Proposal of Reference Values for Home Blood Pressure Measurement: Prognostic Criteria Based on a Prospective Observation of the General Population in Ohasama,Japan

The purpose of this study was to propose reference values, from a viewpoint of prognostic significance, for blood pressure (BP) measured at home with a semiautomated device (home BP measurement) to differentiate normotension and hypertension. We obtained home BP measurements for 1,913 population-based subjects aged 40 years and over in a rural Japanese community and followed up their survival for a mean duration of 5.0 years. There were 141 deaths during the follow-up period. The association between baseline BP values and the overall mortality was examined by Cox proportional hazards regression model, adjusted for age, gender, and the use of antihypertensive medication. The results indicated that the predictive power of home BP level for subsequent mortality was stronger than that of casual screening BP. There was a linear association between home systolic BP and mortality. The association between home diastolic BP and mortality was nonlinear and well approximated with the secondary degree equation of diastolic BP values. Based on this relation, we propose that the reference value for hypertension is 137/84 mm Hg, and normotension is below 137 mm Hg for home systolic BP and between 66 and 83 mm Hg for home diastolic BP. Home diastolic BP below 66 mm Hg should be considered as low diastolic blood pressure. In this population, home systolic BP of 137 mm Hg and home diastolic BP of 84 mm Hg corresponded to the 80th and 87th percentiles, respectively. Then, 29% of the subjects were classified as having hypertension, 52% as normotension, and 19% as low diastolic blood pressure. All previous studies proposing reference values for home BP measurement, derived from cross-sectional observations, were based on the statistical distribution of home BP values. The reference value must, however, be the one that best predicts the risk for morbidity and mortality from hypertension-related complications. This is the first report proposing reference values for home BP measurement based on prognostic criteria.     

Arterial compliance abnormalities in isolated systolic hypertension.

Arterial compliance measurements using intraarterial pulse contour analysis and a modified Windkessel model were carried out in 19 patients with isolated systolic hypertension (> or = 160/< or = 90 mm Hg) and compared to measurements in 29 patients with essential hypertension (diastolic blood pressure [BP] > or = 95 mm Hg) and 47 normotensive control subjects. Arterial capacitive compliance was significantly lower in isolated systolic hypertension than in essential hypertension (P < .0002) and significantly lower in essential hypertension than in normotensive control subjects (P < .0001). Although the isolated systolic hypertension group was older than the essential hypertension group, the reduction of capacitive compliance in isolated systolic hypertension persisted even when comparison was made with a more nearly age-matched group of essential hypertension. In contrast, oscillatory compliance was reduced similarly in isolated systolic hypertension and essential hypertension compared to normotensive control subjects (P < .0001). Although pulse pressure was greater in isolated systolic hypertension than in essential hypertension, only a weak correlation (r = -0.34) existed between pulse pressure and capacitive compliance. These data indicate that both essential hypertension and isolated systolic hypertension patients exhibit comparably abnormal structure or tone of the small vessels that are the site of oscillations or reflections in the arterial vasculature. In isolated systolic hypertension there is a profound reduction in large artery or capacitive compliance that accounts for the increase in systolic BP and decrease in diastolic BP. This abnormality cannot be accurately assessed by pulse pressure alone.     

Cardiovascular Risks Associated With Diastolic Blood Pressure and Isolated Diastolic Hypertension

Hypertension is a major reversible risk factor for cardiovascular complications. According to recent guidelines, hypertension can be subdivided into isolated diastolic, isolated systolic, and systolic and diastolic mixed hypertension using proposed thresholds of various blood pressure components. In the present article, we reviewed the association of cardiovascular outcomes with diastolic blood pressure versus systolic blood pressure and with isolated diastolic hypertension versus systolic and mixed hypertension in observational prospective cohort studies and large-scale individual data-based meta-analysis. Blood pressure was measured either in the clinic or at home or under ambulatory conditions for 24 h in cohort studies. To illustrate the treatment effect of diastolic blood pressure lowering, we also reviewed randomized placebo-controlled outcome trials in diastolic hypertension. Conclusions: The risks conferred by diastolic and systolic blood pressure, irrespective of the methods of blood pressure measurement, are age-dependent. Diastolic blood pressure and isolated diastolic hypertension drive coronary risk in younger subjects, whereas systolic blood pressure is the predominant risk indicator in older people. Reversibility of the risk by diastolic BP lowering treatment in randomized trials confirms that diastolic hypertension is a risk factor that must be treated.     

