Microalbuminuria and casual and ambulatory blood pressure monitoring in normotensives and in patients with borderline and mild essential hypertension

Several reports suggest that urinary albumin excretion may be elevated in patients with essential hypertension and that this index may be a good predictor for cardiovascular complications. The aim of this study was to compare 24-hour urinary albumin excretion in a group of normotensives, borderline, and untreated mild hypertertensives and to assess, in a subgroup of them, the possible relations between microalbuminuria and arterial blood pressure. Fifteen normotensives, 16 borderline, and 19 mild hypertensive patients were studied. Slightly but significantly higher values of microalbuminuria were observed in the mild hypertensives compared to the other two groups. In 21 borderline and mild hypertensive patients 24-hour microalbuminuria was related to casual blood pressure and noninvasive ambulatory blood pressure monitoring. A significant correlation was found between microalbuminuria and average day-time diastolic blood pressure. Our data suggest that albumin excretion is slightly increased in mild arterial essential hypertension; the direct association between microalbuminuria and arterial diastolic blood pressure during daily activities seems to confirm a pathophysiological link between transcapillary protein escape and arterial blood pressure that warrants further studies.     

高原高血压患者的动态血压变化

目的　观察高原高血压患者的昼夜血压变化。方法　采用无创性携带式动态血压监测仪对 51例高原高血压患者及 2 5例正常人进行 2 4 h血压检测 ,分析两组的动态血压变化规律。结果　高原高血压患者中 82 .4 %血压昼夜节律消失或减少 ;其中高血压 2级为 6 9% ,高血压 3级为 96 % ;而正常人仅 8%血压昼夜节律减弱 ( P<0 .0 5)。结论　高原高血压患者血压昼夜节律有明显变化     

Noninvasive ambulatory blood pressure monitoring in patients with recently detected systemic hypertension

Noninvasive ambulatory blood pressure monitoring and Doppler echocardiography were used in a recent study evaluating persons aged 18 to 50 years who were initially found to have mild hypertension by casual blood pressure determination. Ambulatory blood pressure recordings were performed on a day of usual activity in 54 subjects; a subgroup of 24 patients had evaluation of left ventricular dimensions and diastolic filling patterns by Doppler echocardiography. Average ambulatory systolic pressures of 42% of subjects were greater than or equal to 130 mm Hg. Only 35% had average diastolic pressures greater than or equal to 85 mm Hg, and 57% had either systolic or diastolic pressures greater than or equal to 130/85 mm Hg. Correlation between casual and ambulatory pressures was not significant. No subject had left ventricular hypertrophy determined by echocardiography. Abnormal left ventricular diastolic filling was noted in 38% of those patients with average ambulatory pressures greater than or equal to 130/85 mm Hg, but in no patients with average pressures less than 130/85 mm Hg (p less than 0.05). These results suggest that ambulatory blood pressure monitoring may be a specific method for detecting those patients with mild hypertension who may have early and potentially reversible cardiac abnormalities.     

Ambulatory blood pressure monitoring and borderline hypertension.

Blood pressure fluctuates during daytime hours in response to changes in activities and to daily life stressors. Lifestyle factors may influence changes in blood pressure through a modulation of the sympathetic nervous system s activity, which is often elevated in subjects with borderline hypertension. In the HARVEST smoking, consumption of coffee, intake of alcohol, physical activity habits, and use of oral contraceptives influenced daytime blood pressure to a greater extent than did office blood pressure and had an effect on sympathetic tone (determined by measuring levels of urinary catecholamines). Subjects with borderline hypertension have a greater than normal risk of cardiovascular morbidity and mortality, but few data on the relation between ambulatory blood pressure and hypertensive complications during the early stage of hypertension are available. In the HARVEST the impact of ambulatory blood pressure on the walls of the left ventricle and on left ventricular mass in women was remarkable, whereas it was weak for men. The assessment of left ventricular systolic function confirmed that ejective performance in many young borderline hypertensive subjects is greater than normal. However, in 9.2% of the HARVEST participants left ventricular contractility evaluated by midwall measurement was found to be depressed. Although the prevalence of microalbuminuria (rate of excretion of urinary albumin > or = 30mg/24h) appeared to be low (6.1%), rate of excretion of albumin was highly statistically significantly correlated to 24h blood pressure. Ambulatory blood pressure monitoring is useful for identifying those borderline hypertensive subjects for whom antihypertensive treatment should be started.     

