Severe inpatient hypertension prevalence and blood pressure response to antihypertensive treatment

Severe hypertension (HTN) that develops during hospitalization is more common than admission for HTN; however, it is poorly studied, and treatment guidelines are lacking. Our goal is to characterize hospitalized patients who develop severe HTN and assess blood pressure (BP) response to treatment. This is a multi‐hospital retrospective cohort study of adults admitted for reasons other than HTN who developed severe HTN. The authors defined severe inpatient HTN as the first documented BP elevation (systolic BP > 180 or diastolic BP > 110) at least 1 hour after admission. Treatment was defined as receiving antihypertensives (intravenous [IV] or oral) within 6h of BP elevation. As a measure of possible overtreatment, the authors studied the association between treatment and time to mean arterial pressure (MAP) drop ≥ 30% using the Cox proportional hazards model. Among 224 265 hospitalized adults, 10% developed severe HTN of which 40% were treated. Compared to patients who did not develop severe HTN, those who did were older, more commonly women and black, and had more comorbidities. Incident MAP drop ≥ 30% among treated and untreated patients with severe HTN was 2.2 versus 5.7/1000 person‐hours. After adjustment, treated versus. untreated patients had lower rates of MAP drop ≥ 30% (hazard rate [HR]: 0.9 [0.8, 0.99]). However, those receiving only IV treatment versus untreated had greater rates of MAP drop ≥ 30% (1.4 [1.2, 1.7]). Overall, the authors found that clinically significant MAP drop is observed among inpatients with severe HTN irrespective of treatment, with greater rates observed among patients treated only with IV antihypertensives. Further research is needed to phenotype inpatients with severe HTN.     

Blood pressure and mortality risk in older people: comparison between African Americans and whites

OBJECTIVES: To determine the risk from hypertension for all-cause mortality in a racially mixed sample of community-dwelling older adults. DESIGN: Baseline blood pressure was assessed between 1985 and 1986 in a sample of persons 65 years of age and older from five counties of the Piedmont of North Carolina (N = 4,162). All-cause mortality was monitored annually over the subsequent 6 years as part of the Established Populations for Epidemiologic Studies of the Elderly (EPESE) sponsored by the National Institute on Aging. SETTING: Eighteen percent of all respondents in the sample had a systolic blood pressure of > 160 (17% for whites and 18% for African Americans) and 16% had a diastolic blood pressure of >90 (14% for whites and 20% for African Americans). During the 6 years of follow-up, 29% of the sample died (with no difference in mortality rates between whites and African Americans). PARTICIPANTS: 4,000 community-dwelling people age 65 years and older; 1,846 were white and 2,154 were African American. MEASUREMENTS: Systolic and diastolic blood pressure and all-cause mortality. RESULTS: Systolic blood pressure positively related to mortality during the 6 years of follow-up (relative risk = 1.05). Among whites the relationship of diastolic pressure to mortality was nonlinear, with those at the upper and lower ends of the distribution at increased risk. Among African Americans, diastolic pressure was unrelated to mortality. The analyses were controlled for age; gender; education; body mass index (BMI); smoking history; taking a medication to manage blood pressure; a history of cancer, diabetes mellitus, heart attack, or stroke; poor subjective health; impaired functional status; and cognitive impairment. CONCLUSIONS: The findings confirm that among older adults there is a significant relationship overall between systolic blood pressure and mortality over 6 years of follow-up in both whites and African Americans. Diastolic pressure was a risk factor for whites only.     

