Prevalence and clinical outcomes of white-coat and masked hypertension: Analysis of a large ambulatory blood pressure database

The aim of this study was to analyze prevalence and clinical outcomes of the following clinical conditions: normotension (NT; clinic BP < 140/90 mm Hg; 24-hour BP < 130/80 mm Hg), white-coat hypertension (WCHT; clinic BP ≥ 140 and/or ≥90 mm Hg; 24-hour BP < 130/80 mm Hg), masked hypertension (MHT; clinic BP < 140/90 mm Hg; 24-hour BP ≥ 130 and/or ≥80 mm Hg), and sustained hypertension (SHT; clinic BP ≥ 140 and/or ≥90 mm Hg; 24-hour BP ≥ 130 and/or ≥80 mm Hg) in a large cohort of adult untreated individuals. Systematic research throughout the medical database of Regione Lazio (Italy) was performed to estimate incidence of myocardial infarction (MI), stroke, and hospitalizations for HT and heart failure (HF). Among a total study sample of 2209 outpatients, 377 (17.1%) had NT, 351 (15.9%) had WCHT, 149 (6.7%) had MHT, and 1332 had (60.3%) SHT. During an average follow-up of 120.1 ± 73.9 months, WCHT was associated with increased risk of hospitalization for HT (OR 95% CI: 1.927 [1.233-3.013]; P = .04) and HF (OR 95% CI: 3.449 [1.321-9.007]; P = .011). MHT was associated with an increased risk of MI (OR 95% CI: 5.062 [2.218-11.550]; P < .001), hospitalization for HT (OR 95% CI: 2.553 [1.446-4.508]; P = .001), and for HF (OR 95% CI: 4.214 [1.449-12.249]; P = .008). These effects remained statistically significant event after corrections for confounding factors including age, BMI, gender, smoking, dyslipidaemia, diabetes, and presence of antihypertensive therapies.

Cardiovascular Alterations and Management of Patients With White Coat Hypertension: A Meta-Analysis

A large and growing body of literature has focused on the association between "white coat hypertension" (WCH) and the underlying target organ damage. The evidence suggests that WCH is may not an entirely benign phenomenon. However, whether patients with WCH should receive antihypertensive drugs is unresolved. Therefore, we performed a meta-analysis to fully determine the ability of WCH to alter cardiovascular structure and to determine whether patients with WCH could benefit from drug intervention. Medline, EMBASE, and the Cochrane Library were searched from inception through 21 Oct 2019. A total of 25 studies (8,100 individuals) were included. In participants with WCH, values of aortic pulse wave velocity, augmentation index, intima-media thickness, interventricular septum thickness, left ventricular posterior wall thickness, and left ventricular mass index were lower than those with sustained hypertension, but greater than those in the normotensive group. Of note, antihypertensive drug therapy did not reduce the risk of cardiovascular events in patients with WCH. WCH is accompanied by alterations of cardiovascular structure; however, the benefits from antihypertensive therapy are limited.

Blood pressure characteristics of subclinical hypothyroidism: an observation study combined with office blood pressure and 24-h ambulatory blood pressure

OBJECTIVE

To investigate the characteristics of blood pressure in subclinical hypothyroidism by combining office blood pressure and 24-h ambulatory blood pressure.

METHODS

A total of 3078 adults voluntarily participants were enrolled in this study between December 2017 and November 2019. Among 1431 of them who did not fit exclusion criteria, 104 patients were with subclinical hypothyroidism (S-HYPO group), and 1327 were euthyroid participants (euthyroid group). Office blood pressure measurement and 24-h ambulatory blood pressure monitoring were carried out to analyze the characteristics of blood pressure in subclinical hypothyroidism.

RESULTS

There was no statistical difference in office SBP and DBP between the S-HYPO group and the euthyroid group (P > 0.05). On the ambulatory blood pressure level, the daytime SBP, night-time SBP, night-time SBP, 24-h SBP and DBP in the S-HYPO group were significantly higher than those in the euthyroid group (P = 0.048, P = 0.002, P = 0.003, P = 0. 014, P = 0. 046, respectively), and the proportion of nondipper blood pressure in the S-HYPO group was higher than that in the euthyroid group. Comprehensive analysis of blood pressure inside and outside the joint clinic revealed that the S-HYPO group was independently related to sustained hypertension and masked hypertension but not to white-coat hypertension (P = 0.004, P = 0.002, P = 0.886, respectively). After adjusting for age, sex, BMI, and other confounding factors, the above differences were still statistically significant (P < 0.05).

