Maximum value of home blood pressure: a novel indicator of target organ damage in hypertension

The maximum office systolic blood pressure (SBP) has been shown to be a strong predictor of cardiovascular events, independently of the mean SBP level. However, the clinical implications of maximum home SBP have never been reported. We investigated the association between the maximum home SBP and target organ damage (TOD). We assessed the left ventricular mass index (LVMI) and carotid intima-media thickness (IMT) using ultrasonography and the urinary albumin/creatinine ratio (UACR) as measures of TOD in 356 never-treated hypertensive subjects. Home BP was taken in triplicate in the morning and evening, respectively, for 14 consecutive days with a memory-equipped device. The maximum home SBP was defined as the maximum mean triplicate BP reading in the 14-day period for each individual and was significantly correlated with LVMI (r=0.51, P<0.001), carotid IMT (r=0.40, P<0.001), and UACR (r=0.29, P<0.001). The correlation coefficients with LVMI and carotid IMT were significantly larger for the maximum home SBP than the mean home SBP. In multivariate regression analyses, the maximum home SBP was independently associated with LVMI and carotid IMT, regardless of the mean home BP level. In the prediction of left ventricular hypertrophy and carotid atherosclerosis, the goodness-of-fit of the model was significantly improved when the maximum home SBP was added to the sum of the mean office and home BPs (P=0.002 and P<0.001, respectively). These findings indicate that assessment of the maximum home SBP, in addition to the mean home SBP, might increase the predictive value of hypertensive TOD in the heart and artery.     

Maximum home systolic blood pressure is a marker of carotid atherosclerosis

ABSTRACT

Background: Maximum home systolic blood pressure (maximum SBP) has been reported as a parameter of blood pressure (BP) variability. We tested the hypothesis that maximum SBP is one of the risk factors of hypertensive target organ damage (TOD).

Methods: We conducted a cross-sectional study of 4,310 subjects with>1 cardiovascular risk factor. The subjects measured their home BP for 14 consecutive days. Mean and maximum SBPs were used as independent variables. As dependent variables, we used left ventricular mass index (LVMI), brachial-ankle pulse wave velocity (baPWV), maximum carotid intima-media thickness (CIMT), and urine albumin creatinine ratio (UACR).

Results: In a multiple regression analysis, the subjects' mean and maximum SBPs were significantly associated with the above TOD markers. Compared to mean SBP, maximum SBP demonstrated a significantly stronger association with CIMT (p<0.001).

Conclusion: Based on its clinical significance herein, measurement of maximum home SBP is warranted in addition to measurement of mean home SBP.     

Sleep Blood Pressure Self‐Measured at Home as a Novel Determinant of Organ Damage: Japan Morning Surge Home Blood Pressure (J‐HOP) Study

To study whether sleep blood pressure (BP) self‐measured at home is associated with organ damage, the authors analyzed the data of 2562 participants in the J‐HOP study who self‐measured sleep BP using a home BP monitoring (HBPM) device, three times during sleep (2 am , 3 am , 4 am ), as well as the home morning and evening BPs. The mean sleep home systolic BPs (SBPs) were all correlated with urinary albumin/creatinine ratio (UACR), left ventricular mass index (LVMI), brachial‐ankle pulse wave velocity (baPWV), maximum carotid intima‐media thickness, and plasma N‐terminal pro‐hormone pro–brain‐type natriuretic peptide (NTproBNP) (all P<.001). After controlling for clinic SBP and home morning and evening SBPs, associations of home sleep SBP with UACR, LVMI, and baPWV remained significant (all P<.008). Even in patients with home morning BP <135/85 mm Hg, 27% exhibited masked nocturnal hypertension with home sleep SBP ≥120 mm Hg and had higher UACR and NTproBNP. Masked nocturnal hypertension, which is associated with advanced organ damage, remains unrecognized by conventional HBPM.     

Is home blood pressure variability itself an interventional target beyond lowering mean home blood pressure during anti-hypertensive treatment?

