Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. Systolic Hypertension in Europe Trial Investigators

Osteoprotegerin is associated with subclinical left ventricular systolic dysfunction in non-dipper hypertensive patients: a 2D speckle tracking echocardiographic study

BACKGROUND

Past studies have shown that non-dipper hypertensive patients have more frequent subclinical left ventricular (LV) systolic dysfunction compared to dippers. Many different parameters have been examined to predict subclinical LV dysfunction. The role of osteoprotegerin (OPG) in the pathogenesis of heart failure and LV systolic dysfunction through different mechanisms had well described. In the present study, we hypothesized that increased OPG levels could predict subclinical LV systolic dysfunction in non-dipper hypertensive patients.

PATIENTS AND METHODS

Hypertensive patients were divided into two groups according to the results of ambulatory blood pressure (BP) monitoring. Non-dipper patients were subsequently divided into two further groups (normal LV function and impaired LV function) according to LV global longitudinal strain (GLS).

RESULTS

A total of 103 hypertensive patients (51 dippers, 52 non-dippers) were included in the study. In the non-dipper group, LV GLS was normal in 21 patients and impaired in 31 patients. Based on the results of the multivariate logistic regression test, it was determined that OPG levels (OR: 2.413, 95% CI: 1.284-4.535, P  = 0.006) and LVMI (OR: 1.086, 95% CI: 1.013-1.165, P  = 0.021) were independently associated with impaired GLS.

CONCLUSION

Higher OPG values were associated with subclinical LV systolic dysfunction in non-dipper hypertensive patients. It could be used for the early diagnosis of subclinical LV systolic dysfunction, which would allow for strategies to be designed to reduce the cardiovascular event rate in this patient population.

When and how to use ambulatory blood pressure monitoring and home blood pressure monitoring for managing hypertension

Many individuals have different blood pressure (BP) values in the office setting compared to that outside the office setting. Therefore, confirming hypertension based on office BP (OBP) measurement alone can lead to misdiagnosis and mistreatment. The limitations of OBP measurement have led to the complementary use of out-of-office BP measurements, including 24-hour ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). This review aims to describe when and how ABPM or HBPM can be used to accurately diagnose and treat hypertension. Both methods should be performed using validated automated oscillometric devices. To minimize user errors, ABPM should be performed using standard techniques, whereas HBPM requires patient education regarding proper BP measurements. ABPM provides short-term comprehensive information on BP, including daytime, nighttime, morning, and 24-h BP. Therefore, ABPM is recommended for the initial diagnosis of hypertension, assessment of BP phenotypes and circadian patterns, and detection of nocturnal hypertension, Furthermore, ABPM plays a critical role in confirming true resistant hypertension thereby excluding pseudo-resistant hypertension. However, it is not suitable for long-term follow-up of patients with hypertension. In contrast, HBPM involves multiple BP readings taken at specific times during the day and evening over a long period. Therefore, HBPM is recommended for diagnosing hypertension and assessing BP phenotypes. However, this method has limitations in measuring nocturnal BP and circadian BP patterns. HBPM is preferred over ABPM for the long-term follow-up of patients with hypertension. This approach improves patient adherence to treatment and ultimately enhances the rate of control of hypertension. Additionally, both methods play an important role in diagnosing and treating white coat hypertension during pregnancy. Consequently, out-of-office BP measurement is essential to prevent the misdiagnosis and mistreatment of hypertension. However, these two methods offer different information regarding the BP status of an individual, and they indeed show discrepancies in the diagnosis of hypertensive phenotypes. Therefore, it is crucial to understand the advantages and limitations of both ABPM and HBPM to ensure their appropriate use in clinical practice.

Human soluble prorenin receptor expressed in mouse renal collecting duct shows sex-specific effect on cardiorenal function

Soluble prorenin receptor (sPRR), a component of the renin-angiotensin system (RAS), has been identified as a plasma biomarker for hypertension and cardiovascular diseases in humans. Despite studies showing that sPRR in the kidney is produced by tubular cells in the renal collecting duct (CD), its biological actions modulating cardiorenal function in physiological conditions remain unknown. Therefore, the objective of our study was to investigate whether CD-derived human sPRR (HsPRR) expression influences cardiorenal function and examine sex and circadian differences. Thus, we investigated the status of the intrarenal RAS, water and electrolyte balance, renal filtration capacity, and blood pressure (BP) regulation in CD-HsPRR and control (CTL) mice. CD-HsPRR mice were generated by breeding human sPRR-Myc-tag mice with Hoxb7/Cre mice. Renal sPRR expression increased in CD-HsPRR mice, but circulating sPRR and RAS levels were unchanged compared with CTL mice. Only female littermates expressing CD-HsPRR showed 1) increased 24-h BP, 2) an impaired BP response to an acute dose of losartan and attenuated angiotensin II (ANG II)-induced hypertension, 3) reduced angiotensin-converting enzyme activity and ANG II content in the renal cortex, and 4) decreased glomerular filtration rate, with no changes in natriuresis and kaliuresis despite upregulation of the β-subunit of the epithelial Na+ channel in the renal cortex. These cardiorenal alterations were displayed only during the active phase of the day. Taken together, these data suggest that HsPRR could interact with ANG II type 1 receptors mediating sex-specific, ANG II-independent renal dysfunction and a prohypertensive phenotype in a sex-specific manner.NEW & NOTEWORTHY We successfully generated a humanized mouse model that expresses human sPRR in the collecting duct. Collecting duct-derived human sPRR did not change circulating sPRR and RAS levels but increased daytime BP in female mice while showing an attenuated angiotensin II-dependent pressor response. These findings may aid in elucidating the mechanisms by which women show uncontrolled BP in response to antihypertensive treatments targeting the RAS, improving approaches to reduce uncontrolled BP and chronic kidney disease incidences in women.

The role of ambulatory blood pressure monitoring in enhancing medication adherence among patients with newly diagnosed hypertension: an analysis of the National Health Insurance cohort database

BACKGROUND

Improving adherence to antihypertensive medication (AHM) is a key challenge in hypertension management. This study aimed to assess the impact of ambulatory blood pressure monitoring (ABPM) on AHM adherence.

METHODS

We utilized the Korean National Health Insurance Service database. Among patients newly diagnosed with hypertension who started AHM between July 2010 and December 2013, we compared clinical characteristics and adherence between 28,116 patients who underwent ABPM prior to starting AHM and 118,594 patients who did not undergo ABPM. Good adherence was defined as a proportion of days covered (PDC) of 0.8 or higher.

RESULTS

The total study population was 146,710, with a mean age of 50.5 ± 6.4 years; 44.3% were female. Co-morbidities were noted in 4.2%. About a third of patients (33.1%) showed good adherence. The ABPM group had a notably higher PDC (total PDC: 0.64 ± 0.35 vs. 0.45 ± 0.39; P < 0.001), irrespective of the number of medications, dosing frequency, or prescription duration. After adjusting for significant clinical variables, ABPM was still closely linked with good adherence (odds ratio, 2.35; 95% confidence interval, 2.28-2.41; P < 0.001).

CONCLUSIONS

In newly diagnosed hypertension, undergoing ABPM prior to AHM prescription appears to enhance adherence to AHM. The exact mechanisms driving this association warrant further exploration.

Screening for hypertension in adults - the use of tonometric blood pressure monitoring

OBJECTIVES

Arterial hypertension increases the risk of developing cardiovascular disease. Reliable screening tools for diagnosing hypertension are important to ensure correct risk stratification of subjects. In this study, we aimed to analyse if a wrist-worn device using a tonometric technique for measuring of 24-hour blood pressure could be used to diagnose hypertension and non-dipping. A conventional device using oscillometric measurements was used as golden standard. Secondary aim was to compare the degree of discomfort related to monitoring with the two devices.

METHODS

In 89 subjects with a history of normal blood pressure and naive to ambulatory BP monitoring (ABPM), 24-hour ABPM was measured simultaneously with A&D TM2430 (oscillometric technique) and BPro (tonometric technique).

RESULTS

When comparing measurements from the two devices, we found that the tonometric device misclassified 46% of hypertensive subjects and 69% of non-dippers. The tonometric device measured significantly lower systolic 24-hour and daytime blood pressure. The subjects reported less discomfort related to the tonometric than the oscillometric device.

CONCLUSION

Despite less discomfort related to usage of the tonometric device for 24-hour blood pressure monitoring compared to an oscillometric device, misclassification of hypertension and non-dipping makes the tonometric device inappropriate as a screening instrument.

Effects of aerobic exercise on ambulatory blood pressure responses to acute partial sleep deprivation: impact of chronotype and sleep quality

Blood pressure (BP) follows a circadian rhythm intertwined with the sleep-wake cycle. Acute partial sleep deprivation (PSD; sleep ≤ 6 h) can increase BP, associated with increased cardiovascular risk. Acute exercise can reduce BP for up to 24 h, a phenomenon termed postexercise hypotension. The present study tested whether aerobic exercise could mitigate the augmented 24-h ambulatory BP caused by acute PSD. Twenty-four young otherwise healthy adults (22 ± 3 yr; 14 females; self-reported chronotypes: 6 early/10 intermediate/8 late; Pittsburgh sleep quality index: 17 good/7 poor sleepers) completed a randomized crossover trial in which, on different days, they slept normally (2300-0700), restricted sleep [0330-0700 (PSD)], and cycled for 50 min (70-80% predicted heart rate maximum) before PSD. Ambulatory BP was assessed every 30 min until 2100 the next day. Acute PSD increased 24-h systolic BP (control 117 ± 9 mmHg, PSD 122 ± 9 mmHg; P < 0.001) and prior exercise attenuated (exercise + PSD 120 ± 9 mmHg; P = 0.04 vs. PSD) but did not fully reverse this response (exercise + PSD, P = 0.02 vs. control). Subgroup analysis revealed that the 24-h systolic BP reduction following exercise was specific to late types (PSD 119 ± 7 vs. exercise + PSD 116 ± 6 mmHg; P < 0.05). Overall, habitual sleep quality was negatively correlated with the change in daytime systolic BP following PSD (r = -0.56, P < 0.01). These findings suggest that the ability of aerobic cycling exercise to counteract the hemodynamic effects of acute PSD in young adults may be dependent on chronotype and that habitual sleep quality can predict the daytime BP response to acute PSD.NEW & NOTEWORTHY We demonstrate that cycling exercise attenuates, but does not fully reverse, the augmented 24-h ambulatory blood pressure (BP) response caused by acute partial sleep deprivation (PSD). This response was primarily observed in late chronotypes. Furthermore, daytime BP after acute PSD is related to habitual sleep quality, with better sleepers being more prone to BP elevations. This suggests that habitual sleeping habits can influence BP responses to acute PSD and their interactions with prior cycling exercise.