CONCLUSION

The characteristics of blood pressure in subclinical hypothyroidism can be more accurately understood by combining office blood pressure and ambulatory blood pressure.

Waist-to-height-ratio is associated with sustained hypertension in children and adolescents with high office blood pressure

Background

Waist-to-height-ratio (WHtR) has been proposed as another indicator for cardiometabolic risk factors including hypertension. Normally, hypertension can be diagnosed in the office setting by detecting high blood pressure for three occasions. However, patients with high office blood pressure may not exhibit high blood pressure outside the office. Ambulatory blood pressure monitoring (ABPM) is a procedure to measure blood pressure over 24-h. Sustained hypertension is characterized as hypertension detected by both office measurement and ABPM. This study aimed to evaluate the performance of WHtR in the diagnosis of sustained hypertension in patients with high office blood pressure.

Materials and methods

Demographic data, height, body weight, body mass index (BMI), and waist circumference were retrospectively reviewed in children and adolescents who underwent ABPM due to persistently high office blood pressure. Patients were separated into two groups: a sustained hypertension group and a normal ABPM group. BMI was adjusted to z-score using the WHO Anthroplus software. WHtR was calculated by the formula: waist circumference (cm)/height (m). The performances of different parameters were analyzed using the receiver operating characteristic (ROC) curve and multivariate logistic regression.

Results

Sixty patients (63% male) with a mean age of 12.9 ± 3.7 years had persistently high office blood pressure. Twenty-nine (48.3%) had high ambulatory blood pressure parameters so-called "sustained hypertension." The sustained hypertension group had a higher mean BMI z-score (2.32 vs. 1.31, p = 0.01) and a higher mean WHtR (57.7 vs. 49.2 cm/m, p < 0.001) than those of the normal ABPM group. For the diagnosis of sustained hypertension, the ROC analysis revealed that WHtR had a greater area under the ROC curve (AUC) than that of BMI z-score (0.772 vs. 0.723). WHtR remained associated with sustained hypertension (OR 1.2, 95% CI 1.022-1.408, p = 0.026) after adjusting for age, gender, and BMI z-score.

Conclusions

Apart from being a more user-friendly metric, WHtR tended to outperform BMI z-score in predicting sustained hypertension in children and adolescents with persistently high office blood pressure.

Establishment of a scoring model for the differential diagnosis of white coat hypertension and sustained hypertension

OBJECTIVES

This study aimed to establish a scoring model for the differential diagnosis of white coat hypertension (WCH) and sustained hypertension (SHT).

METHODS

This study comprised 553 adults with elevated office blood pressure, normal renal function, and no antihypertensive medications. Through questionnaire investigation and biochemical detection, 17 parameters, such as gender and age, were acquired. WCH and SHT were distinguished by 24 h ambulatory blood pressure monitoring. The participants were randomly divided into a training set (445 cases) and a validation set (108 cases). The above parameters were screened using least absolute shrinkage and selection operator regression and univariate logistic regression analysis in the training set. Afterward, a scoring model was constructed through multivariate logistic regression analysis.

RESULTS

Finally, six parameters were selected, including isolated systolic hypertension, office systolic blood pressure, office diastolic blood pressure, triglyceride, serum creatinine, and cardiovascular and cerebrovascular diseases. Multivariate logistic regression was used to establish a scoring model. The R2 and area under the ROC curve (AUC) of the scoring model in the training set were 0.163 and 0.705, respectively. In the validation set, the R2 of the scoring model was 0.206, and AUC was 0.718. The calibration test results revealed that the scoring model had good stability in both the training and validation sets (mean square error = 0.001, mean absolute error = 0.014; mean square error = 0.001, mean absolute error = 0.025).

CONCLUSION

A stable scoring model for distinguishing WCH was established, which can assist clinicians in identifying WCH at the first diagnosis.

Blood Pressure Phenotype Variations at Different Gestational Stages and Associated Pregnancy Risks

BACKGROUND

Hypertensive disorders of pregnancy (HDP) significantly increase the risk of adverse pregnancy outcomes (APOs). Blood pressure (BP) phenotypes, including masked hypertension (MH), white-coat hypertension (WCH), sustained hypertension (SH), and normotension, are identified through office BP (OBP) and ambulatory BP (ABP) monitoring. The proportion of BP phenotypes at different gestational age and their associations with APOs are not well understood.

