Morning and Evening Home Blood Pressure and Risks of Incident Stroke and Coronary Artery Disease in the Japanese General Practice Population

Expert panel consensus recommendations for home blood pressure monitoring in Asia: the Hope Asia Network

Hypertension is the leading cause of mortality throughout Asia. Home blood pressure monitoring has the potential to improve hypertension control and is a useful adjunct to conventional office blood pressure measurements due to its diagnostic accuracy and prognostic value in predicting cardiovascular outcomes. At present, there are no region-specific guidelines addressing the use of home blood pressure monitoring in Asia. Therefore, an expert panel was convened to address the use of home blood pressure monitoring and develop key recommendations to help guide clinical practice throughout the Asia region. The resulting recommendations support the use of home blood pressure monitoring with a validated device as an accurate adjunct for diagnosing hypertension and predicting cardiovascular outcome. Diagnosis and treatment of hypertension should still be guided by conventional office/clinic blood pressure measurements. The expert panel encourages the incorporation of home blood pressure monitoring into local clinical guidelines and offers practical recommendations to ensure continuity of care where a validated home blood pressure device is not available.

Prognostic significance of home pulse pressure for progression of diabetic nephropathy: KAMOGAWA-HBP study

Pulse pressure (PP) has been noted as a potential independent risk factor for micro and macrovascular diabetic complications. We aimed to examine the prognostic value of home-measured PP (home PP) in patients with type 2 diabetes. This study is a 2-year prospective cohort study of 737 patients with type 2 diabetes. Home blood pressure measurements were performed for 14 consecutive days. We defined the progression of diabetic nephropathy as when the diabetic nephropathy stage advanced to a higher stage during the 2 years. Using logistic regression analyses, we investigated the relationship between home PP and home systolic blood pressure (SBP) in the morning and in the evening and the progression of diabetic nephropathy. Furthermore, we measured the area under the receiver-operating characteristic curve (AUC) to assess the predictive ability of the progression of diabetic nephropathy of home PP. During the 2-year study, progression of diabetic nephropathy was observed in 94 patients. The adjusted odds ratios (95% confidence interval (CI)) of home PP and home SBP to the progression of diabetic nephropathy were 1.23 (1.01-1.49) and 1.14 (0.98-1.33), respectively. The AUC (95% CI) of home PP to the progression of diabetic nephropathy was 0.624 (0.665-0.679). The optimal cut-off points, sensitivity and specificity for home PP that were associated with the progression of diabetic nephropathy were 57.7 mmHg, 0.649 and 0.580, respectively. Our findings suggest, for the first time, that home PP is an independent predictor of the progression of diabetic nephropathy in patients with type 2 diabetes.

Guidance on home blood pressure monitoring: A statement of the HOPE Asia Network

Hypertension is an important modifiable cardiovascular risk factor and a leading cause of death throughout Asia. Effective prevention and control of hypertension in the region remain a significant challenge despite the availability of several regional and international guidelines. Out-of-office measurement of blood pressure (BP), including home BP monitoring (HBPM), is an important hypertension management tool. Home BP is better than office BP for predicting cardiovascular risk and HBPM should be considered for all patients with office BP ≥ 130/85 mm Hg. It is important that HBPM is undertaken using a validated device and patients are educated about how to perform HBPM correctly. During antihypertensive therapy, monitoring of home BP control and variability is essential, especially in the morning. This is because HBPM can facilitate the choice of individualized optimal therapy. The evidence and practice points in this document are based on the Hypertension Cardiovascular Outcome Prevention and Evidence (HOPE) Asia Network expert panel consensus recommendations for HBPM in Asia.

Morning blood pressure monitoring in the management of hypertension

: The aim of the current article is to review the current evidence on the role of morning blood pressure (BP) in the management of hypertension. Morning BP surge had been and will continue to be a hot topic of hypertension research. However, more evidence is needed to prove its clinical usefulness in the management of hypertension. Masked morning hypertension, as the other forms of masked hypertension, requires more research. The concept of morning BP monitoring could be clinically relevant in the therapeutic management of hypertension and in the prevention of cardiovascular complications by defining and treating morning hypertension. Antihypertensive medication is usually taken in the morning. The presence of uncontrolled morning BP during trough effect hours could be a hallmark of inadequate antihypertensive regimen, such as, for instance, the use of short-acting or intermediate-acting drugs, under dosing of drugs, or no or low use of combination therapy. To improve the management of hypertension in general and morning hypertension in particular, long-acting antihypertensive drugs should be used in appropriate often full dosages and in proper combinations. The clinical usefulness of antihypertensive drugs of specific mechanisms against morning BP or split or timed dosing of long-acting drugs in controlling morning BP remains under investigation. In conclusion, there is some evidence that morning BP is critical in the incidence of cardiovascular complications. However, proving its clinical usefulness in the management of hypertension requires further research.