Narcolepsy and cardiovascular disease: A two-sample Mendelian randomization study

BACKGROUND

Observational findings suggest that patients with narcolepsy are at higher risk for cardiovascular diseases (CVDs), but the potential causal relationship between narcolepsy and CVDs is unclear. Therefore, Mendelian randomization (MR) was used to explore the association between narcolepsy and CVDs.

METHODS

Summary statistics related to narcolepsy, coronary artery disease (CAD), myocardial infarction (MI), heart failure (HF), any stroke (AS), and any ischemic stroke (AIS) were extracted from the public database of relevant published genome-wide association studies (GWAS). Independent single nucleotide polymorphisms were selected as instrumental variables under strict quality control criteria. Inverse variance-weighted (IVW) was the main analytical method to assess causal effects. In addition, we conducted MR pleiotropy residual sum and outlier (MR-PRESSO), weighted median, MR-Egger, and leave-one-out sensitivity analysis to verify the robustness and reliability of the results.

RESULTS

The results of the MR study revealed that narcolepsy was significantly associated with an increased risk of HF (OR = 1.714; 95%CI [1.031-2.849]; P = 0.037), CAD (OR = 1.702; 95%CI [1.011-2.864]; P = 0.045). There was no statistically significant causal association between narcolepsy and MI, AS, and AIS. In addition, further sensitivity analysis showed robust results.

CONCLUSIONS

The results of the two-sample MR study reveal a potential causal relationship between the increased risk of HF and CAD in narcolepsy. These findings emphasize the importance of early monitoring and assessment of cardiovascular risk in patients with narcolepsy.

Associations of Diabetic Retinopathy Severity With High Ambulatory Blood Pressure and Suppressed Serum Renin Levels

CONTEXT

The relationships between serum renin levels, severity of diabetic retinopathy (DR), and 24-hour blood pressure (BP) have not been previously reported.

OBJECTIVE

To explore causes for DR and the relationships of 24-hour ambulatory BP, and hormone levels with the severity of DR.

METHODS

The diabetic patients were classified as having no DR, simple DR, or severe DR (preproliferative DR plus proliferative DR) based on funduscopic examination, and we measured 24-hour BP, serum active renin (ARC), aldosterone (SAC), adrenocorticotropic hormone, and cortisol levels in each group.

RESULTS

Compared to those with no DR or simple DR, patients with severe DR showed significantly higher 24-hour BPs, including daytime and nighttime systolic and diastolic BP levels, independent of diabetic duration and HbA1c levels. The variability of nighttime systolic BP was greater in patients with severe DR than in those with nonsevere DR, although nocturnal BP reduction was similar between the groups. The ambulatory BPs were significantly inversely associated with ARC. The ARC was significantly lower in severe DR patients than in those with no DR or simple DR (3.2 [1.5-13.6] vs 9.8 [4.6-18.0] pg/mL, P < .05), but there were no differences in SAC in patients taking calcium channel blockers and/or α-blockers. No associations were found between DR severity and other hormone levels.

CONCLUSION

Severe DR was associated with higher 24-hour BPs and suppressed ARC. These findings suggest that mineralocorticoid receptor overactivation may play a role in higher BP levels and severe DR in diabetic patients.

The effect of bedtime versus morning dosing of antihypertensive drugs on the cardiovascular outcomes: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Antihypertensive drugs are one of the most effective strategies to prevent disability and mortality; however, there have been contradictory findings about the best dosing time for antihypertensive drugs. Therefore, we aim to evaluate the effect of bedtime versus morning dosing of antihypertensive drugs on cardiovascular outcomes.

METHODS

We synthesized randomized controlled studies (RCTs) from the Web of Science, SCOPUS, EMBASE, PubMed, and CENTRAL until 13 October 2022. The risk ratio (RR) for dichotomous outcomes with the corresponding 95% confidence interval (CI) was used. The study protocol was registered in PROSPERO with ID: CRD42022368612.

RESULTS

Five RCTs with 59 200 participants were included. Bedtime dosing was significantly associated with less incidence of myocardial infarction (MI) [RR: 0.80 with 95% CI (0.70-0.91), P = 0.0007] compared with morning dosing; however, there was no statistically significant difference between bedtime and morning dosing, regarding all-cause mortality [RR: 0.77 with 95% CI (0.51-1.16), P = 0.21], cardiovascular mortality [RR: 0.65 with 95% CI (0.35-1.21), P = 0.17], major adverse cardiac events (MACE) [RR: 0.79 with 95% CI (0.56-1.10), P = 0.16], heart failure [RR: 0.68 with 95% CI (0.42-1.09), P = 0.11], cerebrovascular accidents [RR: 0.80 with 95% CI (0.53-1.22), P = 0.30], coronary revascularization [RR: 0.79 with 95% CI (0.50-1.24), P = 0.30}, and angina [RR: 0.91 with 95% CI (0.55-1.50), P = 0.70].

CONCLUSION

Evidence about the comparative efficacy of bedtime versus morning dosing of antihypertensives is still uncertain. However, bedtime dosing significantly reduced MI, which warrants more robust RCTs to validate.

Impact of Successive Office Blood Pressure Measurements During a Single Visit on Cardiovascular Risk Prediction: Analysis of CARTaGENE

BACKGROUND

Multiple office blood pressure (BP) readings correlate more closely with ambulatory BP than single readings. Whether they are associated with long-term outcomes and improve cardiovascular risk prediction is unknown. Our objective was to assess the long-term impact of multiple office BP readings.

METHODS

We used data from CARTaGENE, a population-based survey comprising individuals aged 40 to 70 years. Three BP readings (BP1, BP2, and BP3) at 2-minute intervals were obtained using a semiautomated device. They were averaged to generate BP1-2, BP2-3, and BP1-2-3 for systolic BP (SBP) and diastolic BP. Cardiovascular events (major adverse cardiovascular event [MACE]: cardiovascular death, stroke, and myocardial infarction) during a 10-year follow-up were recorded. Associations with MACE were obtained using adjusted Cox models. Predictive performance was assessed with 10-year atherosclerotic cardiovascular disease scores and their associated C statistics.

RESULTS

In the 17 966 eligible individuals, 2378 experienced a MACE during follow-up. Crude SBP values ranged from 122.5 to 126.5 mm Hg. SBP3 had the strongest association with MACE incidence (hazard ratio, 1.10 [1.05-1.15] per SD) and SBP1 the weakest (hazard ratio, 1.06 [1.01-1.10]). All models including SBP1 (SBP1, SBP1-2, and SBP1-2-3) were underperformed. At a given SBP value, the excess MACE risk conferred by SBP3 was 2× greater than SBP1. In atherosclerotic cardiovascular disease scores, SBP3 yielded the highest C statistic, significantly higher than most other SBP measures. In contrast to SBP, all diastolic BP readings yielded similar results.

CONCLUSIONS

Cardiovascular risk prediction is improved by successive office SBP values, especially when the first reading is discarded. These findings reinforce the necessity of using multiple office BP readings.

Interplay of Race and Neighborhood Deprivation on Ambulatory Blood Pressure in Young Adults

Background

Ambulatory blood pressure (BP) monitoring measures nighttime BP and BP dipping, which are superior to in-clinic BP for predicting cardiovascular disease (CVD), the leading cause of death in America. Compared with other racial/ethnic groups, Black Americans exhibit elevated nighttime BP and attenuated BP dipping, including in young adulthood. Social determinants of health contribute to disparities in CVD risk, but the contribution of neighborhood deprivation on nighttime BP is unclear. Therefore, we examined associations between neighborhood deprivation with nighttime BP and BP dipping in young Black and White adults.

Methods

We recruited 21 Black and 26 White participants (20 M/27 F, mean age: 21 years, body mass index: 25±4 kg/m2) for 24-hour ambulatory BP monitoring. We assessed nighttime BP and BP dipping (nighttime:daytime BP ratio). The area deprivation index (ADI) was used to measure neighborhood deprivation. Associations between ADI and ambulatory BP were examined.

Results

Black participants exhibited higher nighttime diastolic BP compared with White participants (63±8 mmHg vs 58±7 mmHg, p=0.003), and attenuated BP dipping ratios for both systolic (0.92±0.06 vs 0.86±0.05, p=0.001) and diastolic BP (0.86±0.09 vs 0.78±0.08, p=0.007). Black participants experienced greater neighborhood deprivation compared with White participants (ADI scores: 110±8 vs 97±21, p<0.001), and ADI was associated with attenuated systolic BP dipping (ρ=0.342, p=0.019).

Conclusions

Our findings suggest neighborhood deprivation may contribute to higher nighttime BP and attenuated BP dipping, which are prognostic of CVD, and more prevalent in Black adults. Targeted interventions to mitigate the effects of neighborhood deprivation may help to improve nighttime BP.