The study of aortic stiffness in different hypertension subtypes in dialysis patients.

The aim of this study was to validate whether differences in aortic stiffness are responsible for the differences in cardiovascular mortality among hypertension subtypes. Twenty hundred and fifty continuous ambulatory peritoneal dialysis patients were included in the present study. They were classified into four groups: normotensives (n=92) with systolic blood pressure (SBP) <140 mmHg and diastolic blood pressure (DBP) <90 mmHg; isolated systolic hypertensives (ISH, n=84) with SBP > or =140 mmHg and DBP <90 mmHg; isolated diastolic hypertensives (IDH, n=21) with SBP <140 mmHg and DBP > or =90 mmHg; and systolic-diastolic hypertensives (SDH, n=53) with SBP > or =140 mmHg and DBP > or =90 mmHg. Aortic stiffness was assessed by pulse pressure, central pressure parameters and pulse wave velocity. The IDH group had more male patients and a lower mean age than the other groups. The percentage of diabetes in the ISH group was higher than that in the other groups. The comparisons of aortic stiffness showed that the ISH and SDH groups had higher aortic stiffness than the normotension and IDH groups. The aortic stiffness in the ISH group was also higher than that in the SDH group, but there was no significant difference in aortic stiffness between the normotension and IDH groups. In conclusion, this study showed that aortic stiffness was significantly different among different hypertension subtypes, which might be an underlying cause of the differences in cardiovascular mortality among the hypertension subtypes.     

Prognostic significance of blood pressure measured in the office, at home and during ambulatory monitoring in older patients in general practice

The purpose of the study was to assess the prognostic significance of out-of-the-office blood pressure (BP) measurement in older patients in general practice, and to compare the results for BP measured in the office, at home and during 24-h ambulatory monitoring. All registerd patients who were 60 years or older were eligible for the study, except when bedridden, demented or admitted in a home for sick elderly people, or when they had suffered a myocardial infarction or stroke. After baseline measurements in 1990-1993, incidence of major cardiovascular events (cardiovascular death, myocardial infarction and stroke) was ascertained in 2002-2003 and related to the BPs by use of multivariate Cox regression analysis. Age of the 391 patients averaged 71+/-9 years; 40% were men. During median follow-up of 10.9 years, 86 patients (22%) suffered a cardiovascular event. The adjusted relative hazard rate, associated with a 1 s.d. increment in systolic BP was 1.13 for office BP (NS), and, respectively, 1.32, 1.33 and 1.42, for home, daytime and night time BP (P< or =0.01 for all). Results were similar for diastolic BP. The prognostic significance of all out-of-the-office BPs was independent of office BP. The prognostic value of home BP was equal to (systolic) or even better (diastolic) than that of daytime BP. Night time BP predicted cardiovascular events independent of all other BPs. Prognosis of white-coat hypertension was similar to that of true normotension, but better than in sustained hypertension. In conclusion, the prognostic value of home BP is better than that of office BP in older patients in primary care, and is at least equal to that of daytime ambulatory BP. The prognosis of patients with white-coat hypertension is similar to that of true normotensives.     

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.     

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.     

Indapamide SR versus candesartan and amlodipine in hypertension: the X-CELLENT Study

BACKGROUND: Reducing systolic blood pressure (BP) is of major benefit to patients with isolated systolic hypertension, but lowering normal diastolic BP may be harmful in terms of cardiovascular risk. Effects of different drugs on systolic BP, diastolic BP, and pulse pressure are therefore of interest. METHODS: The NatriliX SR versus CandEsartan and amLodipine in the reduction of systoLic blood prEssure in hyperteNsive patienTs study (X-CELLENT) was a randomized, double-blind, placebo-controlled study comparing the effects of three drugs on these BP components. Patients with systolic-diastolic or isolated systolic hypertension (n = 1758) received indapamide (1.5 mg) sustained release (SR), candesartan (8 mg), amlodipine (5 mg), or placebo once daily for 12 weeks. RESULTS: Compared to placebo all active treatments reduced all BP components significantly (P < .001). For the patients with isolated systolic hypertension (n = 388), the three treatments significantly reduced systolic BP, but only indapamide SR did not change diastolic BP and thus reduced pulse pressure significantly relative to placebo (P = .005). In an ancillary study using ambulatory BP monitoring (n = 576), all three treatments significantly reduced BP components during 24 h relative to placebo. Changes in systolic BP and pulse pressure were similar with the three treatments, but the reduction in diastolic BP was significantly smaller, and therefore more favorable, with indapamide SR compared with candesartan (P = .039). In patients with isolated systolic hypertension (n = 106), indapamide SR reduced 24-h systolic BP significantly more than amlodipine (P = .037), and only indapamide SR reduced 24-h pulse pressure significantly relative to placebo (P = .03). All three drugs were well tolerated. CONCLUSIONS: This distinctive BP-lowering profile of indapamide SR seems highly beneficial when compared to the either of candesartan or amlodipine.     

