Reliability of morning, before-dinner, and at-bedtime home blood pressure measurements in patients with hypertension

Second home blood pressure measurements per occasion predict incident cardiovascular events in type 2 diabetes: KAMOGAWA-HBP study

Home blood pressure (HBP) monitoring is a better prognostic predictor than clinical BP monitoring. However, the suggested number of HBP measurements in each occasion varies across guidelines. The study aimed to identify which HBP measurements in each occasion are more closely associated with new cardiovascular events in patients with type 2 diabetes. This retrospective cohort study included 1082 patients with type 2 diabetes without a history of macrovascular complications. HBP was measured three times each morning and evening for 14 days, and the average value over the 14 days was calculated. During a median follow-up of 7.0 years, 117 patients (11.1%) had cardiovascular events. The Cox proportional hazards model was used to examine the association between the average morning home systolic BP (MHSBP) for the 1st, 2nd, and 3rd measurements and cardiovascular events. The adjusted hazard ratios (HR) (95% confidence interval) for the onset of cardiovascular events in the 2nd and 3rd mean MHSBP were 1.129 (1.008-1.265) and 1.135 (1.010-1.275), respectively. The area under the receiver-operating characteristic curve (AUC) for the 2nd, 1st/2nd, 2nd/3rd, and 1st/2nd/3rd mean MHSBP was significantly greater than that of the 1st mean MHSBP (p = 0.040, p = 0.014, p = 0.020, and p = 0.021, respectively). No significant difference was observed between the AUC of the 2nd/3rd and 1st/2nd/3rd mean MHSBP and that of the 1st/2nd mean MHSBP. We recommend that HBP measurements be taken just twice per occasion to predict cardiovascular events in patients with type 2 diabetes.

The role of wearable home blood pressure monitoring in detecting out-of-office control status

Ambulatory blood pressure (ABP) and home blood pressure (HBP) monitoring is currently recommended for management of hypertension. Nonetheless, traditional HBP protocols could overlook diurnal fluctuations, which could also be linked with adverse cardiovascular outcomes. In this observational study, we studied among a group of treated hypertensive patients (N = 62, age: 52.4 ± 10.4 years) by using out-of-office ABP and wearable HBP. They received one session of 24-h ABP measurement with an oscillometric upper-arm monitor, and totally three sessions of 7-day/6-time-daily wearable HBP measurement separated in each month with HeartGuide. Controlled hypertension is defined as an average BP <130/80 mmHg for both daytime ABP and HBP. There was substantial reliability (intraclass correlation coefficient, ICC 0.883-0.911) and good reproducibility (Cohen's kappa = 0.600) for wearable HBP measurement, especially before breakfast and after dinner. Among all patients, 27.4% had both uncontrolled HBP and ABP, 30.6% had uncontrolled HBP only, while 6.5% had uncontrolled ABP only. Female gender and increased numbers of anti-hypertensive agents are correlated with controlled hypertension. Patients with uncontrolled hypertension had a significantly higher maximal daytime blood pressure, which was previously signified as an imperial marker for cardiovascular risk. In conclusion, wearable HBP monitoring in accordance with a dedicated daily-living schedule results in good reliability and reproducibility. Patients with an uncontrolled wearable HBP should benefit from repeated HBP or ABP measurement for risk stratification.

The long-term reproducibility of the white-coat effect on blood pressure as a continuous variable from the Ohasama Study

There is little information about the reproducibility of the white coat effect, which was treated as a continuous variable. To investigate a long-term interval reproducibility of the white-coat effect as a continuous variable. We selected 153 participants without antihypertensive treatment (men, 22.9%; age, 64.4 years) from the general population of Ohasama, Japan, to assess the repeatedly measured white-coat effect (the difference between blood pressures at the office and home) in a 4-year interval. The reproducibility was assessed by testing the intraclass correlation coefficient (two-way random effect model-single measures). The white-coat effect for systolic/diastolic blood pressure slightly decreased by 0.17/1.56 mmHg at the 4-year visit on average. The Bland-Altman plots showed no significant systemic error for the white-coat effects (P ≥ 0.24). The intraclass correlation coefficient (95% confidence interval) of the white-coat effect for systolic blood pressure, office systolic blood pressure, and home systolic blood pressure were 0.41 (0.27-0.53), 0.64 (0.52-0.74), and 0.74 (0.47-0.86), respectively. Change in the white-coat effect was mainly affected by a change in office blood pressure. Long-term reproducibility of the white-coat effect is limited in the general population without antihypertensive treatment. The change in the white-coat effect is mainly caused by office blood pressure variation.

