Masked hypertension in elderly managerial employees and retirees

Masked hypertension is reported to have the same level of hazard risk of cardiovascular mortality and stroke morbidity as sustained hypertension. The number of managerial employees suffering from cardiovascular disease and stroke is known to be greater than other employee. The aim of this study was to compare the 24-h blood pressure (BP) recordings between elderly male managerial employees and retirees and to propose a strategy for identifying masked hypertension. A total of 38 males (16 managerial employees aged 50-69 years and 22 retirees aged 60-65 years) who were not taking any antihypertensive medications participated in this study. Their 24-h BP was measured by an ambulatory BP monitoring device. Daytime (9:00-17:00 h) BPs of the employees (mean, 139/92 mm Hg) were significantly higher than in the retirees (mean 124/80 mm Hg), while there was no difference in BP before and during sleep. In all, 5 of 16 employees (31%) who were diagnosed as normotensive (<140/90 mm Hg) at a periodic health check had hypertension (>135/85 mm Hg) in the morning measured by ambulatory BP monitoring, while 6 (38%) had a similar level of hypertension during the daytime (9:00-17:00 h). These individuals were diagnosed as having masked hypertension. Multiple regression analyses showed that the job was the only factor that contributed to the difference in BP in the subjects during the daytime. This finding suggested that job stress seemed to be one of the main causes of masked hypertension. We argue that more frequent measurements of BP at the work place are necessary to identify subjects with masked hypertension.     

Prognosis of "masked" hypertension and "white-coat" hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study

OBJECTIVES: We sought to investigate the prognosis in subjects with "white-coat" hypertension (WCHT) and "masked" hypertension (MHT), in which blood pressure (BP) is lower in clinical measurements than during ambulatory monitoring. BACKGROUND: The prognostic significance of WCHT remains controversial, and little is known about MHT. METHODS: We obtained 24-h ambulatory BP and "casual" BP (i.e., obtained in clinical scenarios) values from 1,332 subjects (872 women, 460 men) > or =40 years old in a representative sample of the general population of a Japanese community. Survival and stroke morbidity were then followed up for a mean duration of 10 years. RESULTS: Composite risk of cardiovascular mortality and stroke morbidity examined using a Cox proportional hazards regression model for subjects with WCHT (casual BP > or =140/90 mm Hg, daytime BP <135/85 mm Hg; relative hazards [RH])1.28; 95% confidence interval [CI] 0.76 to 2.14) was no different from risk for subjects with sustained normal BP (casual BP <140/90 mm Hg, daytime BP <135/85 mm Hg). However, risk was significantly higher for subjects with MHT (casual BP <140/90 mm Hg, daytime BP > or =135/85 mm Hg; RH 2.13; 95% CI 1.38 to 3.29) or sustained hypertension (casual BP > or =140/90 mm Hg, daytime BP > or =135/85 mm Hg; RH 2.26; 95% CI 1.49 to 3.41) than for subjects with sustained normal BP. Similar findings were observed for cardiovascular mortality and stroke morbidity among subgroups by gender, use of antihypertensive medication, and risk factor level (all p for heterogeneity >0.2). CONCLUSIONS: Conventional BP measurements may not identify some individuals at high or low risk, but these people may be identifiable by the use of ambulatory BP.     

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.     

Prognostic relevance of masked hypertension in subjects with prehypertension

BackgroundThe prognostic impact of masked hypertension is not yet completely clear. The aim of this study was to evaluate the prognostic relevance of masked hypertension in subjects with prehypertension.MethodsThe occurrence of fatal and nonfatal cardiovascular events was evaluated in 591 subjects with prehypertension defined as clinic blood pressure (BP) in the range of 120-139 mm Hg for systolic BP and 80-89 mm Hg for diastolic BP. Among them, 471 were classified as having true prehypertension (clinic BP <140/90 mm Hg and daytime BP <135/85 mm Hg) and 120 as having masked hypertension (clinic BP <140/90 mm Hg and daytime BP >/=135 or 85 mm Hg).ResultsDuring the follow-up (6.6 +/- 4.3 years, range 0.5-15.5 years), 29 cardiovascular events occurred. In subjects with true prehypertension and masked hypertension the event-rates per 100 patient-years were 0.57 and 1.51, respectively. Event-free survival was significantly different between the groups (P < 0.005). After adjustment for other covariates, including clinic BP (forced into the model), Cox regression analysis showed that cardiovascular risk was significantly higher in masked hypertension than in true prehypertension (masked vs. true prehypertension, relative risk 2.65, 95% confidence interval 1.18-5.98, P = 0.018).ConclusionsAmong subjects with prehypertension, those with masked hypertension are at higher cardiovascular risk than those with true prehypertension. Out-of-office BP should be known in individuals with prehypertension, preferably by ambulatory BP monitoring or alternatively by home BP measurement, to obtain a better prognostic stratification.American Journal of Hypertension (2008). doi:10.1038/ajh.2008.196American Journal of Hypertension (2008); 21, 8, 879-883. doi:10.1038/ajh.2008.196.     