It is unknown whether home blood pressure (BP) variability reduction is associated with target organ damage (TOD) protection independently of home mean BP reduction. We enrolled 310 hypertensive patients whose systolic BP (SBP) at home was over 135?mm?Hg. The subjects measured their BP in the morning and evening for 7 days. In addition, we measured urinary albumin excretion (UAE) as a marker of TOD before and after 6 months of candesartan treatment (+thiazidediuretics). At baseline, UAE was associated with average home SBP (r=0.24, P<0.001), the s.d. of home SBP (r=0.15, P=0.011), and the maximum home SBP (r=0.27, P<0.001). During the intervention, significant reductions were found in average home SBP (146±13 vs. 132±12?mm?Hg, P<0.001), s.d. of home SBP (12.9±4.8 vs. 11.8±4.4?mm?Hg, P<0.001), and maximum home SBP (172.5±18.0 vs. 155.9±17.5?mm?Hg, P<0.001). UAE levels were significantly reduced after 6 months of therapy compared with baseline (18.9 vs. 12.1?mg?g(-1) Cre, P<0.001). In multiple regression analysis, the treatment-induced reduction in UAE was significantly associated with that of average home BP (P=0.003) but was not associated with that of s.d. of home SBP or that of maximum home SBP. Home BP variability is not itself an interventional target beyond lowering mean home BP during anti-hypertensive treatment.     

Differential effects of strict blood pressure lowering by losartan/hydrochlorothiazide combination therapy and high-dose amlodipine monotherapy on microalbuminuria: the ALPHABET study

We investigated the effects of losartan/hydrochlorothiazide (HCTZ) fixed combination therapy and high-dose amlodipine monotherapy on BP measurements and target organ protection. In this open-label multicenter trial, hypertensive patients were randomly allocated to receive losartan 50 mg or amlodipine 5 mg for 4 weeks, and the treatments were changed to combination of losartan 50 mg/HCTZ 12.5 mg or amlodipine 10 mg for a further 4 weeks. A total of 91 hypertensive patients (age 63.6 years), 47 in the losartan/HCTZ group and 44 in amlodipine group, were enrolled. After 8 weeks, the clinic BP, home BP, and 24-hour ambulatory BP were successfully controlled to the same level in both treatment groups (P < .001). Furthermore, both groups showed the same degree of BP reduction in the 24-hour, daytime, and nighttime (P < .001). B-type natriuretic peptide (BNP) also significantly decreased to the same level in both groups, whereas the reduction of urinary albumin/creatinine ratio (UACR) was greater in the losartan/HCTZ group than in the high-dose amlodipine group (–47.6% vs 2.4%, P < .001). Losartan/HCTZ combination and high-dose amlodipine have similar effects on clinic, home, and ambulatory BP control and BNP reduction, whereas losartan/HCTZ has superior effect on UACR reduction when compared with high-dose amlodipine.     

Relationship between short-term blood pressure variability and large-artery stiffness in human hypertension: findings from 2 large databases

Short-term blood pressure (BP) variability predicts cardiovascular complications in hypertension, but its association with large-artery stiffness is poorly understood and confounded by methodologic issues related to the assessment of BP variations over 24 hours. Carotid-femoral pulse wave velocity (cfPWV) and 24-hour ambulatory BP were measured in 911 untreated, nondiabetic patients with uncomplicated hypertension (learning population) and in 2089 mostly treated hypertensive patients (83% treated, 25% diabetics; test population). Short-term systolic BP (SBP) variability was calculated as the following: (1) SD of 24-hour, daytime, or nighttime SBP; (2) weighted SD of 24-hour SBP; and (3) average real variability (ARV), that is, the average of the absolute differences between consecutive SBP measurements over 24 hours. In the learning population, all of the measures of SBP variability showed a direct correlation with cfPWV (SD of 24-hour, daytime, and nighttime SBP, r=0.17/0.19/0.13; weighted SD of 24-hour SBP, r=0.21; ARV, r=0.26; all P<0.001). The relationship between cfPWV and ARV was stronger than that with 24-hour, daytime, or nighttime SBP (all P<0.05) and similar to that with weighted SD of 24-hour SBP. In the test population, ARV and weighted SD of 24-hour SBP had stronger relationships with cfPWV than SD of 24-hour, daytime, or nighttime SBP. In both populations, SBP variability indices independently predicted cfPWV along with age, 24-hour SBP, and other factors. We conclude that short-term variability of 24-hour SBP shows an independent, although moderate, relation to aortic stiffness in hypertension. This relationship is stronger with measures of BP variability focusing on short-term changes, such as ARV and weighted 24-hour SD.     