单纯舒张期高血压预后的前瞻性研究

目的 :探讨单纯舒张期高血压 (IDH)对心血管事件 (CVD)发生的危险性。方法 :采用前瞻队列研究方法 ,对北京市自然人群 (40岁以上 )共 7333人于 1991年基线危险因素调查后 ,分别于 1996年、1999年二次进行随访。对在随访期间发生的心血管事件和死亡进行登记。并根据基线调查时收缩压及舒张压水平 ,将队列人群分成以下 4组 :正常血压组 ,单纯舒张期高血压组 ,单纯收缩期高血压组 ,收缩压合并舒张压升高组。不同血压组与CVD事件发生率之间的关系分别进行单因素分析 (Gehan检验 )及多因素分析 (Cox回归 )。结果 :1 单纯舒张期高血压组平均年龄最小 (5 2 1± 8 7岁 ) ,其在中年人中占较大的比例 (82 8% ) ,而单纯收缩期高血压组平均年龄最大 (6 4 3± 9 8岁 ) ,其在老年人中占较大构成比 (6 5 9% )。 2 与正常血压组相比 ,单纯舒张期高血压组发生心血管事件的危险性无显著性差异(RR =1 0 9,95 %CI:0 5 6～ 2 .13) ,而单纯收缩期高血压组及收缩压合并舒张压升高组的危险性显著升高 ,RR分别为 :2 0 3(95 %CI:1 6 3～ 2 .5 2 )、3 38(95 %CI:2 73～ 4 .17)。结论 :1 单纯舒张期高血压预后良好 ,而单纯收缩期高血压及收缩压合并舒张压升高者有较大的发生CVD事件的危险性。 2 对高血压患者 ,应着重对升高     

Predictive values of automated blood pressure measurement: what can we learn from the Japanese population - the Ohasama study

BACKGROUND: Measurements of ambulatory blood pressure (ABP) and of home blood pressure (HBP) as an adjunct to casual/clinic blood pressure (CBP) measurements are currently widely used for the diagnosis and treatment of hypertension. We have monitored a rural cohort of people from the population of Ohasama, Japan, with respect to their prognosis and have previously reported that ABP and HBP are superior to CBP for the prediction of cardiovascular mortality. One reason that CBP is a poor predictor of prognosis is that it incorporates several biases, including the white-coat effect. METHODS AND RESULTS: We examined the prognostic significance of white-coat hypertension for mortality and found that the relative hazard for the overall mortality of patients with white-coat hypertension was significantly lower than that for true hypertension. Short-term blood pressure variability has recently attracted attention as a cause of target-organ damage and cardiovascular complications. Our results confirmed that short-term blood pressure variability (as measured every 30 min) was independently associated with cardiovascular mortality. In addition, research has recently focused on isolated systolic hypertension and pulse pressure as independent risk factors for poor cardiovascular prognosis. The Ohasama study also clearly demonstrated that isolated systolic hypertension and increased pulse pressure, as assessed by HBP, were associated with an increase in the risk of cardiovascular mortality. Circadian blood pressure variation is characterized by a diurnal elevation and a nocturnal decline in blood pressure. We therefore compared morbidity from stroke between dippers (subjects who show an ordinal nocturnal dipping of blood pressure) and non-dippers (those with a diminished nocturnal dipping or nocturnal elevation of blood pressure [inverted dippers]) in the Ohasama study. The incidence of stroke increased with an increased length of observation in dippers using antihypertensive medication but not in non-dippers using antihypertensive medication. In contrast, the relative hazard for mortality increased in non-dippers and inverted dippers. These results suggest a cause-and-effect relationship for both dippers and non-dippers. CONCLUSION: The Ohasama study showed that the level and variability of hypertension as assessed by ABP and HBP are independent predictors of cardiovascular mortality. It also demonstrated an independent association between the prognosis of hypertension and each component of ABP and HBP, indicating the prognostic significance of these blood pressure measurements.     

