Differences of blood pressure measured at clinic versus at home in the morning and in the evening in Europe and Asia: A systematic review and meta‐analysis

Numerous studies have indicated that there might be great differences among different populations in Europe and Asia in terms of home morning and evening blood pressure (BP). Thus, the authors performed a systematic review to determine the quantitative differences of BP measured at clinic versus at home in the morning and in the evening in Europe and Asia. PubMed, Embase, and Scopus databases were searched up to October 2021. Studies that compared clinic BP with home morning and (or) home evening BP in European and Asian populations were included. A random effect model was applied to pool the differences between clinic BP and home morning/evening BP. Thirty‐five studies, for a total of 49 432 patients, were included in this meta‐analysis. Mean clinic systolic blood pressure (SBP) values were significantly higher than home morning SBP values by 3.79 mmHg (95% CI, 2.77–4.80). The differences were much larger in Europe [(6.53 mmHg (95% CI, 4.10–8.97)] than in Asia [(2.70 mmHg (95% CI, 1.74–3.66)], and the region was a significant predictor for the differences. Mean clinic SBP values were also significantly higher than home evening SBP values by 6.59 mmHg (95% CI, 4.98–8.21). The differences were much smaller in Europe [5.85 mmHg (95% CI, 3.24–8.45)] than in Asia [7.13 mmHg (95% CI, 4.92–9.35)], while age and clinic SBP might contribute to it. Our findings showed that the difference between clinic and home morning SBP was much larger in European than Asian populations, whereas the difference between clinic and home evening SBP was the opposite. The differing characteristics of the region, ethnic, age, and clinic BP might explain the diversities.     

Development and implementation of blood pressure screening and referral guidelines for German community pharmacists

Involvement of community pharmacists in the detection and control of hypertension improves patient care. However, current European or North‐American guidelines do not provide specific guidance how to implement collaboration between pharmacists and physicians, especially when and how to refer patients with undetected or uncontrolled hypertension to a physician. The German Society of Cardiology and the ABDA – Federal Union of German Associations of Pharmacists developed and tested referral recommendations for community pharmacists, embedded in two guideline worksheets. The project included a guideline‐directed blood pressure (BP) measurement and recommendations when patients should be referred to their physician. A “red flag” referral within 4 weeks was recommended when SBP was >140 mm Hg or DBP >90 mm Hg (for subjects <80 years), and >160 mm Hg or >90 mm Hg (≥80 years) in undetected individuals, or >130 mm Hg or >80 mm Hg (<65 years) and >140 mm Hg or >80 mm Hg (≥65 years) in treated patients. BP was measured in 187 individuals (86 with known hypertension, mean [±SD] age 62 ± 15 years, 64% female, and 101 without known hypertension, 47 ± 16 years, 75% female) from 17 community pharmacies. In patients with hypertension, poorly controlled BP was detected in 55% (n = 47) and were referred. A total of 16/101 subjects without a history of hypertension were referred to their physician because of uncontrolled BP. Structured BP testing in pharmacies identified a significant number of subjects with undetected/undiagnosed hypertension and patients with poorly controlled BP. Community pharmacists could play a significant role in collaboration with physicians to improve the management of hypertension.     

Clinical significance of nocturnal home blood pressure monitoring and nocturnal hypertension in Asia

