Prevalence and clinical outcomes of white‐coat and masked hypertension: Analysis of a large ambulatory blood pressure database

The aim of this study was to analyze prevalence and clinical outcomes of the following clinical conditions: normotension (NT; clinic BP < 140/90 mm Hg; 24‐hour BP < 130/80 mm Hg), white‐coat hypertension (WCHT; clinic BP ≥ 140 and/or ≥90 mm Hg; 24‐hour BP < 130/80 mm Hg), masked hypertension (MHT; clinic BP < 140/90 mm Hg; 24‐hour BP ≥ 130 and/or ≥80 mm Hg), and sustained hypertension (SHT; clinic BP ≥ 140 and/or ≥90 mm Hg; 24‐hour BP ≥ 130 and/or ≥80 mm Hg) in a large cohort of adult untreated individuals. Systematic research throughout the medical database of Regione Lazio (Italy) was performed to estimate incidence of myocardial infarction (MI), stroke, and hospitalizations for HT and heart failure (HF). Among a total study sample of 2209 outpatients, 377 (17.1%) had NT, 351 (15.9%) had WCHT, 149 (6.7%) had MHT, and 1332 had (60.3%) SHT. During an average follow‐up of 120.1 ± 73.9 months, WCHT was associated with increased risk of hospitalization for HT (OR 95% CI: 1.927 [1.233‐3.013]; P = .04) and HF (OR 95% CI: 3.449 [1.321‐9.007]; P = .011). MHT was associated with an increased risk of MI (OR 95% CI: 5.062 [2.218‐11.550]; P < .001), hospitalization for HT (OR 95% CI: 2.553 [1.446‐4.508]; P = .001), and for HF (OR 95% CI: 4.214 [1.449‐12.249]; P = .008). These effects remained statistically significant event after corrections for confounding factors including age, BMI, gender, smoking, dyslipidaemia, diabetes, and presence of antihypertensive therapies.     

Reproducibility of masked uncontrolled hypertension detected through home blood pressure monitoring

Masked uncontrolled hypertension (MUCH) is an entity described in treated hypertensive subjects, where office blood pressure (BP) is well controlled and out‐of‐office BP is elevated. It has been related to a higher cardiovascular risk. However, the reproducibility of MUCH has been scarcely studied. In this study, we aimed to determine the reproducibility of MUCH detected through home blood pressure monitoring (HBPM). Two sets of measurements were performed in hypertensive adults under stable treatment with a 1‐week interval. Each set of measurements included three office BP readings and a 4‐day HBPM with duplicate readings in the morning, afternoon, and evening (the same validated oscillometric device was employed in both settings). We determined the percentage of agreement regarding the presence of MUCH in the two sets of measurements and quantified such agreement through the Cohen's kappa coefficient (κ), its 95% confidence interval, and P value. We included 105 patients (median age 58.6 [IQR 45.6‐67.2] years old, 53.4% men). MUCH prevalence on at least one occasion was 22.3% (95% CI: 15.2‐31.5). The reproducibility of MUCH was scant: κ = 0.19 (95% CI: 0.0002‐0.38), P = 0.02, due to the poor reproducibility of the office BP component of MUCH in comparison with the home BP component: κ = 0.21 (95% CI: 0.03‐0.39), P = 0.01 vs κ = 0.48 (95% CI 0.29‐0.67), P < 0.001, respectively. In conclusion, the reproducibility of MUCH detected through HBPM is minimal, mainly due to the poor reproducibility of office BP measurements. An HBPM‐based strategy for the management of patients with MUCH may be more adequate in terms of cardiovascular morbidity and mortality.     

