Conventional and ambulatory blood pressure measurement in older patients with isolated systolic hypertension:second progress report on the ambulatory blood pressure monitoring project in the Syst-Eur trial

OBJECTIVES: To compare clinic and ambulatory blood pressure measurement and the reproducibility of these measurements in older patients with isolated systolic hypertension.PATIENTS: A total of 477 patients aged >/= 60 years with isolated systolic hypertension on clinic measurement were monitored during the placebo run-in phase of the Syst-Eur trial. METHODS: The time-weighted 24 h blood pressure, clock time day and night blood pressure, the cumulative sum-derived crest and trough blood pressure and the high and low blood pressure levels of the square-wave model were computed. The daily alteration between the high and low blood pressure spans was quantified using the clock time day-night difference, the cumulative sum-derived circadian alteration magnitude, the Fourier amplitude and the difference between the high and low blood pressure levels of the square-wave model. RESULTS: The daytime ambulatory systolic blood pressure was, on average, 21 mmHg lower than the clinic blood pressure, whereasthe diastolic blood pressure was, on average, similar with both techniques of measurement. In the 132 patients who underwent repeat measurements, clinic blood pressure levels and the parameters describing the difference betgween the daily high and low blood pressure spans were equally reproducible. However, both were less reproducible than the ambulatory blood pressure levels. The repeatability coefficients, expressed as percentages of near maximum variation, were 50 and 51% for the clinic systolic and diastolic blood pressures, 30 and 33% for the mean 24 h systolic and diastolic blood pressures and between 44 and 54% for the parameters describing the daily alteration between the high and low blood pressure spans. CONCLUSION: In older patients with isolated systolic hypertension, clinic and ambulatory systolic blood pressure may differ greatly; the prognostic significance of this difference remains to be elucidated. Furthermore, the level of blood pressure in these patients is more reproducible by ambulatory measurement than it is by clinic measurement.     

老年单纯性收缩期高血压的24h血压及脉压特征

目的　了解老年单纯性收缩期高血压的 2 4h动态血压特征及脉压情况。方法　收集 2 0 0 1年以来门诊及病房的老年单纯性收缩期高血压 12 1例 ,男 5 3例 ,女 6 8例 ,年龄≥ 6 0岁。所有患者均作 2 4h动态血压监测。结果　随着年龄的增加 ,老年单纯收缩期高血压患者的诊室、2 4h、白天及夜间的收缩压 (SBP)均有不同程度的升高 ,舒张压 (DBP)却有不同程度的下降 ;所有患者的脉压 (PP)均明显增大 (PP >6 5mmHg) ;不同年龄组之间 2 4h、白天、夜间的PP随着年龄的增大而增加 (P <0 .0 5 )。年龄 >70岁组的 2 4h和白天的DBP水平显著低于年龄≤ 70岁组 (P <0 .0 5 )。体重指数 (BMI)≥ 2 5患者组的 2 4h平均SBP、夜间平均SBP及DBP均高于BMI<2 5组 (P <0 .0 5 )。动态血压的夜间SBP和DBP的下降率分别为 4 .6 %和 7.0 % ,昼夜节律减弱。白天和夜间的SBP负荷明显增加 ,而DBP负荷正常。结论　随着年龄的增大 ,老年单纯收缩期高血压患者的诊室、2 4h、白天及夜间的SBP均有升高 ,SBP负荷和脉压明显增加 ;昼夜节律减弱     

老年单纯收缩期高血压患者动态血压参数对脑白质病变的影响

目的探讨老年单纯收缩期高血压(ISH)患者24h动态血压参数对脑白质病变(WML)的影响。方法选择老年ISH患者96例,根据WML评分标准分为无-轻度WML组49例和中-重度WML组47例,比较2组患者一般情况及动态血压参数。结果中-重度WML组24h收缩压、昼间收缩压、夜间收缩压、昼间收缩压变异系数、夜间收缩压变异系数、非杓型、反杓型比例明显升高,而24h舒张压、昼间舒张压、夜间舒张压及杓型比例明显降低(P<0.05)。多因素logistic回归分析显示,24h收缩压(OR=2.89,95%CI:1.14~5.89,P=0.016)、昼间收缩压变异系数(OR=1.75,95%CI:1.30~3.42,P=0.005)、夜间收缩压变异系数(OR=1.46,95%CI:0.99~1.55,P=0.001)及年龄(OR=1.13,95%CI:0.82~1.57,P=0.021)是WML的独立危险因素。结论老年ISH患者24h收缩压、昼间收缩压变异系数、夜间收缩压变异系数是WML的独立危险因素,高收缩压、低舒张压、高收缩压变异系数及异常的血压节律对WML的发生、发展有不良影响。     

