White-coat hypertension: a clinical review

Hypertension in an ageing population: Diagnosis, mechanisms, collateral health risks, treatments, and clinical challenges

Ageing population is considerably increasing worldwide, which is considered to reflect an improved quality of life. However, longevity in the human lifespan has increased the burden of late-life illnesses including cancer, neurodegeneration, and cardiovascular dysfunction. Of these, hypertension is the most common condition with huge health risks, with an increased prevalence among the elderly. In this review, we outline the current guidelines for defining hypertension and examine the detailed mechanisms underlying the relationship between hypertension and ageing-related outcomes, including sodium sensitivity, arterial stiffness, endothelial dysfunction, isolated systolic hypertension, white coat effect, and orthostatic hypertension. As hypertension-related collateral health risk increases among the elderly, the available management strategies are necessary to overcome the clinical treatment challenges faced among elderly population. To improve longevity and reduce adverse health effects, potential approaches producing crucial information into new era of medicine should be considered in the prevention and treatment of hypertension among elderly population. This review provides an overview of mechanisms underlying hypertension and its related collateral health risk in elderly population, along with multiple approaches and management strategies to improve the clinical challenges among elderly population.

The Association between Urinary Sodium-Potassium Ratio, Kidney Function, and Blood Pressure in a Cohort from the General Population

INTRODUCTION

Subclinical kidney dysfunction may contribute to salt-sensitive hypertension. We assessed the association between the urinary sodium-potassium ratio (Na/K ratio) and blood pressure (BP) in a general population cohort without diabetes, chronic kidney disease, cardiovascular disease, or treated hypertension. We investigated whether any such association was mediated by the kidney function markers measured glomerular filtration rate (mGFR), urinary albumin-creatinine ratio (ACR), and urinary epidermal growth factor-creatinine ratio (EGF-Cr).

METHODS

The Tromsø Study is a population-based study of inhabitants of the municipality of Tromsø, Northern Norway. Participants aged 50-62 years, without diabetes, chronic kidney disease, or cardiovascular disease, were invited to the substudy Renal Iohexol Clearance Survey in Tromsø 6 (RENIS-T6; 2007-09). For the present study, we excluded participants reporting the use of 1 or more antihypertensive agents, leaving 1,311 RENIS-T6 participants for a cross-sectional analysis. We measured office BP, 24-h ambulatory blood pressure (ABP), and mGFR using iohexol clearance. Na/K ratio, ACR, and EGF-Cr were measured in morning urine samples.

RESULTS

Urinary Na/K ratio was significantly associated with systolic office BP and ABP independently of cardiovascular risk factors and kidney function markers. A one-standard deviation unit increase in the Na/K ratio was associated with increased systolic ABP by 1.0 (0.3-1.6) mm Hg. Urinary Na/K ratio showed a stronger association with office BP than ABP. EGF-Cr, ACR, and mGFR did not mediate the relationship between urinary Na/K ratio and systolic BP.

CONCLUSIONS

In a representative sample of the middle-aged North-European population without diabetes, chronic kidney disease, cardiovascular disease, or treated hypertension, there was a consistent association between urinary Na/K ratio and BP. The association with BP was not mediated through kidney function measures, suggesting a relationship between a diet with high sodium and low potassium and higher BP regardless of kidney function.

Regular use of acupressure mats reduces perceived stress at subjective but not psychophysiological levels: Insights from a three-week relaxation training

Acupressure mats are promoted as stress management tools for easy and effective self-application, promising reduced stress and increased well-being. However, the scientific evidence for these effects is based on few experimental studies and lacks the examination of acupressure mats as a solitary relaxation tool. Our study aimed to examine which changes in stress and well-being can be expected from the use of acupressure mats by healthy young people on the subjective and psychophysiological level. Unexperienced participants practiced relaxation for three weeks either with an acupressure mat or without any tools (active control group [CG]). As a results, subjective well-being and stress decreased, while sleep quality and concentration endurance increased across groups. Blood pressure (BP), heart rate (HR), pain threshold and pain tolerance did not change significantly from pre- to post-training measurements. Most importantly, no significant differences were found between groups, indicating that training with an acupressure mat yielded no superior effects compared with an active control condition in healthy young students. As a conclusion, taking time to relax has some but limited beneficial effects on the subjective levels independent of the specific method for healthy students. Potential beneficial effects of acupressure mats might be bound to specific impairments, such as tension pain.

Head-to-head comparison of the WHO STEPwise approach with immediate unattended and delayed unattended automated blood pressure measurements during household-based screening: a diagnostic accuracy study in Lesotho

Background

WHO introduced the STEPwise approach to surveillance (STEPS) to monitor trends in non-communicable diseases. For arterial hypertension, the STEPS protocol takes the average of the last two out of three standard blood pressure measurements (SBPM). This study assesses the diagnostic accuracy of SBPM, same-day and next-day unattended automated measurement (uABP), with 24 h ambulatory measurement (24 h-ABPM) as reference.

Methods

This diagnostic accuracy study was done within a population-based household survey on cardiovascular risk factors in two districts in Northern Lesotho. Adults (aged ≥ 18 years) with elevated SBPM (defined as ≥140/90 mmHg), and 2:1 age- and sex-matched participants with normal SBPM during the survey were recruited. Following SBPM, first uABP readings were obtained on survey day. Afterwards, participants received a 24 h-ABPM device. Second uABP readings were taken 24 h later, after retrieval of the 24 h-ABPM. The main outcome was overall diagnostic accuracy of all screening measurements (SBPM, first uABP, and second uABP), determined using area under the receiver operating characteristic curve (AUROC), with 24 h-ABPM as a reference.

Findings

Between November 2, 2021 and August 31, 2022, 275 participants (mean age 58 years (SD: 16 years), 163 (59%) female) were enrolled, 183 of whom had elevated and 92 had normal SBPM. Mean difference between systolic daytime 24 h-ABPM and screening measurements was highest for SBPM (mean difference: -13 mmHg; 95% CI: -14 to -11). Mean difference between diastolic daytime 24 h-ABPM and diastolic SBPM was -2 mmHg (95% CI: -4 to -1), whereas no difference was found for mean diastolic first uABP (mean difference: -1 mmHg; 95% CI: -2.0 to 0.3); and mean diastolic second uABP (mean difference: 1.0 mmHg; 95% CI: -0.4 to 2.3). White coat hypertension was highest with SBPM (55 [20%]), followed by first uABP (27 [9.8%]), and second uABP (18 [6.5%]). Using systolic daytime 24 h-ABPM as a reference, the uABPs had higher AUROC (first uABP: 87% [95% CI: 83-91]; second uABP: 88% [95% CI: 84-92]); SBPM: (79% [95% CI: 74-85]). This difference was significant between first uABP and SBPM (P = 0.0024), and between second uABP and SBPM (P = 0.0017).

Interpretation

uABP had better diagnostic performance than SBPM. Integration of uABP into STEPS protocol should be considered.

Funding

Swiss Agency for Development and Cooperation under the ComBaCaL project, and the World Diabetes Foundation.

