Isolated uncontrolled hypertension at home and in the office among treated hypertensive patients from the J-HOME study

OBJECTIVES: To evaluate the current status of blood pressure (BP) control as measured at home and in the office, as well as to clarify and compare the prevalence and characteristics of isolated uncontrolled hypertension as measured at home (home hypertension) and in the office (office hypertension). DESIGN: A cross-sectional study. SETTING: Primary care offices in Japan. PARTICIPANTS: A sample of 3400 patients with essential hypertension (mean age, 66 years; males, 45%) receiving antihypertensive treatment. RESULTS: Overall, the mean home systolic BP (SBP)/diastolic BP (DBP) was 140/82 mmHg, and the mean office SBP/DBP was 143/81 mmHg. Of the 3400 subjects, 19% had controlled hypertension (home SBP/DBP < 135/85 mmHg and office SBP/DBP < 140/90 mmHg), 23% had isolated uncontrolled home hypertension (home SBP/DBP >/= 135/85 mmHg and office SBP/DBP < 140/90 mmHg), 15% had isolated uncontrolled office hypertension (home SBP/DBP < 135/85 mmHg and office SBP/DBP < 140/90 mmHg), and 43% had uncontrolled hypertension (home SBP/DBP >/= 135/85 mmHg and office SBP/DBP >/= 140/90 mmHg). Compared to controlled hypertension, factors associated with isolated uncontrolled home hypertension included obesity, relatively higher office SBP, habitual drinking, and the use of two or more prescribed antihypertensive drugs. Compared to uncontrolled hypertension, factors associated with isolated uncontrolled office hypertension included female gender, lower body mass index, and relatively lower office SBP. CONCLUSIONS: The use of all four, three of four, or all three predictive factors might be useful for the clinician to suspect isolated uncontrolled home or office hypertension.     

Effects of a structured treatment algorithm on blood pressure goal rates in both stage 1 and stage 2 hypertension

This study analysed the efficacy of an angiotensin receptor blocker-based treatment algorithm for achieving goal blood pressure (BP) in patients with stage 1 (systolic BP (SBP) 140-159 mmHg or diastolic BP (DBP) 90-99 mmHg) or stage 2 (SBP > or = 160 mmHg or DBP > or = 100 mmHg) hypertension. In this 24-week, open-label, multicentre study, patients followed a six-step algorithm until goal BP (< or = 130/85 mmHg) was attained. Initially, olmesartan medoxomil 20 mg/day was administered for 4 weeks. The regimen was modified every 4 weeks until goal BP was attained: increase olmesartan medoxomil to 40 mg/day; add hydrochlorothiazide (HCTZ) 12.5 mg/day; increase HCTZ to 25 mg/day; add amlodipine besylate 5 mg/day; increase amlodipine besylate to 10 mg/day. In patients with stage 1 hypertension, 80% (63/79) and 56% (44/79) achieved BP goals of < or = 140/90 mmHg and < or = 130/85 mmHg, respectively, with olmesartan medoxomil monotherapy (94% (74/79) and 89% (70/79) with olmesartan medoxomil/HCTZ double therapy, and 96% (76/79) and 98% (77/79) with addition of amlodipine besylate (triple therapy)). Mean SBP/DBP reductions were 16.7/11.6, 24.8/15.8, and 26.4/16.5 mmHg for mono-, double-, and triple-therapy, respectively. In patients with stage 2 hypertension, 42% (42/100) and 19% (19/100) achieved BP goals of < or = 140/90 mmHg and < or = 130/85 mmHg, respectively, with monotherapy (75% (75/100) and 54% (54/100) with double therapy, and 90% (90/100) and 81% (81/100) with triple-therapy). Mean SBP/DBP reductions in stage 2 patients were 18.4/10.0, 32.7/16.3, and 39.1/19.4 mmHg for mono-, double, and triple therapy, respectively. Overall, most patients with stage 1 or stage 2 hypertension achieved goal BP.     

What is the most relevant definition of orthostatic hypotension: systolic blood pressure drop, diastolic blood pressure drop, or both?

