mmHg for SBP and 6.4 ± 3.9 mm Hg for DBP. The ambulatory estimate for SBP and DBP for an individual over 3 days with 8-hour recordings was 0.70-0.81 for SBP and 0.42-0.51 for DBP with a ± 2.65 mmHg for SBP and ±2.02 mmHg for DBP. For SBP, 98% of metasense measurements were within 15 mm Hg and for DBP, 91% of metasense measurements were within 10 mmHg CONCLUSIONS: The metasense device provides continuous, non-invasive BP estimations that are comparable to ambulatory BP meters. The portability and unobtrusiveness of this device, as well as the ability to continuously measure BP could one day enable long-term ambulatory BP measurement for precision cardiovascular therapeutic regimens.

2023 update and perspectives

Total 276 manuscripts were published in Hypertension Research in 2022. Here our editorial members picked up the excellent papers, summarized the current topics from the published papers and discussed future perspectives in the sixteen fields. We hope you enjoy our special feature, 2023 update and perspectives in Hypertension Research.

Masked Hypertension in Healthy Children and Adolescents: Who Should Be Screened?

PURPOSE OF REVIEW

The goal is to review masked hypertension (MH) as a relatively new phenomenon when patients have normal office BP but elevated out-of-office BP. Firstly, it was described in children in 2004. It has received increased attention in the past decade.

RECENT FINDINGS

The prevalence of MH in different pediatric populations differs widely between 0 and 60% based on the population studied, definition of MH, or method of out-of-office BP measurement. The highest prevalence of MH has been demonstrated in children with chronic kidney disease (CKD), obesity, diabetes, and after heart transplantation. In healthy children but with risk factors for hypertension such as prematurity, overweight/obesity, diabetes, chronic kidney disease, or positive family history of hypertension, the prevalence of MH is 9%. In healthy children without risk factors for hypertension, the prevalence of MH is very low ranging 0-3%. In healthy children, only patients with the following clinical conditions should be screened for MH: high-normal/elevated office BP, positive family history of hypertension, and those referred for suspected hypertension who have normal office BP in the secondary/tertiary center.

Sleep-related factors associated with masked hypertension: the Nagahama study

OBJECTIVES

Masked hypertension, which is characterized by out-of-office hypertension but normal office blood pressure, is a risk factor for cardiovascular disease. However, the factors that contribute to masked hypertension are unclear. We aimed to determine the involvement of sleep-related characteristics in masked hypertension.

METHODS

The study included 3844 normotensive (systolic/diastolic blood pressure < 140/90 mmHg) community residents with no antihypertensive drug use at baseline (mean age 54.3 years). Home morning and evening blood pressure, oxygen desaturation during sleep (pulse oximetry), and sleep efficiency (actigraphy) were measured for 1 week. The number of nocturnal urinations during this period was obtained using a sleep diary.

RESULTS

Masked hypertension (mean morning and evening blood pressure ≥135/85 mmHg) was detected in 11.7% of study participants, and 79.0% of the participants with masked hypertension had sleep hypertension (≥120/70 mmHg). Multinominal logistic regression analysis identified different factors involved in masked hypertension with and without sleep hypertension; factors for masked hypertension with sleep hypertension included the frequency of at least 3% oxygen desaturation (coefficient = 0.038, P  = 0.001), nocturia (coefficient = 0.607, P  < 0.001), and carotid intima-media thickness (coefficient = 3.592, P  < 0.001). Only carotid intima-media thickness and measurement season were associated with masked hypertension without sleep hypertension. Low sleep efficiency was associated with isolated sleep hypertension but not masked hypertension.

CONCLUSION

Sleep-related factors associated with masked hypertension differed depending on the presence of sleep hypertension. Sleep-disordered breathing and nocturnal urination frequency may help identify individuals who need home blood pressure monitoring.

Masked hypertension in a middle-aged population and its relation to manifestations of vascular disease

BACKGROUND

Masked hypertension is associated with cardiovascular disease (CVD). However, previous large studies have not used the same device to measure office and home blood pressure (BP) and adhered to current home BP measurement recommendations of the European Society of Hypertension. We aimed to characterize masked hypertension and explore its relation to manifestations of CVD.

METHODS

A randomly selected cohort of 5057 participants aged 50-64 years from the Swedish CardioPulmonary BioImage Study (SCAPIS) was evaluated with office and home BP using the semi-automatic Omron M10-IT oscillometric device. Additional analyses included pulse wave velocity (PWV) and coronary artery calcium score (CACS).

RESULTS

Of participants, 4122 did not have current antihypertensive treatment, and were thus included in our analyses. Of these, 2634 (63.9%) had sustained normotension, and 172 (4.2%) had masked hypertension. Participants with masked hypertension vs. sustained normotension were more often men (66.9 vs. 46.2%, P  < 0.001). Those with masked hypertension had higher mean PWV [9.3 (95% confidence interval, 95% CI 9.1-9.5) vs. 8.3 (95% CI 8.2-8.4) m/s, P  < 0.001] and odds ratio for CACS at least 100 [1.65 (95% CI 1.02-2.68), P  = 0.040]. These associations were similar in a posthoc analysis of masked hypertension and sustained normotension, matched for age, sex and systolic office BP.

CONCLUSION

Masked hypertension was associated with markers of CVD. This suggests that home BP is a better predictor of risk, even when the recordings are performed with the same measurement device, in a population-based setting with randomized recruitment.

The many faces of hypertension in individuals with type 1 diabetes

Several disturbed blood pressure (BP) patterns, including disparities between office and out-of-office BP measurements (such as white-coat and masked hypertension), disturbed circadian BP variability (such as abnormal dipping patterns and nocturnal hypertension) and treatment-resistant hypertension, are common in individuals with type 1 diabetes. Consequently, office or home BP measurements alone may not reflect real BP variation and may lead to inadequate diagnosis and treatment of hypertension. The early detection of these disturbed BP patterns is especially crucial in individuals with type 1 diabetes, as these patterns may indicate future development of adverse cardiovascular and renal outcomes. In this review we will describe these disturbed BP patterns and discuss recent findings on their prevalence and outcomes. We will also address critical areas for future research to determine the true prevalence and prognosis of disturbed BP patterns, and to optimize and improve the knowledge and management of high-risk individuals with type 1 diabetes and disturbed BP patterns.

Prediction of Masked Uncontrolled Hypertension Detected by Ambulatory Blood Pressure Monitoring

The aim of this study was to provide prediction models for masked uncontrolled hypertension (MUCH) detected by ambulatory blood pressure (BP) monitoring in an Italian population. We studied 738 treated hypertensive patients with normal clinic BPs classified as having controlled hypertension (CH) or MUCH if their daytime BP was < or ≥135/85 mmHg regardless of nighttime BP, respectively, or CH or MUCH if their 24-h BP was < or ≥130/80 mmHg regardless of daytime or nighttime BP, respectively. We detected 215 (29%) and 275 (37%) patients with MUCH using daytime and 24-h BP thresholds, respectively. Multivariate logistic regression analysis showed that males, those with a smoking habit, left ventricular hypertrophy (LVH), and a clinic systolic BP between 130−139 mmHg and/or clinic diastolic BP between 85−89 mmHg were associated with MUCH. The area under the receiver operating characteristic curve showed good accuracy at 0.78 (95% CI 0.75−0.81, p < 0.0001) and 0.77 (95% CI 0.73−0.80, p < 0.0001) for MUCH defined by daytime and 24 h BP, respectively. Internal validation suggested a good predictive performance of the models. Males, those with a smoking habit, LVH, and high-normal clinic BP are indicators of MUCH and models including these factors provide good diagnostic accuracy in identifying this ambulatory BP phenotype.

