Prognosis of isolated systolic and isolated diastolic hypertension as assessed by self-measurement of blood pressure at home: the Ohasama study

BACKGROUND: Although the clinical significance of systolic-diastolic hypertension and isolated systolic hypertension has been established, the significance of isolated diastolic hypertension has not been fully investigated. OBJECTIVE: To clarify the prognostic significance of isolated systolic and isolated diastolic hypertension as assessed by self-measurement of blood pressure (BP) at home (home BP measurements), which has a better reproducibility and prognostic value than casual BP measurements in the general population. SUBJECTS AND METHODS: We obtained home BP measurements for 1913 subjects aged 40 years or older, then followed up their survival status (mean, 8.6 years). We classified the subjects into the following 4 groups according to their home BP levels: systolic-diastolic hypertension, isolated systolic hypertension, isolated diastolic hypertension, and normotension. The prognostic significance of each type of hypertension for the risk of cardiovascular mortality risk was investigated using a Cox proportional hazards regression model adjusted for possible confounding factors. RESULTS: The risk for isolated systolic hypertension and systolic-diastolic hypertension were significantly higher than the relative hazard for normotension, while isolated diastolic hypertension was associated with no significant increase in risk. Home pulse pressure measurement was also independently associated with an increase in the risk of cardiovascular mortality. CONCLUSIONS: Isolated diastolic hypertension, as assessed by home BP measurements, carried a low risk of cardiovascular mortality, similar to that found in subjects with normotension, suggesting that the prognosis of hypertension would be improved by treatment focused on systolic rather than on diastolic home BP measurements. To our knowledge, this study is the first to demonstrate the clinical significance of pulse pressure as assessed by home BP measurement. Arch Intern Med. 2000;160:3301-3306.     

White‐Coat Isolated Systolic Hypertension Is a Risk Factor for Carotid Atherosclerosis

The clinical importance of white‐coat hypertension (WCH) remains a controversial issue. The aim of this study was to evaluate the association of isolated systolic, isolated diastolic, and systolic/diastolic WCH with common carotid artery intima‐media thickness (CCA‐IMT) and to compare each subgroup of WCH against other blood pressure (BP) phenotypes in terms of CCA‐IMT values. A total of 1382 consecutive patients underwent 24‐hour ambulatory BP monitoring and carotid artery ultrasonographic measurements. According to the type of elevated office BP, WCH was divided into three groups: isolated systolic, isolated diastolic, and systolic/diastolic WCH. Patients with isolated systolic WCH (n=112) had significantly higher CCA‐IMT values (0.737 mm) than those with isolated diastolic WCH (n=66) (0.685 mm) and nonsignificantly greater compared with those with systolic/diastolic WCH (n=228) (0.708 mm). Patients with isolated systolic WCH had CCA‐IMT values similar to those with hypertension, patients with isolated diastolic WCH had similar values to those with normotension, and patients with systolic/diastolic WCH had an intermediate risk between normotension and hypertension.     

White-coat hypertension as a risk factor for the development of home hypertension: the Ohasama study

BACKGROUND: White-coat hypertension is a condition characterized by elevated blood pressure (BP) in medical settings combined with normal ambulatory-recorded BP or self-measured BP at home (home BP). However, it is unknown whether this condition represents a transient state in the development of hypertension outside medical settings. METHODS: We followed up 128 subjects with white-coat hypertension (home BP <135/85 mm Hg and office BP > or = 140/90 mm Hg) for 8 years and compared the risk of progression with home hypertension (home BP > or = 135/85 mm Hg or start of treatment with antihypertensive medication) with 649 sustained normotensive subjects (home BP <135/85 mm Hg and office BP <140/90 mm Hg) using data from population-based home BP measurement projects in Japan. RESULTS: During the 8-year follow-up period, 60 subjects (46.9%) with white-coat hypertension and 144 (22.2%) with sustained normotension progressed to home hypertension. The odds ratio of subjects with white-coat hypertension for progression to home hypertension (adjusted for possible confounding factors) was significantly higher than for subjects with sustained normotension (odds ratio, 2.86; P<.001). This association was observed independent of baseline home BP levels. CONCLUSION: The results from the present 8-year follow-up study demonstrate that white-coat hypertension is a transitional condition to hypertension outside medical settings, suggesting that white-coat hypertension may carry a poor cardiovascular prognosis.     

