Weekly variation of home and ambulatory blood pressure and relation between arterial stiffness and blood pressure measurements in community-dwelling hypertensives

Although blood pressure (BP) is a major determinant of pulse wave velocity (PWV), some treatments have independent effects on BP and arterial stiffness. Although both ambulatory BP (ABP) and self-measured BP at home (HBP) have become important measures for the diagnosis and management of hypertension, single day recordings may be insufficient for a proper diagnosis of hypertension or the evaluation of treatment efficacy. To evaluate weekly variations in BP using 7-day HBP and 7-day ABP monitoring and to determine the relation between arterial stiffness and BP measurements in community-dwelling patients with hypertension. We enrolled 68 community-dwelling hypertensive subjects in this study. Significant weekly variations in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were found in the awake ABP data (p < .01, respectively), while no significant weekly variations in the asleep ABP or the morning and evening HBP data were observed. In untreated subjects, significant correlations were obtained between the brachial-ankle PWV and the average awake SBP, the average asleep SBP and the average SBP measured by HBP in the evening. In treated subjects, only the average SBP measured by HBP in the morning was significantly correlated with the baPWV. Differences in the weekly variations in BP were observed between HBP and ABP monitoring. In addition, the morning systolic HBP was not correlated with arterial stiffness in untreated subjects with hypertension but was correlated in treated subjects. Relations between the morning HBP and arterial stiffness might be attributed to morning surges in BP and/or trough levels of antihypertensive drugs.     

Weekly Variation of Home and Ambulatory Blood Pressure and Relation Between Arterial Stiffness and Blood Pressure Measurements in Community-Dwelling Hypertensives

Although blood pressure (BP) is a major determinant of pulse wave velocity (PWV), some treatments have independent effects on BP and arterial stiffness. Although both ambulatory BP (ABP) and self-measured BP at home (HBP) have become important measures for the diagnosis and management of hypertension, single day recordings may be insufficient for a proper diagnosis of hypertension or the evaluation of treatment efficacy. To evaluate weekly variations in BP using 7-day HBP and 7-day ABP monitoring and to determine the relation between arterial stiffness and BP measurements in community-dwelling patients with hypertension. We enrolled 68 community-dwelling hypertensive subjects in this study. Significant weekly variations in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were found in the awake ABP data (p < .01, respectively), while no significant weekly variations in the asleep ABP or the morning and evening HBP data were observed. In untreated subjects, significant correlations were obtained between the brachial-ankle PWV and the average awake SBP, the average asleep SBP and the average SBP measured by HBP in the evening. In treated subjects, only the average SBP measured by HBP in the morning was significantly correlated with the baPWV. Differences in the weekly variations in BP were observed between HBP and ABP monitoring. In addition, the morning systolic HBP was not correlated with arterial stiffness in untreated subjectswith hypertension but was correlated in treated subjects. Relations between the morning HBP and arterial stiffness might be attributed to morning surges in BP and/or trough levels of antihypertensive drugs.     

Lack of adequate blood pressure control in the morning and evening periods in medicated hypertensive patients considered to be controlled in the office.

BACKGROUND AND AIM: In hypertensive patients tight blood pressure (BP) control during the critical morning and evening periods may be relevant for preventing cardiovascular events, which most frequently occur at these times of the day. METHODS: In a prospective study we evaluated 24h ambulatory BP (ABP) values (24h, daytime, nighttime, morning period between 6-10 am and evening period between 6-10 pm), in 103 hypertensive patients (HTs), aged between 18-79 years, considered to be controlled in the office in the previous two months (office BP < 140/90 mmHg, 2 x 3 readings, before taking medication), who were being treated with antihypertensive drugs taken once daily in the morning. Based on ABP data, HTs were considered to have good BP control if daytime BP values were < 135/85 mmHg, < 133.1/85.4 mmHg during the morning period, and < 138.1/89.3 mmHg during the evening period. Otherwise control of ABP was considered poor. These limits correspond to the upper 95% confidence limits of BP calculated for each period in a normotensive control population of 210 subjects age-matched to the HTs. RESULTS: Of the 103 HTs, 39 were under monotherapy and the remaining 64 on combination regimens (34 with two drugs, 29 with three and one with four). Based on ABP data of the 103 HTs, poor ABP control was observed in 36 (35%) in the morning period, in 24 (23%) in the evening period and in 29 (28%) for daytime BP values. ABP values during both the morning and evening periods correlated significantly with daytime values (r = 0.72 and r = 0.89 respectively, p < 0.01) but not with office values. CONCLUSIONS: A significant proportion of treated HTs who are considered to be controlled in the office present abnormally high ABP levels, particularly in the critical early morning period, but also during the evening and throughout the daytime period.     

