2013 Ambulatory Blood Pressure Monitoring Recommendations for the Diagnosis of Adult Hypertension, Assessment of Cardiovascular and other Hypertension-associated Risk, and Attainment of Therapeutic Goals

Clinical trial design for assessing hypertension medications: are critical circadian chronopharmacological principles being taking into account?

INTRODUCTION

Clinical hypertension trials typically rely on homeostatic principles, including single time-of-day office blood pressure (BP) measurements (OBPM), rather than circadian chronopharmacological principles, including ambulatory monitoring (ABPM) done around-the-clock to derive the asleep systolic BP (SBP) mean and sleep-time relative SBP decline - jointly the strongest prognosticators of cardiovascular disease (CVD) risk and true definition of hypertension - to qualify participants and assess outcomes.

AREAS COVERED

Eight chronopharmacological elements are indispensable for design and conduct of hypertension medication trials, mainly those on ingestion-time differences in effects, and also a means of rating quality of investigations. Accordingly, we highlight the findings and shortcomings of: (i) 155 such ingestion-time trials, 83.9% finding at-bedtime/evening treatment more beneficial than conventional upon-awakening/morning treatment; (ii) HOPE and ONTARGET CVD outcomes investigations assessing in the former add-on ramipril at-bedtime and in the latter telmisartan, ramipril, or both in combination in the morning; and (iii) pragmatic TIME CVD outcomes trial.

EXPERT OPINION

Failure to incorporate chronopharmacological principals - including ABPM to derive asleep SBP and SBP dipping to qualify subjects as hypertensive and assess CVD risk - results in deficient study design, dubious findings, and unnecessary medical controversy at the expense of advances in patient care.

Effect of Pharmaceutical Intervention in Pharmacologically Treated Hypertensive Patients-A Cluster-Randomized Clinical Trial: AFPRES-CLM Study

BACKGROUND

Evaluate the effect of a community pharmaceutical intervention on the control of blood pressure in hypertensive patients treated pharmacologically.

METHODS

A cluster-randomized clinical trial of 6 months was carried out. It was conducted in the Autonomous Community of Castilla-La Mancha (Spain). Sixty-three community pharmacies and 347 patients completed the study. Intervention patients received the community pharmaceutical intervention based on a protocol that addresses the individual needs of each patient related to the control of their blood pressure, which included Health Education, Pharmacotherapy Follow-up and 24 h Ambulatory Blood Pressure Measurement. Control patients received usual care in the community pharmacy.

RESULTS

The pharmaceutical intervention resulted in better control of blood pressure (85.8% vs. 66.3% p < 0.001), lower use of emergencies (p = 0.002) and improvement trends in the physical components of quality of life, measured by SF-36 questionnaire, after 6 months of pharmaceutical intervention. No significant changes were observed for any of these variables in the control group. There were also detected 354 negative medication-related outcomes that were satisfactorily resolved in a 74.9% of the cases and 330 healthcare education interventions and 29 Ambulatory Blood Pressure Monitorings were performed in order to increase adherence to pharmacological treatment and minimize Negative Outcomes associated with Medication and prevent medication-related problems.

CONCLUSIONS

Community pharmaceutical intervention can increase hypertensive patients with controlled blood pressure, after 6 months, compared with usual care.

Critical appraisal of recent translational chronopharmacology and chronotherapeutic reviews, meta-analyses, and pragmatic patient trials discloses significant deficiencies of design and conduct and suspect findings

The conduct of molecular and laboratory animal circadian rhythm research has increased exponentially in the past few decades, such that today investigations are being performed by scientists of many diverse disciplines. Knowledge gained from past works is now being explored for translational applications to clinical medicine, often termed "circadian medicine," through the implementation of patient trials. However, these trials are being led, more often than not, by investigators who have little or no formal training and in-depth expertise in the methods of human circadian rhythm research, causing them to be deficient in design and produce dubious findings that have already led to unnecessary medical controversy at the expense of advances in patient care. Evidence of the very significant shortcomings of today's translational circadian medicine research is exemplified in two recent publications in well-read reputable medical journals concerning the chronotherapy of blood pressure (BP) medications: one a review and meta-analysis by Maqsood et al. published in the journal Hypertension in 2023 that pertains to ingestion-time differences in the extent of BP reduction exerted by hypertensive medications and the other a report by Mackenzie et al. in the journal Lancet in 2022 that details the results of the pragmatic TIME study that assessed ingestion-time differences in cardiovascular disease outcomes. Herein, we appraise the inaccurate trial selection, lack of quality assessment, and the numerous other shortcomings that culminated in suspect findings and faulty conclusions of the former, as well as the deficiencies in design and conduct of the latter using as reference the eight items identified in 2021 by a working committee of the International Society for Chronobiology and American Association for Medical Chronobiology and Chronotherapeutics as being necessary for high-quality research of circadian rhythm-dependencies of the therapeutic effects of BP-lowering medications. The TIME study when rated for its quality according to the extent to which its investigational methods satisfy all of the eight recommended items attains a very low overall score of + 1 out of a possible range of -1 to + 7. Moreover, our review of the methods of the currently ongoing pragmatic BedMed trial discloses major deficiencies of the same sort rending a poor quality score of + 0.5. Although the focus of this article is the appraisal of the quality of contemporary circadian medicine hypertension chronotherapy research, it additionally exposes the inadequacies and dubious quality of the critique of such manuscripts submitted for publication to influential journals, in that some peer reviewers might also be deficient in the knowledge required to properly rate their merit.

Food consumption by degree of processing is associated with nocturnal dipping and blood pressure variability: The ELSA-Brasil study

BACKGROUND AND AIMS

Ambulatory blood pressure monitoring (ABPM) allows the assessment of cardiovascular risk markers that cannot be obtained by casual measurements; however, the evidence on the association between food consumption and blood pressure (BP) assessed by ABPM is scarce. We aimed to evaluate the association between food consumption by degree of processing and ambulatory BP.

METHODS AND RESULTS

Cross-sectional analysis (2012-2014) of data from a subsample (n = 815) of ELSA-Brasil cohort participants who performed 24-h ABPM was conducted. Systolic (SBP) and diastolic (DBP) BP means and variability during the 24 h and subperiods (sleep and wake), nocturnal dipping, and morning surge were evaluated. Food consumption was classified according to NOVA. Associations were tested by generalized linear models. The consumption of unprocessed, minimally processed foods, and culinary ingredients (U/MPF&CI) was 63.1% of daily caloric intake, 10.8% of processed (PF), and 24.8% of ultraprocessed (UPF). A negative association was found between U/MPF&CI consumption and extreme dipping (T2: odds ratio [OR] = 0.56, 95% confidence interval [CI] = 0.55-0.58; T3: OR = 0.55; 95% CI = 0.54-0.57); and between UPF consumption and nondipping (T2: OR = 0.68, 95% CI = 0.55-0.85) and extreme dipping (T2: OR = 0.63, 95% CI = 0.61-0.65; T3: OR = 0.95, 95% CI = 0.91-0.99). There was a positive association between PF consumption and extreme dipping (T2: OR = 1.22, 95% CI = 1.18-1.27; T3: OR = 1.34, 95% CI = 1.29-1.39) and sleep SBP variability (T3: Coef = 0.56, 95% CI = 0.03-1.10).