Blood pressure response to standing is a strong determinant of masked hypertension in young to middle-age individuals

OBJECTIVE

The pathophysiologic mechanisms of masked hypertension are still debated. The aim of this study was to investigate whether the blood pressure response to standing is a determinant of masked hypertension in young individuals.

DESIGN AND METHODS

We studied 1078 individuals (mean age 33.2 ± 8.5 years) with stage-1 untreated hypertension at baseline. Orthostatic response was defined as the difference between six SBP measurements in the orthostatic and supine postures. People with a response more than 6.5 mmHg (upper decile) were defined as hyperreactors. After 3 months of follow-up, 24-h ambulatory BP was measured and the participants were classified as normotensives (N = 120), white-coat hypertensive individuals (N = 168), masked hypertensive individuals (N = 166) and sustained hypertensive individuals (N = 624). In 591 participants, 24-h urinary epinephrine was also measured.

RESULTS

Orthostatic response was an independent predictor of masked hypertension after 3 months (P = 0.001). In the whole group, the odds ratio for the Hyperreactors was 2.5 [95% confidence interval (95% CI) 1.5-4.0, P < 0.001]. In the participants stratified by orthostatic response and urinary epinephrine, the odds ratio for masked hypertension was 4.2 (95% CI, 1.8-9.9, P = 0.001) in the hyperreactors with epinephrine above the median and was 2.6 (95% CI, 0.9-7.3, P = 0.069) in those with epinephrine below the median. The association between orthostatic response and masked hypertension was confirmed in the cross-sectional analysis after 3 months (P < 0.001).

CONCLUSION

The present findings indicate that hyperreactivity to standing is a significant determinant of masked hypertension. The odds ratio for masked hypertension was even quadrupled in people with an orthostatic response more than 6.5 mmHg and high urinary epinephrine suggesting a role of sympathoadrenergic activity in the pathogenesis of masked hypertension.

Comparison of community and clinic-based blood pressure measurements: A cross-sectional study from Haiti

Hypertension (HTN) is the leading modifiable cardiovascular disease (CVD) risk factor in low and middle-income countries, and accurate and accessible blood pressure (BP) measurement is essential for identifying persons at risk. Given the convenience and increased use of community BP screening programs in low-income settings, we compared community and clinic BP measurements for participants in the Haiti CVD Cohort Study to determine the concordance of these two measurements. Participants were recruited using multistage random sampling from March 2019 to August 2021. HTN was defined as systolic BP (SBP) ≥ 140mmHg, diastolic BP (DBP) ≥ 90mmHg or taking antihypertensives according to WHO guidelines. Factors associated with concordance versus discordance of community and clinic BP measurements were assessed with multivariable Poisson regressions. Among 2,123 participants, median age was 41 years and 62% were female. Pearson correlation coefficients for clinic versus community SBP and DBP were 0.78 and 0.77, respectively. Using community BP measurements, 36% of participants screened positive for HTN compared with 30% using clinic BPs. The majority of participants had concordant measurements of normotension (59%) or HTN (26%) across both settings, with 4% having isolated elevated clinic BP (≥140/90 in clinic with normal community BP) and 10% with isolated elevated community BP (≥140/90 in community with normal clinic BP). These results underscore community BP measurements as a feasible and accurate way to increase HTN screening and estimate HTN prevalence for vulnerable populations with barriers to clinic access.

Stress-induced arterial hypertension

Stress is considered as one of the factors associated with the development of many diseases, including the cardiovascular system. The history of studying stress as a risk factor for hypertension began in the first half of the 20th century and continued after the introduction of 24-hour blood pressure monitoring (ABPM) into clinical practice. Then it turned out that there is normotension, stable hypertension and latent hypertension: masked (when clinical BP is within the normal range, and arterial hypertension is recorded according to ABPM and/or self-monitoring of BP) and white coat hypertension (increased BP during a visit to the doctor when normal values of blood pressure according to ABPM or self-monitoring of BP). Currently, both variants of latent hypertension are classified as stress-induced arterial hypertension. Several models have been proposed for the study of stress, but two of them are more common in clinical studies: the Karasek model (based on an imbalance between job demands and job decision latitude) and the Siegrist model (based on an imbalance of effort and reward). There are only few studies in where attempts have been made to link the increase in BP with the parameters of stress response (for example, with hormonal levels) or genetic predisposition. The review discusses the most significant studies of stress-induced arterial hypertension published to date.

Blood pressure measurement using only a smartphone

Hypertension is an immense challenge in public health. As one of the most prevalent medical conditions worldwide, it is a major cause of premature death. At present, the detection, diagnosis and monitoring of hypertension are subject to several limitations. In this review, we conducted a literature search on blood pressure measurement using only a smartphone, which has the potential to overcome current limitations and thus pave the way for long-term ambulatory blood pressure monitoring on a large scale. Among the 333 articles identified, we included 25 relevant articles over the past decade (November 2011–November 2021) and analyzed the described approaches to the types of underlying data recorded with smartphone sensors, the signal processing techniques applied to construct the desired signals, the features extracted from the constructed signals, and the algorithms used to estimate blood pressure. In addition, we analyzed the validation of the proposed methods against reference blood pressure measurements. We further examined and compared the effectiveness of the proposed approaches. Among the 25 articles, 23 propose an approach that requires direct contact between the sensor and the subject and two articles propose a contactless approach based on facial videos. The sample sizes in the identified articles range from three to 3000 subjects, where 8 articles used sample sizes of 85 or more subjects. Furthermore, 10 articles include hypertensive subjects in their participant pools. The methodologies applied for the evaluation of blood pressure measurement accuracy vary considerably among the analyzed articles. There is no consistency regarding the methods for blood pressure data collection and the reference blood pressure measurement and validation. Moreover, no established protocol is currently available for the validation of blood pressure measuring technologies using only a smartphone. We conclude the review with a discussion of the results and with recommendations for future research on the topic.

Self-Monitoring Home Blood Pressure in Community-Dwelling Older People: Age Differences in White-Coat and Masked Phenomena and Related Factors—The SONIC Study

Some studies reported that home blood pressure (HBP) monitoring was conducted by community-dwelling older people themselves, but there have been few studies on HBP including very old populations aged over 90 years old. Thus, the aim of the present study was to clarify the current situation of white-coat and masked phenomena defined by on-site and home BP measurements in community-dwelling old and oldest-old populations. The study subjects were 380 participants from the SONIC study, a cohort study of a community-dwelling old population, who measured their HBP in a series of 3–5 days by themselves and brought their HBP records to the venue on the survey day. Study participants' characteristics were as follows: female, 185 (48.7%); male, 195 (51.3%); 70s, 95 (25.0%); 80s, 245 (64.5%); and 90s, 40 (10.5%). A total of 344 (90.5%) participants had hypertension. A total of 291 (76.6%) hypertensive participants taking antihypertensive medication were analyzed in the present study. Regarding the types of hypertension defined by home and on-site BP, they showed white-coat phenomenon, 183 (48.2%); masked phenomenon, 115 (30.3%); sustained hypertension, 130 (34.2%); and normotension, 82 (21.6%). On comparison of age groups, there was a tendency for the white-coat phenomenon to be common in young-old people in their 70s and the masked phenomenon to be common in very old people in their 90s. Therefore, since the detection of white-coat and masked phenomena is closely associated with appropriate BP management, it is very important for community-dwelling older populations to self-monitor HBP.