Carotid atherosclerosis and the association between nocturnal blood pressure dipping and cardiovascular events

The impact of a nondipping blood pressure (BP) pattern, defined as (awake systolic BP - sleep systolic BP)/awake systolic BP < 0.1, on cardiovascular events in populations with different degrees of carotid atherosclerosis is uncertain. The authors hypothesized that a nondipping BP pattern would show differential predictive power for cardiovascular events, including total cardiovascular death, sudden death, nonfatal cardiovascular events, and nonfatal stroke, between populations with and without carotid atherosclerosis. To test this hypothesis, the authors analyzed 493 patients (mean age 67.9 years, 47.5% men) from the J-HOP (Japan Morning Surge-Home Blood Pressure) study for whom ambulatory BP monitoring and carotid intima-media thickness data were available. Twenty-nine cardiovascular events occurred during follow-up (1867 person-years). A nondipping BP pattern was independently associated with cardiovascular events in the population without carotid atherosclerosis, defined as carotid intima-media thickness < 1.1 mm after adjustment for other cardiovascular risk factors including age, sex, diabetes mellitus, chronic kidney disease, and 24-hour systolic BP (hazard ratio, 8.15; 95% confidence interval, 1.76-37.78 [P < .01]). This association was not found in the population with carotid intima-media thickness ≥ 1.1 mm. Therefore, in the hypertensive population without carotid atherosclerosis, physicians should consider ambulatory BP monitoring to determine the nocturnal BP pattern as an alternative approach to assessing cardiovascular events.

Management of morning hypertension: a consensus statement of an Asian expert panel

Morning blood pressure (BP) surge is an important aspect of hypertension research. Morning BP monitoring could be a clinically relevant concept in the therapeutic management of hypertension and in the prevention of cardiovascular complications by defining and treating morning hypertension. Because antihypertensive medication is often taken in the morning, uncontrolled morning BP during the trough effect hours could be a hallmark of inadequate choice of antihypertensive regimen, such as the use of short- or intermediate-acting drugs, underdosing of drugs, or no use or underuse of combination therapy. To improve the management of hypertension in general and morning hypertension in particular, long-acting antihypertensive drugs should be used in appropriate, often full dosages and in proper combinations. The clinical usefulness of antihypertensive drugs with specific mechanisms for morning BP or split or timed dosing of long-acting drugs in controlling morning BP remains under investigation.

Rationale and design for the Asia BP@Home study on home blood pressure control status in 12 Asian countries and regions

Home blood pressure (BP) monitoring is endorsed in multiple guidelines as a valuable adjunct to office BP measurements for the diagnosis and management of hypertension. In many countries throughout Asia, physicians are yet to appreciate the significant contribution of BP variability to cardiovascular events. Furthermore, data from Japanese cohort studies have shown that there is a strong association between morning BP surge and cardiovascular events, suggesting that Asians in general may benefit from more effective control of morning BP. We designed the Asia BP@Home study to investigate the distribution of hypertension subtypes, including white-coat hypertension, masked morning hypertension, and well-controlled and uncontrolled hypertension. The study will also investigate the determinants of home BP control status evaluated by the same validated home BP monitoring device and the same standardized method of home BP measurement among 1600 or more medicated patients with hypertension from 12 countries/regions across Asia.

Association between decreased respiratory function and increased blood pressure variability

OBJECTIVE

The respiratory system is an important component in the control of the autonomic nervous system, and is a possible factor of blood pressure variability (BPV). We examined whether decreased respiratory function is associated with exaggerated BPV in hypertensives.

PATIENTS AND METHODS

This is a substudy of the Japan Morning Surge-Home Blood Pressure Study and patients who underwent both spirometry and ambulatory blood pressure monitoring (ABPM) in the Japan Morning Surge-Home Blood Pressure study were analyzed. In 95 hypertensives without known clinical respiratory diseases, we performed ABPM and the respiratory function test.

RESULTS

Percent vital capacity (%VC), but not forced expiratory volume in 1 s as a percentage of forced vital capacity, was associated with the SD (r=-0.23, P<0.05) and coefficient of variation (r=-0.25, P<0.05) of daytime systolic blood pressure (SBP). Lower %VC was associated with higher SD of daytime SBP (P=0.049 for trend). After adjusting for covariates, %VC tended to be associated with SD of daytime SBP (β=-0.22, P=0.08) and was associated with coefficient of variation of daytime SBP (β=-0.26, P=0.04).