CONCLUSIONS

The high consumption of PF was associated with greater BP variability and extreme dipping, while the U/MPF&CI and UPF consumption were negatively associated with alterations in nocturnal dipping.

Blood Pressure Control in Elderly Chronic Kidney Disease Patients

In elderly chronic kidney disease (CKD) patients, isolated systolic hypertension is common, the rate of renal function decline is slow, and there is a high possibility of physical damage due to side effects such as drug use-related orthostatic hypotension. Therefore, there are still many questions about whether lowering blood pressure in elderly patients will actually improve prognosis. Since many blood pressure-related clinical studies exclude advanced CKD and the elderly, it is particularly difficult to define target blood pressure in these populations. A randomized controlled trial is needed to establish optimal blood pressure targets and treatment strategies in elderly patients with CKD. This review seeks to summarize the guidelines available at this time.

Shift work and cardiovascular strain on working and non-working days

BACKGROUND

Shift work is often associated with adverse effects on cardiovascular health of employees. Only a few studies address the strain of shift and day workers on non-working days compared to working days.

AIMS

This study aims to determine how the cardiovascular strain of hotel and catering industry (HCI) employees who work alternating shifts differs from those working normal day shifts-on both a working day (WD) and a non-working day (ND).

METHODS

The sample consisted of 60 alternating shift (morning and afternoon, mean age: 31.5 ± 8.5 years) and 88 day workers (mean age: 35.3 ± 9.4 years). A 24-h ambulatory measurement of blood pressure (BP) and heart rate (HR) on WD and ND with the time phases DAY, SLEEP, and 24-h TOTAL was used to analyse cardiovascular strain. BP status was assessed by self-measurement (36% hypertensives).

RESULTS

The total strain over 24 h was slightly higher on WD than ND (mean BP: 134/79 versus 127/75 mmHg, P = 0.002-0.020; mean HR: 78 versus 75 bpm, P = 0.055). In trend, shift workers had higher systolic BP than day workers during the individual time phases of DAY, SLEEP, and 24-h TOTAL on WD. Known cardiovascular risk factors emerged as critical determinants of cardiovascular strain: older age, male gender, and hypertensive blood pressure status.

CONCLUSIONS

The results revealed no clear association between the alternating shift system in HCI and increased cardiovascular strain. The 24-h ambulatory measurement is considered ideal for determining cardiovascular strain in everyday life and under working conditions.

Does Patient-Applied Testosterone Replacement Therapy Pose Risk for Blood Pressure Elevation? Circadian Medicine Perspectives

We reviewed medication package inserts, US Food and Drug Administration (FDA) reports, and journal publications concerning the 10 nonbiosimilar patient-applied (PA) testosterone (T) replacement therapies (TRTs) for intraday serum T patterning and blood pressure (BP) effects. Blood T concentration is circadian rhythmic in young adult eugonadal males, being highest around awakening and lowest before bedtime. T level and 24 h variation are blunted in primary and secondary hypogonadism. Utilized as recommended, most PA-TRTs achieve nonphysiologic T 24 h patterning. Only Androderm^® , an evening PA transdermal patch, closely replicates the normal T circadian rhythmicity. Accurate determination of risk for BP elevation and hypertension (HTN) by PA-TRTs is difficult due to limitations of office BP measurements (OBPM) and suboptimal methods and endpoints of ambulatory BP monitoring (ABPM). OBPM is subject to "White Coat" pressor effect resulting in unrepresentative BP values plus masked normotension and masked HTN, causing misclassification of approximately 45% of trial participants, both before and during treatment. Change in guideline-recommended diagnostic thresholds over time causes misclassification of an additional approximately 15% of participants. ABPM is improperly incorporated into TRT safety trials. It is done for 24 h rather than preferred 48 h; BP is oversampled during wakefulness, biasing derived 24 h mean values; 24 h mean systolic and diastolic BP (SBP, DBP) are inappropriate primary outcomes, because of not being best predictors of risk for major acute cardiovascular events (MACE); "daytime" and "nighttime" BP means referenced to clock time are reported rather than biologically relevant wake-time and sleep-time BP means; most importantly, asleep SBP mean and dipping, strongest predictors of MACE, are disregarded. © 2022 American Physiological Society. Compr Physiol 12: 1-20, 2022.

Prognostic significance of reverse dipping status on lower limb event in type 2 diabetic patients without peripheral arterial disease

AIMS

We assessed reverse dipping influence on the risk of lower limb events in type 2 diabetic patients without peripheral arterial disease.

METHODS

Patients with type 2 diabetes addressed for cardiovascular risk stratification in our university hospital from 2008 to 2012 underwent 24 h blood pressure monitoring. Patients with a prior history of limb revascularization or with a stenosis > 50% of the legs were excluded. Reverse dipping was defined as a greater night-versus day-time systolic blood pressure. The endpoint was the first occurrence of lower limb revascularization or limb amputation. Hazard ratios (HRs) and 95% confidence intervals were calculated using the Cox model.

RESULTS

Two hundred and eighty-one patients were included. During a median follow-up of 9.4 [7.7-10.6] years, 20 lower limb events and 45 all-cause deaths were observed. Thirty-five patients were reverse dippers. The reverse dipping status was associated with lower limb events when considering all-cause death as a competitive risk, (HR 3.61 [1.16-11.2], P = 0.026). Reverse dipping, HbA1C and proteinuria were independently associated with lower limb outcome in a multivariable analysis (respectively HR 4.09 [1.29-12.9], P = 0.017, HR 1.30 [1.04-1.63], P = 0.022 and HR 1.06 [1.02-1.11], P = 0.001).

CONCLUSIONS

Reverse dipping status is independently associated with worse limb outcome in type 2 diabetic patients.

Effects of early growth rate and fat soluble vitamins on glucose tolerance, feed transit time, certain liver and pancreas-related parameters, and their share in intra-flock variation in performance indices in broiler chicken

Three hundred fifty 18-day-old Ross 308 male chicks were used to examine the effects of early growth rate (x̄-3SD, x̄-2SD, x̄-SD, x̄, x̄+SD, x̄+2SD and x̄+3SD) and a fat soluble vitamin (FSV) cocktail on glucose tolerance, whole tract feed transit time (FFT), certain liver, and pancreas related traits as well as their share in intra-flock variance of body weight (BW) at d 42 and feed intake (FI) and feed conversion ratio (FCR) in d 21 to 42 of age. Birds with a greater initial BW (21 d) showed greater FI during d 21 to 42 of age and gained a higher final BW at d 42 of age. The broilers injected with a FSV cocktail consumed more feed with an improved FCR and achieved a noticeable greater BW at d 42 of age compared with the untreated birds (P < 0.05). Blood glucose at 15 min after oral gavageing of a glucose solution was elevated in all birds faster than those with a body weight close to the mean population BW. Lipase activity increased by 9.75% and amylase activity decreased by 14.9% in the birds treated with FSV injections compared with those received no vitamin. Multivariate step-wise regression analysis showed liver percentage as the leading variable accounting for about 75 and 62.77% of BW and FI variance, respectively. Serum cholesterol concentration was the major predictor in a poor model (R2 = 52.07) generated for FCR, explaining 29.3 of the FCR viability (P < 0.150). It was concluded that the slow and fast growing birds within a flock showed the same efficiency in dietary glucose absorbing and blood glucose clearing. The faster-growing birds demonstrated slower FTT. Liver percentage was the major parameter explaining a significant fraction of the intra-flock variance in BW at marketing age and FI during days 21 to 42 d.