Monotherapy treatment with chlorthalidone or amlodipine in the systolic blood pressure intervention trial (SPRINT)

This post hoc analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) examined the performance of chlorthalidone (C) versus amlodipine (A) monotherapies. ANOVA was used to analyze the differences in systolic blood pressure (SBP) response between C and A. Logistic regression was used to examine monotherapy failure (adding a second antihypertensive agent or switching to a different antihypertensive agent) rates. Four hundred ninety‐one participants were treated with C monotherapy (n = 210, mean dose = 22 mg/day) or A monotherapy (n = 281, mean dose = 7 mg/day). There was a significant difference in mean SBP reduction between the C and A monotherapies at the third visit (higher reduction with A, adjusted p = .018). Unadjusted analysis showed a higher failure with C in the standard treatment group. Although the average SBP at failure was higher and above the 140 mm Hg cutoff that indicated monotherapy failure with A (142.60) compared with C (138.40), more participants on C failed despite having SBP below the 140 cutoff. This was probably due to decisions made by the investigative teams to change the antihypertensive regimen, because, in their opinion, the clinical picture required it. After adjusting for baseline characteristics, C had higher failure than A only in the standard treatment group (1.64 odds ratio [OR], 95% CI 1.06–2.56, p = .028). A sub‐analysis including participants who had never used antihypertensive treatment before randomization had similar results (2.57 OR, 95% CI 1.34–5.02, p = .004). Overall, in SPRINT chlorthalidone was associated with higher monotherapy failure than amlodipine in the standard treatment group because of decisions of the investigative teams.     

琥珀酸美托洛尔缓释片治疗轻中度原发性高血压的临床研究

目的观察选择性β1受体阻滞剂琥珀酸美托洛尔缓释片(Betaloc ZOK,简称倍他洛克缓释片)治疗轻中度原发性高血压的疗效和安全性。方法30例轻中度原发性高血压患者服用倍他洛克缓释片47.5~95 mg/d 8周。治疗前后测量坐位血压,监测肝肾功能、血糖、血脂,记录药物不良反应。结果治疗8周后,收缩压和舒张压分别下降(13.70±17.70)mm Hg和(11.03±9.85)mm Hg(P均<0.001),26/30例患者血压<140/90 mm Hg,降压达标率为86.7%。心率、肝功能和血糖、血脂指标治疗前后差异无统计学意义。血肌酐显著下降[(0.92±0.2)mg/dlvs.(0.79±0.20)mg/dl,P<0.001]。结论倍他洛克缓释片能有效治疗轻中度原发性高血压,无明显不良反应,患者依从性良好。     

Excessive pulse pressure response to standing in community population with orthostatic systolic hypertension

The postural change of pulse pressure (PP) in the persons with orthostatic hypertension (OHT) is unclear. This study included 2849 (65.0 ± 9.3 years) community participants. Blood pressures (BPs) in supine and standing positions were measured. The differences between upright and supine BP and PP were recorded as ΔBP and ΔPP. The criteria for OHT was ΔBP ≥10 mm Hg, for orthostatic hypotension (OH) was ≤−10 mm Hg and for orthostatic normotension (ONT) was −9 to 9 mm Hg. Fasting blood lipids and glucose were measured. The supine SBP of the sOHT group were similar to that of sONT group (140.9 ± 20.2 mm Hg vs 138.2 ± 19.7 mm Hg), but significantly lower than that of sOH group (151.9 ± 19.2 mm Hg; P < .05). Their PPs were 65.3 ± 15.9, 62.8 ± 14.7, and 71.1 ± 15.1 mm Hg, respectively, and with the similar group difference like SBP. When the position changed from supine to standing, the sOHT group showed PP rise, while sOH and sONT groups showed PP reduction (3.8 ± 7.1 mm Hg vs −17.0 ± 8.5 mm Hg and −5.8 ± 6.6 mm Hg; both P < .05). Thus, the standing PP in the sOHT group was significantly higher than in the sONT (69.1 ± 18.0 mm Hg vs 57.0 ± 15.8 mm Hg; P < .05) and in the sOH (54.2 ± 15.2 mm Hg; P < .05) groups. The postural PP profile varies with the postural responses of SBP. The sOHT group has obviously increased PP and significantly higher standing PP compared with the sONT group.     