Exercise capacity and 24-h blood pressure in prehypertensive men and women

BACKGROUND: Prehypertensive individuals are at increased risk for developing hypertension and cardiovascular disease compared to those with normal blood pressure (BP). Physically active, normotensive individuals are also at lower risk for developing hypertension than sedentary individuals. We assessed the relationship between fitness and 24-h ambulatory BP in prehypertensive men and women. METHODS: We assessed exercise capacity and 24-h BP in 407 men (age 51 +/- 11 years) and 243 women (age 54 +/-10 years) with resting systolic BP 120 to 139 mm Hg and diastolic BP of 80 to 89 mm Hg, defined as prehypertension. Fitness categories (low, moderate, and high) were established according to exercise time and age. RESULTS: Multiple regression analysis revealed that fitness status was inversely associated with ambulatory BP in both genders (P < .001). After adjusting for various confounders, individuals in the lowest fitness category had significantly higher 24-h, daytime, and night-time BP than those in the moderate and high fitness categories. For men, differences between low and moderate fitness categories were 6/4 mm Hg, 8/4 mm Hg, and 7/3 mm Hg for 24-h, daytime, and night-time BP, respectively (P < .05). For women, the differences were 8/5 mm Hg, 9/5 mm Hg, and 8/7 mm Hg for 24-h, daytime, and night-time BP, respectively. Similar differences were evident in both genders between low and high fitness category (P < .05). CONCLUSIONS: Moderate physical activity promotes lower BP during a 24-h period in prehypertensive men and women. The risk for developing hypertension is likely to be lowered if moderate intensity physical activity in this vulnerable population is encouraged.     

Cardiovascular outcome in treated hypertensive patients with responder, masked, false resistant, and true resistant hypertension

BACKGROUND: The aim of this study was to evaluate the cardiovascular outcome in apparently responder hypertensive patients with responder and masked hypertension, and in apparently resistant hypertensive patients with false and true resistant hypertension. METHODS: The occurrence of fatal and nonfatal cardiovascular events was evaluated in 340 patients with responder hypertension (clinic blood pressure [BP] <140/90 mm Hg and daytime BP <135/85 mm Hg), 126 with masked hypertension (clinic BP <140/90 mm Hg and daytime BP >135 or 85 mm Hg), 146 with false resistant hypertension (clinic BP >or=140 or 90 mm Hg and daytime BP <135/85 mm Hg), and 130 with true resistant hypertension (clinic BP >or=140 or 90 mm Hg and daytime BP >135 or 85 mm Hg). RESULTS: During follow-up period (4.98 +/- 2.9 years), the event-rate per 100 patient-years was 0.87, 2.42, 1.2, and 4.1 in patients with responder, masked, false resistant, and true resistant hypertension, respectively. After adjustment for several covariates, including clinic BP (forced into the model), Cox regression analysis showed that cardiovascular risk was significantly higher in masked hypertension (masked versus responder hypertension, relative risk [RR] 2.28, 95% confidence interval [CI] 1.1-4.7, P < .05) and in true resistant hypertension (true resistant versus responder hypertension, RR 2.94, 95% CI 1.02-8.41, P < .05), whereas there was no significant difference between false resistant and responder hypertension. CONCLUSIONS: This study shows that patients with masked hypertension are at higher risk than those with responder hypertension, and that those with false resistant hypertension are at lower risk than those with true resistant hypertension. Ambulatory BP monitoring should be performed in treated hypertensive patients to obtain a better prognostic stratification.     