Clinical Trial Registry

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04576338.

Energy drinks: effects on pediatric 24-h ambulatory blood pressure monitoring. A randomized trial

BACKGROUND

Energy drinks (EDs) are popular beverages among minors. To date, clinical studies investigating ED-induced effects on the pediatric cardiovascular system are sparse. This study aimed to investigate the effects of a single, bodyweight-adjusted ED dosage on 24-h ambulatory blood pressure monitoring (ABPM) in healthy children and adolescents.

METHODS

This study was a randomized, single-blind, placebo-controlled, crossover clinical trial. Study participants received a single, bodyweight-adjusted ED amount or a placebo drink on 2 consecutive days at similar morning hours. Twenty-four-hour ABPM was assessed via an automated oscillometric blood pressure device after beverage consumption on both study days.

RESULTS

A total of 17 healthy children and teenagers (13.90 (12.29-17.89) years) were included in the final analysis. The ED consumption led, compared to the placebo intake, to a significantly higher 24-h systolic (115.90 (110.22-118.04) vs. 110.64 (108.09-115.45) mmHg, p = 0.013) and diastolic blood pressure (66.08 (64.20-68.32) vs. 62.63 (61.40-66.46) mmHg, p = 0.005).

CONCLUSIONS

The single, bodyweight-adjusted ED consumption is linked with a significantly higher systolic as well as diastolic 24-h blood pressure in healthy children and adolescents. Minors, particularly those with an increased cardiovascular morbidity, should be discouraged from drinking EDs.

IMPACT

Energy drinks (EDs) are consumed by many children and teenagers. While adverse cardiovascular events after ED consumption were reported in the literature, the effects of these beverages on the pediatric 24-h blood pressure profile have not been systematically evaluated yet. In our manuscript, we demonstrate for the first time that acute ED consumption is associated with a significantly higher 24-h systolic blood pressure and diastolic blood pressure in healthy minors.

Relationship between clinic and ambulatory blood pressure and mortality: an observational cohort study in 59 124 patients

BACKGROUND

Ambulatory blood pressure provides a more comprehensive assessment than clinic blood pressure, and has been reported to better predict health outcomes than clinic or home pressure. We aimed to examine associations of clinic and 24-h ambulatory blood pressure with all-cause and cardiovascular mortality in a large cohort of primary care patients referred for assessment of hypertension.

METHODS

We did an observational cohort study using clinic and ambulatory blood pressure data obtained from March 1, 2004, to Dec 31, 2014, from the Spanish Ambulatory Blood Pressure Registry. This registry included patients from 223 primary care centres from the Spanish National Health System in all 17 regions of Spain. Mortality data (date and cause) were ascertained by a computerised search of the vital registry of the Spanish National Institute of Statistics. Complete data were available for age, sex, all blood pressure measures, and BMI. For each study participant, follow-up was from the date of their recruitment to the date of death or Dec 31, 2019, whichever occurred first. Cox models were used to estimate associations between usual clinic or ambulatory blood pressure and mortality, adjusted for confounders and additionally for alternative measures of blood pressure. For each measure of blood pressure, we created five groups (ie, fifths) defined by quintiles of that measure among those who subsequently died.

FINDINGS

During a median follow-up of 9·7 years, 7174 (12·1%) of 59 124 patients died, including 2361 (4·0%) from cardiovascular causes. J-shaped associations were observed for several blood pressure measures. Among the top four baseline-defined fifths, 24-h systolic blood pressure was more strongly associated with all-cause death (hazard ratio [HR] 1·41 per 1 - SD increment [95% CI 1·36-1·47]) than clinic systolic blood pressure (1·18 [1·13-1·23]). After adjustment for clinic blood pressure, 24-h blood pressure remained strongly associated with all-cause deaths (HR 1·43 [95% CI 1·37-1·49]), but the association between clinic blood pressure and all-cause death was attenuated when adjusted for 24-h blood pressure (1·04 [1·00-1·09]). Compared with the informativeness of clinic systolic blood pressure (100%), night-time systolic blood pressure was most informative about risk of all-cause death (591%) and cardiovascular death (604%). Relative to blood pressure within the normal range, elevated all-cause mortality risks were observed for masked hypertension (HR 1·24 [95% CI 1·12-1·37]) and sustained hypertension (1·24 [1·15-1·32]), but not white-coat hypertension, and elevated cardiovascular mortality risks were observed for masked hypertension (1·37 [1·15-1·63]) and sustained hypertension (1·38 [1·22-1·55]), but not white-coat hypertension.

INTERPRETATION

Ambulatory blood pressure, particularly night-time blood pressure, was more informative about the risk of all-cause death and cardiovascular death than clinic blood pressure.

FUNDING

Spanish Society of Hypertension, Lacer Laboratories, UK Medical Research Council, Health Data Research UK, National Institute for Health and Care Research Biomedical Research Centres (Oxford and University College London Hospitals), and British Heart Foundation Centre for Research Excellence.

Interpretation of Ambulatory Blood Pressure Monitoring for Risk Stratification in Hypertensive Patients: The 'Ambulatory Does Prediction Valid (ADPV)' Approach

Several outcome-based prospective investigations have provided solid data which support the prognostic value of 24 h ambulatory blood pressure over and beyond cardiovascular traditional risk factors. Average 24 h, daytime, and nighttime blood pressures are the principal components of the ambulatory blood pressure profile that have improved cardiovascular risk stratification beyond traditional risk factors. Furthermore, several additional ambulatory blood pressure measures have been investigated. The correct interpretation in clinical practice of ambulatory blood pressure monitoring needs a standardization of methods. Several algorithms for its clinical use have been proposed. Implementation of the results of ambulatory blood pressure monitoring in the management of individual subjects with the aim of improving risk stratification is challenging. We suggest that clinicians should focus attention on ambulatory blood pressure components which have been proven to act as the main independent predictors of outcome (average 24 h, daytime, and nighttime blood pressure, pulse pressure, dipping status, BP variability).

Role of ambulatory blood pressure on prediction of cardiovascular disease. A cohort study

Ambulatory blood pressure (BP) is associated with mortality, but it is also interesting to expand its association with cardiovascular morbidity. This study sought to evaluate association with cardiovascular morbidity and cardiovascular mortality. Patients without cardiovascular disease who had a first 24-hour ambulatory BP monitoring were followed-up until the onset of the first event (a combined variable of cardiovascular mortality, coronary heart disease, cerebrovascular disease, peripheral arteriopathy, or hospital admission for heart failure). Changes in antihypertensive treatment couldn't be collected. Cox regression analysis was adjusted for risk factors and office BP. We included 3907 patients (mean age, 58.0, SD 13.8 years), of whom 85.5% were hypertensive. The follow up period was 6.6 (95% CI 5.0-8.5) years. A total of 496 (12.7%) events were recorded. The incidence rate was 19.3 (95% CI 17.7-21.1) cases per 1000 person-years. The patients with an event compared to the rest of patients were mostly men, older, with higher office and ambulatory systolic BP, higher prevalence of diabetes, chronic kidney disease, dyslipidemia, and non-dipper or riser circadian profile. In the fully adjusted model, office BP loses its significant association with the main variable. Ambulatory BP association remained significant with cardiovascular morbidity and mortality, HR 1.494 (1.326-1.685) and 0.767 (0.654-0.899) for 24-hour systolic and diastolic BP, respectively. Nighttime systolic BP also maintained this significant association, 1.270 (1.016-1.587). We conclude that nighttime systolic BP and 24-hour BP are significantly associated with cardiovascular events and cardiovascular mortality in patients without cardiovascular disease attended under conditions of routine clinical practice.

Different Factors Associated with Morning Blood Pressure Surge in Antihypertensive-Naïve Dipper and Non-Dipper Subjects

The relationship between the morning blood pressure surge (MBPS) and cardiovascular risk is inconclusive. Previous studies have not taken into consideration dipping status in examining the MBPS and its associated factors. The aim was to examine factors associated with the MBPS in dippers and non-dippers. The MBPS was calculated by data obtained from ambulatory blood pressure monitoring, using the definition of sleep-trough morning surge. Dipping systolic blood pressure (DipSBP) was defined as [1 - (SBPsleeping/SBPawake)] × 100%. The value in milliseconds of standard deviation of normal-to-normal RR interval after waking up (SDNNaw) was calculated during the 2 h period after waking up. A total of 140 eligible subjects were divided into dippers (n = 62) and non-dippers (n = 78). Multiple regression analysis on data for all subjects revealed different correlations with the MBPS: positive in age, body mass index (BMI), and DipSBP, and inverse in cholesterol/high density lipoprotein-cholesterol (HDL-C) ratio, fasting blood glucose, and 2 h SDNNaw. When dippers were examined separately, age, female gender, and BMI correlated positively with MBPS, while cholesterol/HDL-C ratio and 2 h SDNNaw correlated negatively. For non-dippers, only age was associated with the MBPS. The factors associated with the MBPS were different for dippers and non-dippers. The MBPS seems to be a physiological response in this dipper group because age and BMI correlated positively with the MBPS, while parasympathetic neural activity after waking up and cholesterol/HDL-C ratio showed inverse correlations.

Nocturnal blood pressure surge in seconds is associated with arterial stiffness independently of conventional nocturnal blood pressure variability in suspected obstructive sleep apnea patients

Nocturnal blood pressure (BP) surge in seconds (sec-surge), which is characterized as acute transient BP elevation over several tens of seconds is induced by obstructive sleep apnea (OSA) and OSA-related sympathetic hyperactivity. The authors assessed the relationship between sec-surge and arterial stiffness in 34 nocturnal hypertensive patients with suspected OSA (mean age 63.9 ± 12.6 years, 32.4% female). During the night, they had beat-by-beat (BbB) BP and cuff-oscillometric BP measurements, and brachial-ankle pulse wave velocity (baPWV) was assessed as an arterial stiffness index. Multiple linear regression analysis revealed that the upward duration (UD) of sec-surge was significantly associated with baPWV independently of nocturnal oscillometric systolic BP variability (β = .365, p = .046). This study suggests that the UD of sec-surge, which can only be measured using a BbB BP monitoring device, may be worth monitoring in addition to nocturnal BP level.