带刻度袖带与有创导管测量粗臂围者血压对比研究

目的探讨专利产品带刻度袖带测量粗臂围者血压的应用价值。方法采用带刻度袖带同时测量65例臂围>26 cm者的血压和臂围者。依据小号袖带高估粗臂围血压的理论进行校正:臂围每增加1 cm将实测收缩压相应减低1 mm Hg、实测舒张压相应减低2/3 mm Hg;其中有48例受试者粗臂围与实测收缩压>140 mm Hg和(或)舒张压>90 mm Hg同时存在,按简化经验公式计算校正。将实测值和校正值与同步有创导管测压相比较。结果 65例受试者臂围在26～38 cm之间,平均(31.9±2.3)cm。校正收缩压和舒张压与导管测压结果接近[(143.5±9.6)mm Hg比(142.7±9.5)mm Hg;(84.6±6.8)mm Hg比(83.9±6.7)mm Hg,均为P>0.05];而实测收缩压和舒张压明显高于导管测压结果[(150.1±10.3)mm Hg比(142.7±9.5)mm Hg;(89.4±7.5)mm Hg比(83.9±6.7)mm Hg,均为P<0.01]。结论带刻度袖带测量粗臂围者血压校正结果更准确,能避免"袖带性高血压"。     

Ambulatory blood pressure monitoring and risk of cardiovascular disease: a population based study

BACKGROUND: Information on the relationship between ambulatory blood pressure (BP) and cardiovascular disease in the general population is sparse. METHODS: Prospective study of a random sample of 1700 Danish men and women, aged 41 to 72 years, without major cardiovascular diseases. At baseline, ambulatory BP, office BP, and other risk factors were recorded. The end point was a combined end point consisting of cardiovascular mortality, ischemic heart disease, and stroke. RESULTS: After a mean follow-up of 9.5 years, 156 end points were recorded. In multivariate models, the relative risk (95% confidence interval) associated with increments of 10/5 mmHg of systolic/diastolic ambulatory BP were 1.35 (1.21-1.50) and 1.27 (1.16-1.39). The corresponding figures for office BP were 1.18 (1.09-1.29) and 1.11 (1.03-1.19). Compared with normotension (office BP <140/90 mm Hg; daytime BP <135/85 mm Hg) the relative risks associated with isolated office hypertension (office BP >/=140/90 mm Hg; daytime BP <135/85 mm Hg), isolated ambulatory hypertension (office BP <140/90 mm Hg; daytime BP >/=135/85 mm Hg), and sustained hypertension (office BP >/=140/90 mm Hg; daytime BP >/=135/85 mm Hg) were 0.66 (0.30-1.44), 1.52 (0.91-2.54), and 2.10 (1.45-3.06), respectively. A blunted BP decrease at night was a risk factor (P = .02) in subjects with daytime ambulatory hypertension, but not in subjects with daytime ambulatory normotension (P = .13). CONCLUSIONS: Ambulatory BP provided prognostic information about cardiovascular disease better than office BP. Isolated office hypertension was not a risk factor and isolated ambulatory hypertension tended to be associated with increased risk. A blunted BP decrease at night was a risk factor in subjects with daytime ambulatory hypertension.     

Home Blood Pressure as a Predictor of Future Blood Pressure Stability in Borderline Hypertension: The Tecumseh Study