Physical Exercise in Resistant Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Physical exercise reduces blood pressure (BP) in patients with hypertension in general but more evidence is needed specifically for a high-risk phenotype associated with intensive medication, resistant hypertension (RH). In this systematic review and meta-analysis, we aimed to summarize current evidence of the exercise effects on BP in patients with RH. A systematic search was conducted in PubMed, Web of Science and Cochrane Library (from inception to 3rd November, 2021). A random effects meta-analysis was performed when at least two trials assessed the effect of either acute or regular exercise (vs. a control condition) on the same outcome. Ten studies (N = 380 participants; 51% female; mean age 52 to 67 years) were included in the review, of which four (N = 58) and six (N = 322) assessed the effects of acute and regular exercise, respectively. Evidence overall suggests that a single bout of acute exercise results in a short-term (≤ 24 h) reduction of BP, although no meta-analysis could be performed. As for regular exercise, three randomized controlled trials (N = 144, 50% female) could be meta-analyzed, which showed that exercise training intervention (8-12 weeks, 3 sessions/week) significantly reduces 24-h (-9.9 mmHg, 95% confidence interval -15.4-4.4 for systolic BP; and -5 mmHg, -7.0-3.0 for diastolic BP) and daytime ambulatory BP (-11.7 mmHg, -17.8-5.7; and -7.4 mmHg, -11.9-2.9). In summary, physical exercise appears as an effective option to reduce BP in patients with RH, although more research is needed to confirm these findings as well as to determine the most effective exercise characteristics.

Direct comparison of the reproducibility of in-office and self-measured home blood pressures

OBJECTIVE

The aim was to compare short-term and long-term reproducibilities of in-office unattended blood pressure (BP), namely automated office blood pressure (AOBP), conventionally measured attended office BP, and self-measured home BP.

METHODS

A multicentre, clinical study was conducted in Japan, and 287 Japanese outpatients on antihypertensive drug medication were followed-up for 1 year.

RESULTS

The intensity of drug treatment was sustained consistently throughout the study period (defined daily doses, 1.62-1.68; P = 0.12). The mean SBP differences between baseline and 1 month later, as well as baseline and 1 year later, were less than 1.5 mmHg, whereas the standard deviations of the differences for home, AOBP, and attended office measurements for the 1-year interval were 7.7, 14.5, and 15.3 mmHg, respectively. The coefficients of variation were significantly smaller for home BP than for AOBP among all patients at both 1-month and 1-year intervals (P < 0.0001). In the 1-month interval, partial correlation coefficients of home BP (r, 0.73/0.88 for systolic/diastolic measures) were significantly higher than of conventional BP (r, 0.47/0.69). However, the correlations converged to the modest level regardless of BP information (r, 0.49-0.54/0.63-0.73) when the 1-year interval was assessed. Results were confirmatory when patients on the same drug regimen (n = 167) were analysed.

CONCLUSION

A higher reproducibility of home BP was demonstrated compared with in-office BP, including AOBP. However, the modest correlations for the 1-year interval support the importance of regular assessment of BP, regardless of in-office or home measurements for treatment of hypertension.

Acute Aerobic Exercise Induces Short-Term Reductions in Ambulatory Blood Pressure in Patients With Hypertension: A Systematic Review and Meta-Analysis

[Figure: see text].

Exercise Reduces Ambulatory Blood Pressure in Patients With Hypertension: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background Although exercise training reduces office blood pressure (BP), scarcer evidence is available on whether these benefits also apply to ambulatory blood pressure (ABP), which is a stronger predictor of cardiovascular disease and mortality. The present study aims to assess the effects of exercise training on ABP in patients with hypertension based on evidence from randomized controlled trials. Methods and Results A systematic search of randomized controlled trials on the aforementioned topic was conducted in PubMed and Scopus (since inception to April 1, 2020). The mean difference between interventions (along with 95% CI) for systolic BP and diastolic BP was assessed using a random-effects model. Sub-analyses were performed attending to (1) whether participants were taking antihypertensive drugs and (2) exercise modalities. Fifteen studies (including 910 participants with hypertension) met the inclusion criteria. Interventions lasted 8 to 24 weeks (3-5 sessions/week). Exercise significantly reduced 24-hour (systolic BP, -5.4 mm Hg; [95% CI, -9.2 to -1.6]; diastolic BP, -3.0 mm Hg [-5.4 to -0.6]), daytime (systolic BP, -4.5 mm Hg [-6.6 to -2.3]; diastolic BP, -3.2 mm Hg [-4.8 to -1.5]), and nighttime ABP (systolic BP, -4.7 mm Hg [-8.4 to -1.0]; diastolic BP, -3.1 mm Hg [-5.3 to -0.9]). In separate analyses, exercise benefits on all ABP measures were significant for patients taking medication (all P<0.05) but not for untreated patients (although differences between medicated and non-medicated patients were not significant), and only aerobic exercise provided significant benefits (P<0.05). Conclusions Aerobic exercise is an effective coadjuvant treatment for reducing ABP in medicated patients with hypertension.