The agreed definition of orthostatic hypotension (OH) is a drop of 20 mmHg systolic and/or 10 mmHg diastolic blood pressure (BP) within the first 3 min of erect posture. For elderly people, a question can be raised about diastolic BP relevance in OH's definition. OBJECTIVE: To determinate HO's prevalence and risks factors considering systolic blood pressure (SBP)'s drop, or diastolic blood pressure (DBP)'s drop, or either. METHODS: We assessed OH for 554 consecutive, ambulatory, elderly subjects, attending a geriatric outpatient clinic. OH was defined as a SBP drop>20mmHg (SBP-OH), or a DBP drop>10 mmHg (DBP-OH), or a drop in either (SBP. DBP-OH). OH's prevalence and risks factors were determined. RESULTS: In this population, 76 +/- 6 years of age, (70% hypertension), SBP-OH's prevalence was 17%, DBP-OH's prevalence was 12% and SBP. DBP-OH's prevalence was 25%. OH's risks factors varied considering OH's definition. After adjusting for significant determinants, SBP-OH's risk factors were: Antihypertensive therapy (OR=2.95; IC 95%: 1.21-4.04), age>75years (OR=2.11; IC 95%: 1.22-3.66), anti-hypertensive poly therapy (OR=2.01; IC 95%: 1.39-2.92) and SBP level (OR=1.16; IC 95%: 1.01-1.33). Considering DBP-OH, the only significant risk factor was DBP's level (OR=2.64; IC 95%: 1.89-3.68). SBP. DBP-OH was only determined by anti-hypertensive poly therapy (OR=1.61; IC 95%: 1.13-2.29) and DPB level (OR=1.32; IC 95%: 1.08-1.60). CONCLUSION: For elderly people, OH's prevalence and risks factors vary considering OH's definition. SBP's drop seems to be more relevant than DBP's drop. A long term follow up is necessary to determine if SBP-OH is correlated with HO' s side effects and to establish the dangerous level of SBP' s drop.     

Arterial stiffness is related to augmented seasonal variation of blood pressure in hypertensive patients

BACKGROUND: Seasonal variation in blood pressure (BP), a usual tendency of both systolic (SBP) and diastolic BP (DBP) to rise during winter in hypertensive patients, may be related to the higher cardiovascular mortality in winter. However, it is not yet clear what factors are relevant to the seasonal BP changes. We hypothesized that arterial stiffness is related to the BP changes between summer and winter. METHODS AND RESULTS: Eighty-five elderly (>55 years) patients with essential hypertension (33 males, 64+/-6.0 years) were enrolled. Seasonal BP profiles over at least 2 years were studied along with arterial stiffness and clinical variables (age, gender, smoking, duration of hypertension, anti-hypertensive medications and body mass index). Both SBP and DBP were significantly higher during winter compared with three other seasons (spring 128+/-10.0/79+/-7.3 mmHg, summer 127+/-9.8/78+/-7.1 mmHg, autumn 127+/-10.3/78+/-8.0 mmHg, winter 136+/-12.5/81+/-7.6 mmHg; SBP changes; p<0.001, DBP changes; p<0.001). There were no significant seasonal differences among spring, summer and autumn. Pulse wave velocity (PWV), a widely used clinical indicator of arterial stiffness was correlated with winter-summer differences in SBP (r = 0.272, p = 0.012), but not in DBP (r = 0.188, p = 0.085). Age, which was correlated with PWV strongly (p<0.001), was not significantly related to the seasonal changes in BP (SBP changes; p = 0.114, DBP changes; p = 0.298). No other clinical variables had significant correlation with seasonal BP changes. Multivariate regression analysis revealed that PWV is the only significant predictor for winter-summer SBP changes. CONCLUSIONS: Our results established a feasible link between arterial stiffness and seasonal BP variation. These findings may partly explain higher cardiovascular risk in patients with increased arterial stiffness.     

Low ambulatory blood pressure is associated with lower cognitive function in healthy elderly men

INTRODUCTION: Low blood pressure (BP) has been found to be associated with cerebrovascular damage in the elderly. Studies of the relation of ambulatory BP to cognitive function in elderly persons aged 80 years or above is lacking, however. METHODS: Ninety-seven 81-year-old men from the population study 'Men born in 1914' underwent ambulatory BP monitoring and were given a cognitive test battery, 79 subjects completing all six tests. Low ambulatory systolic blood pressure (SBP) was defined as <130 mmHg and low ambulatory diastolic blood pressure (DBP) as <80 mmHg (corresponding in terms of office BP to approximately <140 and <90 mmHg, respectively). Odds ratios (OR) for lower cognitive function were calculated using a forward stepwise logistic regression model, controlling for confounding factors. RESULTS: Subjects with ambulatory SBP <130 mmHg had higher OR values for daytime (OR 2.6; P=0.037), nighttime (OR 3.6; P=0.032) and 24h (OR 2.6; P=0.038) BP measurements. A lower cognitive function was associated with lower nighttime SBP and DBP levels and lower 24-h mean SBP compared to subjects with higher cognitive function. OR values connected to low nocturnal SBP, had a tendency to be particularly high among subjects on anti-hypertensive drugs (OR 9.1; P=0.067, n.s.). CONCLUSION: Ambulatory SBP levels <130 mmHg and lower nighttime SBP and DBP were associated with lower cognitive function in healthy elderly men. Further investigation is needed to ascertain the effects of the presently recommended treatment goal of <140 mmHg for office SBP also on elderly over 80 years of age.     