Is perioperative blood pressure monitoring during intravitreal injections important?

Background:

Anti-vascular endothelial growth factor intravitreal injections (IVIs) have proved to be a boon for patients suffering from several retinal pathologies. They are one of the most commonly performed procedures in ophthalmology. A perioperative rise in blood pressure (BP) has been noted during cataract surgery.

Objectives:

To evaluate the perioperative BP changes during IVI, and the associated risk factors.

Design:

Cross-sectional observational study

Methods:

The patients undergoing IVI from May 2019 to August 2019 were evaluated. All the patients underwent BP measurement before, during, and 1 h after the IVI. The correlation between the demographics and, the systemic comorbidities of the patients, and the ocular condition for which IVI was given was evaluated.

Results:

The study included 302 patients (mean age of 59.9 ± 10.7 years). The mean increase in systolic BP (SBP) and diastolic BP (DBP) at the time of injection was 25.7 ± 21.0 and 1.3 ± 13.4 mmHg, respectively. A ⩾ 10, ⩾ 20, ⩾ 30 mmHg increase in SBP at the time of injection was seen in 83.8% (n = 253), 69.5% (n = 210) and 49.0% (n = 148) patients, respectively. Forty-one (13.6%) patients developed intra-procedural hypertensive urgency, out of which six patients (14.6%) did not recover even after 1 h of the procedure. None of the patients experienced any cardiovascular events. The univariate and multivariate linear regression analyses showed that the change in intra-procedural SBP correlated positively with the age of the patient and negatively with the baseline SBP.

Conclusion:

There is a significant rise of SBP at the time of IVI, especially in patients with advanced age and high baseline SBP. Some of the patients can experience hypertensive urgency at the time of injection and may take more than 1 h to recover. The patients receiving IVI should undergo a detailed physician evaluation before the procedure.

“What if It’s not Just an Item of Clothing?” – A Narrative Review and Synthesis of the White Coat in the Context of Aged Care

Although increasingly disputed, the white coat uniform is ubiquitous in geriatric care, which may reflect a phenomenon called medicalisation of ageing. This narrative review is the first attempt at integrating several theoretical approaches, such as the “white coat effect” and “enclothed cognition”, in order to gain a comprehensive understanding of the use of this clothing item. Based on extensive empirical evidence, we will examine the consequences of wearing a uniform, not only on patients (in this case, older patients) and healthcare professionals, but also on their relationship. The white coat has powerful symbolic functions for healthcare professionals and is still preferred by older adults. However, the negative repercussions of wearing a uniform require us to question its use, particularly in environments where older persons live, such as nursing homes.

The Impact of the COVID-19 Pandemic on Oncology Care and Clinical Trials

Simple Summary

The coronavirus pandemic has had a considerable impact on all parts of society. Unsurprisingly, healthcare has been particularly affected, including cancer care and trials of new drugs. This article will summarize the impact the pandemic has had on cancer healthcare taking into consideration how the pandemic affected potential cancer patients and stopped them seeking medical advice for new symptoms. The pandemic also affected the ability of people to access healthcare services and undergo the tests necessary to diagnose cancer. This article will also discuss the impact of the pandemic on existing treatments and the trials of new drugs. In light of the unprecedented speed of development of new treatments and vaccines for the virus itself, it will also review whether some of these adaptations could be used to accelerate the development of novel cancer therapies.

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has caused considerable global disruption to clinical practice. This article will review the impact that the pandemic has had on oncology clinical trials. It will assess the effect of the COVID-19 situation on the initial presentation and investigation of patients with suspected cancer. It will also review the impact of the pandemic on the subsequent management of cancer patients, and how clinical trial approval, recruitment, and conduct were affected during the pandemic. An intriguing aspect of the pandemic is that clinical trials investigating treatments for COVID-19 and vaccinations against the causative virus, SARS-CoV-2, have been approved and conducted at an unprecedented speed. In light of this, this review will also discuss the potential that this enhanced regulatory environment could have on the running of oncology clinical trials in the future.

White-coat hypertension detected during opportunistic blood pressure screening in a dental healthcare setting

OBJECTIVE

To study white-coat hypertension (WCHT, blood pressure ≥140/90 mmHg in a clinic and normal blood pressure <135/85 mmHg at home), with blood pressure screening of a healthy population during their dental healthcare visit and the associated risk factors.

DESIGN

A multicentre observational study.

SETTING

A healthy general population at four dental clinics in a region in southern Sweden.

SUBJECTS

2025 individuals aged 40-75 years were screened for high blood pressure at their annual regular check-up dental visit.

MAIN OUTCOME MEASURES

Frequencies of normal and elevated blood pressure (BP) in dental clinics, with home BP as a reference. According to BP results, the population was divided into three groups: normotension (NT), WCHT and suspected hypertension (HT). Background and life style factors were measured: sex, age, family history of hypertension, body mass index (BMI kg/m²), education level, tobacco use, and physical activity level.

RESULTS

The overall prevalence of WCHT in the study was 17.7%, and the prevalence was 57.2% among those with clinically high blood pressure. Compared with NT, WCHT was associated with male sex (OR 1.56, CI 1.18-2.06), older age group (OR 2.33, CI 1.66-3.26), family history of hypertension (OR 1.61, CI 1.24-2.10), high BMI kg/m² (OR 2.36, CI 1.80-3.10), daily snuff use (OR 1.74, CI 1.19-2.53). In comparison with WCHT, HT was associated with male sex (OR 2.16, CI 1.44-3.25), older age group (OR 2.85, CI 1.75-4.65), daily smoking (OR 2.10, CI 1.14-3.85), less daily snuff use (OR 0.59, CI 0.34-0.99).

CONCLUSIONS

The prevalence of WCHT in a healthy population was 17.7%. Regarding cardiovascular risk factors, WCHT seems to be in the middle of NT and HT. Individuals with WCHT can be identified and given lifestyle advice in connection with a dental check-up, but follow-up and assessment of their cardiovascular risk should take place in primary care.Key pointsScreening in dental practice can detect white-coat hypertension (WCHT) (17.7%) and suspected hypertension (HT) (12.4%).Individuals with WCHT have more cardiovascular risk factors than normotensive individuals.Individuals with WCHT could be given lifestyle advice in dental clinics according to current guidelines.

Investigation of the effects of veterinarians' attire on ratings of trust, confidence, and comfort in a sample of pet owners in Canada

OBJECTIVE

To examine companion animal owners' perceptions of appropriate veterinarian attire and investigate potential associations between a veterinarian's attire and clients' ratings of trust in, confidence in, and comfort with a veterinarian.

SAMPLE

449 pet owners.

PROCEDURES

Participants were randomly assigned to complete a questionnaire containing photos of a male or female model veterinarian photographed in 8 attire types (formal attire, white dress shirt with black pants, white casual shirt with khaki pants, surgical scrubs, white casual shirt with jeans, surgical scrub top with jeans, surgical scrub top with khaki pants, and white laboratory coat with khaki pants). Participants were asked to rate their trust in, confidence in, and comfort with the pictured individual on a response scale of 1 (low) to 7 (high), rank photos according to their preferences for attire, and provide input on the importance of attire and other appearance-related subjects. Attire and gender of photographed individual and participant demographics were investigated for associations with trust, confidence, and comfort scores.