The 2022 focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension

Hypertension is the leading cause of death in human being, which shows high prevalence and associated complications that increase the mortality and morbidity. Controlling blood pressure (BP) is very important because it is well known that lowering high BP effectively improves patients' prognosis. This review aims to provide a focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension. The importance of ambulatory BP and home BP monitoring was further emphasized not only for the diagnosis but also for treatment target. By adopting corresponding BPs, the updated guideline recommended out-of-office BP targets for both standard and intensive treatment. Based on the consensus on corresponding BPs and Systolic Blood Pressure Intervention Trial (SPRINT) revisit, the updated guidelines recommended target BP in high-risk patients below 130/80 mmHg and it applies to hypertensive patients with three or more additional cardiovascular risk factors, one or more risk factors with diabetes, or hypertensive patients with subclinical organ damages, coronary or vascular diseases, heart failure, chronic kidney disease with proteinuria, and cerebral lacunar infarction. Cerebral infarction and chronic kidney disease are also high-risk factors for cardiovascular disease. However, due to lack of evidence, the target BP was generally determined at < 140/90 mmHg in patients with those conditions as well as in the elderly. Updated contents regarding the management of hypertension in special situations are also discussed.

What did we learn from the International Databases on Ambulatory and Home Blood Pressure in Relation to Cardiovascular Outcome?

To assess in individual-person meta-analyses how out-of-office blood pressure (BP) contributes to risk stratification and the management of hypertension, an international consortium set up the International Databases on Ambulatory (IDACO) and Home (IDHOCO) Blood Pressure in Relation to Cardiovascular Outcome. This review summarizes key findings of recent IDACO/IDHOCO articles. Among various BP indexes derived from office and ambulatory BP recordings, the 24-h and nighttime BP level were the best predictors of adverse health outcomes. Second, using the 10-year cardiovascular risk associated with guideline-endorsed office BP thresholds as reference, corresponding thresholds were derived for home and ambulatory BP. Stratified by the underlying cardiovascular risk, the rate of cardiovascular events in white-coat hypertensive patients and matched normotensive controls were not substantially different. The observation that masked hypertension carries a high cardiovascular risk was replicated in Nigerian Blacks, using home BP monitoring. The thresholds for 24-h mean arterial pressure, i.e., the BP component measured by oscillometric devices, delineating normotension, elevated BP and hypertension were <90, 90 to 92 and ≥92 mmHg. At young age, the absolute risk associated with out-of-office BP was low, but the relative risk was high, whereas with advancing age, the relative risk decreased and the absolute risk increased. Using pulse pressure as an exemplary case, the relative risks of death, cardiovascular endpoints and stroke decreased over 3-fold from 55 to 75 years of age, whereas in contrast absolute risk rose 3-fold. In conclusion, IDACO/IDHOCO forcefully support the notion that the pressing need to curb the hypertension pandemic cannot be met without out-of-the-office BP monitoring.

Position of 24-hour ambulatory blood pressure monitoring in modern practice

Currently, 24-hour ambulatory blood pressure (BP) monitoring (ABPM) is the gold standard for diagnosing hypertension (HTN) and evaluating the effectiveness of antihypertensive therapy. The method provides information about some BP parameters that cannot be obtained in any other way. ABPM is reasonable in any patient with a documented increase in BP, especially if specific BP phenotypes are suspected: white coat HTN and masked HTN. Antihypertensive therapy under the ABPM, on average, is more economical and is not associated with overprescribing of drugs and their combinations. Based on the ABPM data, calculating a number of additional indicators of the 24-hour BP profile is possible, but their scope is still limited to the research field. In the conclusion on ABPM data, the results of office BP measurement and antihypertensive therapy should be indicated.

Factors Associating with Non-Dipping Pattern of Nocturnal Blood Pressure in Patients with Essential Hypertension

Background: In patients with essential hypertension, a non-dipping blood pressure pattern is a strong risk factor for cardiovascular diseases. However, background factors associating with such a blood pressure pattern remain unknown. Methods: Untreated essential hypertensive patients without chronic kidney diseases who were admitted to our outpatient clinic were included. Blood sampling and 24 h ambulatory blood pressure monitoring were mandatorily performed. Non-dipper status was defined as a maximum decrease in nocturnal systolic blood pressure within 10%. Clinical factors associating with non-dipper status were investigated. Results: A total of 154 patients (56 ± 12 years old, 86 men) were included. Among baseline characteristics, a higher serum uric acid level was independently associated with non-dipper status (odds ratio 1.03, 95% confidence interval 1.00−1.05, p < 0.05). Among those with non-dipper status, a higher high-sensitivity C-reactive protein level tended to be associated with incremental nighttime systolic blood pressure levels (p = 0.065). Conclusions: Hyperuricemia and micro-inflammation might be associated with attenuated nocturnal blood pressure dipping and incremental nighttime systolic blood pressure levels.

The Association Between 24-Hour Blood Pressure Profiles and Dementia

Midlife hypertension increases risk for dementia. Around one third of adults have diagnosed hypertension; however, many adults are undiagnosed, or remain hypertensive despite diagnosis or treatment. Since blood pressure (BP) follows a circadian rhythm, ambulatory BP monitoring allows for the assessment of BP over a 24-hour period and provides an important tool for improving the diagnosis and management of hypertension. The measurement of 24-hour BP profiles, especially nocturnal BP, demonstrate better predictive ability for cardiovascular disease and mortality than office measurement. However, few studies have examined 24-hour BP profiles with respect to dementia risk. This is an important topic since improvements in BP management could facilitate the primary prevention of vascular cognitive impairment and dementia. Therefore, this review discusses the evidence linking BP to dementia, with a focus on whether the implementation of 24-hour BP measurements can improve risk prediction and prevention strategies. Pathways linking nocturnal BP to dementia are also discussed as are risk reduction strategies. Overall, limited research suggests an association between 24-hour BP elevation and poorer cognition, cerebral small vessel disease, and dementia. However, most studies were cross-sectional. Further evidence is needed to substantiate 24-hour BP profiles, over and above office BP, as predictors of vascular cognitive impairment and incident dementia.

Role of ambulatory blood pressure monitoring in hypertensive patients having controlled office blood pressure

BACKGROUND AND OBJECTIVES

Ambulatory blood pressure (BP) monitoring has become useful in the diagnosis and management of hypertensive individuals. In this study we tried to know the role of office and ambulatory BP in treated hypertensive patients.

METHODS AND PATIENTS

Prospective cohort of 561 treated hypertensive patients were enrolled in the study. Hypertension definitions were according to JNC 8 classification. Office BP and ambulatory BP monitoring was done according to defined protocol.

RESULTS

From a subgroup of 158 treated hypertensive patients, 91(16.2%) patients were having white coat hypertension (p value 0.00 by Pearson chi square test). In a subset of 403 patients who were having controlled BP on the day of enrolment as well as on the day of attaching ambulatory BP monitor; 98 (17.4%) patients were having masked uncontrolled hypertension (MUCH). In addition there was very significant percentage of non-dippers and reverse dippers. In our study we found that office BP has a moderate to low specificity and sensitivity and low negative predictive value for overall control in treated hypertensive patients.

CONCLUSION

Ambulatory BP monitoring should be included in the management protocol of treated hypertensive patients, for the optimal BP control.

Assessing the Added Value of Vital Signs Extracted from Electronic Health Records in Healthcare Risk Adjustment Models

Purpose

Patient vital signs are related to specific health risks and outcomes but are underutilized in the prediction of health-care utilization and cost. To measure the added value of electronic health record (EHR) extracted Body Mass Index (BMI) and blood pressure (BP) values in improving healthcare risk and utilization predictions.

Patients and Methods

A sample of 12,820 adult outpatients from the Johns Hopkins Health System (JHHS) were identified between 2016 and 2017, having high data quality and recorded values for BMI and BP. We evaluated the added value of BMI and BP in predicting health-care utilization and cost through a retrospective cohort design. BMI, mean arterial pressure (MAP), systolic and diastolic BPs were summarized as annual aggregated values. Concurrent annual BMI and MAP changes were quantified as the difference between maximum and minimum recorded values. Model performance estimates consisted of repeated 10-fold cross validation, compared to base model point estimates for demographic and diagnostic, coded events: (1) patient age and sex, (2) age, sex, and the Charlson weighted index, (3) age, sex and the Johns Hopkins ACG system’s DxPM risk score.

Results

Both categorical BMI and BP were progressively indicative of disease comorbidity, but not uniformly related to health-care utilization or cost. Annual change in BMI and MAP improved predictions for most concurrent year outcomes when compared to base models.

Conclusion

When a healthcare system lacks relevant diagnostic or risk assessment information for a patient, vital signs may be useful for a simple estimation of disease risk, cost and utilization.

24-Hour Blood Pressure Control with Amlodipine: A Review of the Current Scenario

Introduction Hypertension is the leading cause of cardiovascular diseases and premature death worldwide. Antihypertensive therapy using calcium channel blockers (CCBs) is one of the preferred choices to treat blood pressure (BP) and control blood pressure variability (BPV). In contrast to clinic BP, 24-hour ambulatory BP monitoring (ABPM) has evolved into an accurate and reproducible tool for the assessment and management of hypertension. Amlodipine, a longer acting dihydropyridine CCB is effective for 24 hours BP control and also minimizing BPV. The present article is the comprehensive review highlighting the efficacy of amlodipine in controlling 24-hour BP and minimizing BPV from the review of recent studies.

