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 24-hour blood pressure monitoring in patients with resistant hypertension

The aim of the study was to assess the usefulness of 24-hour blood pressure (BP) and heart rate (HR) monitoring in patients with "resistant" hypertension. 30 patients (44.1 +/- 9.9 years) with diastolic BP 100 mm Hg or more in spite of treatment with three or more antihypertensive drugs were studied. Ambulatory recording of BP and HR was performed by means of Del Mar Avionics monitoring system 9000. Mean recording time was 21.5 hours and mean number of measurements during one recording--56.7. Mean ambulatory systolic and diastolic BP values were significantly lower than mean value of three casual measurements (146.0 +/- 24.6 vs 171.5 +/- 21.2 mm Hg for systolic and 97.2 +/- 11.3 vs 110.4 +/- 7.5 mm Hg for diastolic BP p less than 0.01) In 14 (46.6%) systolic BP and in 10 patients (33.3%) diastolic BP were normal. The patients with normal and abnormal ambulatory BP recordings did not differ in regard to age and mean clinic BP levels. However, patients with abnormal ambulatory BP recordings were more often overweight and showed a greater frequency of left ventricular hypertrophy and family history of hypertension and its complications. The results of the study show that ambulatory BP monitoring may be of value in assessing the response to antihypertensive treatment in patients with so called resistant hypertension as judged on the basis of clinic pressure.     

Association between 24-hour ambulatory heart rate and arterial stiffness

Clinical and experimental studies point to a positive association between carotid-femoral pulse wave velocity (PWVcf) and casual heart rate. However, an association with 24-h ambulatory heart rate has never been investigated. Twenty-four hour ambulatory heart rate and PWVcf (automatic computerised technique) were simultaneously measured in 213 subjects with untreated mild-to-moderate essential hypertension. It was found that mean ambulatory heart rate was higher in women than in men but the difference reached statistical significance only in those below 50 years of age during night-time measurements. As well as age and blood pressure, 24-h ambulatory heart rate was also an independent factor influencing PWVcf. Independent of gender, the relationship between PWVcf and ambulatory heart rate was stronger in patients over 50 years of age. Casual heart rate was not a significant determinant of PWVcf in this population. In conclusion, ambulatory heart rate contribution to explain pulse wave velocity is more important than casual heart rate. The relationship between 24-h heart rate and pulse wave velocity is stronger for subjects older than 50 years of age independent of gender.     

Crossover comparison of atenolol, enalapril, hydrochlorothiazide and isradipine for isolated systolic systemic hypertension.

The benefit of antihypertensive therapy in reducing cardiovascular morbidity and mortality associated with isolated systolic hypertension has now been established by the Systolic Hypertension in the Elderly Program. However, there is little information about the relative effectiveness of different drug regimens in this condition. This study compared the efficacy and tolerability of 50 mg of atenolol, 10 mg of enalapril, 25 mg of hydrochlorothiazide and 2.5 mg of isradipine in the treatment of isolated systolic hypertension. After a 3-week placebo run-in phase, 24 subjects were randomized into a 4-period double-blind crossover study by use of an orthogonal latin square design. Treatment periods were of 6 weeks' duration with titration to a higher dose after 4 weeks in those not reaching goal blood pressure (BP). Each active treatment was followed by a 3-week placebo washout. Casual clinic and 24-hour ambulatory BP (Accutracker II) were measured at the end of each treatment phase. Routine biochemistry was also performed after the placebo run-in, at the end of each active treatment phase, and after the placebo run-out. Of the 24 subjects entered (mean age 72.3 years, 38% men) 20 completed the whole study. Mean +/- standard deviation of supine clinic and daytime ambulatory BP on entry were 181/79 +/- 21/9 mm Hg and 165/82 +/- 23/15 mm Hg, respectively. All drugs reduced mean casual and ambulatory BP significantly relative to placebo but only hydrochlorothiazide and enalapril produced a consistent hypotensive effect throughout the entire 24-hour period. Isradipine and enalapril exhibited a relatively greater effect on reducing systolic BP than either hydrochlorothiazide or atenolol.(ABSTRACT TRUNCATED AT 250 WORDS)     

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 (9:00–17:00h). 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.     

