Wearable blood pressure measurement devices and new approaches in hypertension management: the digital era

Out-of-office blood pressure (BP) measurement is considered an integral component of the diagnostic algorithm and management of hypertension. In the era of digitalization, a great deal of wearable BP measuring devices has been developed. These digital blood pressure monitors allow frequent BP measurements with minimal annoyance to the patient while they do promise radical changes regarding the diagnostic accuracy, as the importance of making an accurate diagnosis of hypertension has become evident. By increasing the number of BP measurements in different conditions, these monitors allow accurate identification of different clinical phenotypes, such as masked hypertension and pathological BP variability, that seem to have a negative impact on cardiovascular prognosis. Frequent measurements of BP and the incorporation of new features in BP variability, both enable well-rounded interpretation of BP data in the context of real-life settings. This article is a review of all different technologies and wearable BP monitoring devices.

Sympathetic nervous system activity and unattended blood pressure measurement

Background/Introduction

Sympathetic nervous system activation plays a crucial role in the pathophysiology and variability of hypertension. It has been hypothesized that measurement of unattended blood pressure (BP) may provide additional information to conventionally attended BP measurement, as it can lead to the limitation of the white coat effect.

Purpose

The aim of this study was to demonstrate the relationship of sympathetic nervous system activation and BP measurement variations with and without medical supervision.

Methods

We studied 103 untreated hypertensive patients, who underwent muscle sympathetic nerve activity (MSNA) estimation by microneurography. Both unattended (patient alone in the room, an oscillometric device programmed to perform 3 BP measurements at 1-minute intervals, after 5 minutes of rest) and attended BP measurements were conducted in all participants, with the same device, on the same day of MSNA recording in random order. Patients were divided into two groups based on the difference between attended and unattended BP. In group A, patients had unattended BP greater than attended BP (n=31) and in group B, patients had unattended BP lower than attended BP (n=72). The two groups were compared regarding the median value of MSNA recordings in our population (median MSNA = 63 bursts per 100 heartbeats).

Results

The two groups did not differ as regards both attended SBP levels (group A: 142.3±15.4 mmHg, group B: 145.6±13.7 mmHg, p=0.29) and attended DBP levels (group A: 89.2±9.8 mmHg, group B: 91.2±11.5 mmHg, p=0.25). A difference was observed concerning unattended SBP levels (group A: 152±16.3 mmHg, group B: 142.5±13.8 mmHg, p=0.03) and unattended DBP levels (group A: 94.4±10.3 mmHg, group B: 85.2±11.8 mmHg, p<0.01). Higher levels of MSNA were recorded in patients in group A when compared to group B, although this difference was not statistically significant (66.8±15.6 vs. 61.6±14.8 bursts per 100 heartbeats, p=0.11). Higher percentage of patients in group A had MSNA levels greater than the median value of MSNA compared to group B (68% vs 46% respectively).

Conclusions

In the present study, we found that the majority of patients who exhibit higher BP during the unattended measurement also record high MSNA values, suggesting a more stimulated sympathetic nervous system. On the contrary, most of the patients who can calm down during the unattended measurement exhibit lower levels of MSNA. More patients are needed to fully determine the clinical significance of this observation.

Funding Acknowledgement

Type of funding sources: None.

Microcirculation and blood pressure/heart rate response during exercise stress testing in hypertensive patients

Background/Purpose

A hypertensive response during exercise has been associated with adverse cardiovascular outcomes in general population and hypertensive patients. On the other hand, microcirculation is the major site of control of vascular resistance and thus has a key role in the etiopathogenesis of hypertension. The aim of our study was to investigate the presence of a possible correlation between blood pressure and heart rate response during exercise with a microcirculation index (capillary rarefaction) in a cohort of hypertensive patients.

Methods

We studied 105 untreated patients with stage I-II essential hypertension (70% men, mean age: 59.5 years, mean office blood pressure: 150/92mmHg). Patients with diabetes mellitus, secondary hypertension, atherosclerotic cardiovascular disease, heart failure, significant chronic renal or pulmonary disease and any other systemic illness or orthopedic problems that would not allow maximal effort on a treadmill were excluded. All participants underwent maximal exercise testing, using the Bruce protocol, as well as nail-fold videocapillaroscopy assessment by using VideoCap 3.0 videomicroscope.