Materials and Methods The literature search was done using PubMed, Google Scholar, and MEDLINE databases. The studies to be included for review, were identified through the keywords: “amlodipine,” “ambulatory BP monitoring (ABPM),”“blood pressure variability (BPV),” “CCBs,” and filtering articles published in English language only.

Results Pharmacological evidence suggests that amlodipine has the ability to block all the subtypes of CCBs such as L-, N-, P-, Q-, R-, and T-type. Various clinical studies reported that amlodipine is a powerful, well-tolerated, and safe antihypertensive agent which is widely used either alone or as a key component of combination therapy for control of 24 hours BP.

Conclusion Overall, amlodipine is a proven and effective antihypertensive drug and helpful in controlling 24-hour BP, minimizing BP variability and hence reducing the risk of cardiovascular complications.

Effect of celery (Apium graveolens) seed extract on hypertension: A randomized, triple-blind, placebo-controlled, cross-over, clinical trial

In the present work, the antihypertensive effects of celery seed extract (Apium graveolens) with active ingredients, such as 3-n-butylphthalide, were studied as a drug supplement in the treatment of hypertension. This study was a randomized, triple-blind, placebo-controlled, cross-over clinical trial. Fifty-two patients were divided into two groups (celery and placebo) and completed the two-step clinical trial. Four celery seed extract capsules (totally 1.34 g per day) or 4 placebo capsules per day were administered to the patients during a 4-week clinical trial. The blood pressure was assessed using a 24-hr ambulatory blood pressure monitoring method. In celery group, systolic blood pressure changed from 141.2 ± 5.91 to 130.0 ± 4.38 mmHg (p < .001) while diastolic blood pressure changed from 92.2 ± 5.74 to 84.2 ± 4.87 mmHg (p < .001). Moreover, the mean arterial blood pressure changed from 108.5 ± 5.76 to 99.5 ± 4.66 mmHg (p < .001), and pulse pressure decreased from 49.0 ± 6.21 to 45.8 ± 6.01 mmHg (p < .01). However, no significant changes were observed in placebo group in terms of the above-mentioned parameters (p > .05). Furthermore, no significant side effect was reported in the celery group, compared to the placebo group (p > .05). The results were promising and indicated the therapeutic effects of celery seed extract as a supplement in the management of hypertension.

Abnormal Circadian Blood Pressure Variation is Associated with SYNTAX Scores in Hospitalized Patients with Acute Coronary Syndrome

BACKGROUND

Blunted nocturnal blood pressure (BP) reduction, referred to as non-dipper hypertension, is a strong predictor of cardiovascular morbidity and mortality.

OBJECTIVES

This study aimed to investigate the relationship between non-dipper hypertension and the severity and complexity of coronary artery disease using SYNTAX score in hospitalized patients with acute coronary syndrome.

METHODS

A total of 306 consecutive patients with acute coronary syndrome were screened. Patients who were clinically stable and admitted to the intermediate intensive care unit at least 24 hours after angiography and/or successful revascularization. After the exclusion criteria, 141 patients (34 female and 107 male; mean age 61 ± 11 years) were included. Non-dipper hypertension has been defined as a 0% to 10% decrease in average systolic BP at nighttime compared to daytime, measured at hourly intervals using the same automatic BP measuring device on bedside monitors (Vismo PVM-2701; Nihon Kohden Corp., Tokyo, Japan). SYNTAX score was calculated with an online calculator. The independent predictors of SYNTAX score were assessed using multivariable logistic regression analysis. P < 0.05 was considered statistically significant.

RESULTS

The patients with non-dipper hypertension had higher SYNTAX score than the patients with dipper hypertension (11.12 ± 6.41 versus 6.74 ± 6.45, p < 0.0001). In a multivariable logistic regression model, non-dipper hypertension status (odds ratio: 5.159; 95% confidence interval: 2.246 to 11.852, p < 0.001), sex (p = 0.012) and low-density lipoprotein cholesterol (p = 0.008) emerged as independent predictors of high SYNTAX score.

CONCLUSIONS

The results of our study provide a possible additional mechanism linking abnormal circadian BP profile with coronary artery disease severity and complexity in patients with acute coronary syndrome.

Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease

Patients with widespread atherosclerosis such as peripheral artery disease (PAD) have a high risk of cardiovascular and limb symptoms and complications, which affects their quality of life and longevity. Over the past 2 decades there have been substantial advances in diagnostics, pharmacotherapy, and interventions including endovascular and open surgical to aid in the management of PAD patients. To summarize the evidence regarding approaches to diagnosis, risk stratification, medical and intervention treatments for patients with PAD, guided by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, evidence was synthesized, and assessed for quality, and recommendations provided-categorized as weak or strong for each prespecified research question. Fifty-six recommendations were made, with 27% (15/56) graded as strong recommendations with high-quality evidence, 14% (8/56) were designated as strong recommendations with moderate-quality evidence, and 20% (11/56) were strong recommendations with low quality of evidence. Conversely 39% (22/56) were classified as weak recommendations. For PAD patients, strong recommendations on the basis of high-quality evidence, include smoking cessation interventions, structured exercise programs for claudication, lipid-modifying therapy, antithrombotic therapy with a single antiplatelet agent or dual pathway inhibition with low-dose rivaroxaban and aspirin; treatment of hypertension with an angiotensin converting enzyme or angiotensin receptor blocker; and for those with diabetes, a sodium-glucose cotransporter 2 inhibitor should be considered. Furthermore, autogenous grafts are more effective than prosthetic grafts for surgical bypasses for claudication or chronic limb-threatening ischemia involving the popliteal or distal arteries. Other recommendations indicated that new endovascular techniques and hybrid procedures be considered in patients with favourable anatomy and patient factors, and finally, the evidence for perioperative risk stratification for PAD patients who undergo surgery remains weak.

Ambulatory diastolic blood pressure: a marker of comorbidity in elderly fit hypertensive individuals?

BACKGROUND

Masked diastolic hypotension is a new blood pressure (BP) pattern detected by ambulatory blood pressure monitoring (ABPM) in elderly hypertensives. The aim of this study was to relate ABPM and comorbidity in a cohort of fit elderly subjects attending an outpatient hypertension clinic.

METHODS

Comorbidity was assessed by Charlson comorbidity index (CCI) and CHA₂DS₂VASc score. All subjects evaluated with ABPM were aged ≥ 65 years. CCI and CHA₂DS₂VASc score were calculated. Diastolic hypotension was defined as mean ambulatory diastolic BP < 65 mmHg and logistic regression analysis was carried out in order to detect and independent relationship between comorbidity burden and night-time diastolic BP < 65 mmHg.

RESULTS

We studied 174 hypertensive elderly patients aged 72.1 ± 5.2 years, men were 93 (53.4%). Mean CCI was 0.91 ± 1.14 and mean CHA₂DS₂VASc score of 2.68 ± 1.22. Subjects with night-time mean diastolic values < 65 mmHg were higher in females [54.7% vs. 45.3%, P = 0.048; odds ratio (OR) = 1.914, 95% CI: 1.047-3.500]. Logistic regression analysis showed that only CHA₂DS₂VASc score was independently associated with night-time mean diastolic values < 65 mmHg (OR = 1.518, 95% CI: 1.161-1.985; P = 0.002), but CCI was not.

CONCLUSIONS

ABPM and comorbidity evaluation appear associated in elderly fit subjects with masked hypotension. Comorbid women appear to have higher risk for low ambulatory BP.

Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke

Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant. Important questions in a secondary prevention setting include should everyone be treated regardless of their poststroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored. We review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.

Clinical Trial Design Principles and Outcomes Definitions for Device-Based Therapies for Hypertension: A Consensus Document From the Hypertension Academic Research Consortium

The clinical implications of hypertension in addition to a high prevalence of both uncontrolled blood pressure and medication nonadherence promote interest in developing device-based approaches to hypertension treatment. The expansion of device-based therapies and ongoing clinical trials underscores the need for consistency in trial design, conduct, and definitions of clinical study elements to permit trial comparability and data poolability. Standardizing methods of blood pressure assessment, effectiveness measures beyond blood pressure alone, and safety outcomes are paramount. The Hypertension Academic Research Consortium (HARC) document represents an integration of evolving evidence and consensus opinion among leading experts in cardiovascular medicine and hypertension research with regulatory perspectives on clinical trial design and methodology. The HARC document integrates the collective information among device-based therapies for hypertension to better address existing challenges and identify unmet needs for technologies proposed to treat the world’s leading cause of death and disability. Consistent with the Academic Research Consortium charter, this document proposes pragmatic consensus clinical design principles and outcomes definitions for studies aimed at evaluating device-based hypertension therapies.

Effect of a fixed-dose combination of Telmisartan/S-amlodipine on circadian blood pressure compared with Telmisartan monotherapy: TENUVA-BP study

Background

This study evaluated the circadian efficacy of a telmisartan 40 mg/S-amlodipine 2.5 mg fixed-dose combination (Telmisartan40/S-Amlodipine2.5) compared to telmisartan 80 mg (Telmisartan80) in patients with essential hypertension who did not respond to 2–4 weeks’ treatment with telmisartan 40 mg.

Methods

Eligible patients with essential hypertension (clinic mean sitting systolic blood pressure [MSSBP] ≥140 mmHg, or ≥ 130 mmHg in those with diabetes mellitus or chronic kidney disease) were randomly assigned to Telmisartan40/S-Amlodipine2.5 or Telmisartan80 for 8 weeks. All patients underwent ambulatory BP monitoring (ABPM) at baseline and 8 weeks later. Primary endpoints were changes in mean 24-h SBP and DBP on 24-h ABPM from baseline after 8 weeks. Secondary endpoints were changes in daytime, nighttime, and morning SBP and DBP, and clinic MSSBP and MSDBP.