Relationship of Ambulatory Blood Pressure and the Heart Rate Profile with Renal Function Parameters in Hypertensive Patients with Chronic Kidney Disease

Strict blood pressure (BP) control is reportedly important for the management of hypertensive patients with chronic kidney disease (CKD). The purpose of this cross-sectional study was to examine whether the variables of ambulatory BP and the heart rate (HR) profile, central hemodynamics, and arterial stiffness were closely related to the renal function parameters (urine albumin excretion rate [UACR] and estimated glomerular filtration rate [eGFR]) observed in 25 consecutive hospitalized hypertensive patients with CKD. There were significant positive relationships between UACR and 24-hour, daytime, and nighttime ambulatory systolic BP. In addition, there were significant negative relationships between UACR and 24-hour and daytime HR variability. The circulating B-type natriuretic peptide level and hemoglobin A1c were also positively related to UACR. With respect to eGFR, although the 24-hour and nighttime HR variability were positively associated with eGFR, the circulating pentosidine and nighttime HR had a negative relationship with eGFR. On the other hand, central hemodynamics and arterial stiffness did not exhibit any significant association with renal function parameters. These results indicate that ambulatory BP and the HR profile are closely modulated by renal function deterioration. Further studies are needed to investigate the causal relationship between ambulatory BP and the HR profile and renal function parameters in hypertensive patients with CKD.     

Relationship between base blood pressure during sleep and health-related quality of life in healthy adults

There are many reports indicating that night time blood pressure (BP) is closely associated with target organ damage. However, BP in the waking period is influenced by physical activity and also by the psychological status. Recently, base BP (BP0: minimum and stable BP during sleep) has been reported to correlate with organ damage in hypertensives. However, little is known about the implications of BP0. We examined how BP0 is associated with BP, heart rate variability and health-related quality of life (HRQOL) in healthy subjects. One hundred and thirty-five participants, composed of 88 male and 47 female (age: 21-33 years) underwent a 24-h ambulatory BP monitoring (ABPM). Sympathetic nervous activity (ratio of low-frequency to high-frequency component: LF/HF) and parasympathetic nervous activity (high-frequency component: HF) were calculated by electrocardiogram monitoring. BP0 was calculated as previously reported. HRQOL was assessed by Medical Outcome Study Short-Forum 36-Item Health Survey. Base systolic BP (SBP0) positively correlated with 24-h systolic BP (SBP) (r=0.662, P<0.0001) and night time SBP (r=0.810, P<0.0001). SBP0 positively correlated with 24-h LF/HF (r=0.214, P<0.02) and night time LF/HF (r=0.326, P<0.001). Moreover, SBP0 negatively correlated with the scores of body pain (r=-0.223, P<0.02). Multiple linear regression analysis showed that SBP0 correlated with gender (P<0.01), night time LF/HF (P<0.04) and the scores of body pain (P<0.04). In conclusion, SBP0 correlated with BP, LF/HF and the scores of body pain (HRQOL). SBP0 may be a useful indicator for assessing 24-h BP, sympathetic nervous functions and HRQOL in healthy subjects.     

Clinical relevance of nighttime blood pressure and of daytime blood pressure variability.