An ambulatory blood pressure monitoring study of the comparative antihypertensive efficacy of two angiotensin II receptor antagonists,irbesartan and valsartan

BACKGROUND: The primary objective of this study was to compare the change from baseline in mean diastolic ambulatory blood pressure (ABP) at 24 h post dose (trough measurement) after 8 weeks of treatment with irbesartan or valsartan in subjects with mild-to-moderate hypertension. Secondary objectives included comparing the mean changes from baseline in systolic ABP at trough; 24-h ABP; morning and night-time ABP; self-measured systolic blood pressure (SBP) and diastolic blood pressure (DBP); and office-measured SBP and DBP at trough. DESIGN: After a 3-week, single blind, placebo lead-in period, 426 subjects were randomized to receive either irbesartan 150 mg or valsartan 80 mg for 8 weeks. METHODS: Ambulatory blood pressure measurements were obtained at baseline and at week 8. Self-measured morning and evening DBP and SBP readings were obtained at home over a 7-day period at baseline and at week 8. Office-measured seated DBP and SBP measurements were obtained at trough, at baseline, and at week 8. RESULTS: Irbesartan demonstrated significantly greater reductions than valsartan for mean change from baseline in diastolic ABP at trough (-6.73 versus -4.84 mmHg, respectively; P = 0.035). Irbesartan produced significantly greater reductions than valsartan for mean systolic ABP at trough (-11.62 versus -7.5 mmHg, respectively; P < 0.01) and for mean 24-h diastolic ABP (-6.38 versus -4.82 mmHg, respectively; P = 0.023) and systolic ABP (-10.24 versus -7.76 mmHg; P < 0.01). Irbesartan also produced significantly greater reductions than valsartan for office-measured seated DBP (-10.46 versus 7.28 mmHg, respectively; P < 0.01) and SBP (-16.23 versus -9.96 mmHg, respectively; P < 0.01) and for self-measured morning DBP (-6.28 versus -3.75 mmHg, respectively; P < 0.01) and SBP (-10.21 versus -6.97 mmHg, respectively; P < 0.01). Both drugs were well tolerated. CONCLUSION: Irbesartan was more effective than valsartan in reducing DBP and SBP at trough and in providing greater overall 24-h blood pressure-lowering efficacy.     

The effect of high evening blood pressure on obstructive sleep apnea–related morning blood pressure elevation: does sex modify this interaction effect?

Purpose

Obstructive sleep apnea (OSA) can lead to increased morning blood pressure (BP). We hypothesized that high evening BP may aggravate OSA-related morning BP elevation. Additionally, this interactional effect may be modified by sex.

Methods

This retrospective, cross-sectional study included newly diagnosed OSA patients with an apnea-hypopnea index (AHI) ≥?5 per hour on a full-night polysomnography. An analysis of covariance (ANCOVA) was used to determine whether severe OSA (AHI?≥?30) was associated with higher morning BP than mild-to-moderate OSA (5?≤?AHI?<?30) and whether there was an interaction between apnea severity and evening BP on morning BP. To identify the sex effects, analyses were performed separately in each sex group.

Results

A total of 1445 patients with an average age of 51.9 years (SD 11.7) (male 77.9% vs. female 22.1%; high evening BP group 22.4% vs. normal evening BP group 59.6%) were included in the study. Based on the ANCOVA, patients with severe OSA had significantly higher morning systolic BP (SBP) (p?=?0.003), diastolic BP (DBP) (p?<?0.001), and mean BP (MBP) (p?<?0.001) than the mild-to-moderate group in male subjects. A significant interaction between apnea severity and evening BP was identified on morning DBP and MBP in male subjects. However, there were no differences in morning BP between severe and mild-to-moderate OSA groups in female subjects.

Conclusions

In male subjects, severe OSA contributed to higher morning BP than mild-to-moderate OSA. OSA-associated morning BP elevation was more prominent in the high evening BP group than in the normal BP group. Such relations were not found in female subjects.

