Clinical value of ambulatory blood pressure: Is it time to recommend for all patients with hypertension?

Patient-specific multifactorial mortality risk assessment using classification and regression tree analysis in the context of ambulatory blood pressure monitoring

BACKGROUND

Ambulatory blood pressure monitoring is essential for understanding blood pressure patterns beyond clinical visits, aiding in risk assessment, treatment evaluation, and managing hypertension. This retrospective cohort study aimed to identify risk factors for all-cause mortality and major cardiovascular events in patients who underwent ambulatory blood pressure monitoring.

METHODOLOGY

Eligible participants aged 18 or older, with an estimated glomerular filtration rate (eGFR) > 60 ml/min/1.73 m2, who underwent ambulatory blood pressure monitoring for various reasons, were included in the study. Data were gathered through telephone interviews, electronic health records, and the national health record system. Descriptive analysis and classification and regression tree modeling were used to uncover significant risk factors related to all-cause mortality and cardiovascular events, and to assess the model's performance compared to traditional Cox survival analysis.

RESULTS

The study included 1291 patients, primarily male (51.8%) with a mean age of 61.1 ± 15.2 years. During a mean follow-up of 46.9 months, 76 (5.9%) patients died of any cause, and 195 (15.1%) had a cardiovascular event. The highest survival rates were observed in patients with a diastolic blood pressure (BP) dipping percentage between - 2% and 29%, nighttime systolic BP variability below 32 mmHg, and age below 72. Conversely, smokers with a diastolic BP dipping percentage below - 10% showed the lowest survival rates. The best cardiovascular outcomes were observed in patients with diastolic BP dipping above - 11%, nighttime mean systolic BP < 144 mmHg, no statin use, normotensive status, and daytime mean heart rate ≥ 60 bpm. Conversely, the worst outcomes were seen in patients with diastolic BP dipping below - 11% and a morning surge ≥ 14 mmHg. In all-cause mortality and cardiovascular event analysis, the combined model demonstrated excellent calibration and predictive power, like the classification and regression tree model and traditional analysis.

CONCLUSION

These findings highlight the potential of a combined model for assessing mortality and cardiovascular event risk in patients who have undergone ambulatory blood pressure monitoring.

The many faces of hypertension in individuals with type 1 diabetes

Several disturbed blood pressure (BP) patterns, including disparities between office and out-of-office BP measurements (such as white-coat and masked hypertension), disturbed circadian BP variability (such as abnormal dipping patterns and nocturnal hypertension) and treatment-resistant hypertension, are common in individuals with type 1 diabetes. Consequently, office or home BP measurements alone may not reflect real BP variation and may lead to inadequate diagnosis and treatment of hypertension. The early detection of these disturbed BP patterns is especially crucial in individuals with type 1 diabetes, as these patterns may indicate future development of adverse cardiovascular and renal outcomes. In this review we will describe these disturbed BP patterns and discuss recent findings on their prevalence and outcomes. We will also address critical areas for future research to determine the true prevalence and prognosis of disturbed BP patterns, and to optimize and improve the knowledge and management of high-risk individuals with type 1 diabetes and disturbed BP patterns.

Assessment of hypertension in obstructive sleep apnea by ambulatory blood pressure monitoring: a systematic review and meta-analysis

Among obstructive sleep apnea (OSA) patients, there exists a high prevalence of hypertension. Determining the optimal blood pressure (BP) monitoring modality in this population will lead to a better understanding of hypertension profiles and a more accurate diagnosis of hypertension. PubMed, Ovid/Medline, Web of Science, Scopus, Cochrane Library, and CINAHL databases were screened, and the relevant articles regarding BP monitoring in OSA patient population were selected. Studies evaluating both ambulatory (ABPM) and office BP measurements were selected to be analyzed for the hypertension diagnosis specificity of ABPM measurement in OSA patients compared with office measurements. If reported, additional information regarding white-coat, masked hypertension, and circadian BP pattern prevalence was included. A cumulative analysis of five studies revealed a prevalence of hypertension based on BP to be 44%, whereas a cumulative analysis of four studies revealed a prevalence of hypertension based on ABPM to be 66%. Excluding a study with the nighttime assessment of hypertension reduced the cumulative prevalence of hypertension in OSA patients to 59%. The cumulative prevalence of Studies demonstrated the prevalence of masked and white-coat hypertension to be 34 and 9%, respectively. As a higher prevalence of hypertension was detected by ABPM and nighttime measurement, it can be deduced that ABPM is more sensitive in determining OSA patients with hypertension, and that nighttime ABPM further increases this sensitivity. The presence of masked and white-coat hypertension in OSA patients underlines the importance of correct hypertension diagnosis as it affects further management in this population with increased cardiovascular risk.