Comparison between office and ambulatory blood pressure in young and elderly subjects with isolated systolic hypertension

BACKGROUND: It has been claimed that isolated systolic hypertension (ISH) in the elderly is not a sustained condition but a short-lasting increase in office systolic blood pressure magnified by arterial stiffness. DESIGN: Office and ambulatory blood pressures werecompared at baseline and after 3 months of observation of young and elderly subjects with ISH. METHODS: The study was carried out in 39 young (mean age 27.1+/-9.8 years) and 37 elderly patients (mean age 72.5+/-5.7 years). Office blood pressure was defined as the mean of six readings. All subjects underwent two non-invasive 24 h blood pressure monitorings performed 3 months apart and echocardiography (n = 50). RESULTS: The difference between office and mean 24 h systolic/diastolic blood pressure was 27.9/8.2 mmHg in the young and 18.9/6.9 mmHg in the elderly patients (P < 0.01 for systolic blood pressure). Twenty-four-hour (P < 0.001), daytime (P = 0.001) and night-time (P < 0.001) systolic blood pressures were higher in the elderly and the difference between daytime and night-time systolic blood pressure was greater in the young (P < 0.05). Office and ambulatory heart rates were significantly higher in the young subjects. The elderly patients showed a greater left ventricular wall thickness ( P = 0.005 for posterior wall; P < 0.005 for septum), relative wall thickness (P = 0.01) and left ventricular mass index (P = 0.001) and impaired left ventricular filling rate ( P = 0.05), whereas systolic performance and stroke volume were no different in the two groups. Due to the higher heart rate, cardiac output was greater in the young (P = 0.03). CONCLUSION: These data show that larger differences between office and ambulatory systolic blood pressure are not unique to elderly patients with ISH. Increased ambulatory blood pressure levels and a decreased nocturnal blood pressure fall were associated with left ventricular structural and functional abnormalities in the elderly subjects.     

高龄老年高血压患者动态血压特点

目的探讨高龄老年高血压患者动态血压特点。方法选择我院心血管内科及老年医学科住院的高血压患者265例,按年龄分为高龄老年组(年龄≥80岁)94例、老年组(60～79岁)90例和60岁组81例,行动态血压监测,分析其血压节律、3个时段(24h、昼间及夜间)血压均值及血压变异性的特点。结果高龄老年组和老年组杓型血压发生率、24h舒张压、昼间舒张压、昼间平均压、夜间舒张压明显低于60岁组,反杓型血压发生率、24h脉压、昼间脉压、夜间收缩压、夜间脉压明显高于60岁组(P0.05,P0.01);高龄老年组杓型血压发生率及24h、昼间、夜间舒张压明显低于老年组[13.83%vs 26.66%,(66.17±7.39)mm Hg(1mm Hg=0.133kPa)vs (70.39±10.96)mm Hg,(66.90±7.55)mm Hg vs (70.88±11.68)mm Hg,(64.10±8.14)mm Hg vs (68.27±11.86)mm Hg,P0.05,P0.01],24h、夜间脉压明显高于老年组(P0.05,P0.01),昼间收缩压变异明显高于老年组和60岁组,24h收缩压变异高于60岁组,差异有统计学意义(P0.01);老年组24h平均压明显低于60岁组(P0.05)。结论高龄老年高血压患者动态血压表现出血压节律异常、脉压增大、血压变异性升高等特点。     

Treatment of isolated systolic hypertension in the elderly: the Syst-Eur trial. Systolic Hypertension in Europe (Syst-Eur) Trial Investigators.