Arterial hypertension and mortality in the elderly

BACKGROUND: The aim of this study was to evaluate at a population level whether hypertension is a risk factor for cardiovascular mortality and to verify whether or not this is true for both genders at any age. METHODS: This population-based, long-lasting, prospective study includes a 14-year mortality (institutional epidemiology in primary care). Unselected, unbiased subjects (5185) aged 22 to 95 years were recruited from the Italian general population, and divided into normotensive (<140 mm Hg systolic blood pressure [BP] and <90 mm Hg diastolic BP and untreated) and hypertensive groups. The main aim was to identify the significant predictors of mortality due to stroke, coronary artery disease, heart failure, and pulmonary embolism, and to quantify the age-adjusted relative risk of hypertension in men and women, at different age classes (<70, 70 to 79, >or =80 years) for each mortality cause. The analysis was repeated among 1091 normotensive and 1091 hypertensive age-matched subjects to clean statistics from the effects of age. RESULTS: There were 846 cardiovascular deaths, 178 due to stroke, 273 to coronary disease, 351 to heart failure, and 44 to pulmonary embolism. Hypertension predicted stroke mortality, but not that due to other causes. This prediction was only significant in women, not in men. No prediction was possible after the age of 80 years. Age-matching increased the significance level of stroke mortality prediction in women aged <80 years; in these women, systolic BP predicted stroke mortality directly and diastolic inversely. CONCLUSIONS; In this population, hypertension predicted only stroke mortality in women aged <80 years. High systolic and low diastolic BP were predictive of stroke mortality, confirming a prognostic role for high pulse pressure.     

Significance of white-coat hypertension in older persons with isolated systolic hypertension: a meta-analysis using the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes population

The significance of white-coat hypertension in older persons with isolated systolic hypertension remains poorly understood. We analyzed subjects from the population-based 11-country International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes database who had daytime ambulatory blood pressure (BP; ABP) and conventional BP (CBP) measurements. After excluding persons with diastolic hypertension by CBP (≥90 mm Hg) or by daytime ABP (≥85 mm Hg), a history of cardiovascular disease, and persons <18 years of age, the present analysis totaled 7295 persons, of whom 1593 had isolated systolic hypertension. During a median follow-up of 10.6 years, there was a total of 655 fatal and nonfatal cardiovascular events. The analyses were stratified by treatment status. In untreated subjects, those with white-coat hypertension (CBP ≥140/<90 mm Hg and ABP <135/<85 mm Hg) and subjects with normal BP (CBP <140/<90 mm Hg and ABP <135/<85 mm Hg) were at similar risk (adjusted hazard rate: 1.17 [95% CI: 0.87-1.57]; P=0.29). Furthermore, in treated subjects with isolated systolic hypertension, the cardiovascular risk was similar in elevated conventional and normal daytime systolic BP as compared with those with normal conventional and normal daytime BPs (adjusted hazard rate: 1.10 [95% CI: 0.79-1.53]; P=0.57). However, both treated isolated systolic hypertension subjects with white-coat hypertension (adjusted hazard rate: 2.00; [95% CI: 1.43-2.79]; P<0.0001) and treated subjects with normal BP (adjusted hazard rate: 1.98 [95% CI: 1.49-2.62]; P<0.0001) were at higher risk as compared with untreated normotensive subjects. In conclusion, subjects with sustained hypertension who have their ABP normalized on antihypertensive therapy but with residual white-coat effect by CBP measurement have an entity that we have termed, "treated normalized hypertension." Therefore, one should be cautious in applying the term "white-coat hypertension" to persons receiving antihypertensive treatment.     

Optimal schedule for home blood pressure measurement based on prognostic data: the Finn-Home Study

Current guidelines based on cross-sectional statistical parameters derived from reference populations make equivocal recommendations for the optimal schedule of home blood pressure (BP) measurement. The objective of this study was to determine a schedule for home BP measurements in relation to their predictive value for total cardiovascular risk. Home BP was measured twice every morning and evening for 1 week in an unselected nationwide population of 2081 subjects aged 45 to 74 years. The prognostic significance of BP for fatal and nonfatal cardiovascular events was examined using adjusted Cox proportional hazards regression models. A total of 162 cardiovascular events were recorded during a 6.8-year follow-up. The predictive value of home BP increased progressively with the number of measurements, showing the highest predictive value with the average of all measurements (systolic/diastolic hazard ratio per 1-mm Hg increase in BP: 1.021/1.034; systolic/ diastolic 95% CI: 1.012 to 1.030/1.018 to 1.049). However, most of this increase was achieved during the first 3 days of measurement (hazard ratio: 1.017/1.028; 95% CI: 1.009 to 1.026/1.013 to 1.045), and only minimal increase occurred after day 6. No additional benefit was achieved by discarding the values obtained during the first day of measurement. Morning and evening BPs were equally predictive of future cardiovascular events. Novel prognostic data from this study show that measurement of home BP twice in the morning and evening, preferably for a period of 7 days, or for at least 3 days, provides a thorough image of a patient's BP level. This information should be used to prepare a unified international guideline for home BP measurement.     

