肾实质性高血压24小时动态血压分析

目的：分析肾实质性高血压24小时动态血压变化。方法：实验组（A组）对象为经临床和实验室检查确诊的肾实质性高血压病人，共52例；对照组（B组）为同期随机抽取的我院52例轻、中度原发性高血压病人。两组均作动态血压检测（ABPM）。结果：A、B两组之间24小时收缩压、舒张压，白天收缩压、舒张压无显著性差异（P〉0．05），夜间收缩压、舒张压则有高度显著性差异（P〈0．01），夜间血压下降率A组收缩压、舒张压均〈10％，B组则〉10％，两组间亦有高度显著性差异（P〈0．01）。结论：肾实质性高血压夜间收缩压、舒张压下降较少，昼夜节律减弱。     

原发性高血压24小时动态血压分析

目的：分析原发性高血压24小时动态血压变化。方法：应用美国产动态血压监测仪观察40例原发性高血压24小时动态血压并与96例血压正常进行比较。结果：单纯高血压患白天,夜间,平均收缩压,平均舒张压及24小时血压负荷值均比血压正常组高（P＜0．01）,高血压靶器官损害各组收缩压和舒张压又比单纯高压患高（P＜0．01）,结论：24小时动态血压与高血压靶器官损害有关,血压越高,靶器官损害越多,多脏器损害血压最高,脑,肾损害血压次之。     

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.     

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.     

Twenty-four hour ambulatory blood pressure monitoring pattern of resistant hypertension

OBJECTIVE: Ambulatory blood pressure monitoring (ABPM) is a tool to diagnose resistant hypertension (RH). The objective of this study is to describe the pattern of 24-h ABPM in patients using at least three anti hypertensive drugs without blood pressure (BP) control, classifying them as true RH or white-coat RH. METHODS: A cross-sectional study involving resistant hypertensives that were submitted to clinical, laboratory and 2D-echocardiographic evaluation. Ambulatory blood pressure monitoring was used to diagnose true or white-coat RH. The chi-squared test was used for comparisons among categorical variables and Kruskall-Wallis test for continuous ones. RESULTS: Of the 286 patients, 161 (56.3%) were classified as true RH and 125 (43.7%) as white-coat RH. Sex, age, office BP and the cardiovascular risk factors for both groups were similar. True resistant hypertensives had more target organ damage then white-coat resistant hypertensives; nephropathy (40.1 versus 23.9%, P=0.007) and left ventricular hypertrophy (83.3 versus 76.3%, P=0.05). In ABPM, the true RH group had a smaller nocturnal systolic and diastolic BP reduction (6.4+/-8.8 versus 9.8+/-7.5 mmHg, P=0.0004; 10.4+/-9.6 versus 13.6+/-9.2 mmHg, P=0.001) and 68.7% of them were non-dippers versus 49.6% in the white-coat RH group (P=0.001). True RH also had a larger 24 h pulse pressure (65.8+/-13.7 versus 51.5+/-10.0 mmHg, P < 0.0001). CONCLUSIONS: Ambulatory blood pressure monitoring is a fundamental tool to diagnose RH, and to check treatment efficacy. The presence of a greater pulse pressure and a lower nocturnal blood pressure reduction in true RH patients may be responsible for this increased cardiovascular risk profile.     

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)     

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.     

动态血压监测在高血压诊治中的价值

目的分析动态血压监测应用于高血压诊治中的临床价值。方法选取2011年9月-2013年9月接收的高血压患者(研究组)以及血压正常的体检者(对照组)各70例,均分别进行动态血压和常规方式血压监测,对两组采用不同监测方式的24h血压和脉压监测值,以及白天和夜间的血压和脉压监测值分别比较分析。结果研究组在不同监测方式下,24h血压监测值以及白天和夜间血压平均监测值均存在明显性差别(P0.05),对照组则均无明显性的差别(P0.05)。结论动态血压监测应用于高血压诊治中,可对血压进行更准确的监测,利于临床诊治效果的改善和心脑血管疾病等发生率的降低,有重要的应用价值。     

动态血压监测与高血压病预后的关系

目的 :探讨动态血压 (ABP)及偶测血压 (CBP)与高血压预后的关系。方法 :2 2 0例原发性高血压患者入选时分别测量基础状态下ABP及CBP、并根据白昼舒张压水平分为高、中、低 3个亚组 (HL、ML、LL) ,然后长期随访观察与高血压病相关的心脑血管“事件”。结果 :平均随访 38个月 ,发生各类“事件”者 2 6例 ,单因素分析表明 :“事件”组各项ABP参数明显高于“非事件”组 (P <0 0 5～ 0 0 1) ,而 2组CBP间无显著差异 (P >0 0 5 )。LL、ML、HL 3个亚组中“事件”发生率分别为 2例 10 0人年、3 4例 10 0人年及 6 3例 10 0人年。多因素分析显示 :SBP节律、夜间SBP水平及总胆固醇 (CT)水平为高血压患者“事件”发生的独立危险因素 ,分别为RR =3 0 8、RR =1.2 6、RR =1.4 9(P <0 0 5～ 0 0 1)。结论 :ABP在判断高血压预后方面较CBP更具有临床意义 ,较高的ABP水平提示不良的预后 ,SBP节律、夜间SBP水平是预测高血压患者心脑血管“事件”及肾脏受损的独立危险因素     

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。     

Clinical implications of white coat hypertension: an ambulatory blood pressure monitoring study