BACKGROUND--The purpose of this study was to assess whether hypertensive target organ damage is related to average nighttime blood pressure (BP) and to BP variability. METHODS--Sixty-seven normotensive subjects and 171 borderline, 309 mild, 140 moderate, and 41 severe hypertensive patients were studied with noninvasive ambulatory BP monitoring. Each subject was assigned a target organ damage score of 0 to 5 on the basis of funduscopic changes and degree of left ventricular hypertrophy calculated from electrocardiogram and chest roentgenogram. RESULTS--When the 728 subjects were subdivided into five classes of increasing daytime BP, in each class a significantly higher degree of target organ damage was present in the subjects with higher nighttime diastolic BP. A similar, although nonsignificant, trend was observed in the subjects with higher nighttime systolic BP. In particular, higher nighttime BP levels were accompanied by a more severe degree of left ventricular hypertrophy. As for variability, subjects with higher daytime systolic BP SD, but not with higher daytime diastolic SD, displayed a more severe degree of target organ damage; this was accounted for by a higher degree of retinal abnormalities. The association between target organ damage and systolic BP SD was present both in men and women, while that with nighttime BP was present only in men. No relationship was found between degree of cardiovascular complications and peaks of pressure. CONCLUSIONS--These results suggest that a reduced day-night BP difference and an increased daytime BP variability, evaluated as the SD, are associated with a higher degree of hypertensive cardiovascular complications. Whether this BP profile is the cause or the consequence of target organ damage remains to be established.     

Differing Effects of Aliskiren/Amlodipine Combination and High‐Dose Amlodipine Monotherapy on Ambulatory Blood Pressure and Target Organ Protection

The aim of this study was to compare an aliskiren/amlodipine combination with high‐dose amlodipine monotherapy on ambulatory blood pressure monitoring (ABPM) and organ protection. The study was a prospective, randomized, multicenter, open‐label trial in elderly essential hypertensive patients. A total of 105 patients with clinic BP (CBP) ≥140/90 mm Hg with amlodipine 5 mg were randomly allocated to aliskiren (150–300 mg)/amlodipine (5 mg) (ALI/AML group, n=53) or high‐dose amlodipine (10 mg) (h‐dAML group, n=52) and treated for 16 weeks. Each patient's CBP, ABPM, urine albumin‐to‐creatinine ratio (UACR), and brachial‐ankle pulse wave velocity (baPWV) were measured at baseline and at the end of the study. The ALI/AML and h‐dAML groups showed similarly reduced mean 24‐hour SBP, daytime SBP, nighttime SBP, and baPWV. However, UACR reduction was significantly greater in the ALI/AML group (P=.02). ALI/AML was significantly less effective in reducing early‐morning BP (P=.002) and morning BP surge (P=.001) compared with h‐dAML.     

动脉粥样硬化性肾动脉狭窄患者24小时动态血压特征及靶器官损害相关研究

目的探讨动脉粥样硬化性肾动脉狭窄(ARAS)患者24 h动态血压、昼夜节律变化特征及靶器官损害。方法选择2014年1月~2018年12月在上海交通大学医学院附属瑞金医院高血压科连续住院的ARAS患者121例(ARAS组),另选择同期年龄、性别、体质量指数和高血压病程等匹配的原发性高血压(EH)患者418例(EH组),观察并比较2组诊室及24 h动态血压及靶器官损害的差异。结果与EH组比较,ARAS组诊室收缩压[(155±23)mm Hg(1mm Hg=0.133k Pa)vs(145±22)mm Hg,P<0.01]、诊室脉压[(75±20)mm Hg vs(65±18)mm Hg,P<0.01]、24h收缩压[(143±19)mm Hg vs(130±16)mm Hg,P<0.01]、昼间收缩压[(145±18)mm Hg vs(133±16)mm Hg,P<0.01]、夜间收缩压[(138±21)mm Hg vs(123±18)mm Hg,P<0.01]、夜间舒张压[(75±12)mm Hg vs(73±10)mm Hg,P<0.05]明显升高,差异有统计学意义。与EH组比较,ARAS组杓型血压比例明显降低,反杓型血压比例明显升高(P<0.05)。校正相关因素后,与EH组比较,ARAS组颈动脉内膜中层厚度、左心室质量指数及血浆N末端B型钠尿肽前体水平明显升高,差异有统计学意义(P<0.01)。结论ARAS患者收缩压及夜间血压较高,更多表现为反杓型血压。有独立于血压及肾功能水平更严重的靶器官损害。     