Left ventricular cardiac geometry and ambulatory blood pressure in children

Limited information is available regarding the relationship between ambulatory blood pressure monitoring (ABPM) and cardiac geometry in hypertensive children. ABPM and 2D‐echocardiography were retrospectively reviewed in children and adolescents <21 years old with primary hypertension. A total of 119 participants (median age 15.0 [IQR 12, 16] years) with hypertension were included. Left ventricular hypertrophy was diagnosed in 39.5% of participants. Normal geometry was found in 47.1%, concentric remodeling (CR) in 13.4%, concentric hypertrophy (CH) in 15.1%, and eccentric hypertrophy (EH) in 24.4% of children. After adjustment for age, sex, and body mass index z‐score, awake systolic blood pressure (BP) index (BPi) (OR 1.07, 95% CI: 1.001‐1.14, P = 0.045), awake diastolic BPi (OR 1.04, 95% CI: 1.00‐1.09, P = 0.048), awake systolic BP load (OR 1.02, 95% CI: 1.000‐1.04, P = 0.047), and sleep systolic BP load (OR 1.02, 95% CI: 1.001‐1.04, P = 0.03) were directly associated with CH. No ABPM parameters were significant predictors of EH. In conclusion, ABPM parameters were found to be independent predictors of cardiac geometry, specifically CH.     

Increased risk of cognitive impairment and more severe brain lesions in hypertensive compared to non‐hypertensive patients with cerebral small vessel disease

Although cerebral small vessel disease (SVD) is traditionally associated with aging and hypertension (HT), there are patients exhibiting sporadic SVD, free of HT. We aimed to investigate the differences in clinical and neuroradiological presentation in SVD patients in reference to the presence of HT as a risk factor (RF). Vascular RF, cognitive and functional status were evaluated in a cohort of 424 patients. Patients were classified in two groups based on the presence of HT. Severity of vascular lesions was assessed using 1.5 T magnetic resonance imaging with Age‐Related White Matter Changes scale total score (tARWMC) and Fazekas scale periventricular (PV) and deep subcortical (DS) scores. No difference between groups in age and sex distribution was noted. In univariate analysis, HT was associated with vascular cognitive impairment (vCI) (OR 2.30, 1.53‐3.45, P < 0.0001), functional status (OR 1.47, 1.11‐1.95, P = 0.007), depression (OR 2.13, 1.23‐3.70, P = 0.007), tARWMC (OR 1.10, 1.05‐1.16 95% CI, P < 0.0001), Fazekas PV score (OR 1.34, 1.08‐1.67 95% CI, P = 0.008), Fazekas DS score (OR 1.95, 1.44‐2.63 95% CI, P < 0.0001) and total number of lacunes (OR 1.10, 1.02‐1.18 95% CI, P = 0.009). Multivariate logistic regression analysis indicated that HT was an independent RF for vCI (OR 1.74, 1.09‐2.76 95% CI, P = 0.020) and higher Fazekas DS score (OR 1.57, 1.11‐2.22 95% CI, P = 0.011). The Kaplan‐Meier curve of estimates of survival of SVD patients without vCI revealed a higher proportion of patients with HT progressing to vCI over time when compared to HT‐free cases. In patients with sporadic SVD, HT is a contributing factor to worse clinical outcomes and neuroradiological presentation.     

Blood pressure variability at different time periods within first 24 hours after admission and outcomes of acute ischemic stroke

This study discusses the association between blood pressure (BP) variability at different time periods within first 24 hours after admission and the functional outcome in acute ischemic stroke (AIS). We observed BP variability within first 24 hours after admission and evaluated the association between BP variability at different time periods (4 am ‐8 am , 10 am ‐2 pm , 4 pm ‐8 pm , 10 pm ‐2 am ) and the functional outcome in AIS. National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were applied to evaluate short‐ (7 days) and long‐term functional outcome. The 24 hours after admission and early morning (4 am ‐8 am ) systolic blood pressure (SBP) variability were associated with poor outcome at day 7 (adjusted OR = 1.567, 95% CI = 1.076‐2.282; adjusted OR = 1.507, 95% CI = 1.028‐2.209, respectively). Compared with the impact of the 24‐hour BP variability on long‐term functional outcome, the early morning SBP was proved to be a strongly independent predictor for functional outcome at 3 months (adjusted OR = 1.505, 95% CI = 1.053‐2.152), 6 months (adjusted OR = 1.560, 95% CI = 1.048‐2.226), and 12 months (adjusted OR = 1.689, 95% CI = 1.104‐2.584). The BP variability in other time period groups was shown to have no influence on functional outcome. In addition, attempts to explain early morning BP variability with baseline characteristic factors at admission found that baseline SBP is the most influential (2.71%) factor. About 95.87% of the SBP variability in early morning was unexplained. In our study, early morning SBP variability is the strongest independent predictor for functional outcome in (AIS) patients, and baseline SBP after admission should be monitored as a control indicator of early morning SBP variability in the treatment of AIS patients.     