CONCLUSION

Decreased respiratory function was associated with exaggerated ambulatory BPV, especially in the daytime in hypertensives without respiratory diseases. This is the first study to show an association between respiratory function and increased BPV as assessed by ABPM. The results of our study indicate that low respiratory function could exaggerate BPV, and thus may be one of the mechanisms underlying the elevated cardiovascular risk in patients with decreased respiratory function.

Morning surge in blood pressure and sympathetic activity in Mongolians and Han Chinese: a multimodality investigation of hypertension and dyssomnia

Background

Hypertension and dyssomnia are increasing significantly in Mongolians, and the related factors of ethnic differences in hypertension and dyssomnia between Mongolians and Han Chinese are unclear. This study examined the relationship of morning surge in blood pressure (MBP) with ethnicity, sleep situation, and sympathetic activity throughout the day.

Methods

Of 692 hypertensive patients screened, 202 subjects with dyssomnia were selected. They were then divided into Mongolian (n = 87) and Han (n = 115) groups. The differences in dyssomnia, 24-h blood pressure, and urinary catecholamine were analyzed in all subjects; they were then further divided according to the degree of dyssomnia (low, moderate, and severe) to determine the differences in blood pressure and catecholamine.

Results

Mongolians had a lower history of smoking, daytime dysfunction, nocturnal heart rates, and dopamine levels, but their body mass index, triglyceride, fasting glucose, morning surge in systolic blood pressure (MSBP), nocturnal systolic blood pressure (NSBP), nocturnal diastolic blood pressure, daytime systolic blood pressure, daytime heart rates, and dopamine level (D-DA) were higher than those of Han Chinese. With the aggravation of dyssomnia, MSBP, NSBP, D-NE, daytime epinephrine, and D-DA of Mongolians and Han Chinese increased gradually, but the rate of increase was faster in the latter (p < 0.05). D-DA was entered into the MSBP regression model of Mongolians (intercept, 157 mmHg), whereas D-DA and D-NE were entered into the MSBP regression model of Han Chinese (intercept, 142 mmHg).

Conclusion

Worsened dyssomnia induces higher MSBP and augments sympathetic excitability in Mongolians and Han Chinese. Mongolians with hypertension and dyssomnia had higher MSBP baseline and D-DA but lower N-DA. With an increase in D-DA, MSBP in Han and Mongolian patients increased gradually.

Current status of home blood pressure monitoring in Asia: Statement from the HOPE Asia Network

Hypertension represents a major burden in Asia, with a high prevalence rate but poor level of awareness and control reported in many countries in the region. Home blood pressure monitoring has been validated as an accurate and reliable measure of blood pressure that can help guide hypertension treatment as well as identify masked and white-coat hypertension. Despite its benefits, there has been limited research into home blood pressure monitoring in Asia. The authors reviewed the current evidence on home blood pressure monitoring in Asia, including but not limited to published literature, data presented at congresses, and national hypertension management guidelines to determine the current utilization of home blood pressure monitoring in clinical practice in the region. Public policies to enable greater access to home blood pressure monitoring and its use in clinical care would add considerably to improving hypertension outcomes in Asia.

Difference in evening home blood pressure between before dinner and at bedtime in Japanese elderly hypertensive patients

The authors evaluated the differences between evening home blood pressure (HBP) readings taken before dinner and those taken at bedtime, which were documented in a European and a Japanese guideline, respectively. Forty-eight patients (mean age, 76.4 years) measured their evening HBP twice each day (two measurements both before dinner and at bedtime) for 14 days. The authors defined the at-bedtime (B) minus the before-dinner (D) systolic HBP as the B-D difference. The mean B-D difference was -8.7 mm Hg (P<.001). The depressor effect of bathing was significantly prolonged for 120 minutes. The B-D difference with alcohol consumption was significantly greater than that without alcohol. In the linear mixed model analysis, time after bathing ≤120 minutes and alcohol consumption were significantly associated with the B-D difference after adjustment with covariates. There was a marked difference between evening HBP values. When patients' evening HBP is measured according to the guidelines, their daily activities should be considered.