Determination of prevalence and control level of hypertension in the community: Hypertension Management Audit Project--Vicenza]

As a part of the "Hypertension Management Audit Project" a random sample of 4070 subjects was drawn from the population aged 35-64 living in the city of Vicenza, in order to assess the prevalence and the level of control of hypertension in the community. 2854 (70.1%) were screened in the first step of the survey. Two blood pressure (BP) reading, height and weight measurements were performed and a short questionnaire filled in. Systolic BP (SBP) and diastolic BP (DBP) were (mean and 95% confidence interval) 143.7 (142.6-144.7) and 88.3 (87.7-88.8) mmHg in males; 137.8 (136.8-138.8) and 84.9 (84.5-85.5) mmHg in females, respectively. The BP value corresponding to the 95 degrees percentile of the cumulative distribution of BP was 180 mmHg for SBP and 105 mmHg for DBP in males; 173 mmHg for SBP and 100 mmHg for DBP in females. Systo-diastolic hypertension was present in 12.3% of the screened population; isolated diastolic hypertension in 9.1%; isolated systolic hypertension in 5.3%; borderline hypertension in 31.6%; severe hypertension (DBP > or = 115 mmHg) was present in 1.9% of females and in 2.2% of males. Prevalence in males was significantly higher with respect to females in all three categories of defined hypertension, but not in borderline hypertension. The second step of the survey involved 849 subjects (29.7% of the screened population) who completed two re-examinations because at the screening they had: 1) history of high BP; 2) BP > or = 160/95 mmHg; 3) ongoing antihypertensive treatment. At the end of the survey, 772 of these subjects (91%) were confirmed as hypertensives (mean BP of six readings > or = 140/90 mmHg and/or taking antihypertensive drugs). Patients aware of their high BP were 78.8%; aware and treated 51.0%; treated and controlled (BP < 140/90 mmHg) 19.1%. All indices of control were significantly higher in female with respect to male patients. Treated patients were significantly older than untreated patients; treated females had significantly lower BP than treated males, whereas no difference was detected between untreated patients; patients unaware of high BP had the highest BP values if compared to treated and untreated patients. This survey reveals a high prevalence of hypertension in the adult population of the city of Vicenza; quality of control shows a moderate improvement if compared to previous studies carried out in our country.     

Comparison of the effect of blood pressure on the development of stroke, acute myocardial infarction, and end-stage renal disease.

Hypertension is a known risk factor for cardiovascular disease, but few epidemiological studies have examined simultaneously the effect of baseline blood pressure on the development of stroke, acute myocardial infarction (AMI), and end-stage renal disease (ESRD). In 1983, a large, community-based mass screening covered about 14% of the adult population in Okinawa, Japan. The total number of people screened was 107,192 (51,122 men, 56,070 women). We had access to two independent registries of end-organ damage: the Co-operative Study Group of Morbidity and Mortality of Cardiovascular Diseases in Okinawa (COSMO) registry for stroke and AMI, and the Okinawa Dialysis Study (OKIDS) registry for ESRD. The total number of people registered was 4,756 with stroke, 1,059 with AMI, and 641 with ESRD during the study period from April 1, 1988, to March 31, 1991. By using the name, sex, birth date, and ZIP code of registrants, we identified those registrants who were screened in 1983 and had developed stroke, AMI, or ESRD. Hypertension was defined as systolic blood pressure (SBP) of 140 mmHg or higher or diastolic blood pressure (DBP) of 90 mmHg or higher. Other readings were regarded as normotensive. The prevalence of hypertension was 35.8% (N=37,299). The cumulative incidence of stroke, AMI, and ESRD was 154, 21, and 19 subjects among those with SBP < or = 119 mmHg, and 1933, 315, and 71 subjects among those with SBP > or = 160 mmHg. Similarly, the incidence of stroke, AMI, and ESRD was 234, 44, and 25 subjects among those with DBP < or = 69 mmHg and 1980, 381, and 364 subjects among those with DBP > or = 110 mmHg. Hypertension was prevalent in the adult population in Okinawa, Japan, and was a significant predictor of stroke, AMI, and ESRD. However, the effect of blood pressure on target organs differed and was more evident in those with stroke than in those with AMI and ESRD.     