动态血压监测指导依那普利抗原发性高血压治疗临床观察

目的根据原发性高血压患者24h血压变化规律决定依那普利给药时间,观察降压疗效。方法对于临床确诊的1~2级原发性高血压患者,服用安慰剂2周后,根据24h动态血压监测夜间血压与白昼相比是否下降≥10%或10mmHg,分为勺型高血压及非勺型高血压,对勺型高血压者6:00及下午血压最高值前3h分别给予依那普利5mg,非勺型者6:00及18:00分别给予依那普利5mg,2周后,若患者坐位舒张压≥90mmHg,依那普利加量至10mg,每日2次。8周后复查24h动态血压。结果完成研究的80例原发性高血压患者中勺型58例,占72.5%,非勺型22例,占27.5%。依那普利对勺型组和非勺型组患者有效率分别为(52/58)89.7%,(19/22)86.4%,勺型组24h平均血压、白昼(6:00~22:00)血压、夜间(22:00~6:00)血压分别下降9.9/6.6mmHg,9.0/6.8mmHg,2.8/2.6mmHg,非勺型组分别下降13.9/7.6mmHg,11.9/6.6mmHg,13.8/10.4mmHg。两组白昼及夜间血压负荷均显著下降。勺型组收缩压与舒张压谷峰比值分别为66.6%,63.5%,非勺型组70.6%,66.5%。结论在时间治疗学理论指导下,依那普利每日给药两次能24h平稳降压,是一种价廉物美的降压药物,值得推广应用。     

Transcranial doppler sonography and ambulatory blood pressure monitoring in patients with hypertension.

To appraise the value of transcranial Doppler sonography (TCD) for assessment of hypertensive cerebrovascular damage, the relationship between ambulatory blood pressure (BP) and indices of cerebral circulation determined by TCD was investigated. Subjects were 55 inpatients with or without hypertension, including 13 patients with histories of cerebrovascular attacks. Mean flow velocity (MFV) in the middle cerebral artery was measured by TCD, then the cerebrovascular resistance index (CVRI; mean BP/MFV) and the Fourier PI1 (pulsatility index of the first Fourier harmonic of the flow-velocity waveform) were determined as indices of cerebrovascular resistance. CO2 reactivity of MFV was estimated as an index of cerebrovascular flow reserve. CVRI positively correlated with both daytime and nighttime BP as well as with age (p<0.01). Fourier PI1 positively correlated with nighttime BP and age (p<0.01). CO2 reactivity did not correlate with any of the ambulatory BP parameters, but negatively correlated with age (p<0.01). LV mass index significantly correlated with ambulatory BP parameters, CVRI, and Fourier PI1 but did not correlate with CO2 reactivity. Multiple regression analyses showed that nighttime systolic BP was a significant correlate for CVRI and Fourier PI1, but not for CO2 reactivity, and that history of cerebrovascular attack was significant for CVRI and CO2 reactivity. We conclude that cerebrovascular resistance determined by TCD accords with the results of ambulatory BP and LVMI, and thus could be successfully used to detect the early stage of hypertensive cerebrovascular change. Cerebrovascular flow reserve would be relatively preserved in hypertensive patients without cerebrovascular diseases.     