Nocturnal home blood pressure (BP) monitoring has been used in clinical practice for ~20 years. The authors recently showed that nocturnal systolic BP (SBP) measured by a home BP monitoring (HBPM) device in a Japanese general practice population was a significant predictor of incident cardiovascular disease (CVD) events, independent of office and morning home SBP levels, and that masked nocturnal hypertension obtained by HBPM (defined as nocturnal home BP ≥ 120/70 mmHg and average morning and evening BP < 135/85 mmHg) was associated with an increased risk of CVD events compared with controlled BP (nocturnal home BP < 120/70 mmHg and average morning and evening BP < 135/85 mmHg). This evidence revealed that (a) it is feasible to use a nocturnal HBPM device for monitoring nocturnal BP levels, and (b) such a device may offer an alternative to ambulatory BP monitoring, which has been the gold standard for the measurement of nocturnal BP. However, many unresolved clinical problems remain, such as the measurement schedule and conditions for the use of nocturnal HBPM. Further investigation of the measurement of nocturnal BP using an HBPM device and assessments of the prognostic value are thus warranted. Asians are at high risk of developing nocturnal hypertension due to high salt sensitivity and salt intake, and the precise management of their nocturnal BP levels is important. Information and communication technology‐based monitoring devices are expected to facilitate the management of nocturnal hypertension in Asian populations.     

Differences in ambulatory blood pressure profiles between Japanese and Thai patients with hypertension /suspected hypertension

Ethnic differences in the profiles of hypertension and cardiovascular risk have been reported between Asians and Westerners. However, blood pressure (BP) profiles and the risk factors for cardiovascular disease might differ even among different Asian populations because of the diversity of cultures, foods, and environments. We retrospectively examined differences in 24‐h BP profiles between 1051 Japanese (mean age, 62.5 ± 12.4 years; medicated hypertension, 75.7%) and 804 Thai (mean age, 56.9 ± 18.5 years; medicated hypertension, 65.6%) by using the Japanese and Thai ambulatory BP monitoring (ABPM) databases, in order to check the BP control status in treated hypertensives and to inform the clinical diagnosis of hypertension. The two populations had similar office systolic BP (SBP) (142.7 ± 20.0 vs 142.3 ± 20.6 mm Hg, p = .679). However, the Japanese population had higher 24‐hr average and daytime SBP, and the Thai population had higher nighttime SBP even after adjusting for cardiovascular risk factors (all p < .05). Greater morning BP surge was observed in Japanese (31.2 vs 22.8 mm Hg, p < .001). Regarding nocturnal BP dipping status, the prevalence of riser status (higher nighttime than daytime SBP) was higher in the Thai population (30.5% vs 10.9%). These findings suggest that a substantial difference in 24‐hr BP profiles exists between even neighboring countries in Asia.     

High prevalence of masked uncontrolled morning hypertension in elderly non‐valvular atrial fibrillation patients: Home blood pressure substudy of the ANAFIE Registry

In the ANAFIE Registry home blood pressure subcohort, we evaluated 5204 patients aged ≥75 years with non‐valvular atrial fibrillation (NVAF) to assess blood pressure (BP) control, prevalence of masked hypertension, and anticoagulant use. Mean clinic (C) and home (H) systolic/diastolic BP(SBP/DBP) was 128.5/71.3 and 127.7/72.6 mm Hg, respectively. Overall, 77.5% of patients had hypertension; of these, 27.7%, 13.4%, 23.4%, and 35.6% had well‐controlled, white coat, masked, and sustained hypertension, respectively. Masked hypertension prevalence increased with diabetes, decreased renal function, age ≥80 years, current smoker status, and chronic obstructive pulmonary disease. By morning/evening average, 59.0% of patients had mean H‐SBP ≥ 125 mm Hg; 48.9% had mean C‐SBP ≥ 130 mm Hg. Early morning hypertension (morning H‐SBP ≥ 125 mm Hg) was found in 65.9% of patients. Although 51.1% of patients had well‐controlled C‐SBP, 52.5% of these had uncontrolled morning H‐SBP. In elderly NVAF patients, morning H‐BP was poorly controlled, and masked uncontrolled morning hypertension remains significant.     