Development of hypertension over 6 years in a birth cohort of young middle-aged men: the Cardiovascular Risk Factor Study in southern Sweden (CRISS)

OBJECTIVES: To explore the development of hypertension (HT) in a cohort of young middle-aged men. DESIGN: Prospective birth-cohort study of men surveyed over 6 years. SETTING: Helsingborg County Hospital, Sweden, 1990-97. SUBJECTS: A total of 628 men born in 1953-54, all surveyed at 37, 40 and 43 years of age. MAIN OUTCOME MEASURES: Systolic blood pressure (SBP), diastolic blood pressure (DBP), S-cholesterol, body mass index (BMI), alcohol consumption, ethnicity. HT was defined as SBP > or = 140 mmHg and/or DBP > or = 90 mmHg, or ongoing treatment. Using SBP < 130 mmHg and DBP < 85 mmHg as reference, the odds of conversion to HT in men with high normal blood pressure (BP) (SBP 130-139 mmHg and DBP 85-89 mmHg) was investigated. RESULTS: At age 37, 243 men (39%) had reference BP, 167 (26%) had high normal BP and 218 (35%) were hypertensive. Corresponding numbers at age 40 were 265 (42%), 166 (27%) and 197 (31%); and at age 43, 180 (29%), 142 (22%) and 306 (49%), respectively. High normal BP at baseline was associated with the development of HT both at age 40 (odds ratio (OR)=2.45 confidence interval (CI): 1.42-4.22) and at age 43 (OR=2.46, CI: 1.59-3.80), independent of other cardiovascular disease risk factors and ethnicity. The progression to HT was predicted also by S-cholesterol, alcohol consumption, BMI and weight gain. CONCLUSIONS: Over a short-term period, a substantial proportion of young middle-aged men with high normal BP develop HT with overweight and alcohol consumption as important determinants. These findings have implications for the prevention, screening and medical care of HT in this target population.     

Is masked hypertension an artefact due to the blood pressure measurement method and threshold effects?

From results of office and home measurements of blood pressure (BP), patients can be classified as "hypertensive (HT)", "normotensive (NT)", "office hypertensive (OH)" or "masked hypertensive (MH)" by crossing the classifications obtained from each method. It seems that 9 to 20% of patients could be MH with a prognosis close to HT (SHEAF study). OBJECTIVES: To test the hypothesis that at least one part of the prevalence of MH would be an artefact due to the difference between the methods of measurements (shygmomanometer vs semi-automatic device) and/or due to different definitions of office hypertension (OHT). To determine the impact of different definitions of OHT on the prevalence of MH. METHODS: During the course of a phase IV study, BP was measured with the same semi-automatic device (OMRON 705CP) both at doctor's office (3 measurements at 1-minute intervals) and at home, by the patient himself (3 measurements in the morning and in the evening at 1-minute intervals over the 7 days before the visit). Following definitions were used: Office HT: SBP > or =140 mmHg, DBP > or =90 mmHg, SBP > or =140 mmHg or DBP > or =90 mmHg; Home HT: SBP > or =135 mmHg, DBP> or =85 mmHg, SBP > or =135 mmHg or DBP > or =85 mmHg. Another definition of office HT was used SBP > or =135 mmHg, DBP > or =85 mmHg SBP > or =135 mmHg or DBP > or =85 mmHg. RESULTS: 575 patients were analysed. Results from the two methods of measurements are closed but significantly different (difference for SBP: 3.2 +/- 16.5 mmHg; p < 0.0001; difference for DBP: 1.4 +/- 10.3 mmHg; p = 0.002)     

Predictive factors for masked hypertension within a population of controlled hypertensives

CONTEXT: Prevalence of masked hypertension (MH) is far from negligible reaching 40% in some studies. The SHEAF study (Self measurement of blood pressure at Home in the Elderly: Assessment and Follow-Up) and others clearly showed that masked hypertension (MH) as detected by home blood pressure measurement (HBPM) is associated with poor cardiovascular prognosis. OBJECTIVE: Systematic HBPM to detect MH is not yet routine. The aim of this work is to better define the clinical profile of masked hypertensives within a population with controlled office blood pressure (BP) and the factors associated with a higher prevalence of MH. MATERIALS AND METHODS: BP was measured at the clinic by the doctor and at home by the patient himself. Risk factors for MH were analysed in a cohort of 1150 treated hypertensive patients over the age of 60 (mean age 70 +/- 6.5, 48.9% men) with controlled office BP. (SBP < 140 mmHg and DBP < 90 mmHg). RESULTS: 463 patients (40%) were masked hypertensives (SBP > or = 135 mmHg or DBP > or = 85 mmHg at home). Three parameters were associated with MH (odds ratio OR): office SBP (OR = 1.110), male gender (OR = 2.214) and age (OR = 1.031). Decision trees showed a 130 mmHg SBP was an efficient threshold to propose HBPM with a higher probability to detect MH. Subsequent variables were male gender and age over 70 in males. CONCLUSION: To detect masked hypertension, it would be logical to first of all select patients whose office SBP is between 130 and 140 mmHg.     