Masked hypertension and target organ damage in treated hypertensive patients

BACKGROUND: Recent studies have shown that an elevated ambulatory or home blood pressure (BP) in the absence of office BP-a phenomenon called masked hypertension-is associated with poor cardiovascular prognosis. However, it remains to be elucidated how masked hypertension modifies target organ damage in treated hypertensive patients. METHODS: A total of 332 outpatients with chronically treated essential hypertension were enrolled in the present study. Patients were classified into four groups according to office (<140/90 or >or=140/90 mm Hg) and daytime ambulatory (<135/85 or >or=135/85 mm Hg) BP levels; ie, controlled hypertension (low office and ambulatory BP), white-coat hypertension (high office but low ambulatory BP), masked hypertension (low office but high ambulatory BP), and sustained hypertension (high office and ambulatory BP). Left ventricular mass index, carotid maximal intima-media thickness, and urinary albumin levels were determined in all subjects. RESULTS: Of the patients, 51 (15%), 65 (20%), 74 (22%), and 142 (43%) were identified as having controlled hypertension, white-coat hypertension, masked hypertension, and sustained hypertension, respectively. Left ventricular mass index, maximal intima-media thickness, and urinary albumin level in masked hypertension were significantly higher than in controlled hypertension and white-coat hypertension, and were similar to those in sustained hypertension. Multivariate regression analyses revealed that the presence of masked hypertension was one of the independent determinants of left ventricular hypertrophy, carotid atherosclerosis, and albuminuria. CONCLUSIONS: Our findings indicate that masked hypertension is associated with advanced target organ damage in treated hypertensive patients, comparable to that in cases of sustained hypertension.     

White coat hypertension and pregnancy outcome.

The presence and outcome effect of white coat hypertension in pregnancy was determined with 24-h ambulatory blood pressure (BP) monitoring. Sixty women presenting with high clinic BP (>/=140/90 mm Hg) in the second trimester were included. Patients were divided into two groups based on daytime ambulatory BP findings: <135/85 mm Hg, white coat hypertension (n = 37); >/=135/85 mm Hg, 'true' hypertension (n = 23). Complicated pregnancy outcome was defined as the presence of pre-eclampsia and/or intrauterine growth restriction. Groups were compared for pregnancy outcome and for background and delivery factors. The predictive value of ambulatory BP measurements for pregnancy outcome was determined. Pregnancy outcome was better in the white coat hypertension group than in the true hypertension group: pre-eclampsia-3 (8.1%) vs 13 (56.5%) (P = 0.0046); intrauterine growth restriction-5 (13.5%) vs 10 (43.4%) (P = 0. 0139); and preterm delivery-11 (29.7%) vs 15 (65.2%) (P = 0.015). Night-time ambulatory BP measurements were the best predictor of complicated pregnancy, followed by daytime and 24-h measurements. We conclude that second trimester ambulatory BP monitoring can be used to differentiate patients who have white coat hypertension, which is associated with a better pregnancy outcome than true hypertension.     

Is resistant hypertension really resistant?

BACKGROUND: Managing resistant hypertension is difficult and mostly involves expensive testing seeking an underlying secondary cause. This study was undertaken to determine 1) the extent of the white-coat phenomenon in patients with resistant hypertension, and 2) whether 24-h ambulatory blood pressure (BP) monitoring (ABPM) or having BP recorded by a nurse instead of the referring doctor could clarify how many apparently resistant hypertensives actually have controlled BP. METHODS: This study involved 611 patients with BP > or = 140/90 mm Hg who were referred for 24-h ABPM by their specialist or general practitioner, including 277 patients who were taking no antihypertensives (group 1), 216 taking one or two antihypertensive drugs (group 2), and 118 taking at least three antihypertensives in combination (group 3). Each had BP recorded by one of two nurses before 24-h ABPM. Controlled BP was defined as awake ambulatory BP <135/85 mm Hg and the white-coat effect was the difference between the BP recorded by the referring doctor or nurse and the average awake ambulatory BP. RESULTS: Those with resistant hypertension (group 3) were older (61 years (12) v group 1: 46 years (14) and group 2: 56 (14) years; P < .001), but were of similar weight, height, and arm circumference to the other groups. Referral systolic, but not diastolic BP was higher in resistant hypertensives (mean 171/95 v 154/95 mm Hg and 164/94 mm Hg, respectively, P < .001 for systolic BP only). Twenty-eight percent of resistant hypertensives and 32% of those taking no antihypertensive drugs had normal awake ambulatory BP and the white-coat effect attributable to the referring doctor was always greater than that due to the nurse (range 16 to 26/12 to 14 mm Hg v 9 to 17/4 mm Hg, P < .001). Nurse recorded BP was highly sensitive (97%) in identifying awake hypertension but lacked specificity (57%) to replace ABPM. CONCLUSION: Our results show that approximately one in four patients with apparent resistant hypertension referred for ABPM have controlled BP and one-third of patients referred for initial evaluation of office or clinic hypertension have normal BP using ABPM, ie, white-coat hypertension. Twenty-four-hour ABPM appears an appropriate initial step before further investigating or treating patients with apparently resistant hypertension.     