A clinical trial evaluating the 24-hour effects of bisoprolol/hydrochlorothiazide 5 mg/6.25 mg combination in patients with mild to moderate hypertension

This study used 24-h ambulatory blood pressure (BP) monitoring to investigate the effectiveness of a novel low-dose combination of bisoprolol/hydrochlorothiazide in adult patients with mild to moderate essential hypertension. Thirty-six patients with stable mild to moderate hypertension (sitting diastolic BP 95–114 mmHg) after a placebo run-in phase received oral bisoprolol/hydrochlorothiazide 5 mg/6.25 mg once daily for 4 weeks in a single-blind regimen. At office visits, BP and pulse were measured with statistically significant reductions (p<0.01) recorded after 2 and 4 weeks of treatment Twenty-four-h ambulatory BP monitoring at the completion of therapy revealed significant reductions (p<0.01) in both systolic and diastolic 24-h, daytime, and nighttime BP, compared with the end of the placebo treatment phase. Systolic and diastolic load were also reduced (p<0.01). The combination was well tolerated, and overall quality-of-life questionnaire scores indicated an improvement after bisoprolol/hydrochlorothiazide therapy (p = 0.02). No clinically significant changes from baseline in laboratory parameters were observed; in particular, serum potassium was unchanged. This is the first study to demonstrate the 24-h effectiveness of the bisoprolol/hydrochlorothiazide 5 mg/6.25 mg combination, using 24-h ambulatory BP monitoring. In addition, antihypertensive therapy with low doses of bisoprolol/hydrochlorothiazide in combination may improve tolerability.     

Blood pressure measurement: Should technique define targets?

Accurate assessment of blood pressure (BP) is the cornerstone of hypertension management. The objectives of this study were to quantify the effect of medical personnel presence during BP measurement by automated oscillometric BP (AOBP) and to compare resting office BP by AOBP to daytime average BP by 24‐h ambulatory BP monitoring (ABPM). This study is a prospective randomized cross‐over trial, conducted in a referral population. Patients underwent measurements of casual and resting office BP by AOBP. Resting BP was measured as either unattended (patient alone in the room during resting and measurements) or as partially attended (nurse present in the room during measurements) immediately prior to and after 24‐h ABPM. The primary outcome was the effect of unattended 5‐min rest preceding AOBP assessment as the difference between casual and resting BP measured by the Omron HEM 907XL. Ninety patients consented and 78 completed the study. The mean difference between the casual and Omron unattended systolic BP was 7.0 mm Hg (95% confidence interval [CI] 4.5, 9.5). There was no significant difference between partially attended and unattended resting office systolic BP. Resting office BP (attended and partially attended) underestimated daytime systolic BP load from 24‐h ABPM. The presence or absence of medical personnel does not impact casual office BP which is higher than resting office AOBP. The requirement for unattended rest may be dropped if logistically challenging. Casual and resting office BP readings by AOBP do not capture the complexity of information provided by the 24‐h ABPM.     

Assessment of the daily blood pressure load as a determinant of cardiac function in patients with mild-to-moderate hypertension