The Syst-Eur study investigated whether active antihypertensive treatment could reduce cardiovascular complications in elderly patients with isolated systolic hypertension. Patients (> or = 60 years) were randomly assigned to active treatment (n = 2398), i.e. nitrendipine, with the possible addition of enalapril and hydrochlorothiazide, or matching placebos (n= 2297). In the intention-to-treat analysis, the between-group difference in blood pressure amounted to 10.1/4.5 mm Hg (P < 0.001). Active treatment reduced the total incidence of stroke (primary endpoint) by 42% (P = 0.003), of all cardiac endpoints by 26% (P = 0.03), and of all cardiovascular endpoints combined by 31% (P < 0.001). Cardiovascular mortality was slightly lower on active treatment (-27%; P = 0.07), but all-cause mortality was not influenced (-14%; P = 0.22). For total (P = 0.009) and cardiovascular mortality (P = 0.09), the benefit of antihypertensive treatment weakened with advancing age and for total mortality it decreased with higher systolic blood pressure at entry (P = 0.05). The benefits of active treatment were not independently related to gender or to the presence of cardiovascular complications at entry. Further analyses also suggested benefit in patients who were taking nitrendipine as the sole therapy. The per-protocol analysis largely confirmed the intention-to-treat results. It can be concluded that stepwise antihypertensive drug treatment, starting with the dihydropyridine calcium channel blocker nitrendipine, improves prognosis in elderly patients with isolated systolic hypertension.     

Ambulatory blood pressure monitoring in elderly patients with isolated systolic hypertension.

OBJECTIVES: This study compared clinic and ambulatory blood pressure measurement and the reproducibility of these measurements in older patients with isolated systolic hypertension (ISH). PATIENTS: Eighty-seven patients aged greater than or equal to 60 years with ISH on clinic measurement were followed in the placebo run-in phase of the Syst-Eur trial. METHODS: Clinic blood pressure was defined as the mean of two blood pressure readings on each of three clinic visits (six readings in total). Ambulatory blood pressure was measured over 24 h using non-invasive ambulatory blood pressure monitors. RESULTS: Daytime ambulatory systolic pressure was, on average, 21 mmHg lower than the clinic blood pressure, whereas diastolic pressure was, on average, similar with both techniques of measurement. In the 42 patients who had repeat measurements, clinic blood pressure levels nad the amplitude of the diurnal blood pressure profile (fitted by Fourier analysis) were equally reproducible. However, both were less reproducible than ambulatory blood pressure levels. The repeatability coefficients, expressed as per cent of near maximum variation (four times the standard deviation of a given measurement), were 52% and 45% for the clinic systolic and diastolic pressures, 56% and 42% for the amplitude of the diurnal profile, and 29% and 26% for mean 24-h pressures. CONCLUSIONS: In older patients with ISH, clinic and ambulatory systolic blood pressure measurements may differ largely: the prognostic significance of this difference remains to be elucidated. Furthermore, in these patients the level of pressure is more reproducible by daytime ambulatory blood pressure measurement than by clinic measurement.     

高龄老年高血压患者动态血压和动态心电图特点及临床分析

目的分析高血压患者的24h动态血压、心电图的特点，并结合临床分析，为临床高龄老年高血压防治提供可参考依据。方法共入选老年高血压患者214例，按年龄分为两组，A组：高龄老年组（≥80岁）96例；B组：低龄老年组（60～79岁）118例。采用24h动态血压和24h动态心电图同步监测技术，记录血压和心电图变化，同时采集多次住院病历，观察高血压患者治疗过程中血压控制情况，心律失常以及靶器官损害发生情况。结果高龄老年组的大部分患者血压控制良好。24h动态血压水平两组之间仍有明显差异，高龄老年组心律失常、心脑血管事件次数、糖尿病、体重指数、左心室重量指数等均显著高于低龄老年组。结论与低龄老年组相比，80岁以上的高龄老年高血压患者肾损害明显，其24h动态血压水平与动态心电图改变及肾损害之间密切相关。     

阿托伐他汀并厄贝沙坦对单纯收缩期高血压患者脉压的影响

目的：观察阿托伐他汀和厄贝沙坦片联合用药对老年单纯收缩期高血压（ISH）患者脉压（PP）的影响。方法：64例老年ISH患者被随机分为两组，对照组32例用厄贝沙坦（150mg／d），治疗组32例用厄贝沙坦（150mg／d）加阿托伐他汀（10mg／d），观察12周，每2周随访血压1次并记录。结果：在治疗12周时，对照组PP从治疗前（74．67±7．77）mmHg降至（67．37±5．53）mmHg；治疗组PP从治疗前（75．06±6．96）mmHg降至（59．75±5．92）mmHg。治疗后两组PP的差异有显著性（t=5．255，P〈0．01）。结论：阿托伐他汀和厄贝沙坦联合用药有助于改善老年ISH患者的PP。     