Isolated nocturnal hypertension and arterial stiffness in a Chinese population

OBJECTIVE: We reported previously that normotensive Chinese had higher nighttime diastolic blood pressure (BP) compared with non-Chinese. We, therefore, studied the prevalence and characteristics of isolated nocturnal hypertension and its association with arterial stiffness, an intermediate sign of target organ damage. METHODS: We recorded ambulatory BP, the central and peripheral systolic augmentation indexes, the ambulatory arterial stiffness index, and brachial-ankle pulse wave velocity in 677 Chinese enrolled in the JingNing population study (53.6% women; mean age: 47.6 years). RESULTS: The prevalence of isolated nocturnal hypertension (> or = 120/70 mmHg from 22 : 00 to 4 : 00 h) was 10.9%. Patients with isolated nocturnal hypertension, compared with participants with ambulatory normotension (45.8%), were older (53.7 vs. 40.7 years), more often reported alcohol intake (68.9 vs. 51.0%), and had faster nighttime pulse rate (62.8 vs. 60.7 bpm), higher serum cholesterol (5.12 vs. 4.77 mmol/l), and higher blood glucose (4.84 vs. 4.38 mmol/l). They also had higher indexes of arterial stiffness (P<0.05) than participants with ambulatory normotension. Of 74 patients with isolated nocturnal hypertension, only four (5.4%) had hypertension on conventional office BP measurement (> or = 140/90 mmHg). CONCLUSION: Isolated nocturnal hypertension can only be diagnosed by ambulatory BP monitoring, is prevalent among Chinese, and is associated with increased arterial stiffness.     

Effect of the rs168924 single-nucleotide polymorphism in the SLC6A2 catecholamine transporter gene on blood pressure in Caucasians

J Clin Hypertens (Greenwich). 2012; 14:293–298. ©2012 Wiley Periodicals, Inc. The NG_016969.1 :g.5003A>G promoter polymorphism (rs168924) in the SLC6A2 norepinephrine transporter gene was found to be predictive of the hypertensive status in a Japanese population, but no data are available for Caucasians. Genotyping for rs168924 was performed in 282 young men with normal blood pressure (BP), grade 1 or 2 hypertension. In addition to casual BP, 24‐hour ABPM and echocardiography were performed. Multiple regression analysis revealed a significant association of rs168924 genotype with diagnosis of hypertension (P=.044), casual systolic BP (SBP) levels (P=.028), and daytime ambulatory SBP (P=.02). The finding that rs168924 was also significantly associated with diastolic posterior wall thickness (P=.041), an echocardiographic index of hypertensive cardiac target organ damage, further supports the notion that the rs168924 SNP in SLC6A2 in fact might influence BP. Unlike previous findings in a Japanese population, in our Caucasian study cohort the presence of the minor rs168924 G allele was associated with lower prevalence of hypertension. J Clin Hypertens (Greenwich). 2012;00:00–00. ©2012 Wiley Periodicals, Inc.     

Nighttime blood pressure and nocturnal dipping are associated with daytime urinary sodium excretion in African subjects

Blood pressure (BP) follows a circadian rhythm, with 10% to 15% lower values during nighttime than during daytime. The absence of a nocturnal BP decrease (dipping) is associated with target organ damage, but the determinants of dipping are poorly understood. We assessed whether the nighttime BP and the dipping are associated with the circadian pattern of sodium excretion. Ambulatory BP and daytime and nighttime urinary electrolyte excretion were measured simultaneously in 325 individuals of African descent from 73 families. When divided into sex-specific tertiles of day:night ratios of urinary sodium excretion rate, subjects in tertile 1 (with the lowest ratio) were 6.5 years older and had a 9.8-mm Hg higher nighttime systolic BP (SBP) and a 23% lower SBP dipping (expressed in percentage of day value) compared with subjects in tertile 3 (P for trend <0.01). After adjustment for age, the SBP difference across tertiles decreased to 5.4 mm Hg (P=0.002), and the SBP dipping difference decreased to 17% (P=0.05). A similar trend across tertiles was found with diastolic BP. In multivariate analyses, daytime urinary sodium and potassium concentrations were independently associated with nighttime SBP and SBP dipping (P<0.05 for each). These data, based on a large number of subjects, suggest that the capacity to excrete sodium during daytime is a significant determinant of nocturnal BP and dipping. This observation may help us to understand the pathophysiology and clinical consequences of nighttime BP and to develop therapeutic strategies to normalize the dipping profile in hypertensive patients.     