METHODS AND RESULTS

This retrospective study included 967 women at high risk or diagnosed with HDP who underwent OBP and ABP measurement at different gestational stages [0-19+6 (n=150), 20+0-29+6 (n=221), 30+0-32+6 (n=135), 33+0-35+6 (n=185), and ≥36+0 gestational weeks (GW) (n=276)]. Women with ABP monitored at 20+0-29+6 GW had the lowest BP levels corresponding to the highest prevalence of NT. Compared to OBP, hypertension determined by ABP demonstrated stronger and more consistent associations with APOs, defined as a composite of maternal (e.g., severe preeclampsia, preterm birth) and fetal (pregnancy loss and SGA infants) outcomes. SH was consistently associated with the highest risk for APOs, with risk decreasing as gestation advanced after 20+0 GW. MH was significantly associated with APOs, particularly between 30+0-32+6 GW. WCH had no association with fetal outcomes at any gestational stage.

CONCLUSION

The associations between BP phenotypes and APOs differ across gestational stages. SH detected earlier in pregnancy carries the highest risks, while WCH is generally benign for fetal outcomes. These findings highlight the critical role of ABP monitoring in BP phenotyping and underscore the need for gestational-stage-specific diagnostic thresholds to enable tailored interventions and optimize APOs.

Health football beats them all: subgroup analysis of the 3F (Fit&Fun with Football) study on white-coat hypertension, sustained hypertension, dippers, nondippers, and on pharmacologically un(treated) arterial hypertension

BACKGROUND

The 3F study (Fit&Fun with Football) demonstrated a significant reduction in blood pressure, antihypertensive medication, body weight, stress and depression through health football. Health football could be a popular tool to unleash the full preventive potential of physical activity. This work analyses the effect of health football on hypertensive subgroups: dipper, nondipper, white-coat hypertension (WCH), sustained hypertension, (un)treated hypertensive patients (UH, TH).

METHODS

A prospective interventional study with 1-year follow-up. Football group (FG): n  = 103, 'health'-football training (1×/week, 90 min) led by licensed football coaches. Physical inactive, hypertensive patients older than 45 years were compared with a control group (CG) ( n  = 105). Subgroups were divided by ambulatory blood pressure monitoring (ABPM), casual blood pressure (CBP), medication schedule and compared by blood pressure (BP), laboratory results and weight.

RESULTS

In all three subgroups (WCH vs. sustained hypertension, TH vs. UH, D vs. ND), health football reduced BP and weight significantly compared with the CG, and compared with the admission. An even greater effect in CBP was found in people with WCH than in sustained hypertension (FG: WCH: 141-127 mmHg, sustained Hypertension (SH): 142-132 mmHg; CG: WCH: 141-143 mmHg, SH: 140-141 mmHg). In contrast, the significant reduction in CBP and ABPM was comparable in treated and untreated patients, although antihypertensive drugs were reduced significantly more frequently in FG than in CG. BP reduction in nondippers and dippers was also comparable. In the nondipper group, nocturnal BP was significantly reduced in the FB (122.0-111.5 mmHg), but not in the CG or the dippers.

CONCLUSION

All evaluated football subgroups achieved a significant BP reduction (compared with CG). This applied to dipper, nondipper, (un)treated hypertension, WCH and SH. All mentioned subgroups displayed a clear benefit. The even greater reduction in BP in WCH demonstrates the importance of physical activity before the additional prescription of antihypertensive medications, underscoring the recommendations of the ESC and ISH in WCH.

The assessment of relationship between left ventricular geometry and microvolt T-wave alternans in sustained hypertension

OBJECTIVE

Left ventricular (LV) hypertrophy (LVH) predicts increased mortality in part due to an elevated incidence of sudden cardiac death in hypertension. The aim of the present study was to investigate the relation of microvolt T-wave alternans (MTWA) with different LV geometric patterns in patient with sustained hypertension.