Ambulatory diastolic blood pressure: a marker of comorbidity in elderly fit hypertensive individuals?

BACKGROUND

Masked diastolic hypotension is a new blood pressure (BP) pattern detected by ambulatory blood pressure monitoring (ABPM) in elderly hypertensives. The aim of this study was to relate ABPM and comorbidity in a cohort of fit elderly subjects attending an outpatient hypertension clinic.

METHODS

Comorbidity was assessed by Charlson comorbidity index (CCI) and CHA₂DS₂VASc score. All subjects evaluated with ABPM were aged ≥ 65 years. CCI and CHA₂DS₂VASc score were calculated. Diastolic hypotension was defined as mean ambulatory diastolic BP < 65 mmHg and logistic regression analysis was carried out in order to detect and independent relationship between comorbidity burden and night-time diastolic BP < 65 mmHg.

RESULTS

We studied 174 hypertensive elderly patients aged 72.1 ± 5.2 years, men were 93 (53.4%). Mean CCI was 0.91 ± 1.14 and mean CHA₂DS₂VASc score of 2.68 ± 1.22. Subjects with night-time mean diastolic values < 65 mmHg were higher in females [54.7% vs. 45.3%, P = 0.048; odds ratio (OR) = 1.914, 95% CI: 1.047-3.500]. Logistic regression analysis showed that only CHA₂DS₂VASc score was independently associated with night-time mean diastolic values < 65 mmHg (OR = 1.518, 95% CI: 1.161-1.985; P = 0.002), but CCI was not.

CONCLUSIONS

ABPM and comorbidity evaluation appear associated in elderly fit subjects with masked hypotension. Comorbid women appear to have higher risk for low ambulatory BP.

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

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

[Factors associated with poor blood pressure control in Moroccan hypertensive patients]

STUDY AIM

Hypertension is a major public health concern worldwide and non-controlling it can lead to various cardiovascular complications. Controlling blood pressure and reducing overall cardiovascular risk are two main goals of treatment. Thus, this study aimed to determine the proportion and factors associated with uncontrolled hypertension in hypertensive patients living in the Beni Mellal city.

PATIENTS AND METHODS

The cross-sectional survey took place between June and March 2019. It involved 580 hypertensive patients attending the primary health care facilities in Beni Mellal city, using systematic sampling.

RESULTS

A total of 580 hypertensive patients were recruited, with a mean age of 55.78 (± 10.82 years) and of which 66.89% were female. The proportion of poor blood pressure control was 74.1% and was associated in multivariate analysis with a family history of hypertension(OR = 1.60; 95% CI = [1.02-2.50]), dyslipidemia (OR = 2.05; 95% CI = [1.32 -3.20]), non-adherence to a regular BP measurement (OR = 4.13; 95% CI = [2.49 -6.86]), to treatment (OR = 3.64; 95% CI = [2.34-5.65]) and regular biological monitoring (OR = 2.45; 95% CI = [1.46-4.08]).

CONCLUSION

Despite the free and available of treatment, the proportion of uncontrolled hypertension was high. This might be linked to a lack of awareness and education concerning disease self-management.

Factors affecting systolic blood pressure trajectory in low and high activity conditions

Background: Typically, blood pressure dips during sleep and increases during daytime. The blood pressure trend is affected by the autonomic nervous system. The activity of this system is observable in the low and high activity conditions. The aim of this study was to assess the effect of individual characteristics on systolic blood pressure (SBP) across day-night under low and high activity conditions.

Methods: The samples were 34 outpatients who were candidates for evaluation of 24 hours of blood pressure with an ambulatory. They were admitted to the heart clinic of Farshchian hospital, located in Hamadan province in the west of Iran. The hourly SBP during 24 hours was considered as a response variable. To determine the factors effecting SBP in each condition, the hidden semi-Markov model (HSMM), with 2 hidden states of low and high activity, was fitted to the data.

Results: Males had lower SBP than females in both states. The effect of age was positive in the low activity state (β=0.30; p<0.001) and negative in high activity state (β= -0.21; p=0.001). The positive effect of cigarette smoking on SBP was seen in low activity state (β=5.02; p=0.029). The overweight and obese patients had higher SBP compared to others in high activity state (β=11.60; p<0.001 and β=5.87; p=0.032, respectively).

Conclusion: The SBP variability can be displayed by hidden states of low and high activity. Moreover, the effects of studied variables on SBP were different in low and high activity states.

Ingestion-time differences in the pharmacodynamics of dual-combination hypertension therapies: Systematic review and meta-analysis of published human trials

The pharmacodynamics of hypertension medications can be significantly affected by circadian rhythms in the biological mechanisms of the 24 h blood pressure (BP) pattern. Hypertension guidelines fail to recommend the time of day when patients, including those who require treatment with multiple medications, are to ingest BP-lowering therapy. We conducted a systematic review of published prospective trials that investigated hypertension medications for ingestion-time differences in BP-lowering, safety, patient adherence, and markers of target organ pathology. Among the search-retried 155 trials, 17 published between 1991 and 2020 totaling 1,508 hypertensive participants concerned the differential ingestion-time dependent effects of 14 unique dual-combination therapies. All but one (94.1%) of the trials, involving 98.5% of the total number of investigated individuals, reported clinically and statistically significant benefits - including enhanced reduction of asleep BP without induction of sleep-time hypotension, reduced prevalence of BP non-dipping, decreased adverse effects, improved kidney function, and reduced cardiac pathology - when dual-combination hypertension medications were ingested at-bedtime/evening rather than upon-waking/morning. A systematic and comprehensive review of the literature published in the past three decades reveals no single dual-combination hypertension trial reported significantly better benefit of the still conventional, yet unjustified by medical evidence, upon-waking/morning hypertension treatment scheme.

Circadian Rhythm, Clock Genes, and Hypertension: Recent Advances in Hypertension

Accumulating evidence suggests that the molecular circadian clock is crucial in blood pressure (BP) control. Circadian rhythms are controlled by the central clock, which resides in the suprachiasmatic nucleus of the hypothalamus and peripheral clocks throughout the body. Both light and food cues entrain these clocks but whether these cues are important for the circadian rhythm of BP is a growing area of interest. The peripheral clocks in the smooth muscle, perivascular adipose tissue, liver, adrenal gland, and kidney have been recently implicated in the regulation of BP rhythm. Dysregulation of the circadian rhythm of BP is associated with adverse cardiorenal outcomes and increased risk of cardiovascular mortality. In this review, we summarize the most recent advances in peripheral clocks as BP regulators, highlight the adverse outcomes of disrupted circadian BP rhythm in hypertension, and provide insight into potential future work in areas exploring the circadian clock in BP control and chronotherapy. A better understanding of peripheral clock function in regulating the circadian rhythm of BP will help pave the way for targeted therapeutics in the treatment of circadian BP dysregulation and hypertension.