Association of West African ancestry and blood pressure control among African Americans taking antihypertensive medication in the Jackson Heart Study

African Americans have a wide range of continental genetic ancestry. It is unclear whether racial differences in blood pressure (BP) control are related to ancestral background. The authors analyzed data from the Jackson Heart Study, a cohort exclusively comprised of self‐identified African Americans, to assess the association between estimated West African ancestry (WAA) and BP control (systolic and diastolic BP < 140/90 mm Hg). Three nested modified Poisson regression models were used to calculate prevalence ratios for BP control associated with the three upper quartiles, separately, vs the lowest quartile of West African ancestry. The authors analyzed data from 1658 participants with hypertension who reported taking all of their antihypertensive medications in the previous 24 hours. WAA was estimated using 389 ancestry informative markers and categorized into quartiles (Q1: <73.7%, Q2: >73.7%‐81.0%, Q3: >81.0%‐86.3%, and Q4: >86.3%). The proportion of participants with controlled BP in the lowest‐to‐highest WAA quartile was 75.2%, 76.1%, 76.6%, and 74.4%. The prevalence ratios (95% CI) for controlled BP comparing Q2, Q3, and Q4 to Q1 of WAA were 1.00 (0.93‐1.08), 1.02 (0.94‐1.10), and 0.99 (0.91‐1.07), respectively. Among African Americans in the Jackson Heart Study taking antihypertensive medication, BP control rates did not differ across quartiles of WAA.     

Addition of chlorthalidone to slow-release nifedipine in the treatment of arterial hypertension: A controlled study versus placebo

Summary The use of calcium antagonists and diuretics in combination for treatment of hypertension is controversial.In a single-blind study 16 patients (8 men, 8 women, age range 39 to 62 years) with primary hypertension of mild to moderate degree were given slow-release nifedipine 20 mg twice daily for 6 weeks, thereafter either chlorthalidone 25 mg (Group A) or placebo (group B) daily was randomly added for a further 6-week period.Blood pressure (BP), heart rate, plasma renin activity (PRA), aldosterone, and 24 hour urinary electrolytes were evaluated.Nifedipine decreased supine BP from 159/92±16/8 to 151/89±10/6 mmHg in group A and from 162/94±20/12 to 145/85±14/6 mmHg in group B. A further fall to 139/84±7/6 mmHg (p<.05) was observed after addition of chlorthalidone.PRA significantly increased with combined treatment compared to baseline (3.3±0.8 to 9.9±3.3 ng/ml/hr;p<0.05). A slight reduction of 24-hour urinary calcium was observed after the addition of chlorthalidone.These data indicate that the combination of nifedipine and chlorthalidone might be beneficial in the treatment of arterial hypertension.     

Meal-induced blood pressure fall in patients with isolated morning hypertension

Abstract

We aimed to determine a possible association between isolated morning hypertension (IMH) and meal-induced blood pressure (BP) fall in adult treated hypertensive patients who underwent home BP measurements. A total of 230 patients were included, median age 73.6, 65.2% women. After adjusting for age, sex, number of antihypertensive drugs, office and home BP levels, the association between IMH and meal-induced BP fall was statistically significant. In conclusion, meal-induced BP fall and IMH detected through home blood pressure monitoring (HBPM) are independently associated in hypertensive patients. The therapeutic implications of such observation need to be clarified in large-scale prospective studies.     

A double-blind comparison of once-daily metoprolol controlled-release and atenolol in the treatment of Chinese patients with mild to moderate hypertension