Assessment of suitable antihypertensive therapies: Combination with high‐dose amlodipine/irbesartan vs triple combination with amlodipine/irbesartan/indapamide (ASAHI‐AI study)

Angiotensin receptor blockers (ARBs) plus calcium channel blockers (CCBs) are a widely used combination therapy for hypertensive patients. In order to determine which combination was better as the next‐step therapy for standard‐dose combination of ARBs and CCBs, a combination with high‐dose CCBs or a triple combination with diuretics, the authors conducted a prospective, randomized, open‐label trial to determine which of the following combination is better as the next‐step treatment: a combination with high‐dose CCBs or a triple combination with diuretics. Hypertensive outpatients who did not achieve their target blood pressure (BP) with usual dosages of ARBs and amlodipine 5 mg were randomly assigned to treatment with irbesartan 100 mg/amlodipine 10 mg (Group 1: n = 48) or indapamide 1 mg in addition to ARBs plus amlodipine 5 mg (Group 2: n = 46). The primary end point was changes in the systolic BP (SBP) and diastolic BP (DBP) after the 12‐week treatment period, while secondary end points were changes in BP after the 24‐week treatment period and laboratory values. At 12 weeks, the SBP/DBP significantly decreased from 152.1/83.4 mm Hg to 131.5/76.1 mm Hg in Group 1 and 153.9/82.1 mm Hg to 132.7/75.9 mm Hg in Group 2. Although both groups produced a similar efficacy in reducing the SBP/DBP (−19.2/‐9.2 mm Hg in Group 1 and −21.6/‐8.8 mm Hg in Group 2; SBP P = .378, DBP P = .825), high‐dose CCBs combined with ARBs controlled hypertension without elevation of serum uric acid. These results will provide new evidence for selecting optimal combination therapies for uncontrolled hypertensive patients.     

Rationale and design for the Asia BP@Home study on home blood pressure control status in 12 Asian countries and regions

Home blood pressure (BP) monitoring is endorsed in multiple guidelines as a valuable adjunct to office BP measurements for the diagnosis and management of hypertension. In many countries throughout Asia, physicians are yet to appreciate the significant contribution of BP variability to cardiovascular events. Furthermore, data from Japanese cohort studies have shown that there is a strong association between morning BP surge and cardiovascular events, suggesting that Asians in general may benefit from more effective control of morning BP. We designed the Asia BP@Home study to investigate the distribution of hypertension subtypes, including white‐coat hypertension, masked morning hypertension, and well‐controlled and uncontrolled hypertension. The study will also investigate the determinants of home BP control status evaluated by the same validated home BP monitoring device and the same standardized method of home BP measurement among 1600 or more medicated patients with hypertension from 12 countries/regions across Asia.     

Pharmacological treatment of high‐normal blood pressure (prehypertension) in high‐risk patients for primary prevention of cardiovascular events

Currently, the best treatment strategy for patients with a high‐normal blood pressure (prehypertension) is not known. The authors aimed to determine whether pharmacological reduction of systolic blood pressure (SBP) to a normal level (<120 mm Hg) would prevent cardiac morbidity and mortality in prehypertensive patients. In this secondary analysis, the authors obtained the data from SPRINT from the National Heart, Lung, and Blood Institute data repository center. Among 9361 patients enrolled in SPRINT, 289 high‐risk (ASCVD risk = 24.8% ± 13.0 [10‐65]) prehypertensive patients without previous cardiovascular disease and not receiving any antihypertensive medications were enrolled. One hundred and forty‐eight of them were assigned to standard treatment which consisted of clinical follow‐up till SBP goes above 140 mm Hg and then staring medications to keep SBP <140 mm Hg. One hundred and forty‐one were assigned to the intensive treatment receiving pharmacological SBP reduction to <120 mm Hg upon enrollment. The primary composite outcome was myocardial infarction, and other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Throughout the 3.06 years of follow‐up, a primary outcome event was confirmed in three participants (0.74% per year) in the intensive‐treatment group and 8 (1.61% per year) in the standard‐treatment group (hazard ratio [HR], 0.19; P = .045). Rates of serious adverse events were not increased by intensive‐treatment (HR, 0.83; P = .506). Based on this secondary post hoc analysis, intensive SBP reduction may probably be beneficial for primary prevention of cardiovascular morbidity and mortality in high‐risk prehypertensive patients. This finding needs to be evaluated in a larger trial designed specifically to answer this question.     