老年高血压病及脑卒中患者动态血压分析的探讨

目的　探讨老年高血压病及脑卒中患者动态血压的特点。方法　对 30 7例高血压病患者进行动态血压监测 ,并根据年龄分为 :A组 (对照组n =16 1) ,年龄 <6 0岁 ;B组 (观察组n =14 6 ) ,年龄≥ 6 0岁。两组中又根据是否合并脑卒中 ,进一步分为 4个亚组A1 、B1 组 (无脑卒中 ) ,A2 、B2 组 (脑卒中 )。结果　B组老年高血压患者无论有无脑卒中 ,其血压昼夜节律性明显低于A组 (P <0 .0 5 )。B组脉压 [B1 组昼脉压 5 2 .9mmHg(1mmHg =0 .133kPa) ,夜脉压4 9.4mmHg;B2 组昼脉压 5 3.2mmHg ,夜脉压 5 3mmHg]较A组脉压 (A1 组昼脉压 4 3.6mmHg ,夜脉压 4 0 .3mmHg ;A2组昼脉压 4 7.2mmHg ,夜脉压 4 4mmHg)明显增大 (P <0 .0 5 )。B2 组夜间收缩压 (12 8.1mmHg)明显高于其余 3组 (A1组 117.4mmHg、A2 组 12 1.1mmHg、B1 组 12 0 .7mmHg ,P <0 .0 5 )。结论　血压昼夜节律降低、动态脉压增大及夜间收缩压增高是老年高血压患者动态血压的特点     

高龄老年高血压患者动态血压特点

目的探讨高龄老年高血压患者动态血压特点。方法选择我院心血管内科及老年医学科住院的高血压患者265例,按年龄分为高龄老年组(年龄≥80岁)94例、老年组(60～79岁)90例和60岁组81例,行动态血压监测,分析其血压节律、3个时段(24h、昼间及夜间)血压均值及血压变异性的特点。结果高龄老年组和老年组杓型血压发生率、24h舒张压、昼间舒张压、昼间平均压、夜间舒张压明显低于60岁组,反杓型血压发生率、24h脉压、昼间脉压、夜间收缩压、夜间脉压明显高于60岁组(P0.05,P0.01);高龄老年组杓型血压发生率及24h、昼间、夜间舒张压明显低于老年组[13.83%vs 26.66%,(66.17±7.39)mm Hg(1mm Hg=0.133kPa)vs (70.39±10.96)mm Hg,(66.90±7.55)mm Hg vs (70.88±11.68)mm Hg,(64.10±8.14)mm Hg vs (68.27±11.86)mm Hg,P0.05,P0.01],24h、夜间脉压明显高于老年组(P0.05,P0.01),昼间收缩压变异明显高于老年组和60岁组,24h收缩压变异高于60岁组,差异有统计学意义(P0.01);老年组24h平均压明显低于60岁组(P0.05)。结论高龄老年高血压患者动态血压表现出血压节律异常、脉压增大、血压变异性升高等特点。     

Experience with 24-hour ambulatory blood pressure monitoring in hypertension

Traditional sphygmomanometric blood pressure measurements may lead to errors in the diagnosis of arterial hypertension due to a number of factors, among which are the alerting reaction and pressor response induced in patients by the doctor's visit. This phenomenon, as quantified in our laboratory by continuous intraarterial recordings, is responsible for an average rise in systolic and diastolic blood pressure of 27/15 mm Hg, a rise that does not seem to be reduced by simply desensitizing the patient by means of more frequent physician visits. Twenty-four hour ambulatory blood pressure monitoring may theoretically improve the diagnostic approach to hypertensive patients by overcoming some limitations of isolated cuff measurements. In recording intraarterial blood pressure in 108 ambulant hypertensive subjects, we have found that 24-hour blood pressure values are able to discriminate among patients with different degrees of target organ damage better than isolated sphygmomanometric readings. Moreover, these studies have indicated that 24-hour blood pressure variability may be as important as blood pressure mean values in the assessment of cardiovascular complications. In clinical practice, however, intraarterial blood pressure monitoring is not feasible, and only noninvasive recorders can be used. Use of these devices does not induce any alerting reaction in the patients and does not interfere with day-night blood pressure changes. Although it is characterized by intermittent readings, this approach is not incompatible with a precise estimate of 24-hour blood pressure mean values.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arterial distensibility and ambulatory blood pressure monitoring in essential hypertension