Usefulness of the alpha1-blocker doxazosin as a third-line antihypertensive drug.

It has been reported that a substantial majority of hypertensives receive insufficient blood pressure (BP) control. As combination therapy for the treatment of hypertension, Ca channel blockers (CCBs), angiotensin II (AII) receptor blockers (ARBs), and/or AII-converting enzyme (ACE) inhibitors are mainly prescribed, while the efficacy of alpha(1)-blockers in such combination therapy remains unknown. The aim of this study was to investigate the efficacy of a low dose of an alpha(1)-blocker added to combination therapy with CCBs and either ARBs or ACE inhibitors for the treatment of hypertension. Subjects were 41 hypertensive patients (23 women and 18 men, mean age 66+/-12 years) who had been followed at the National Kyushu Medical Center. All patients showed poor BP control despite haven taken a combination of CCBs and ARBs or ACE inhibitors for more than 3 months. Doxazosin at a dose of 1 to 2 mg was added to each treatment regimen. The changes in various clinical parameters, including BP and blood chemistry, following the addition of doxazosin were then evaluated. The mean follow-up period was 170 days. BP decreased from 152+/-14/81+/-12 mmHg to 135+/-14/70+/-11 mmHg after the addition of doxazosin at a mean dose of 1.5 mg/day (p<0.001). When good systolic blood pressure (SBP) control was defined as <140 mmHg, the prevalence of patients with good SBP control increased from 24% to 61% (p<0.01). Similarly, the prevalence of patients with good diastolic blood pressure (DBP) control (<90 mmHg) increased from 78% to 98% (p<0.01). Patients whose SBP decreased more than 10 mmHg (n=25) showed significantly higher baseline SBP, serum total cholesterol and low-density lipoprotein (LDL) cholesterol levels compared to those who showed less SBP reduction (<10 mmHg) (n=16, p<0.01). Comparable BP reductions were obtained between obese (body mass index [BMI] > or =25, DeltaBP at 3 months: -15+/-15/-12+/-9 mmHg, n=18) and non-obese (BMI<25, DeltaBP: -14+/-19/-7+/-8 mmHg, n=23) patients. The results suggest that addition of a low dose of the alpha(1)-blocker doxazosin effectively reduces BP in patients taking CCBs and ARBs or ACE inhibitors. Thus, doxazosin seems to be useful as a third-line antihypertensive drug.     

Tolerability and antihypertensive efficacy of Fosinopril on 24-hr ambulatory blood pressure in hypertensive elderly subjects

The tolerability and antihypertensive efficacy of Fosinopril were assessed in 34 elderly patients with mild to moderate hypertension. Twenty-four-hour ambulatory blood pressure (BP) was measured before and after 5 months of therapy. The patients' mean age was 67 years. At the end of the treatment the mean 24-hour systolic BP (SBP) fell from 153.4 +/- 14 to 137.7 +/- 13 mmHg and the mean 24-hour diastolic BP from 91 +/- 11 to 84.2 +/- 9 mmHg (p < 0.01). The mean decrease in SBP was 15.9 mmHg during the day and 10.3 during the night, and in diastolic BP (DBP) 8.3 mmHg during the day and 10.3 mmHg during the night (p < 0.05 between day and night). There was no significant percentage difference between the SBP and DBP decreases. The mean morning maximum of SBP decreased from 171 +/- 18 to 158 +/- 19 mmHg and there was a reduction in pressure increase between the night and day. The number of SBP peaks over 180 mmHg and 160 mmHg numerically decreased to 20.1% and 37.6% versus baseline, those of DBP over 105 mmHg and 95 mmHg to 41.6% and 58.3% versus baseline, respectively. There were no variations in the blood chemistry parameters and the drug had no adverse side effects. The authors conclude that Fosinopril is useful and well tolerated in the treatment of moderate hypertension in the elderly.     

