Masked, white coat and sustained hypertension: comparison of target organ damage and psychometric parameters

Cyclothymic affective temperament is independently associated with left ventricular hypertrophy in chronic hypertensive patients

OBJECTIVE

Affective temperaments (depressive, anxious, irritable, hyperthymic, and cyclothymic) are regarded as the stable core of personality and when present in their dominant form, are considered subclinical manifestations and high-risk states for various affective disorders. Furthermore, cumulating evidence supports their relationship with cardiovascular diseases. Our aim was to assess the association between affective temperaments and left ventricular hypertrophy (LVH) in chronic hypertensive patients.

METHODS

In the present cross-sectional study, 296 patients referred to coronary computed tomography angiography (CCTA) due to suspected coronary artery disease were analyzed. All patients completed the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A). Left ventricular mass was quantified by CCTA and indexed to the body surface area (LVMi). Logistic regression analysis was used to identify predictors of LVH (men: ≥67.2 g/m² and women: ≥54.7 g/m²).

RESULTS

Among our patient cohort (mean age: 59.4 ± 10.6, 44.9% female), the median LVM and LVMi were 115.5 [88.4-140.7] g and 58.4 [47.4-64.2] g/m², respectively. Elevated BMI (OR = 1.04 CI: 1.01-1.10, p = 0.04) and cyclothymic affective temperament scores (OR = 1.06 CI: 1.00-1.12, p = 0.04) significantly increased the odds of LVH in multivariate logistic regression analysis.

CONCLUSION

Assessment of affective temperaments may allow for the identification of chronic hypertensive patients with elevated risk for LVH as a potential target for earlier primary intervention.

Characteristics and control of the 24-hour ambulatory blood pressure in patients with metabolic syndrome

Asian countries are facing an increasing prevalence of metabolic syndrome (MetS), which may aggravate the burden of cardiovascular diseases in this region. MetS is closely associated with ambulatory blood pressure (BP). Patients with MetS, compared to those without, had a twofold higher risk of new-onset office, home, or ambulatory hypertension. Furthermore, the risk of new-onset MetS in patients with white-coat, masked and sustained hypertension was also doubled compared to normotensives. High-risk masked hypertension and blunted nighttime BP dipping are common in patients with MetS, suggesting perfect 24-hour BP control with long-acting antihypertensive drugs and early initiation of combination therapy might be especially important for patients with MetS.

Risk of Target Organ Damage in Patients with Masked Hypertension versus Sustained Hypertension: A Meta-analysis

Objective: To compare the risk of target organ damage in masked hypertension (MH) and sustained hypertension (SH).Methods: A systematic review and meta-analysis was performed. A search of PubMed, Embase, and the Cochrane Library of relevant case-control studies was performed from inception to December 2019, and articles on MH and SH selected according to the inclusion criteria were analyzed. The primary end point was target organ damage in the heart. The secondary end points were target organ damage in the kidneys and blood vessels.Results: Seventeen studies that met the screening criteria were included in the meta-analysis. Compared with the SH group, in the MH group carotid intima-media thickness (IMT) and E/A ratio were significantly greater and the prevalence of left ventricular remodeling and the pulse wave velocity were significantly lower. Other indicators in the heart, kidneys, and blood vessels were not statistically different between the two groups. IMT: P=0.01, E/A ratio: P=0.01, prevalence of left ventricular remodeling: P=0.02, pulse wave velocity: P=0.01.Conclusion: Our study has shown that MH may have almost the same degree of target organ damage as SH, so clinicians may need to consider target organ damage.

Hypertension after Kidney Transplantation: Clinical Significance and Therapeutical Aspects

Most of the kidney transplanted patients develop arterial hypertension after renal transplantation. Together with very well-known and usual risk factors, post-transplant hypertension contributes to the whole cardiovascular morbidity and mortality in the kidney transplant population. The reasons of post-transplant hypertension are factors related to donors and recipients, immunosuppressive therapy like Calcineurin Inhibitors (CNI) and surgery procedures (stenosis and kinking of the renal artery and ureteral obstruction). According to Eighth National Committee (JNC 8) recommendations, blood pressure > 140/90 mmHg is considered as hypertension. The usual antihypertensive drugs used for the control of hypertension are Calcium channel blockers (CCB), Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin -II receptor blockers (ARB), B- blockers and diuretics. Follow the KDIGO guidelines the target blood pressure < 140/90 mmHg for patients without proteinuria and < 125/75 mmHg in patients with proteinuria is recommended. Better control of post-transplant hypertension improves the long-term graft and patient's survival.