Results

A total of 316 Korean patients were enrolled, 217 patients were randomized to treatment, and 192 patients completed the study. Compared to Telmisartan80, Telmisartan40/S-Amlodipine2.5 showed significantly better reductions in 24-h mean SBP and DBP after 8 weeks. Telmisartan40/S-Amlodipine2.5 also significantly reduced secondary endpoints compared to Telmisartan80. Among 15 adverse events (7 [Telmisartan40/S-Amlodipine2.5] and 8 [Telmisartan80]), there were five adverse drug reactions; 14 events were mild, and none were identified with significant between-group differences.

Conclusions

Telmisartan40/S-Amlodipine2.5 was tolerable and more effective than Telmisartan80 in lowering 24-h mean ambulatory BP in patients with essential hypertension not responding adequately to Telmisartan40. Our findings support the fact that the combination of S-amlodipine with telmisartan is more appropriate than increasing the dose of telmisartan monotherapy.

Trial registration

ClinicalTrials.gov, NCT02231788. Registered 4 September 2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-021-00184-0.

Chronic Kidney Disease and Left Ventricular Hypertrophy. Potent Modifiers of the Prognostic Impact of Circadian Blood Pressure Changes

BACKGROUND

It is unclear whether the prognostic value of blood pressure (BP) changes from day to night is modified by concomitant risk factors and organ damage.

METHODS

We studied 3247 clinically hypertensive patients who underwent off-therapy 24-hour ambulatory BP monitoring during their initial diagnostic work-up. Over a mean 9.9-year follow-up, 292 patients developed a first primary outcome event (composite of nonfatal myocardial infarction, nonfatal stroke, cardiovascular death, hospitalization for heart failure) and 281 died. The day-night BP changes were analyzed as night-to-day systolic BP ratio and included in semiparametric Cox models.

RESULTS

After allowance for age, sex, diabetes, cigarette smoking, low-density lipoprotein cholesterol, serum uric acid and average 24-hour systolic BP, the night-to-day systolic BP ratio maintained an independent association with outcome (hazard ratio, 1.17 [1.01-1.35]; P=0.041). When 2 markers of organ damage, chronic kidney disease and left ventricular hypertrophy, were added to the model, the night-to-day systolic BP ratio failed to maintain an independent association with outcome (hazard ratio, 1.19 [0.97-1.31]). The Akaike Information Criterion and the Schwarz-Bayes Information Criterion showed that, after allowance for other covariables, the night-to-day systolic BP ratio: (1) provided less information when compared with chronic kidney disease and left ventricular hypertrophy and (2) did not improve information provided by chronic kidney disease and left ventricular hypertrophy. Results were comparable on all-cause death as well as using categories of the night-day systolic BP ratio (extreme dippers, dippers, nondippers, reverse dippers).

CONCLUSIONS

Chronic kidney disease and left ventricular hypertrophy are potent modifiers of the prognostic value of the circadian BP changes.

Glycoprotein Acetyls: A Novel Inflammatory Biomarker of Early Cardiovascular Risk in the Young

Background Low-grade inflammation in the young may contribute to the early development of cardiovascular disease. We assessed whether circulating levels of glycoprotein acetyls (GlycA) were better able to predict the development of adverse cardiovascular disease risk profiles compared with the more commonly used biomarker high-sensitivity CRP (C-reactive protein). Methods and Results A total of 3306 adolescents and young adults from the Avon Longitudinal Study of Parents and Children (mean age, 15.4±0.3; n=1750) and Cardiovascular Risk in Young Finns Study (mean age, 32.1±5.0; n=1556) were included. Baseline associations between inflammatory biomarkers, body composition, cardiovascular risk factors, and subclinical measures of vascular dysfunction were assessed cross-sectionally in both cohorts. Prospective risk of developing hypertension and metabolic syndrome during 9-to-10-year follow-up were also assessed as surrogate markers for future cardiovascular risk. GlycA showed greater within-subject correlation over 9-to-10-year follow-up in both cohorts compared with CRP, particularly in the younger adolescent group (r=0.36 versus 0.07). In multivariable analyses, GlycA was found to associate with multiple lifestyle-related cardiovascular disease risk factors, cardiometabolic risk factor burden, and vascular dysfunction (eg, mean difference in flow-mediated dilation=-1.2 [-1.8, -0.7]% per z-score increase). In contrast, CRP levels appeared predominantly driven by body mass index and showed little relationship to any measured cardiovascular risk factors or phenotypes. In both cohorts, only GlycA predicted future risk of both hypertension (risk ratio [RR], ≈1.1 per z-score increase for both cohorts) and metabolic syndrome (RR, ≈1.2-1.3 per z-score increase for both cohorts) in 9-to-10-year follow-up. Conclusions Low-grade inflammation captured by the novel biomarker GlycA is associated with adverse cardiovascular risk profiles from as early as adolescence and predicts future risk of hypertension and metabolic syndrome in up to 10-year follow-up. GlycA is a stable inflammatory biomarker which may capture distinct sources of inflammation in the young and may provide a more sensitive measure than CRP for detecting early cardiovascular risk.

Assessment of hypertension in kidney transplantation by ambulatory blood pressure monitoring: a systematic review and meta-analysis

Background

Hypertension (HTN) is common following renal transplantation and it is associated with adverse effects on cardiovascular (CV) and graft health. Ambulatory blood pressure monitoring (ABPM) is the preferred method to characterize blood pressure (BP) status, since HTN misclassification by office BP (OBP) is quite common in this population. We performed a systematic review and meta-analysis aimed at determining the clinical utility of 24-h ABPM and its potential implications for the management of HTN in this population.

Methods

Ovid-MEDLINE and PubMed databases were searched for interventional or observational studies enrolling adult kidney transplant recipients (KTRs) undergoing 24-h ABP readings compared with OBP or home BP. The main outcome was the proportion of KTRs diagnosed with HTN by ABPM, home or OBP recordings. Additionally, day-night BP variability and dipper/non-dipper status were assessed.

Results

Forty-two eligible studies (4115 participants) were reviewed. A cumulative analysis including 27 studies (3481 participants) revealed a prevalence of uncontrolled HTN detected by ABPM of 56% [95% confidence interval (CI) 46-65%]. The pooled prevalence of uncontrolled HTN according to OBP was 47% (95% CI 36-58%) in 25 studies (3261 participants). Very few studies reported on home BP recordings. The average concordance rate between OBP and ABPM measurements in classifying patients as controlled or uncontrolled hypertensive was 66% (95% CI 59-73%). ABPM revealed HTN phenotypes among KTRs. Two pooled analyses of 11 and 10 studies, respectively, revealed an average prevalence of 26% (95% CI 19-33%) for masked HTN (MHT) and 10% (95% CI 6-17%) for white-coat HTN (WCH). The proportion of non-dippers was variable across the 28 studies that analysed dipping status, with an average prevalence of 54% (95% CI 45-63%).

Conclusions

In our systematic review, comparison of OBP versus ABP measurements disclosed a high proportion of MHT, uncontrolled HTN and, to a lesser extent, WCH in KTRs. These results suggest that HTN is not adequately diagnosed and controlled by OBP recordings in this population. Furthermore, the high prevalence of non-dippers confirmed that circadian rhythm is commonly disturbed in KTRs.

Impact of the ambulatory blood pressure monitoring profile on cognitive and imaging findings of cerebral small-vessel disease in older adults with cognitive complaints

We investigated ambulatory blood pressure (BP) monitoring (ABPM) profiles and magnetic resonance imaging (MRI) findings of cerebral small-vessel disease (cSVD) in older adults with cognitive complaints who were grouped as follows: subjective cognitive decline, mild cognitive impairment, and dementia of Alzheimer's type. Group comparisons and correlation analyses among demographic characteristics, cognitive and MRI findings, and ABPM profiles were performed. Furthermore, multivariate logistic regression analyses for dependent variables of (1) dementia or not and (2) MRI criteria of subcortical vascular dementia (SVaD) or not were conducted with independent variables of dichotomized ABPM profiles. A total of 174 subjects (55 males and 119 females) were included: mean age 75.36 ± 7.13 years; Mini-Mental State Examination (MMSE) score 20.51 ± 6.23. No MRI and ABPM findings except medial temporal atrophy were different between three groups. Twenty-four-hour systolic BP (sBP) was correlated with MMSE score (r = -0.182; p = 0.022) and the severity of white matter hyperintensity (WMH) (r = 0.157; p = 0.048). A higher daytime sBP was associated with dementia (odds ratio (OR): 3.734; 95% confidence interval (CI): 1.041-13.390; p = 0.043) and MRI finding of SVaD (OR: 10.543; 95% CI: 1.161-95.740; p = 0.036). Although there were no differences in ABPM profiles between three groups, a higher BP-especially a higher sBP-correlated with cognitive dysfunction and severity of WMH in older adults. Only higher daytime sBP was an independent predictor for dementia and MRI findings of SVaD. Among various ABPM profiles in this study, a higher BP, especially a higher sBP, may be considered the most important for clinical and MRI findings of cSVD.

Hypertensive Phenotypes and Pattern of Ambulatory Blood Pressure in Patients of Diabetes Mellitus of Kashmir Valley

BACKGROUND

Patients of diabetes mellitus (DM) with hypertension (HTN) have a fourfold increased risk of cardiovascular disease (CVD) as compared to normotensive nondiabetic controls. However, many patients of DM who are normotensive or have controlled blood pressure on office BP measurement (OBPM) may assume that they do not have increased risk of CVD but may be having HTN or uncontrolled blood pressure on ambulatory blood pressure monitoring (ABPM).