We evaluated time-related blood pressure trends in the Tecumseh study participants, none of whom received antihypertensive treatment. At baseline the blood pressures were measured in the field clinic and by self measurement at home (twice daily for 7 days). After a mean of 3.2 ± 0.42 years, the clinic and home pressure readings were repeated. Nine hundred forty-six subjects had clinic and home blood pressure readings at baseline. Of these 735 (380 men, 355 women; average age, 32 years) also completed the second examination. Blood pressure, morphometric data, and biochemical measures at the first examination were used as predictors of future clinic blood pressures.Five hundred ninety-six subjects were normotensive on both examinations (81%). Of 79 subjects (10.7%) with clinic hypertension (>140 mg Hg systolic or 90 mm Hg diastolic) at baseline, 38 remained hypertensive (“sustained hypertension”) and 41 became normotensive (“transient hypertension”) after 3 years. Another 60 normotensives at baseline (10.4%) became hypertensive on second examination (“de novo hypertensives”; incidence; 8.1%).The home blood pressure readings on both examinations were reproducible. The three hypertensive groups had elevated home blood pressure, were overweight, had dyslipidemia, and higher insulin values. Only the home blood pressure proved predictive of subsequent blood pressure trends. A home blood pressure of 128 and 83 mm Hg or higher detected “sustained” hypertension with a 48% sensitivity and 93% specificity. Readings of 120 and 80 mm Hg or lower predicted future normotension with a 45% sensitivity and a 91% specificity.We conclude that self determination of the blood pressure at home is useful in the management of borderline hypertension. An algorithm for the management of these patients is proposed.     

Systolic versus diastolic blood pressure versus pulse pressure

Elevation of systolic blood pressure (BP) has been recognized as an independent risk factor that far exceeds the risk associated with an elevated diastolic BP in older patients with hypertension. Isolated systolic hypertension (ISH) is a disorder typically defined when the systolic BP is greater than 140 mm Hg but with diastolic BP below 90 mm Hg. Pulse pressure (the difference between systolic and diastolic pressure) has recently become an active area of discussion in the literature as an independent factor of cardiovascular risk. An increased pulse pressure nearly always indicates reduced vascular compliance of large arteries and, by definition, is always increased in patients with isolated systolic hypertension. Although the evidence that a widened pulse pressure is an independent marker of cardiovascular risk is quite well established, therapeutic morbidity and mortality studies in ISH have focused on reductions in systolic pressure. At the present time, outcomes data have not been well established for reductions in pulse pressure in older patients with hypertension.     

Stroke risk in systolic and combined systolic and diastolic hypertension determined using ambulatory blood pressure. The Ohasama study

BACKGROUND: To investigate the risk of stroke in subjects with isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and combined systolic and diastolic hypertension (SDH) in a Japanese general population, we used 24-h ambulatory blood pressure (ABP) and casual-screening blood-pressure (CBP) readings. METHODS: Subtypes of hypertension were defined based on systolic blood pressure (SBP) >135 mm Hg or diastolic blood pressure (DBP) >80 mm Hg for 24-h ABP, and SBP >140 mm Hg or DBP >90 mm Hg for CBP. We obtained 24-h ABP and CBP data for 1271 (40% male) subjects aged > or =40 years (mean age, 61 years) without a history of symptomatic stroke; their stroke-free survival was then determined. The prognostic significance of each subtype of hypertension was determined by Cox proportional hazard analysis. RESULTS: There were 113 symptomatic strokes during follow-up (mean time, 11 years). Compared with normotension, among the hypertension subtypes determined by 24-h ABP, the adjusted relative hazards (RHs) of stroke were 2.24 for ISH (P = .002) and 2.39 for SDH (P = .0004). The association was less marked among subtypes determined by CBP (RH = 1.40 and P = .13 for ISH; RH = 2.07 and P = .017 for SDH). The IDH group was excluded from the Cox analysis because both the prevalence and the number of events were low in this group. CONCLUSIONS: Isolated systolic hypertension, as determined by 24-h ABP measurements, was associated with a high risk of stroke, similar to that found in SDH subjects; this suggests that the prognosis of hypertensive patients would be improved by focusing treatment on 24-h systolic ABP.     