     

Transient but not sustained blood pressure increments by occupational noise. An ambulatory blood pressure measurement study

OBJECTIVE: Studies on the effects of chronic exposure to industrial noise on clinic blood pressure (BP) at rest have yielded inconsistent results. The aim of this study was to evaluate the effect of occupational noise exposure on ambulatory blood pressure (ABP) in normotensive subjects. METHODS: We studied 476 normotensive workers, aged 20-50 years (systolic blood pressure (SBP) < 140, diastolic blood pressure (DBP) < 90), at a metallurgical factory; 238 were exposed to high levels of noise (> 85 dB), while 238 were not exposed (< 80 dB). Clinical evaluation included measurements of casual BP (by standard mercury sphygmomanometer, Korotkoff sound phase I and V) and heart rate (HR) (by pulse palpation), body height and weight. All subjects underwent a 24 h non-invasive ABP monitoring (by SpaceLabs 90207 recorder; SpaceLabs, Redmond, Washington, USA) twice within 14 days: one during a normal working day and one during a non-working day. Measurements were performed every 15 min. Computed analysis of individual recordings provided average SBP, DBP and HR values for 24 h, daytime working hours (0800-1700 h), daytime non-working hours (1700-2300 h) and night-time (2300-0800 h). RESULTS: No significant difference in clinic SBP, DBP and HR was observed between exposed and non-exposed subjects. Results obtained by ABP monitoring showed in the exposed workers: (a) a higher SBP (by a mean of 6 mmHg, P < 0.0001 versus controls) and DBP (by a mean of 3 mmHg, P < 0.0001) during the time of exposure and the following 2 or 3 h, whereas no difference between the two groups was found during the non-working day; (b) an increase in HR, which was present not only during the time of exposure to noise (+3.7 beats-per-minute (bpm), P < 0.0001 versus controls), but also during the non-working hours (+2.8 bpm, P < 0.001) and during the day-time hours of the non-working day (+2.8 bpm, P < 0.003); (c) a significant increase in BP variability throughout the working day. CONCLUSIONS: These findings suggest that in normotensive subjects below the age of 50 years, chronic exposure to occupational noise is associated with a transient increase in BP, which is not reflected in a sustained BP elevation. The possible role of repeated BP and HR fluctuations due to frequent and prolonged exposure to noise in accounting for the higher prevalence of hypertension reported in noise-exposed workers above age 50 years, requires longitudinal studies to be clarified.     

Impact of blood pressure variability on cardiac and cerebrovascular complications in hypertension

BACKGROUND: The independent prognostic value of daytime and night-time blood pressure (BP) variability estimated by noninvasive 24-h BP monitoring is unclear. METHODS: We followed 2649 initially untreated subjects with essential hypertension for up to 16 years (mean, 6). Variability of BP was estimated by the standard deviation of daytime or night-time systolic BP (SBP) and diastolic BP (DBP). A BP variability either less than or equal to the group median or greater than the group median (12.7/10.4 mm Hg for daytime SBP/DBP and 10.8 and 8.9 mm Hg for night-time SBP/DBP) identified subjects at low or high BP variability. RESULTS: During follow-up there were 167 new cardiac and 122 new cerebrovascular events. The rate of cardiac events (x100 person-years) was higher (all P < .05) in the subjects with high than in those with low BP variability (daytime SBP: 1.45 v 0.72, daytime DBP: 1.29 v 0.91; night-time SBP: 1.58 v 0.62; night-time DBP: 1.32 v 0.85). The rate of cerebrovascular events was also higher (all P < .05) in the subjects with high than in those with low BP variability. In a multivariate analysis, after adjustment for several confounders, a high night-time SBP variability was associated with a 51% (P = .024) excess risk of cardiac events. The relation of daytime BP variability to cardiac events and that of daytime and night-time BP variability to cerebrovascular events lost significance in the multivariate analysis. CONCLUSIONS: An enhanced variability in SBP during the night-time is an independent predictor of cardiac events in initially untreated hypertensive subjects.     

Determinants of the Awakening Rise in Systemic Blood Pressure in Obstructive Sleep Apnea Syndrome

To investigate the factors responsible for the morning rise in blood pressure (BP) in obstructive sleep apnea syndrome (OSAS) we examined a group of 253 consecutive snorers or OSAS patients. On the basis of their AHI the patients were classified in four groups. BP was measured on the evening before sleep onset and on the following morning after 15min of rest by a finger arterial pressure device (Finapres). In 150 subjects BP was monitored during the night by a Finapres device. In the morning BP increased in the patient group with an average difference of 9.9 0.5 mmHg for systolic (SBP) and 9.9 0.4 mmHg for diastolic pressure (DBP). The increase was significant in snorers and OSAS patients without differences between groups. The morning rise in SBP was related to diurnal values of SBP, age and AHI whereas the time spent in apnea and the diurnal values of DBP significantly contributed to the DBP increase. In the subgroup of 150 patients in whom BP was analyzed during sleep, the awakening increase was related to the absolute BP value during sleep and to the BP changes from wakefulness to sleep. The magnitude of the BP changes from evening to morning was not dependent on the degree of BP variability during sleep. We conclude that the awakening increase in BP in patients with snoring or OSAS may be mediated by the setting of pressure response to apnea or to mechanical effort during sleep. Anthropometric variables and diurnal cardiovascular setting may play an additional role in modulating the final pressure response to upper airway obstruction.     