The distribution of blood pressure (BP) values over the day and night was assessed in a group of 30 never previously treated patients with mild-to-moderate essential hypertension via 24-hour ambulatory BP monitoring. Elevated BP values during the awake hours (greater than 140/90 mm Hg) and sleeping hours (greater than 120/80 mm Hg) were used to calculate the total percentage of abnormal BP values (load) in each patient. The relationship between BP load and several indexes of hypertensive cardiac target organ involvement was compared to the relationships among office (casual), 24-hour average BP values, and cardiac indexes. Casual systolic and diastolic BP values did not correlate with left ventricular mass index, left atrial index, or peak left ventricular filling rate. Both 24-hour average BP and systolic and diastolic BP loads correlated with all indexes of cardiac target organ involvement. The BP loads were related to left ventricular mass index and left atrial index more strongly than were the mean 24-hour BP values; however, they were equally correlated for peak left ventricular filling rate. If greater than 40% of the ambulatory BP values were elevated, the likelihood of increased mass or decreased filling was greater than 61%, whereas if less than 40% of the BP values were elevated, the incidence of an abnormal cardiac test result decreased to less than 17%. These data show that the percentage of elevated BP values that includes both the awake and asleep periods is predictive of cardiac target organ involvement in patients with mild-to-moderate hypertension. Patients with mild hypertension who have more than 40% abnormal BP values should strongly be considered for antihypertensive therapy.     

Impact of disease duration and cardiovascular dysautonomia on hypertension in Parkinson's disease

The authors evaluated the association of Parkinson’s disease (PD) duration with hypertension, assessed by office measurements and 24‐hour (ambulatory) monitoring, in 167 patients. Hypertension was evaluated through both office and ambulatory blood pressure (BP) measurements. Among participants (mean age 73.4±7.6 years; 35% women), the prevalence of hypertension was 60% and 69% according to office and ambulatory BP measurements, respectively (Cohen's k=0.61; P<.001). PD duration was inversely associated with hypertension as diagnosed by office measurements (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.86–0.98) but not by ambulatory monitoring (OR, 0.94; 95% CI, 0.81–1.01). Ambulatory BP patterns showed higher nocturnal BP among patients with long‐lasting disease. In conclusion, ambulatory BP monitoring improves the detection of hypertension by 15% in PD, compared with office evaluation. The likelihood of having hypertension does not decrease during the PD course; rather, BP pattern shifts towards nocturnal hypertension.     

比索洛尔、拉西地平和赖诺普利对高血压病患者24小时血压的影响

目的比较比索洛尔、拉西地平和赖诺普利对２９例高血压病患者的降压疗效。方法采用随机、单盲和交叉的方法，运用２４小时动态血压监测。结果三药均能显著降低血压，彼此间降低偶测血压的幅度无显著差异。比索洛尔和拉西地平降低２４小时平均和白天平均血压的幅度大于赖诺普利。三药均能有效控制清晨血压高峰期的血压，它们的降压谷／峰比值都超过６５％。结论比索洛尔、拉西地平和赖诺普利均可每日服用１次，前二药控制２４小时血压及清晨醒后的高峰期血压较后者为佳。     

Ambulatory blood pressure measurement, smoking and abnormalities of glucose and lipid metabolism in essential hypertension.

OBJECTIVE: Casual (mercury sphygmomanometer) and ambulatory blood pressure measurements were determined in 61 subjects with sustained essential hypertension. DESIGN: Patients were classified into three subgroups: smokers or non-smokers; patients with or without hyperglycemia; and patients with or without plasma lipoprotein abnormality. Mean casual blood pressure were shown to be identical in these three subgroups. RESULTS: When ambulatory blood pressure was analyzed, smokers exhibited a significant increase in pulse pressure exclusively during the activity period, whereas diastolic blood pressure and mean arterial pressure (MAP) were not modified in comparison with controls. Patients with abnormal plasma glucose showed a significant increase in systolic and pulse pressure during both activity and non-activity periods, with a slight increase in MAP during the activity period. Patients with and without plasma lipid abnormality displayed similar ambulatory blood pressure. CONCLUSION: The study provides evidence that, in spite of similar casual blood pressure levels among smokers and non-smokers, as well as among those with elevated fasting glucose levels, smokers and patients with hyperglycemia have a higher systolic and pulse pressure during 24-h monitoring, pointing to the possible role of cyclic stress in the deterioration in the structure of the hypertensive arterial wall.     

