Role of ambulatory blood pressure monitoring for the management of hypertension in Asian populations

Out‐of‐clinic blood pressure (BP) measurement, eg, ambulatory BP monitoring, has a strong association with target organ damage and is a powerful predictor of cardiovascular events compared with clinic BP measurement. Ambulatory BP monitoring can detect masked hypertension or various BP parameters in addition to average 24‐hour BP level. Short‐term BP variability assessed by standard deviation or average real variability, diminished nocturnal BP fall, nocturnal hypertension, and morning BP surge assessed by ambulatory BP monitoring have all been associated with target organ damage and cardiovascular prognosis. Recently, the authors compared the degree of sleep‐trough morning BP surge between a group of Japanese and a group of Western European untreated patients with hypertension and found that sleep‐trough morning BP surge in Japanese persons was significantly higher than that in Europeans. Although Asian persons have been known to have a higher incidence of stroke than heart disease, the difference in characteristics of BP indices assessed by ambulatory BP monitoring might be the cause of racial differences in stroke incidence between Asian and Western populations. This review focuses on Asian characteristics for the management of hypertension using ambulatory BP monitoring.     

Task Force II: blood pressure measurement and cardiovascular outcome

OBJECTIVE: To reach a consensus on the prognostic significance of new techniques of automated blood pressure measurement. METHODS: A Task Force on the prognostic significance of ambulatory blood pressure monitoring wrote this review in preparation for the Eighth International Consensus Conference (28-31 October 2001, Sendai, Japan). This synopsis was amended to account for opinions aired at the conference and to reflect the common ground reached in the discussions. POINTS OF CONSENSUS: (1) Prospective studies in treated and untreated hypertensive patients and in the general population have demonstrated that, even after adjusting for established risk factors, the incidence of cardiovascular events is correlated with blood pressure on conventional as well as ambulatory measurement. Ambulatory monitoring, however, significantly refines the prediction already provided by conventional blood pressure measurement. (2) White-coat hypertension is usually defined as an elevated clinic blood pressure in the presence of a normal daytime ambulatory blood pressure. Event-based studies in hypertensive patients have convincingly demonstrated that the risk of cardiovascular disease is less in patients with white-coat hypertension than in those with higher ambulatory blood pressure levels even after controlling for concomitant risk factors. Based on prognostic evidence, white-coat hypertension can now be defined as a conventional blood pressure that is persistently equal to or greater than 140/90 mmHg with an average daytime ambulatory blood pressure of below 135/85 mmHg. The issue of whether or not white-coat hypertension predisposes to sustained hypertension needs further research. (3) There is a growing body of evidence showing that a decreased nocturnal fall in blood pressure (<10% of the daytime level) is associated with a worse prognosis, irrespective of whether night-time dipping is studied as a continuous or a class variable. (4) Intermittent techniques of ambulatory blood pressure monitoring are limited in terms of quantifying short-term blood pressure variability. Proven cardiovascular risk factors such as old age, a higher than usual blood pressure and diabetes mellitus are often associated with greater short-term blood pressure variability. After adjusting for these risk factors, some - but not all - studies have nevertheless reported an independent and positive relationship between cardiovascular outcome and measures of variability of daytime and night-time blood pressure, for example standard deviation. (5) Reference values for ambulatory blood pressure measurement in children are currently based on statistical parameters of blood pressure distribution. In children and adolescents, functional rather than distribution-based definitions of ambulatory hypertension have yet to be developed. (6) Several studies of gestational hypertension have shown that, compared with office measurement, ambulatory blood pressure monitoring is a better predictor of maternal and fetal complications. Pregnancy is a special indication for ambulatory monitoring so that the white-coat effect can be measured and pregnant women are not given antihypertensive drugs unnecessarily. (7) Ambulatory pulse pressure and the QKD interval are measurements obtained by ambulatory monitoring that to some extent reflect the functional characteristics of the large arteries. The QKD interval is correlated with left ventricular mass, and ambulatory pulse pressure is a strong predictor of cardiovascular outcome. (8) Under standardized conditions, the self-measurement of blood pressure is equally as effective as ambulatory blood pressure monitoring in identifying the white-coat effect, but further studies are required to elucidate fully the prognostic accuracy of self-measured blood pressure in comparison with conventional and ambulatory blood pressure measurement. CONCLUSIONS: Ambulatory blood pressure measurement refines the prognostic information provided by conventional blood pressure readings obtained in the clinic or the doctor's office. Longitudinal studies of patients with white-coat hypertension should clarify the transient, persistent or progressive nature of this condition, particularly in paediatric patients, in whom white-coat hypertension may be a harbinger of sustained hypertension and target-organ damage in adulthood. Finally, the applicability, cost-effectiveness and long-term prognostic accuracy of the self-measurement of blood pressure should be evaluated in relation to conventional blood pressure measurement and ambulatory monitoring.     