RESULTS

Most (317/445 [71%]) respondents indicated veterinarians' attire was important. Attire type was significantly associated with respondents' trust, confidence, and comfort scores. Model veterinarian gender and participant education level were also associated with trust and comfort scores.

CONCLUSIONS AND CLINICAL RELEVANCE

Veterinarians' attire is a form of nonverbal communication that is likely to inform clients' first impressions and may influence clients' trust in, confidence in, and comfort with a veterinarian. Veterinary personnel and veterinary management should consider how attire and general appearance represent staff members or their practice.

Differences in personality between sustained hypertension, isolated clinic hypertension and normotension

The aim of this study was to determine whether there are differences in personality between hypertension and normotension. Forty‐two male patients with essential hypertension were divided into two groups after self‐assessment of blood pressure, 18 with sustained hypertension and 24 with isolated clinic (white coat) hypertension, and were compared with 25 men with normotension on Spielberger's State‐Trait Anxiety Inventory and the Jenkins Activity Survey. In line with hypotheses, the sustained hypertensive group showed higher levels of trait anxiety, Type A behaviour pattern, and hard‐driving behaviours/competitiveness than the normotensive group, whereas isolated clinic hypertensives occupied an intermediate position between those two groups. Results provide support to the hypothesised relationship between personality and hypertension and stress the need of distinguishing sustained hypertension from isolated clinic hypertension. Copyright © 2006 John Wiley & Sons, Ltd.

Healthcare communication distress scale: Pilot factor analysis and validity

OBJECTIVE

To develop psychometrically an evidence-based, patient-centred measure of patient-practitioner communication. We explored the underlying constructs of a self-report questionnaire measuring adult patients' enduring perceptions of their emotional experiences when communicating with primary healthcare practitioners.

METHODS

A cross-sectional on-line survey included 16 items from a piloted questionnaire, as well as existing measures of generalised anxiety, psychological distress, and body vigilance. Exploratory factor analysis and hierarchical multiple regression were used to explore underlying constructs in an Australian sample (N = 220).

RESULTS

A 6-item communication distress factor and a 3-item environmental arousal factor were supported, indicating good face validity and internal consistency. Bivariate correlations support convergent and discriminant validity for both factors. Hierarchical analysis exploring predictors of communication distress included sex, age, and chronic condition status; and scores on body vigilance, anxiety, distress, and environmental arousal in healthcare. Environmental arousal was the most important significant predictor of communication distress.

CONCLUSION

The patient communication questionnaire can be developed into a brief scale to measure patient distress associated with engaging with, and communicating in, healthcare settings.

PRACTICE IMPLICATIONS

A brief self-report measure to identify patients' communication distress and environmental arousal could assist in clinical practice and provide useful data in healthcare communication research.

A comparison of first trimester blood pressures obtained at the time of first trimester pre-eclampsia screening and those obtained during prenatal care visits

OBJECTIVE

To determine if enrollment blood pressures in a study on first trimester preeclampsia prediction significantly differed from those obtained during routine prenatal care visits in the first trimester.

STUDY DESIGN

Women carrying a singleton gestation were prospectively enrolled in a first trimester study on preeclampsia prediction, and had systolic and diastolic blood pressure (SBP, DBP) measured at the time of enrollment. Blood pressure was also measured with the same technique by clinic nurses during the routine prenatal visits throughout the first trimester of pregnancy (9-14 weeks). The enrollment-BP (E-BP) and average first trimester-BP (aFT-BP) were compared using a paired samples t-test or Wilcoxon test, as appropriate. Smokers and patients on antihypertensive medications were excluded from the analysis. test.

RESULTS

644 women had prenatal care in the primary study center and met study criteria. The mean gestational age at study enrollment was 12.5 weeks. No significant difference was found between E-SBP and aFT-SBP (p = 0.10). Enrollment DBP and mean arterial pressure (MAP) were significantly lower than the aFT- DBP and -MAP (median DPB 67 vs 70 mm Hg and median MAP 83.7 vs 85 mmHg, respectively, p < 0.001). However, the difference was not clinically relevant (3 mmHg for DBP, and 1.3 mmHg for MAP).

CONCLUSIONS

Blood pressures obtained in a setting of preeclampsia screening are not higher than those obtained during regular prenatal care in the first trimester. This suggests that the setting in which pre-eclampsia screening is performed is unlikely to be a confounder for blood pressure measurements and the risk assessment.

Using out-of-office blood pressure measurements in established cardiovascular risk scores: a secondary analysis of data from two blood pressure monitoring studies

BACKGROUND

Blood pressure (BP) measurement is increasingly carried out through home or ambulatory monitoring, yet existing cardiovascular risk scores were developed for use with measurements obtained in clinics.

AIM

To describe differences in cardiovascular risk estimates obtained using ambulatory or home BP measurements instead of clinic readings.

DESIGN AND SETTING

Secondary analysis of data from adults aged 25-84 years in the UK and the Netherlands without prior history of cardiovascular disease (CVD) in two BP monitoring studies: the Blood Pressure in different Ethnic groups (BP-Eth) study and the Home versus Office blood pressure MEasurements: Reduction of Unnecessary treatment Study (HOMERUS).

METHOD

The primary comparison was Framingham risk calculated using BP measured as in the Framingham study or daytime ambulatory BP measurements. Statistical significance was determined using non-parametric tests.

RESULTS

In 442 BP-Eth patients (mean age = 58 years, 50% female [n = 222]) the median absolute difference in 10-year Framingham cardiovascular risk calculated using BP measured as in the Framingham study or daytime ambulatory BP measurements was 1.84% (interquartile range [IQR] 0.65-3.63, P = 0.67). In 165 HOMERUS patients (mean age = 56 years, 46% female) the median absolute difference in 10-year risk for daytime ambulatory BP was 2.76% (IQR 1.19-6.39, P<0.001) and only 8 out of 165 (4.8%) of patients were reclassified.

CONCLUSION

Estimates of cardiovascular risk are similar when calculated using BP measurements obtained as in the risk score derivation study or through ambulatory monitoring. Further research is required to determine if differences in estimated risk would meaningfully influence risk score accuracy.

White coat syndrome and its variations: differences and clinical impact

Hypertension is closely linked to increased cardiovascular risk and development of target organ damage (TOD). Therefore, proper clinical follow-up and treatment of hypertensive subjects are mandatory. A great number of individuals present a variation on blood pressure (BP) levels when they are assessed either in the office or in the out-of-office settings. This phenomenon is defined as white coat syndrome - a change in BP levels due to the presence of a physician or other health professional. In this context, the term "white coat syndrome" may refer to three important and different clinical conditions: 1) white coat hypertension, 2) white coat effect, and 3) masked hypertension. The development of TOD and the increased cardiovascular risk play different roles in these specific subgroups of white coat syndrome. Correct diagnose and clinical guidance are essential to improve the prognosis of these patients. The aim of this review was to elucidate contemporary aspects of these types of white coat syndrome on general and hypertensive population.