氯沙坦对高血压病人24小时血压的影响

目的观察氯沙坦对高血压病人24小时血压的影响,探讨其临床意义。 方法20例Ⅰ-Ⅱ级高血压病人,入院后停药2周,服氯沙坦50mg,qd,疗程12周,1个月后血压若未降至140/90mmHg以下,可加大剂量到100mg,qd,治疗前后复查24小时动态血压。以二次给药间距终末时血压下降数除以给药间距中最大血压下降数值作为药物降压的谷/峰比(T∶P),以夜间血压均值与白昼血压均值比较时下降10%或大于10mmHg者为夜间血压下降或"杓型者",反之为夜间血压不下降者或"非杓型者"。 结果　发现(1)氯沙坦能明显降低高血压病人的24小时平均血压(mmHg)(SBP134±14比113±8,DBP89±12比71±5,P<0.01);有效率为85.0%.(2)氯沙坦降压的SBP和DBPTP比率分别为78.6%(48%～93.9%)和76.2%(46.4%～89.6%).SBP,DBP和MBP的平滑曲线指数分别是1.23±0.32,1.36±0.41和1.32±0.38.(3)对夜间血压高于正常值(120/80mmHg)的高血压患者,氯沙坦明显降低夜间血压(mmHg)(SBP142.6±8.8降至116.3±11.4,DBP89.2±9.6降至74.3±6.8,P<0.01),对夜间血压已属正常者,氯沙坦无进一步降压作用(SBP120.3±3.7比116.3±6.8;DBP78.2±6.1比74.3±7.2,P>0.05).(3)24小时SBP,DBP下降幅度与治疗前SBP,DBP明显相关,r分别为0.803和0.797,P<0.01. 结论　氯沙坦是一种安全有效的降压药,其主要优点是24小时平稳降压,谷峰比满意,夜间无过度降压的危险,晨间血压上升受到明显抑制,基础血压越高,降压效果越好。     

Relation between nocturnal arterial oxygen desaturation and morning blood pressure

OBJECTIVE: Arterial oxygen saturation (SpO2) in volunteers had been previously investigated, and the possibility that a decrease in SpO2 leads to an increase in blood pressure (BP) in airline passengers experiencing oxygen desaturation at high altitudes was reported. It was also shown that mean nocturnal SpO2 was lower in subjects with high-normal BP or mild hypertension than in those with normal BP. The present study investigated nocturnal SpO2, evening BP, and morning BP of volunteers during daily life and examined the relation between nocturnal SpO2 and change in BP (morning BP minus evening BP) to determine the influence of SpO2 on BP. METHODS: Sixty-two volunteers (31 men and 31 women) aged 40-87 years (mean: 55.9 +/- 12 [SD] years) underwent measurement of SpO2 and heart rate with a ring-shaped pulse oximeter during sleep at home. Evening BP and morning BP were measured by automatic BP recorder. Subjects that were classified as having high SpO2 (mean nocturnal SpO2 >or= 95%; n = 23, 10 men and 13 women; mean age: 53.2 +/- 12 years) or low SpO2 (mean nocturnal SpO2 < 94%; n = 21, 12 men and 9 women; mean age: 58.7 +/- 13 years) were compared. The relation between mean nocturnal SpO2 and morning BP and the relation between mean nocturnal SpO2 and change in BP were investigated. RESULTS: There was a significant negative correlation between mean nocturnal SpO2 and morning systolic BP (SBP; r = -0.50, p < 0.01) and between mean nocturnal SpO2 and morning diastolic BP (DBP; r = -0.37, p < 0.01). A significant negative correlation between mean nocturnal SpO2 and change in SBP was observed (r = -0.57, p < 0.01). Morning BP was significantly higher in the low nocturnal SpO2 group than in the high nocturnal SpO2 group (p < 0.001). CONCLUSION: The increase in morning BP from evening BP was significantly greater in subjects with a low nocturnal SpO2. The decrease in SpO2 during sleep may affect morning BP rise.     