Comparison of different schedules of nocturnal home blood pressure measurement using an information/communication technology‐based device in hypertensive patients

The objective of this study was to test our hypothesis that nocturnal home blood pressure (BP) measurement adapted to the chosen bedtime of participants (measurement at 2, 3, and 4 hour after the chosen bedtime) would be more reliable than measurement at fixed time points (2:00, 3:00, and 4:00 am). Forty‐eight hypertensives were randomized to two groups undergoing two seven‐night measurement phases in a crossover manner and were asked to measure nocturnal home BP for 14 consecutive nights using a validated automatic information/communication technology‐based device. The intraclass correlation coefficients (ICCs) of systolic BP (SBP) obtained by a single measurement per night over two nights showed lower agreement than those of systolic BP obtained by multiple measurements based on a participant‐specified bedtime (0.539‐0.625 vs 0.675‐0.768) and multiple measurements at fixed times (0.468‐0.505 vs 0.661‐0.790). The ICCs obtained using specific bedtime‐based time points and those obtained using fixed time points showed major agreement when SBP was obtained by multiple measurements. The standard errors of measurement for SBP were similar between the bedtime‐based measurement phase (1.4‐1.7 mm Hg) and the fixed‐time measurement phase (1.2‐1.6 mm Hg). Neither a fixed bias nor a proportional bias was observed between the SBP values measured by the specific bedtime‐based time points and those measured by the fixed‐time measurement phase. In conclusion, the reliability of nocturnal home BP measurement appeared to be similar between nocturnal home BP adapted to the chosen bedtime of participants and that measured at fixed time points.     

Office blood pressure threshold of 130/80 mmHg better predicts uncontrolled out‐of‐office blood pressure in apparent treatment‐resistant hypertension

The objective of this study was to compare the diagnostic accuracy of office blood pressure (BP) threshold of 140/90 and 130/80 mmHg for correctly identifying uncontrolled out‐of‐office BP in apparent treatment‐resistant hypertension (aTRH). We analyzed 468 subjects from a prospectively enrolled cohort of patients with resistant hypertension in South Korea (clinicaltrials.gov: {"type":"clinical-trial","attrs":{"text":"NCT03540992","term_id":"NCT03540992"}}NCT03540992). Resistant hypertension was defined as office BP ≥ 130/80 mmHg with three different classes of antihypertensive medications including thiazide‐type/like diuretics, or treated hypertension with four or more different classes of antihypertensive medications. We conducted different types of BP measurements including office BP, automated office BP (AOBP), home BP, and ambulatory BP. We defined uncontrolled out‐of‐office BP as daytime BP ≥ 135/85 mmHg and/or home BP ≥ 135/85 mmHg. Among subjects with office BP < 140/90 mmHg and subjects with office BP < 130/80 mmHg, 66% and 55% had uncontrolled out‐of‐office BP, respectively. The prevalence of controlled and masked uncontrolled hypertension was lower, and the prevalence of white‐coat and sustained uncontrolled hypertension was higher, with a threshold of 130/80 mmHg than of 140/90 mmHg, for both office BP and AOBP. The office BP threshold of 130/80 mmHg was better able to diagnose uncontrolled out‐of‐office BP than 140/90 mmHg, and the net reclassification improvement (NRI) was 0.255. The AOBP threshold of 130/80 mmHg also revealed better diagnostic accuracy than 140/90 mmHg, with NRI of 0.543. The office BP threshold of 130/80 mmHg showed better than 140/90 mmHg in terms of the correspondence to out‐of‐office BP in subjects with aTRH.     