Summary The efficacy and tolerability of controlled-release metoprolol (metoprolol CR/ZOK), 100–200 mg, and atenolol, 50–100 mg, once daily was compared in Chinese patients with mild to moderate essential hypertension. The study was of a randomized, double-blind, two-way crossover design. The active treatment periods lasted 4 weeks each and were preceded by a 4-week placebo run-in period. The two double-blind phases were separated by a 2-week washout period on placebo. Blood pressures and heart rates were measured at rest in each 2-week visit and during exercise at the end of each treatment period. Twenty-four patients (M/F=14/10) were valid for efficacy analysis. Their ages ranged from 39 to 68, with a mean of 53.5 years. The rest supine blood pressure and heart rate before active treatment was 160±15/106±6 mmHg and 75±14 beats/min (mean±SD), respectively. A responder was defined as exhibiting a supine diastolic blood pressure 90 mmHg or a supine diastolic blood pressure reduction of at least 10% of the baseline level. Both agents had high response rate: 88% and 92% of all patients responded to metoprolol CR/ZOK and atenolol, respectively. Both active treatments considerably reduced resting systolic and diastolic blood pressures and heart rates as compared with baseline (p<0.001), respectively. With controlled-release metoprolol, a more pronounced ₁ blockade was obtained than with atenolol, which was expressed as a significant reduction in exercise-induced heart rate at the highest comparable workload compared with placebo (p<0.05). These findings are compatible with those reported from western populations.     

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

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

Blood pressure variability and target organ damage regression in hypertension

The study by Triantafyllidi et al. supports the view that regression of subclinical cardiac damage requires an effective 24‐hour blood pressure (BP) control along with a reduction in BP variability and suggests that the assessment of BPV and its modifications during the course of therapy may be an useful approach in predicting the beneficial effects of treatment on cardiac structure. However, some aspects and limitations of this study require caution in drawing firm conclusions. So, further investigation is needed to determine if reduction of BPV is actually associated with a regression in cardiac and extracardiac organ damage to identify which which classes of antihypertensive drugs are most effective in reducing BPV, and to elucidate whether those treatments provide additional clinical benefit, independent of the conventional BP targets.     

Diagnosis of hypertension: Ambulatory pediatric American Heart Association/European Society of Hypertension versus blood pressure load thresholds

The agreement between the traditionally‐used ambulatory blood pressure (ABP)‐load thresholds in children and recently‐recommended pediatric American Heart Association (AHA)/European Society of Hypertension (ESH) ABP thresholds for diagnosing ambulatory hypertension (AH), white coat hypertension (WCH), and masked hypertension (MH) has not been evaluated. In this cross‐sectional study on 450 outpatient participants, the authors evaluated the agreement between previously used ABP‐load 25%, 30%, 40%, 50% thresholds and the AHA/ESH thresholds for diagnosing AH, WCH, and MH. The American Academy of Pediatrics thresholds were used to diagnose office hypertension. The AHA threshold diagnosed ambulatory normotension/hypertension closest to ABP load 50% in 88% (95% CI 0.79, 0.96) participants (k 0.67, 95% CI 0.59, 0.75) and the ESH threshold diagnosed ambulatory normotension/hypertension closest to ABP load 40% in 86% (95% CI 0.77, 0.94) participants (k 0.66, 95% CI 0.59, 0.74). In contrast, the AHA/ESH thresholds had a relatively weaker agreement with ABP load 25%/30%. Therefore, the diagnosis of AH was closest between the AHA threshold and ABP load 50% (difference 3%, 95% CI ‐2.6%, 8.6%, p = .29) and between the ESH threshold and ABP load 40% (difference 4%, 95% CI ‐2.1%, 10.1%, p = .19) than between the AHA/ESH and ABP load 25%/30% thresholds. A similar agreement pattern persisted between the AHA/ESH and various ABP load thresholds for diagnosing WCH and MH. The AHA and ESH thresholds diagnosed AH, WCH, and MH closest to ABP load 40%/50% than ABP load 25%/30%. Future outcome‐based studies are needed to guide the optimal use of these ABP thresholds in clinical practice.     

Basal blood pressure variability and reactivity of blood pressure to emotional stress in essential hypertension

Summary Blood pressure variability under basal conditions and blood pressure reactivity to emotional stress were studied in 38 hypertensives and 13 normotensives.Systolic basal blood pressure variability correlated with systolic blood pressure reactivity. Variability increased with higher basal blood pressure. Thus in the hypertension group the blood pressure variability was greater than in the normotension group. Besides, the hypertension group showed a greater reactivity of systolic blood pressure to emotional stress, too. An influence of age on basal blood pressure, blood pressure variability, and reactivity could be evaluated; but no influence of sex on these parameters was detected.The results indicate that variability and reactivity of blood pressure can be referred to a common central nervous blood-pressure-regulating mechanism. As both parameters are increased in hypertension, a greater lability of blood pressure must be assumed. This greater lability may be attributed to a stronger neurogenic influence or to structural changes of peripheral blood vessels.     