Masked hypertension and effort-reward imbalance at work among 2369 white-collar workers

Hypertension is an important risk factor of cardiovascular diseases, the leading cause of death worldwide. Adverse effects of psychosocial factors at work might increase the risk of masked hypertension, but evidences are still scarce. The objective of this study is then to determine whether adverse psychosocial work factors from the effort-reward imbalance (ERI) model are associated with the prevalence of masked hypertension in a population of white-collar workers. White-collar workers were recruited from three public organizations. Blood pressure was measured at the workplace for manually operated measurements (mean of the first three readings taken by a trained assistant) followed by ambulatory measurements (mean of all subsequent readings taken during the working day). Masked hypertension was defined as manually operated BP<140/90 mm Hg and ambulatory BP ⩾135/85 mm Hg. ERI exposure at work was measured using Siegrist's validated questionnaire. Blood pressure readings were obtained from 2369 workers (participation proportion: 85%). ERI exposure (OR: 1.53 (95% CI: 1.16-2.02) and high efforts at work (OR: 1.61 (95% CI: 1.13-1.29) were associated with masked hypertension, after adjusting for sociodemographic and cardiovascular risk factors. Workers exposed to an imbalance between efforts spent at work and reward had a higher prevalence of masked hypertension. High efforts at work might be of particular importance in explaining this association. Future studies should be designed to investigate how clinicians can include questions on psychosocial work factors to screen for masked hypertension and how workplace interventions can decrease adverse psychosocial exposures to lower BP.

Prevalence and determinants of left ventricular geometric abnormalities in hypertensive patients: A study based on the updated classification system of left ventricular geometry

OBJECTIVE

This study was to determine whether different risk factors were associated with different type of left ventricular (LV) geometric abnormalities.

METHODS

This retrospective analysis included 2290 hypertensive participants without other cardiovascular disease, valve disease and with ejection fraction ≥50%. The type of LV geometric abnormality was defined on the basis of the new classification system.

RESULTS

LV geometric abnormalities were detected in 1479 subjects (64.6%), wherein concentric LV remodeling is the most common LV geometric abnormality (40.3%). Large waist circumference (WC) and neck circumference (NC) were positively associated with concentric LV remodeling, whereas body mass index (BMI) [odds ratio (OR) 0.89, 95% CI 0.85∼0.92, P ＜ 0.001] and systolic blood pressure (SBP) (OR 0.99, 95% CI 0.98∼0.99, P = 0.018) were inversely associated with concentric abnormalities. SBP and age were positively associated with eccentric dilated LVH, while male was inversely associated with eccentric dilated left ventricular hypertrophy (LVH). Age was the strongest risk factor for eccentric dilated LVH (OR 1.05, 95% CI 1.03∼1.07, P ＜ 0.001). Age, NC, SBP, hyperuricemia, and alcohol use were positively associated with concentric LVH, whereas BMI (OR 0.95, 95% CI 0.90∼0.99, P = 0.033) and male (OR 0.12, 95% CI 0.07∼0.18, P ＜ 0.001) were negatively associated with concentric LVH.

CONCLUSION

The prevalence of hypertensive LV geometric abnormality in rural area of Southern China was obvious higher. Compared with eccentric LV geometric abnormalities, there were more risk factors, including large WC and NC, age, NC, SBP, hyperuricemia, alcohol use, BMI and gender, which were associated with concentric LV geometric abnormalities.

Are personality traits associated with white-coat and masked hypertension?

OBJECTIVES

Anxiety and other psychological dispositions are thought to be associated with blood pressure. This study tests whether personality traits have long-term associations with masked and white-coat effects.

METHODS

A community-based sample of 2838 adults from Sardinia (Italy) completed the Revised NEO Personality Inventory, and 7 years later, blood pressure was assessed in the clinic and with ambulatory monitoring. Logistic regressions were used to test whether anxiety, neuroticism, extraversion, openness, agreeableness, and conscientiousness predicted the white-coat and masked hypertension phenomena. Age, sex, and antihypertensive medication use were tested as moderators.

RESULTS

Significant interactions were found between personality traits and antihypertensive medications in predicting masked and white-coat effects. Only among those taking antihypertensive medication, higher anxiety was associated with a higher risk of pseudo-resistant hypertension due to white-coat effect (odds ratio 1.39, 95% confidence interval 1.01-1.91) and higher conscientiousness was associated with a lower risk of masked uncontrolled hypertension (odds ratio 0.70, 95% confidence interval 0.49-0.99). There were no significant interactions with age or sex.

CONCLUSIONS

Among those on antihypertensive medications, anxious individuals were more likely to have pseudo-resistant hypertension due to white-coat effect and less conscientious individuals were at increased risk of masked uncontrolled hypertension. Particularly among anxious and less conscientious individuals, ambulatory monitoring may improve the tailoring of pharmacological treatments.

Relationship between socioeconomic level, and the prevalence of masked hypertension and asymptomatic organ damage

Background

This study aimed to determine the prevalence of masked hypertension (MHT) and its association with asymptomatic organ damage (AOD) in a low socioeconomic district of Ankara, Turkey.