Prognostic relevance of masked hypertension in subjects with prehypertension

BackgroundThe prognostic impact of masked hypertension is not yet completely clear. The aim of this study was to evaluate the prognostic relevance of masked hypertension in subjects with prehypertension.MethodsThe occurrence of fatal and nonfatal cardiovascular events was evaluated in 591 subjects with prehypertension defined as clinic blood pressure (BP) in the range of 120-139 mm Hg for systolic BP and 80-89 mm Hg for diastolic BP. Among them, 471 were classified as having true prehypertension (clinic BP <140/90 mm Hg and daytime BP <135/85 mm Hg) and 120 as having masked hypertension (clinic BP <140/90 mm Hg and daytime BP >/=135 or 85 mm Hg).ResultsDuring the follow-up (6.6 +/- 4.3 years, range 0.5-15.5 years), 29 cardiovascular events occurred. In subjects with true prehypertension and masked hypertension the event-rates per 100 patient-years were 0.57 and 1.51, respectively. Event-free survival was significantly different between the groups (P < 0.005). After adjustment for other covariates, including clinic BP (forced into the model), Cox regression analysis showed that cardiovascular risk was significantly higher in masked hypertension than in true prehypertension (masked vs. true prehypertension, relative risk 2.65, 95% confidence interval 1.18-5.98, P = 0.018).ConclusionsAmong subjects with prehypertension, those with masked hypertension are at higher cardiovascular risk than those with true prehypertension. Out-of-office BP should be known in individuals with prehypertension, preferably by ambulatory BP monitoring or alternatively by home BP measurement, to obtain a better prognostic stratification.American Journal of Hypertension (2008). doi:10.1038/ajh.2008.196American Journal of Hypertension (2008); 21, 8, 879-883. doi:10.1038/ajh.2008.196.     

How well do office and exercise blood pressures predict sustained hypertension? A Dundee Step Test Study

Exercise systolic blood pressure (BP) appears to be a better predictor of cardiac mortality than casual office BP. We tested whether this could be explained by exercise systolic BP being a better predictor of sustained hypertension than casual office BP. Exercise systolic BP was measured using the lightweight 3-min single stage, submaximal Dundee Step Test in 191 consecutive subjects (102 male, age 52 (s.d. 13) years) who were referred to a specialist hypertension clinic for assessment. Exercise systolic BP was compared with office BP and daytime ambulatory BP (ABP). Sustained hypertension was defined as a mean daytime systolic and/or diastolic ABP of >/=140/90 mm Hg. Receiver operating characteristic (ROC) curves of exercise systolic BP and office BP in predicting sustained hypertension were compared. The positive predictive value of office diastolic BP >/=90 mm Hg and office systolic BP >/=140 mm Hg for sustained hypertension were 64% and 67% respectively. However, exercise systolic BP >/=180 mm Hg had a positive predictive value of 76%. Twenty-two percent (42/191) of subjects had an exercise systolic BP rise to >/=210 mm Hg, and 93% of this group had sustained hypertension on ABP. Whilst exercise systolic BP was a better predictor of sustained hypertension using currently recommended office BP treatment thresholds, the ROC curves of these indices were not different. In a multiple regression analysis, exercise systolic BP was an independent predictor of sustained hypertension, accounting for 36% of the variance of daytime systolic ABP after adjusting for age, gender and antihypertensive drug treatment. In conclusion, exercise systolic BP was a marginally better predictor of sustained hypertension than office BP. This may partly explain why exercise systolic BP is a potent predictor of cardiac mortality.     

Arterial hypertension difficult to control in the elderly patient. The significance of the "white coat effect"]