24-Hour ambulatory blood pressure control with triple-therapy amlodipine, valsartan and hydrochlorothiazide in patients with moderate to severe hypertension

To determine the effectiveness and safety of once-daily combination therapy with amlodipine, valsartan and hydrochlorothiazide for reducing ambulatory blood pressure (ABP) in patients with moderate to severe hypertension, a multicenter, double-blind study was performed (N=2271) that included ABP monitoring in a 283-patient subset. After a single-blind, placebo run-in period, patients were randomized to receive amlodipine/valsartan/hydrochlorothiazide (10/320/25?mg), valsartan/hydrochlorothiazide (320/25?mg), amlodipine/valsartan (10/320?mg) or amlodipine/hydrochlorothiazide (10/25?mg) each morning for 8 weeks. Efficacy assessments included change from baseline in 24-h, daytime and night time mean ambulatory systolic BP (SBP) and diastolic BP (DBP). Statistically significant and clinically relevant reductions from baseline in all these parameters occurred in all treatment groups (P<0.0001, all comparisons versus baseline). At week 8, least squares mean reductions from baseline in 24-h, daytime and night time mean ambulatory SBP/DBP were 30.3/19.7, 31.2/20.5 and 28.0/17.8?mm?Hg, respectively, with amlodipine/valsartan/hydrochlorothiazide; corresponding reductions with dual therapies ranged from 18.8-24.1/11.7-15.5, 19.0-25.1/12.0-16.0 and 18.3-22.6/11.1-14.3?mm?Hg (P≤0.01, all comparisons of triple versus dual therapy). Treatment with amlodipine/valsartan/hydrochlorothiazide maintained full 24-h effectiveness, including during the morning hours; all hourly mean ambulatory SBP and mean ambulatory DBP measurements were ≤130/85?mm?Hg at end point. Amlodipine/valsartan/hydrochlorothiazide combination therapy was well tolerated. Once-daily treatment with amlodipine/valsartan/hydrochlorothiazide (10/320/25?mg) reduces ABP to a significantly greater extent than component-based dual therapy and maintains its effectiveness over the entire 24-h dosing period.     

A home blood pressure monitoring study comparing the antihypertensive efficacy of two angiotensin II receptor antagonist fixed combinations

BACKGROUND: The objective of this prospective, randomized, open-label, blinded-endpoint study was to compare the antihypertensive efficacy of valsartan 80 mg v irbesartan 150 mg when combined with hydrochlorothiazide (HCTZ) 12.5 mg. METHODS: Untreated or uncontrolled hypertensive adults (n = 800) were enrolled by primary care physicians. After a 5-week open-label lead-in phase in which all patients received 12.5 mg HCTZ once daily, subjects whose blood pressure (BP) remained uncontrolled were randomized (n = 464) to valsartan/HCTZ (80/12.5 mg) or irbesartan/HCTZ (150/12.5 mg) for 8 weeks. Home BP monitoring (HBPM) was performed in the morning and in the evening for 5 days, at baseline, and after 8 weeks. Office BP measurements were obtained at baseline and after 8 weeks. RESULTS: Irbesartan/HCTZ produced greater reductions in average systolic BP (SBP) and diastolic BP (DBP) measured by HBPM than valsartan/HCTZ (SBP: -13.0 v -10.6 mm Hg, P = .0094; DBP: -9.5 v -7.4 mm Hg, P = .0007). These differences were more pronounced in the morning (trough) than in the evening. Office BP measurements also showed greater reductions in trough seated SBP and DBP with irbesartan/HCTZ compared with valsartan/HCTZ. Normalization rates observed with HBPM (SBP <135 mm Hg and DBP <85 mm Hg) were significantly greater with irbesartan/HCTZ than with valsartan/HCTZ (50.2 v 33.2%; P = .0003). The overall safety was similar in the two groups. CONCLUSIONS: The superior BP-lowering potency of the fixed combination irbesartan/HCTZ (150/12.5 mg) over valsartan/HCTZ (80/12.5 mg), evidenced independently from the investigators by HBPM, supports the use of this technique in trials with prospective, randomized, open-label, blinded-endpoint designs.     

Efficacy and Duration of Action of the Four Selective Angiotensin II Subtype 1 Receptor Blockers,Losartan, Candesartan,Valsartan and Telmisartan,in Patients with Essential Hypertension Determined by Home Blood Pressure Measurements