Effect of antihypertensive medications on thrombolysis therapy and outcomes in acute ischemic stroke patients

There are concerns that specific risk factors may alter the benefits of thrombolysis in stroke patients with controlled contraindications including hypertension. The objective of this study was to evaluate the association between clinical risk factors and outcomes in ischemic stroke patients that received thrombolysis therapy pretreated with antihypertensive medications. Using data obtained from a stroke registry, a non‐randomized retrospective data analysis was conducted on patients with the primary diagnosis of acute ischemic stroke with hypertension pretreated with antihypertensive medications. The association between clinical risk factors and functional ambulatory outcome was determined using logistic regression while odd ratios (OR) were used to predict the odds of achieving improved ambulatory outcome in thrombolysis treatment status. Improved or poor functional ambulatory outcome was considered as the end point in our analysis. A total of 4665 acute ischemic stroke patients were identified, of whom 1446 (31.0%) were eligible for thrombolysis, while 3219 were not, and 595 received rtPA, of whom 288 were on antihypertensive medications, while 233 were not. In the rtPA group with antihypertensive (anti‐HTN) medication, only NIHSS score (OR = 1.094, 95% CI, 1.094‐1.000, P = 0.005) was associated with improved functional outcome while patients with congestive heart failure (OR = 0.385, 95% CI, 0.385‐0.159, P = 0.035) and patients with a history of previous TIA (OR = 0.302, 95% CI, 0.302‐0.113, P = 0.017) were more likely to be associated with poor functional outcomes. Congestive heart failure and TIA are independent predictors of functional outcomes in stroke patients pretreated with antihypertensive medications prior to thrombolysis 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.     

Longitudinal control of blood pressure among a cohort of Ghanaians with hypertension: A multicenter,hospital‐based study

There are limited data on factors associated with longitudinal control of blood pressure (BP) among Ghanaians on antihypertensive treatment. We sought to evaluate associations between prospective BP control and 24 putative factors within socio‐demographic, biological, and organizational domains. This is a cohort study involving 1867 (65%) adults with hypertension and 1006 (35%) with both hypertension and diabetes mellitus at five public hospitals. Clinic BP was measured every 2 months for 18 months of follow‐up. A multivariate logistic regression analysis was fitted via generalized linear mixed models to identify factors associated with clinic BP ≥ 140/90 mm Hg at each clinic visit during follow‐up. Mean age of study participants was 58.9 ± 16.6 years and 76.8% were females. Proportions with controlled BP increased from 46.3% at baseline to 59.8% at month 18, P < .0001. Eight factors with adjusted OR (95% CI) associated prospectively with uncontrolled BP were male gender: 1.37 (1.09‐1.72), secondary education: 1.32 (1.00‐1.74), non‐adherence to antihypertensive treatment: 1.03 (1.00‐1.06), fruit intake: 0.94 (0.89‐1.00), duration of hypertension diagnosis: 1.01 (1.00‐1.02), hypertension with diabetes mellitus: 2.05 (1.72‐2.46), number of antihypertensive medications: 1.63 (1.49‐1.79), and estimated glomerular filtration rate (mL/min rise): 0.82 (0.76‐0.89). Interventions aimed at addressing modifiable factors associated with poorly controlled BP would be critical in prevention of cardiovascular diseases among Ghanaians.     

Antihypertensive drug use and blood pressure control among stroke survivors in the United States: NHANES 2003‐2014