Results

A significant negative correlation between diastolic BP at minute-1 of the recovery phase and capillary density expressed in capillaries/mm was revealed (Pearson's r=−0.365, p=0.043). A significant negative correlation was also observed between capillary density and peak heart rate (Pearson's r=−0.364, p=0.024) as well as between heart rate increase from stage 1 to 2 and capillary density (Pearson's r=−0.746, p=0.013).

Conclusions

Our study shows that in a small cohort of hypertensive patients, capillary rarefaction was associated with a steeper increase in heart rate during exercise, as well as with a higher peak heart rate and higher diastolic blood pressure values during the recovery phase. These findings suggest that new indices such as capillary rarefaction may provide insights into possible autonomic dysfunction and could also be taken into account in the assessment of hypertensive patients.

Funding Acknowledgement

Type of funding sources: None.

Effect of blood pressure reduction on cardiovascular outcomes in patients with different baseline cardiovascular risk: systematic review and meta-analysis of randomized trials

Background/Introduction

Blood pressure (BP) lowering is accompanied by a reduction on cardiovascular (CV) outcomes and death in hypertensive patients. There is no data on the effect of lowering BP in patients stratified according to their baseline CV risk as indicated by SCORE 2.

Purpose

The aim of this meta-analysis was to demonstrate the impact of BP-lowering treatment on the occurrence of CV events in these previously reported patients.

Methods

A systematic review in electronic databases (Pubmed and CENTRAL, years: 1966 to 9/2021) was conducted to identify randomized trials that study the effect of BP-lowering treatment against placebo or less aggressive BP reduction on 6 fatal or non-fatal CV outcomes and all-cause death. Selected studies reported outcomes in patients without a history of previous CV disease. In each study, baseline cardiovascular risk was estimated using SCORE-2. Risk ratios (RR) were calculated together with their 95% confidence interval (CI) under the random-effects model.

Results

The analysis was composed of 54 studies, of which 12 trials included patients with low-to-moderate CV risk, (n=21,192 patients), 13 trials with high CV risk patients (n=66,886) and 29 trials with very high CV risk patients (n=79,061). For a standard SBP/DBP reduction of 10/5 mmHg, the relative risk of the combined outcome of major CV events (i.e., myocardial infarction, stroke, and heart failure) was decreased by 27% (95% CI, 22–35%) in the category of very high-risk patients. This reduction was significantly greater (p=0.02) compared to high-risk trials (0.90 [95% CI, 0.77–1.04]). CV death showed a significant reduction in the high-risk group of patients compared to the low-moderate risk group (p=0.005), as well as in the very high-risk group compared to the low-moderate risk group (p=0.001). The same pattern was observed for all-cause death in the very high-risk group compared to the high-risk group (p=0.045).

Conclusions

With the present meta-analysis, we observed that the greatest benefit from BP lowering in primary prevention in the occurrence of CV events and mortality is observed in patients at higher baseline cardiovascular risk, as calculated by the SCORE-2.

Funding Acknowledgement

Type of funding sources: None.

Parameters indicating development of hypertension in three-year follow-up study of subjects with high normal blood pressure

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

The clinical importance of a hypertensive response to exercise (HRE) in subjects with high normal blood pressure (BP) is not fully elucidated, while sympathetic overactivity followed by arterial stiffening are linked with development of hypertension (HTN).

Purpose

The aim of this study was to assess the relation of HRE with sympathetic drive as assessed by muscle sympathetic nerve activity (MSNA) and arterial stiffness in subjects with high normal BP who developed hypertension in a 3 year follow up.

Methods

100 subjects with high normal office BP [systolic BP=130-139 mmHg and diastolic BP=85-89 mmHg] underwent a treadmill exercise stress test. Arterial stiffness was evaluated based on carotid to femoral pulse wave velocity (PWV). Sympathetic drive was assessed by MSNA levels. Follow up was every 6 months for 3 years, where BP was measured at both office (OffBP) and ambulatory blood pressure monitoring (ABPM). All participants offered lifestyle advises. Endpoint was development of HTN diagnosed either from OffBP or from ABPM. Then they were divided into Group I: those developed HTN and Group II: those remained normotensive.