Masked nocturnal hypertension and target organ damage in hypertensives with well-controlled self-measured home blood pressure.

It has been reported that masked hypertension, a state in which patients show normal clinic blood pressure (BP) but elevated out-of-clinic BP by self-measured home BP, is a predictor of cardiovascular morbidity much like sustained hypertension. In addition, nocturnal BP is closely associated with cardiovascular disease. This might mean that ambulatory and self-measured home BP monitoring each provide independent information. We performed ambulatory BP monitoring, self-measured home BP monitoring, echocardiography and carotid ultrasonography in 165 community-dwelling subjects. We subclassified the patients according to the ambulatory and self-measured home BP levels as follows: in the masked nocturnal hypertension group, the self-measured home BP level was <135/85 mmHg and the ambulatory nocturnal BP level was >or=120/75 mmHg; in the normotensive group, the self-measured home BP level was <135/85 mmHg and the ambulatory nocturnal BP level was <120/75 mmHg. The intima-media thickness (IMT) and relative wall thickness (RWT) were greater in the masked nocturnal hypertension group than in the normotensive group (IMT: 0.76+/-0.20 vs. 0.64+/-0.14 mm, p<0.05; RWT: 0.50+/-0.14 vs. 0.41+/-0.10, p<0.05). Even in hypertensives with well-controlled self-measured home BP, elevated ambulatory nocturnal BP might promote target organ damage. We must rule out masked hypertension using self-measured home BP monitoring, and we might also need to rule out nocturnal masked hypertension using ambulatory BP monitoring.     

Ambulatory blood pressure and cardiovascular risk in chronic kidney disease

Diagnosis of hypertension is critically dependent on accurate blood pressure (BP) measurement, especially in patients with chronic kidney disease (CKD), in whom early antihypertensive treatment is imperative to prevent cardiovascular events. Ambulatory BP monitoring (ABPM) has successfully identified hypertensive patients at increased risk, but its role in management of CKD patients is not well defined. Loss of the nocturnal decline in BP, which is common in CKD, is associated with adverse cardiovascular events. Increased BP variability has been documented as related to worse outcome, and patients on dialysis are subject to marked BP swings. Traditional measurement in the office fails to provide a thorough picture of the 24-hour BP pattern in CKD patients. Thus, ABPM appears mandatory to better define the hypertensive status in these subjects because it provides information on diurnal BP rhythm and variability and allows identification of subjects with white-coat and masked hypertension.     

Ambulatory Blood Pressure Monitoring in Pediatric Renal Transplantation

Hypertension is a common and serious complication after renal transplantation. It is an important risk factor for graft loss and adverse cardiovascular outcomes. Blood pressure (BP) in transplanted children should be measured not only by clinic BP (cBP) measurement, but also by ambulatory blood pressure monitoring (ABPM), because ABPM has distinct advantages over cBP, specifically the ability to reveal nocturnal, masked or white-coat hypertension. These types of hypertension are common in transplanted children (nocturnal hypertension 36?C71?%, masked hypertension 24?C45?%). It may also reveal uncontrolled hypertension in treated children, thereby improving control of hypertension. Regular use of ABPM and ABPM-guided therapy of hypertension may help to decrease cardiovascular and renal target organ damage in transplanted children. Therefore, ABPM should be routinely performed in all transplanted children at least once a year, regardless of the values of cBP.     

Masked hypertension and target organ damage in treated hypertensive patients

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

Ambulatory blood pressure monitoring and type 2 diabetes mellitus

Hypertension is one of the main risk factors for the onset and progression of chronic complications in type 2 diabetes mellitus (DM). Ambulatory blood pressure (BP) monitoring (ABPM) provides a better correlation with target organ lesions than BP obtained in the office. Furthermore, it allows the evaluation of distinct BP parameters such as the 24-h, daytime and nighttime systolic and diastolic BP means, BP loads and the absence of nocturnal drop of BP, as well as the identification of white-coat and masked hypertension. DM patients have higher daytime and nighttime BP means than non-DM patients. In addition, one third of normotensive type 2 DM patients have masked hypertension, which is associated with an increase in albuminuria and in left ventricle wall thickness. On the other hand, the prevalence and effect of white-coat hypertension in type 2 DM patients have not yet been properly evaluated. The absence of nocturnal drop of BP does not add information to the 24 h, daytime or nighttime BP measurements, but the nighttime BP means seem to be relevant in DM retinopathy. In conclusion, BP determination by ABPM allows better patient risk stratification for the development of DM chronic complications and is an essential instrument for effective BP control in these patients.     