Material/Methods

We retrospectively reviewed data obtained from the medical records of 712 patients with no known diagnosis of hypertension who presented to a polyclinic due to symptoms related to elevated blood pressure (BP) and were screened for MHT. Essential hypertension (EHT) existed in 86 patients screened for AOD. The presence of AOD in patients diagnosed with MHT and EHT was recorded.

Results

Among the 712 patients, 206 were diagnosed with EHT. Among the remaining 506 patients, 73 were diagnosed with MHT. The patients with MHT had significantly higher left ventricular mass index, carotid intima-media thickness, and 24-h urinary microalbuminuria level (all indicators of AOD) than those with EHT.

Conclusions

A significantly higher percentage of patients with MHT had AOD, as compared to those with EHT, in a low socioeconomic district of Ankara. Based on this finding, patients who present with hypertensive symptoms but have a normal BP should be advised to measure their BP at home.

Does the control of negative emotions influence blood pressure control and its variability?

The aim was to assess the control of negative emotions in treated patients with hypertension in comparison with normotensive individuals and to evaluate the association between suppression of negative emotions, control of blood pressure (BP) on ambulatory blood pressure monitoring (ABPM) and blood pressure variability (BPV). We studied 195 patients (women/men: 89/106); mean age 45.4 ± 15.9 years. All patients had ABPM and completed the Courtauld Emotional Control Scale (CECS). The total CECS score and scores for subscales for anger, depression and anxiety were analyzed together with mean BP values from ABPM, and their SD and coefficient of variation as BPV measures. The mean CECS score was 54 ± 12 in all subjects; highest in uncontrolled hypertension 56 ± 11, intermediate 53 ± 12 in controlled hypertension and lowest 48 ± 12 in normotensive subjects. The reference value for the Polish population is 50 ± 11. Significant differences of mean CECS scores among groups were observed (p = 0.0165) also in multivariate analysis. The difference between uncontrolled hypertension and normotension was significant (p = 0.0262). Few significant, weak correlations were observed between CECS score or its subscales and ABPM derivates in all subjects. Conclusion. Suppression of negative emotions may adversely affect BP control in treated hypertensive patients and it should be considered a cause of uncontrolled hypertension.

Target organ damage and masked hypertension in the general population: the Finn-Home study

BACKGROUND

The relation of masked hypertension to target organ damage has very seldom been investigated in a general population.

METHODS

An unselected population cohort (n = 1989 of which 1540 were not treated for hypertension) underwent office (duplicate measurements on one visit by a nurse) and home (duplicate measurements on 7 days) blood pressure (BP) measurements and evaluation of electrocardiographic left ventricular hypertrophy (ECG-LVH, n = 1989/1540), carotid intima-media thickness (cIMT, n = 758/592), and pulse wave velocity (PWV, n = 237/158). ECG-LVH was diagnosed using Cornell voltage criteria. PWV was measured using whole-body impedance cardiography. Masked hypertension was defined as office BP less than 140/90 mmHg with home BP at least 135/85 mmHg and white-coat hypertension as office BP at least 140/90 mmHg and home BP less than 135/85 mmHg.

RESULTS

Masked and sustained hypertensive individuals had significantly higher age-adjusted and sex-adjusted Cornell voltage, cIMT, and PWV than normotensive individuals. White-coat hypertensive patients had higher age-adjusted and sex-adjusted Cornell voltage than normotensive individuals but significantly lower Cornell voltage and PWV than sustained hypertensive patients. The differences in Cornell voltage and PWV remained significant after adjustment for confounding factors. However, all differences became nonsignificant after adjustment for systolic home BP.

CONCLUSION

Masked and sustained hypertension is accompanied by increased risk for hypertensive target organ damage, whereas white-coat hypertension seems to be a more benign phenomenon.

Working conditions and masked hypertension

INTRODUCTION

Masked hypertension, i.e., normal clinic blood pressure but elevated blood pressure during normal daily activities as measured by ambulatory monitoring, is a common problem and a serious cardiovascular risk factor. Given previously reported associations between work stressors and ambulatory blood pressure, an inquiry into the relationship between work stressors and masked hypertension is warranted.

OBJECTIVE

To assess the relationship between working conditions and masked hypertension.

DESIGN

Cross-sectional study.

SETTING

Hospital and home care employers in New York City.

STUDY PARTICIPANTS

Forty-five male and 119 female hospital and home care employee volunteers wore an ambulatory blood pressure monitor during working hours.

MAIN OUTCOME MEASURES

Masked hypertension was defined as work systolic ambulatory blood pressure ≥135 mmHg or diastolic ambulatory blood pressure ≥85 mmHg, and casual blood pressure <140/90 mmHg with no use of antihypertensive medications. Associations between work stressors and masked hypertension were tested by multiple logistic regression.