The HOPE Asia Network activity for "zero" cardiovascular events in Asia: Overview 2020

The impact of hypertension-related cardiovascular disease and target organ damage, and therefore the benefits of blood pressure (BP) control, is greater in Asian than in Western countries. Asia-specific features of hypertension and its effective management are important and active areas of research. The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was formed in 2016 and is now a member of the World Hypertension League. The main goal of the HOPE Asia Network is to improve the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia. Considerable work has already been done on the journey to achieving this goal. We have shown that BP control status in Asia differs between countries, and even between regions within the same country. Several expert panel consensus recommendations and clinical guidance papers are available to support the use of home and ambulatory BP monitoring in the region. In addition, the AsiaBP@Home study prospectively investigated home BP control status across 15 specialist centers using the same validated device and measurement schedule. We have also proposed the concept of systemic hemodynamic atherothrombotic syndrome (SHATS), a vicious cycle of BP variability and vascular disease on cardiovascular events and organ damage, and suggested a SHATS score for risk stratification for clinical practice. This special issue of the journal collates Asia-specific resources and data, contributing to advances in hypertension management and cardiovascular disease prevention in the region.

The influence of the ambient temperature on blood pressure and how it will affect the epidemiology of hypertension in Asia

Epidemiologic studies have consistently demonstrated an increased risk of cardiovascular disease during colder temperatures. Hemodynamic changes associated with cold temperature and an increase in thrombogenicity may both account for the increase in cardiovascular risk and mortality. Studies using both in-office and out-of-office BP measurements have consistently shown an elevation in BP during the colder seasons. The large difference in BP between cold and warm months may increase the incidence of hypertension and reduce the hypertension control rate, potentially resulting in increased cardiovascular risk, especially among those at risk of cardiovascular disease. The current trends in global warming and climate change may have a profound impact on the epidemiology of hypertension and cardiovascular disease, as changes in the climate may significantly affect both BP variability and cardiovascular disease, especially in those with high cardiovascular risk and the elderly. Furthermore, climate change could have a significant influence on hypertension in Asia, considering the unique characteristics of hypertensive patients in Asia. As an increase in ambient temperature decreases the mean daytime average and morning surge in BP, but increases the nocturnal BP, it is difficult to predict how environmental changes will affect the epidemiology and prognosis of hypertension in the Asian-Pacific region. However, these seasonal variations in BP could be minimized by adjusting the housing conditions and using anticipation medicine. In this review, we discuss the impact of seasonal variation in the ambient temperature on hypertension and cardiovascular disease and discuss how this may impact the epidemiology of hypertension and cardiovascular disease.

Impact of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines on the Next Blood Pressure Guidelines in Asia

PURPOSE OF REVIEW

To estimate the impact of the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for high blood pressure (BP) on the next hypertension guidelines in Asia.

RECENT FINDINGS

The 2017 ACC/AHA guidelines for high BP in adults changed the diagnostic threshold and the management goal of BP from 140/90 to 130/80 mmHg. Another characteristic of the new guideline is its focus on a practical approach for the effective management of hypertension by using home and ambulatory BP monitoring; this point is also recommended in the 2014 Japanese Society of Hypertension Guidelines for the Management of Hypertension. In Japan, the guidelines for hypertension management are currently under revision and will be released in the spring of 2019. The core concept of the 2019 Japanese Society of Hypertension Guidelines for the Management of Hypertension, i.e., early and tight BP control over 24 h, will contribute to target-organ protection and cardiovascular disease prevention for Asians.