Diminished nocturnal decline in blood pressure in elderly hypertensive patients with left ventricular hypertrophy.

To assess the circadian blood pressure (BP) changes in elderly hypertensive patients with left ventricular hypertrophy (LVH), the ambulatory BP was measured noninvasively every 30 minutes for 24 hours in those patients with LVH (n = 15) and without LVH (n = 23), and in normotensive elderly subjects (n = 11). Although the daytime systolic BP (SBP) was comparable in the two hypertensive groups, the nighttime SBP in patients with LVH tended to be higher than in patients without LVH (149.0 +/- 15.1 versus 138.4 +/- 20.1 mm Hg, p less than 0.10). The LV mass index correlated significantly with the nighttime SBP (r = 0.43, p less than 0.01), but not with the daytime SBP (r = 0.24, ns), with clinic SBP (r = 0.14, p = ns) or the SBP after handgrip exercise (r = 0.31, p = ns). The difference in the systolic BP between daytime and nighttime (D-N SBP) in patients with LVH (2.8 +/- 9.4 mm Hg) was significantly less than that in patients without LVH (12.8 +/- 16.0 mm Hg) (p less than 0.02). In addition, the D-N SBP correlated inversely with the left ventricular mass index (r = -0.33, p less than 0.05). It was concluded that hypertension in the elderly with LVH was associated with a diminished nocturnal decline in blood pressure.     

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。     

Is Daytime Systolic Load an Important Risk Factor for Target Organ Damage in Pediatric Hypertension?

The aim of this study was to compare ambulatory blood pressure (BP) monitoring (ABPM) data and determine which hypertension type is a risk factor in target organ damage. A total of 82 children (47 boys) with suspected hypertension based on office BP measurements and considered hypertensive by ABPM were studied. Target organ damage included the following: 35.3% hypertensive retinopathy, 25.6% microalbuminuria, 15.8% increased left ventricular mass index, 29.2% increased carotid intima‐media thickness (cIMT), 24.3% high augmentation index (AIx), and 19.5% high pulse wave velocity (PWV). The association between BP load, PWV, and cIMT was statistically significant. There were significant correlations between daytime systolic BP load, PWV, AIx, and cIMT. A statistically significant difference was also detected between nighttime systolic BP load, PWV, and cIMT values and nighttime diastolic BP load levels and values of AIx and cIMT. There was also a statistically significant difference between the high level of nighttime diastolic BP load and cIMT. The authors found that target organ damage was seen more often in children with primary hypertension who had systolic loads.     

Does the reduction in systolic blood pressure alone explain the regression of left ventricular hypertrophy?

Systolic blood pressure (SBP) is an important determinant of the development and regression of left ventricular hypertrophy (LVH) in hypertensive humans. However, comparative assessments with other BP components are scarce and generally limited in size. As part of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA), 743 hypertensive subjects underwent echocardiography and 24-h ambulatory BP monitoring before and after an average of 3.9 years of treatment. The changes in left ventricular mass showed a significant direct association with the changes in 24-h SBP (r=0.40), diastolic blood pressure (DBP) (r=0.33) and pulse pressure (PP) (r=0.35). Weaker associations were found with the changes in clinic BP (r=0.32, 0.31 and 0.16, respectively). In a multivariate linear regression analysis, the changes in 24-h SBP were the sole independent determinants of the changes in left ventricular mass (LVM) according to the following equation: percentage changes in LVM=0.73 x (percentage changes in 24-h SBP) -0.48 (P<0.0001). For any given reduction in 24-h SBP, the reduction in LVM did not show any association with the changes in DBP and PP, either clinic or ambulatory. These data indicate that SBP is the principal determinant of LVH regression in hypertensive humans.     