Our objective was to compare the efficacy and duration of action of 4 angiotensin II receptor blockers (ARBs)—losartan (25–100 mg), candesartan (2–12 mg), valsartan (40–80 mg), and telmisartan (10–40 mg)—in patients with essential hypertension using self-measurement of blood pressure at home (home BP) and to examine the differential effect of the four ARBs on home pulse pressure (home PP). After a 2-week run-in period, each of the 4 ARBs was assigned to subjects who were diagnosed as having hypertension on the basis of home BP and who were over 30 years old. The subjects were asked to take the ARB once daily in the morning and to measure home BP once in the evening and in the morning. We compared the efficacy of each ARB on home BP and home PP and assessed the duration of the BP-lowering effect using the morning effect versus evening effect ratio (M/E ratio). The antihypertensive effects of telmisartan on home systolic BP (SBP) both in the evening and in the morning and on home diastolic BP (DBP) in the morning were significantly greater than those of losartan. The effect of each ARB on home BP in the morning and in the evening was expressed as a ratio (M/E ratio). The M/E ratios of SBP/DBP in patients treated with losartan, candesartan, valsartan, and telmisartan were 0.49/0.16, 0.69/1.01, 0.82/0.88, and 0.88/0.88, respectively. The home PP-lowering effect was greater for valsartan and telmisartan than for losartan and candesartan in the morning. Among the 4 ARBs, the duration of the BP-lowering effect of losartan did not persist throughout 24 hr. The effects of the other 3 ARBs, in particular telmisartan, persisted over 24 hr when they were administered once daily in the morning. In addition, the duration of the PP-lowering effect was similar to that of the BP-lowering effect. Such long-acting property of several ARBs is essential for the modern antihypertensive treatment, and home BP measurements are useful for determining the duration of action of antihypertensive drugs. Losartan, 25 mg a day, which is usually used as an initial dose in Japan, is apparently insufficient to obtain adequate antihypertensive effect and sufficient duration of action.     

Efficacy and duration of action of the four selective angiotensin II subtype 1 receptor blockers, losartan, candesartan, valsartan and telmisartan, in patients with essential hypertension determined by home blood pressure measurements

Our objective was to compare the efficacy and duration of action of 4 angiotensin II receptor blockers (ARBs)--losartan (25-100 mg), candesartan (2-12 mg), valsartan (40-80 mg), and telmisartan (10-40 mg)-in patients with essential hypertension using self-measurement of blood pressure at home (home BP) and to examine the differential effect of the four ARBs on home pulse pressure (home PP). After a 2-week run-in period, each of the 4 ARBs was assigned to subjects who were diagnosed as having hypertension on the basis of home BP and who were over 30 years old. The subjects were asked to take the ARB once daily in the morning and to measure home BP once in the evening and in the morning. We compared the efficacy of each ARB on home BP and home PP and assessed the duration of the BP-lowering effect using the morning effect versus evening effect ratio (M/E ratio). The antihypertensive effects of telmisartan on home systolic BP (SBP) both in the evening and in the morning and on home diastolic BP (DBP) in the morning were significantly greater than those of losartan. The effect of each ARB on home BP in the morning and in the evening was expressed as a ratio (M/E ratio). The M/E ratios of SBP/DBP in patients treated with losartan, candesartan, valsartan, and telmisartan were 0.49/0.16, 0.69/1.01, 0.82/0.88, and 0.88/0.88, respectively. The home PP-lowering effect was greater for valsartan and telmisartan than for losartan and candesartan in the morning. Among the 4 ARBs, the duration of the BP-lowering effect of losartan did not persist throughout 24 hr. The effects of the other 3 ARBs, in particular telmisartan, persisted over 24 hr when they were administered once daily in the morning. In addition, the duration of the PP-lowering effect was similar to that of the BP-lowering effect. Such long-acting property of several ARBs is essential for the modern antihypertensive treatment, and home BP measurements are useful for determining the duration of action of antihypertensive drugs. Losartan, 25 mg a day, which is usually used as an initial dose in Japan, is apparently insufficient to obtain adequate antihypertensive effect and sufficient duration of action.     

吸烟对男性高血压患者晨间血压上升速度的影响

目的探讨长期吸烟对男性高血压患者血压昼夜节律的影响,进一步阐述晨间血压上升速度是否是发生心血管事件的危险因素。方法选择男性高血压患者300例,年龄40～79岁,受试者均无糖尿病病史,根据吸烟状况分为不吸烟组(n=100)、戒烟组(n=100)和吸烟组(n=100),由同一研究小组完成24h动态血压监测,采用双重逻辑方程模型(double logistic curve-fitting procedure)分析动态血压参数并进行统计学分析。结果①各组间年龄、体质量指数、饮酒比例、高血压病程、血糖、血脂、血肌酐、血尿酸等差异无统计学意义(P>0.05)。②吸烟组24h平均收缩压、白昼平均收缩压、24h脉压比不吸烟组和戒烟组高(P<0.05或P<0.01),收缩压白昼平台较戒烟组高(P<0.05)。不吸烟组与戒烟组各项参数比较,差异无统计学意义(均P>0.05)。③吸烟组晨间收缩压上升速度要高于不吸烟组和戒烟组[(16.5±1.2)比(7.3±0.9)mm Hg/h,P<0.01;(16.5±1.2)比(9.8±0.9)mm Hg/h,P<0.01]。④单因素相关分析示晨间收缩压上升速度与收缩压白昼平台、24h脉压有相关性(r=0.151,0.143,P<0.05),不吸烟组及吸烟组收缩压上升速度仅与收缩压白昼平台有相关性(r=0.152,P<0.01;r=0.128,P<0.01)。校正年龄、体质量指数等因素后,偏相关分析显示:收缩压上升速度仍与收缩压白昼平台呈正相关(r总=0.232,P<0.01;r不吸烟=0.274,P<0.01;r吸烟=0.283,P<0.01)。⑤Logistic回归分析结果显示,晨间收缩压上升速度(OR=1.326,95%CI1.083～1.624,P=0.006)及收缩压白昼平台水平(OR=1.292,95%CI1.046～1.595,P=0.017)是靶器官损害的危险因素。结论长期吸烟的男性高血压患者白昼收缩压水平较高,晨间收缩压上升速度明显加快,晨间收缩压上升速度加快可能是心脑血管事件的危险因素。     