24-hour blood pressure differences in hypertension and normotension in bed-confined subjects

This study investigates whether the degree of hypertension may be evaluated by information derived from the 24-h blood pressure (BP) curve unrelated to the pressure height. We performed 24-h BP intra-arterial monitoring in 52 bed-confined subjects (10 normotensives, 10 borderlines, and 32 hypertensives on WHO criteria). Computer analysis of 1152 BP values per subject per 24-h revealed the following: During the night hours, the percentage of the 1152 systolic BP values greater than or equal to 160 (in mmHg) increased (or did not change if 100%) in all subjects with mean 24-h systolic BP (24-h BP) greater than 170 and it decreased (or did not change if 0%) in all subjects with 24-h BP less than 150. The change in the percentage of the 1152 diastolic BP values greater than or equal to 95 during the night hours did not correlate to either the mean 24-h diastolic or systolic BP. The higher the mean 24-h systolic BP, the lower the skewness of the distribution of the 1152 systolic BP values (p less than 0.01). No such correlation existed between the skewness of the distribution of the 1152 diastolic BP values and either the mean 24-h diastolic or systolic BP. It is concluded that both the change in systolic BP during the night hours and the skewness of its distribution during the 24-h monitoring period are correlated to the severity of hypertension.     

The changes in blood pressure after acute stroke: abolishing the ‘white coat effect’ with 24-h ambulatory monitoring

Objectives . To assess the changes in 24-h and casual blood pressure (BP) levels following hospitalization for acute stroke. Design . Prospective study of patients admitted with acute hemispheric stroke and hospitalized controls using casual and 24-h BP monitoring. Setting . Medical wards in a large teaching hospital. Subjects . Thirty-three patients (median age 77 years, 17 male) and 21 control subjects admitted non-acutely. Interventions . All subjects underwent 24-h BP monitoring within 24 h of stroke onset (patients) or admission (controls) and again at 1 week. Casual BPs were recorded over the same period. Main outcome measures . The change in BP over the first week in each group. Eleven stroke subjects had 24-h BP monitoring repeated at 6 months. Results . In the stroke group, 24-h systolic BP (SBP) fell by 7 mmHg (95% CI, 0 to 14 mmHg; P < 0.05) and diastolic BP (DBP) by 3 mmHg (95% CI, 0 to 6 mmHg; P < 0.02) over the first week. Mean 24-h BP levels in the control group did not change during this period. However, casual BP recordings fell in both stroke (18/12 mmHg) and control (19/9 mmHg) groups. Stroke subjects followed to 6 months showed no further change in 24-h BP (day 7: 137±17/79±13 mmHg; month 6: 138 ± 16/78 ± 11 mmHg). Conclusions . Although there was a large fall in causal BPs seen in both groups there, was only a small, but a significant fall in mean 24-h BP over the first week following hemispheric stroke that was not seen in control subjects. Although the ‘white coat effect’ and admission to hospital play an important part in the high casual BP observed in the days following acute stroke they are unlikely to be the sole factors.     

Primary arterial hypertension. 24-hour recording or casual blood pressure measurement?]

In 134 patients with essential hypertension 24-hour blood pressure ambulatory monitoring (ABPM) as well as traditional blood pressure measurements (casual BP) were performed. Maximal and mean whole-day systolic and diastolic blood pressure values in ABPM were compared with casual BP (using test t). The casual BP was also compared with mean systolic and diastolic blood pressure values calculated separately in three eight-hours periods of day. Maximal BP values in ABPM were significantly higher and mean significantly lower than casual BP values. Blood pressure registered during work hours was closest to casual BP values. Blood pressure in the evening was similar to whole-day blood pressure mean. The results indicate, that automatic blood pressure monitoring performed in this period of day has the greatest diagnostic value because it could be free from "white coat hypertension" syndrome.     

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.     