Is It Possible to Manage Hypertension and Evaluate Therapy Without Ambulatory Blood Pressure Monitoring?

In the management of patients with hypertension, blood pressure (BP) has been traditionally measured in the physician's office. The contribution of ambulatory BP monitoring (ABPM) to the management of hypertensive patients has been increasingly recognized through clinical and epidemiological research. Ambulatory BP monitoring can enhance the ability to detect white-coat or masked hypertension, determine the absence of nocturnal dipping status, and evaluate BP control in patients on antihypertensive therapy. Recently, the United Kingdom National Clinical Guideline Centre published guidelines for the clinical management of primary hypertension in adults, recommending the routine use of ABPM to make the initial diagnosis of hypertension. While the advantages of ABPM are apparent from a clinical perspective, its use should be considered in relation to the cost of the equipment, data evaluation, and staff training as well as the possible inconvenience to the patient. In this review, we summarize the clinical importance of ABPM and discuss the current guidelines for establishing the diagnosis of hypertension.     

Masked hypertension in obstructive sleep apnea syndrome

BACKGROUND: Ambulatory blood pressure (BP) monitoring (ABPM) detects subjects with normal clinic but high ambulatory 24-h BP, that is, masked hypertension. METHODS: One hundred and thirty newly diagnosed obstructive sleep apnea syndrome (OSAS) patients, free of recognized cardiovascular disease were included (111 men, age = 48 +/- 1 years, BMI = 27.6 +/- 0.4 kg/m, respiratory disturbance index (RDI = 42 +/- 2/h). Clinic BP, 24-h ABPM, baroreflex sensitivity (BRS), echocardiography and carotid intima-media thickness (IMT) were assessed. RESULTS: Forty-one patients (31.5%) were normotensive, 39 (30.0%) exhibited masked hypertension, four (3.1%) white-coat hypertension and 46 (35.4%) hypertension. Significant differences were found between normotensive, masked hypertensive and hypertensive patients in terms of BRS (10.5 +/- 0.8, 8.0 +/- 0.6 and 7.4 +/- 0.4 ms/mmHg, respectively, P < 0.001), carotid IMT (624 +/- 17, 650 +/- 20 and 705 +/- 23 microm, respectively, P = 0.04) and left ventricular mass index (37 +/- 1, 40 +/- 2 and 43 +/- 1 g/height2.7, respectively, P = 0.003). A clinic systolic BP more than 125 and a diastolic BP more than 83 mmHg led to a relative risk (RR) of 2.7 and a 90% positive predictive value for having masked hypertension. CONCLUSION: Masked hypertension is frequently underestimated in OSAS and is nearly always present when clinic BP is above 125/83 mmHg.     

Prognostic significance of ambulatory blood pressure.

Measurements of ambulatory blood pressure as an adjunct to casual/clinic blood pressure measurements are currently widely used for the diagnosis and treatment of hypertension. There have been many recent reports on the clinical significance of ambulatory blood pressure. The relationship between ambulatory blood pressure level and target-organ damage uniformly demonstrated on a cross-sectional basis that average ambulatory blood pressure is correlated to target-organ damage. The main limitation of cross-sectional studies, however, is the difficulty of drawing inferences about causality from them. We have been monitoring the prognosis of the Ohasama population and reported that ambulatory blood pressure is superior to casual blood pressure for the prediction of mortality. We also observed that the daytime ambulatory blood pressure is a better predictor for cardiovascular mortality in the general population than is the night-time ambulatory blood pressure. It is widely recognized that casual/clinic blood pressure is less representative of the true blood pressure level than is average ambulatory blood pressure. One reason that clinic blood pressure is a poor predictor of prognosis is that clinic blood pressure includes several biases, including the white-coat effect. For determining white-coat hypertension, measurement of blood pressure in a non-medical setting such as ambulatory blood pressure monitoring is indispensable. We examined the prognostic significance for mortality of white-coat hypertension and reversed white-coat hypertension (clinic blood pressure 相似文献   