广州茶涪街社区高血压病的发病率、知晓率及治疗依从性研究

目的 了解广州市荔湾区茶涪街社区高血压病的发病率、知晓情况及依从性,为进一步做好高血压病的预防提供资料。方法随机抽取该社区住户中年龄≥20岁的居民2420名（社区总人口的8．77％）,给予问卷调查并测量血压。判定高血压的标准为：收缩压≥140mmHg和（或）舒张压≥90mmHg。判定单纯收缩期高血压的标准为收缩压≥140mmHg且舒张压〈90mmng。结果该社区20岁以上人员高血压病的发病率为16．12％,其中58．72％的高血压患者没有认识到自己患有高血压。在既往确诊病例中,70．19％的患者对降压治疗无良好的依从性。单纯收缩期高血压的发病率为4．71％。年龄≥60岁的高血压病患者中有43．56％为单纯收缩期高血压。结论广州市荔湾区茶涪街社区高血压病高发。有超过一半的高血压患者对自己患有高血压病不知晓。在老年高血压患者中,单纯收缩期高血压患者不少。大部分患者依从性差,仅少部分患者可将血压控制在理想水平。在社区内定期对居民血压进行普查并进行宣教是必要的。     

Age-varying association between blood pressure and risk of dementia in those aged 65 and older: a community-based prospective cohort study

OBJECTIVES: To assess variation in the association between blood pressure (BP) and risk for dementia across a spectrum of older ages and to examine BP changes before dementia onset. DESIGN: Prospective cohort study. SETTING: A large health maintenance organization in Seattle, Washington. PARTICIPANTS: A cohort of 2,356 members of a large health maintenance organization aged 65 and older who were initially without dementia. MEASUREMENTS: Dementia diagnosis was assessed biennially, and systolic (SBP) and diastolic BP (DBP) were measured at baseline and at four follow-up assessments. Cox proportional hazards models were used to estimate hazard ratios (HRs) for dementia and Alzheimer's disease (AD) associated with baseline BP in different age groups. RESULTS: Within the youngest age group (65-74 at enrollment) a greater risk for dementia was found in participants with high SBP (> or = 160 mmHg) (hazard ratio (HR) = 1.60, 95% confidence interval (CI) = 1.01-2.55) or borderline-high DBP (80-89 mmHg) (HR = 1.59, 95% CI = 1.07-2.35) than for those with normal BP (SBP < 140 mmHg and DBP < 80 mmHg). The dementia risk associated with SBP declined with increasing age (SBP-by-age interaction, P=.01). SBP declined similarly with aging in subjects who developed dementia and those who did not. Thus, in this sample, the association between SBP and dementia risk was not dependent on when BP was measured in relation to onset of dementia. CONCLUSION: High SBP was associated with greater risk of dementia in the young elderly (< 75) but not in older subjects. Adequate control of hypertension in early old age may reduce the risk for dementia.     

Clinical prediction of normotension in borderline hypertensive men--a 10 year study

OBJECTIVE: To investigate 24-h ambulatory blood pressure measurements (ABPM) as a tool for long-term prediction of future blood pressure (BP) status in high normal and low stage 1 hypertensives. DESIGN, SETTING AND PARTICIPANTS: A total of 165 men from a population screening program with diastolic BP (DBP) 85-94 mmHg and a systolic BP (SBP) < 150 mmHg performed a 24-h ABPM. Ten years later, 120 participants (73%) returned for renewed measurements. MAIN OUTCOME MEASURES: Blood pressure status at 10 years. RESULTS: At the 10-year follow-up, 53% of the participants were classified as hypertensive (HT) (BP > or = 140/90 or taking anti-hypertensive medication) and 47% were classified as normotensive (NT) (BP < 140/90 mmHg). There was no significant baseline differences in office SBP levels between those who were normotensive or hypertensive at follow-up (136/91 versus 138/92 mmHg), whereas both SBP and DBP night-time levels were significantly lower in the future normotensives as compared to the future hypertensives (107/69 versus 112/74 mmHg, P < 0.01). Using recommended normalcy night-time ABP levels of < 120/75 mmHg in addition to office BP (140/90) at baseline, over 85% of the subjects were correctly classified provided they met both clinic and ambulatory night-time criteria for HT and NT classification at baseline. CONCLUSION: The use of ABPM in addition to office BP's in patients with borderline hypertension greatly increases the possibility of identifying those individuals who are at a very small risk of developing future hypertension. This could potentially lead to considerable savings in both patient anxiety, physician time and resource consumption.     