Understanding the patterns of antihypertensive drug use and blood pressure (BP) control among stroke survivors in the “real‐world” setting is important to identify gaps in treatment and control, if any. The objective of our study was to assess trends and patterns in antihypertensive drug use and BP control among stroke survivors in the United States. We performed a retrospective cross‐sectional analysis of the 2003‐2014 National Health and Nutrition Examination Survey (NHANES). Stroke and hypertension diagnoses were self‐reported. Information regarding the use of antihypertensive drugs was collected during an in‐person interview. Measurement of BP was performed by trained medical professionals in mobile examination centers. A total 1244 adult stroke survivors (equating to 6 232 215 stroke survivors nationwide) were identified, of which 956 had hypertension. Antihypertensive drug use increased from 2003 (79.5%) to 2014 (92.2%; P for trend < 0.001). The prevalence of drug use was lower (52%) among survivors aged 20‐39 years compared with older age groups. Use of ≥2 antihypertensive drugs was prevalent (63.8%), but diuretics alone or in combination with angiotensin‐converting enzyme inhibitors were underutilized (22.4%). More than one‐third of the survivors were not at BP goal (ie, BP < 140/90 mm Hg). Males were more likely to attain BP goal than female stroke survivors (odds ratio [OR] = 2.02; 95% CI: 1.34‐3.05). Our findings suggest that despite improvements in antihypertensive drug use in the recent years, BP is not adequately controlled in a significant proportion of stroke survivors. Further research focusing on understanding the reasons for unmet BP goal in stroke survivors is needed.     

Risk factors and clinical outcomes of pediatric liver transplant recipients with post‐transplant lymphoproliferative disease in a multi‐ethnic Asian cohort

Background

We aimed to evaluate clinical characteristics, risk factors, and disease outcomes for liver transplant recipients (LTR) with post‐transplant lymphoproliferative disease (PTLD) at our center.

Methods

Retrospective review of data of all pediatric LTR (1991‐2015) was conducted.

Results

The overall incidence of PTLD was 16.4% (18/110), the majority (13/18) were early lesions, while 3/18 were polymorphic/monomorphic PTLD. The risk factors significant on univariate analysis were as follows: mean age (years) at transplant (1.66 vs 4.76, P = .006); age <2 years at transplant (odds ratio [OR] 3.53 [95% confidence interval [CI]: 1.16‐10.73], P = .026); cytomegalovirus (CMV) primary infection (OR 11.39 [95% CI: 3.44‐37.7], P < .001); recipient CMV seronegativity (OR 7.50 [95% CI: 2.02‐27.78], P = .003); presence of CMV end‐organ disease (OR 4.00 [95% CI: 1.22‐13.16], P = .022); Chinese ethnicity; and higher mean duration of intravenous ganciclovir prophylaxis. In multivariate analysis, CMV primary infection (OR 5.22 [95% CI: 1.25‐21.87], P = .024), CMV seronegativity (OR 5.91 [95% CI: 1.13‐30.90, P = .035]), and having acute cellular rejections (ACR) prior to PTLD (OR 5.53 [95% CI: 1.43‐21.48, P = .013]) were significant risk factors for PTLD, with the latter two factors having a synergistic effect in increasing PTLD risk in a stratified analysis. The final multivariate model in predicting the risk of PTLD, utilizing CMV primary infection, recipient CMV seronegativity, and ACR before PTLD as predictive variables, was statistically significant (likelihood ratio chi square statistic = 25.18, P < .0001 with df = 3).

Conclusions

We report a unique clinicopathologic and risk factor profile in our cohort—early lesion PTLD accounts for the majority and the incidence of monomorphic PTLD remains low. In addition, we show a synergism between CMV naivety and ACR on PTLD risk, a higher prevalence of gastrointestinal manifestations, and a lack of significant association with Epstein‐Barr virus seronegativity.     

Association of vitamin D serum levels and its common genetic determinants,with severity of liver fibrosis in genotype 1 chronic hepatitis C patients