The Circadian Rhythm of Thermoregulation Modulates both the Sleep/Wake Cycle and 24 h Pattern of Arterial Blood Pressure

Borbély proposed an interacting two-component model of sleep regulation comprising a homeostatic Process S and a circadian Process C. The model has provided understanding of the association between core body temperature (CBT) as a key element of Process C that is deterministic of sleep onset and offset. However, it additionally provides a new perspective of the importance of the thermoregulatory mechanisms of Process C in modulating the circadian rhythm of arterial blood pressure (ABP). Herein, we examine the circadian physiology of thermoregulation, including at the end of the activity span the profound redistribution of cardiac output from the systemic circulation to the arteriovenous anastomoses of the glabrous skin that markedly enhances convective transfer of heat from the body to the environment to cause (i) decrease of the CBT as a pathway to sleep onset and (ii) attenuation of the asleep ABP mean and augmentation of the ABP decline (dipping) from the wake-time mean, in combination the strongest predictors of the risk for blood vessel and organ pathology and morbid and mortal cardiovascular disease events. We additionally review the means by which blood perfusion to the glabrous skin can be manipulated on demand by selective thermal stimulation, that is, mild warming, on the skin of the cervical spinal cord to intensify Process C as a way to facilitate sleep induction and promote healthy asleep ABP. © 2021 American Physiological Society. Compr Physiol 11:1-14, 2021.

Association of morning blood pressure surge with chronic kidney disease progression in patients with chronic kidney disease and hypertension

Blood pressure (BP) usually rise from being asleep to awake, which is named the morning blood pressure surge (MBPS). Researches have reported that elevated MBPS was related with CV events, incident CKD in hypertensive patients. However, there have been no studies that have investigated the association between MBPS and renal or heart outcomes in patients with CKD and hypertension, in these patients, the MBPS is much lower because of high prevalence of night hypertension and reduced BP dipping. In this prospective two-center observational study, we enrolled patients with CKD and hypertension and the 24 h ambulatory blood pressure monitoring (ABPM) was conducted in all patients. Time to total mortality, CKD progression and CV events was recorded; Finally, a total of 304 patients were enrolled and 94 (30.9%) of them had elevated MBPS. After a follow-up for median 30 months, 23 (7.6%), 34 (11.2%), and 95 (31.3%) patients occurred death, CKD progression and new-onset CV events, respectively. The Cox regression analysis suggested the elevated MBPS was a strong predictor of CKD progression (HR 2.35, 95%CI 1.2 -4.63, p = .013), independent of morning BP, while no associations were found between elevated MBPS and CV events (HR 1.02, 95%CI 0.66 -1.57), as well as death (HR 1.08, 95%CI 0.46 -2.55). In conclusion, we provided the first evidence that elevated MBPS was an important risk factor of CKD progression in patients with CKD and hypertension. Appropriate evaluation and management of MBPS may be helpful to postpone CKD progression.

Elevated asleep blood pressure and non-dipper 24h patterning best predict risk for heart failure that can be averted by bedtime hypertension chronotherapy: A review of the published literature

Several prospective studies consistently report elevated asleep blood pressure (BP) and blunted sleep-time relative systolic BP (SBP) decline (non-dipping) are jointly the most significant prognostic markers of cardiovascular disease (CVD) risk, including heart failure (HF); therefore, they, rather than office BP measurements (OBPM) and ambulatory awake and 24 h BP means, seemingly are the most worthy therapeutic targets for prevention. Published studies of the 24 h BP pattern in HF are sparse in number and of limited sample size. They report high prevalence of the abnormal non-dipper/riser 24 h SBP patterning. Despite the established clinical relevance of the asleep BP, past as do present hypertension guidelines recommend the diagnosis of hypertension rely on OBPM and, when around-the-clock ambulatory BP monitoring (ABPM) is conducted to confirm the elevated OBPM, either on the derived 24 h or "daytime" BP means. Additionally, hypertension guidelines do not advise the time-of-day when BP-lowering medications should be ingested, in spite of known ingestion-time differences in their pharmacokinetics and pharmacodynamics. Between 1976 and 2020, 155 unique trials of ingestion-time differences in the effects of 37 different single and 14 dual-combination hypertension medications, collectively involving 23,972 patients, were published. The vast majority (83.9%) of them found the at-bedtime/evening in comparison to upon-waking/morning treatment schedule resulted in more greatly enhanced: (i) reduction of asleep BP mean without induced sleep-time hypotension; (ii) reduction of the prevalence of the higher CVD risk non-dipper/riser 24 h BP phenotypes; (iii) improvement of kidney function, reduction of cardiac pathology, and with lower incidence of adverse effects. Most notably, no single published randomized trial found significantly better BP-lowering, particularly during sleep, or medical benefits of the most popular upon-waking/morning hypertension treatment-time scheme. Additionally, prospective outcome trials have substantiated that the bedtime relative to the upon-waking, ingestion of BP-lowering medications not only significantly reduces risk of HF but also improves overall CVD event-free survival time.

Systematic review and quality evaluation of published human ingestion-time trials of blood pressure-lowering medications and their combinations

The pharmacokinetics (PK) - absorption, distribution, metabolism, and elimination - and pharmacodynamics (PD) of hypertension medications can be significantly affected by circadian rhythms. As a consequence, the time when blood pressure (BP) lowering medications are ingested, with reference to the staging of all involved circadian rhythms modulating PK and PD, can affect their duration of action, magnitude of effect on features of the 24 h BP profile, and safety. We conducted a systematic and comprehensive review of published prospective human trials that investigated individual hypertension medications of all classes and their combinations for ingestion-time differences in BP-lowering, safety, patient adherence, and markers of hypertension-associated target organ pathology of the kidney and heart. The systematic review yielded 155 trials published between 1976 and 2020 - totaling 23,972 hypertensive individuals - that evaluated 37 different single and 14 dual-combination therapies. The vast (83.9%) majority of them reported clinically and statistically significant benefits - including enhanced reduction of asleep BP mean without induced sleep-time hypotension, reduced prevalence of the higher cardiovascular risk non-dipper 24 h BP profile, decreased incidence of adverse effects, improved kidney function, and reduced cardiac pathology - when hypertension medications are ingested at-bedtime/evening rather than upon-waking/morning. Nonetheless, the findings and conclusions of some past conducted trials are inconsistent, often due to disparities and deficiencies of the investigative protocols. Accordingly, we developed a quality assessment method based upon the eight items identified as crucial according to the recently published guidelines of the International Society for Chronobiology and the American Association for Medical Chronobiology and Chronotherapeutics for the design and conduct of human clinical trials on ingestion-time differences of hypertension medications. Among the most frequent deficiencies are: absence or miscalculation of minimum required sample size (83.2%), incorrect choice of primary BP endpoint (53.6%), and inappropriate arbitrary and unrepresentative clock hours chosen for tested treatment times (53.6%). The inability of the very small proportion (16.1%) of trials to verify the advantages of the at-bedtime/evening treatment strategy is likely explained by deficiencies of their study design and conduct. Nonetheless, regardless of the quality score of the 155 trials retrieved by our systematic review, it is most noteworthy that no single published prospective randomized trial reported significantly enhanced BP-lowering, safety, compliance, or other benefits of the unjustified by medical evidence, yet still most recommended, upon-waking/morning hypertension treatment-time scheme.