Low Diastolic Ambulatory Blood Pressure Is Associated with Greater All-Cause Mortality in Older Patients with Hypertension

OBJECTIVES: To assess the relationship between office and ambulatory systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure (PP) and total mortality in elderly patients with hypertension.
DESIGN: Observational prospective cohort study.
SETTING: Hypertension outpatient clinic in a geriatric academic hospital.
PATIENTS AND METHODS: Eight hundred five older (≥60) subjects with hypertension underwent office and ambulatory BP measurement. Mortality was assessed after a mean follow-up of 3.8 years.
RESULTS: In a total of 3,090 person-years of follow-up, 107 participants died (average mortality rate 3.5% per year). With bivariate analysis, participants who died had higher SBP and PP and lower DBP, with office and ambulatory measurements. Mortality rates were greater with higher SBP and lower with higher DBP. As a combined effect of these trends, PP was associated with the widest death rate gradients, from 12 to 66, 13 to 63, and 9 to 70 per 1,000 person-years across office, 24-hour, daytime, and nighttime PP quartiles, respectively. Multivariate Cox analysis confirmed these trends; the adjusted hazard of death increased linearly with increasing ambulatory SBP and PP, whereas it decreased significantly with increasing ambulatory DBP. A five times greater risk of death was detected when comparing night-time PP quartile 4 (median PP value 78 mmHg) with quartile 1 (median PP value 46 mmHg).
CONCLUSION: In older patients with hypertension, low DBP and high PP, particularly when measured using ambulatory BP monitoring, are associated with greater risk of death. The achievement of an SBP treatment goal should not be obtained at the expense of an excessive DBP reduction.     

Ambulatory blood pressure measurements are related to albumin excretion and are predictive for risk of microalbuminuria in young people with type 1 diabetes

Aims/hypothesis  The relationship between BP and microalbuminuria in young people with type 1 diabetes is not completely clear. As microalbuminuria is preceded by a gradual rise in albumin excretion within the normal range, we hypothesised that ambulatory BP (ABP) may be closely related to albumin excretion and progression to microalbuminuria. Methods  ABP monitoring (ABPM) was performed in 509 young people with type 1 diabetes (age median [range]: 15.7 [10.7–22.6] years) followed with annual assessments of three early morning urinary albumin:creatinine ratios (ACRs) and HbA_1c. Systolic BP (SBP) and diastolic BP (DBP) and the nocturnal fall in BP were analysed in relation to ACR. Results  All ABPM variables were significantly related to baseline log₁₀ ACR (p < 0.001). After the ABPM evaluation, 287 patients were followed for a median of 2.2 (1.0–5.5) years. ABP at baseline was independently related to mean ACR during follow-up. Nineteen initially normoalbuminuric patients developed microalbuminuria after 2.0 (0.2–4.0) years and their baseline daytime DBP was higher than in normoalbuminuric patients (p < 0.001). After adjusting for baseline ACR and HbA_1c, there was an 11% increased risk of microalbuminuria for each 1 mmHg increase in daytime DBP. Forty-eight per cent of patients were non-dippers for SBP and 60% for DBP; however, ACR was not different between dippers and non-dippers and there were no differences in the nocturnal fall in BP between normoalbuminuric and future microalbuminuric patients. Conclusions/interpretation  In this cohort of young people with type 1 diabetes, ABP was significantly related to ACR, and daytime DBP was independently associated with progression to microalbuminuria. Increasing albumin excretion, even in the normal range, may be associated with parallel rises in BP. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorised users.     