Within routine clinical practice, white coat hypertension (where blood pressure is persistently higher in the presence of the doctor or nurse but normal outside the medical setting) makes the diagnosis and management of hypertension difficult. There are conflicting data regarding the prevalence and significance of white coat hypertension. This study has used ambulatory blood pressure monitoring to detect the presence of white coat hypertension in 186 patients referred to an out-patient hypertension unit. The presence of white coat hypertension was defined as an average office blood pressure (measured on three occasions over a 2-month period) of >140/90 mm Hg and an ambulatory awake blood pressure < or = 136/86 mm Hg. The prevalence of white coat hypertension in those patients with borderline hypertension (diastolic blood pressure 90-99 mm Hg) and those with mild-to-moderate hypertension (diastolic blood pressure > or = 100 mm Hg) was determined. Echocardiography was used to assess left ventricular mass index in patients with and without white coat hypertension. The prevalence of white coat hypertension in the total group was 23%. However, the prevalence was higher (33%) in those patients with borderline hypertension compared to 9% of those patients with mild-to-moderate hypertension. There was a statistically significant increase in left ventricular mass index in patients with no evidence of white coat hypertension (125 gm/m2) compared to those with white coat hypertension (102 gm/m2). We conclude that, if office blood pressure is used to identify patients with hypertension who may require treatment, some patients will be incorrectly diagnosed and may be treated inappropriately. We recommend that ambulatory blood pressure monitoring is used in the routine assessment of all newly diagnosed hypertensive patients. Furthermore, we recommend echocardiography in patients with borderline hypertension as some will already have an increased left ventricular mass index.     

Diagnosis of white coat hypertension by ambulatory blood pressure monitoring.

White coat hypertension (WCH) is common in referred hypertensive patients. Ambulatory blood pressure monitoring (ABPM) is not free from the white coat syndrome. We examined the use of the elevation of the first and last measurements of ABPM for diagnosis of WCH in a hypertensive population that had been referred to a hospital-based hypertension unit. Data were obtained on 1350 patients for clinic and ABPM parameters. WCH, as diagnosed by conventional clinic blood pressure (BP) measurement, was compared with a variety of alternative methods determined from ABPM. In all cases, mean daytime pressure was <135 mm Hg/85 mm Hg with an elevation of clinic BP >/=140 mm Hg systolic or 90 mm Hg diastolic. The definitions tested for this elevation were first hour mean pressure, first reading, maximum reading in first hour, last hour mean pressure, last reading, maximum reading in the last hour and maximum reading in first or last hour. Elevation of the maximum pressure in the first hour or last hour above 140 mm Hg systolic or 90 mm Hg diastolic showed a high level of agreement (kappa=0.91) with classical WCH for diagnosis of the white coat syndrome. Termed ambulatory white coat hypertension, patients with this finding were older than classic white coat patients and had higher daytime (127+/-6/78+/-5 mm Hg versus 121+/-5.5/74+/-6 mm Hg, P<0.005 for systolic and diastolic) and nighttime (114+/-11/67+/-8 mm Hg versus 106+/-9/61+/-6 mm Hg, P<0.005 for systolic and diastolic) pressures. They also had a significantly greater Sokolow-Lyon index (leads V(1)+V(5), 21+/-7 mV versus 18+/-6 mV). Elevation of BP above 140 mm Hg systolic or 90 mm Hg diastolic in the first or last hour of monitoring diagnoses patients with a white coat response in whom there is a higher BP profile than in patients with classic white coat response alone. We suggest, therefore, that this is a better measure of the white coat phenomenon.     

Clinical characteristics of resistant hypertension evaluated by ambulatory blood pressure monitoring

Strict control of blood pressure is important to prevent cardiovascular disease, although it is sometimes difficult to decrease blood pressure to target levels. The aim of this study was to investigate the clinical characteristics of resistant hypertension evaluated by ambulatory blood pressure monitoring. One hundred in-hospital patients, whose 24-hour average blood pressure was higher than 130/80?mmHg even after treatment with more than three antihypertensive drugs, were included in the present analysis. Circadian variation of blood pressure was evaluated by nocturnal fall in systolic blood pressure. Average blood pressures of all patients were high in both daytime and nighttime, 150.0/82.9 and 143.8/78.2?mmHg, respectively. Twenty patients had been treated with hemodialysis or peritoneal dialysis. In 63 patients out of the other 80 patients (79%), estimated glomerular filtration rate (eGFR) was also decreased (<60?mL/min/1.73 m²). The patients classified into dipper, non-dipper, riser and extreme-dipper were 20%, 43%, 34% and 3%, respectively. In addition, in 17 patients whose eGFR was preserved, 12 patients showed a non-dipper or riser pattern, suggesting that it was difficult to account for this altered circadian blood pressure variation only by renal dysfunction. These results show that a large number of the patients with resistant hypertension suffered from renal dysfunction, although it was difficult to explain altered circadian blood pressure variation based on renal dysfunction alone.     

Individual smoothing of blood pressure profiles to define responders or non-responders to drugs

OBJECTIVE: To compare different methods of individual therapyh efficacy assessment in order to define responding subjects. METHODS: Hypertensive patients were included in three double-blind clinical trials (placebo versus bisoprolol, lisinopril and amlodipine) and ambulatory blood pressure measurements (four per hour) were performed at the end of each month. We analysed the effect of therapy (placebo minus treatment) according to the following criteria: type of model (hourly mean, moving average, fast Fourier analysis), determination of the time to the peak effect (the lowest value of the modelled blood pressure) and the sampling time around this peak (1, 2,., 24 h). RESULTS: Regardless of the type of model, the level of individual therapy efficacy is significantly higher than that of the overall subjects (group efficiency), when the sampling time around this peak decreases. The proportion of responders decreases as the sampling time used to calculate the drop in blood pressure increases, whatever the kind of model and the threshold used to define responders (5 or 10 mmHg in systolic blood pressure). CONCLUSION: By this method, it is possible to appreciate the percentage of subjects considered individuallyas responders according to the time around the peak. This evaluation complements information given by the trough: peak ratio.