Results

Mean age 54±8 years, 42 males, baseline offBP: 132/82 mmHg, ABPM: 122/76 mmHg). Out of them, 50 subjects developed HRE (BP ³210mmHg in men and ³190 mmHg in women) and 40 HTN. Group I developed higher HRE (75% vs. 13%, p=0.026), higher levels of PWV (8.35 vs 7.5 m/sec, p=0.043) and MSNA levels (37 vs. 31 bursts, p=0.04), while did not differ at their metabolic profile. Echocardiographically left ventricular mass index did not differ statistically as E/A ratio of mitral valve inflow (0.92 vs 1.05, p=0.034). Those who developed HTN was related to night systolic BP from ABPM (116 vs 112 mmHg, p<0.04), as also to intermediate stage intervals of 3 min (160 vs 147 mmHg, p=0.068) and 6 min (181 vs 164, p=0.035) of Bruce protocol. A novel metric, the SBP/MET-slope [(peak SBP—resting SBP)/(peak MET-1)] found to add crucial information. Regarding those who developed HTN, SBP/MET-slope was higher in all stages till peak exercise (stage 1: 6.25 vs 4.25, stage 2: 7.6 vs 5.3, peak: 7.22 vs 5.1, p=0.035). It was noticed that they performed a higher exercise capacity (10 vs 11.5 METs) and additionally differ significantly in their maximal heart rate (HR) at peak exercise (154 vs 164, p=0.001).

Conclusion

In subjects with high normal BP, a HRE, the intermediate BP intervals along with the SBP/MET-slope, identifies a state of systemic vascular resistance, arterial stiffening and sympathetic overdrive, as reflected by increased PWV and MSNA levels respectively. Additionally, exercise capacity demonstrates cardiovascular functional tolerance. These findings suggest that exercise testing provides determining clinical information regarding the overall cardiovascular status, proving its superior prognostic value as a hypertension screening tool, that alarms the physician to warn the patient to take action.

Parameters of treadmill exercise test and sympathetic activation are linked to the development of hypertension in subjects with high normal blood pressure

Background/Introduction

The clinical importance of a hypertensive response to exercise (HRE) in subjects with high normal blood pressure (BP) is not fully elucidated, while sympathetic overactivity followed by arterial stiffening are linked with development of hypertension.

Purpose

The aim of this study was to assess parameters related to the development of hypertension in a 3 year follow in subjects with high normal BP.

Methods

One hundred consecutive subjects with high normal office BP (54±8 years, 42 males, baseline office BP: 132/82 mmHg, 24-hour BP: 122/76 mmHg) at baseline underwent a negative for ischemia treadmill exercise test. Arterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (PWV) values and sympathetic drive was assessed by muscle sympathetic nerve activity (MSNA) based on established methodology. SBP/MET-slope defined as: peak systolic BP–resting SBP)/(peak MET-1) was assessed. Follow up was scheduled every 6 months for 3 consecutive years, where BP was measured both in the office and with ambulatory blood pressure monitoring. End point was the development of hypertension diagnosed from office blood pressure measurements and confirmed from ambulatory blood pressure monitoring.

Results

Patients who developed hypertension (n=35) compared to those who remained normotensives (n=65) had at baseline higher prevalence of HRE (75% vs. 13%, p=0.026), higher levels of carotid to femoral PWV (8.35 vs. 7.5 m/sec, p=0.043) and MSNA (37 vs. 31 bursts per minute, p=0.04), while their metabolic profile did not differ at the follow up (p=NS for all). In those who developed hypertension, SBP/MET-slope was higher in all Bruce protocol stages till peak exercise (stage 1: 6.25 vs. 4.25, stage 2: 7.6 vs. 5.3, peak exercise: 7.22 vs. 5.1; p<0.05 for all). Additionally, those who remained normotensives compared to those who developed hypertension exhibited a higher exercise capacity (10 vs. 11.5 METs, p<0.05) and maximal heart rate at peak exercise (154 vs. 164, p=0.001).

Conclusion

In subjects with high normal BP, those who develop hypertension during follow-up are characterized by more frequent HRE accompanied with lower exercise capacity, arterial stiffening and sympathetic overactivation. These results suggest that exercise BP response, along with PWV and MSNA estimation could contribute to identify high normal BP subjects who are more prone to become hypertensives.

Funding Acknowledgement

Type of funding sources: None.

Ambulatory blood pressure variability measures in hypertensive patients according to non-alcoholic fatty liver disease state

Background

Nonalcoholic fatty liver disease (NAFLD) represents the most frequent cause of chronic hepatic disease and independently determines hypertension and future cardiovascular events. Increased blood pressure variability (BPV) assessed by 24-hour blood pressure (BP) monitoring including mean arterial morning surge have been also associated with increased rates of cardiovascular events.