Impact of SPRINT results on hypertension guidelines: implications for "frail" elderly patients

In the last years, guidelines for the treatment of hypertension recommended individualized blood pressure goals for geriatric population because of elderly susceptibility to adverse outcomes and higher mortality rate deriving from the excessive blood pressure lowering, especially in "frail" elderly. Recent findings from the SPRINT study, which demonstrated that intensive blood pressure lowering was associated with lower rates of cardiovascular events and mortality in both hypertensive fit and frail elderly subjects compared to standard treatment, heavily influenced the recent US guidelines. In SPRINT sub-study analysis of adults aged ≥75 years, the most controversial issue appears the method of blood pressure measurement, the selection of patients and related-frailty degree that appears to be very light. Accordingly, it has been described that light frailty is related to good outcomes in older adults. SPRINT findings in "frail elderly patients" cannot be applied to the clinical practice because this condition has been clearly under-estimated. Thus, frailty status should be routinely and correctly quantified in order to identify the frailty degree and to find the best harms-benefits balance of antihypertensive drug treatment in frail older adults.

Predicting Out-of-Office Blood Pressure in the Clinic for the Diagnosis of Hypertension in Primary Care: An Economic Evaluation

Clinical guidelines in the United States and United Kingdom recommend that individuals with suspected hypertension should have ambulatory blood pressure (BP) monitoring to confirm the diagnosis. This approach reduces misdiagnosis because of white coat hypertension but will not identify people with masked hypertension who may benefit from treatment. The Predicting Out-of-Office Blood Pressure (PROOF-BP) algorithm predicts masked and white coat hypertension based on patient characteristics and clinic BP, improving the accuracy of diagnosis while limiting subsequent ambulatory BP monitoring. This study assessed the cost-effectiveness of using this tool in diagnosing hypertension in primary care. A Markov cost-utility cohort model was developed to compare diagnostic strategies: the PROOF-BP approach, including those with clinic BP ≥130/80 mm Hg who receive ambulatory BP monitoring as guided by the algorithm, compared with current standard diagnostic strategies including those with clinic BP ≥140/90 mm Hg combined with further monitoring (ambulatory BP monitoring as reference, clinic, and home monitoring also assessed). The model adopted a lifetime horizon with a 3-month time cycle, taking a UK Health Service/Personal Social Services perspective. The PROOF-BP algorithm was cost-effective in screening all patients with clinic BP ≥130/80 mm Hg compared with current strategies that only screen those with clinic BP ≥140/90 mm Hg, provided healthcare providers were willing to pay up to £20 000 ($26 000)/quality-adjusted life year gained. Deterministic and probabilistic sensitivity analyses supported the base-case findings. The PROOF-BP algorithm seems to be cost-effective compared with the conventional BP diagnostic options in primary care. Its use in clinical practice is likely to lead to reduced cardiovascular disease, death, and disability.

Prevalence of resistant hypertension and associated factors for blood pressure control status with optimal medical therapy using Korean ambulatory blood pressure monitoring registry data

Background

Resistant hypertension (RH) may be one of the cause of the plateau in improving the control rate in hypertension (HT) management. The misdiagnosis of RH by clinic blood pressure (BP) is important clinical problem. Aim of the study were to investigate the prevalence of RH by ambulatory blood pressure monitoring (ABPM) and the factor associated with control status of ambulatory BPs.

Methods

For 1230 subjects taking one or more antihypertensive medication (AHM) enrolled in the Korean Ambulatory Blood Pressure Monitoring (Kor-ABP) registry, the prevalence of RH was calculated which was defined as uncontrolled BP by three AHM classes including diuretic or BP in need of four or more AHM classes. The prevalence determined by clinic versus ambulatory BP was compared.

Results

The age was 59.3 ± 12.5 years, and 44.3 % were female (n = 1230). Among them 72 subjects were taking three AHM drugs including diuretics and 105 subjects were taking four or more AHM classes. With uncontrolled daytime ambulatory BP in 41 among 72 subjects, prevalence of RH was 11.9 % (146/1230). By using nighttime BP criteria, there was significant difference in the prevalence of RH for clinic versus nighttime BP (146/177 vs. 159/177, p = 0.0124). For control status of daytime BP, masked uncontrolled BP was 16.9 % and controlled BP with white-coat effect was 14.1 %. For nighttime BP control status, odd ratios for smoking (0.624), drinking (1.512), coronary artery disease (0.604), calcium antagonist (1.705), and loop diuretics (0.454) were all significant.

Conclusion

The prevalence itself was 11.9 % by daytime BP and it was significantly higher when using nighttime BP criteria. Control status of daytime BP was misclassified in 31.0 %. Smoking, drinking, coronary artery disease, calcium antagonist, and loop diuretics were associated with nighttime BP control status.

Electrocardiographic and Echocardiographic Imaging of the Heart of Athletes and Patients with Hypertension

INTRODUCTION

"Athlete's heart syndrome" is a condition characterized by structural, electrophysiologic and functional adaptation of the myocardium to physical activity (training), depending on the activity intensity, duration and type. In athletes left ventricular hypertrophy often resembles comorbid conditions (hypertension or hypertrophic cardiomyopathy) so the differential diagnosis of the disease is very important and crucial, especially in people who are in active training. In fact, if an athlete has finding which indicate thickening of the left ventricle walls, should be distinguished hypertrophy which occurred as a result of many years of training from accidental existence of hypertension or hypertrophic cardiomyopathy in the same person. Therefore, it is important to make a diagnostic difference between healthy and sick heart.

MATERIAL AND METHODS

The study involved male persons aged 20-45 which have increased muscle mass of the left ventricle due to different etiology. Definite sample included 80 respondents divided into two groups. All respondent underwent interview, clinical examination, ECG and echocardiography.

RESULTS

Average systolic blood pressure (SBP) for the athletes were 115.8±7.2 mmHg, and in patients, with hypertension 154.4±3.5 mmHg, average values of diastolic blood pressure (DBP) for the athletes were 74.2±8.1 mmHg in patients, hypertensive 96.2 ± 3.9 mmHg. Values of SBP and DBP were significantly lower in the group of athletes compared to patients with hypertension (p=0.001). The value of the SFO/min was significantly lower in the group of athletes compared to patients with hypertension (p <0.001). There was a statistically significant difference in the sum of SV2 RV5 and between groups of athletes and groups of patients with hypertension (p<0.05). There was no significant difference in the echocardiography parameters between two groups. There was a statistically significant difference in the sum of SV2 and RV5 between groups of athletes and groups of patients with hypertension (p<0.05).

CONCLUSION

ECG parameters, PQ, QRS, QT did not prove to be useful in the differentiation between the groups because no statistically significant differences in their values were found. Echocardiography is a reliable diagnostic tool in differentiating physiologic hypertrophy of athletes compared to hypertrophy in patients with hypertension.