OBJECTIVE: Previous studies have revealed a high prevalence of white coat effect among treated hypertensive patients. The difference between clinic and ambulatory blood pressure seems to be more pronounced in older patients. This abnormal rise in blood pressure BP in treated hypertensive patients can lead to a misdiagnosis of refractory hypertension. Clinicians may increase the dosage of antihypertensive drugs or add further medication, increasing costs and producing harmful secondary effects. Our aim was to evaluate the discrepancy between clinic and ambulatory blood pressure in hypertensive patients on adequate antihypertensive treatment and to analyse the magnitude of the white coat effect and its relationship with age, gender, clinic blood pressure and cardiovascular or cerebrovascular events. POPULATION AND METHODS: We included 50 consecutive moderate/severe hypertensive patients, 58% female, mean age 68 +/- 10 years (48-88), clinic blood pressure (3 visits) > 160/90 mm Hg, on antihypertensive adequate treatment > 2 months with good compliance and without pseudohypertension. The patients were submitted to clinical evaluation (risk score), clinic blood pressure and heart rate, electrocardiogram and ambulatory blood pressure monitoring (Spacelabs 90,207). Systolic and diastolic 24 hour, daytime, night-time blood pressure and heart rate were recorded. We considered elderly patients above 60 years of age (80%). We defined white coat effect as the difference between systolic clinic blood pressure and daytime systolic blood pressure BP > 20 mm Hg or the difference between diastolic clinic blood pressure and daytime diastolic blood pressure > 10 mm Hg and severe white coat effect as systolic clinic blood pressure--daytime systolic blood pressure > 40 mm Hg or diastolic clinic blood pressure--daytime diastolic blood pressure > 20 mm Hg. The patients were asked to take blood pressure measurements out of hospital (at home or by a nurse). The majority of them performed an echocardiogram examination. RESULTS: Clinic blood pressure was significantly different from daytime ambulatory blood pressure (189 +/- 19/96 +/- 13 vs 139 +/- 18/78 +/- 10 mm Hg, p < 0.005). The magnitude of white coat effect was 50 +/- 17 (8-84) mm Hg for systolic blood pressure and 18 +/- 11 (-9 +/- 41) mm Hg for diastolic blood pressure. A marked white coat effect (> 40 mm Hg) was observed in 78% of our hypertensive patients. In elderly people (> 60 years), this difference was greater (50 +/- 15 vs 45 +/- 21 mm Hg) though not significantly. We did not find significant differences between sexes (males 54 +/- 16 mm Hg vs 48 +/- 17 mm Hg). In 66% of these patients, ambulatory blood pressure monitoring showed daytime blood pressure values < 140/90 mm Hg, therefore refractory hypertension was excluded. In 8 patients (18%) there was a previous history of ischemic cardiovascular or cerebrovascular disease and all of them had a marked difference between systolic clinic and daytime blood pressure (> 40 mm Hg). Blood pressure measurements performed out of hospital did not help clinicians to identify this phenomena as only 16% were similar (+/- 5 mm Hg) to ambulatory daytime values. CONCLUSIONS: Some hypertensive patients, on adequate antihypertensive treatment, have a significant difference between clinic blood pressure and ambulatory blood pressure measurements. This difference (White Coat Effect) is greater in elderly patients and in men (NS). Although clinic blood pressure values were significantly increased, the majority of these patients have controlled blood pressure on ambulatory monitoring. In this population, ambulatory blood pressure monitoring was of great value to identify a misdiagnosis of refractory hypertension, which could lead to improper decisions in the therapeutic management of elderly patients (increasing treatment) and compromise cerebrovascular or coronary circulation.     

Remission of mild to moderate hypertension after treatment with carteolol, a beta-adrenoceptor blocker with intrinsic sympathomimetic activity

Previous studies have indicated that some hypertensive patients, following a period of effective treatment with certain antihypertensive drugs, may experience prolonged normotension after drug withdrawal. We have studied the ability of carteolol, a nonselective beta-adrenoceptor antagonist with intrinsic sympathomimetic activity, to produce such remissions of hypertension. Thirty-four patients whose diastolic blood pressure was controlled at 90 mm Hg or less with carteolol monotherapy (2.5 to 5.0 mg/d for an average of 328 days) were randomized to a nine-month, double-blind, placebo-controlled drug-withdrawal trial. Those patients randomized to continue carteolol therapy had initially responded to carteolol treatment with reduction in blood pressure from 151 +/- 4/99 +/- 2 to 132 +/- 4/80 +/- 2 mm Hg. Those randomized to treatment with placebo had initially responded with blood pressure reductions from 154 +/- 4/97 +/- 2 to 137 +/- 4/81 +/- 2 mm Hg. Changes in mean systolic and diastolic blood pressure (mm Hg +/- SEM) from baseline during carteolol therapy to the final visit at nine months were not different for patients receiving placebo (13 +/- 5/6 +/- 4 mm Hg, recumbent; 11 +/- 6/4 mm Hg, standing) or carteolol (11 +/- 5/7 +/- 3 mm Hg, recumbent; 12 +/- 6/7 +/- 3 mm Hg, standing). The final mean recumbent diastolic blood pressure (86.9 mm Hg) was the same in both groups. Prolonged normotension may follow a period of carteolol treatment, again suggesting the potential importance of periodic withdrawal of antihypertensive medication.     