Lower 25‐hydroxyvitamin D [25(OH)D] serum levels have been associated with the severity of liver fibrosis in genotype 1 chronic hepatitis C patients (G1CHC). In addition, a recent genome‐wide study identified genetic variants (rs12785878, near dehydrocholesterol reductase, DHCR7; rs10741657, near CYP2R1; and rs7041, near vitamin D‐binding protein, GC) affecting 25(OH)D serum levels in healthy populations. We aimed to assess the association between vitamin D serum levels and its genetic determinants, with the severity of liver fibrosis. Two hundred and sixty patients with biopsy‐proven G1CHC were consecutively evaluated. The 25(OH)D serum levels were measured by high‐pressure liquid chromatography. All patients were genotyped for DHCR7 rs12785878, CYP2R1 rs10741657 and GC rs7041 single nucleotide polymorphisms. DHCR7 GG genotype (P = 0.003) and the severity of fibrosis (P = 0.03) were independent factors associated with lower 25(OH)D serum levels in multiple linear regression analysis. Interestingly, 53.8% (7/13) of patients with DHCR7 GG genotype had severe liver fibrosis, compared to 27.1% (67/247) of those with DHCR7 TT/TG genotype (P = 0.03). By multivariate logistic regression analysis, severe fibrosis was independently associated with older age (OR, 1.056; 95% CI, 1.023–1.089, P = 0.001), low cholesterol (OR, 0.984; 95% CI, 0.974–0.994, P = 0.002), high triglycerides (OR, 1.008; 95% CI, 1.002–1.015, P = 0.01), low 25(OH)D (OR, 0.958; 95% CI, 0.919–0.999, P = 0.04), DHCR7 GG genotype (OR, 4.222; 95% CI, 1.106–16.120; P = 0.03), moderate–severe steatosis (OR, 2.588; 95% CI, 1.355–4.943; P = 0.004) and moderate–severe necroinflammatory activity (grading) (OR, 2.437; 95% CI, 1.307–4.763; P = 0.001). No associations were found between liver fibrosis and both CYP2R1 and GC genotypes. In patients with G1CHC, GG homozygosis for DHCR7 gene and lower 25(OH)D levels are independently associated with the severity of liver fibrosis.     

Blood pressure variability and outcome in acute severe stroke: A post hoc analysis of CHASE—A randomized controlled trial

The influence of blood pressure variability (BPV) on outcomes in patients with severe stroke is still largely unsettled. Using the data of CHASE trial, the authors calculated the BPV during the acute phase and subacute phase of severe stroke, respectively. The primary outcome was to investigate the relationship between BPV and 90‐day modified Rankin scale (mRS) ≥ 3. The BPV was assessed by eight measurements including standard deviation (SD), mean, maximum, minimum, coefficient of variation (CV), successive variation (SV), functional successive variation (FSV), and average real variability (ARV). Then, the SD of SBP was divided into quintiles and compared the quintile using logistic regression in three models. The acute phase included 442 patients, and the subacute phase included 390 patients. After adjustment, six measurements of BPV during the subacute phase rather than acute phase were strongly correlated with outcomes including minimum (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.69‐0.99, p = .037), SD (OR: 1.10, 95% CI: 1.03‐1.17, p = .007), CV (OR: 1.12, 95% CI: 1.03‐1.23, p = .012), ARV (OR: 1.13, 95% CI: 1.05‐1.20, p < .001), SV (OR: 1.09, 95% CI: 1.04‐1.15, p = .001), and FSV (OR: 1.12, 95% CI: 1.05‐1.19, p = .001). In the logistic regression, the highest fifth of SD of SBP predicted poor outcome in all three models. In conclusion, the increased BPV was strongly correlated with poor outcomes in the subacute phase of severe stroke, and the magnitude of association was progressively increased when the SD of BP was above 12.     

Association between HIV infection and attenuated diurnal blood pressure rhythm in untreated hypertensive individuals*

Objective

Hypertensive cardiovascular complications are more closely associated with ambulatory blood pressure (ABP), particularly the attenuated diurnal blood pressure (BP) rhythm (i.e. a fall in systolic blood pressure <10% during the night compared with the day), than with casual BP. The aim of the study was to assess the ABP pattern in an HIV‐infected cohort in which hypertension was newly diagnosed.

Methods

ABP over 24 h was compared between 77 newly diagnosed, untreated hypertensive HIV‐positive individuals and 76 HIV‐uninfected untreated hypertensive controls.

Results

More HIV‐infected subjects had an attenuated ABP rhythm with a reduced nocturnal fall than HIV‐negative hypertensive control subjects (60 vs. 33%, respectively; P=0.001). The dipping pattern was observed despite newly diagnosed hypertension, a low prevalence of microalbuminuria, and the absence of signs of overt kidney disease. Furthermore, the prevalence of nondipping in the HIV‐infected subjects was independent of combination antiretroviral treatment. Multiple logistic regression analysis with dipping pattern as the dependent variable showed that HIV status was an independent predictor of nondipping BP [P=0.002; odds ratio (OR) 0.33; 95% confidence interval (CI) 0.17–0.66]; casual SBP (P=0.37; OR 1.001; 95% CI 0.99–1.04) and microalbuminuria (P=0.39; OR 1.56; 95% CI 0.57–4.28) were not associated with dipping pattern.