Efficacy of Blood Pressure reduction of Losartan in selected Thai populations using Home Blood Pressure Monitoring and Office Blood Pressure measurements

Background:

Angiotensin Receptor Blockades (ARB) is becoming a first line drug for essential Hypertension for many types of patient. Losartan is the prototype of ARB due to its vast clinical trials. Home Blood pressure monitoring can provide accurate evaluation of certain drug effect on blood pressure with small number of patient samples. Local production of medicine has made the Medicine readily available and could bring about clinical improvement. Our hypothesis was that Thai population with essential hypertension responded quite well to Losartan and Generic Losartan was not inferior to Original- Losartan.

Objective:

To evaluate the effectiveness and safety in BP reduction by Losartan in certain Thai population and to compare these parameters between Generic Losartan and Original-Losartan using both office and HBPM method.

Method:

After a two-week run-in period when they would learn to use HBPM device and their blood pressure were still recorded to be higher than 140/90 by office BP or 135/85 by HBPM with or without previous medical regimen, 24 patients were randomized to receive either Generic Losartan or Original-Losartan for 6 weeks. Then they would cross over to receive the alternative and were followed again at 6 weeks. HBPM was performed in the morning and in the evening for 5 days, at baseline, and after 6 & 12 weeks. Office BP measurements were obtained at baseline and after 6 & 12 weeks.

Result:

One patient in each group dropped out from the study. 22 patients with average age of 54 and averaged office BP 154/88 completed the 12 weeks study. By office BP, SBP was reduced by 27±14.2 at week 6 and 28±15.1 mmHg at week 12. By HBPM, SBP dropped by 17±10.8 at week 6 and by 18±9. at week12. At the end of 12 weeks 68% (15/22) of patients had Office BP <140/90 and 64% (14/22) of patients had HBPM <135/85. There was no significant difference of BP reduction at week 6 between Original-xLosartan and Generic Losartan group. After crossover the BP reduction was maintained in both groups. The percentage of patient whose Office BP <140/90 or HBPM <135/85 were not different among the two Losartan groups. There was no serious adverse side effect.

Conclusion:

Using both office BP and HBPM this group of Thai patient with essential hypertension responded well to Losartan and Generic Losartan.

Discordance between ambulatory versus clinic blood pressure according to global cardiovascular risk group

BACKGROUND/AIMS

The detection of white coat hypertension (WCH), treated normalized hypertension, and masked hypertension (MH) is important to improve the effectiveness of hypertension management. However, whether global cardiovascular risk (GCR) profile has any effect on the discordance between ambulatory blood pressure (ABP) and clinic blood pressure (CBP) is unknown.

METHODS

Data from 1,916 subjects, taken from the Korean Multicenter Registry for ABP monitoring, were grouped according to diagnostic and therapeutic thresholds for CBP and ABP (140/90 and 135/85 mmHg, respectively). GCR was assessed using European Society of Hypertension 2007 guidelines.

RESULTS

The mean subject age was 54.1 ± 14.9 years, and 48.9% of patients were female. The discordancy rate between ABP and CBP in the untreated and treated patients was 32.5% and 26.5%, respectively (p = 0.02). The prevalence of WCH or treated normalized hypertension and MH was 14.4% and 16.0%, respectively. Discordance between ABP and CBP was lower in the very high added-risk group compared to the moderate added-risk group (odds ratio [OR], 0.649; 95% confidence interval [CI], 0.487 to 0.863; p = 0.003). The prevalence of WCH or treated normalized hypertension was also lower in the very high added-risk group (OR, 0.451; 95% CI, 0.311 to 0.655).

CONCLUSIONS

Discordance between ABP and CBP was observed more frequently in untreated subjects than in treated subjects, and less frequently in the very high added-risk group, which was due mainly to the lower prevalence of WCH or treated normalized hypertension.

White coat hypertension: improving the patient-health care practitioner relationship

White coat hypertension is characterized by the variability of a patient’s blood pressure measurements between the physician’s office and the patient’s home environment. A patient with white coat hypertension has high blood pressure levels in the physician’s office and normal blood pressure levels in their typical environment. This condition is likely caused by the patient’s anxiety within the physician’s office and in the presence of the physician. Research has shown that improving the relationship between a patient and their health care provider can decrease the patient’s anxiety, with the implication of decreasing the patient’s likelihood of demonstrating white coat hypertension. This review provides an overview of the previous literature regarding white coat hypertension, its prevalence, and the consequences for those who develop persistent hypertension. Furthermore, this review discusses the implications of improving patient and health care provider interactions through effective communication, empathy, and trust, as well as the implications for future research studies in improving the patient and health care provider’s relationship.

Hypertension 2005: an evidence-based approach to diagnosis and treatment – an American perspective

Midway into the first decade of the 21st century, evidence-based medicine has become the predominant methodology for the education and practice of medicine. In the ascent to this pre-eminent position, evidence-based medicine has challenged several methodologies through which medicine was taught and practiced throughout the 20th century, including the clinical anecdote, the concept that medicine is an art, the notion that the physician acts as the filter through which medical knowledge is individualized for the patient, and to some extent, the application of principles of pathophysiology to guide individual patient care. Indeed, it appears that in many cases, this mechanism-based approach to disease has been replaced by a broad strokes population-based approach based on outcomes research. However, as in the law, evidence is open to interpretation, varying opinion and nuance. Perhaps nowhere is this more evident than in the field of hypertension, which arguably can be credited with developing the field of evidence-based medicine with randomized clinical trials in the early 1960s and early adaptation and promotion of outcomes-based research, beginning with the first Joint National Committee report on prevention, detection, evaluation and treatment of high blood pressure in the 1970s. The purpose of this chapter is to review the evidence in the diagnosis and treatment of essential hypertension, focusing on the following areas. First, use of ambulatory and home blood pressure monitoring as diagnostic and prognostic tools; second, recent clinical trials in the treatment of essential hypertension that form the basis of evidence-based therapeutics; and third, presentation of the key features of the Joint National Committee (JNC) 7, which forms the current basis of treatment for essential hypertension.

Evaluation of discrete upper septal thickening on 64-slice coronary computed tomographic angiography

PURPOSE

Discrete upper septal thickening (DUST) has been well described in the echocardiology literature. To our knowledge, the computed tomography findings of DUST, however, have not been previously described.

MATERIALS AND METHODS

Five hundred consecutive coronary computed tomography angiograms were evaluated by 2 cardiothoracic radiologists for the presence of DUST.

RESULTS

Of the 500 studies reviewed, 23 cases had features consistent with DUST (23/500 = 5%). The average systolic blood pressure of patients with DUST (150/77 mm Hg) was higher than that of patients without DUST (133/75 mm Hg). Patients with DUST were older (mean 63 y) than patients without DUST (mean 50 y). None of these patients had evidence of abnormal systolic anterior motion of the mitral valve on cine imaging.

CONCLUSIONS

DUST is seen on coronary computed tomography angiograms and has imaging characteristics distinct from significant pathology, such as hypertrophic cardiomyopathy. Recognizing DUST is important because, unlike hypertrophic cardiomyopathy, previous studies have not found an associated adverse prognosis with DUST.