Utility of ambulatory blood pressure monitoring in detection of masked hypertension and risk of hypertension mediated organ damage in normotensive patients with type 2 diabetes mellitus

PURPOSE

In patients with diabetes, unrecognised hypertension is a serious problem risk factor for the development and progression of chronic complications. The study aimed to determine the prevalence of masked hypertension in normotensive diabetic patients, the factors affecting it, and its association with diabetes complications using ambulatory blood pressure monitoring (ABPM).

MATERIALS AND METHODS

A cross-sectional observational study was conducted on 150 normotensive diabetic patients. Patients were subjected to an interview and clinical examination to record demographic data, epidemiological data, and significant past history. ABPM was performed for each patient. Urine samples, echocardiogram, and ophthalmologic fundoscopy were done to check for diabetes-related complications.

RESULTS

The mean age of all participants was 56.7 ± 7.8 years. A total of 93 patients (62%) were males. 99 (66%) patients had masked hypertension. A total of 85 (56.7%) were non-dippers, 49 (32.7%) were dippers, 1 (0.7%) was extreme dipper and 15 (10%) were reverse dippers. Non-dipping and reverse dipping were associated with concentric left ventricular hypertrophy LVH (p < .001). Masked hypertension was associated with concentric LVH (p = .001) and nephropathy (p =.008) whereas, nocturnal hypertension was associated with concentric LVH (p = .001) and nephropathy (p =.003).

CONCLUSIONS

A single office blood pressure (BP) reading cannot rule out hypertension in patients with diabetes. Regardless of hypertension, clinicians should have all patients, especially patients with diabetes, undergo ABPM at least once. Masked hypertension, changes in nocturnal dipping and other phenomena that raise the risk of diabetes complications but cannot be measured by office BP can be measured by ABPM, and thus ABPM can provide a good prognostic benefit.

Self-Perceived Psychological Stress and Risk of First Stroke in Treated Hypertensive Patients

OBJECTIVE

We aimed to investigate the prospective association between self-perceived psychological stress and first stroke, and to examine possible effect modifiers among adults with hypertension.

METHODS

A total of 20,688 hypertensive adults with information on self-perceived psychological stress at baseline were included from the China Stroke Primary Prevention Trial. Participants were randomly assigned to a double-blind treatment of receiving a single tablet daily with either 10 mg enalapril and 0.8 mg folic acid or 10 mg enalapril alone. Follow-up visits occurred every 3 months after randomization. Psychological stress was measured with a one-item 3-point rating scale. The primary outcome was first stroke (fatal or nonfatal).

RESULTS

The median treatment period was 4.5 years. Compared with participants with low levels of psychological stress, those with high psychological stress had a significantly higher risk of first stroke (adjusted hazard ratio = 1.40, 95% confidence interval = 1.01 to 1.94) or first ischemic stroke (adjusted hazard ratio = 1.45; 95% confidence interval = 1.01 to 2.09). Moreover, a stronger positive relationship between psychological stress and first stroke was found in participants with time-averaged mean arterial pressure <101 mm Hg (median; p-interaction = .004) during the treatment period. However, our study did not find a significant association between psychological stress and first hemorrhagic stroke.

CONCLUSIONS

Higher psychological stress was associated with an increased risk of first stroke among treated hypertensive patients, especially in those with lower mean arterial pressure during the treatment period.

Awareness, Knowledge, and Attitudes Toward Screening and Treatment of Masked Hypertension in Primary Care

BACKGROUND

Hypertension guidelines recommend screening and treatment for masked hypertension (MHT). Yet, few primary care providers (PCPs) screen for MHT, and little is known about PCP awareness, knowledge, and attitudes toward MHT.

METHODS

Three focus groups involving 30 PCPs from 3 medical centers in New York were conducted. Focus group transcripts were analyzed using thematic content analysis.

RESULTS

Awareness of MHT varied, and only 2 providers had diagnosed MHT. There was also low knowledge about the prevalence and impact of MHT. While some PCPs were receptive to MHT screening after learning about its significance, others viewed the current evidence as insufficient to change practice. Providers were discomforted by labeling patients with nonelevated office blood pressure (BP) as hypertensive and reluctant to add another screening test to their workload without stronger evidence. There was distrust in the accuracy of home BP monitoring to screen for MHT. There was more confidence in ambulatory BP monitoring (ABPM) for MHT screening, but ABPM was viewed as largely inaccessible. There was broad agreement with lifestyle changes for MHT. There were concerns that antihypertensive medication lacked evidence from randomized trials and could induce harmful side effects.

CONCLUSIONS

Limited PCP knowledge about MHT, concerns about the accuracy and accessibility of screening tests, overloaded PCPs, and insufficient evidence were major barriers to screening and treatment for MHT. Prior to broad uptake by PCPs, randomized trials demonstrating the net benefits of MHT screening and treatment may be needed, along with increased dissemination of knowledge about MHT and improved access to ABPM.

Comparison of Dialysis Unit and Home Blood Pressures: An Observational Cohort Study

RATIONALE & OBJECTIVE

Prior studies of patients receiving maintenance hemodialysis have shown that, on average, blood pressure (BP) measured predialysis is higher than BP measured at home. We hypothesized that a subset of hemodialysis patients has BP that is higher when measured at home than when measured predialysis and this subgroup of patients has a higher prevalence of left ventricular hypertrophy.

STUDY DESIGN

Prospective cohort.

SETTING & PARTICIPANTS

97 hypertensive hemodialysis patients enrolled in the Blood Pressure in Dialysis Study (BID), a randomized trial of comparing target predialysis BP ≤140/90 to 155-165/90 mm Hg.

EXPOSURE

Differences between predialysis and next-day home systolic BP measured ≥6 times over 1 year.

OUTCOME

Left ventricular mass index (LVMI) by cardiac magnetic resonance imaging.

ANALYTICAL APPROACH

A hierarchical clustering analysis divided patients into 3 clusters based on the average and variability of differences in systolic predialysis and home BP. Clusters were compared with respect to clinical factors and LVMI.

RESULTS

Mean differences between predialysis and home systolic BP were 19.1 (95% CI, 17.0 to 21.1) mm Hg for cluster 1 ("home lower"), 3.7 (95% CI, 1.6 to 5.8) mm Hg for cluster 2 ("home and predialysis similar"), and -9.7 (95% CI, -12.0 to -7.4) mm Hg for cluster 3 ("home higher"). Systolic BP declined during dialysis in clusters 1 and 2 but increased in cluster 3. Interdialytic weight gains did not differ. After adjusting for sex and treatment arm, LVMI was higher in cluster 3 than in clusters 1 and 2: differences in means of 10.6 ± 4.96 (SE) g/m² (P = 0.04) and 12.0 ± 5.08 g/m² (P = 0.02), respectively.

LIMITATIONS

Limited statistical power.

CONCLUSIONS

Nearly one-third of participants had home BPs higher than predialysis BPs. These patients had LVMI higher than those with similar or lower BPs at home, indicating that their BP may have been undertreated.

Influence of hypertension and other risk factors on the onset of sublingual varices

Background

Sublingual varices (SV) are dilatations of tortuous veins that increased with age. Previous studies showed that this pathology could be correlated to some risk factors such as hypertension, age, gender and diabetes mellitus. In this study we evaluated, on a large number of subjects, the relationship between SV and different grades of hypertension as well as some risk factors extending the analysis to new risk factors such as dyslipidemia, obesity and antihypertensive therapy, modelling a possible dependence of SV on all these factors.