Purpose

To compare different BPV measures in hypertensive patients with and without NAFLD.

Methods

Consecutive newly diagnosed untreated hypertensive patients without history of cardiovascular disease underwent clinic and ambulatory BP measurements. NAFLD was diagnosed by liver ultrasound to separate patients into those with and without NAFLD. BPV was derived by assessment of standard deviation (SD) of systolic and diastolic BP (24-h, daytime and nighttime), average real variability (ARV) of systolic and diastolic BP, coefficient of variation (CV) of systolic BP (24-h, daytime), weighted SD (wSD) of systolic BP (24-h, daytime), maximum BP and mean arterial morning surge.

Results

Among 146 hypertensive patients (mean age 57±11 years, 64 men, 24-h mean systolic/diastolic BP 140±10/84±9 mmHg) those with NAFLD (n=76) compared to the non-NAFLD group (n=70) were younger (54.7±10.1 vs 58.6±11.2 years, respectively, p=0.03), male gender was more prevalent (42 vs 22 respectively, p=0.004), and body mass index was more increased (33.2±4.1 vs 27.0±3.5 kg/m2, p<0.001). Moreover, NAFLD patients compared to those without NAFLD were characterized by higher levels of mean arterial pressure morning surge (12.4±8.9 vs 8.7±8.5 mmHg, p=0.03), but the remaining BPV measures were not different between the two groups. NAFLD was a determinant of both diastolic BP ARV (B=0.34, p=0.007) and mean arterial morning surge (B=0.47, p=0.006) after adjustment.

Conclusions

Mean arterial pressure morning surge was significantly higher in hypertensive patients with NAFLD compared to their non-NAFLD counterparts, while whole day BPV measures were not increased in NAFLD except for ARV of diastolic BP. Our findings may partially explain the increased cardiovascular risk of comorbid NAFLD in hypertension.

Funding Acknowledgement

Type of funding sources: None.

Comparison of cardiovascular events and estimation of hazard ratio for hypertensive patients with and without hypertensive urgencies after a 12-month follow up

Background

Few epidemiological data show a worst prognosis of hypertensive emergencies compared with hypertensive urgencies (HU). To the best of our knowledge, there is even fewer published evidence comparing prognosis of hypertensive patients (HP) with and without HU.

Purpose

The purpose of our prospective study was to record the prevalence and clinical characteristics of patients with HU assessed in the emergency department (ED) in a tertiary Hospital and to compare them with HP without urgencies for new events and hard-end points for a 12-month follow-up.

Methods

The study population consisted of 256 patients presenting at the ED with acute increase in blood pressure (BP) (systolic BP≥180mmHg and/or diastolic BP≥120mmHg) with absence of acute hypertension-mediated target organ damage in a period of one year. Each of these participants were matched one-to-one by age, gender and history of hypertension with HP with either controlled, grade 1 or grade 2 hypertension attending our Hypertension excellence center the same period. However, 78 of HU did not conclude the follow up and 5 could not be matched with HP for the above covariates and were therefore excluded. Both groups, 173 of HU and 173 of controls, concluded 12 months follow up for fatal and non fatal cardiovascular events, including acute coronary syndrome, stroke, newly diagnosed heart failure or deterioration of NYHA class, and composite end points such as stroke-myocardial infarction and overall cardiovascular disease outcome.

Results

The mean age of all patients was 64.9±12.5 years (64±12.2 for controls and 65.7±12.7 for HU), 48.8% were males (49.1% of controls and 48.6% of HU) and 26.6% had a history of smoking (22.5% of controls and 30.6% of HU). Overall, 15 (5.5%) patients had nonfatal clinical cardiovascular events and 4 (1.2%) had fatal cardiovascular events. Cox regression models were adjusted for age, gender, smoking, previous cardiovascular disease, diabetes mellitus and the population. The frequency of the composite stroke-myocardial infarction event was statistically significant higher in HU (5 vs 4, p<0.0001, Hazard Ratio for HU 181.7, 95% Confidence Intervals 19.7–1677.2) adjusted for the rest covariates. In addition, there was a higher trend for stroke in the group of HU (p=0.067) and in patients with a history of diabetes mellitus irrespective of group (p=0.055). Finally, the Cox regression analysis identified age (p=0.035) and history of cardiovascular disease (p=0.038) as independent predictors for death, and smoking (p=0.035) as independent predictor for overall cardiovascular events.