An elevated systolic blood pressure response at 8 minutes in full contact exercise may identify hypertensive subjects

The aim of this study was to identify hypertension (HT) in karate competitors (KCs) in high intensity exercise. Values were compared with an exercise control group (EC). The 84 subjects were randomly divided into two groups: KC and EC. Resting blood pressure (BP) was measured the day before and immediately precompetition. A further three measurements were taken postexercise for all subjects at 1-, 2-, and 8- minute intervals. At rest, day one, mean BP of KC was 134/84 ± 3/2 mmHg vs. EC, 124/72 ± 1/2 mmHg and on day 2, was 141/79 ± 3/2 mmHg vs. EC, 125/72 ± 1/2 mmHg, respectively. Eight minutes postcompetition, BP of KCs was 140/77 ± 2/1 mmHg vs. EC 135/75 ± 2/1 mmHg. High blood pressure (HBP) was recorded in 60.5% of KCs on day 2, and essential HT that required medical therapy was subsequently diagnosed in 5% of KCs. Five percent of EC also had HBP, but subsequent medical examination reported normal values.

Pre-anesthesia systolic blood pressure increases with age regardless of sex

PURPOSE

Pre-anesthesia hypertension (PAH) is the temporary elevation of blood pressure (BP), compared with normal ambulatory recorded BP or self-measured BP at home, in patients waiting for operation in the operating room (OR) before anesthesia induction. In general, the incidence of sustained hypertension (SH) increases progressively with age and the increase is greater in males than in females. In this study, we investigated the influence of age and sex on PAH.

METHODS

Sampling data on consecutive patients who were more than 20 years old and who had undergone surgery under general, intrathecal, or epidural anesthesia were retrospectively collected from hospital records and anesthesia records. Patients with SH, which was defined as a past history of hypertension and taking oral antihypertensive medications, were excluded from the analyses, and the data of 231 patients, 102 males and 129 females, were used for the analyses.

RESULTS

The proportions of male and female patients with a systolic BP (sBP) of more than 140 mmHg in the OR before anesthesia induction were 55.9 and 42.6%, respectively. The proportions of male and female patients with a diastolic BP (dBP) of more than 90 mmHg were 34.3 and 23.3%, respectively. There was no difference in the proportions of male and female patients with PAH. The differences in sBP between measurements in the hospital room (HR) before the operation and those in the OR (ΔsBP) in males and females were 22.9 ± 25.6 and 19.0 ± 24.0 mmHg, respectively. The differences in dBP between measurements in the HR and those in the OR (ΔdBP) in males and females were 12.7 ± 16.5 and 8.4 ± 17.9 mmHg, respectively. There were no differences in ΔsBP and ΔdBP between males and females. The sBP in the OR and the ΔsBP increased significantly with age in both males and females.

CONCLUSION

Age is an important clinical factor related to PAH. Pre-anesthesia sBP and the change in pre-anesthesia sBP increase progressively with age regardless of sex. These findings suggest that the higher BP seen in the elderly in the OR before anesthesia induction, as reported previously, might be explained in part by a greater impact of PAH in older people.

White-coat hypertension in the elderly. Echocardiographic analysis. A substudy of the EPICARDIAN project

The aims of this study were to investigate echocardiographic abnormalities in the elderly and to evaluate differences between those who are normotensive and those who have white-coat hypertension or sustained hypertension. The study used data on a subsample of participants in the EPICARDIAN project who came from the Lista district of Madrid, Spain. Of the 271 included, 61 (22.5%) were normotensive, 81 (29.9%) had white-coat hypertension and 129 (49.6%) had sustained hypertension. The left ventricular mass index was significantly different between the subgroups: 94.9 g/m2 in normotensives, 125.6 g/m2 in those with white-coat hypertension and 136.3 g/m2 in those with sustained hypertension (P< .001). The prevalence of left ventricular hypertrophy, defined using Deveraux's criteria, was 13.2% in normotensives, 49.1% in those with white-coat hypertension and 54.3% in those with sustained hypertension (P=.00007). White-coat hypertension is not a innocuous finding in the elderly because its implications for cardiac health are closer to those of sustained hypertension than to those of normal blood pressure.

Identifying and managing factors that interfere with or worsen blood pressure control

Hypertension is a major risk factor for ischemic heart disease, stroke, and heart failure. Even moderate blood pressure (BP) elevation can have a significant impact on outcomes. Maintaining BP within recommended levels significantly reduces the risk of cardiovascular morbidity and mortality. Yet, more than one-third of people receiving treatment for hypertension in the United States have uncontrolled BP. When faced with a patient whose BP is no longer controlled, clinicians need to develop a differential diagnosis of potential contributing factors. These factors may include BP measurement issues, poor adherence to antihypertensive medications, therapeutic inertia on the part of clinicians, lifestyle changes, secondary causes of hypertension, or ingestion of substances that interfere with BP control. Patients who demonstrate a deterioration in BP control should be questioned about adherence, recent changes to diet and lifestyle, signs and symptoms of secondary causes of hypertension, and use of any concomitant medications or other substances that may be known to increase BP or interfere with antihypertensive therapy. Common substances that can interfere with BP control include nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, glucocorticoids, antidepressants, decongestants, alcohol, or other stimulants like cocaine and methamphetamines. Because of the high prevalence of both osteoarthritis and hypertension among elderly people, NSAIDs are a common potential factor in this age group. In the face of worsening BP control, clinicians must actively investigate potential contributing factors and appropriately increase or adjust antihypertensive therapy.

Differences in emotional personality traits and stress between sustained hypertension and normotension

This study was aimed at determining whether there are differences in emotional personality traits and psychosocial stress between hypertension and normotension. From a large community sample of adults, 14 individuals having hypertension and showing clinic blood pressures (BP) >or=140/90 mm Hg and self-measured BPs >or=135/85 mm Hg (sustained hypertensives) were selected and compared with a sex- and age-matched group of 14 individuals with normotension (clinic BPs <140/90 mm Hg and self-measured BPs <135/85 mm Hg) on measures of trait anxiety, trait depression, trait anger and stress derived from standardized questionnaires. There were no significant differences between hypertensives and normotensives on trait anger, but, in line with hypotheses, the sustained hypertensive group showed higher levels of trait anxiety, trait depression and stress than did the normotensive group. A discriminant analysis revealed that trait depression was the most important psychological variable to discriminate between sustained hypertension and normotension. Results provide support to the hypothesized relationship of emotional personality traits and stress with hypertension, and underscore the need to define hypertension on the basis of both clinic and home/ambulatory BP measurements and to simultaneously evaluate all relevant negative emotional constructs, when conducting research on psychological factors in hypertension.

Target organ status in white-coat hypertensives: usefulness of serum procollagen type I propeptide in the respect of left ventricular diastolic dysfunction

BACKGROUND

Myocardial fibrosis is a feature of diastolic dysfunction and target organ damage, which was compared among subjects with normotension (NT), white-coat hypertension (WCH) and essential hypertension (EH). Serum procollagen type I propeptide (PIP) level was assessed as a marker of diastolic dysfunction in WCH.