Twenty-four hour ambulatory blood pressure for the management of antihypertensive treatment: a randomized controlled trial

The aim of this study was to assess whether the use of 24-h blood pressure (BP) measurement in the management of antihypertensive therapy improves BP in patients with sustained hypertension. Patients with sustained hypertension (office BP > or =140/90 mm Hg, and 24-h systolic BP > or =130/80 mm Hg) were randomly assigned to a strategy using 24-h BP to manage antihypertensive treatment (target <130/80 mm Hg) or to a standard strategy using office BP (target <140/90 mm Hg). The primary end point was change in 24-h systolic BP at 1 year of follow-up. We included 136 patients in the primary analysis. After 1 year of follow-up, the change in 24-h systolic BP was significantly greater in the ambulatory BP group compared with the office BP group (mean difference (95% confidence interval) -3.6 (-7.0, -0.3), P=0.03). Intention-to-treat analysis revealed essentially unchanged results. The mean number of antihypertensive drugs per participant at 1 year of follow-up was 1.76+/-1.1 and 1.95+/-0.9 in the ambulatory and office BP group, respectively (P=0.049). The benefit of ambulatory BP monitoring was mainly seen in patients with previously known hypertension (mean difference -7.2 (-11.6, -2.8), P=0.002), but not in those with newly detected hypertension (mean difference 0.2 (-4.9, 5.4), P=0.93). In conclusion, using 24-h BP for the management of antihypertensive therapy in patients with sustained hypertension leads to a greater BP reduction compared with a standard treatment strategy using office BP, although fewer antihypertensive drugs were used in the ambulatory BP group.     

Home blood pressure is as reliable as ambulatory blood pressure in predicting target-organ damage in hypertension

BACKGROUND: Our objective was to assess the value of home blood pressure (BP) monitoring in comparison to office BP measurements and ambulatory monitoring in predicting hypertension-induced target-organ damage. METHODS: Sixty-eight untreated patients with hypertension with at least two routine prestudy office visits were included (mean age, 48.6 +/- 9.1 [SD] years; 50 men). Office BP was measured in two study visits, home BP was measured for 6 workdays, and ambulatory BP was monitored for 24 h. All BP measurements were obtained using validated electronic devices. Target-organ damage was assessed by measuring the echocardiographic left-ventricular mass index (LVMI), urinary albumin excretion rate (AER) in two overnight urine collections, and carotid-femoral pulse-wave velocity (PWV) (Complior device; Colson, Garges-les-Gonesse, Paris, France). RESULTS: The correlation coefficients of LVMI with office BP were 0.24/0.15 (systolic/diastolic), with home BP 0.35/0.21 (systolic, P < .01), and with 24-h ambulatory BP 0.23/0.19, awake 0.21/0.16, and asleep 0.28/0.26 (asleep, both P < .05). The correlation coefficients of AER with office BP were 0.24/0.31 (diastolic, P < .05), with home BP 0.28/0.26 (both P < .05), and with 24-h ambulatory BP 0.25/0.24, awake 0.24/0.25 (diastolic, P < .05), and asleep 0.26/0.18 (systolic, P < .05). There was a trend for negative correlations between PWV and diastolic BP measurements (not significant). In multiple-regression models assessing independent predictors of each of the three indices of target-organ damage, systolic home BP and age were the only independent predictors of increased LVMI that reached borderline statistical significance. CONCLUSIONS: These data suggest that home BP is as reliable as ambulatory monitoring in predicting hypertension-induced target-organ damage, and is superior to carefully taken office measurements.     

Supine hypertension with transient papilledema

A 68-year-old male, married, retired public official was admitted to hospital for thorough examination and appropriate treatment of gait disturbance and dizziness. He had been diagnosed with diabetes mellitus and hypertension for at least 28 years, and had been treated with insulin and antihypertensive medications intermittently at another hospital. We identified the major cause of his complaints as orthostatic hypotension, and controlled his casual systolic blood pressure (BP) to within the range of 140–160 mmHg in a sitting position. After a few weeks, on ophthalmic study, right papilledema was diagnosed. There was no progression of visual disturbance nor circulatory impairment in the optic fundi. Based on the results of 24-h ambulatory BP monitoring, we assumed that his supine systolic hypertension triggered the papilledema, so we controlled his supine systolic BP to within the range of approximately 140–160 mmHg. After 2 weeks of controlled BP the papilledema improved. Visual disturbance was not reported during 1 year of follow up. In case of severe autonomic disorder such as orthostatic hypotension, attention should be paid to changes in the optic fundi, and ophthalmoscopic examination should be performed regularly.     