Methods

In the study 1008 subjects, 284 with and 724 without SV, were examined. The blood pressure was measured in office condition and, to exclude subjects with white coat syndrome or masked hypertension, also using a 24 h Holter pressure monitor. Hypertensive subjects were divided in resistant, drugs controlled (compensated) and patients with prior unknown hypertension (new diagnosed) groups. The presence or absence of SV as well as of the risk factors was assessed clinically. We tested the influence of age on the presence of SV by using the chi-square test and the relation between each risk factor and SV by the Cochran–Mantel–Haenszel test. Finally, we carried out a multivariate regression tree analysis in order to predict the presence of SV.

Results

We confirmed the influence of age on SV and found a significant relationship between SV and both the compensated and resistant hypertension grades. We highlighted a relationship between SV and dyslipidemia in subjects with new diagnosed hypertension, and between SV and smoking in subjects with compensated hypertension grade. The regression tree showed a classification accuracy of about 75% using as variables hypertension grades, age and antihypertensive treatment.

Conclusions

We confirmed the SV dependence on age, resistant hypertension and smoking, highlighting a new association with dyslipidemia in new diagnosed hypertensive subjects and new relations depending on the hypertension grades. Thus, the SV inspection could be used to suggest a lipidologist as well as a hypertension specialist visit for a pharmacological and pressure check particularly in subjects presenting SV and dyslipidemia. However, further parameters are to be considered to improve the sensitivity of the prognostic tree model.

Prevalence of masked hypertension evaluated by home blood pressure monitoring in a large sample of patients with office blood pressure <140/90 mmHg

AIM

Patients with masked hypertension have a higher incidence of target organ damage, including increased left ventricular mass and carotid atherosclerosis and cardiovascular events when compared with normotensive patients. The adverse cardiovascular risks are even greater in patients already taking antihypertensive medication.

OBJECTIVE

To identify the prevalence and clinical characteristics of masked hypertension in a large multicenter Brazilian sample that underwent office and home blood pressure monitoring.

METHODS

This was an observational cross-sectional analytical study based on secondary data from the teleMRPA online platform, which included 32 cities from 15 states in the five regions of Brazil. The database included 3704 outpatient participants with office blood pressure <140/90 mmHg who performed home blood pressure monitoring for diagnostic investigation (diagnosis group; n = 1819) or treatment (treatment group; n = 1885) of hypertension in 2018.

RESULTS

The prevalence of masked hypertension was 18.0% in the whole studied population and 15.4% and 20.4% in the diagnostic and treatment group, respectively. Masked hypertension was more frequently detected in patients with office blood pressure classified as high normal [systolic blood pressure (SBP) = 130-139 mmHg or diastolic blood pressure (DBP) = 85-89 mmHg], followed by those classified as normal (SBP = 120-129 mmHg or DBP = 80-84 mmHg) and optimal (SBP < 120 mmHg and DBP < 80 mmHg), with respective prevalence of 28.3, 13.4 and 4.4% in the diagnostic group and 30.8, 18.8 and 7.1% in the treatment group.

CONCLUSION

Masked hypertension has a significant prevalence among individuals with office blood pressure <140/90 mmHg, which is greater with patients with high normal office blood pressure and even higher in patients already using antihypertensive medication.

Blood Pressure Prediction by a Smartphone Sensor using Fully Convolutional Networks

Heart disease and stroke are the leading causes of death worldwide. High blood pressure greatly increases the risk of heart disease and stroke. Therefore, it is important to control blood pressure (BP) through regular BP monitoring; as such, it is necessary to develop a method to accurately and conveniently predict BP in a variety of settings. In this paper, we propose a method for predicting BP without feature extraction using fully convolutional neural networks (CNNs). We measured single multi-wave photoplethysmography (PPG) signals using a smartphone. To find an effective wavelength of PPG signals for the generation of accurate BP measurements, we investigated the BP prediction performance by changing the combinations of the input PPG signals. Our CNN-based BP predictor yielded the best performance metrics when a green PPG time signal was used in combination with an instantaneous frequency signal. This combination had an overall mean absolute error (MAE) of 5.28 and 4.92 mmHg for systolic and diastolic BP, respectively. Thus, our CNN-based approach achieved comparable results to other approaches that use a single PPG signal.

Prognostic Value of Masked Uncontrolled Hypertension Defined by Different Ambulatory Blood Pressure Criteria

BACKGROUND

Masked uncontrolled hypertension (MUCH), that is, nonhypertensive clinic but high out-of-office blood pressure (BP) in treated patients is at increased cardiovascular risk than controlled hypertension (CH), that is, nonhypertensive clinic and out-of-office BP. Using ambulatory BP, MUCH can be defined as daytime and/or nighttime and/or 24-hour BP above thresholds. It is unclear whether different definitions of MUCH have similar prognostic information. This study assessed the prognostic value of MUCH defined by different ambulatory BP criteria.

METHODS

Cardiovascular events were evaluated in 738 treated hypertensive patients with nonhypertensive clinic BP. Among them, participants were classified as having CH or daytime MUCH (BP ≥135/85 mm Hg) regardless of nighttime BP (group 1), nighttime MUCH (BP ≥120/70 mm Hg) regardless of daytime BP (group 2), 24-hour MUCH (BP ≥130/80 mm Hg) regardless of daytime or nighttime BP (group 3), daytime MUCH only (group 4), nighttime MUCH only (group 5), and daytime + nighttime MUCH (group 6).

RESULTS

We detected 215 (29%), 357 (48.5%), 275 (37%), 42 (5.5%),184 (25%) and 173 (23.5%) patients with MUCH from group 1 to 6, respectively. During the follow-up (10 ± 5 years), 148 events occurred in patients with CH and MUCH. After adjustment for covariates, compared with patients with CH, the adjusted hazard ratio (95% confidence interval) for cardiovascular events was 2.01 (1.45–2.79), 1.53 (1.09–2.15), 1.69 (1.22–2.34), 1.52 (0.80–2.91), 1.15 (0.74–1.80), and 2.29 (1.53–3.42) from group 1 to 6, respectively.

CONCLUSIONS

The prognostic impact of MUCH defined according to various ambulatory BP definitions may be different.

[Machine Learning Methods in Assessing the Risks of Target Organ Damage in Masked Hypertension]

Aim To develop models for predicting the risk of target organs damage (TOD) in different phenotypes of "masked" arterial hypertension (MAH) based on methods of machine learning (ML).Material and methods A retrospective cohort analysis was performed for 284 clinical records of patients (261 males, 23 females; median age, 38 years). Group 1 included 125 patients with grade 1-2 arterial hypertension (AH) and low or moderate risk; group 2 included 159 subjects with normal "office" blood pressure (BP) exposed to chronic professional stress. The 24-h BP monitoring (24-h BPM) and ultrasound examination of the heart and carotid arteries were performed; glomerular filtration rate (GFR) was estimated using the СКD-EPI formula. MAH was phenotyped by clustering 24-h BPM data, and the risk of TOD was predicted by analysis of odd ratios (OR) and with the ML methods, random forest (RF) and artificial neural networks (ANN). Data were analyzed using the R language in the RStudio environment.Results According to results of the 24-h BPM and cluster analysis, 121 (76.1 %) subjects of group 2 had MAH. The MAH phenotypes were identified as follows: systolic-diastolic (SDMAH) (43.8 %); isolated systolic (ISMAH) (35.5 %), and isolated diastolic (IDMAH) (20.7%). As compared to stable AH, subjects with different MAH phenotypes showed both increases and decreases in individual 24-h BPM indexes. Thus, in subjects with IDMAH, mean 24-h values of systolic and diastolic BP were significantly lower than with AH while in SDMAH, they were considerably higher. The OR analysis demonstrated that odds of differently located TOD were associated with definite MAH phenotypes. With that, ISMAH was associated with the highest risk of glomerular hyperfiltration; IDMAH was associated with reduced GFR and vascular remodeling; and SDMAH was associated with left ventricular myocardial hypertrophy. The developed models for predicting the risk of TOD based on the RF and ANN methods showed a high accuracy, which was provided by multistep procedures of selecting the predictors and cross-validation.Conclusion Modern ML technologies enhance the risk stratification of patients with different clinical variants of AH.