Safety and efficacy of empagliflozin in elderly Japanese patients with type 2 diabetes mellitus: A post hoc analysis of data from the SACRA study

Elderly diabetic patients are likely to have uncontrolled nocturnal hypertension, which confers higher risks of cardiovascular events and heart failure. To investigate the efficacy and safety of empagliflozin in elderly patients with type 2 diabetes (T2DM), a sub‐analysis was performed of data from the SGLT2 inhibitor and Angiotensin receptor blocker Combination theRapy in pAtients with diabetes and uncontrolled nocturnal hypertension (SACRA) study, a multi‐center, double‐blind, randomized, parallel study of T2DM patients who were treated with empagliflozin for 12 weeks. In the present analysis, we compared efficacy and safety outcomes in participants aged <75 and ≥75 years. At baseline, 44 participants were ≥75 years and 87 were <75 years. Nighttime ambulatory systolic blood pressure (SBP) decreased by 4.2 mm Hg in the ≥75‐year‐old group and by 7.9 mm Hg in the <75‐year‐old group (p = .884 for the between‐age group difference in the change between baseline and week 12) [primary endpoint]. Empagliflozin, but not placebo, significantly reduced mean 24‐h SBP (−8.7 mm Hg in ≥75‐year‐olds vs. −11.0 mm Hg in <75‐year‐olds) and daytime SBP (−10.8 mm Hg in ≥ 75‐year‐olds vs. −12.3 mm Hg in <75‐year‐olds) between baseline and week 12, with no significant differences between the groups. In addition, there were significant reductions in glycated hemoglobin, body weight, and uric acid during 12 weeks of empagliflozin treatment in the two age groups. The incidences of hypoglycemic episodes, hypotension, and metabolic adverse events were similar in the two groups. Thus, empagliflozin was effective and well tolerated in elderly diabetic patients with uncontrolled nocturnal hypertension when administered for 12 weeks.     

Attended vs unattended systolic blood pressure measurement: A randomized comparison in patients with cardiovascular disease

Recent clinical guidelines recommend lower blood pressure (BP) goals for most patients, and recent trends have favored use of automated unattended BP measurements in the office setting to minimize observer error and white‐coat effects. Patients attending a routinely scheduled CVD clinic visit were prospectively randomized to BP measured using an attended, followed by an unattended method, or vice versa, after a controlled rest period. All study BP measurements were obtained in triplicate using the automated Omron HEM‐907XL BP monitor, and averaged. The outcome was difference in SBP. Routinely measured clinic BP from the same visit was extracted from the medical record, and compared with attended and unattended BP. A total of 102 patients were randomized, and mean age was 63 years, 52% female and 75% Caucasian. Attended and unattended SBP was 125.4 ± 20.4 and 122.6 ± 21.0 mm Hg, mean ± SD, respectively. Routine clinic SBP was 130.6 ± 23.6 mm Hg. Attended SBP was 2.7 mm Hg higher than the unattended measurement (95% CI 1.3‐4.1; P = .0002). Routine clinic SBP was 5.2 mm Hg higher than attended SBP (95% CI 2.4‐8.0; P = .0003) and 8.0 mm Hg higher than unattended SBP (95% CI 5.4‐10.5; P < .0001). Attended measurement of BP is significantly higher than unattended measurement and the difference is physiologically meaningful, even in a CVD cohort with generally well‐controlled hypertension. Furthermore, routine clinic SBP substantially overestimates both attended and unattended automated SBP, with important implications for treatment decisions like dose and/or drug escalation.     

Blood pressure measurement protocol determines hypertension phenotypes in a Middle Eastern population