Conclusions

The prevalence of a nondipping BP pattern in HIV‐infected subjects with newly diagnosed hypertension who had not received antihypertensive treatment was high and significantly greater than in hypertensive control subjects.     

Effect of baseline resistance‐associated substitutions on the efficiency of glecaprevir/pibrentasvir in chronic hepatitis C subjects: A meta‐analysis

The effect of baseline resistance‐associated substitutions on the sustained virologic response at 12 weeks in chronic hepatitis C subjects has drawn considerable attention. However, it has been reported that the relationship between such substitutions and sustained virologic response at 12 weeks in chronic hepatitis C subjects is variable in different treatments. This meta‐analysis was performed to evaluate this relationship in subjects treated with glecaprevir/pibrentasvir. A systematic literature search up to May 2020 was done, and 17 studies were identified with 6501 chronic hepatitis C subjects. They were reporting relationships between baseline resistance‐associated substitutions and sustained virologic response at 12 weeks in chronic hepatitis C subjects treated with glecaprevir/pibrentasvir. The odds ratio (OR) with 95% confidence intervals (CIs) was calculated to evaluate the prognostic role of baseline resistance‐associated substitutions on the sustained virologic response at 12 weeks in chronic hepatitis C subjects treated with glecaprevir/pibrentasvir using the dichotomous method with a random or fixed‐effect model. Lower sustained virologic response at 12 weeks post‐treatment in chronic hepatitis C subjects was significantly related to baseline resistance‐associated substitutions in overall genotypes (OR, 0.03; 95% CI, 0.15‐0.61, P < .001), baseline NS5a resistance‐associated substitutions in genotype‐1 (OR, 0.16; 95% CI, 0.04‐0.57, P = .005), baseline resistance‐associated substitutions in genotype‐3 (OR, 0.14; 95% CI, 0.05‐0.38, P < .001), and baseline NS5a resistance‐associated substitutions in genotype‐3 (OR, 0.21; 95% CI, 0.09‐0.49, P < .001). Sustained virologic response at 12 weeks in chronic hepatitis C subjects was not significantly related to the baseline NS5a resistance‐associated substitutions (OR, 0.61; 95% CI, 0.17‐2.22, P = .45), and baseline resistance‐associated substitutions in genotype‐1 (OR, 0.35; 95% CI, 0.12‐1.088, P = .07). In conclusion, the impact of baseline resistance‐associated substitutions on the sustained virologic response at 12 weeks in chronic hepatitis C subjects treated with glecaprevir/pibrentasvir may have a great prognostic effect, especially in genotype‐3 as a tool to improve treatment prediction. Chronic hepatitis C subjects with baseline resistance‐associated substitutions may have an independent risk relationship with poor treatment outcomes. This relationship forces us to recommend testing prior to treatment selection to avoid any possible treatment failure.     

Association of interarm blood pressure difference with cardio‐cerebral vascular disease: A community‐based,cross‐sectional study

Interarm blood pressure difference (IAD) is a risk factor for peripheral artery disease and cardio‐cerebral vascular disease (CCVD). The current study examines the association of IAD with stroke and coronary heart disease in a Chinese community. A cross‐sectional study was conducted in Pudong New Area in Shanghai, China. A total of 10 657 residents aged 15 years and older were randomly selected through three‐stage sampling. Volunteers had systolic and diastolic blood pressure (BP) measured in both arms at recruitment, and IAD was defined in both arms as the absolute difference in BP. Medical records of study participants were reviewed by investigators to confirm measurements. Logistic regression models were used to assess the association between systolic interarm blood pressure difference (sIAD) and diastolic interarm blood pressure difference (dIAD) with stroke and coronary heart disease. Compared with dIAD <5 mm Hg, the multivariate adjusted odds ratio (OR) of stroke prevalence was 1.357 (95% CI 0.725‐2.542, P = 0.034) for dIAD ≥20 mm Hg and 1.702 (95% CI1.025‐2.828, P = 0.040) for dIAD between 15 and 19 mm Hg, and the multivariate adjusted OR of coronary heart disease prevalence was 1.726 (95% CI 1.093‐2.726, P = 0.019) for dIAD ≥20 mm Hg and 1.498 (95% CI 0.993‐2.261, P = 0.044) for dIAD between 15 and 19 mm Hg. The relationship between cardio‐cerebral vascular disease and dIAD was significant in a Chinese community population. Further cohort studies are needed to investigate the association of different levels of IAD with the incidence of cardiovascular and cerebrovascular diseases and subsequent mortality.     