Arterial distensibility estimated by carotid femoral pulse wave velocity was evaluated in 22 patients with sustained essential hypertension, together with 3 different methods of blood pressure (BP) measurement: mercury sphygmomanometer, semiautomatic BP recording using the Dinamap apparatus and 24-hour ambulatory BP monitoring using a Spacelabs monitor. Although pulse wave velocity did not correlate with BP measured by mercury sphygmomanometer, it strongly and positively correlated with BP measurements using the other 2 procedures. The best correlation was observed with ambulatory BP with respect to systolic BP only (r = 0.685, p less than 0.001). Since cardiovascular morbidity and mortality in hypertensive patients is mainly related to lesions of the large arteries, the determination of pulse wave velocity together with ambulatory BP measurements is proposed for the evaluation of cardiovascular risk.     

Cost-effectiveness of ambulatory blood pressure monitoring in the follow-up of hypertension

Aims. To study the cost of the follow-up of hypertension in primary care (PC) using clinical blood pressure (CBP) and ambulatory blood pressure monitoring (ABPM), and to analyse the cost-effectiveness (CE) of both methods. Major findings and principal conclusion. Good control of hypertension was achieved in 8.3% with CBP (95% CI 4.8-11.8) and in 55.6% with ABPM (95% CI 49.3-61.9). The cost of one patient with good control of hypertension is almost four times higher with CBP than with ABPM (€940 vs €238). Reaching the gold standard (ABPM) involved an after-cost of €115 per patient. The results for a 5% discount rate showed a saving of €68,883 if ABPM was performed in all the patients included in the study (n = 241, €285 per patient). An analysis of sensitivity, changing the discount rate and life expectancy indicated that ABPM provides a better CE ratio and a lower global cost. ABPM is more cost-effective than CBP. However, if we include the new treatment cost of poorly monitored patients, it is less cost-effective. Excellent control of hypertension is still an important challenge for all healthcare professionals, especially for those working in PC, where most monitoring of hypertensive patients takes place.     

Assessment of patients with office hypertension by 24-hour noninvasive ambulatory blood pressure monitoring

To assess the discrepancy between casual (office) and home blood pressure readings in patients performing home blood pressure monitoring, we analyzed office, home, and 24-hour ambulatory blood pressure and heart rates in 19 patients in a prospective four-week study. After the month of study, the average difference between mean office and manual home blood pressures in this office hypertensive group was 30 +/- 17/20 +/- 6 mm Hg. The blood pressures taken in the office were substantially greater than the 24-hour average blood pressures and ambulatory blood pressures during work or while at home (awake). An analysis of the automatic monitor readings while in the doctor's office and at 15-minute intervals after leaving the office showed a progressive reduction in blood pressure and heart rate during the first hour after leaving the office. A mean 24-hour blood pressure of less than 130/80 mm Hg was found in 13 (68%) patients. These data suggest that patients with office hypertension are usually normotensive but may have a persistent and recurrent pressor response in a medical care setting. Ambulatory blood pressure monitoring provides confirmation of not only the office-home disparity, but also suggests that stress other than office visits fails to elicit a hypertensive response.     

高血压病患者运动血压与动态血压关系的研究

目的　探讨高血压病患者运动血压与动态血压的关系。方法　分别以活动平板运动试验中最大运动量时收缩压 (peakSBP)和舒张压 (peakDBP)过度升高和反应正常分组 ,以运动后收缩压(recSBP)和舒张压 (recDBP)恢复慢和恢复正常分组 ,对比分析 30 3例 1、2级高血压病患者的动态血压变化。结果　peakSBP、peakDBP过度升高组动态血压各检测值均显著高于反应正常组 (P <0 0 5或0 0 1) ;recSBP恢复慢组的夜间平均收缩压、舒张压显著高于恢复正常组 (P <0 0 1) ;recDBP恢复慢组白昼舒张压负荷显著高于恢复正常组 (P <0 0 1)。多元逐步回归分析显示 ,对peakSBP、peakDBP、recSBP最具影响的共同参数为夜间平均舒张压。结论　高血压病患者运动试验中 74 2 6 %～ 81 85 %存在运动中血压过度升高和运动后收缩压恢复慢并与动态血压检测值有显著统计意义。     