Epidemiological Impact and Clinical Consequences of Masked Hypertension: A Narrative Review

Masked hypertension (MHT) is a clinical condition characterized by normal blood pressure (BP) levels during clinical consultation and above normal out-of-office BP values. MHT is associated to an increased risk of developing hypertension-mediated organ damage (HMOD) and major cardiovascular (CV) outcomes, such as myocardial infarction, stroke, and hospitalizations due to CV causes, as well as to metabolic abnormalities and diabetes, thus further promoting the development and progression of atherosclerotic disease. Previous studies showed contrasting data on prevalence and clinical impact of MHT, due to not uniform diagnostic criteria (including either home or 24-h ambulatory BP measurements, or both) and background antihypertensive treatment. Whatever the case, over the last few years the widespread diffusion of validated devices for home BP monitoring has promoted a better diagnostic assessment and proper identification of individuals with MHT in a setting of clinical practice, thus resulting in increased prevalence of this clinical condition with potential clinical and socio-economic consequences. Several other items, in fact, remain unclear and debated, particularly regarding the therapeutic approach to MHT. The aim of this narrative review is to illustrate the clinical definition of MHT, to analyze the diagnostic algorithm, and to discuss the potential pharmacological approaches to be adopted in this clinical condition, in the light of the recommendations of the recent European hypertension guidelines.

Autonomic dysregulation and phenobarbital in patients with masked primary hypertension

Introduction

Primary hypertension can be masked and be responsible of a severe impact on the target bodies. The purpose of this study was to see if Phenobarbital at low dose is able to decrease the sympathetic hyperactivity assessed by cardiovascular autonomic reflexes in patients with masked hypertension.

Materials and methods

This prospective study was conducted on a total of 91 patients with masked hypertension (average age 52.1 ± 10.3 years old). The cardiovascular autonomic tests performed in this group, before and after 3 months of daily oral administration of Phenobarbital, included deep breathing, hand-grip, mental stress and orthostatic tests. Statistical analysis was done using the Student's t-test, Univariate and Multivariate logistic regression analysis; p is significant if < 0.05.

Results

Cardiovascular autonomic reflexes responses before and after 3 months of Phenobarbital oral administration were as follows: Vagal response (XDB) obtained on deep breathing test was of 32.6 ± 5.4% VS 30.4 ± 6.1%, (p = 0.08), alpha peripheral sympathetic response (alpha SP) obtained on hand grip test was of 35.6 ± 8.7% VS 12.0 ± 2.5%, (p < 0.001), alpha central sympathetic response (alpha SC), beta central sympathetic response (beta SC) obtained during mental stress were of respectively 29.3 ± 9.2% VS 11.8 ± 2.4%, (p < 0.001) and 11.0 ± 5.3% VS 10.4 ± 6.1%, (p = 0.2), alpha peripheral adrenergic sympathetic (alpha PAS) obtained during orthostatic test was of 25.3 ± 6.0% VS 13.0 ± 3.4%, (p < 0.001).

Conclusion

These results demonstrated that Phenobarbital at low dose may have an anti-sympathetic effect in patients with masked hypertension.

Phenotypes of Hypertensive Ambulatory Blood Pressure Patterns: Design and Rationale of the ECHORN Hypertension Study

Objective

To describe the rationale and design of a prospective study of ambulatory blood pressure measurement (ABPM) combined with measurement of contextual factors to identify hypertensive phenotypes in a Caribbean population with high rates of HTN and cardiovascular disease.

Design

Prospective, multi-center sub-study.

Setting

Eastern Caribbean Health Outcomes Research Network Cohort (ECHORN) Study, with study sites in Puerto Rico, the US Virgin Islands, Trinidad and Tobago, and Barbados.

Participants

Community-residing adults without a diagnosis of HTN and not taking antihypertensive medication.

Intervention

Ambulatory BP patterns are assessed using 24-hour ABPM. Contextual factors are assessed with: ecological momentary assessment (7-item survey of experiences, exposures and responses associated with daytime BP measurements); actigraphy (capturing physical activity and sleep quality); and self-report surveys (assessing physical and social health, environmental and social stressors and supports).

Main Outcome Measures

Phenotypes of contextual factors associated with hypertensive BP patterns (sustained HTN, masked HTN, and nocturnal non-dipping).

Methods and Results

This study will enroll 500 participants; assessments of blood pressure and contextual factors will be conducted during Waves 2 and 3 of the ECHORN parent study, occurring 2 years apart. In Wave 2, we will assess the association between contextual factors and ABPM patterns. Using advanced analytic clustering methods, we will identify phenotypes of contextual factors associated with hypertensive ABPM patterns. We will then test the stability of these phenotypes and their ability to predict change in ABPM patterns between Waves 2 and 3.

Conclusions

Assessment of ABPM, and the contextual factors influencing ABPM, can identify unique phenotypes of HTN, which can then be used to develop more precision-based approaches to the prevention, detection and treatment of HTN in high-risk populations.

Association of Cardiovascular Outcomes With Masked Hypertension Defined by Home Blood Pressure Monitoring in a Japanese General Practice Population

Importance

The clinical outcomes associated with masked hypertension defined by home blood pressure monitoring (HBPM) in clinical settings remain uncertain.

Objective

To assess the association between masked hypertension and cardiovascular disease events in clinical settings.

Design, Setting, and Participants

This observational cohort study used data from 4261 outpatients treated at 71 primary practices or university hospitals throughout Japan who were enrolled in the Japan Morning Surge-Home Blood Pressure study between January 1, 2005, and December 31, 2012. Participants had a history of or risk factors for cardiovascular disease and were followed up through March 31, 2015. Participants underwent clinic blood pressure (BP) measurements on 2 occasions as well as HBPM measurements in the morning and evening for a 14-day period. Urine albumin to creatinine ratio and circulating brain (or B-type) natriuretic peptide levels were quantified at baseline as a marker of cardiovascular end-organ damage. Data were analyzed from July 1, 2017, to October 31, 2017.

Exposures

Participants were categorized into 4 BP groups: (1) masked hypertension-hypertensive home BP levels (systolic, ≥135 mm Hg; diastolic, ≥85 mm Hg) and nonhypertensive clinic BP levels (systolic, <140 mm Hg; diastolic, <90 mm Hg); (2) white-coat hypertension-nonhypertensive home BP levels (systolic, <135 mm Hg; diastolic, <85 mm Hg) and hypertensive clinic BP levels (systolic, ≥140 mm Hg; diastolic, ≥90 mm Hg); (3) sustained hypertension-hypertensive home and clinic BP levels; and (4) controlled BP-nonhypertensive home and clinic BP levels.

Main Outcomes and Measures

Incident stroke and coronary heart disease.

Results

Of the 4261 participants, 2266 (53.2%) were women, 3374 (79.2%) were taking antihypertensive medication, and the mean (SD) age was 64.9 (10.9) years. During a median (interquartile range) follow-up of 3.9 (2.4-4.6) years, 74 stroke (4.4 per 1000 person-years) and 77 coronary heart disease (4.6 per 1000 person-years) events occurred. The masked hypertension group had a greater risk for stroke compared with the controlled BP group (hazard ratio, 2.77; 95% CI, 1.20-6.37), independent of traditional cardiovascular risk factors, urine albumin to creatinine ratio, and circulating B-type natriuretic peptide levels. Conversely, masked hypertension yielded no association with coronary heart disease risk.