The association of nocturnal hypertension and nondipping blood pressure with treatment‐resistant hypertension: The Jackson Heart Study

Apparent treatment‐resistant hypertension (aTRH), nocturnal hypertension, and nondipping blood pressure (BP) have shared risk factors. The authors studied the association between aTRH and nocturnal hypertension and aTRH and nondipping BP among 524 black Jackson Heart Study participants treated for hypertension. Nocturnal hypertension was defined by mean nighttime systolic BP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping BP was defined by mean nighttime to daytime systolic BP ratio >0.90. aTRH was defined by mean clinic systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg with three medication classes or treatment with four or more classes. The risk for developing aTRH associated with nondipping BP and nocturnal hypertension was estimated. After multivariable adjustment, participants with aTRH were more likely to have nocturnal hypertension (prevalence ratio, 1.20; 95% confidence interval, 1.03–1.39) and nondipping (prevalence ratio, 1.25; 95% confidence interval, 1.09–1.43). Over a median 7.3 years of follow‐up, nocturnal hypertension and nondipping BP at baseline were not associated with developing aTRH after adjustment.     

Blood pressure abnormalities in children with chronic kidney disease

OBJECTIVES: Disturbances of blood pressure (BP) rhythms have been demonstrated in patients with various degrees of renal impairment. The purpose of this study was to determine the prevalence of BP abnormalities in children with chronic kidney disease (CKD) and evaluate possible factors associated with nocturnal BP abnormalities. METHODS: 42 children between 2 and 19 years of age with CKD stages 2-5 completed 24-h ambulatory BP monitoring. RESULTS: The percentage of patients with daytime hypertension was less than 10% but rates were higher at nighttime where 14% had systolic and 24% diastolic hypertension. A similar percentage of patients had a BP load >50%. BP abnormalities that were not evident in clinic BP readings were identified in 49% of the participants. The nocturnal BP dipping percentage tended to decrease as the estimated glomerular filtration rate decreased. Proteinuria was significantly associated with nocturnal BP nondipping. CONCLUSION: 24-h ambulatory BP monitoring may provide additional insight into hypertension in pediatric patients as early as CKD stage 2. Several BP abnormalities were identified that were not evident in casual BP measurements including nocturnal hypertension, elevated BP load, and nocturnal BP nondipping.     

When and how to use self (home) and ambulatory blood pressure monitoring

This American Society of Hypertension position paper focuses on the importance of out-of-office blood pressure (BP) measurement for the clinical management of patients with hypertension and its complications. Studies have supported direct and independent associations of cardiovascular risk with ambulatory BP and inverse associations with the degree of BP reduction from day to night. Self-monitoring of the BP (or home BP monitoring) also has advantages in evaluating patients with hypertension, especially those already on drug treatment, but less is known about its relation to future cardiovascular events. Data derived from ambulatory BP monitoring (ABPM) allow the identification of high-risk patients, independent from the BP obtained in the clinic or office setting. While neither ABPM nor self-BP monitoring are mandatory for the routine diagnosis of hypertension, these modalities can enhance the ability for identification of white-coat and masked hypertension and evaluate the extent of BP control in patients on drug therapy.     

When and how to use self (home) and ambulatory blood pressure monitoring

This American Society of Hypertension position paper focuses on the importance of out-of-office blood pressure (BP) measurement for the clinical management of patients with hypertension and its complications. Studies have supported direct and independent associations of cardiovascular risk with ambulatory BP and inverse associations with the degree of BP reduction from day to night. Self-monitoring of the BP (or home BP monitoring) also has advantages in evaluating patients with hypertension, especially those already on drug treatment, but less is known about its relation to future cardiovascular events. Data derived from ambulatory BP monitoring (ABPM) allow the identification of high-risk patients, independent from the BP obtained in the clinic or office setting. While neither ABPM nor self-BP monitoring are mandatory for the routine diagnosis of hypertension, these modalities can enhance the ability for identification of white-coat and masked hypertension and evaluate the extent of BP control in patients on drug therapy.     