Appropriate time interval to repeat ambulatory blood pressure monitoring in patients with white-coat resistant hypertension

Resistant hypertension is defined as uncontrolled office blood pressure, despite the use of ≥3 antihypertensive drugs. Ambulatory blood pressure monitoring (ABPM) is mandatory to diagnose 2 different groups, those with true and white-coat resistant hypertension. Patients are found to change categories between controlled/uncontrolled ambulatory pressures without changing their office blood pressures. In this way, ABPM should be periodically repeated. The aim of this study was to evaluate the most appropriate time interval to repeat ABPM to assure sustained blood pressure control in patients with white-coat resistant hypertension. This prospective study enrolled 198 patients (69% women; mean age: 68.9±9.9 years) diagnosed as white-coat resistant hypertension on ABPM. Patients were submitted to a second confirmatory examination 3 months later and repeated twice at 6-month intervals. Statistical analyses included Bland-Altman repeatability coefficients and multivariate logistic regression. Mean office blood pressure was 163±20/84±17 mm Hg, and mean 24-hour blood pressure was 118±8/66±7 mm Hg. White-coat resistant hypertension diagnosis presented a moderate reproducibility and was confirmed in 144 patients after 3 months. In the third and fourth ABPMs, 74% and 79% of patients sustained the diagnosis. In multivariate regression, a daytime systolic blood pressure ≤115 mm Hg in the confirmatory ABPM triplicated the chance of white-coat resistant hypertension status persistence after 1 year. In conclusion, a confirmatory ABPM is necessary after 3 months of the first white-coat-resistant hypertension diagnosis, and the procedure should be repeated at 6-month intervals, except in patients with daytime systolic blood pressure ≤115 mm Hg, in whom it may be repeated annually.     

动态血压监测评价老年高血压患者靶器官损害

目的探讨动态血压监测对老年高血压患者靶器官损害的价值.方法对232例已经接受服药治疗并且至少伴有一个靶器官损害的老年高血压患者进行24 h动态血压监测,根据累及靶器官损害数目和并存心脏、脑和肾脏临床状况分为3组,结合临床资料进行统计学分析.结果靶器官损害数目与24 h平均收缩压、夜间平均舒张压、血压波动的昼夜节律异常和血压负荷增高密切相关,靶器官损害累及3个器官与累及1个器官相比差异有统计学意义（P＜0.01）;并存脑血管疾病组夜间平均舒张压增高显著,并存心血管疾病组和肾脏病变组的患者以24 h平均收缩压增高和血压负荷增加显著,并存临床状况的患者,血压波动的昼夜节律异常多见,并存心、脑和肾临床状况组分别与靶器官损害组相比差异有统计学意义（P＜0.01）.结论24 h平均收缩压、夜间平均舒张压和血压负荷越高,靶器官损害数目越多;血压波动的昼夜节律异常多见于并存临床状况的老年高血压患者,应用动态血压监测有助于指导临床治疗.     