Reproducibility of ambulatory blood pressure measurements in essential hypertension

BACKGROUND: Data on the reproducibility of serial measurements of ambulatory blood pressure in hypertensive patients are lacking. The purpose of this study was to examine (1) the reproducibility of four consecutive ambulatory blood pressure measurements, and (2) the reproducibility of nocturnal falls in blood pressure in hypertensive patients. METHODS: Twenty patients with mild to moderate essential hypertension underwent four separate ambulatory blood pressure monitorings, on the same day of the week, at 30-day intervals. Antihypertensive therapy was discontinued for 2 weeks before each recording. Comparing the mean values of blood pressure over 24h, as well as diurnal, nocturnal and hourly periods, among the four recordings determined the reproducibility of blood pressure measurements. A day/night difference in mean systolic and in mean diastolic blood pressure defined the nocturnal fall in blood pressure. RESULTS: No significant differences were observed in either hourly, 24-h, diurnal or nocturnal systolic blood pressure, diastolic blood pressure and heart rate, or in the nocturnal fall in systolic and diastolic blood pressure among the four recordings. CONCLUSIONS: Hourly systolic blood pressure, diastolic blood pressure, heart rate, and nocturnal fall in blood pressure were reproducible in four ambulatory blood pressure monitorings recorded over 4 months. These findings suggest that ambulatory blood pressure monitoring is a reliable tool to monitor blood pressure changes.     

Renin dependency of blood pressure in isolated systolic hypertension

The role of the renin system in the maintenance of the elevated systolic blood pressure in isolated systolic hypertension was investigated in 31 patients who received long-term treatment with propranolol (120 mg daily) and in another group of 22 patients with isolated systolic hypertension who received a test dose of captopril (25 or 50 mg). The greatest systolic blood pressure decrease (35 +/- 5 mm Hg) by propranolol occurred in the high-renin group (n = 9), and the smallest decrease (3 +/- 2 mm Hg) in the low-renin group (n = 9), whereas in the normal-renin group (n = 13), systolic blood pressure was decreased by propranolol by 22 +/- 5 mm Hg. For all the propranolol-treated patients, the decrement in the systolic blood pressure by propranolol was related to the control plasma renin activity (r = 0.63, p less than 0.01) and to the concurrent change in plasma renin activity (r = 0.70, p less than 0.001). Captopril decreased the systolic blood pressure by 55 +/- 10 mm Hg in the high-renin group (n = 11) and by 17 +/- 5 mm Hg in the normal-renin group (n = 6), whereas the smallest decrease (12 +/- 5 mm Hg) in systolic blood pressure occurred in the low-renin group (n = 5). In all the captopril-tested patients (n = 22), the decrease in systolic blood pressure by captopril was related to the control plasma renin activity (r = 0.75, p less than 0.001). These results indicate that the plasma renin activity value indicates the participation of the renin-angiotensin system in the maintenance of the elevated systolic blood pressure in patients with isolated systolic hypertension.     

Short-term and long-term repeatability of the morning blood pressure in older patients with isolated systolic hypertension