Conclusions and Relevance

In the Japanese general practice population, masked hypertension defined by HBPM may be associated with an increased risk for stroke events. Use of HBPM may improve the assessment of BP-related risks and identify new therapeutic interventions aimed at preventing cardiovascular disease events.

Effort-reward imbalance and ambulatory blood pressure among female Las Vegas hotel room cleaners

BACKGROUND

Effort-reward imbalance (ERI) was hypothesized to be associated with ambulatory blood pressure (ABP) and pulse pressure (PP) among female hotel room cleaners.

METHODS

ERI, ABP, and PP were assessed among 419 cleaners from five hotels during 18 waking hours. Adjusted linear regression models were used to assess associations of ERI with ABP and PP during 18-hours, work hours, and after work hours.

RESULTS

There was a pattern of higher ERI being associated with higher 18-hour systolic ABP and 18-hour PP although the results were imprecise. An increase of ERI by half its range was associated with a 1.6 mmHg (95% CI, -1.6-4.7) increase in 18-hour systolic blood pressure (SBP) and a 0.7 mmHg (95% CI, -1.1-2.5) increase in 18-hour PP. An increase in rewards by half its range was associated with a 2 mmHg decrease in after-hours SBP (-2.2, 95% CI, -5.4-1.0) and after-hours PP (-1.9, 95% CI, -3.8-0.0). Among females 45 years or older, ERI was associated with 2.1 and 2.2 mmHg increase in 18-hour and work hours diastolic ABP, respectively, compared to a 0 mmHg change in 18-hour and work hours diastolic ABP in younger women. The number of dependents at home attenuated the association.

CONCLUSIONS

ERI was positively associated with ABP, particularly SBP, and the association was modified by age and the number dependents at home, although the estimates were imprecise. Workplace interventions that integrate stress management and active ABP surveillance appear warranted. However, larger studies with Latina women need to confirm our results.

Prognostic Value of Masked Uncontrolled Hypertension

The prognostic relevance of masked uncontrolled hypertension (MUCH) is incompletely clear, and its global impact on cardiovascular outcomes and mortality has not been assessed. The aim of this study was to perform a meta-analysis on the prognostic value of MUCH. We searched for articles assessing outcome in patients with MUCH compared with those with controlled hypertension (CH) and reporting adjusted hazard ratio and 95% CI. We identified 6 studies using ambulatory blood pressure monitoring (12 610 patients with 933 events) and 5 using home blood pressure measurement (17 742 patients with 394 events). The global population included 30 352 patients who experienced 1327 events. Selected studies had cardiovascular outcomes and all-cause mortality as primary outcome, and the main result is a composite of these events. The overall adjusted hazard ratio was 1.80 (95% CI, 1.57-2.06) for MUCH versus CH. Subgroup meta-analysis showed that adjusted hazard ratio was 1.83 (95% CI, 1.52-2.21) in studies using ambulatory blood pressure monitoring and 1.75 (95% CI, 1.38-2.20) in those using home blood pressure measurement. Risk was significantly higher in MUCH than in CH independently of follow-up length and types of studied events. MUCH was at significantly higher risk than CH in all ethnic groups, but the highest hazard ratio was found in studies, including black patients. Risk of cardiovascular events and all-cause mortality is significantly higher in patients with MUCH than in those with CH. MUCH detected by ambulatory or home blood pressure measurement seems to convey similar prognostic information.

Normotensive patients with obstructive sleep apnoea: changes in 24-h ambulatory blood pressure monitoring with continuous positive airway pressure treatment

BACKGROUND

Continuous positive airway pressure (CPAP) treatment reduces blood pressure (BP) in obstructive sleep apnoea (OSA) and hypertensive patients, but there is a lack of data about the effects of CPAP on the BP in normotensive patients.

OBJECTIVE

The aim of the study was to evaluate BP changes in normotensive OSA individuals receiving CPAP treatment.

METHODS

We selected 131 normotensive outpatients with an apnoea/hypopnoea index (AHI) greater than 15 events/hour who required CPAP treatment. All patients underwent a sleep study and 24-h ambulatory BP monitoring (ABPM) at baseline and after 6 months. In addition, the patients were assessed for the presence of baseline masked hypertension, defined as office BP less than 140/90 mmHg and increased BP on 24-h ABPM (mean 24-h BP ≥130/80 mmHg).

RESULTS

After 6 months of CPAP treatment, a mild reduction in all 24-h ABPM variables was observed, but only the mean 24-h DBP [-1.39 mmHg, 95% confidence interval (95% CI), -2.50 to -0.27], mean daytime DBP (-1.39 mmHg, 95% CI -2.56 to -0.22) and the mean 24-h ambulatory BP (-1.80 mmHg, 95% CI, -3.16 to -0.44) reached statistical significance. The reduction was primarily due to BP changes in individuals with masked hypertension who displayed a mean BP reduction of -4.78 mmHg (-7.25 to -2.30 mmHg). Consistent with a circadian BP pattern, a reduction in mean nocturnal BP of -4.73 mmHg (-7.39 to -2.06 mmHg) was observed at 6 months in nondippers; in contrast, the mean nocturnal BP in dippers increased by 2.61 mmHg (0.60-4.62 mmHg).

CONCLUSION

Our findings suggest that the CPAP effects may be different in normotensive outpatients depending on the presence of undiagnosed masked hypertension and the dipping pattern. Therefore, it is important to consider measuring ABPM in this type of patient.

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.

Left ventricular mass independently associates with 24-hour sodium excretion in young masked hypertensive adults: The African-PREDICT study

BACKGROUND

Due to the known contribution of excess sodium intake on elevations in blood pressure, salt reduction regulations are being introduced in countries all over the world. To study the contribution of sodium intake on cardiovascular disease development, we determined whether left ventricular mass associates with sodium excretion in young adults free from overt cardiovascular disease and those with masked hypertension.

METHODS

We included 681 participants (41% men and 50% black) in a cross-sectional analysis from the African-PREDICT study with complete 24-hour urine collections and successful ambulatory blood pressure monitoring (>70% valid readings). The participants were categorized as normotensive (n = 534) or masked hypertensive (n = 147). In addition, we determined left ventricular mass index (LVMI) along with traditional risk factors.

RESULTS

Masked hypertensive individuals had higher sodium excretion (149 vs. 128 mmol/L/day) and LVMI (78.1 vs. 69.6 g/m2) than normotensives. In single, partial and multiple regression analyses, LVMI independently associated with higher sodium excretion in the total group of young adults (β = 0.089; p = 0.011). This result was also evident among masked hypertensives (β = 0.215; p = 0.008), but not in normotensives (β = 0.054; p = 0.134).

CONCLUSION

Our results indicated that higher sodium excretion (reflecting a higher salt intake) may contribute to increased left ventricular mass, potentially driven by the early development of masked or undetected hypertension.

Masked uncontrolled hypertension: Prevalence and predictors

Background

There are limited data on ‘masked uncontrolled hypertension’ (MUCH) in patients with treated and apparently well-controlled BP is unknown.

Objectives

To define the prevalence and predictors of MUCH among hypertensive patients with controlled office blood pressure.