Insulin resistance, body mass index, waist circumference are independent risk factor for high blood pressure

OBJECTIVES: The purpose of the present study was to investigate the relationships between blood pressure (BP), insulin resistance as determined by a homeostasis model (HOMA-IR), and body fat distribution. METHODS: Anthropometric indices of adiposity, metabolic variables (fasting serum insulin and a homeostasis model assessment [HOMA] index of insulin sensitivity), BP and several cardiovascular risk factors were measured during a cross sectional survey of 53477 apparently healthy Korean subjects who requested a health status check. Hypertension was defined as a systolic BP > or = 140 mmHg or a diastolic BP > or = 90 mmHg and we excluded the subjects taking BP-lowering medication. RESULTS: Systolic and diastolic blood pressure (SBP, DBP) were positively and significantly associated with age, body mass index, waist circumference, and waist/hip ratio. In addition, SBP and DBP were positively associated with fasting serum insulin levels and the HOMA index. By multiple regression analysis age, waist circumference, body mass index, HOMA index and female sex were independently associated with either increased SBP or DBP. When the population is divided into quintiles according to insulin resistance (measured by HOMA analysis) prevalence of hypertension in the second, third, fourth and fifth quintiles compared to subjects in the first quintile are 1.004(95% CI 0.875-1.152, p = 0.957), 1.200(95% CI 1.052-1.369, p = 0.007), 1.312(95% CI 1.151-1.494 p < 0.001 ), and 1.603(95% CI 1.408-1.825 p < 0.001). In addition age, sex, body mass index and waist circumference were found to be significantly associated with hypertension. CONCLUSION: Our results showed that insulin resistance, body mass index and waist circumference are independent risk factors of a high BP in Koreans.     

Control of blood pressure as measured at home and office, and comparison with physicians' assessment of control among treated hypertensive patients in Japan: First Report of the Japan Home versus Office Blood Pressure Measurement Evaluation (J-HOME) study.

The Japan Home versus Office Blood Pressure Measurement Evaluation (J-HOME) study was conducted to measure the control of blood pressure (BP) as evaluated by home BP measurement among 3,400 patients with essential hypertension (mean age: 66 years; females: 55%) receiving antihypertensive treatment in primary care settings in Japan. The purpose of this first report was to compare characteristics of BP control as measured at home and in the clinic (office) and define their association with BP control as evaluated by physicians. Mean systolic/diastolic BP (SBP/DBP) values were 140/82 mmHg for home BP and 143/81 mmHg for office BP. BP levels were not adequately controlled among approximately 60% of the patients, according to reference values described in the national guidelines (office BP: <140/90 mmHg; home BP: <135/85 mmHg). Even among patients evaluated by physicians as having excellent or fairly good BP control, office and home SBP values were insufficiently controlled in approximately 50%. Although the tendency was more remarkable among older patients, whose recommended target BP levels are higher than those of middle-aged patients in the Japanese Hypertension Society 2000 criteria, office and home BP values were not adequately controlled in approximately 50% of the middle-aged patients whose BP control was evaluated as good. Our findings suggest that an important reason why home and office BP values are not adequately controlled is that physicians approve relatively higher BP levels under treatment, even among middle-aged patients.     

Blood pressure response after two-step exercise as a powerful predictor of hypertension: the Osaka Health Survey

OBJECTIVE : To investigate the relationship between blood pressure at 4 min after exercise using a Master's two-step and the risk for hypertension. DESIGN : Prospective cohort study. SETTING : Work site in Osaka, Japan. PARTICIPANTS : A total of 6557 Japanese men, aged 35-63 years with systolic blood pressure (SBP) < 140 mmHg and diastolic blood pressure (DBP) < 90 mmHg, and no history of hypertension or diabetes at baseline. MAIN OUTCOME MEASURES : Blood pressure was measured by standard techniques, using 160/95 mmHg for diagnosis of hypertension. Normotension was defined as no history of hypertension, and SBP < 130 mmHg and DBP < 85 mmHg. High normal blood pressure was defined as no history of hypertension and SBP >or= 130 and < 140 mmHg or DBP >or= 85 and < 90 mmHg. RESULTS : During the 63 696 person-years follow-up period, we confirmed 660 cases of hypertension. SBP and DBP after exercise were associated with an increased risk for developing hypertension. The multiple-adjusted relative risk for SBP and DBP after exercise were 1.55 per 10 mmHg (confidence interval, 1.42-1.69) and 1.55 per 10 mmHg (confidence interval, 1.42-1.69), respectively. These associations were independent of resting SBP and DBP. Even after stratifying subjects according to blood pressure at rest, SBP or DBP at 4 min after exercise was associated with an increased risk for hypertension in subjects with normotension or high normal blood pressure at rest. CONCLUSIONS : The blood pressure response after exercise with a two-step was associated with an increased risk for hypertension, independently of resting blood pressures.     