Home blood pressure control status in 2017-2018 for hypertension specialist centers in Asia: Results of the Asia BP@Home study

A self-measured home blood pressure (BP)-guided strategy is an effective practical approach to hypertension management. The Asia BP@Home study is the first designed to investigate current home BP control status in different Asian countries/regions using standardized home BP measurements taken with the same validated home BP monitoring device with data memory. We enrolled 1443 medicated hypertensive patients from 15 Asian specialist centers in 11 countries/regions between April 2017 and March 2018. BP was relatively well controlled in 68.2% of patients using a morning home systolic BP (SBP) cutoff of <135 mm Hg, and in 55.1% of patients using a clinic SBP cutoff of <140 mm Hg. When cutoff values were changed to the 2017 AHA/ACC threshold (SBP <130 mm Hg), 53.6% of patients were well controlled for morning home SBP. Using clinic 140 mm Hg and morning home 135 mm Hg SBP thresholds, the proportion of patients with well-controlled hypertension (46%) was higher than for uncontrolled sustained (22%), white-coat (23%), and masked uncontrolled (9%) hypertension, with significant country/regional differences. Home BP variability in Asian countries was high, and varied by country/region. In conclusion, the Asia BP@Home study demonstrated that home BP is relatively well controlled at hypertension specialist centers in Asia. However, almost half of patients remain uncontrolled for morning BP according to new guidelines, with significant country/regional differences. Strict home BP control should be beneficial in Asian populations. The findings of this study are important to facilitate development of health policies focused on reducing cardiovascular complications in Asia.

Comparison of different schedules of nocturnal home blood pressure measurement using an information/communication technology-based device in hypertensive patients

The objective of this study was to test our hypothesis that nocturnal home blood pressure (BP) measurement adapted to the chosen bedtime of participants (measurement at 2, 3, and 4 hour after the chosen bedtime) would be more reliable than measurement at fixed time points (2:00, 3:00, and 4:00 am). Forty-eight hypertensives were randomized to two groups undergoing two seven-night measurement phases in a crossover manner and were asked to measure nocturnal home BP for 14 consecutive nights using a validated automatic information/communication technology-based device. The intraclass correlation coefficients (ICCs) of systolic BP (SBP) obtained by a single measurement per night over two nights showed lower agreement than those of systolic BP obtained by multiple measurements based on a participant-specified bedtime (0.539-0.625 vs 0.675-0.768) and multiple measurements at fixed times (0.468-0.505 vs 0.661-0.790). The ICCs obtained using specific bedtime-based time points and those obtained using fixed time points showed major agreement when SBP was obtained by multiple measurements. The standard errors of measurement for SBP were similar between the bedtime-based measurement phase (1.4-1.7 mm Hg) and the fixed-time measurement phase (1.2-1.6 mm Hg). Neither a fixed bias nor a proportional bias was observed between the SBP values measured by the specific bedtime-based time points and those measured by the fixed-time measurement phase. In conclusion, the reliability of nocturnal home BP measurement appeared to be similar between nocturnal home BP adapted to the chosen bedtime of participants and that measured at fixed time points.

Morning Home Blood Pressure and Cardiovascular Events in a Japanese General Practice Population Over 80 Years Old: The J-HOP Study

BACKGROUND

Home blood pressure (BP) measurement has been well accepted for use in the diagnosis and treatment of hypertension. However, data regarding the association between home BP levels and cardiovascular events in a general practice population aged ≥80 years are sparse.

METHODS

We analyzed the cases of 349 patients ≥80 years old from the Japan Morning Surge-Home Blood Pressure (J-HOP) Study, a nationwide practice-based study of 4,310 Japanese with a history of and/or risk factors for cardiovascular disease. Home BP measurements were performed twice daily (morning and evening) over 14 consecutive days at baseline.

RESULTS

During a median follow-up of 3.0 years, 32 composite cardiovascular events (13 strokes and 19 nonstroke events) occurred. Higher morning systolic BP (SBP) was a significant risk factor for composite cardiovascular events (hazard ratio (HR) per 10mm Hg, 1.23; 95% confidence interval (CI): 1.01-1.50) and stroke events (HR per 10mm Hg, 1.47; 95% CI: 1.08-2.00) after adjustment by the 4-year cardiovascular risk scores and clinic SBP. In the adjusted model, morning diastolic BP also tended to be a significant risk factor of stroke events (HR per 5 mm Hg, 1.43; 95% CI: 1.00-2.05). However, these associations were not found for evening BP or clinic BP.

CONCLUSIONS

Morning home BP showed a positive linear association with cardiovascular events, especially with stroke. This association was not observed for clinic BP or evening home BP. Based on these results, in very elderly Asian populations, measuring morning home BP might be important in clinical practice regardless of the individual's office BP level.