Methods

One hundred ninety-nine hypertensive patients presented to the specialized hypertension clinics at two University Hospitals. All patients had controlled office blood pressure (less than 140/90 mmHg). Patients were assessed regarding history, clinical examination, and laboratory data. All patients underwent ambulatory blood pressure monitoring (ABPM) for 24 h, within a week after the index office visit. MUCH was diagnosed if average 24-h ABPM was elevated (systolic BP ≥ 130 mmHg and/or diastolic BP ≥ 80 mmHg) despite controlled clinic BP.

Results

Sixty-six patients (33.2%) had MUCH according to 24-h ABPM criteria (mean age 53.5 ± 9.3 years, 60.6% men). MUCH was mostly caused by the poor control of nocturnal BP; with the percentage of patients in whom MUCH was solely attributable to an elevated nocturnal BP almost double that due to daytime BP elevation (57.3% vs. 27.1%, P < 0.001). The most common predictors of MUCH were smoking, DM and positive family history of DM.

Conclusion

The prevalence of masked suboptimal BP control is high. Office BP monitoring alone is thus inadequate to ascertain optimal BP control because many patients have an elevated nocturnal BP. ABPM is needed to confirm proper BP control, especially in patients with high cardiovascular risk profile. Smoking, DM and positive family history of DM were the most common predictors of MUCH.

Feasibility of Telemonitoring Blood Pressure in Patients With Kidney Disease (Oxford Heart and Renal Protection Study-1): Observational Study

Background

Blood pressure (BP) is a key modifiable risk factor for patients with chronic kidney disease (CKD), with current guidelines recommending strict control to reduce the risk of progression of both CKD and cardiovascular disease. Trials involving BP lowering require multiple visits to achieve target BP, which increases the costs of such trials, and in routine care, BP measured in the clinic may not accurately reflect the usual BP.

Objective

We sought to assess whether a telemonitoring system for BP (using a Bluetooth-enabled BP machine that could transmit BP measurements to a tablet device installed with a bespoke app to guide the measurement of BP and collect questionnaire data) was acceptable to patients with CKD and whether patients would provide sufficient BP readings to assess variability and guide treatment.

Methods

A total of 25 participants with CKD were trained to use the telemonitoring equipment and asked to record BP daily for 30 days, attend a study visit, and then record BP on alternate days for the next 60 days. They were also offered a wrist-worn applanation tonometry device (BPro) which measures BP every 15 minutes over a 24-hour period. Participants were given questionnaires at the 1- and 3-month time points; the questionnaires were derived from the System Usability Scale and Technology Acceptance Model. All eligible participants completed the study.

Results

Mean participant age was 58 (SD 11) years, and mean estimated glomerular filtration rate was 36 (SD 13) mL/min/1.73m2. 13/25 (52%) participants provided >90% of the expected data and 18/25 (72%) provided >80% of the expected data. The usability of the telemonitoring system was rated highly, with mean scores of 84.9/100 (SE 2.8) after 30 days and 84.2/100 (SE 4.1) after 90 days. The coefficient of variation for the variability of systolic BP telemonitoring was 9.4% (95% CI 7.8-10.9) compared with 7.9% (95% CI 6.4-9.5) for the BPro device, P=.05 (and was 9.0% over 1 year in a recently completed trial with identical eligibility criteria), indicating that most variation in BP was short term.

Conclusions

Telemonitoring is acceptable for patients with CKD and provides sufficient data to inform titration of antihypertensive therapies in either a randomized trial setting (comparing BP among different targets) or routine clinical practice. Such methods could be employed in both scenarios and reduce costs currently associated with such activities.

Trial Registration

International Standard Randomized Controlled Trial Number ISRCTN13725286; http://www.isrctn.com/ISRCTN13725286 (Archived by WebCite at http://www.webcitation.org/74PAX51Ji).

Psychosocial Stressors at Work and Ambulatory Blood Pressure

PURPOSE OF REVIEW

Psychosocial stressors at work from the demand-latitude and effort-reward imbalance models are adverse exposures affecting about 20-25% of workers in industrialized countries. This review aims to summarize evidence on the effect of these stressors on blood pressure (BP).

RECENT FINDINGS

Three systematic reviews have recently documented the effect of these psychosocial stressors at work on BP. Among exposed workers, statistically significant BP increases ranging from 1.5 to 11 mmHg have been observed in prospective studies using ambulatory BP (ABP). Recent studies using ABP have shown a deleterious effect of these psychosocial stressors at work on masked hypertension as well as on blood pressure control in pharmacologically treated patients. Evidence on the effect of these psychosocial stressors on BP supports the relevance to tackle these upstream factors for primary prevention and to reduce the burden of poor BP control. There is a need for increased public health and clinical awareness of the occupational etiology of high BP, hypertension, and poor BP control.

Masked hypertension incidence and risk factors in a prospective cohort study

Aims

Masked hypertension may affect up to 30% of the general population and is associated with a high cardiovascular disease risk. No previous study has examined the incidence of masked hypertension and its risk factors. The study aim was to determine the incidence of masked hypertension and to examine its related risk factors.

Methods

This is a cohort study including 1836 initially normotensive participants followed up on average for 2.9 years. Blood pressure was measured using Spacelabs 90207. Manual blood pressure was defined as the mean of the first three readings taken at rest. Ambulatory blood pressure was defined as the mean of the next readings recorded every 15 minutes during daytime working hours. Masked hypertension incidence at follow-up was defined as manual blood pressure less than 140 and less than 90 mmHg and ambulatory blood pressure at least 135 or at least 85 mmHg. Generalised estimating equations were used.

Results

The cumulative incidence of masked hypertension was 10.3% and was associated with male gender (relative risk (RR) 1.51, 95% confidence interval (CI) 1.18–1.94), older age (RR40–49 years 1.56, 95% CI 1.16–2.11, RR≥50 years 1.50, 95% CI 1.06–2.10), higher education (RRcollege 1.31, 95% CI 1.03–1.65), body mass index (RR≥27 1.43, 95% CI 1.11–1.85), smoking (RR 1.51, 95% CI 1.09–2.010) and alcohol intake (RR≥6/week 1.65, 95% CI 1.13–2.03).

Conclusion

The present study is the first to identify risk factors for the incidence of masked hypertension. Current guidelines for hypertension detection recommend ambulatory blood pressure in patients with an elevated blood pressure reading at the clinic. As it is impractical to measure ambulatory blood pressure in all normotensive patients, factors identified in the present study should be considered for the screening of at-risk individuals and for primary prevention of masked hypertension.

Validity of ambulatory blood pressure monitoring in daily primary healthcare practice in France

OBJECTIVE

The objective of the study was to assess 24-h ambulatory blood pressure monitoring (ABPM) validity in daily primary healthcare practice in France.

PATIENTS AND METHODS

An observational, longitudinal, prospective, multicenter study was performed in the Burgundy region, France. Participants were patients who had been prescribed ABPM by their general practitioner (GP), whatever its indication. ABPM was performed by employees of the healthcare providers group, which is publicly funded. The validity of ABPM was established according to the European Society of Cardiology (ESC) criteria. GPs interpretation of the ABPM results was collected and compared with the ESC recommendations. Determinants of ABPM validity were identified using logistic regression models.

RESULTS

Among the 531 patients included, 357 (67.23%) had a valid ABPM measurement. Multivariate analyses showed that ABPM validity was associated with nonmanual worker status [odds ratio (OR)=1.14; 95% confidence interval (CI)=1.04-1.23], participant's age of at least 65 years (OR=0.88; 95% CI=0.81-0.95) and participant's BMI above 30 kg/m (OR=0.90; 95% CI=0.81-0.99). GPs' interpretation of ABPM results was consistent with the ESC recommendation in 508 (95.67%) cases.