Reproducibility of nocturnal blood pressure fall in early phases of untreated essential hypertension: a prospective observational study

A number of studies have shown that a smaller than normal nocturnal blood pressure (BP) decrease is associated with cardiovascular disease. However, no large prospective studies have examined the reliability of nocturnal dipping within individuals. The aim of our study was to investigate the short-term variability of nocturnal BP fall in a large cohort of patients with recently diagnosed essential hypertension. In all, 414 uncomplicated never treated hypertensive patients referred to our outpatient hypertension hospital clinic (mean age 46+/-12 years; 257 M, 157 F) prospectively underwent: (1). repeated clinic BP measurements; (2). routine examinations recommended by WHO/ISH guidelines; and (3). ambulatory BP monitoring (ABPM) twice within a 4-week period. Dipping pattern was defined as a reduction in the average systolic and diastolic BP at night greater than 10% compared to average daytime values. Overall, 311 patients (75.1%) showed no change in their diurnal variations in BP. Of the 278 patients who had a dipping pattern on the first ABPM, 219 (78.7%) confirmed this type of profile on the second ABPM, while 59 (21.3%) showed a nondipping pattern. Among 37 dipper patients with >20% of nocturnal systolic BP decrease (extreme dippers), only 16 (43.2%) had this marked fall in BP on the second ABPM. Of the 136 patients who had a nondipping pattern on the first ABPM, 92 (67.6%) confirmed their initial profile on the second ABPM, while 44 (32.4%) did not. Patients with reproducible nondipping profile were older (48+/-12 years) than those with reproducible dipping profile (44+/-12 years, P<0.05). These findings indicate that: (1). short-term reproducibility of nocturnal fall in BP in untreated middle-aged hypertensives is rather limited: overall, one-fourth of patients changed their initial dipping patterns when they were studied again after a few weeks; (2). this was particularly true for extreme dipping and nondipping patterns; (3). abnormalities in nocturnal BP fall, assessed by a single ABPM, cannot be taken as independent predictors of increased cardiovascular risk.     

The Role of Out-of-Clinic Blood Pressure Measurements in Preventing Hypertension

Purpose of Review

One of the possible strategies for preventing hypertension is identifying high-risk people and then implementing lifestyle modifications or therapeutic interventions. Out-of-clinic blood pressure measurements, either home or ambulatory blood pressure monitoring, may identify people with early blood pressure elevation or white-coat or masked hypertension and potentially help prevent hypertension. In this review, we will summarize the evidence on the role of out-of-clinic blood pressure measurements in preventing hypertension either from prehypertension or high normal or elevated blood pressure, or from white-coat or masked hypertension.

Recent Findings

Early blood pressure elevation, either termed as prehypertension or as high normal or elevated blood pressure, identified by home blood pressure monitoring was associated with a 3- to 5-fold risk of sustained hypertension. White-coat and masked hypertension, identified by either home or ambulatory blood pressure monitoring, was associated with a 2- to 4-fold risk of sustained hypertension.

Summary

Out-of-office blood pressure measurements may potentially help prevent hypertension. However, to prove reversibility, controlled clinical trials are required.

     

Cardiovascular risk in white-coat and sustained hypertensive patients

We compared cardiovascular outcome between patients with white-coat and sustained hypertension who had previously participated in the Ambulatory Blood Pressure Monitoring and Treatment of Hypertension (APTH) trial. Baseline characteristics, including office and ambulatory blood pressure (BP), were measured during the 2-month run-in period of the APTH trial. During follow-up, information on the occurrence of major cardiovascular events (death, myocardial infarction, stroke and heart failure), achieved office BP and treatment status was obtained. At entry, 326 patients had sustained hypertension (daytime ambulatory BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic) and 93 had daytime ambulatory BP below these limits and were classified as white-coat hypertensives. During 2088 patientyears of follow-up (median follow-up 5.3 years), all major cardiovascular events ( n = 22) occurred in the patients with sustained hypertension (rate 12.7 per 1000 patient-years, p = 0.02 for between-group difference). Furthermore, multiple Cox regression confirmed that after adjustment for important covariables, daytime ambulatory BP - but not office BP at entry - significantly and independently predicted cardiovascular outcome. After additional adjustment for office BP, daytime ambulatory BP still predicted the occurrence of major cardiovascular events. Although white-coat hypertension was less frequently associated with antihypertensive drug treatment during follow-up, it carried a significantly better prognosis than sustained hypertension.     