Clinic blood pressure (BP) measurement remains a crucial step in managing hypertension. While the number of measures recorded in different settings varies, with typically 1‐3 measures, there has been no prior justification for the actual number of measures required. We investigated the pattern of BP variability over 5 consecutive automated readings (R1‐R5) and the influence of patient characteristics on this pattern to identify the phenotype of hypertension in a Middle Eastern population. There were 1389 outpatients (51% men, 49% women), age range (18‐87 y) who had 5 unattended automated consecutive BP measurements with one‐minute intervals using the validated Datascope Mindray Passport V Monitor with the patient blinded from the results. Mean (±SEM) SBP for R1 (136.0 ± 2 mm Hg) was similar to R2 (136.2 ± 2 mm Hg). Thereafter SBP progressively declined till R5 by total of 5.5 mm Hg. The SBP decline was less (4.2 mm Hg) in older (>50 years) vs younger participants (8.1 mm Hg; P < .001) and was blunted in diabetic and hypertensive participants. Overall, 43% of participants had R2 > R1, and 24% additionally had R5 > R1. Age was a strong independent predictor of having both R2 > R1 and R5 > R1, as well as diabetes. Diastolic blood pressure (DBP) decreased by average 2.8 mm Hg from R1 to R5. Females had a 5‐fold greater total decline in DBP vs males (P < .001). Using the mean of 5 BP measures resulted in fewer participants being classified as hypertensive (36% of the population) compared to using one measurement (46%), or established BP guidelines which use different combinations of R1‐R3 (37%‐42%). Our findings in a Middle Eastern population highlight the importance of the BP measurement protocol in combination with patient characteristics in determining whether a patient is diagnosed with hypertension. Protocols that rely on different combinations of only 3 measures (R1‐3) will classify more participants as hypertensive, compared to using 5 measures or disregarding a high R2.     

Peak blood pressure‐guided monitoring may serve as an effective approach for blood pressure control in the out‐of‐office setting

We aimed to explore whether diurnal blood pressure (BP) peak characteristics have a significant influence on the association between left ventricular damage with the two BP components (morning BP vs. afternoon peak BP) in untreated hypertensives. This cross‐sectional study included 1084 hypertensives who underwent echocardiography and 24‐h ambulatory BP monitoring. Participants were stratified according to the relationship between morning systolic BP (MSBP; average SBP within 2 h of waking up) and afternoon peak systolic BP (ASBP; average SBP between 16:00 and 18:00). Afternoon and morning hypertension was defined as ≥ 135/85 mm Hg. The morning and afternoon peak BPs occurred at around 7:00 and 17:00, respectively. In general hypertensives, morning BP and afternoon peak BP are significantly different in absolute values (for binary SBP, McNemar''s χ² = 6.42; p = .014). ASBP was more pronounced than MSBP in 602 patients (55.5%), in whom 24‐h SBP showed higher consistency with ASBP than with MSBP (Kappa value: 0.767 vs 0.646, both p < .01). In subjects with ASBP ≥ MSBP, ASBP was associated with left ventricular hypertrophy independent of MSBP (logistic regression analysis odds ratio: 1.046, p < .01), and left ventricular mass index was more strongly correlated with ASBP than with MSBP (multiple regression coefficient β: 0.453, p < .01), in which the relationships held true independently of 24‐h SBP. The opposite results were obtained in subjects with MSBP > ASBP. Peak BP‐guided monitoring may serve as an effective approach to out‐of‐office hypertension monitoring and control, providing the best consistency with 24‐h average SBP and highest discrimination performance for target organ damage, independently of 24‐h SBP.     

Focus on blood pressure levels and variability in the early phase of acute ischemic stroke with hypertension and carotid stenosis

To investigate the optimal blood pressure (BP) levels and relative importance of BP and BP variability in the early phase of acute ischemic stroke (AIS) for hypertensive patients with carotid artery stenosis (CAS). A single‐center cohort study included 750 AIS patients with hypertension and tests were performed for CAS. Participants were categorized to Group 1 (SBP < 140 mm Hg and DBP < 90 mm Hg), Group 2: (SBP: 140–159 mm Hg and or DBP: 90–99 mm Hg), and Group 3: (SBP ≥160 mm Hg and/or DBP ≥100 mm Hg) according to the guidelines. The associations of mean BP levels and variability with outcomes (recurrent stroke, all‐cause death and the composite cardiovascular events) at 6 months were analyzed by Cox proportional hazard models. The associations of BP variability with BP levels and cerebral blood flow (CBF) were analyzed by linear regression and generalized additive models. Both for primary and secondary outcome, more events occurred in Group 1 compared with Group 2, while no significant difference was found in Group 3 with higher BP levels. Lower systolic BP variability showed better prognosis and higher CBF. The associations were more significant in patients with CAS ≥50%. BP variability exhibited a linear negative relationship with BP levels. In the early phase of AIS with hypertension and CAS, maintaining low blood pressure variability may be important to improve outcomes while low BP levels (SBP/DBP < 140/90 mm Hg) were harmful, especially in those patients with CAS ≥ 50%.     