METHODS AND RESULTS

Of 90 subjects, 30 had NT and 30 had WCH (ambulatory daytime blood pressure <135/85 mmHg) and 30 had EH (untreated mild to moderate hypertension); all underwent biochemical and echocardiographic examinations. Those with WCH had a lower left ventricular (LV) mass index than those with EH, but it was higher than in the NT group. WCH patients had a lower mitral valve E/A ratio and a higher LV E/E' (E': septal mitral annular peak velocity) ratio than NT patients, whereas these values were higher and lower respectively than in the EH group. The LV E/E' ratio, an estimate of LV diastolic function, correlated with the serum PIP concentration in WCH patients (r=0.39, P=0.03).

CONCLUSION

WCH is an intermediate group between NT and EH in respect of target organ damage. These results show a relationship between LV diastolic function and serum PIP in WCH, so the serum PIP level may be a useful marker of diastolic dysfunction and target organ damage in such patients.

Prevalence, causes, and consequences of masked hypertension: a meta-analysis

BACKGROUND

Masked hypertension (MH) is a relatively newly detected condition of which little is known. More information about MH may help to improve overall antihypertensive health care. We aimed to investigate the prevalence, potential causes, and associated consequences of MH.

METHODS

We searched published literature using MEDLINE, EMBASE, and the Cochrane database completed with references cited in reviews and original study articles. We restricted our research to articles written in the English, German, French, and Spanish language. Studies were included only when the prevalence of MH was reported, office blood pressure (BP) values were given, and methods of BP measurements were described in detail. All data were extracted independently by two readers with a standardized protocol and data-collection form.

RESULTS

The prevalence of MH averaged 16.8% (95% confidence interval 13.0-20.5%). The MH prevalence was 7% for children and 19% for adults. MH prevalences did not differ significantly when determined with self or ambulatory BP measurement (21.1% vs. 16.8%; P = 0.42). Subjects with MH had significantly higher left ventricular mass index (LVMI) values than normotensives (110 vs. 98 g/m2; P < 0.01) but similar values as sustained hypertensives (109 g/m2). In addition, patients with MH were more often smokers than normotensives (mean difference 18%; P < 0.03).

CONCLUSIONS

MH strikes about a quarter of the patients who were initially classified as normotensives (based on office BP measurements) and of treated hypertensives. Patients with MH seem to have a similar cardiovascular risk as sustained hypertensives but they may remain undetected. The presence of MH seems to be a matter of a coincidently low office BP value not related to certain subject characteristics although the chance of its presence may be increased by smoking and antihypertensive treatment.

Prevalence of white coat hypertension in underweight and overweight subjects

The aim of the present study was to determine if there is any association between white coat hypertension (WCH) and body mass index. The study was performed in two phases. In the first phase, we studied consecutive underweight patients, while in the second phase, age-matched consecutive normal weight, overweight, and obese cases were studied. Although we detected 61 cases in the underweight group with a mean age of 24.1 years, we could only detect 12 age-matched cases in the obesity group, and thus the obesity group was not used for comparison. When we looked at the prevalences of sustained normotension (NT), WCH, and HT in the groups, there were gradual and significant increases in the prevalences of WCH in addition to the gradual and significant decreases in the sustained NT from the underweight towards the normal weight and overweight groups. Eventually, only 31.5% of the overweight group had sustained NT, even though the mean age of the cases was very young. Due to the gradually increased prevalence of WCH from the underweight towards the normal weight and overweight groups, parallel to the already known increasing prevalences of HT, type 2 diabetes mellitus, hyperbetalipoproteinemia, dyslipidemia, and coronary heart disease and the very low prevalence of sustained NT among the overweight cases even in the early decades here, WCH should preferentially be accepted as an alarming sign of excess weight and many associated disorders in the future, rather than just being considered a predisposing factor of HT or atherosclerosis alone.

Design and baseline characteristics of an observational study in Japanese patients with hypertension: Japan Hypertension Evaluation with Angiotensin II Antagonist Losartan Therapy (J-HEALTH)

The Japan Hypertension Evaluation with Angiotensin II Antagonist Losartan Therapy (J-HEALTH) study is a nationwide, prospective, multicenter observational study that was designed to enroll hypertensive Japanese patients (>30,000 subjects). The patients in this study received treatment with open-label losartan, an angiotensin II receptor antagonist, for a maximum of 5 years. This report summarizes the study protocol and the baseline characteristics of the patients. Between June 2000 and May 2002, patients were screened in all 47 prefectures around Japan. Among the 31,515 patients screened, 31,048 patients were enrolled in this study and treated with losartan at a daily dose of 25-50 mg. These patients were 62.4 +/- 12.1 years old (mean +/- SD) and the mean clinic systolic/diastolic blood pressure (BP) values were 165.3 +/- 17.3/94.3 +/- 11.7 mmHg (mean +/- SD). The complications of hyperlipidemia, diabetes mellitus, cardiovascular disease, and cerebrovascular disease were also present in 38.5%, 13.1%, 8.0%, and 4.4% of patients, respectively. Regarding the World Health Organization classification, grade 2 hypertension was most frequent in this patient cohort. Nearly 10,000 patients agreed to perform home BP monitoring and report details regarding their lifestyles at baseline. Among the patients, 4.2% had white coat hypertension at the baseline. The J-HEALTH study is expected to provide valuable information about the significance of clinic and home BP control and home BP monitoring for the management of hypertension in Japanese patients.

Drugs for the perioperative control of hypertension: current issues and future directions

The management of hypertension continues to pose important challenges. Recent developments have established the importance of more rigorous blood pressure control in the community. In the perioperative setting, hypertension has long been recognised as undesirable, although the adverse impact of high blood pressure on the acute risks of elective surgery may have been previously overstated.A number of agents and techniques are available to control blood pressure perioperatively. These include principally general and regional anaesthetics, alpha(2)-adrenoceptor agonists, peripheral alpha(1)- and beta-adrenoceptor antagonists, dihydropyridine calcium channel antagonists, dopamine D(1A)-receptor agonists (fenoldopam), and nitric oxide donors. Recent years have seen important developments in the receptor selectivity of new compounds and in pharmacokinetics, particularly esterase metabolism. The future study of genomics may enable us to identify patients at risk for hypertension-related adverse events and target therapies most effectively to these high-risk groups.

Athletes with systemic hypertension

Hypertension is rare in the young, but its prevalence increases with aging. Currently, about 25% of the population has hypertension and this is expected to increase to up to about 29% in 2025. The overall risk of the hypertensive patient depends not only on blood pressure but also on the presence of other cardiovascular risk factors, target organ damage, and associated clinical conditions. The recommendations for preparticipation screening, sports participation, and follow-up depend on the cardiovascular risk profile of the individual athlete. When antihypertensive treatment is required, calcium channel blockers and blockers of the renin-angiotensin system are currently the drugs of choice.