Losartan versus atenolol on 24-hour ambulatory blood pressure. A LIFE substudy

Objective. The Losartan Intervention For Endpoint reduction in hypertension (LIFE) study showed that losartan-based treatment reduced risk of the composite endpoint of cardiovascular death, stroke and myocardial infarction compared with atenolol-based treatment in patients with hypertension and left ventricular hypertrophy with similar office blood pressure (BP) reduction. Our aim was to investigate the effect of losartan- and atenolol-based treatment on 24-h ambulatory BP and heart rate (HR) in LIFE. Methods: In 110 patients, 24-h ambulatory BP and heart rate were recorded at baseline and 1 year after randomization. Results: Ambulatory BP was comparably reduced throughout the 24-h period after 1 year of losartan- vs atenolol-based antihypertensive treatment. Office and ambulatory BP were comparably reduced in the follow-up period. Early morning surge in BP was similar between groups. Non-dipping status was more frequent in the losartan group (p = 0.01). From baseline to Year 1 the 24-h HR profile for the losartan group was unchanged, but, as expected, there was a significant decrease in daytime HR in the atenolol group, which was not as large during early night-time. Conclusion: There were no differences in 24-h BP burden and HR that could explain the difference in outcome in favor of losartan vs atenolol in the LIFE study.     

Ambulatory pulse pressure aspredictor of outcome in older patients with systolic hypertension

We enrolled 808 older patients with isolated systolic hypertension (160 to 219/71 <95 mm Hg) to investigate whether ambulatory measurement of pulse pressure and mean pressure can refine risk stratification. The patients (≥60 years) were randomized to nitrendipine (10 to 40 mg/day) with the possible addition of enalapril (5 to 20 mg/day) or hydrochlorothiazide (12.5 to 25 mg/day) or to matching placebos. At baseline, pulse pressure and mean pressure were determined from six conventional blood pressure (BP) readings and from 24-h ambulatory recordings. With adjustment for significant covariables, we computed mutually adjusted relative hazard rates associated with 10 mm Hg increases in pulse pressure or mean pressure. In the placebo group, the 24-h and nighttime pulse pressures consistently predicted total and cardiovascular mortality, all cardiovascular events, stroke, and cardiac events. Daytime pulse pressure predicted cardiovascular mortality, all cardiovascular end points, and stroke. The hazard rates for 10 mm Hg increases in pulse pressure ranged from 1.25 to 1.68. Conventionally measured pulse pressure predicted only cardiovascular mortality with a hazard rate of 1.35. In the active treatment group compared with the placebo patients, the relation between outcome and ambulatory pulse pressure was attenuated to a nonsignificant level. Mean pressure determined from ambulatory or conventional BP measurements was not associated with poorer prognosis. In conclusion, in older patients with isolated systolic hypertension higher pulse pressure estimated by 24-h ambulatory monitoring was a better predictor of adverse outcomes than conventional pulse pressure, whereas conventional and ambulatory mean pressures were not correlated with a worse outcome.     

Low-dose atorvastatin reduces ambulatory blood pressure in patients with mild hypertension and hypercholesterolaemia: a double-blind, randomized, placebo-controlled study