Cardiovascular remodeling is greater in isolated systolic hypertension than in diastolic hypertension in older adults: the Insufficienza Cardiaca negli Anziani Residenti (ICARE) a Dicomano Study

OBJECTIVE: We investigated cardiac and vascular remodeling in an unselected older population with either diastolic hypertension (HTN) or isolated systolic hypertension (ISH). BACKGROUND: Isolated systolic hypertension accounts for a substantial proportion of hypertension in individuals older than 65 years and is strongly associated with an increased risk of cardiac and cerebrovascular events. The exact mechanisms underlying the increased risk associated with ISH and elevated pulse pressure (PP), in comparison with HTN, have not been extensively investigated. METHODS: Community-dwelling residents age >/=65 years in a small town in Italy (Dicomano) were enrolled. Untreated subjects considered in this study included 173 normotensive subjects (blood pressure [BP] <140/90 mm Hg), 95 subjects with HTN (diastolic BP >/=90 mm Hg), and 43 subjects with ISH (BP >/=160/<90 mm Hg). All subjects underwent extensive clinical examination, echocardiography, carotid ultrasonography, and carotid applanation tonometry. RESULTS: Subjects with ISH had higher left ventricular (LV) mass, which was independently related to PP but not to systolic or mean pressures. Both carotid wall cross-sectional area and vascular stiffness were greater in ISH patients than in HTN and normal subjects and were independently related to PP but not to systolic BP. In addition, ISH was associated with a higher prevalence of carotid plaque and more extensive carotid atherosclerosis. CONCLUSIONS: In our community-based elderly population, individuals with ISH had higher prevalences of LV hypertrophy and carotid atherosclerosis than subjects with HTN despite lower mean BP. These findings provide potential pathophysiologic mechanisms underlying the associations of ISH and PP with increased risk of cardiovascular morbidity and mortality.     

High pulse pressure and low mean arterial pressure: two predictors of death after a myocardial infarction

OBJECTIVES: Although the negative prognostic implication of a clinical history of arterial hypertension in myocardial infarction (MI) survivors is well known, the predictive role of the blood pressure (BP) regimen after MI is not well defined. The aim of this study was to investigate the prognostic significance of different BP indices in post-MI. METHODS AND RESULTS: We evaluated the relationship between baseline systolic, diastolic, pulse and mean arterial pressure (MAP), measured by sphygmomanometry at discharge from hospital or within 3 months of an MI, and total and cardiovascular mortality in 11 116 patients enrolled in the GISSI-Prevenzione trial. Over 3.5 years of follow-up, 999 patients died, 657 of them from cardiovascular causes. Low mean and high pulse pressure were significantly associated with total and cardiovascular mortality after controlling for potential confounders in the multivariate analysis. As compared with patients with less extreme BP values, patients with MAP of 80 mmHg or less (n = 1241; 11.2%) had a 48% higher risk of cardiovascular death [95% confidenceinterval (CI) 1.16-1.87; P = 0.001] and those with pulse pressure greater than 60 mmHg (n = 958; 8.6%) had a 35% higher risk (95% CI 1.09-1.69; P = 0.007); only four subjects (0.04%) had both a high pulse pressure and a low MAP (relative risk of cardiovascular death 3.48; 95% CI 0.48-25.88; P = 0.218). CONCLUSIONS: Our results show for the first time an additional prognostic importance of two easily measurable components of BP, definitely high pulse pressure (> 60 mmHg) and low MAP (< or = 80 mmHg), in a large sample of non-selected patients surviving MI who entered a modern programme of cardiovascular prevention.     