唑吡坦对睡眠障碍高血压患者血压以及血压形态的影响

目的研究唑吡坦对睡眠障碍原发性高血压（高血压）患者血压以及血压形态的影响。方法选择2008年10月至2011年4月在广州市花都区人民医院心血管内科住院和部分门诊就诊,诊断为高血压伴睡眠障碍且为非杓型血压的患者91例为研究对象,根据电脑随机数字表法分为两组：强化治疗组46例,联合治疗组45例。强化治疗组口服苯磺酸左旋氨氯地平2．5mg早、晚各1次;联合治疗组早上口服苯磺酸左旋氨氯地平2．5mg,晚上口服酒石酸唑吡坦10mg。治疗4周后行动态血压监测,评价血压及血压形态;行阿森斯失眠量表（Athensinsomniascale,AIS）自测,评估睡眠质量。结果两组基线资料比较,差异无统计学意义（P〉0．05）。经4周治疗,强化治疗组白昼收缩压以及黑夜收缩压均较治疗前明显降低,收缩压下降率（ASBP％）明显升高,差异有统计学意义（P〈O．05）。联合治疗组黑夜收缩压以及黑夜舒张压均较治疗前明显降低,收缩压下降率及舒张压下降率（ADBP％）均明显升高,差异有统计学意义（R0．05）。治疗后联合治疗组白昼收缩压、收缩压下降率及舒张压下降率显著高于强化治疗组,差异有统计学意义（P〈0．05）。联合治疗组非杓型血压纠正为杓型血压的比例明显高于强化治疗组[47．7％（21／44）us.22．7％（10／44）,P〈0．05]。结论对于伴有睡眠障碍的非杓型高血压患者,联合使用唑吡坦,能够显著降低夜间血压,纠正非杓型血压形态。     

Role of blood pressure response to provocative tests in the prediction of hypertension inadolescents

To assess the value of exercise stress testing and of mentalstress as predictors of hypertension, we studied 130 normotensivemales 14–18 years of age. Sixty-five had at least onehypertensive parent (SHT), while 65 had normotensive parents(SNT). Systolic (SBP) and diastolic (DBP) blood pressure, rate-pressureproduct (RPP) and 12-lead ECG were recorded at rest, throughoutthe tests and during the recovery phase.The two groups werenot significantly different at rest for the examined variables.However, the SHT group showed a greater average SBP than theSNT group (198.4±18.7 vs 189.5±14.9 mmHg; P<0.05)at the peak of exercise. A significantly higher proportion ofSHT subjects (40.0% vs 18.5%: P<0.01) had SBP >200 mmHg.No difference in the ECG pattern between the two groups wasobserved.During mental stress, no significant differences inthe examined variables between the two groups were noted, althoughSBP, DBP, HR and RPP were slightly higher in SHT than in SNTsubjects.These data suggest that the SBP response to dynamicexercise may be a good predictor of hypertension in subjectsat risk.     

The white-coat hypertension response

This study was designed to determine the clinical characteristics of hypertensive patients whose blood pressures are substantially higher in the medical office than in their natural environments. Thirty-nine percent of patients enrolled in a nonpharmacologic hypertension treatment program had systolic or diastolic office blood pressures (OBPs) that were at least 10 mm Hg higher than their ambulatory blood pressures (ABPs). Although these white-coat responders (WCRs) had higher systolic OBPs than did non-white-coat responders (NRs), both their systolic (p<0.02) and their diastolic (p<0.0001) ABPs were significantly lower than those of NRs. Furthermore, patients with white-coat hypertension did not have greater blood pressure reactivity in their natural environments, suggesting that their blood pressure elevations may be specific to the medical setting. White-coat hypertensives were older (p<0.005), had less angry dispositions (p<0.01), and reported less overt anger expression (p<0.005). They were also taking more antihypertensive medications than were the other patients in the study (p<0.001).     