METHODS

This study consisted of 311 consecutive patients with sustained hypertension who were divided into four groups according to LV geometrical patterns. 90 patients were in the normal geometry group (NGG) [mean age 49.6 ± 7.8 years; 60 males (66.7%)], 99 patients were in the concentric remodeling group (CRG) [mean age 50.9 ± 6.6 years; 50 males (50.6%)], 63 patients were in the concentric hypertrophy group (CHG) [mean age 51.6 ± 7.3 years; 32 males (50.7%)] and 58 patients were in the eccentric hypertrophy group (EHG) [mean age 51.6 ± 9.0 years; 30 males (51.7%)]. Physical examination, laboratory work-up, office blood pressure measurement, transthoracic echocardiography and MTWA measurements were performed on all participants.

RESULTS

MTWA positivity was significantly higher in EHG and CHG as compared to CRG and NGG (p < 0.001). Left ventricle mass index (LVMI), LV end-diastolic diameter (LVEDD), LV end-systolic diameter (LVESD), interventricular septum diameter (IVSd), posterior wall diameter (PWd) and office systolic blood pressure (SBP) were found to be significantly positively correlated with MTWA (all p-values < 0.05).

CONCLUSION

We demonstrated that increased LVMI is associated with an elevated MTWA positivity in sustained hypertensives. Moreover, clinically significant LV geometric patterns including both concentric and eccentric hypertrophy are related with a raised MTWA positivity, which may lead to particular predilection to life-threatening ventricular arrhythmias and sudden cardiac death in sustained hypertension.

Impact of sustained hypertension on new cardiovascular events in patients with type 2 diabetes: KAMOGAWA-HBP study

We have previously shown that masked hypertension (MH) and sustained hypertension (SH) contribute to the progression of diabetic nephropathy. Although the risk of target organ damage and cardiovascular events in MH and SH is significantly higher than that in normotension and white coat hypertension, the role of MH or SH in cardiovascular events has never been reported in studies specific to diabetic patients. Therefore, in this study, we aimed to determine whether blood pressure control status contributes to the development of new cardiovascular events. A longitudinal study of 1082 patients with type 2 diabetes mellitus and no history of cardiovascular events was conducted. Patients were instructed to have their blood pressure measured three times, every morning and evening, for 14 consecutive days. Hypertension status was classified into four groups based on the systolic blood pressure measurements in the clinic and at home. The primary endpoint was the first cardiovascular event. After a median follow-up of 7.0 (interquartile range, 4.0-9.0) years, 119 patients developed cardiovascular events. The hazard ratio (95% confidence interval) for the risk of developing cardiovascular events was significantly higher in the SH group than in the controlled blood pressure group (1.63 [1.02-2.59]). SH is a useful predictor of cardiovascular events. Both at home and in the clinic, blood pressure monitoring should be assessed in routine clinical practice to predict future cardiovascular events in patients with type 2 diabetes.

Ambulatory Blood Pressure Phenotypes, Arterial Stiffness, and Cardiac Remodeling

BACKGROUND

Evidence on the association of arterial stiffness and left ventricular (LV) concentric remodelling/LVH assessed by echocardiography, with abnormal blood pressure (BP) phenotypes, defined by office and ambulatory BP monitoring (ABPM) in the community is scanty. Thus, we investigated this issue in the participants to the Pressioni Monitorate E Loro Associazioni (PAMELA) study.

METHODS

The present study included 491 participants who attended the second and third survey of the PAMELA study performed after 10 and 25 years from the initial evaluation. Data collection included medical history, anthropometric parameters, blood examinations, office, ABPM, echocardiographic and Cardio-Ankle Vascular Index (CAVI) measurements.

RESULTS

In the whole study sample (age 66+10 years, 50% males), the prevalence rates of sustained normotension (NT), white coat hypertension (WCH), masked hypertension (MH), sustained hypertension (SH) and non-dipping (ND) were 31.2, 10.0, 24.2, 34.6, and 35.8% and respectively. The likelihood of having SH, the BP phenotype carrying the greatest CV risk, was four times higher (OR= 4.31, CI:2.39-7.76, p<0.0001) in participants with increased CAVI and LV remodelling/LVH compared to their counterparts without organ damage. This association showed an incremental value in discriminating SH compared to both isolated markers of organ damage (OR=1.92,p=0.03 for increased CAVI and OR= 2.02, p=0.02 for LV remodelling/LVH). The presence of isolated but also combined organ damage was unrelated to ND.

CONCLUSIONS

Our study provides new evidence of the incremental value of looking for both vascular and cardiac target organ damage to optimize the identification and clinical management of SH in the general population.