The assessment of hypertension in kidney transplant patients: time to change our approach?

Kidney transplantation (KT) is an increasingly utilized treatment for end-stage kidney disease. Hypertension either as a cause of kidney disease or as a complication of chronic kidney disease is the most frequently encountered comorbidity of KT patients. Hence, the management of hypertension in KT patients is crucial to prolong patient and graft survival. Ambulatory blood pressure monitoring (ABPM) appeared as a promising technique that has superiority over office and home blood pressure (BP) monitoring to correctly diagnose and manage hypertension. A recent meta-analysis by Pisano et al. including 42 studies with 4115 participants provided strong data for the comparison of ABPM with office BP monitoring in KT patients. In addition to the current literature knowledge, the findings of Pisano et al. filled the long-awaited evidence gap to suggest ABPM as a first-line BP monitoring technique for KT patients. Despite its disadvantages, such as patient discomfort, cost–effectiveness and limited availability, ABPM has crucial advantages in the management of hypertension including the detection of abnormal circadian BP patterns, the assessment of effects of physical activity and short-term variability of BP, and the exclusion of masked and white-coat hypertension.

Ambulatory blood pressure and arterial stiffness in individuals with type 1 diabetes

AIMS/HYPOTHESIS

This study aimed to assess the use of ambulatory BP monitoring (ABPM) to identify the presence of masked, nocturnal and white-coat hypertension in individuals with type 1 diabetes, patterns that could not be detected by regular office-based BP monitoring alone. We also analysed associations between BP patterns and arterial stiffness in order to identify individuals at cardiovascular risk.

METHODS

This substudy included 140 individuals with type 1 diabetes from the Helsinki metropolitan area, who attended the Finnish Diabetic Nephropathy Study (FinnDiane) Centre in Helsinki between January 2013 and August 2017. Twenty-four hour ABPM and pulse wave analysis were performed simultaneously using a validated non-invasive brachial oscillometric device (Mobil-O-Graph). Definitions of hypertension were based on the European Society of Hypertension guidelines. Masked hypertension was defined as normal office BP (BP obtained using a standardised automated BP device) but elevated 24 h ABPM, and white-coat hypertension as elevated office BP but normal 24 h ABPM.

RESULTS

A total of 38% of individuals were normotensive and 33% had sustained hypertension, while 23% had masked and 6% had white-coat hypertension. About half of the cohort had increased absolute levels of night-time BP, half of whom were untreated. In the ambulatory setting, central BP and pulse wave velocity (PWV) were higher in participants with masked hypertension than in those with normotension (p ≤ 0.001). In a multivariable linear regression model adjusted for age, sex, BMI, antihypertensive treatment and eGFR, masked hypertension was independently associated with higher 24 h PWV (β 0.50 [95% CI 0.34, 0.66]), but not with PWV obtained during resting conditions (adjusted β 0.28 [95% CI -0.53, 1.10]), using normotension as the reference group.

CONCLUSIONS/INTERPRETATION

ABPM analysis revealed that one-quarter of the participants with type 1 diabetes had masked hypertension; these individuals would not have been detected by office BP alone. Moreover, arterial stiffness was increased in individuals with masked hypertension. These findings support the use of ABPM to identify individuals at risk of cardiovascular disease.