Differences in Dynamic Diurnal Blood Pressure Variability Between Japanese and American Treatment-Resistant Hypertensive Populations

BACKGROUND

Dynamic diurnal changes in 24-h ambulatory systolic blood pressure (SBP) are associated with increased cardiovascular risk. We compared ambulatory BP dynamics in Japanese and American black and white populations with treatment-resistant hypertension.Methods and Results:Both HTN-Japan (n=41) and SYMPLICITY HTN-3 (n=384 white and n=140 black patients) enrolled patients with office SBP ≥160 mmHg and 24-h ambulatory SBP ≥135 mmHg while on ≥3 antihypertensive medications. Indices of circadian variation in ambulatory BP, including morning and nighttime dynamic surges, were retrospectively compared. All 3 cohorts had similar baseline office SBP. The Japanese cohort had significantly lower body mass index, less obstructive sleep apnea, and less hypercholesterolemia than the black and white cohorts, but significantly greater morning SBP levels, including moving peak morning SBP (183 vs. 169 vs. 169 mmHg, P<0.001), morning dynamic surge (37.9 vs. 28.6 vs. 24.2 mmHg, P<0.001) and nighttime dynamic surge (24.9 vs. 8.3 vs. 7.7 mmHg, P<0.001). These racial differences in SBP surge parameters persisted despite adjustment for baseline demographic population differences through multivariate regression.

CONCLUSIONS

Greater diurnal BP variability, including dynamic surges, in Japanese compared with black and white patients may indicate ethnic differences in the underlying BP regulatory mechanism of resistant hypertension. These differences may be important to take into consideration for more specific drug and device-based therapy strategies based on ethnicity.

Brachial-Ankle Pulse Wave Velocity and the Risk Prediction of Cardiovascular Disease: An Individual Participant Data Meta-Analysis

An individual participant data meta-analysis was conducted in the data of 14 673 Japanese participants without a history of cardiovascular disease (CVD) to examine the association of the brachial-ankle pulse wave velocity (baPWV) with the risk of development of CVD. During the average 6.4-year follow-up period, 687 participants died and 735 developed cardiovascular events. A higher baPWV was significantly associated with a higher risk of CVD, even after adjustments for conventional risk factors (P for trend <0.001). When the baPWV values were classified into quintiles, the multivariable-adjusted hazard ratio for CVD increased significantly as the baPWV quintile increased. The hazard ratio in the subjects with baPWV values in quintile 5 versus that in those with the values in quintile 1 was 3.50 (2.14-5.74; P<0.001). Every 1 SD increase of the baPWV was associated with a 1.19-fold (1.10-1.29; P<0.001) increase in the risk of CVD. Moreover, addition of baPWV to a model incorporating the Framingham risk score significantly increased the C statistics from 0.8026 to 0.8131 (P<0.001) and also improved the category-free net reclassification (0.247; P<0.001). The present meta-analysis clearly established baPWV as an independent predictor of the risk of development of CVD in Japanese subjects without preexisting CVD. Thus, measurement of the baPWV could enhance the efficacy of prediction of the risk of development of CVD over that of the Framingham risk score, which is based on the traditional cardiovascular risk factors.

Perfect 24-h management of hypertension: clinical relevance and perspectives

Out-of-office blood pressure (BP) measured by home BP monitoring, or ambulatory BP monitoring, was demonstrated to be superior to office BP for the prediction of cardiovascular events. The J-HOP study of a nationwide Japanese cohort demonstrated that morning home BP is the best stroke predictor. In the prospective HONEST study of >21 000 hypertensives, on-treatment morning home BP was shown to be a strong predictor both of future coronary artery disease and stroke events. In subjects whose office BP was maintained at ⩾150 mm Hg, there was no increase in cardiovascular events when their morning systolic BP was well-controlled at <125 mm Hg. Since Asians show greater morning BP surges, it is particularly important for Asians to achieve 'perfect 24-hr BP control,' that is, the 24-h BP level, nocturnal BP dipping and BP variability including morning surge. The morning BP surge and the extremes of disrupted circadian rhythm (riser and extreme dipper patterns) are independent risks for stroke in hypertensives. A morning BP-guided approach is thus the first step toward perfect 24-h BP control, followed by the control of nocturnal hypertension. In the resonance hypothesis, the synergistic resonance of BP variability phenotypes would produce an extraordinary large 'dynamic BP surge' that can trigger a cardiovascular event, especially in high-risk patients with systemic hemodynamic atherothrombotic syndrome, a vicious cycle of exaggerated BP variability and vascular disease. In the future, information and communications technology and artificial intelligence technology with the innovation of wearable continuous surge BP monitoring will contribute to 'anticipation medicine' with the goal of zero cardiovascular events.