Ingestion-time differences in the pharmacodynamics of hypertension medications: Systematic review of human chronopharmacology trials

Pharmacokinetics of hypertension medications is significantly affected by circadian rhythms that influence absorption, distribution, metabolism and elimination. Furthermore, their pharmacodynamics is affected by ingestion-time differences in kinetics and circadian rhythms comprising the biological mechanism of the 24 h blood pressure (BP) pattern. However, hypertension guidelines do not recommend the time to treat patients with medications. We conducted a systematic review of published evidence regarding ingestion-time differences of hypertension medications and their combinations on ambulatory BP-lowering, safety, and markers of target organ pathology. Some 153 trials published between 1976 and 2020, totaling 23,869 hypertensive individuals, evaluated 37 different single and 14 dual-fixed combination therapies. The vast (83.7%) majority of the trials report clinically and statistically significant benefits - including enhanced reduction of asleep BP without inducing sleep-time hypotension, reduced prevalence of the higher cardiovascular disease risk BP non-dipping 24 h profile, decreased incidence of adverse effects, improved renal function, and reduced cardiac pathology - when hypertension medications are ingested at-bedtime/evening rather than upon-waking/morning. Non-substantiated treatment-time difference in effects by the small proportion (16.3%) of published trials is likely explained by deficiencies of study design and conduct. Systematic and comprehensive review of the literature published the past 45 years reveals no single study reported significantly better benefit of the still conventional, yet unjustified by medical evidence, upon-waking/morning hypertension treatment schedule.

Extent of asleep blood pressure reduction by hypertension medications is ingestion-time dependent: Systematic review and meta-analysis of published human trials

Combined evidence of published prospective outcome trials and meta-analyses substantiate elevated asleep blood pressure (BP) and blunted sleep-time relative BP decline (non-dipping), regardless of wake-time office BP and awake or 24 h BP means, are jointly the most highly significant independent prognostic markers of cardiovascular disease (CVD) risk and worthy therapeutic targets for prevention. Nonetheless, current guidelines continue to recommend the diagnosis of hypertension, when based on ambulatory BP monitoring (ABPM), rely, solely, on either the 24 h or "daytime" BP means. They also fail to recommend the time to treat patients. We conducted a systematic review of published human trials regarding ingestion-time differences in the effects of hypertension medications on asleep BP and sleep-time relative BP decline. Some 62 such trials published between 1992 and 2020, totaling 6120 hypertensive persons, evaluated 21 different single and 8 dual-fixed combination therapies. The vast (82.3%) majority of the trials substantiate the bedtime/evening vs. upon-waking/morning treatment schedule produces statistically significant better clinical benefits, including enhanced reduction of asleep systolic BP by an average 5.17 mmHg (95%CI [4.04, 6.31], P < 0.001 between treatment-time groups) without inducing sleep-time hypotension, reduced prevalence of the high CVD risk non-dipper 24 h BP pattern, improved kidney function, and reduced cardiac pathology. Furthermore, systematic and comprehensive review of the ABPM-based literature published the past 29 years reveals no single study that reported significantly better benefits of the most recommended, yet unjustified by medical evidence, morning hypertension treatment-time scheme.

Guidelines for the design and conduct of human clinical trials on ingestion-time differences - chronopharmacology and chronotherapy - of hypertension medications

Current hypertension guidelines fail to provide a recommendation on when-to-treat, thus disregarding relevant circadian rhythms that regulate blood pressure (BP) level and 24 h patterning and medication pharmacokinetics and pharmacodynamics. The ideal purpose of ingestion-time (chronopharmacology, i.e. biological rhythm-dependent effects on the kinetics and dynamics of medications, and chronotherapy, i.e. the timing of pharmaceutical and other treatments to optimize efficacy and safety) trials should be to explore the potential impact of endogenous circadian rhythms on the effects of medications. Such investigations and outcome trials mandate adherence to the basic standards of human chronobiology research. In-depth review of the more than 150 human hypertension pharmacology and therapeutic trials published since 1974 that address the differential impact of upon-waking/morning versus at-bedtime/evening schedule of treatment reveals diverse protocols of sometimes suboptimal or defective design and conduct. Many have been "time-of-day," i.e. morning versus evening, rather than circadian-time-based, and some relied on wake-time office BP rather than around-the-clock ambulatory BP measurements (ABPM). Additionally, most past studies have been of too small sample size and thus statistically underpowered. As of yet, there has been no consensual agreement on the proper design, methods and conduct of such trials. This Position Statement recommends ingestion-time hypertension trials to follow minimum guidelines: (i) Recruitment of participants should be restricted to hypertensive individuals diagnosed according to ABPM diagnostic thresholds and of a comparable activity/sleep routine. (ii) Tested treatment-times should be selected according to internal biological time, expressed by the awakening and bed times of the sleep/wake cycle. (iii) ABPM should be the primary or sole method of BP assessment. (iv) The minimum-required features for analysis of the ABPM-determined 24 h BP pattern ought to be the asleep (not "nighttime") BP mean and sleep-time relative BP decline, calculated in reference to the activity/rest cycle per individual. (v) ABPM-obtained BP means should be derived by the so-called adjusted calculation procedure, not by inaccurate arithmetic averages. (vi) ABPM should be performed with validated and calibrated devices at least hourly throughout two or more consecutive 24 h periods (48 h in total) to achieve the highest reproducibility of mean wake-time, sleep-time and 48 h BP values plus the reliable classification of dipping status. (vii) Calculation of minimum required sample size in adherence with proper statistical methods must be provided. (viii) Hypertension chronopharmacology and chronotherapy trials should preferably be randomized double-blind, randomized open-label with blinded-endpoint, or crossover in design, the latter with sufficient washout period between tested treatment-time regimens.

Disparities of perceived wellness by smoking and professional status among young individuals in Brasov, Brasov County, Romania

Objective

We aimed to evaluate the association of risk factors such as smoking and professional status (students vs employed) as determinants of disparities in perceived wellness among Romanian individuals.

Methods

We conducted a cross-sectional study in which 145 participants were enrolled from December 2017 to February 2018, in Brasov, Brasov County, Transylvania, Romania. We used a simplified Perceived Wellness Survey model to measure the holistic individual perceived wellness status by professional and smoking status. Basic descriptive and multivariate analyses of variance were used to assess and contrast participants' characteristics and wellness score distributions. A factor analysis was used to estimate Kaiser-Meyer-Olkin values and calculate standardized Cronbach's coefficients.