Blood pressure control and physician management of hypertension in hospital hypertension units in Spain

Goal blood pressure (BP) was defined by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) and the World Health Organization-International Society of Hypertension (WHO/ISH) as <140 mm Hg systolic and <90 mm Hg diastolic for the general and <130 mm Hg systolic and <85 mm Hg diastolic for special high-risk populations. However, there are few reports that address BP control among special subgroups of hypertensives by reference to targeted BP. We therefore conducted a study to evaluate BP control of 4049 hypertensives in 47 hospital-based hypertension units in Spain. Overall, 42% of patients achieved goal BP (<140 mm Hg systolic and <90 mm Hg diastolic). Only 13% of diabetic patients and 17% of those with renal disease achieved the BP goal (<130 mm Hg systolic and <85 mm Hg diastolic), and only 10% and 12%, respectively, achieved the even more rigorous goal (<130 mm Hg systolic and <80 mm Hg diastolic). Likewise, only 18% of patients in JNC-VI risk group C and 17% of WHO/ISH high-risk patients attained a goal BP <130 mm Hg systolic and <85 mm Hg diastolic. BP control (<125 mm Hg systolic and <75 mm Hg diastolic) was extremely low (2%) in patients with proteinuria >1 g/d. Poorer BP control was observed among patients at high risk, with diabetes, renal disease, or obesity, than in lower-risk groups. BP control was lower for systolic than for diastolic BP. In >50% of uncontrolled patients, no measures were taken by doctors to optimize pharmacologic treatment, and approximately one-third of patients were still using drug monotherapy. Control of BP, particularly of systolic BP, is still far from optimal in hospital-based hypertension units. Patients at high risk, with diabetes or proteinuria, warrant focused attention. Moreover, a more aggressive behavior of doctors treating uncontrolled hypertension is needed.     

Add‐On Use of Eplerenone Is Effective for Lowering Home and Ambulatory Blood Pressure in Drug‐Resistant Hypertension

The authors aimed to investigate the blood pressure (BP)–lowering ability of eplerenone in drug‐resistant hypertensive patients. A total of 57 drug‐resistant hypertensive patients whose home BP was ≥135/85 mm Hg were investigated. The patients were randomized to either an eplerenone group or a control group and followed for 12 weeks. The efficacy was evaluated by clinic, home, and ambulatory BP monitoring. Urinary albumin, pulse wave velocity, and flow‐mediated vasodilation (FMD) were also evaluated. Home morning systolic BP (148±15 vs 140±15 mm Hg) and evening systolic BP (137±16 vs 130±16 mm Hg) were significantly lowered in the eplerenone group (n=35) compared with baseline (both P<.05), while unchanged in the control group (n=22). BP reductions in the eplerenone group were most pronounced for ambulatory awake systolic BP (P=.04), awake diastolic BP (P=.004), and 24‐hour diastolic BP (P=.02). FMD was significantly improved in the eplerenone group. In patients with drug‐resistant hypertension, add‐on use of eplerenone was effective in lowering BP, especially home and ambulatory awake BP.     

On-treatment diastolic blood pressure and prognosis in systolic hypertension

BACKGROUND: It has been suggested that low diastolic blood pressure (BP) while receiving antihypertensive treatment (hereinafter called on-treatment BP) is harmful in older patients with systolic hypertension. We examined the association between on-treatment diastolic BP, mortality, and cardiovascular events in the prospective placebo-controlled Systolic Hypertension in Europe Trial. METHODS: Elderly patients with systolic hypertension were randomized into the double-blind first phase of the trial, after which all patients received active study drugs (phase 2). We assessed the relationship between outcome and on-treatment diastolic BP by use of multivariate Cox regression analysis during receipt of placebo (phase 1) and during active treatment (phases 1 and 2). RESULTS: Rates of noncardiovascular mortality, cardiovascular mortality, and cardiovascular events were 11.1, 12.0, and 29.4, respectively, per 1000 patient-years with active treatment (n = 2358) and 11.9, 12.6, and 39.0, respectively, with placebo (n = 2225). Noncardiovascular mortality, but not cardiovascular mortality, increased with low diastolic BP with active treatment (P < .005) and with placebo (P < .05); for example, hazard ratios for lower diastolic BP, that is, 65 to 60 mm Hg, were, respectively, 1.15 (95% confidence interval, 1.00-1.31) and 1.28 (95% confidence interval, 1.03-1.59). Low diastolic BP with active treatment was associated with increased risk of cardiovascular events, but only in patients with coronary heart disease at baseline (P < .02; hazard ratio for BP 65-60 mm Hg, 1.17; 95% confidence interval, 0.98-1.38). CONCLUSIONS: These findings support the hypothesis that antihypertensive treatment can be intensified to prevent cardiovascular events when systolic BP is not under control in older patients with systolic hypertension, at least until diastolic BP reaches 55 mm Hg. However, a prudent approach is warranted in patients with concomitant coronary heart disease, in whom diastolic BP should probably not be lowered to less than 70 mm Hg.     