CONCLUSION

ABPM is feasible in daily primary healthcare practice in the studied condition, that is to say relying on trained employees. GPs should be careful when prescribing ABPM to patients aged 65 years and older, to those with BMI over 30 or to manual workers.

Clinical Correlates of Ambulatory Blood Pressure Phenotypes at a Tertiary Care Hospital in Turkey

BACKGROUND/AIMS

Hypertension and its complications are major public health issues worldwide due to their association with high cardiovascular morbidity and mortality. Despite significant progress in health, the prevalence of hypertension is increasing. Ambulatory blood pressure monitoring (ABPM) is becoming increasingly important for the management of hypertension. In this study, we aimed to investigate the clinical and laboratory correlates of ambulatory blood pressure (ABP) phenotypes at a tertiary care hospital in Turkey.

METHODS

The characteristics of 1053 patients were retrospectively obtained from the hospital database. Hypertension was defined as patients with office blood pressure (BP) ≥140/90 mmHg and/or previously diagnosed hypertension and/or the use of antihypertensive medication. According to the office BP and ABPM results patients were identified namely: (1) sustained normotensive (SNT) patients (both office BP and ABPM were normal), (2) sustained hypertensive (SHT) patients (both office BP and ABPM were high), (3) masked hypertensive (MHT) patients (office BP were normal, but ABPM were high), (4) white coat hypertensive (WCHT) patients (office BP were above limits, but ABPM were normal).

RESULTS

A total of 1053 patients were included to the study (female/male: 608/445 and mean age 55 ± 15 years). The mean age of patients with hypertension was significantly higher than without hypertension (p< 0.0001). Hypertension was more frequent in females (p=0.009). The rates of history of diabetes mellitus (DM), hyperlipidemia (HL), and chronic kidney disease (CKD) were higher in patients with hypertension (p< 0.0001). Among patients with hypertension (n=853, 81%), ABPM results showed that 388 (45%) of patients had SHT, 92 (11%) had MHT, and 144 (17%) had WCHT, whereas 229 (27%) had SNT. Patients with MHT were significantly older than patients with SNT (p=0.025). The prevalence of SHT was higher in men than in women, whereas the prevalence of WCHT was higher in women than in men (p< 0.0001). There was no significant difference between 4 groups with regard to body mass index (p=0.142), a history of DM (p=0.189) and smoking status (self-reported) (p=0.306). Patients with SHT had the highest prevalence of history of hypertension, HL and CKD (p< 0.0001). Among patients without hypertension, 26 (13%) of patients had MHT and none of those patients was on antihypertensive treatment.

CONCLUSION

Potential usages of ABPM in Turkey may include screening of high risk individuals who have traditional cardiovascular risk factors. It also provides clinicians valuable information on abnormal ABP phenotypes. Future studies are needed to clarify the risk factors of different ABP phenotypes and to evaluate the role of ABPM on detection and control of hypertension.

Blood Pressure Control in Hypertensive Patients, Cardiovascular Risk Profile and the Prevalence of Masked Uncontrolled Hypertension (MUCH)

Introduction:

The term masked hypertension (MH) should be used for untreated individuals who have normal office blood pressure but elevated ambulatory blood pressure. For treated patients, this condition should be termed masked uncontrolled hypertension (MUCH).

Research Objectives:

Masked uncontrolled hypertension (MUCH) has gone unrecognized because few studies have used 24-h ABPM to determine the prevalence of suboptimal BP control in seemingly well-treated patients, and there are few such studies in large cohorts of treated patients attending usual clinical practice. This is important because masked hypertension is associated with a high risk of cardiovascular events. This study was conducted to obtain more information about the association between hypertension and other CV risk factors, about office and ambulatory blood pressure (BP) control as well as on cardiovascular (CV) risk profile in treated hypertensive patients, also to define the prevalence and characteristics of masked uncontrolled hypertension (MUCH) among treated hypertensive patients in routine clinical practice.

Patients and methods:

In this study 2514 male and female patients were included during a period of 5 years follow up. All patients have ambulatory blood pressure monitoring (ABPM) for at least 24h. We identified patients with treated and controlled BP according to current international guidelines (clinic BP, 140/90mmHg). Cardiovascular risk assessment was based on personal history, clinic BP values, as well as target organ damage evaluation. Masked uncontrolled hypertension (MUCH) was diagnosed in these patients if despite controlled clinic BP, the mean 24-h ABPM average remained elevated (24-h systolic BP ≥130mmHg and/or 24-h diastolic BP ≥80mmHg).

Results:

Patients had a mean age of 60.2+10 years, and the majority of them (94.6%) were followed by specialist physicians. Average clinic BP was 150.4+16/89.9+12 mmHg. About 70% of patients displayed a very high-risk profile. Ambulatory blood pressure monitoring (ABPM) was performed in all recruited patients for at least 24h. Despite the combined medical treatment (78% of the patients), clinic control (<140/90 mmHg) was achieved in only 26.2% of patients, the corresponding control rate for ambulatory BP (<130/80 mmHg) being 32.7%. From 2514 patients with treated BP, we identified 803 with treated and controlled office BP control (<140/90 mmHg), of whom 258 patients (32.1%) had MUCH according to 24-h ABPM criteria (mean age 57.2 years, 54.7% men). The prevalence of MUCH was slightly higher in males, patients with borderline clinic and office BP (130–139/80–89 mmHg), and patients at high cardiovascular risk (smokers, diabetes, obesity). Masked uncontrolled hypertension (MUCH) was most often due to poor control of nocturnal BP, with the proportion of patients in whom MUCH was solely attributable to an elevated nocturnal BP almost double that solely attributable to daytime BP elevation (22.3 vs. 10.1%, P 0.001).

Conclusion:

The prevalence of masked suboptimal BP control in patients with treated and well-controlled clinic BP is high. The characteristics of patients with MUCH (male, longer duration of hypertension, obesity, smoking history, and diabetes) indicate that this is a higher-risk group with most to gain from improved BP.

Blood Pressure and Arterial Stiffness in Kenyan Adolescents With the Sickle Cell Trait

The potential association between sickle cell trait (SCT) and increased arterial stiffness/blood pressure (BP) has not been evaluated in detail despite its association with stroke, sudden death, and renal disease. We performed 24-hour ambulatory BP monitoring and arterial stiffness measurements in adolescents raised in a malaria-free environment in Kenya. Between December 2015 and June 2016, 938 randomly selected adolescents (ages 11–17 years) who had been continuous residents of Nairobi from birth were invited to participate in the study. Standard clinic BP measurement was performed, followed by 24-hour ambulatory BP monitoring and arterial stiffness measurement using an Arteriograph24 (TensioMed Ltd., Budapest, Hungary) device. SCT status was determined using DNA genotyping in contemporaneously collected blood samples. Of the 938 adolescents invited to participate, 609 (65%) provided complete data for analysis. SCT was present in 103 (15%). Mean 24-hour systolic and diastolic BPs were 116 (standard deviation (SD), 11.5) mm Hg and 64 (SD, 7) mm Hg, respectively, in children with SCT and 117 (SD, 11.4) mm Hg and 64 (SD, 6.8) mm Hg, respectively, in non-SCT children. Mean pulse wave velocity (PWV) was 7.1 (SD, 0.8) m/second and 7.0 (SD, 0.8) m/second in SCT and non-SCT children, respectively. We observed no differences in PWV or in any clinic or ambulatory BP-derived measures between adolescents with and without SCT. These data suggest that SCT does not independently influence BP or PWV.