Results

The average age of our participants was 27.7 years. Compared with students, more employed participants tended to smoke electronic cigarettes (p < 0.0001). The association between professional status and perceived wellness was non-significant. Employed participants were nevertheless more likely to regard themselves as more proactive in dealing with emotional (p < 0.0001), environmental (p = 0.0042), and spiritual issues (p = 0.0039). Perceived physical wellness was statistically different by smoking status (p < 0.0001).

Conclusion

Among our study participants, there is an association between smoking and perceived wellness. For emotional, environmental, and spiritual domains, employed participants are more likely to regard themselves as more confident. Our study demonstrates the direct application of the Perceived Wellness Survey model in predicting the disparities of perceived wellness among young individuals. It allows health agencies to target disparity interventions among populations with high risk of low perceived wellness.

Current evidence on the circadian-time-dependent effects of hypertension medications and their combinations in relation to findings of MAPEC and Hygia Chronotherapy Trial

The main purpose of this commentary is to update, based on our extensive review of the published literature of the past 45 yrs, the differential therapeutic effects of hypertension medications of various classes and their combinations when ingested in the evening/at-bedtime versus in the morning/upon-awakening. Interestingly, revision of the currently available evidence on the differential circadian-time-dependent effects of hypertension medications of six different classes and their combinations indicates among the 137 published hypertension medication trials that evaluated blood pressure (BP)-lowering efficacy according to treatment-time, 112 (81.75%) documented significant better benefits by evening/bedtime compared to morning/awakening-scheduled therapy. The remaining 25 published trials found no treatment-time difference in effects; indeed, no single study has reported better benefits of the still conventional, but scientifically unjustified, morning than evening/at-bedtime treatment scheme.

Chronotherapy for reduction of cardiovascular risk

Numerous prospective studies establish that elevated asleep blood pressure (BP) constitutes a significant cardiovascular disease (CVD) risk factor, irrespective of daytime office BP measurements or awake and 24h BP measurements. Moreover, except for a small number of studies with flawed methodology, multiple clinical trials of high consistency document significantly better BP-lowering efficacy of hypertension medication and their combinations when ingested at bedtime compared to upon awakening as is customary. Additionally, recent trials conclude bedtime hypertension chronotherapy markedly reduces CVD risk not only in the general population, but also in more vulnerable patients of advanced age, with kidney disease, diabetes, or resistant hypertension. Collectively, these results call for a new definition of true arterial hypertension and its proper diagnosis and management.

New perspectives on the definition, diagnosis, and treatment of true arterial hypertension

INTRODUCTION

Office blood pressure measurements (OBPM), still used today for diagnosis and management of hypertension, fail to reveal clinically important features of the mostly predictable blood pressure (BP) 24 h pattern, and lead to >45% of individuals being misclassified. Current hypertension guidelines do not provide recommendation on when-to-treat, despite multiple prospective clinical trials documenting improved normalization of 24 h BP pattern and significant reduction in cardiovascular disease (CVD) events when hypertension medications are ingested at bedtime rather than upon waking.

AREAS COVERED

In this review, the authors discuss current evidence on the: (i) most relevant attributes of the 24 h BP pattern deterministic of CVD risk; (ii) asleep systolic BP (SBP) mean as the most significant therapeutic target for CVD risk reduction; (iii) ingestion-time differences in pharmacodynamics of BP-lowering medications as reported with high consistency in multiple clinical trials; and (iv) enhanced prevention of CVD events achieved by bedtime hypertension chronotherapy.

EXPERT OPINION

Several prospective trials consistently document asleep SBP mean and sleep-time relative SBP decline (dipping) constitute highly significant CVD risk factors, independent of OBPM. Bedtime, compared to customary upon-waking, hypertension chronotherapy reduces risk of major CVD events. Collectively, these findings call for new definition of true hypertension and, accordingly, its proper diagnosis and management.

On the use of actigraphy in clinical evaluation of diurnal blood pressure profile

A disturbed diurnal blood pressure profile is one of the most important risk factors of cardiovascular diseases. This review analyzes the use of simultaneous diurnal ambulatory blood pressure monitoring (ABPM) and motion activity monitoring (actigraphy) to obtain additional information for correct interpretation of ABPM results in clinically significant decision-making. The article considers practical aspects of actigraphy in expert ABPM for clock-independent calculation of the parameters of nighttime and daytime blood pressure (BP); detection of BP changes during sleep; connection with respiratory disturbances during sleep, motion activity, and body position; and sleep deprivation in shift workers. Original illustrations of simultaneous ABPM and actigraphy are provided.

A Variant in the NEDD4L Gene Associates With Hypertension in Chronic Kidney Disease in the Southeastern Han Chinese Population

BACKGROUND

"Neuronal precursor cell expressed developmentally down-regulated 4-like" (NEDD4L) is considered a candidate gene for hypertension-both functionally and genetically-through the regulation of the ubiquitination of the epithelial sodium channel (ENaC). This study explores the relationship between genetic variation in NEDD4L and hypertension with chronic kidney disease (CKD) in the southeastern Han Chinese population.

METHODS

We recruited 623 CKD patients and measured ambulatory blood pressure monitoring (ABPM), and the rs4149601 and rs2288774 polymorphisms in NEDD4L were genotyped using quantitative polymerase chain reaction.

RESULTS

For rs4149601, significant differences in genotype frequencies in an additive model (GG vs. GA vs. AA) were observed between normotensive patients and hypertensive patients when hypertension was classified into ambulatory hypertension, clinical hypertension, and ambulatory systolic hypertension (P = 0.038, 0.005, and 0.006, respectively). In a recessive model (GG + GA vs. AA), the frequency of the AA genotype of rs4149601 in the hypertension groups was all higher than that in the normotensive groups. The genotype distribution of rs2288774 did not differ significantly between the normotensive and hypertensive patients. In both the full cohort and the propensity score matching (PSM) cohort, the AA genotype of rs4149601 (compared with the GG + GA genotype group) was independently correlated with ambulatory hypertension, clinical hypertension, and ambulatory systolic hypertension by multivariate logistic regression analysis.

CONCLUSIONS

The present study indicates that the AA genotype of rs4149601 associates with hypertension in CKD. Consequently, the rs4149601 A allele might be a risk factor for hypertension with CKD.

The Importance of Sleep Fragmentation on the Hemodynamic Dipping in Obstructive Sleep Apnea Patients

Introduction

Obstructive sleep apnea (OSA) has been associated with non-dipping blood pressure (BP). The precise mechanism is still under investigation, but repetitive oxygen desaturation and arousal induced sleep fragmentation are considered the main contributors.