Accuracy of the Dinamap 1846 XT automated blood pressure monitor

Accurate blood pressure (BP) measurement is important for the detection and treatment of hypertension. Despite widespread use of automated devices, there is limited published evidence for their reliability and accuracy. To determine the reliability and accuracy of the Dinamap 1846XT (Critikon Corporation, Tampa, FL, USA), a commonly used non-invasive oscillometric BP monitor The Dinamap was evaluated against the mercury manometer in 70 randomly selected adult hospitalised medical patients. Each individual underwent three sets of standardised BP measurement by automated method and three sets by mercury manometer by two independent observers. Reliability of BP measurement was assessed by repeated measures analysis. Dinamap accuracy was evaluated according to the American Association of Medical Instrumentation (AAMI) and British Hypertension Society (BHS) guidelines. Most patients were either normotensive or had stage I hypertension. The Dinamap tended to overestimate lower diastolic BP, and displayed poor reliability (P < 0.05). despite meeting aami guidelines, only 59% of systolic and 56% of diastolic dinamap readings were within 5 mm hg of the mercury manometer and 84% of systolic and 80% of diastolic readings were within 10 mm hg (bhs grade c). systolic and diastolic accuracy were worse with pressures >160/90 mm Hg (grade D) although these measures were based on a smaller sample of subjects. In conclusion the Dinamap yields inaccurate estimates of both systolic and diastolic BP even under standardised, and thus optimal conditions. This inaccuracy is exaggerated at higher BP (>160/90 mm Hg), although the number of measurements at higher pressures was small. We recommend that this device not be used when accurate BP measurement is needed for therapeutic decision-making.     

A comparison of home measurement and ambulatory monitoring of blood pressure in the adjustment of antihypertensive treatment

BACKGROUND: The purpose of this study was to compare home and ambulatory blood pressure (BP) in the adjustment of antihypertensive treatment. METHODS: After a 4-week washout period, patients whose untreated daytime diastolic ambulatory BP averaged > or = 85 mm Hg were randomized to be treated according to their ambulatory or home BP. Antihypertensive treatment was adjusted at 6-week intervals according to the mean daytime ambulatory diastolic BP or the mean home diastolic BP, depending on the patient's randomization group. If the diastolic BP stayed above 80 mm Hg, the physician blinded to randomization intensified hypertensive treatment. RESULTS: Ninety-eight patients completed the study. During the 24-week follow-up period both systolic and diastolic BP decreased significantly within both groups (P < .001). At the end of the study, the systolic/diastolic differences between ambulatory (n = 46) and home (n = 52) BP groups in home, daytime ambulatory, night-time ambulatory, and 24-h ambulatory BP changes averaged 2.6/2.6 mm Hg, 0.6/1.7 mm Hg, 1.0/1.4 mm Hg, and 0.6/1.5 mm Hg, respectively (P range .06 to .75) A nonsignificant trend to more intensive drug therapy in the ambulatory BP group and a nonsignificant trend to larger share of patients reaching (57.7% v 43.5%, P = .16) the target pressure in the home BP group was observed due to the 3.8 mm Hg difference in ambulatory and home diastolic BP at randomization. CONCLUSIONS: The adjustment of antihypertensive treatment based on either ambulatory or home BP measurement led to good BP control. No significant between-group differences in BP changes were seen at the end of the study. Additional research is needed to provide more conclusive results.     