Antihypertensive efficacy and safety of olmesartan medoxomil compared with amlodipine for mild-to-moderate hypertension

The antihypertensive efficacy of the angiotensin II receptor blocker olmesartan medoxomil has been shown to compare favourably with that of other antihypertensive agents. This randomized, double-blind study compared the antihypertensive efficacy of the starting dose of olmesartan medoxomil with that of the calcium channel blocker amlodipine besylate (amlodipine) in subjects with mild-to-moderate hypertension. Following a 4-week, single-blind, placebo run-in period, 440 subjects aged >/=18 years were randomized to the starting dose of olmesartan medoxomil (20 mg/day), amlodipine (5 mg/day), or placebo for 8 weeks. Subjects were evaluated by 24-h ambulatory blood pressure monitoring (ABPM) and by seated cuff blood pressure (BP) measurements at trough. The primary end point was the change from baseline in mean 24-h diastolic blood pressure (DBP) by ABPM at Week 8. Secondary end points included change from baseline in mean 24-h ambulatory systolic blood pressure (SBP) at 8 weeks, change from baseline in mean seated trough cuff DBP and SBP measurements, and response and control rates for DBP <90 and <85 mmHg. Control rates for SBP <140 and <130 mmHg were also calculated. Olmesartan medoxomil and amlodipine produced significantly greater reductions in ambulatory and seated DBP and SBP compared with placebo. Mean reductions in ambulatory and seated BP were similar between the two active agents; however, in the olmesartan medoxomil group, significantly more patients achieved the SBP goal of <130 mmHg and the DBP goal of <85 mmHg. Both drugs were well tolerated at the recommended starting dose. Although amlodipine was associated with a higher incidence of oedema, this did not reach statistical significance. Olmesartan medoxomil is an effective antihypertensive agent, with BP-lowering efficacy at the starting dose similar to that of amlodipine, and is associated with more patients achieving the rigorous BP goals of SBP <130 mmHg and DBP <85 mmHg.     

Relationship between joint national committee-VI classification of hypertension and ambulatory blood pressure in patients with hypertension diagnosed by casual blood pressure

Background: White-coat hypertension has been diagnosed arbitrarily based on different criteria. In 1997, the Joint National Committee-VI (JNC-VI) reported a new classification of hypertension and strongly emphasized the importance of ambulatory blood pressure (ABP) monitoring. The report pronounced normal ABP values for the first time. Hypothesis: The study's aim was to clarify the relationship between casual blood pressure (BP) and ABP of patients with essential hypertension in each stage of JNC-VI classification, and the prevalence of white-coat hypertension diagnosed by using JNC-VI normal ABP criteria. Methods: Ambulatory blood pressure was monitored noninvasively in 232 patients with essential hypertension whose casual BP was ≥ 140/90 mmHg. The patients were classified according to JNC-VI classification, and their casual BP was compared with ABP. The criterion of white-coat hypertension was defined as casual BP ≥ 140/90 mmHg with normal ABP according to JNC-VI criteria (< 135/85 during daytime and < 120/75 during nighttime). Results: Mean ABP increased as the stage advanced, and the differences between casual BP and ABP also increased. There were considerable overlaps in the distribution of ABP among stages. The prevalence of white-coat hypertension was 13% overall: 30% of the patients with isolated systolic hypertension, 19% of those in stage 1,10% in stage 2, and 4% in stage 3. Conclusions: Classification of hypertension based on casual BP may not always correspond in severity to that based on ABP. Ambulatory blood pressure monitoring recommended by JNC-VI is very useful for the evaluation of hypertension to differentiate white-coat hypertension from true hypertension.