Sympathoadrenergic and metabolic factors are involved in ambulatory blood pressure rise in childhood obesity

We investigated in a young Italian obese population, the relationship between ambulatory BP (ABP) and several pathophysiological factors linking obesity to hypertension. A total of 89 obese children and adolescents underwent a 24-h ambulatory BP monitoring (ABPM) and an oral glucose tolerance test. The circulating levels of insulin, lipids, uric acid, C-reactive protein, interleukin-6, renin and aldosterone and the 24-h urinary levels of epinephrine, norepinephrine and albumin excretion rate were measured. Nine percent of subjects had daytime sustained hypertension (SH), 26% night-time hypertension and 11% a non-dipping pattern. SH subjects compared to those with sustained normotension (SN) were more obese (P<0.05), with a more frequent family history of hypertension (P<0.05), higher urinary catecholamine (P<0.05) and heart rate values (P<0.05) after adjustment for standard deviation score (SDS) of body mass index (BMI) and sex. Subjects with night-time hypertension compared to those with night-time normotension were more obese (P<0.0001), with a higher prevalence of impaired glucose tolerance (P<0.05) and metabolic syndrome (P<0.05) and higher 2-h glucose (P<0.05), uric acid (P<0.05) and triglycerides (P<0.05). In multivariate regression analysis, daytime systolic BP (SBP) remained independently correlated with urinary norepinephrine and SDS-BMI (P<0.05 for both), daytime diastolic BP (DBP) with waist circumference (P<0.05) and night-time SBP and DBP with SDS-BMI (P<0.01 for both). The risk of having systolic and diastolic hypertension increased with the increase in SDS-BMI and waist circumference, respectively. In conclusion, in our cohort of obese children and adolescents, daytime and night-time hypertension were associated with activation of the sympathoadrenal system and worst metabolic conditions, respectively.     

Efficacy of combination antihypertensive therapy with low-dose indapamide: assessment by blood pressure self-monitoring at home

We examined the effects of the addition of low-dose indapamide to antihypertensive drugs of other classes, as well as its duration of action, using blood pressure (BP) self-monitoring at home. Seventy-six patients undergoing monotherapy with a calcium channel blocker (CCB), angiotensin converting-enzyme inhibitor (ACEI), or angiotensin AT1-receptor blocker (ARB), but had an average morning home systolic BP (SBP) > or =135 mmHg or diastolic BP (DBP) > or =85 mmHg, were studied. Indapamide (1 mg) was added to their existing treatment once daily for 4 weeks. The additional hypotensive effects of indapamide were evaluated by casual and home BPs, and the results were compared among the three groups of subjects classified according to their initial drug treatment classes. The morning/evening (M/E) ratio of BP reduction was calculated to assess the duration of the effect. Overall, indapamide significantly (P < 0.001) lowered morning home BP (147 +/- 12/87 +/- 9 mmHg to 135 +/- 12/81 +/- 9 mmHg), evening home BP (138 +/- 15/79 +/- 10 mmHg to 126 +/- 12/73 +/- 9 mmHg), and casual BP (145 +/- 21/86 +/- 14 mmHg to 136 +/- 17/81 +/- 13 mmHg). All groups showed significant indapamide-induced home SBP/DBP decreases, whereas only the ACEI and ARB groups, but not the CCB group, showed a home pulse pressure (PP) reduction. Evening SBP and PP decreases were significantly greater in the ARB group than in the CCB group. The mean M/E ratio with indapamide was 0.95 for SBP and 0.85 for DBP. Low-dose indapamide used in combination can provide additional anti-hypertensive efficacy lasting for 24 h. The added effect of indapamide may be more prominent on ARBs than on CCBs.     

老年轻中度原发性高血压患者家庭自测血压变异与冷加压试验的相关性

目的探讨老年轻中度原发性高血压患者家庭自测血压变异与冷加压试验的相关性。方法于2012年5月~2013年8月自山东省临沂市兰山区高血压社区管理的高血压患者中,筛选老年轻中度原发性高血压患者259例,所有入选受试者均进行7d家庭血压自测,计算后6d连续的收缩压及舒张压变异性相关指标及平均心率;采用冷加压试验以刺激全身交感神经兴奋,并将冷加压试验阳性作为阳性组116例,冷加压试验阴性作为阴性组143例。结果阳性组早间舒张压、收缩压标准差、舒张压标准差、最高收缩压、最高舒张压、早-晚收缩压差、早-晚舒张压差、最高-最低收缩压差、最高-最低舒张压差,平均心率均高于阴性组(P<0.05)。阳性组晚间收缩压、晚间舒张压低于阴性组(P<0.05)。回归分析显示,即刻及60s收缩压变化幅度始终是影响收缩压标准差、舒张压标准差、早-晚收缩压差、早-晚舒张压差、最高-最低收缩压差及最高-最低舒张压差的主要因素。结论老年轻中度原发性高血压患者的家庭自测血压变异与冷加压试验反应相关,冷加压试验反应越强,血压变异越大。