The association of nocturnal hypertension and nondipping blood pressure with treatment‐resistant hypertension: The Jackson Heart Study

Apparent treatment‐resistant hypertension (aTRH), nocturnal hypertension, and nondipping blood pressure (BP) have shared risk factors. The authors studied the association between aTRH and nocturnal hypertension and aTRH and nondipping BP among 524 black Jackson Heart Study participants treated for hypertension. Nocturnal hypertension was defined by mean nighttime systolic BP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping BP was defined by mean nighttime to daytime systolic BP ratio >0.90. aTRH was defined by mean clinic systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg with three medication classes or treatment with four or more classes. The risk for developing aTRH associated with nondipping BP and nocturnal hypertension was estimated. After multivariable adjustment, participants with aTRH were more likely to have nocturnal hypertension (prevalence ratio, 1.20; 95% confidence interval, 1.03–1.39) and nondipping (prevalence ratio, 1.25; 95% confidence interval, 1.09–1.43). Over a median 7.3 years of follow‐up, nocturnal hypertension and nondipping BP at baseline were not associated with developing aTRH after adjustment.     

Reverse epidemiology of hypertension and cardiovascular death in the hemodialysis population: the 58th annual fall conference and scientific sessions

Maintenance hemodialysis patients in the United States have a high prevalence (approximately 80%) of systolic hypertension and a high mortality (approximately 20% per year). Some reports indicate a paradoxical association between hypertension and mortality in hemodialysis patients (ie, a normal to low blood pressure is associated with poor outcome), whereas high pressure confers survival advantages, a phenomenon referred to as "reverse epidemiology." We hypothesized that malnutrition-inflammation complex syndrome may be a cause of this paradoxical association. We studied a 15-month cohort of 40 933 hemodialysis patients in the United States whose predialysis and postdialysis blood pressure values were recorded routinely during each hemodialysis treatment. Patients were 59.8+/-15.3 years old; 54% were women and 46% diabetics. Cox proportional hazard models were used for blood pressure categories (systolic <110, > or =190 mm Hg; diastolic <50, > or =110; and increments of 10 mm Hg in between). Unadjusted, case-mix and dialysis dose-adjusted, and additional malnutrition-inflammation-adjusted hazard ratios of all-cause and cardiovascular death showed progressively increasing all-cause and cardiovascular death risk for decreasing blood pressure values. The lowest mortality was associated with predialysis systolic pressure of 160 to 189 mm Hg, whereas normal to low predialysis pressure values were associated with significantly increased mortality. Adjustment for the malnutrition-inflammation mitigated only a small portion of paradoxical associations between the low blood pressure and mortality. Predialysis systolic hypertension remained a significant predictor of highest all-cause and cardiovascular survival rate. Although these associations may not be causal, they call into question whether treatment goals for the general population can be applied to dialysis patients or other similar populations.     

Reproducibility of Home Blood Pressure Measurements Over a 1-Year Period

We compared the reproducibility over time of blood pressure measured at the health examinations (screening blood pressure) and blood pressure measured at home (home blood pressure). Both screening and home blood pressure were measured in subjects of a rural community. Subjects measured their own blood pressure at home once in the morning using a semiautomatic oscillometric blood pressure measuring device at least three times (on at least 3 days) in each of two 4-week periods separated by one year. Similarly, two screening blood pressure measurements were obtained from the subjects at each of two health examinations also taken 1 year apart. A total of 136 untreated subjects without cardiovascular complications (40 men and 96 women, 56 ± 11.7 years, mean ± SD) were analyzed in the study. The correlations between the first and second blood pressure measurements of the subjects were significantly higher for the home blood pressure measurements (systolic: r = 0.844 and diastolic: r = 0.830) than for the screening blood pressure measurements (systolic: r = 0.692 and diastolic: r = 0.570). The mean differences between the first and second home blood pressure (0.8 ± 7.7 mm Hg for systolic BP and 0.9 ± 5.5 mm Hg for diastolic BP) were significantly smaller than those for the screening blood pressure (-3.9 ± 13.8 for systolic BP and −3.1 ± 10.2 for diastolic BP) (P < .001 for both comparisons), suggesting that the reproducibility of home blood pressure over time is superior to that of screening blood pressure. Such reliable blood pressure measurements obtained at home have a clinical significance for the diagnosis and treatment of hypertension and as a tool for evaluating the efficacy of antihypertensive drugs. Home blood pressure measurements also may be more useful than screening blood pressure measurements in predicting future cardiovascular events.