Conclusions

Our study emphasizes the higher trend for cardiovascular outcomes, especially stroke, in the group of HU compared with HP without urgencies, while it highlights the necessity for more intensive follow-up for the first group and the need for further research in this pathological entity.

Funding Acknowledgement

Type of funding sources: None.

Exploring the cross-talk between liver and vessels through increased morning blood pressure in hypertension

Background

Nonalcoholic fatty liver disease (NAFLD) is associated with hypertension and predicts future cardiovascular events.

Purpose

To compare blood pressure (BP) morning surge assessed by ambulatory blood pressure monitoring (ABPM) in hypertensive patients with and without NAFLD.

Methods

Sixty-five consecutive patients with newly diagnosed essential hypertension (age 57±10 years, office BP 139/87±16/9 mmHg) were studied. In all patients a routine biochemical blood examination was undertaken while BP morning surge was automatically calculated by a Spacelabs 90207 device. NAFLD was confirmed by a liver ultrasound. Accordingly, patients were divided in those with and without NAFLD (control group).

Results

Patients with NAFLD (n=44) in comparison with controls (n=21) had similar 24h systolic (141.6±9.9 vs 143.2±10.4 mmHg) and diastolic BP (83.6±10.23 vs 84.7±9.53 mmHg) while office BP was also not different between groups (p=NS). However, those with NAFLD were younger (55±10 vs 61±9 years, respectively, p=0.046), had higher body mass index (32.5±4.5 vs 26.3±3.8 kg/m2, p<0.001), glomerular filtration rate (93.8±17 vs 82.6±9.2 ml/min/1.73m2, p=0.013), and higher levels of morning BP surge (14.29±8.5 vs 5.92±9.01mmHg, p=0.034), compared to the non-NAFLD group. Standard deviation of BP, average real variability, coefficient of variation and dipping status were not different between groups.

Conclusions

At the same levels of clinic and ambulatory BP, hypertensive patients with NAFLD compared to their non-NAFLD counterparts demonstrated increased morning surge BP levels. Our finding suggests that NAFLD may demonstrate a detrimental effect to early-morning at variance to the whole-day hemodynamics.

Funding Acknowledgement

Type of funding sources: None.

Correlations between sympathetic nervous system activity and smoking, as well as unattended blood pressure in essential hypertension

Background/Introduction

It is a well-known fact that the sympathetic nervous system is involved with the pathophysiology of hypertension. Smoking, which is one of the most significant risk factors for cardiovascular morbidity and mortality, also contributes to the development of hypertension mainly through the stimulation of the sympathetic nervous system. Moreover, measurement of unattended blood pressure (BP) may provide additional information compared to conventionally attended BP.

Purpose

The aim of this study was to demonstrate the impact of smoking on sympathetic nervous system stimulation, and on BP measurement variations with and without medical supervision.

Methods

We studied patients with essential hypertension, who were separated into two groups, depending on their smoking habits (Group I: non-smokers, Group II: smokers). In all participants, sympathetic drive was assessed by MSNA estimations based on established methodology (microneurography). Both unattended (patient alone in the room, an oscillometric device programmed to perform 3 BP measurements, at 1-minute intervals, after 5 minutes of rest) and attended BP measurements were conducted with the same device, on the same day of MSNA recording, in random order. Then, we compared the two BP measurement values of each patient to assess which of the two was higher.

Results

Ninety-two consecutive patients (58±11 years, 50 males) were evaluated. Smokers (n=19) did not differ as regards 24-h ambulatory BP levels, glucose levels, renal function and left ventricular mass index when compared to non-smokers (n=73). However, higher levels of MSNA were recorded to smokers (73.16±13.42 vs. 61.04±18.10 bursts per 100 heartbeats, p<0.01). Furthermore, higher percentage of smokers recorded to have unattended BP values higher than attended (73.7% vs. 47.9% of them respectively, p=0.045). In particular, in smokers unattended BP was higher than attended by 10.07±6.7 mmHg, while in non-smokers unattended BP was lower than attended by 6.6±7.14 mmHg. No correlation was found between the MSNA and the differences observed in the two values resulting from the two different measurements of BP, maybe due to the small size of the sample.