Among several beneficial cardiovascular actions of statins, experimental studies have suggested that statins may also induce a mild blood pressure (BP) reduction. However, clinical data were controversial and the potential hypotensive statin effect remains uncertain. This study aimed to investigate the effect of atorvastatin on ambulatory BP in patients with mild hypertension and hypercholesterolaemia. A total of 50 patients with mild hypertension and hypercholesterolaemia participated in this double-blind, randomized, placebo-controlled study. Patients were randomized to either 10 mg atorvastatin or placebo for 26 weeks. Background antihypertensive treatment, if any, remained unchanged during follow-up. At baseline and study-end (26 weeks), ambulatory BP monitoring and blood sampling for determination of standard biochemical and safety parameters were performed in all participants. BP loads were defined as the percentage of BP measurements exceeding the hypertension threshold of 140/90 mm?Hg for daytime and 125/75 mm?Hg nighttime period. Atorvastatin significantly reduced 24-h systolic and diastolic BP (DBP; median (range)) as compared with placebo (-5.0 (-21.0, 4.0) vs +1.0 (-6.0, 7.0) mm?Hg, P<0.001 and -3.0 (-16.0, 2.0) vs +0.1 (-7, 4) mm?Hg, P<0.01, respectively). Reductions in systolic and DBP loads during follow-up were also evident in the atorvastatin, but not in the placebo group. BP-lowering effects of atorvastatin were consistent in both daytime and nighttime periods. This study shows a mild, but consistent throughout the 24-h period BP-lowering effect of atorvastatin in patients with mild hypertension and hypercholesterolaemia. This beneficial effect of atorvastatin on BP may represent another pathway through which this drug class provides cardiovascular risk reduction.     

Masked Hypertension Defined by Ambulatory Blood Pressure Monitoring Is Associated With an Increased Serum Glucose Level and Urinary Albumin‐Creatinine Ratio

J Clin Hypertens(Greenwich). 2010;12:578–587. © 2010 Wiley Periodicals, Inc. The authors evaluated the relationship of hypertensive target organ damage to masked hypertension assessed by ambulatory blood pressure (BP) and home blood pressure (HBP) monitoring in 129 participants without taking antihypertensive medication. Masked hypertension was defined as office BP ≤140/90 mm Hg and 24-hour ambulatory BP ≥130/80 mm Hg. The masked hypertensive participants defined by 24-hour ambulatory BP (n=13) had a higher serum glucose level (126 vs 96 mg/dL, P=.001) and urinary albumin-creatinine ratio (38.0 vs 7.5 mg/gCr, P<.001) than the normotensive participants (n=74); however, these relationships were not observed when the authors defined groups using HBP (≥135/85 mm Hg). Masked hypertension by both 24-hour ambulatory BP and HBP had a higher urinary albumin-creatinine ratio than normotension by both 24-hour ambulatory BP and HBP (62.1 vs 7.4 mg/gCr, P=.001), and than masked hypertension by HBP alone (9.3 mg/gCr, P=.009). Masked hypertension defined by 24-hour ambulatory BP is associated with an increased serum glucose level and urinary albumin-creatinine ratio, but these relationships are not observed in masked hypertension defined by HBP.     

Evidence-based hypertension treatment in patients with diabetes

J Clin Hypertens (Greenwich). 2011;00:00–00. ©2011 Wiley Periodicals, Inc. Both impaired glucose tolerance and diabetes are associated with substantially increased prevalence of hypertension, cardiovascular and renal disease. The goal for hypertension treatment in diabetic patients is in evolution, because of recent clinical trials. For example, the results of the recent Action to Control Cardiovascular Risk in Diabetes—BP Arm (ACCORD BP) trial failed to show an additional benefit on cardiovascular event reduction at a mean systolic BP of 119 mm Hg. A post hoc analysis of 6,400 patients with type 2 diabetes from the International Verapamil‐Trandolapril Study (INVEST) also failed to show additional cardiovascular risk reduction among patients who achieved a BP <130/80 mm Hg. While the evidence fails to support a lower BP goal to reduce coronary events, there was a risk reduction in stroke events both in ACCORD and the Appropriate Blood Pressure Control in NIDDM (ABCD) trial. A number of other clinical trials also demonstrate that when systolic pressures fall to less than 130 mm Hg, a reduction in stroke but not coronary disease events occurs. Thus, the precise BP goal for diabetic patients remains unresolved. We would posit that a BP goal of 135/85 mm Hg may be a reasonable compromise when viewing the impact of BP reduction on composite stroke and coronary artery disease in extant trials.     