Short-term blood pressure variability and long-term blood pressure variability: which one is a reliable predictor for recurrent stroke

The relationship between blood pressure variability (BPV) and stroke recurrence is controversial. This study aimed to evaluate the predictive value of short-term and long-term BPV for stroke recurrence. The data from blood pressure and clinical outcome in TIA or ischemic stroke (BOSS) study included participants with acute ischemic stroke or transient ischemic attack (TIA) within 7 days after onset. Short-term BPV was measured by 24-h ambulatory BP measurement during hospitalisation. Long-term BPV, based on home blood pressure measurement, was measured by patients or their families from discharge to 90 days after qualifying events onset (twice daily). Variability for systolic blood pressure (SBP) was assessed as the s.d., coefficients of variance (CV). The clinical outcome was recurrent stroke within 1 year. Cox proportional hazards models were used to test the association of short-term BPV, long-term BPV and stroke recurrence. Among 1764 participants, the mean age was 62.45±10.99 years, and 32.1% were females, during 1-year follow-up, 106 (6.0%) participants experienced recurrent stroke. Indices of long-term BPV were significantly associated with stroke recurrence (s.d.: adjusted HR: 1.939, 95% CI: 1.122-3.351; CV: adjusted HR 1.955, 95% CI: 1.174-3.255), independent of mean SBP. However, all indices of short-term BPV (s.d., CV) were not associated with stroke recurrence (s.d.: adjusted HR: 1.245, 95% CI: 0.680-2.280; CV: adjusted HR: 1.142, 95% CI: 0.640-2.038). In conclusion, long-term variation of SBP is a better predictor than short-term variation of SBP for recurrent stroke after acute ischemic stroke or TIA.

Circadian blood pressure abnormalities in patients with primary nephrotic syndrome

BACKGROUND

Only a few studies have evaluated the abnormalities of ambulatory blood pressure (ABP) in patients with nephrotic syndrome (NS).

METHODS

The 24-h ABPs were measured in primary NS patients with acute onset of disease and analyzed in relation to the clinical variables.

RESULTS

Our subjects comprised 21 patients: 17 with minimal change disease and 4 with focal segmental glomerulosclerosis. Of these patients, 8 (38%) had daytime hypertension, 13 (62%) had nighttime hypertension, and 13 (62%) were non-dippers (nighttime-to-daytime ratio of ABP: NDR > 0.9). The serum sodium level was correlated with the average 24-h ABP and NDR, after adjustment for other clinical variables, such as the increase in body weight, serum albumin level, and urinary protein excretion. The data from repeated ABP measurements, before and after the achievement of remission, showed a marked decrease in the average 24-h ABP after remission. Furthermore, change in the serum sodium level was significantly correlated with the change in NDR.

CONCLUSION

These results suggest that alteration in renal handling of sodium and water, which might be reflected in serum sodium level, is involved in the abnormality of circadian blood pressure in primary NS patients.

Novel Approaches to Investigate One-Carbon Metabolism and Related B-Vitamins in Blood Pressure

Hypertension, a major risk factor for heart disease and stroke, is the world's leading cause of preventable, premature death. A common polymorphism (677C→T) in the gene encoding the folate metabolizing enzyme methylenetetrahydrofolate reductase (MTHFR) is associated with increased blood pressure, and there is accumulating evidence demonstrating that this phenotype can be modulated, specifically in individuals with the MTHFR 677TT genotype, by the B-vitamin riboflavin, an essential co-factor for MTHFR. The underlying mechanism that links this polymorphism, and the related gene-nutrient interaction, with hypertension is currently unknown. Previous research has shown that 5-methyltetrahydrofolate, the product of the reaction catalysed by MTHFR, appears to be a positive allosteric modulator of endothelial nitric oxide synthase (eNOS) and may thus increase the production of nitric oxide, a potent vasodilator. Blood pressure follows a circadian pattern, peaking shortly after wakening and falling during the night, a phenomenon known as 'dipping'. Any deviation from this pattern, which can only be identified using ambulatory blood pressure monitoring (ABPM), has been associated with increased cardiovascular disease (CVD) risk. This review will consider the evidence linking this polymorphism and novel gene-nutrient interaction with hypertension and the potential mechanisms that might be involved. The role of ABPM in B-vitamin research and in nutrition research generally will also be reviewed.