Methods

We analyzed beat-to-beat measurements of hemodynamic parameters (HPs) during a 25-min period of wake–sleep transition. Differences in the mean HP values for heart rate (HR), systolic BP (SBP), and stroke volume (SV) during wake and sleep and their standard deviations (SDs) were compared between 34 controls (C) and 22 OSA patients. The Student’s t-test for independent samples and the effect size by Cohen’s d (d) were calculated. HP evolution was investigated by plotting the measured HP values against each consecutive pulse wave. After a simple regression analysis, the calculated coefficient beta (SCB) was used to indicate the HP evolution. We furthermore explored by a hierarchical block regression which variables increased the prediction for the SCB: model 1 BMI and age, model 2 + apnea/hypopnea index (AHI), and model 3 + arousal index (AI).

Results

Between the two groups, the SBP increased in OSA and decreased in C resulting in a significant difference (p = 0.001; d = 0.92). The SV demonstrated a similar development (p = 0.047; d = 0.56). The wake/sleep variation of the HP measured by the SD was higher in the OSA group—HR: p < 0.001; d = 1.2; SBP: p = 0.001; d = 0.94; and SV: p = 0.005; d = 0.82. The hierarchical regression analysis of the SCB demonstrated in SBP that the addition of AI to AHI resulted in ΔR²: +0.163 and ΔF + 13.257 (p = 0.001) and for SV ΔR²: +0.07 and ΔF 4.83 (p = 0.003). The AI but not the AHI remained statistically significant in the regression analysis model 3—SBP: β = 0.717, p = 0.001; SV: β = 0.469, p = 0.033.

Conclusion

In this study, we demonstrated that in OSA, the physiological dipping in SBP and SV decreased, and the variation of all investigated parameters increased. Hierarchical regression analysis indicates that the addition of the AI to BMI, age, and AHI increases the prediction of the HP evolution following sleep onset for both SBP and SV and may be the most important variable.

Asleep blood pressure: significant prognostic marker of vascular risk and therapeutic target for prevention

Aims

Sleep-time blood pressure (BP) is a stronger risk factor for cardiovascular disease (CVD) events than awake and 24 h BP means, but the potential role of asleep BP as therapeutic target for diminishing CVD risk is uncertain. We investigated whether CVD risk reduction is most associated with progressive decrease of either office or ambulatory awake or asleep BP mean.

Methods and results

We prospectively evaluated 18 078 individuals with baseline ambulatory BP ranging from normotension to hypertension. At inclusion and at scheduled visits (mainly annually) during follow-up, ambulatory BP was measured for 48 consecutive hours. During the 5.1-year median follow-up, 2311 individuals had events, including 1209 experiencing the primary outcome (composite of CVD death, myocardial infarction, coronary revascularization, heart failure, and stroke). The asleep systolic blood pressure (SBP) mean was the most significant BP-derived risk factor for the primary outcome [hazard ratio 1.29 (95% CI) 1.22-1.35 per SD elevation, P < 0.001], regardless of office [1.03 (0.97-1.09), P = 0.32], and awake SBP [1.02 (0.94-1.10), P = 0.68]. Most important, the progressive attenuation of asleep SBP was the most significant marker of event-free survival [0.75 (95% CI 0.69-0.82) per SD decrease, P < 0.001], regardless of changes in office [1.07 (0.97-1.17), P = 0.18], or awake SBP mean [0.96 (0.85-1.08), P = 0.47] during follow-up.

Conclusion

Asleep SBP is the most significant BP-derived risk factor for CVD events. Furthermore, treatment-induced decrease of asleep, but not awake SBP, a novel hypertension therapeutic target requiring periodic patient evaluation by ambulatory monitoring, is associated with significantly lower risk for CVD morbidity and mortality.

Non-invasive continuous blood pressure monitoring systems: current and proposed technology issues and challenges

High blood pressure (BP) or hypertension is the single most crucial adjustable risk factor for cardiovascular diseases (CVDs) and monitoring the arterial blood pressure (ABP) is an efficient way to detect and control the prevalence of the cardiovascular health of patients. Therefore, monitoring the regulation of BP during patients' daily life plays a critical role in the ambulatory setting and the latest mobile health technology. In recent years, many studies have been conducted to explore the feasibility and performance of such techniques in the health care system. The ultimate aim of these studies is to find and develop an alternative to conventional BP monitoring by using cuff-less, easy-to-use, fast, and cost-effective devices for controlling and lowering the physical harm of CVDs to the human body. However, most of the current studies are at the prototype phase and face a range of issues and challenges to meet clinical standards. This review focuses on the description and analysis of the latest continuous and cuff-less methods along with their key challenges and barriers. Particularly, most advanced and standard technologies including pulse transit time (PTT), ultrasound, pulse arrival time (PAT), and machine learning are investigated. The accuracy, portability, and comfort of use of these technologies, and the ability to integrate to the wearable healthcare system are discussed. Finally, the future directions for further study are suggested.

Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial

Aims

The Hygia Chronotherapy Trial, conducted within the clinical primary care setting, was designed to test whether bedtime in comparison to usual upon awakening hypertension therapy exerts better cardiovascular disease (CVD) risk reduction.

Methods and results

In this multicentre, controlled, prospective endpoint trial, 19 084 hypertensive patients (10 614 men/8470 women, 60.5 ± 13.7 years of age) were assigned (1:1) to ingest the entire daily dose of ≥1 hypertension medications at bedtime (n = 9552) or all of them upon awakening (n = 9532). At inclusion and at every scheduled clinic visit (at least annually) throughout follow-up, ambulatory blood pressure (ABP) monitoring was performed for 48 h. During the 6.3-year median patient follow-up, 1752 participants experienced the primary CVD outcome (CVD death, myocardial infarction, coronary revascularization, heart failure, or stroke). Patients of the bedtime, compared with the upon-waking, treatment-time regimen showed significantly lower hazard ratio—adjusted for significant influential characteristics of age, sex, type 2 diabetes, chronic kidney disease, smoking, HDL cholesterol, asleep systolic blood pressure (BP) mean, sleep-time relative systolic BP decline, and previous CVD event—of the primary CVD outcome [0.55 (95% CI 0.50–0.61), P &lt; 0.001] and each of its single components (P &lt; 0.001 in all cases), i.e. CVD death [0.44 (0.34–0.56)], myocardial infarction [0.66 (0.52–0.84)], coronary revascularization [0.60 (0.47–0.75)], heart failure [0.58 (0.49–0.70)], and stroke [0.51 (0.41–0.63)].

Conclusion

Routine ingestion by hypertensive patients of ≥1 prescribed BP-lowering medications at bedtime, as opposed to upon waking, results in improved ABP control (significantly enhanced decrease in asleep BP and increased sleep-time relative BP decline, i.e. BP dipping) and, most importantly, markedly diminished occurrence of major CVD events.

Trial registration

ClinicalTrials.gov, number NCT00741585.