Evaluation of the Antihypertensive Effect of Barnidipine, a Dihydropyridine Calcium Entry Blocker, as Determined by the Ambulatory Blood Pressure Level Averaged for 24 h, Daytime, and Nighttime

We evaluated the effect of barnidipine, a dihydropyridine calcium antagonist, administered once daily in the morning in a dose of 5, 10, or 15 mg on ambulatory blood pressure (BP) in 34 patients (51.3 ± 9.6 years). Hypertension was diagnosed based on the clinic BP. The patients were classified into groups according to the ambulatory BP: group 1, dippers with true hypertension; group 2, nondippers with true hypertension; group 3, dippers with false hypertension; and Group 4, nondippers with false hypertension. Barnidipine reduced the clinic systolic BP (SBP) and diastolic BP (DBP) in all groups and significantly reduced the average 24 h ambulatory BP (133.0 ± 16.5/90.7 ± 12.3 mm Hg v 119.7 ± 13.7/81.8 ± 10.3 mm Hg, P < .0001 for both SBP and DBP). Barnidipine significantly reduced the daytime ambulatory SBP in groups 1, 2, and 3, but not in group 4, and significantly reduced daytime ambulatory DBP in group 1 but not in groups 2, 3, and 4. Barnidipine significantly reduced the nighttime ambulatory SBP only in group 2 and the nighttime ambulatory DBP in groups 2 and 4. Once-a-day administration of barnidipine influenced 24 h BP on true hypertensives (the ratio of the trough to peak effect > 50%), but had minimal effect on low BP such as the nocturnal BP in dippers and the ambulatory BP in false hypertensives. These findings suggest that barnidipine can be used safely in patients with isolated clinic (“white coat”) hypertension and in those with dipping patterns of circadian BP variation whose nocturnal BP is low before treatment.     

A comparison of home measurement and ambulatory monitoring of blood pressure in the adjustment of antihypertensive treatment

BACKGROUND: The purpose of this study was to compare home and ambulatory blood pressure (BP) in the adjustment of antihypertensive treatment. METHODS: After a 4-week washout period, patients whose untreated daytime diastolic ambulatory BP averaged > or = 85 mm Hg were randomized to be treated according to their ambulatory or home BP. Antihypertensive treatment was adjusted at 6-week intervals according to the mean daytime ambulatory diastolic BP or the mean home diastolic BP, depending on the patient's randomization group. If the diastolic BP stayed above 80 mm Hg, the physician blinded to randomization intensified hypertensive treatment. RESULTS: Ninety-eight patients completed the study. During the 24-week follow-up period both systolic and diastolic BP decreased significantly within both groups (P < .001). At the end of the study, the systolic/diastolic differences between ambulatory (n = 46) and home (n = 52) BP groups in home, daytime ambulatory, night-time ambulatory, and 24-h ambulatory BP changes averaged 2.6/2.6 mm Hg, 0.6/1.7 mm Hg, 1.0/1.4 mm Hg, and 0.6/1.5 mm Hg, respectively (P range .06 to .75) A nonsignificant trend to more intensive drug therapy in the ambulatory BP group and a nonsignificant trend to larger share of patients reaching (57.7% v 43.5%, P = .16) the target pressure in the home BP group was observed due to the 3.8 mm Hg difference in ambulatory and home diastolic BP at randomization. CONCLUSIONS: The adjustment of antihypertensive treatment based on either ambulatory or home BP measurement led to good BP control. No significant between-group differences in BP changes were seen at the end of the study. Additional research is needed to provide more conclusive results.     

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.     

Additive effect of drospirenone/17-beta-estradiol in hypertensive postmenopausal women receiving enalapril

BACKGROUND: Aldosterone has been implicated in the pathogenesis of progressive cardiovascular disease. Drospirenone (DRSP) is a novel progestin with aldosterone receptor antagonist activity developed for hormone replacement therapy (HRT) as DRSP/17beta-estradiol (DRSP/ E2). We investigated the additive effect of DRSP/E2 versus placebo on 24-h ambulatory blood pressure (BP) in postmenopausal women with hypertension treated with enalapril maleate (ENA). METHODS: This was a double-blind, randomized, two-parallel group trial. Twenty-four nonsmoking postmenopausal women receiving 10 mg of ENA twice a day before study were randomized to DRSP/E2 + ENA (n = 12) or placebo (P) + ENA (n = 12) for 14 days. Twenty-four-hour ambulatory BP, plasma renin activity, and serum aldosterone were determined at baseline and on day 14. RESULTS: Compared to placebo, 24-h mean [SD] BP in the DRSP/E2 + ENA group decreased significantly from baseline (139/80 mm Hg), systolic (-9 [51 mm Hg, P = .014) and diastolic (-5 [4] mm Hg, P = .007). Essentially no change from baseline (139/83 mm Hg) in systolic or diastolic 24-h ambulatory BP were observed in the P + ENA group. Aldosterone (mean [SD]) increased from baseline by 2.6 [4.5] ng/dL in the DRSP/E2 + ENA group, and decreased by 0.3 [5.5] ng/dL in the P + ENA group (P = .08) consistent with an antimineralocorticoid effect. CONCLUSIONS: Our results suggest a significant additive BP-lowering effect of DRSP/E2 on both systolic and diastolic BP in hypertensive postmenopausal women receiving ENA, consistent with an antimineralocorticoid effect. DRSP/E2, a HRT with antimineralocorticoid effects, could offer a novel potential mechanism for reducing cardiovascular end points in postmenopausal women.     