Time rate of blood pressure variation is associated with increased common carotid artery intima-media thickness

The extent of target-organ damage has been positively associated with the magnitude of blood pressure (BP) variability in essential hypertension. However, the clinical implications of the rate of BP changes have never been investigated. We evaluated the association between the rate of systolic BP (SBP) variation derived from ambulatory BP monitoring (ABPM) data analysis and the extent of common carotid artery (CCA) intima-media thickness (IMT) in normotensive (n=280) and in uncomplicated hypertensive subjects (n=234). The 24-hour rate of SBP variation was significantly (P<0.001) higher in hypertensive (0.608 mm Hg/min; 95% confidence interval [CI], 0.595 to 0.622) than in normotensive individuals (0.567 mm Hg/min; 95% CI, 0.555 to 0.578), even after adjusting for baseline characteristics, day-night BP changes, 24-hour heart rate (HR), SBP, and HR variability. In the entire group of patients, multiple linear regression models revealed independent determinants of CCA-IMT in the following rank order: age (P<0.001), 24-hour rate of SBP variation (P<0.001), male gender (P=0.004), cholesterol (P=0.009), and smoking (P=0.014). A 0.1 mm Hg/min increase in the 24-hour rate of SBP variation was associated to an increment of 0.029 mm (95% CI, 0.018 to 0.040) in CCA-IMT independent of BP and HR levels, BP and HR variability, and dipping status. The rate of SBP variation during the morning BP surge correlated independently (P<0.001) to larger CCA-IMT values after adjustment for baseline characteristics and other ABPM parameters. Thus, the rate of BP fluctuations is greater in hypertensive patients and correlates to increased CCA-IMT. This finding indicates that steeper BP variations may produce a greater stress on the vessel wall and consequently result in medial hypertrophy of the large arteries.     

Psychological and physical stress-induced cardiovascular reactivity and diurnal blood pressure variation in women with different work shifts.

There is increasing evidence that diurnal blood pressure (BP) variation, in addition to high BP per se, is related to target organ damage and the incidence of cardiovascular events. However, the determinants of diurnal BP variation are not adequately understood. This paper tests the hypothesis that cardiovascular reactivity to acute stress and/or delayed recovery predicts greater diurnal BP variation (i.e., a lower sleep/awake BP ratio). We studied the relationship of diurnal BP variation (assessed by ambulatory BP monitoring) to mental stress (mental arithmetic and anger recall tasks) and physical stress (treadmill)-induced cardiovascular reactivity and recovery in 87 female nurses who worked different shifts. The sleep/awake systolic BP (SBP) ratio was negatively correlated with relative SBP reactivity (maximum SBP increase/baseline SBP: r = -0.21, p = 0.06) and relative stress response (average of SBP during stress/baseline SBP:r = -0.23, p = 0.04) induced by anger recall, while the correlations of the sleep/awake SBP ratio with other parameters of reactivity or recovery in the anger recall or mental arithmetic task were not significant. When subjects were divided into day-shift workers (n=54) and night-shift workers (n = 33), the sleep/awake SBP ratio was negatively correlated with relative SBP reactivity (r = -0.41, p = 0.02) and relative stress response of SBP (r = -0.48, p = 0.006) induced by anger recall, and positively correlated with recovery rate (r = 0.34, p = 0.06) in the latter group, while these correlations were not significant in the former group. The sleep/awake SBP ratio was inversely correlated with the exercise-induced SBP increase in the day-shift workers (r = -0.30, p = 0.03), while this association was not found in the night-shift workers. In conclusion, cardiovascular reactivity triggered by psychological and physical stress in the laboratory may be a weak, but significant, determinant of diurnal BP variation; in addition, work shift (day or night) appears to moderate the relationship between these two pressor mechanisms.