Determinants of exaggerated difference in morning and evening blood pressure measured by self-measured blood pressure monitoring in medicated hypertensive patients: Jichi Morning Hypertension Research (J-MORE) Study

BACKGROUND: Morning blood pressure (BP) surge in ambulatory BP monitoring was a risk factor for stroke in our previous study. We studied the determinants of the morning minus evening systolic BP difference (ME difference) in self-measured BP monitoring, as a possible risk factor for stroke in medicated hypertensive patients. METHODS: Nine hundred sixty-nine hypertensive outpatients receiving stable antihypertensive drug treatment were studied using self-measured BP monitoring in the morning and evening. RESULTS: The ME difference ranged from -37.3 to 53.3 mm Hg (mean 7.9 mm Hg). The highest quartile (Q4) of the ME difference group (>15.0 mm Hg) had older age (68.0+/-9.8 years v 66.2+/-10.3 years, P=.01) and higher prevalence of men (48.3% v 39.9%, P=.02), regular alcohol drinkers (34.7% v 26.0%, P=.01) and beta-blocker use (26.9% v 19.9%, P=.03) than the other quartile groups (Q1 to Q3), whereas there was no significant difference in the average of morning and evening (ME average) BP. In logistic regression analysis controlling for ME average and other confounding factors, independent risks for Q4 of ME difference were older age (10 years older: odds ratio [OR] 1.21, P=.01, 95% confidence interval (CI) 1.04-1.42), regular alcohol drinker (OR 1.51, P=.04, 95% CI 1.01-2.26), and beta-blocker use (OR 1.50, P=.02, 95% CI 1.06-2.12). CONCLUSIONS: Older age, beta-blocker use, and regular alcohol drinking were significant determinants of the exaggerated ME difference in medicated hypertensive patients.     

Effects of antihypertensive treatment in Asian populations: A meta-analysis of prospective randomized controlled studies (CARdiovascular protectioN group in Asia: CARNA)

To examine the effects of antihypertensive treatment on cardiovascular disease (CVD) in Asian populations, we systematically evaluated prospective randomized studies carried out in Asia (1991–2013). We identified 18 trials with 23,215 and 21,986 hypertensive patients in the intervention (ie, strict blood pressure [BP] lowering or add-on treatment) and reference groups, respectively (mean age, 65 years; follow-up duration, 3.2 years). Analysis was performed through 1) first subgroup: eight trials that compared active antihypertensive treatment with placebo or intensive with less intensive BP control and 2) second subgroup: 10 trials that compared different antihypertensive treatments. In the first subgroup analysis, BP was reduced from 160.3/87.3 mm Hg to 140.2/78.4 mm Hg in the intervention group with a −6.7/−2.2 mm Hg (P < .001) greater BP reduction than the reference group. Compared with the reference group, the intervention group had a lower risk of composite CVD events (odd ratio [OR], 0.73; 95% confidence interval [CI], 0.66–0.81), myocardial infarction (OR, 0.79; 95% CI, 0.63–1.0), stroke (OR, 0.71; 95% CI, 0.63–0.80), and CVD mortality (OR, 0.81; 95% CI, 0.68–0.97; all P ≤ .05). In the second subgroup analysis, no difference was found for any outcome between renin-angiotensin blockers and calcium-channel blockers or diuretics. The meta-regression line among the 18 trials indicated that a 10 mm Hg reduction in systolic BP was associated with a reduced risk for composite CVD events (−39.5%) and stroke (−30.0%). Our meta-analysis shows a benefit when a BP target of less than 140/80 mm Hg is achieved in Asian hypertensives. BP reduction itself, regardless of BP lowering agents, is important for achieving CVD risk reduction.     