STUDY DESIGN OBJECTIVE

A cross-sectional observational study to compare OBPM with ABPM and thus predict various hypertensive phenotypes like masked hypertension (MH) and white coat hypertension and pattern of blood pressure in diabetic patients of our population.

MATERIALS AND METHODS

Two hundred patients of DM with or without HTN were included in this study. The cases were subjected to detailed history, clinical examination, OBPM, and ABPM.

RESULTS

Out of 200 patients of DM, 32 were normotensives, 46 were hypertensives controlled on antihypertensive treatment, 22 were hypertensives not on anti-hypertensive treatment, and 100 were hypertensives uncontrolled on anti-hypertensive treatment. Among 32 normotensive diabetics, 17 (53%) patients had MH on ABPM. Out of these 32 normotensive patients, 7 (21.8%) had isolated nocturnal hypertension, 3 (9.3%) had isolated day-time HTN (IDH) and 7 (21.8%) had day-time and nocturnal HTN (DNH). Patients with MH had higher BMI, an observation that was statistically significant. Non-dipping pattern was found in 53% of patients of masked HTN. Out of 46 hypertensive diabetics with controlled OBPM on antihypertensive treatment, 26 (56.5%) had masked effect or masked uncontrolled hypertension on ABPM. Out of 22 diabetics with treatment naïve HTN, 7 (32%) were found to have white coat hypertension on ABPM. Fifteen (15%) patients out of 100 hypertensive diabetics with uncontrolled OBPM despite on anti-hypertensive were found to have white coat effect on ABPM. Patients with white coat effect had higher body mass index an observation that was statistically significant (p = 0.039). Non-dipping pattern was significantly associated with longer duration of diabetes (≥ 120 months), retinopathy and neuropathy.

CONCLUSION

To rely exclusively on OBPM to diagnose HTN and monitor blood pressure may underestimate the CVD risk especially in diabetics. ABPM is a tool that may not only help clinicians in starting anti-HTN treatment perspicuously, but also may help in avoiding unnecessary anti-hypertensive treatment and/or withdrawing anti-hypertensive treatment as indicated and thus avoiding credulity.

Association of nocturnal subconjunctival hemorrhage and non-dipper blood pressure pattern: A benign clue for serious diseases

PURPOSE

To evaluate the association between non-dipper blood pressure pattern and subconjunctival hemorrhage (SCH).

METHODS

Twenty-seven consecutive patients with nocturnal SCH and 27 age, sex-matched controls were enrolled. Demographic, blood parameters, office blood pressure measurements, 24-h ambulatory blood pressure monitoring (ABPM) were evaluated.

RESULTS

Mean diastolic blood pressure (DBP) for nighttime (65.03 ± 7.1 vs. 70.78 ± 10.5, p: 0.22), mean heart rate for nighttime (64.54 ± 8.26 vs. 69.93 ± 9.85, p: 0.034), Minimum Systolic Blood pressure(SBP) and DBP values for nighttime (92.44 ± 9.72 vs. 99.44 ± 10.66, p:0.015 and 51.15 ± 8.31 vs. 57.7 ± 11.2, p: 0.018) were higher, nocturnal fall ratio of SBP and DBP were significantly lower in the SCH ( + ) group compared to SCH (-) group (5.38 ± 8.39 vs. 10.34 ± 6.08, p: 0.016 and 4.26 ± 8.92 vs. 13.78 ± 6.97, p < 0001 respectively). Ten patients (37%) in the SCH (-) group and 18 patients (66.7%) in the SCH ( + ) group were non-dippers (p: 0.029). Mean daytime SBP and DBP were higher compared to office measurements of 4 patients (14.8%) in the SCH (-) group and 11 patients (40.7%) in the SCH ( + ) group (p: 0.033).

CONCLUSION

SCH had a strong association with non-dipper blood pressure pattern, higher nocturnal heart rate and masked hypertension which are precursors of myocardial infarction, stroke and renal failure. So, SCH should be considered as a clue for serious diseases such as coronary artery disease, myocardial infarction, stroke and patients should be evaluated for ABPM.

Nocturnal blood pressure surge in seconds is a new determinant of left ventricular mass index

Nocturnal blood pressure (BP) surge in seconds (sec‐surge), which is characterized as acute transient BP elevation over several tens of seconds, could be a predictor of target organ damage. However, it is not clear that the severity of sec‐surge is different between sec‐surges induced by sleep apnea (SA) (apnea/hypopnea detected by polysomnography (PSG) or oxygen desaturation) and those induced by non‐SA factors (rapid eye movement, micro arousal, etc.), and sec‐surge variables associate with left ventricular hypertrophy (LVH) independently of conventional BP variables. The authors assessed these points with 41 patients (mean age 63.2±12.6 years, 29% female) who underwent full PSG, beat‐by‐beat (BbB) BP, and cuff‐oscillometric BP measurement during the night. All patients were included for the analysis comparing sec‐surge severity between inducing factors (SA and non‐SA factors). There were no significant differences in the number of sec‐surges/night between SA‐related sec‐surges and non‐SA‐related sec‐surges (19.5±26.0 vs. 16.4±29.8 events/night). There were also no significant differences in the peak of sec‐surges, defined as the maximum systolic BPs (SBPs) in each sec‐surge, between SA‐related sec‐surges and non‐SA‐related sec‐surges (148.2±18.5 vs. 149.3±19.2 mm Hg). Furthermore, as a result of multiple regression analysis (n = 18), the peak of sec‐surge was significantly and strongly associated with the left ventricular mass index (standardized β = 0.62, p = .02), compared with the mean nocturnal SBPs measured by oscillometric method (β = −0.04, p = .87). This study suggests that peak of sec‐surge could be a better predictor of LVH compared to parameters derived from regular nocturnal oscillometric SBP.

Catheter-Based Renal Denervation Therapy: Evolution of Evidence and Future Directions

Motivated by the persistence of uncontrolled blood pressure and its public health impact, the development and evaluation of device-based therapies for hypertension has advanced at an accelerated pace to complement pharmaceutical and lifestyle intervention strategies. Countering widespread interest from early studies, the lack of demonstrable efficacy for renal denervation (RDN) in a large, sham-controlled randomized trial motivated revision of trial design and conduct to account for confounding variables of procedural technique, medication variability, and selection of both patients and end points. Now amidst varied trial design and methods, several sham-controlled, randomized trials have demonstrated clinically meaningful reductions in blood pressure with RDN. With this momentum, additional studies are underway to position RDN as a potential part of standard therapy for the world's leading cause of death and disability. In parallel, further studies will address unresolved issues including durability of blood pressure lowering and reduction in antihypertensive medications, late-term safety, and impact on clinical outcomes. Identifying predictors of treatment effect and surveys of patient-reported outcomes and treatment preferences are also evolving areas of investigation. Aside from confirmatory studies of safety and effectiveness, these additional studies will further inform patient selection, expand experience with RDN in broader populations with hypertension, and provide guidance to how RDN may be incorporated into treatment pathways.

Practice Patterns in the Acceptance of Medically Complex Living Kidney Donors with Obesity, Hypertension, Family History of Kidney Disease, or Donor-Recipient Age Discrepancy

Background  To assess the practice patterns of the acceptance of medically complex living kidney donors (MCLKDs).

Methods  We distributed a survey to nephrologists and transplant surgeons (TS) across the world through major international transplant societies. The survey contained questions regarding obesity, abnormal blood glucose profile, mild hypertension, donor-recipient age discrepancy, or family history of kidney disease of unknown etiology.

Results  In total, 239 respondents from 29 countries (42% were nephrologists and 58% were TS).

Most respondents would allow donations from obese donors, especially if they intended to lose weight but would be cautious if these donors had abnormal blood glucose or family history of diabetes mellitus. In hypertensive donors, future pregnancy plans mattered in decisions regarding the acceptance of female donors. Most respondents would allow young donors but would be more cautious if they had a future risk of hypertension or a family history of kidney disease of unknown etiology. They would also allow donations from an older person if prolonged waiting time was anticipated. We found multiple areas of consensus of practice among the diverse members of international transplant societies, with some interesting variations among nephrologists and TS.

Conclusions  This survey highlights the practice patterns of the acceptance of MCLKDs among the international community. In the absence of clear guidelines, this survey provides additional information to counsel kidney donors with these conditions.

Isolated Diastolic Hypertension in the IDACO Study: An Age-Stratified Analysis Using 24-Hour Ambulatory Blood Pressure Measurements

[Figure: see text].

Morning blood pressure surge in the early stage of hypertensive patients impacts three-dimensional left ventricular speckle tracking echocardiography

BACKGROUND

The aim of this study was to examine left ventricular (LV) function in untreated, newly diagnosed hypertensive patients with morning blood pressure surge (MBPS) status using three-dimensional (3D) speckle tracking echocardiography (STE).

METHODS

In this study, 163 newly diagnosed hypertensive patients were included, and all patients underwent 24-h ambulatory blood pressure monitoring (ABPM). According to ABPM, participants were divided into a MBPS group and a non-MBPS group. The entire study population was examined by complete two-dimensional (2D) transthoracic echocardiography (TTE) and 3D STE.

RESULT

The results of this study showed that 3D LV longitudinal strain was significantly decreased in the MBPS group compared with the non-MBPS group (- 30.1 ± 2.0 vs. -31.1 ± 2.7, p = 0.045). Similar trends were observed for 3D twist (9.6 ± 6.1 vs. 12.1 ± 4.8, p = 0.011) as well as for 3D torsion (1.23 ± 0.78 vs. 1.49 ± 0.62, p = 0.042). The LV principal strain was decreased in the MBPS group (- 33.9 ± 1.7 vs. -35.5 ± 2.8, p < 0.001). The 3D LV global longitudinal strain (GLS) and principal strain were significantly associated with quartile of MBPS as measured by systolic blood pressure (SBP).