OBJECTIVE: Using 24-h ambulatory blood pressure monitoring, we studied the repeatability of the morning blood pressure in older (> or =60 years) patients with isolated systolic hypertension. METHODS: The sleep-through morning surge was the morning blood pressure minus the lowest nighttime blood pressure. The preawake morning surge was the morning blood pressure minus the preawake blood pressure. In addition, we determined the cusum plot height of blood pressure from 04:00 to 10:00 h from a plot of cumulative sums. RESULTS: In 173 patients with repeat recordings within 33 days (median), the short-term repeatability coefficients, expressed as percentages of maximal variation, ranged from 35 to 41% for the daytime and nighttime blood pressures and from 50 to 56% for the night-to-day blood pressure ratios. Short-term repeatability ranged from 52 to 75% for the sleep-through and the preawake morning surge, and from 51 to 62% for the cusum plot height. In 219 patients with repeat recordings within 10 months (median), the corresponding long-term estimates ranged from 45 to 64%, from 69 to 71%, from 76 to 83%, and from 50 to 78%, respectively. In categorical analyses of the short-term repeatability of the sleep-through morning surge and the preawake morning surge, using the 75th percentile as arbitrary cut-off, surging status changed in 28.0 and 26.8% of patients (kappa-statistic < or =0.33). In the long-term interval, these proportions were 32.0 and 32.0%, respectively (kappa-statistic < or =0.20). The kappa-statistic threshold for moderate reproducibility is 0.4. CONCLUSION: The morning surge of blood pressure is poorly reproducible, irrespective of whether it is analysed as continuous or categorical variable.     

Relation of baseline systolic blood pressure and long-term outcomes in ambulatory patients with chronic mild to moderate heart failure

We studied the impact of baseline systolic blood pressure (SBP) on outcomes in patients with mild to moderate chronic systolic and diastolic heart failure (HF) in the Digitalis Investigation Group trial using a propensity-matched design. Of 7,788 patients, 7,785 had baseline SBP data and 3,538 had SBP ≤ 120 mm Hg. Propensity scores for SBP ≤ 120 mm Hg, calculated for each of the 7,785 patients, were used to assemble a matched cohort of 3,738 patients with SBP ≤ 120 and >120 mm Hg who were well-balanced in 32 baseline characteristics. All-cause mortality occurred in 35% and 32% of matched patients with SBPs ≤ 120 and >120 mm Hg respectively, during 5 years of follow-up (hazard ratio [HR] when SBP ≤ 120 was compared to >120 mm Hg 1.10, 95% confidence interval [CI] 0.99 to 1.23, p = 0.088). HRs for cardiovascular and HF mortalities associated with SBP ≤ 120 mm Hg were 1.15 (95% CI 1.01 to 1.30, p = 0.031) and 1.30 (95% CI 1.08 to 1.57, p = 0.006). Cardiovascular hospitalization occurred in 53% and 49% of matched patients with SBPs ≤ 120 and > 120 mm Hg, respectively (HR 1.13, 95% CI 1.03 to 1.24, p = 0.008). HRs for all-cause and HF hospitalizations associated with SBP ≤ 120 mm Hg were 1.10 (95% CI 1.02 to 1.194, p = 0.017) and 1.21 (95% CI 1.07 to 1.36, p = 0.002). In conclusion, in patients with mild to moderate long-term systolic and diastolic HF, baseline SBP ≤ 120 mm Hg was associated with increased cardiovascular and HF mortalities and all-cause, cardiovascular, and HF hospitalizations that was independent of other baseline characteristics.     

Twenty-four hour blood pressure monitoring in the Syst-Eur trial.

This article describes the objectives and protocol of a study on ambulatory blood pressure in elderly patients with isolated systolic hypertension. This study constitutes an optional side-project to the Syst-Eur trial. The multicentre Syst-Eur trial investigates whether antihypertensive treatment of elderly patients with isolated systolic hypertension will influence the incidence of stroke. Secondary endpoints include cardiovascular events, such as myocardial infarction. The main objective of the side-project is to investigate whether ambulatory blood pressure monitoring will improve the prediction of cardiovascular complications based on blood pressure measurement in the clinic. The side-project also provides the opportunity to evaluate the diurnal profile of blood pressure in elderly patients with isolated systolic hypertension randomized to placebo or active antihypertensive treatment.     

Systolic blood pressure reduction with olmesartan medoxomil versus nitrendipine in elderly patients with isolated systolic hypertension