Prevalence of isolated systolic and isolated diastolic hypertension subtypes in China

BACKGROUND: Isolated systolic hypertension (ISH), more so than any other hypertension subtype, increases the risk for stroke and coronary heart disease. The prevalence of ISH versus other hypertension subtypes in the general Chinese adult population is not known. METHODS: The prevalence of isolated systolic and isolated diastolic hypertension (IDH) was examined in a representative national sample of 15,540 Chinese adults aged 35 to 74 years. Three seated blood pressure (BP) measurements taken after 5 min of rest were averaged and hypertension subtypes were defined among individuals not receiving antihypertensive therapy as follows: ISH as systolic BP >/=140 mm Hg and diastolic BP <90 mm Hg; IDH as systolic BP <140 mm Hg and diastolic BP >/=90 mm Hg; and combined systolic/diastolic hypertension (SDH) as a systolic BP >/=140 mm Hg and diastolic BP >/=90 mm Hg. RESULTS: Overall, 7.6% of the Chinese adult population had ISH, 7.4% had SDH, and 4.4% had IDH. The prevalence of ISH increased with age and was more common in older women than in older men. Stage 1 hypertension was much more prevalent than stage 2 hypertension among all hypertension subtypes. The prevalence of SDH, IDH, and ISH (women, only) were higher in northern China than southern. The prevalence of ISH and SDH (women, only) were higher among rural residents versus urban residents. CONCLUSIONS: These data document high rates of ISH in China. Given the risk of cardiovascular disease associated with ISH, our findings underscore the critical need for enhanced hypertension screening and treatment programs in China.     

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.     

Should diastolic and systolic blood pressure be considered for cardiovascular risk evaluation: a study in middle-aged men and women

OBJECTIVES: The goal of this study was to evaluate the role of diastolic blood pressure (DBP) in cardiovascular mortality for different systolic blood pressure (SBP) levels in middle-aged men and women. BACKGROUND: In middle-aged subjects it is unclear whether DBP, in addition to SBP, should be considered for risk evaluation. METHODS: Subjects (77,023 men; 48,480 women) aged 40 to 70 years old, had no major cardiovascular disease, no antihypertensive treatment and were examined at the Centre d'Investigations Preventives et Cliniques between 1972 and 1988. Mortality was assessed for an 8- to 12-year period. RESULTS: In both genders, cardiovascular mortality increased with the SBP level. In men and women with normal SBP levels, DBP did not influence cardiovascular mortality after adjustment for age and SBP. In men with systolic hypertension, a U-shaped curve relationship between cardiovascular mortality and DBP was observed, with the lowest mortality rates in the group with DBP 90 to 99 mm Hg. Compared with this group, age- and SBP-adjusted cardiovascular mortality was higher by 73% (p < 0.02) in the group with DBP <90 mm Hg and by 65% (p < 0.001) in the group with DBP > or =110 mm Hg. In women with systolic hypertension, however, DBP was positively correlated with cardiovascular mortality. CONCLUSIONS: In middle-aged subjects, classification of cardiovascular risk according to DBP levels should take into account gender, especially when SBP levels are elevated. Men with systolic hypertension are at higher risk when their DBP is "normal" than when they present a mild to moderate increase in DBP. In women of the same age, however, systolic-diastolic hypertension represents a higher risk than isolated systolic hypertension.     

Plasma viscosity in isolated systolic hypertension: the role of pulse pressure

Atherosclerosis is increasingly recognized as an inflammatory vascular disease, and high blood pressure (BP) has been suggested to exert a proinflammatory action. Whether plasma viscosity (PV), a major determinant of blood flow in microcirculation and a marker of systemic inflammation and cardiovascular risk, is increased in elderly subjects with isolated systolic hypertension is not known. In addition, the correlation of BP and its pulsatile component (ie, pulse pressure [PP]), with PV levels independent of the confounding effect of other cardiovascular risk factors has not been investigated. To this aim, we measured PV in 108 elderly men with never treated, uncomplicated isolated systolic hypertension, and in 60 healthy matched normotensive control subjects. The PV values were higher in hypertensive subjects than in controls (1.39+/-0.11 v 1.34+/-0.09 cP, P<.01). The PV showed a significant direct relation with both systolic BP (r=0.32) and PP (r=0.37, both P<.01), but not with diastolic BP (r=-0.03, P=.68). The PV was also directly associated with serum low-density lipoprotein cholesterol and triglycerides. In a multivariate analysis, PP was a significant predictor of PV levels when a consistent number of cardiovascular risk factors were simultaneously controlled for. In conclusion, PV is elevated in elderly subjects with isolated systolic hypertension. Systolic BP and PP appear to be major determinants of PV levels in these patients, independent of the potential proinflammatory action of traditional cardiovascular risk factors.     

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.