RESULTS

Masked hypertension, observed in 24.0% of males and 17.6% of females with normal casual office obtained blood pressure, was associated with evening, night or rotating shiftwork (odds ratio (OR) 8.25, 95% confidence interval (CI) 2.11-40.31) and with the combination of job strain and effort-reward imbalance (OR 2.97, 95% CI 1.02-8.60) after controlling for age. Associations remained substantial, and statistically significant for shiftwork, after individual adjustment for each of 10 potential confounders. Masked hypertension was not associated with total weekly work hours.

CONCLUSIONS

Masked hypertension is a significant individual and public health concern. Additional research is needed to clarify the role of work-related risk factors in the development of masked hypertension, and to develop an appropriate clinical and public health strategy for diagnosis, treatment and prevention.

Prevalence and distinguishing features of masked hypertension in type 2 diabetic patients

OBJECTIVE

The prevalence and clinical features of masked hypertension (MH) in type 2 diabetes mellitus patients (T(2)DM) were investigated to define clinical indices which may aid diagnosis and treatment.

METHODS

Clinical blood pressure (CBP) and ambulatory blood pressure (ABP) were measured in 856 T(2)DM patients to differentiate normotensive (NT), essential hypertensive (EH), and MH. Waist circumference (WC), abdominal circumference (AC), body mass index (BMI), waist to height ratio (WHtR), fasting blood glucose (FBG), and glycated hemoglobin levels were measured and compared between BP groups.

RESULTS

In total, 359 patients had normal CBP, of which 13.37% were diagnosed with MH based on established criteria. Males had significantly higher rates of MH (15.30%) than females (11.36%) (P=0.036). The MH detection rate increased with age and T(2)DM duration. There were no significant differences in BMI, WC or WHtR between total MH and EH groups. MH females, however, had lower BMIs than female EH females (P=0.023). Smoking, alcohol, and familial EH history were lower in MH than EH patients (smoking, P=0.029; alcohol ,P=0.001; and EH history, P=0.000), while BMI (male, P=0.037, female, P=0.015), WC (male, P=0.012, female, P=0.021), WHtR (P=0.011), smoking (P=0.016), and alcohol consumption (P=0.000) were higher in MH than NT patients. BMI, WHtR, 6-15 year disease course of diabetes, smoking and alcoholism were independent risk factors of T(2)DM complicated with MH. The dipper BP circadian pattern was significantly lower in MH than NT patients (P=0.001). The non-dipper pattern was lower in MH than EH (P=0.018) but higher than in NT (P=0.000).

CONCLUSIONS

A significant fraction of T(2)DM patients were diagnosed with MH. Clinical presentation also contrasted sharply from EH, MH is a specific blood pressure status that may severely damage target organs in T(2)DM.

Cognitive and autonomic dysfunction measures in normal controls, white coat and borderline hypertension

Background

White coat hypertension (WCHT) is a significant clinical condition with haemodynamic differences and presence of functional changes. We aim to compare cognitive and autonomic dysfunction variables (heart rate variability) between subjects with normal blood pressure (controls), WCHT, and borderline hypertension (BLH).

Methods

We performed a cross-sectional study in a cohort of 69 subjects (mean age ± SD; 38.2 ±10.8 years) comprising comparable number of normal controls, WCHT, and BLH. We measured clinic and 24-hour ambulatory blood pressure monitoring (ABPM), cognitive function parameters, and heart rate variability (HRV). All subjects underwent 24-hour ambulatory electrocardiography monitoring which was analyzed for HRV measurements. We performed a routine echocardiography (ECHO) for all subjects.

Results

Multiple comparison between the three groups revealed significant (p < 0.04) differences in mean day-time ABPM (systolic and diastolic). In the state anxiety inventory (SAI), both subjects with WCHT and BLH had significantly (p < 0.006) higher anxiety levels than the control group. In memory tasks WCHT subjects scored significantly (p < 0.004) lower in comparison with the other two groups. WCHT significantly (p < 0.001) performed less in memory tests, whereas BLH subjects had significantly (p < 0.001) lower reaction time. We found a significant (p < 0.05) difference in the 24-hour RMSSD and SDNN between the three groups. There was significant correlation between 24-hour RMSSD and computer CANTAB scores. The Echocardiography assessment revealed no significant differences in LV mass indices and diastolic function.

Conclusions

WCHT and BLH subjects showed lower cognitive performance and higher levels of anxiety when compared to controls. Autonomic function reflected by HRV indices was lower in WCHT and BLH in contrast to control, though not significantly. Our results suggest that WCHT may not be a benign condition as it may contribute to the overall risk for cardiovascular disease and LV damage. Longitudinal studies of patients with WCHT should clarify the transient, persistent or the progressive nature of this condition.