Efficacy and safety of azilsartan medoxomil/chlortalidone fixed‐dose combination in hypertensive patients uncontrolled on azilsartan medoxomil alone: A randomized trial

Patients with grade 2‐3 essential hypertension and postplacebo mean clinic systolic blood pressure (SBP) 160‐190 mm Hg and 24‐hour SBP 140‐175 mm Hg by ambulatory blood pressure monitoring (ABPM) received 40 mg azilsartan medoxomil (AZL‐M) monotherapy for 4 weeks. “Nonresponders” were then randomized to 8 weeks of double‐blind treatment with AZL‐M 40 mg, AZL‐M/chlortalidone (CLD) 40/25, or AZL‐M/CLD 40/12.5 mg. After 8 weeks, mean clinic SBP change was −21.1 (±1.04) mm Hg for AZL‐M/CLD 40/25 mg, −15.8 (±1.08) mm Hg for AZL‐M/CLD 40/12.5 mg, and −6.4 (±1.05) mm Hg for AZL‐M 40 mg (P < 0.001 for both AZL‐M/CLD vs AZL‐M, ANCOVA). Drug discontinuation rates were 8.9% (AZL‐M/CLD 40/25 mg), 7.5% (AZL‐M 40 mg), and 3.9% (AZL‐M/CLD 40/12.5 mg). Creatinine increased in 8.1% (AZL‐M/CLD 40/25), 3.1% (AZL‐M/CLD 40/12.5 mg), and 3.0% (AZL‐M 40 mg) of patients. AZL‐M/CLD was effective and well tolerated in patients not achieving blood pressure targets with AZL‐M.     

The impact of changing home blood pressure monitoring cutoff from 135/85 to 130/80 mmHg on hypertension phenotypes

This study investigated the impact of changing abnormal home blood pressure monitoring (HBPM) cutoff from 135/85 to 130/80 mmHg on the prevalence of hypertension phenotypes, considering an abnormal office blood pressure cutoff of 140/90 mmHg. We evaluated 57 768 individuals (26 876 untreated and 30 892 treated with antihypertensive medications) from 719 Brazilian centers who performed HBPM. Changing the HBPM cutoff was associated with increases in masked (from 10% to 22%) and sustained (from 27% to 35%) hypertension, and decreases in white‐coat hypertension (from 16% to 7%) and normotension (from 47% to 36%) among untreated participants, and increases in masked (from 11% to 22%) and sustained (from 29% to 36%) uncontrolled hypertension, and decreases in white‐coat uncontrolled hypertension (from 15% to 8%) and controlled hypertension (from 45% to 34%) among treated participants. In conclusion, adoption of an abnormal HBPM cutoff of 130/80 mmHg markedly increased the prevalence of out‐of‐office hypertension and uncontrolled hypertension phenotypes.     