Baroreflex sensitivity changes with calcium antagonist therapy in elderly subjects with isolated systolic hypertension

In order to study the effects of calcium-blocking therapy on cardiovascular homeostasis in elderly subjects with isolated systolic hypertension, we performed a randomised double-blind placebo-controlled crossover study of 6 weeks therapy with modified-release nifedipine or placebo. Changes with calcium-blocker treatment in clinic and 24-h blood pressure (BP), heart rate, BP variability, baroreflex sensitivity (BRS) by three methods (Valsalva manoeuvre, phenylephrine and sodium nitroprusside injection), and in baroreflex- and non-baroreflex-mediated reflexes (tilt and cold face stimulus) were studied in 14 elderly subjects (mean age [+/- SEM] 70 +/- 1 years) with sustained isolated systolic hypertension (clinic BP 179 +/- 3/85 +/- 1 mm Hg). Clinic systolic BP, but not diastolic BP, was reduced with treatment (by 14 +/- 6 mm Hg, P = 0.03, diastolic BP 4 +/- 3 mm Hg, P = 0.16). Twenty-four hour BP was also reduced by nifedipine treatment (by 18 +/- 3/9 +/- 2 mm Hg, both P < 0.001). Clinic and 24-h heart rate, and daytime BP variability, were unchanged with treatment. BRS was significantly increased during nifedipine therapy by all three measurement methods (all P < 0.05). With 60 degrees tilt during active treatment, subjects exhibited a greater heart rate increase (P < 0.01), and a reduced fall in systolic (P < 0.05) and diastolic BP (P < 0.05). Thus despite the arteriosclerosis and reductions in large artery compliance described in elderly patients with isolated systolic hypertension, clinically important improvements in clinic and ambulatory BP and some aspects of cardiovascular homeostasis can be achieved with calcium-channel blocking therapy.     

Cardiovascular outcome in relation to progression to hypertension in the Copenhagen MONICA cohort

BACKGROUND: Previous studies of the risk associated with high-normal blood pressure (BP) determined BP category in a cross-sectional fashion. METHODS: In 1982-1984, we measured BP in a random sample of 2357 Danes without previous cardiovascular complications, aged 30 to 60 years. We determined progression from optimal (<120/80 mm Hg), normal (120 to 129/80 to 84 mm Hg), and high-normal (130 to 139/85 to 89 mm Hg) BP to hypertension (>or=140/90 mm Hg or start of antihypertensive treatment) by follow-up until 1993-1994. We studied the prognostic significance of progression by subsequent follow-up until 2003. RESULTS: During 10.9 years (median), the crude progression rates to hypertension from optimal, normal, and high-normal BP were 10.4%, 37.3%, and 58.1%, respectively. During an additional 9.4 years (median), 218 first cardiovascular end points (cardiovascular death, nonfatal stroke, and nonfatal coronary heart disease) occurred. With sustained optimal or normal BP as reference, the multivariate-adjusted hazard ratios were similar (P > .60) for progression to high-normal BP (1.57; 95% confidence interval [CI], 1.06-2.33), for progression to hypertension (1.64; 95% CI, 1.19-2.26), and for sustained high-normal BP or hypertension (1.78; 95% CI, 1.39-2.29). The absolute 10-year cardiovascular risks were 5.1% for optimal or normal BP without progression, 11.1% and 13.9% for progression to high-normal BP or hypertension, respectively, and 18.7% for sustained high-normal BP or hypertension. CONCLUSIONS: Progressing from optimal or normal BP to high-normal BP or hypertension carries nearly the same risk as sustained high-normal BP or hypertension.