Metformin and parameters of physical health

BACKGROUND

The prevalence of excess weight, including overweight and obesity, is increasing with a high cost on health in society.

METHODS

Consecutive cases with excess weight, aged between 50 and 70 years and desiring weight loss, were divided into two subgroups according to wishes of patients about whether they prefer medication or just a diet. Metformin at a daily dose of 2,550 mg was given to the medication group.

RESULTS

As for the very high prevalences, 84.8% (313/369) of cases at or above the age of 50 years were overweight or obese, 67.2% (248/369) of them had white coat hypertension (WCH) or hypertension (HT), 52.5% (194/369) of them had impaired glucose tolerance (IGT) or diabetes mellitus (DM), and 68.8% (254/369) of them had dyslipidemia. Initially 143 cases with excess weight preferred the diet and 162 of them preferred the metformin therapy. But 42 cases (25.9%) stopped the drug because of excessive anorexia. At the end of the six-month period, there were highly significant differences between the two groups according to prevalences of resolved WCH, hyperbetalipoproteinemia, hypertriglyceridemia, dyslipidemia, overweight, and obesity and a decreased fasting plasma glucose below 110 mg/dL (p<0.001 for all).

CONCLUSION

Due to the very high prevalences of excess weight and probably many associated disorders with the excess weight, including IGT or DM, WCH or HT, and dyslipidemia, above the age of 50 years, and the detected significant benefits of metformin on all of the above parameters, metformin treatment should be initiated in patients with excess weight in their fifties.

Estimate of white-coat effect and arterial stiffness

OBJECTIVES

Blood pressure (BP) measured in the office is usually higher than the average ambulatory BP, a difference generally taken as an estimate of the white-coat effect. This study was designed to assess whether such a difference is associated with impairment of the conduit arterial system.

METHODS

We calculated the difference between office and average daytime peak systolic blood pressure (DeltaSBP) in 2778 hypertensive participants (1240 women) of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale cohort. Arterial stiffness was evaluated using an adjusted office pulse pressure to stroke volume ratio (PP/SV), measured at rest, which has previously been shown to predict cardiovascular outcome independent of echocardiographic left ventricular hypertrophy. Effective arterial elastance was also estimated.

RESULTS

Across quintiles of PP/SV, significant linear, positive trends were found with age, the proportion of women, plasma glucose and triglyceride levels (0.05 > P < 0.0001). Heart rate measured in the office increased mildly with quintiles of PP/SV (P < 0.05). After adjusting for age, sex, body weight and office heart rate, DeltaSBP progressively increased with increasing quintiles of PP/SV (P for trend < 0.0001), whereas stroke volume decreased, paralleling the increase in left ventricular relative wall thickness (both P < 0.0001) and left ventricular mass index (P < 0.05). The significant increase in effective arterial elastance with quintiles of PP/SV was also independent of peak systolic BP, in addition to age, sex, heart rate and body weight.

CONCLUSIONS

The difference between office BP and ambulatory BP, an estimate of the white-coat effect, is strongly associated with increased arterial stiffness, evaluated by a two-element fluid system accumulator.

Do we need out-of-office blood pressure in every patient?

PURPOSE OF REVIEW

The limitations affecting office blood pressure readings have spurred the development of techniques for measuring blood pressure out of a clinical environment. The increasing use of home and ambulatory blood pressure monitoring has allowed the identification of specific blood pressure patterns related either to a discrepancy between office and out-of-office blood pressure or to alterations in the 24-h blood pressure profiles. This review offers an update on the most recent data published on the above issues.

RECENT FINDINGS

A critical overview is provided on recent data published on blood pressure patterns suggested to have clinical relevance. These include white coat hypertension, the so-called masked hypertension, enhanced overall blood pressure variability over 24 h, a steeper morning blood pressure surge and a blunted or an excessive blood pressure fall at night.

SUMMARY

All of these different conditions have been variably reported to carry prognostic implications, and may represent specific targets for antihypertensive treatment. Their identification and management require information on out-of-office blood pressure, which suggests that self blood pressure monitoring at home or 24-h ambulatory blood pressure monitoring should be used more frequently in clinical practice, following the indications issued in recent guidelines.

Isolated systolic hypertension in an elderly Danish population. Prevalence and daytime ambulatory blood pressure

Isolated systolic hypertension (ISH) is a major risk factor for cardiovascular complications. Nevertheless, data on the prevalence in a representative population do not seem to be available. The prevalence of ISH and the white coat effect was thus studied in a cross-sectional survey of 2806 inhabitants aged 70-80 years. In untreated subjects, the prevalence of ISH was 17.4% (95% CI 14.9-20.2) in women and 13.5% (95% CI 11.3-15.9) in men using clinic blood pressure at first visit. The prevalence increased significantly with age. The prevalence was reduced to 10.4% when using the average of all-visits clinic blood pressures. By a simulation model, it was demonstrated that his reduction mainly resulted from a regression towards the mean. Average all-visits clinic blood pressure was 172.6 +/- 10.4/81.1 +/- 6.0 mmHg. Less than one-third of those with all-visit ISH had sustained ISH. Identifying subjects with sustained ISH requires measurements in more than three visits.

Prevalence of the white-coat effect at multiple visits before and during treatment

OBJECTIVE

To investigate the prevalence and persistence of the white-coat effect (WCE) and white-coat hypertension (WCH) on multiple blood pressure measurement occasions in hypertensive patients with and without treatment.

DESIGN

Essential hypertensive patients in whom we took office blood pressure measurements (OBPM) at eight visits (three readings per visit) performed self blood pressure measurements (SBPM) for 1 week prior to each visit (42 readings per week) over a period of 1 year. All measurements were performed with the same automatic device (Omron 705CP). In addition, 24-h ambulatory blood pressure monitoring (ABPM) was performed at the start and at the end of the study. At the start, patients did not use any medication but on subsequent visits they were treated on the basis of their SBPM values. WCH was defined as an OBPM-value > or = 140 and/or 90 mmHg and a SBPM or daytime ABPM value < 135/85 mmHg. This definition was used irrespective of treatment. We also determined the prevalence of a substantial WCE (OBPM 20 mmHg systolic or 10 mmHg diastolic higher than SBPM or daytime ABPM).

SETTING

Patients were recruited at hospital or general practice.

PATIENTS

A total of 163 mild-to-moderate essential hypertensive patients with a mean age of 56 years (56% males).

RESULTS

At eight blood pressure (BP) measurement occasions, 75% of all patients had a substantial WCE at least once, while 57% had WCH at least once. One-third of the patients consistently had a substantial WCE and 14% consistently had WCH on three or more occasions The magnitude of the WCE was significantly related to the height of blood pressure in treated but not in untreated patients.

CONCLUSION

In some patients, WCH or a substantial WCE occurs consistently on multiple OBPM visits. Especially in untreated patients, the magnitude of the WCE varies widely among individuals. These results support the incorporation of SBPM and/or ABPM into optimal management of hypertension, not only to prevent misdiagnosis in untreated patients but also to determine the need for adjusting antihypertensive therapy in treated subjects.