 

Diagnosis and management of hypertension: around-the-clock ambulatory blood pressure monitoring is substantially more effective and less costly than daytime office blood pressure measurements

The cost-effectiveness of ambulatory blood pressure (BP) monitoring (ABPM) versus traditional office BP measurement (OBPM) for the diagnosis and management of hypertension has been evaluated only by few studies and based solely on the reduction of medical care expenses through avoiding treatment of isolated-office hypertension. Data from the 21963 participants in the Hygia Project, a multicenter outcomes study that incorporates into routine primary care periodic, at least yearly, 48 h ABPM evaluation, were utilized to assess the cost-effectiveness - relative to vascular pathology expenditures countrywide in Spain - of ABPM versus OBPM. The actual reported Spanish healthcare expenditure for vascular pathology in 2015 - aggregate costs of medical examinations, outpatient and inpatient care, therapeutic interventions, plus non-healthcare services (productivity losses due to morbidity/mortality and informal family/friends-provided care) - was used to compare yearly costs when diagnostic and treatment decisions for hypertension are based on the OBPM versus the ABPM-model. Our economic analysis is based on the more realistic and feasible approach of restricting ABPM solely to high-risk individuals of age ≥60 years and/or with diabetes, chronic kidney disease, and/or previous cardiovascular event, who in the Hygia Project accounted for >90% of all documented events. The projected net benefit countrywide in favor of the proposed ABPM-model is ~5294M€/year, i.e., 360.33€/year (95%CI [347.52-374.85]) per ABPM-evaluated person. This highly conservative economic analysis indicates ABPM is a much more cost-effective strategy than repeated OBPM not only for accurate diagnosis and management of true hypertension but marked reduction of expenditures on elevated BP-associated vascular pathology.

Cardiovascular autonomic dysfunction, altered sleep architecture, and muscle overactivity during nocturnal sleep in pediatric patients with narcolepsy type 1

Study Objectives

Arterial blood pressure (ABP) decreases during sleep compared with wakefulness and this change is blunted in mouse models of and adult patients with narcolepsy type 1 (NT1). We tested whether: (1) pediatric patients with NT1 have similar cardiovascular autonomic abnormalities during nocturnal sleep; and (2) these abnormalities can be linked to hypocretin-1 cerebrospinal fluid concentration (CSF HCRT-1), sleep architecture, or muscle activity.

Methods

Laboratory polysomnographic studies were performed in 27 consecutive drug-naïve NT1 children or adolescents and in 19 matched controls. Nocturnal sleep architecture and submentalis (SM), tibialis anterior (TA), and hand extensor (HE) electromyographic (EMG) activity were analyzed. Cardiovascular autonomic function was assessed through the analysis of pulse transit time (PTT) and heart period (HP).

Results

PTT showed reduced lengthening during total sleep and REM sleep compared with nocturnal wakefulness in NT1 patients than in controls, whereas HP did not. NT1 patients had altered sleep architecture, higher SM EMG during REM sleep, and higher TA and HE EMG during N1–N3 and REM sleep when compared with controls. PTT alterations found in NT1 patients were more severe in subjects with lower CSF HRCT-1, but did not cluster or correlate with sleep architecture alterations or muscle overactivity during sleep.

Conclusion

Our results suggest that pediatric NT1 patients close to disease onset have impaired capability to modulate ABP as a function of nocturnal wake–sleep transitions, possibly as a direct consequence of hypocretin neuron loss. The relevance of this finding for cardiovascular risk later in life remains to be determined.

Comparisons between different blood pressure measurement techniques in patients with chronic kidney disease

BACKGROUND

Automated office blood pressure (AOBP) machines measure blood pressure (BP) multiple times over a brief period. We aimed to compare the results of manual office blood pressure (MOBP) and AOBP methods with ambulatory BP monitoring (ABPM) in patients with chronic kidney disease (CKD).

METHODS

This study was performed on 64 patients with CKD (stages 3-4). A nurse manually measured the BP on both arms using a mercury sphygmomanometer, followed by AOBP of the arm with the higher BP and then ABPM. Mean BP readings were compared by paired t test and Bland-Altman graphs.

RESULTS

The mean ± standard deviation (SD) age of participants was 59.3 ± 13.6. The mean ± SD awake systolic BP obtained by ABPM was 140.2 ± 19.0 mmHg, which was lower than the MOBP and AOBP methods (156.6 ± 17.8 and 148.8 ± 18.6 mmHg, respectively; P < 0.001). The mean ± SD awake diastolic BP was 78.6 ± 13.2 mmHg by ABPM which was lower than the MOBP and AOBP methods (88.9 ± 13.2 and 84.1 ± 14.0 mmHg, respectively; P < 0.001). Using Bland-Altman graphs, MOBP systolic BP readings showed a bias of 16.4 mmHg, while AOBP measurements indicated a bias of 8.6 mmHg compared with ABPM.

CONCLUSION

AOBP methods may be more reliable than MOBP methods for determining BP in patients with CKD. However, the significantly higher mean BPs recorded by AOBP method suggested that AOBPs may not be as accurate as ABPM in patients with CKD.

Ivabradine reversed nondipping heart rate in rats with l-NAME-induced hypertension

We hypothesized that decreasing elevated night-time heart rate (HR) in hypertension by administering a bradycardic agent (ivabradine) at bedtime could bring cardiovascular benefit. Since rats are nocturnal animals, they exhibit circadian rhythms phase-shifted relative to humans. Sixty-six Wistar rats were divided into non-diseased controls and rats with l-NAME-induced hypertension to compare the haemodynamic effects of daytime-dosed and night-time-dosed ivabradine. l-NAME-induced hypertension inverted the physiological 5.6% night-to-day HR dip to an undesirable HR rise by 11.1%. Ivabradine dosed at daytime (the rat's resting phase) reverted a night-to-day HR rise to HR dip by 14.2%. These results suggest a cardiovascular benefit of ivabradine dosed at the human's resting phase (night-time) for hypertensive patients with nondipping HR.

Evaluation of posttraumatic stress disorder diagnosis and therapy on diurnal blood pressure patterns from 24-hour ambulatory blood pressure monitoring

Introduction

The veteran population has a high incidence of posttraumatic stress disorder (PTSD), which is associated with increased risk of hypertension and cardiovascular death. Ambulatory blood pressure monitoring (ABPM) can identify abnormal diurnal blood pressure (BP) patterns, which are associated with increased risk of cardiovascular events. The intent of this evaluation was to examine prior ABPM studies to determine whether veterans with PTSD are more likely to have abnormal nocturnal dipping patterns compared with the general veteran population.

Methods

Retrospective chart review was performed on all archived ABPM studies and classified by nocturnal dipping status and BP control rates. Pertinent patient demographics of age, sex, concomitant PTSD, and use of selected PTSD therapies were identified at the time of ABPM study. Association between dipping status, BP control rates, and patient demographics were analyzed using appropriate statistical tests.

Results

A total of 470 ABPM studies were determined to be valid and included. There were no differences in the distribution of nocturnal dipping patterns in veterans with or without PTSD. Likewise, rates of nocturnal, awake, and 24-hour hypertension were similar between groups. In patients with PTSD who were treated with evening PTSD therapy, there was a higher rate of normal dipping status compared with those without treatment (66.7% vs 29.7%, P = .03).

Discussion

Veterans with PTSD had similar distributions of dipping patterns and rates of overall, awake, and nocturnal hypertension compared with the general veteran population. The association of nocturnal PTSD therapy prescription in patients with PTSD and higher rates of normal dipping status may warrant further investigation.