Blood pressure means rather than nocturnal dipping pattern are related to complications in Type 2 diabetic patients

Aim To determine whether systolic and diastolic blood pressure (BP) means, during ambulatory BP monitoring (ABPM), are more strongly correlated with microvascular complications and echocardiographic structural alterations than night‐time/daytime (N/D) BP ratio. Methods A cross‐sectional study was conducted in 270 Type 2 diabetes mellitus (DM) outpatients who underwent clinical and laboratory investigations, urinary albumin excretion rate (UAER) determination, echocardiography, office and 24‐h ABPM (Spacelabs 90207). Results UAER, after multivariate adjustments, was associated with office BP (systolic: R²_a 0.162, P < 0.001; diastolic: R²_a 0.124, P < 0.001) and ABPM (24‐h systolic: R²_a 0.195, P < 0.001; 24‐h diastolic: R²_a 0.197, P < 0.001) but not with N/D BP ratios (systolic: R²_a 0.062, P = 0.080; diastolic: R²_a 0.063, P = 0.069). Similar results were observed for echocardiographic parameters. The presence of retinopathy was associated only with night‐time BP values [systolic means: odds ratio (OR) 1.13, 95% confidence interval (CI) 1.03–1.24 and diastolic means: OR 1.21, CI 1.04–1.40 and N/D diastolic BP ratio > 0.90, OR 3.21, CI 1.65–6.25]. Conclusions UAER and echocardiographic structural alterations had more consistent correlations of a greater magnitude with systolic BP means than with N/D BP ratios. The nocturnal BP values appear to be more relevant for diabetic retinopathy. BP measurement in patients with Type 2 DM should take into account the 24‐h period rather than focusing on a specific time span of BP homeostasis.     

Sleep Blood Pressure Self‐Measured at Home as a Novel Determinant of Organ Damage: Japan Morning Surge Home Blood Pressure (J‐HOP) Study

To study whether sleep blood pressure (BP) self‐measured at home is associated with organ damage, the authors analyzed the data of 2562 participants in the J‐HOP study who self‐measured sleep BP using a home BP monitoring (HBPM) device, three times during sleep (2 am , 3 am , 4 am ), as well as the home morning and evening BPs. The mean sleep home systolic BPs (SBPs) were all correlated with urinary albumin/creatinine ratio (UACR), left ventricular mass index (LVMI), brachial‐ankle pulse wave velocity (baPWV), maximum carotid intima‐media thickness, and plasma N‐terminal pro‐hormone pro–brain‐type natriuretic peptide (NTproBNP) (all P<.001). After controlling for clinic SBP and home morning and evening SBPs, associations of home sleep SBP with UACR, LVMI, and baPWV remained significant (all P<.008). Even in patients with home morning BP <135/85 mm Hg, 27% exhibited masked nocturnal hypertension with home sleep SBP ≥120 mm Hg and had higher UACR and NTproBNP. Masked nocturnal hypertension, which is associated with advanced organ damage, remains unrecognized by conventional HBPM.     

Hypertension Control and Its Correlates Among Adults Attending a Hypertension Clinic in Tanzania

Hypertension control rates are low in sub‐Saharan Africa. Population‐specific determinants of blood pressure (BP) control have not been adequately described. The authors measured BP and conducted interviews to determine factors associated with BP control among adults attending a hypertension clinic in Tanzania. Three hundred adults were enrolled. BP was controlled in 47.7% of patients at the study visit but only 28.3% over three consecutive visits. Demographic and socioeconomic factors were not associated with control. Obesity and higher medication cost were associated with decreased control. Their effect was mediated through adherence. Good knowledge of (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.0–6.1; P=.047), attitudes towards (OR, 2.7; 95% CI, 1.0–7.1; P=.04), and practices concerning (OR, 5.4; 95% CI, 2.3–13.0; P<.001) hypertension were independently associated with increased control, even after adjusting for mediation through adherence. Good adherence had the strongest association with control (OR, 14.6; 95% CI, 5.8–37.0; P<.001). Strategies to reduce hypertension‐related morbidity and mortality in sub‐Saharan Africa should target these factors. Interventional studies of such strategies are needed.