Association of optimal blood pressure with mortality in patients taking antihypertensive medications

We investigated the relationship between blood pressure (BP) and mortality in patients taking antihypertensive medications in the Korean using data from the 2007‐2015 Korean National Health and Nutrition Examination Surveys. A total of 6601 patients aged 30‐74 years were included. Systolic BP (SBP) and diastolic BP (DBP) were both divided into four groups as follows: SBP < 120, 120 ≤ SBP ≤ 129 130 ≤ SBP ≤ 139, and SBP ≥ 140; DBP < 70, 70 ≤ DBP ≤ 79, 80 ≤ DBP ≤ 89, and DBP ≥ 90. The survival rates and hazard ratios were evaluated using Kaplan‐Meier curves and multivariable Cox regression analyses. To evaluate the predictability of all‐cause mortality according to SBP and/or DBP, we calculated Harrell''s concordance‐index. The lowest DBP group had a high risk of mortality regardless of the SBP status. The group with DBP < 70 mm Hg and SBP ≥ 140 mm Hg showed the highest mortality. The discriminatory ability calculated using Harrell''s C‐indexes was greater for the combination of SBP and DBP compared to DBP or SBP alone. These results suggest that it is more effective to simultaneously evaluate the effect of SBP and DBP to predict mortality; clinicians should manage DBP < 70 mm Hg when treating hypertensive patients.     

Comparison of day‐to‐day blood pressure variability in hypertensive patients with type 2 diabetes mellitus to those without diabetes: Asia BP@Home Study

Blood pressure variability (BPV) has been shown to be independently associated with cardiovascular (CV) mortality and morbidity. Patients with type 2 diabetes mellitus (T2DM) have also been shown to have increased BPV. We aimed to compare BPV in hypertensive patients with diabetes with those without diabetes. A total of 1443 hypertensive patients measured their blood pressure (BP) twice in the morning and twice before bed at home for a week. Demographic data, history of T2DM, and anti‐hypertensive use were captured. Clinic BP was measured twice in the clinic. Control of BP was defined as clinic systolic BP (SBP) <140 mm Hg and home SBP < 135 mm Hg. BPV was based on home SBP measurements. A total of 362(25.1%) hypertensives had diabetes and 47.4% were male. Mean age was 62.3 ± 12.1 years. There was no difference in the mean clinic SBP in both groups (139.9 mm Hg vs 138.4 mm Hg P = .188). However, the mean morning home SBP was significantly higher and control rate lower in hypertensives with diabetes than those without (132.3 ± 15 mm Hg vs 129.7 ± 14.4 mm Hg P = .005, 39.4% vs 47.6% P = .007), respectively. Masked uncontrolled morning hypertension was higher in those with diabetes versus those without (12.8% vs 8.4%, respectively). There was no statistically significant difference in BPV between those with and without diabetes. In summary, clinic SBP was similar in hypertensives with or without diabetes. However, control of BP based on both clinic and home SBP thresholds was poorer in hypertensives with diabetes compared to those without. Masked uncontrolled morning hypertension was higher in those with diabetes than those without. There was no difference in BPV between the two groups.     

The difference between nocturnal dipping status and morning blood pressure surge for target organ damage in patients with chronic kidney disease

The authors aimed to investigate the epidemiology of morning blood pressure (BP) surge (MBPS) in chronic kidney disease (CKD) patients, and the interaction effect between MBPS and dipping status for target organ damage (TOD). A total of 823 non‐dialysis CKD patients were enrolled in this cross‐sectional study. Subjects were grouped according to their systolic BP morning surge and dipping status, assessed by 24‐hour ambulatory BP monitoring. Patients with elevated MBPS had the highest quartile of MBPS (≥26.89 mm Hg). Non‐dipping pattern was defined as a decline in the nocturnal systolic BP of <10%. The factorial‐designed analysis of variance indicated that there was no statistically significant interaction effect for TOD between MBPS and dipping status (P > .05). There was a statistically significant association between MBPS and the non‐dipping pattern (OR 0.17, 95% CI 0.12‐0.25; OR 0.92, 95% CI 0.91‐0.93). Multiple linear regression analyses showed that excessive MBPS is an independent risk factor for poor renal function, independent of a non‐dipping pattern, and BP level, whereas the non‐dipping pattern was an important risk factor for left ventricular hypertrophy. Special attention should be paid to synchronous control of MBPS and nocturnal BP in CKD patients in clinical practice.