Conclusions

Cigarette smoking is accompanied with higher sympathetic nervous system activation. Moreover, smokers exhibit higher unattended blood pressure values than normal measurements. The emerging hypothesis is that the stimulation of the sympathetic system causes this difference in measurements. A larger sample of patients is needed to fully determine the clinical significance of the above observation.

Funding Acknowledgement

Type of funding sources: None.

Blood pressure response in exercise is associated with future cardiac structural alterations in hypertensive patients

Background/Introduction

Exaggerated blood pressure response (EBPR) during the exercise treadmill test (ETT) is often observed in individuals without known cardiovascular disease. Although it is generally considered as an abnormal response and a risk factor for hypertension development, its clinical significance remains controversial. On the other hand, regression of left ventricular hypertrophy (LVH) is independently associated with improved cardiovascular outcome.

Purpose

In this study we aimed to investigate the role of EBPR during exercise in LVH regression in hypertensive subjects over time.

Methods

1413 hypertensive subjects, (mean age 57±11 years), 51% males, with baseline office blood pressure (BP) 144/89mmHg were followed for a mean period of 6.4±3.0 years. At baseline and last follow-up visit all patients underwent office BP, laboratory tests and echocardiographical determination of left ventricular mass index (LVMI). At baseline, all subjects underwent treadmill exercise testing (Bruce protocol) in order to identify the presence of EBPR based on the systolic BP elevation at peak exercise (> or =210 mmHg for men and > or =190 mmHg for women). Main outcome variable was LVH Regression/prevention (LVH Regr/prev), defined as: LVH at baseline visit with normal LVMI values at last visit or absence of LVH at baseline and last visit. BP control was considered optimal when the mean of office BP measurements during follow-up was <140/90mmHg.

Results

46% of study population presented LVH Regr/prev during follow-up period. Cox-regression analysis, after adjustment for clinical and biochemical variables, revealed that low levels of baseline LVMI (HR=0.98, 95% CI 0.97–0.99, p<0.0001), absence of EBPR (HR=0.81, 95% CI 0.67–0.98, p=0.02) and optimal BP control during follow-up (HR=1.19, 95% CI 1.01–1.56, p=0.03) were independent predictors of LVH Regr/prev during follow-up.

Conclusions

Beyond optimal BP control, EBPR is a significant predictor of left ventricular mass changes overtime. Hence, ETT can provide clinical relevant information, including EBPR, which may help in the improvement of risk stratification of hypertensive subjects.

Funding Acknowledgement

Type of funding source: None

Time in blood pressure range for different blood pressure targets and risk of cardiovascular disease: an analysis of a 7-year follow-up registry

Objective

Recent guideline recommendations have revisited the optimal target blood pressure (BP) for hypertensive patients. The Time in BP Range (TBPR) is an alternative metric for evaluation of long-term achieved BP. We investigated the association of TBPR for different levels of BP control with cardiovascular outcome among treated hypertensives.

Design and method

This is a retrospective analysis of 1202 treated hypertensive patients (age 59±11 years) without a history of cardiovascular disease followed for a mean period of 7±3 years. We calculated the TBPR [(No of Visits in BP range/ Total No of Visits) x 100%] for office systolic BP targets of 130–139mmHg, 120–129mmHg and <120mmHg and examined the associated cardiovascular risk. The outcome studied was the composite of stroke and coronary artery disease. Time spent in systolic BP≥140mmHg served as the reference.

Results

In the entire population, mean TBPR for systolic BP 130–139mmHg, 120–129mmH, and <120mmHg were 26%, 19% and 11% respectively. A TBPR of ≥50% for systolic BP 130–139mmHg, 120–129mmHg and <120mmHg was observed in 332 (28%), 226 (19%) and 107 (9%) patients respectively. The composite endpoint occurred in 54 patients (4.5%). Patients with a TBPR for 120–140mmHg of ≥50% presented with a HR: 0.6 (95% CI: 0.34–1.06) for cardiovascular events. The TBPR of ≥50% for systolic BP 130–139mmHg, 120–129mmHg and <120mmHg was associated with HR of 0.48 (95% CI: 0.23–1.01, p=0.05), 0.64 (95% CI: 0.29–1.39, p=0.26) and 0.72 (95% CI: 0.26–2.05) respectively. This pattern was sustained but further attenuated after controlling for standard risk factors. In comparison, a mean BP across visits of 130–139mmHg, 120–129mmHg and <120mmHg was associated with a HR of 0.54 (5% CI: 0.28–1.03), 0.61 (95% CI: 0.29–1.26) and 0.80 (95% CI: 0.24–2.65).