CONCLUSION

The 3D STE revealed that LV mechanics were more impaired in the MBPS group than in the non-surge newly diagnosed, untreated hypertensive patients; even the 2D TTE parameters showed no difference.

Nocturnal blood pressure rise as a predictor of cognitive impairment among the elderly: a retrospective cohort study

Background

This study investigated the different blood pressure patterns that were evaluated by ambulatory blood pressure monitoring (ABPM) among elderly patients and explored the effect of pressure patterns on cognitive impairment and mortality.

Methods

A total of 305 elderly participants aged ≥65 years were divided into the cognitive impairment group (CI, n = 130) and the non-cognitive impairment group (NCI, n = 175) according to the MMSE score. All participants underwent ABPM to evaluate possible hypertensive disorder and cerebral MRI for the evaluation of cerebral small vessel disease. Follow-up was performed by telephone or medical records. The primary outcome was all-cause mortality. Secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE).

Results

Among 305 participants, 130 (42.6%) were identified with cognitive impairment (CI), with average systolic blood pressure (BP) of 127 mmHg and diastolic BP of 66 mmHg. According to ABPM, only 13.1% had a dipper pattern, 45.6% had a nocturnal BP rise, while 41.3% had a non-dipper pattern. Compared with NCI patients, the CI group had significantly higher night-time systolic BP (130.0 ± 18.2 vs. 123.9 ± 15.1, p = 0.011), and more participants had nocturnal BP rise (52.3% vs. 40.6%, p = 0.042). Nocturnal BP rise was associated with greater white matter hyperintensities (WMH) (p = 0.013). After 2.03 years of follow-up, there were 35 all-cause deaths and 33 cases of major adverse cardiac and cerebrovascular events (MACCE). CI was independently associated with all-cause mortality during long-term observation (p < 0.01). Nocturnal BP rise had no significant predictive ability for all-cause mortality in elderly patients (p = 0.178).

Conclusions

Nocturnal BP rise contributed to greater cognitive impairment in elderly patients. Not nocturnal BP rise, but CI could significantly increase all-cause mortality. Controlling BP based on ABPM is critical for preventing the progression of cognitive dysfunction.

Effects of Cranberry Juice Supplementation on Cardiovascular Disease Risk Factors in Adults with Elevated Blood Pressure: A Randomized Controlled Trial

Emerging cardiovascular disease (CVD) risk factors, including central vascular function and HDL efflux, may be modifiable with food-based interventions such as cranberry juice. A randomized, placebo-controlled, crossover trial was conducted in middle-aged adults with overweight/obesity (n = 40; mean BMI: 28.7 ± 0.8 kg/m²; mean age: 47 ± 2 years) and elevated brachial blood pressure (mean systolic/diastolic BP: 124 ± 2/81 ± 1 mm Hg). Study participants consumed 500 mL/d of cranberry juice (~16 fl oz; 27% cranberry juice) or a matched placebo juice in a randomized order (8-week supplementation periods; 8-week compliance break), with blood samples and vascular measurements obtained at study entry and following each supplementation period. There was no significant treatment effect of cranberry juice supplementation on the primary endpoint of central systolic blood pressure or central or brachial diastolic pressure. Cranberry juice significantly reduced 24-h diastolic ambulatory BP by ~2 mm Hg compared to the placebo (p = 0.05) during daytime hours. Cranberry juice supplementation did not alter LDL-C but significantly changed the composition of the lipoprotein profile compared to the placebo, increasing the concentration of large LDL-C particles (+29.5 vs. −6.7 nmol/L; p = 0.02) and LDL size (+0.073 vs. −0.068 nm; p = 0.001). There was no effect of treatment on ex vivo HDL efflux in the total population, but exploratory subgroup analyses identified an interaction between BMI and global HDL efflux (p = 0.02), with greater effect of cranberry juice in participants who were overweight. Exploratory analyses indicate that baseline C-reactive protein (CRP) values may moderate treatment effects. In this population of adults with elevated blood pressure, cranberry juice supplementation had no significant effect on central systolic blood pressure but did have modest effects on 24-h diastolic ambulatory BP and the lipoprotein profile. Future studies are needed to verify these findings and the results of our exploratory analyses related to baseline health moderators.

Twenty-Four-Hour Ambulatory Blood Pressure Monitoring

The diagnosis, management, and estimated mortality risk in patients with hypertension have been historically based on clinic or office blood pressure readings. Current evidence indicates that 24-hour ambulatory blood pressure monitoring should be an integral part of hypertension care. The 24-hour ambulatory monitors currently available on the market are small devices connected to the arm cuff with tubing that measure blood pressure every 15 to 30 minutes. After 24 hours, the patient returns, and the data are downloaded, including any information requested by the physician in a diary. The most useful information includes the 24-hour average blood pressure, the average daytime blood pressure, the average nighttime blood pressure, and the calculated percentage drop in blood pressure at night. The most widely used criteria for 24-hour measurements are from the American Heart Association 2017 guidelines and the European Society of Hypertension 2018 guidelines. Two important scenarios described in this document are white coat hypertension, in which patients have normal blood pressures at home but high blood pressures during office visits, and masked hypertension, in which patients are normotensive in the clinic but have high blood pressures outside of the office. The Centers for Medicare and Medicaid Services has made changes in its policy to allow reimbursement for a broader use of 24-hour ambulatory blood pressure monitoring within some specific guidelines. Primary care physicians should make more use of ambulatory blood pressure monitoring, especially in patients with difficult to manage hypertension.

Association of self-measured home, ambulatory, and strictly measured office blood pressure and their variability with intracranial arterial stenosis

OBJECTIVE

Hypertension and intracranial artery stenosis (ICAS) are closely related; however, few studies have compared the strength of the relationship between strictly measured office and out-of-office blood pressure (BP) measurements. The relationship of day-by-day or short-term variability in BP to asymptomatic ICAS also remains unclear.

METHODS

In apparently healthy 677 men (mean age, 70 years) from a population-based cohort, we examined the association of strictly measured office BP and 7-day home BP with ICAS on magnetic resonance angiography. We conducted 24-h ambulatory BP monitoring in 468 of the men. Variability indices included day-by-day, daytime, and night-time variability, nocturnal decline, and morning pressor surge. Any ICAS was defined as either mild (1-49%) or severe (≥50%) stenosis.

RESULTS

We observed mild and severe ICAS in 153 (22.6%) and 36 (5.3%) participants, respectively. In multivariable-adjusted Poisson regression with robust error variance, higher SBP in office, home, or ambulatory BP monitoring was associated with the presence of any or severe ICAS. The associations with ICAS were comparable between office, home, and ambulatory SBP (all heterogeneity P values >0.1). Independent of mean SBP, greater nocturnal decline or morning pressor surge, but not day-by-day, daytime, or night-time variability, in SBP was associated with higher burden of any or severe ICAS.

CONCLUSION

The magnitude of association of strictly measured office BP for asymptomatic ICAS was comparable with that of BP measured at home or in ambulatory BP monitoring. Circadian BP variation based on ambulatory BP monitoring was positively associated with asymptomatic ICAS burden.

The Impact of Various Blood Pressure Measurements on Cardiovascular Outcomes

Hypertension is a potent risk factor for cardiovascular morbidity and mortality. High blood pressure (BP) correlates closely with all-cause and cardiovascular mortality. Although the gold standard remains office BP (auscultatory or automated), other methods (central or out-of-office) are gaining popularity as better predictors of CV events. In this review, we investigated the prognostic value of each method of BP measurement and explored their advantages and pitfalls. Unattended automated office BP is a novel technique of BP measurement with promising data. Ambulatory BP monitoring, and to a lesser extent, home BP measurements, seem to predict cardiovascular events and mortality outcomes better, while at the same time, they can help distinguish hypertensive phenotypes. Data on the association of central BP levels with cardiovascular and mortality outcomes, are conflicting. Future extensive cross-sectional and longitudinal studies are needed to evaluate head-to-head the corresponding levels and results of each method of BP measurement, as well as to highlight disparities in their prognostic utility.

Roles of cardiovascular autonomic regulation and sleep patterns in high blood pressure induced by mild cold exposure in rats

Increased blood pressure (BP) caused by exposure to cold temperatures can partially explain the increased incidence of cardiovascular events in winter. However, the physiological mechanisms involved in cold-induced high BP are not well established. Many studies have focused on physiological responses to severe cold exposure. In this study, we aimed to perform a comprehensive analysis of cardiovascular autonomic function and sleep patterns in rats during exposure to mild cold, a condition relevant to humans in subtropical areas, to clarify the physiological mechanisms underlying mild cold-induced hypertension. BP, electroencephalography, electromyography, electrocardiography, and core body temperature were continuously recorded in normotensive Wistar-Kyoto rats over 24 h. All rats were housed in thermoregulated chambers at ambient temperatures of 23, 18, and 15 °C in a randomized crossover design. These 24-h physiological recordings either with or without sleep scoring showed that compared with the control temperature of 23 °C, the lower ambient temperatures of 18 and 15 °C not only increased BP, vascular sympathetic activity, and heart rate but also decreased overall autonomic activity, parasympathetic activity, and baroreflex sensitivity in rats. In addition, cold exposure reduced the delta power percentage and increased the incidence of interruptions during sleep. Moreover, a correlation analysis revealed that all of these cold-induced autonomic dysregulation and sleep problems were associated with elevation of BP. In conclusion, mild cold exposure elicits autonomic dysregulation and poor sleep quality, causing BP elevation, which may have critical implications for cold-related cardiovascular events.