Blood pressure related to age: The India ABPM study

The present paper reports trends in office blood pressure (BP) measurement (OBPM) and ambulatory blood pressure measurement (ABPM) with age in a large multi‐center Indian all comers’ population visiting primary care physicians. ABPM and OBPM data from 27 472 subjects (aged 51 ± 14 years, males 68.2%, treated 45.5%) were analyzed and compared. Individual differences between OBPM and ABPM patterns were compared for patients according to 10‐year age categories. Results showed that systolic (S) BP values started to increase with age from the age of 40, BP variability (SD) increased from the age of 30 years. Diastolic (D) BP values started to decrease from the age of 50 years. Mean OBPM values were higher than daytime ABPM values (all P < .001) in all age‐groups. The prevalence of white coat hypertension (WCH) and masked hypertension (MH) was based on OBPM and daytime, 24‐hour, and nighttime average BPs together. WCH decreased with age from 15.1% and 12.4% in treated and untreated subjects at the youngest age to 7.2% and 6.9% in the oldest age, respectively. MH prevalence was higher for untreated than for treated subjects but remained similar for all age‐groups (range of 18.6%‐21.3%). The prevalence of reverse dippers increased with age from the youngest to oldest group with 7.3%‐34.2% (P < .001 for trend). Dippers prevalence decreased from 42.5% to 17.9% from the youngest to oldest age‐groups, respectively (P < .001 for trend). These findings confirm that BP patterns show clear differences in trends with age, particularly regarding nighttime BP.     

Systemic blood pressure and glomerular leakage with particular reference to diabetes and hypertension

Both day and night blood pressure have considerable ranges in normal individuals and also in diabetic patients. In addition, there is considerable variation intra-individually, with considerable excurses in blood pressure, e.g. during exercise, other daily activities as well as on exposure to medical personnel. There is good evidence to suggest that elevated blood pressure is an important factor in the progression of renal disease in diabetes, even from the initial phase of the slight elevation of the albumin excretion rate. From the earliest phase of microalbuminuria, blood pressure may increase by an average of 3–4 mmHg per year in contrast to 1 mmHg per year in healthy controls and in clearly normoalbuminuric individuals. Throughout the course of the complications of diabetes, both insulin-dependent and non-insulin-dependent, there is a correlation between albuminuria and blood pressure in cross-sectional studies; also there is a significant correlation between blood pressure and the progression of albuminuria. The same findings are available in essential hypertension and also to some extent in the background population, although in the latter the correlation between albuminuria and blood pressure is much less precise, although highly significant. Several trials conducted over the years uniformly show that antihypertensive treatment reduces albuminuria and, in many studies, progression in renal disease also, as measured by the glomerular filtration rate (GFR) fall. Therefore, it could be considered as a means to reduce blood pressure generally in diabetic individuals, even from the start of diabetes, with the aim of future further prevention of renal complications and possibly other complications. Such a proposal is less attractive in the background population because renal disease is much more rare. Another similar approach would be the prevention of increasing blood pressure in individuals at risk of renal disease, e.g. diabetics. Obviously, abnormalities in the vascular wall of a biochemical/functional nature may make diabetics more pressure-sensitive, and the indication is that several other risk factors are involved, in particular poor metabolic control. Nevertheless, it is proposed that trials should be conducted very early in the course of diabetes, to see if the same positive effect can be obtained early as that documented later in the course of microalbuminaria and overt renal disease, both in insulin-dependent and in non-insulin-dependent diabetes. In essential hypertension, antihypertensive treatment has a profound effect on albuminuria, and this may be associated with long-term renoprotection, but this is less well documented.