Conclusions

Among treated hypertensives, a time in BP of 130–140mmHg of more than 50% is associated with the greatest reduction in cardiovascular risk. The TBPR is a potentially useful measure of BP control for evaluation of risk reduction in hypertensive patients.

Funding Acknowledgement

Type of funding source: None

Exercise duration as apredictor ofcardiovascular disease in arterial hypertension. Data from a 6-year follow-up study

Background

Current hypertension guidelines necessitate an individualized cardiovascular risk assessment through a process that includes several parameters and remains challenging. Exercise capacity has been strongly associated with prognosis in cardiovascular disease and can be easily assessed by the exercise treadmill test (ETT).

Purpose

The aim of the present study was to investigate theprognostic role of exercise capacity for future cardiovascular events in a cohort of essential hypertensive subjects.

Methods

We followed up 1037 hypertensive adults (mean age 56 years, 53% males) with no previous history of cardiovascular disease, for a mean period of 6±3 years. During the baseline visit all subjects underwent a complete echocardiographic study, office blood pressure measurements, ECG, routine blood testing and an ETT with a Bruce protocol.During follow-up, all subjects were reviewed at least annually. Exercise capacity was expressedwithexercise duration the distribution of which was split by the median (9min). Accordingly, the subjects were classified into those with high (51%) and low exercise capacity (49%). The cardiovascular endpoint of interest was the composite of coronary artery disease and stroke.

Results

The incidence of cardiovascular eventsduring the follow-up period was 4.1% (35 cases of coronary artery disease and 10 cases of stroke).Cox regression analysis revealed that high exercise capacity was associated with a lower risk for future cardiovascular events (HR = 0.35 (95% CI 0.172–0.741, p=0.006). In multivariate models adjusting for standard clinical and laboratory cardiovascular risk factors this association was sustained.

Conclusion

Exercise duration shows a significant prognostic value for future CV events among hypertensivepatients. Exercise capacity assessment by means of TTE could enhance the identification of asymptomatic hypertensives at higher risk.

Funding Acknowledgement

Type of funding source: None

Prevalence, pattern and associated cardiovascular risk of t-wave inversion in hypertensive patients: a 5-year follow-up study

Background

Data on prevalence and associated prognosis of repolarization abnormalities among hypertensive patients are limited.

Purpose

We investigated the presence and extent of ST-segment and T-wave changes in a hypertensive population and their predictive ability for cardiovascular disease.

Methods

We studied 1851 white Caucasian hypertensive patients (age 58±12 years, 51%females) without a history of cardiovascular disease for a mean period of 5.3±3.4 years. At the baseline examination, all patients underwent standard 12-lead electrocardiography. T-wave inversion (TWI) was defined as T-wave deflection ≥−0.1 mV in ≥2 contiguous leads,unless associated with bundle branch block. Anterior, lateral or inferior TWI was defined as TWIin leads V2-V4 or V5,V6, I, AVL or II, aVF respectively. Thedepth in millimeters of TWI in each lead was recorded and the maximum depth per location was calculated. ST depression was defined as ≥1mm in depth in two or more contiguous leads.During follow-up, patients underwent clinic visits at least yearly for management of hypertension and risk factors. The outcome studied was theincidence of cardiovascular morbidity set as the composite of non-fatal coronary artery disease and stroke.

Results

In the entire population, prevalence of TWI was 3.8%, of which 39% presented withanterior TWI, 73% withlateral TWI and 11% with inferior TWI. ST depression was observed in 3.6% of patients (anterior in 0.8%, inferior in 0.9% and lateral in 2.6%). Incidence of the composite endpoint during follow-up was 4%. Cox regression analysis revealed that presence of TWI was associated with a significantly greater risk for cardiovascular events (HR: 2.6, 95% CI: 1.1–5.9, p=0.025). The association was stronger for lateral TWI (HR: 3.3, 95%: CI: 1.34–8.30, p=0.01) compared to other locations. In multivariate models controlling for standard confounders these associations were overall sustained. Depth of TWI and presence of ST depression were not associated with cardiovascular risk.

Conclusions

Among hypertensive patients without cardiovascular disease, TWI is infrequent but significantly associated with future cardiovascular events.Lateral TWI carries the worse prognosis

Funding Acknowledgement

Type of funding source: None