Canadian hypertension society guidelines for ambulatory blood pressure monitoring

The Canadian Hypertension Society has developed guidelines for the use of ambulatory blood pressure (BP) monitoring in clinical practice. Published articles with the best available levels of evidence were used to support the following recommendations:Physicians should only use ambulatory BP monitoring devices that have been validated independently using established protocols.A decision to withhold drug therapy based upon the ambulatory BP should take into account normal values for 24-h and awake ambulatory BP.Based upon studies on prognosis and a clinical trial based upon BP control as an outcome, ambulatory BP monitoring should be considered for untreated patients whenever an office-induced increase in BP is suspected.Ambulatory BP monitoring should be considered for treated patients suspected of having an office-induced increase in BP, including individuals with apparent resistance to drug therapy, symptoms suggestive of hypotension, and fluctuating office BP readings.Based upon studies on prognosis, changes in nocturnal BP should be taken into account in any decision to withhold drug therapy based upon the ambulatory BP.Further studies are required to determine whether the clinical benefit of antihypertensive therapy is more closely related to ambulatory or office BP.     

Verapamil and 24-hour ambulatory blood pressure monitoring in essential hypertension

The antihypertensive effects of oral regular and slow-release verapamil, a calcium-channel blocking agent, were evaluated in 22 patients with mild to moderate hypertension (sitting diastolic blood pressure [DBP] 95 to 112 mm Hg). The dose required to control blood pressure varied from 80 to 120 mg, 3 times a day. All patients received regular verapamil for a further 3 to 4 months, when systolic blood pressure (SBP) and DBP had risen from the end of the open-label phase. During a double-blind phase patients were randomly assigned to continue the same dose of regular verapamil, 3 times a day, or an equivalent daily dose of sustained-release verapamil (240 to 360 mg once a day). Seven of the 11 patients on regular and 3 of the 11 on sustained-release verapamil were also taking diuretics. This antihypertensive program was continued for at least 4 weeks. During the efficacy period, 24-hour ambulatory blood pressure monitoring was carried out. Mean 24-hour SBP and DBP were 133 +/- 20 and 89 +/- 13 mm Hg, respectively, on regular and 131 +/- 22 and 87 +/- 12 mm Hg, respectively, on sustained-release verapamil. There were no statistically significant differences noted between the 2 groups. Mean SBP and DBP varied similarly during awake and sleep hours with both formulations of verapamil. With regular verapamil, SBP was 139 +/- 18 and 124 +/- 20 mm Hg and DBP 92 +/- 11 and 84 +/- 13 mm Hg during awake and sleep hours, respectively; with sustained release, SBP was 138 +/- 21 and 122 +/- 22 mm Hg and DBP 92 +/- 10 and 80 +/- 10 mm Hg during awake and sleep hours, respectively. Heart rate fell during the entry period and continued during the entire study period. No other adverse effects were noted during the double-blind phase. In summary, verapamil is an effective antihypertensive medication and can be administered once a day as a sustained-release preparation; it is most useful in patients in whom adrenergic blocking drugs are indicated.     

氯沙坦的降压疗效及其对血压谷/峰比值的影响

目的:以动态血压观察氯沙坦片对原发性高血压病患者的疗效及其对血压谷峰比值的影响。方法:60例原发性高血压病患者被随机均分为氯沙坦片组和苯那普利片组(各30例),分别给予氯沙坦片50～100mg和苯那普利片10～20mg,晨服,1次/日,疗程16周。结果:治疗后两组病人的血压均有明显下降,氯沙坦片组,收缩压(SBP)由治疗前的168.2±16.3 mmHg降至138.3±17.2mmHg,舒张压(DBP)由治疗前的99.8±8.1mmHg降至治疗后的85.3±6.4mmHg,SBP、DBP谷/峰比值分别为0.73和0.68;苯那普利组;SBP由治疗前的169.4±16.7mmHg降至139.3±16mmHg,DBP由治疗前的98.7±9.2mmHg降至治疗后的84.6±6.3mmHg,SBP、DBP谷/峰比值分别为0.67、0.63,与治疗前比较,P均<0.01,但组间比较差异不显著(P>0.05)。氯沙坦组无明显副作用,苯那普利组有6例出现咳嗽,2例咳嗽较剧烈,退出观察。结论:氯沙坦片能安全、有效、平稳地降低高血压病人的血压,其疗效与苯那普利疗效相似,但副作用明显少于后者,是高血压治疗的理想用药。