The impact of the degree of obesity on the discrepancies between office and ambulatory blood pressure values in youth

OBJECTIVES: Obesity is an increasingly frequent problem among children and adolescents, and may lead to blood pressure (BP) increase. The aim of the present study was to assess the prevalence of hypertension, white-coat and masked hypertension in obese adolescents making systematic use of both office BP and 24-h ambulatory BP measurement. The impact of different degrees of obesity on BP and heart rate variability was also investigated. METHODS: Office and ambulatory BP were obtained in 285 overweight and obese Caucasian adolescents (11-18 years old) and in 180 age- and sex-matched controls. The extent of obesity was quantified using body mass index z score. RESULTS: A significant positive relationship between body mass index z score and both office and ambulatory systolic BP was found after adjusting for age and height in both boys and girls. Obese youths had not only higher BP levels, but also higher BP variability compared with controls. Among obese youths, 20.8% had abnormal BP conditions, 6.6% were white-coat hypertensives, 9.2% were masked hypertensives and 5% were sustained hypertensives. CONCLUSIONS: The prevalence of these abnormal BP conditions, which can be identified thanks to ambulatory BP monitoring, further emphasizes the usefulness of this diagnostic tool in obese youths.     

Nocturnal pulse rate correlated with ambulatory blood pressure and target organ damage in patients with chronic kidney disease

The relationship between resting pulse rate (PR) and the occurrence of hypertension and cardiovascular (CV) mortality has been described in the general population. Few studies have examined the relationship between ambulatory PR, ambulatory blood pressure (BP), and target organ damage (TOD) in patients with chronic kidney disease (CKD). A total of 1509 patients with CKD were recruited in our hospital. Ambulatory blood pressure monitoring (ABPM) over a 24‐hours period was performed and referenced with clinical data in this cross‐sectional study. TOD was measured by estimated glomerular filtration rate (eGFR), left ventricular hypertrophy (LVH), and carotid intima‐media thickness (cIMT). Univariate and multivariate analyses were used to evaluate the relationship between PR, BP, and TOD. The percentage of male patients was 58.3% with a mean age of 44.6 ± 16.2 years. Nocturnal PR rather than 24‐hours PR or daytime PR was an independent risk factor for clinical hypertension, 24‐hours hypertension, BP dipper state, poor renal function, and LVH. In addition, the authors found that nighttime PR >74 beats/min (bpm) group was independently associated with clinical hypertension, 24‐hours hypertension, day and night hypertension, nondipping BP, lower eGFR, and LVH when compared with nighttime PR <64 bpm group. Furthermore, 1:1 propensity score matching between PR ≤74 bpm group and PR >74 bpm group was performed. Multivariate analyses indicated nighttime PR >74 bpm remained independently associated with clinical hypertension, daytime and nighttime hypertension, and LVH. An increased nocturnal PR is associated with TOD, higher BP, and nondipping BP in patients with CKD.     

Diagnosis of hypertension in children and adolescents based on home versus ambulatory blood pressure monitoring

OBJECTIVE: To investigate the usefulness of home blood pressure measurements in comparison with ambulatory monitoring in the diagnosis of sustained, white-coat hypertension and masked hypertension in children and adolescents. SUBJECTS AND METHODS: One hundred and two subjects, referred for elevated blood pressure, were assessed with clinic (two visits), home (6 days) and awake ambulatory blood pressure measurements [64 boys, mean age 12.8 +/- 2.9 (SD) years, range 6-18 years]. RESULTS: Office hypertension was diagnosed in 38 subjects, ambulatory hypertension in 31 and home hypertension in 23 (P = 0.07). On the basis of clinic and ambulatory blood pressure, 52% of subjects were normotensive, 20% hypertensive, 18% had white-coat hypertension and 11% masked hypertension, whereas on the basis of clinic and home blood pressure, 55, 15, 23 and 8%, respectively. There was an agreement between ambulatory and home blood pressure in the diagnosis of hypertension in 82 cases (80%). When a 5-mmHg gray zone of diagnostic uncertainty was applied above and below the diagnostic thresholds, there were only eight cases with clinically important disagreement. By taking ambulatory blood pressure as the reference method for the diagnosis of hypertension, the sensitivity, specificity and positive and negative predictive values of home blood pressure were 55, 92, 74 and 82%, respectively, for the diagnosis of white-coat hypertension 89, 92, 70 and 98%, respectively, and for masked hypertension 36, 96, 50 and 93%, respectively. CONCLUSION: In children and adolescents, there is a reasonable agreement between home and ambulatory blood pressure measurements as diagnostic methods in hypertension. Home blood pressure appears to be a useful diagnostic test in this population, particularly for the detection of white-coat hypertension.