Postprandial hypotension predicts all-cause mortality in older, low-level care residents

OBJECTIVES: To evaluate which indices of blood pressure (BP) homeostasis are the strongest predictors of mortality in older low-level-care residents in long-term health facilities. DESIGN: Prospective cohort study. SETTING: Eight long-term healthcare facilities in Canberra, Australia. PARTICIPANTS: A total of 179 randomly selected semi-independent residents aged 65 and older (mean age+/-standard deviation 83.2+/-7.0; 80% women). MEASUREMENTS: Baseline BP levels taken while lying, after standing for 1 and 3 minutes, and sitting before and 1 hour after meal intake were recorded, as well as demographic information, chronic medical conditions, medications, and all-cause mortality during follow-up. Postprandial hypotension (PPH) was defined as a fall in systolic BP (SBP) of 20 mmHg or more 1 hour postmeal while sitting. Orthostatic hypotension (OH) was defined as a fall in SBP of 20 mmHg or more or in diastolic BP (DBP) of 10 mmHg or more within 3 minutes of standing from a supine position. Hypertension was defined as BP greater than 160/90 mmHg at commencement of the study. Mean arterial pressure (MAP) and pulse pressure (PP) were calculated. RESULTS: At baseline, 47% of participants had hypertension, 38% PPH, and 23% OH; PP was 70 mmHg or greater in 54%, and DBP was 65 mmHg or lower in 6%. Over 4.7 years, 97 (54%) participants died. Those who died were significantly older and more likely to have PPH (47% vs 28%) and atrial fibrillation (35% vs 17%) and a significantly greater decrease in BP after meal intake. Mortality rates in those with and without PPH were 145.0 and 98.5 per 1,000 person-years, respectively. Using multivariate Cox proportional hazards models after adjustment for age, sex, presence of atrial fibrillation, Parkinson's disease, and use of diuretics, PPH was the only BP parameter that significantly and independently predicted 4.7-year all-cause mortality (relative risk (RR)=1.79; 95% confidence interval (CI)=1.19-2.68; P=.005). Further adjustment for the presence of OH, hypertension, low resting BP, coronary artery disease, cerebrovascular disease, congestive heart failure, history of syncope, cognitive impairment, cancer, diabetes mellitus, chronic obstructive pulmonary disease, and history of smoking did not reveal any new statistically significant associations. There was a dose-response relationship between postprandial fall in SBP and mortality rates. Absolute postprandial SBP of 120 mmHg or less was also significantly associated with total mortality (RR=1.69, 95% CI=1.04-2.78; P=.04). Low DBP was also associated with increased mortality (RR=1.10, 95% CI=1.01-1.13; P=.03), although this association became nonsignificant in multivariate analysis. CONCLUSION: In older low-level-care residents, PPH is an independent predictor of all-cause mortality with no added predictive value explained by other BP indices: OH, hypertension, PP, MAP.     

Hypertension magnitude and management in the elderly population of Spain

OBJECTIVE: The present study assessed the prevalence, awareness, treatment and control of hypertension among the elderly population of Spain. DESIGN: Based on a nationally representative sample of 4009 individuals aged 60 years, two sets of six blood pressure measurements were obtained by trained observers at each subject's home, using standardized methods. In each set, three mercury-based measurements were alternated with three automated measurements. RESULTS: The mean systolic blood pressure (SBP)/diastolic blood pressure (DBP) was 143/79 mmHg, and the pulse pressure was 64 mmHg. The prevalence rate of hypertension (SBP 140 mmHg, DBP 90 mmHg, or current drug treatment) was 68.3%. No result obtained was sensitive to a particular measurement device. Of the hypertensives, 65% were aware of their condition, 55.3% were treated and 16.3% were controlled. Among treated hypertensives, SBP control (32.2%) was much lower than DBP control (82.3%). Control was lower in men than in women, in older than in younger subjects, and in those with lowest than in those with higher educational levels. About 57% of uncontrolled treated hypertensives were on monotherapy. Weight loss was among the least heeded items of advice (39% among overweight hypertensives). CONCLUSIONS: Hypertension is a major public health problem in elderly Spaniards. Most hypertensives had their hypertension uncontrolled. Greater emphasis should be laid on the most disadvantaged (the older, men, and those with lowest education) in terms of hypertension management, and on reinforcing weight loss and combining drugs for enhanced hypertension control.