OBJECTIVE: The prevalence of isolated systolic hypertension (ISH) is high in the elderly, and the objective of this study was to compare the antihypertensive efficacy of olmesartan medoxomil with that of nitrendipine in elderly (65-74 years) and very elderly (>/= 75 years) male and female patients with ISH. METHODS: Patients were randomized to 24 weeks of treatment with either olmesartan medoxomil 20 mg daily (n = 256) or nitrendipine 20 mg (n = 126) twice daily, with possible dose increase (to 40 mg daily) and addition of hydrochlorothiazide (HCTZ) 12.5 or 25 mg daily if required. RESULTS: On the primary endpoint [reduction in mean sitting systolic blood pressure (SBP) after 12 weeks of treatment], the two treatments were similar (olmesartan medoxomil, -30.0 mmHg; nitrendipine, -31.4 mmHg). No significant difference between the treatment groups was observed, and non-inferiority of olmesartan medoxomil to nitrendipine was demonstrated using an analysis of covariance (ANCOVA) model. Reductions in mean sitting and standing SBP and diastolic blood pressure (DBP) up to week 24 were also similar with both treatments. Blood pressure (BP) goal attainment rates (sitting SBP 相似文献   

Lowering of blood pressure and coronary blood flow in isolated systolic hypertension.

BACKGROUND: In essential hypertension, the lower limit of autoregulation of coronary flow shifts to higher perfusion and the hypertensive ventricle is at a higher than normal risk of ischemia, and less able to tolerate acute reduction of coronary perfusion pressure. Little is known about pattern of coronary flow in isolated systolic hypertension, a pathologic condition in which the elevated systolic blood pressure is associated with a lower than normal vascular compliance and normal or slightly greater than normal mean arterial pressure and vascular resistance. OBJECTIVE: To evaluate the effects of rapid normalization of blood pressure on coronary blood flow in isolated systolic hypertension. METHODS: We subjected 20 patients with isolated systolic hypertension to intraoperative hemodynamic and transesophageal echocardiographic monitoring during peripheral vascular surgery. Coronary flow velocity integrals and diameters in the left anterior descending coronary artery were evaluated under baseline conditions and after normalization of blood pressure, which occurred spontaneously during anesthesia (10 cases; group 1A) or was induced by infusion of nitrate (10 cases, group 1B). RESULTS: After normalization of systolic blood pressure integrals decreased significantly only for patients in group 1A; percentage changes of diameter were significantly greater for patients in group 1B. Therefore, coronary blood flow after normalization of systolic blood pressure increased for patients in group 1B (by 28+/-25%) and decreased for patients in group 1A (by 30+/-21%). Changes in integrals were inversely related to those in diameter (r= -0.72, P < 0.001); for patients in group 1A changes in coronary perfusion pressure and diameter were related to those of integrals (r= 0.94; P < 0.0005). CONCLUSIONS: In isolated systolic hypertension, despite there being similar changes of the systolic blood pressure, administration of nitrates caused a marked increase of coronary flow through direct effects on coronary circulation, whereas spontaneous normotension was associated with a significant reduction of coronary flow.     

Modest salt reduction lowers blood pressure in isolated systolic hypertension and combined hypertension

Many randomized trials have shown that a reduction in salt intake lowers blood pressure in hypertensive individuals. However, few have looked at the effects according to hypertension category. A recent analysis of the third and fourth National Health and Nutrition Examination Survey suggests that salt intake may not be related to blood pressure in isolated systolic or combined hypertension. To look at this further, we reanalyzed the data of our previous salt reduction trials. Hypertensive individuals were studied in randomized double-blind crossover studies: 1 month of usual salt intake compared with 1 month of reduced salt intake. In isolated systolic hypertension (n=24), blood pressure was reduced from 166+/-19/86+/-7 to 156+/-20/85+/-7 mm Hg (systolic P<0.001; diastolic P=0.459) with a reduction in urinary sodium from 175+/-51 to 87+/-38 mmol per 24-hour period (10.3 to 5.1 g per day of salt). In combined hypertension (n=88), blood pressure was reduced from 161+/-16/100+/-9 to 154+/-17/96+/-9 mm Hg (P<0.001) with a reduction urinary sodium from 176+/-65 to 98+/-51 mmol per 24-hour period (10.4 to 5.8 g per day of salt). These results demonstrate that salt reduction has a significant effect on blood pressure in isolated systolic and combined hypertension. The fall in systolic observed in isolated systolic hypertension would be predicted to reduce stroke by approximately one third, ischemic heart disease by one quarter, and heart failure by one quarter in the population between 60 and 80 years of age, in whom isolated systolic hypertension is the predominate form of hypertension and carries the highest risk. These results provide strong support for universal salt reduction in all hypertensives.