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

Asian Expert Consensus on Nocturnal Hypertension Management

There is consistent and strong evidence that nighttime blood pressure is a better predictor of target organ damage and cardiovascular events, and the prevalence of nocturnal hypertension is high in all populations but higher in Asians than Europeans. Excessive salt intake and salt sensitivity have long been believed to be risk factors for elevated nighttime blood pressure in Asians. For various reasons, the control rate of nocturnal hypertension is low, for example, insufficient monitoring and inappropriate therapeutic regimens. With the increasing evidence and possibility of management, it is highly relevant to have thorough discussions among Asian experts and to reach a consensus on major aspects in regard to the management of nocturnal hypertension. The consensus involves 5 aspects, including definitions and diagnosis, epidemiology, risk and risk factors, treatment, and future perspectives.

Peak nocturnal home blood pressure as an early and strong novel risk factor for stroke: the practitioner-based nationwide J-HOP Nocturnal BP study

Clinical implications of high peak nighttime home blood pressure (BP) are currently unknown. This study investigated the association between peak nighttime home systolic BP (SBP) and cardiovascular events in individuals with at least one cardiovascular risk factor. In the Japan Morning Surge-Home Blood Pressure (J-HOP) study, nighttime home BP was automatically measured three times each night for 14 days at baseline using a nighttime home BP monitoring device (HEM-5001, Omron Healthcare). Peak nighttime home SBP was defined as average of the highest three values over the 14-night measurement period. Cardiovascular events (stroke, coronary artery disease, heart failure, aortic dissection) were tracked over a mean follow-up period of 7.1 years. This analysis included 2545 individuals (mean age 63.3 ± 10.3 years, 49% male). After adjusting for covariates (including age, sex, and average office, morning, evening, and nighttime home SBP), stroke risk was significantly higher in individuals with peak nighttime home SBP in the highest quintile (≥149.0 mmHg) compared to the lowest quintile (<119.3 mmHg) (hazard ratio [HR] 4.24, 95% confidence interval [CI] 1.07-16.77; p = 0.039 overall and 8.92, 1.49-53.43; p = 0.017 in the subgroup with ≥6 nighttime home SBP measurements). This increased stroke risk remained significant after controlling for day-by-day average real variability of nighttime BP. The average peak nighttime home SBP cut-off value for predicting an increased risk of incident stroke was 136 mmHg. We propose that exaggerated peak nighttime home SBP, determined from ≥6 measurements, is a novel risk factor for stroke, independent of conventional office and home BP values. The exaggerated peak nighttime home systolic blood pressure (HSBP) determined from six or more measurements as a novel risk factor for stroke, independent of conventional office and home blood pressure (BP) values.

Time-Space Network Hypertension in the Digital Era - Update From Jichi Medical University Hypertension Study

Time-space network hypertension is a data science approach that connects diverse information related to hypertension within a time-space framework. This field of academic research aims to predict disease onset and direct effective, individualized, optimized treatments by integrating and analyzing the variability of multiple internal biological and external environmental signals as they relate to blood pressure variability across different time phases. By linking time series changes in blood pressure and biological distribution with multi-environmental and physiological information, enabled by advances in digital technology, the time-space network hypertension approach contributes to "digital hypertension" research. This article from Jichi Medical University provides an update on research relating to the time-space network hypertension approach, which is designed to progress hypertension management towards achieving net zero cardiovascular events.

Circadian disruption and its impact on the cardiovascular system

Circadian rhythms are highly conserved biorhythms of ~24 h that govern many fundamental biological processes, including cardiovascular (CV) homeostasis. Disrupting the timing of cellular oscillators promotes cellular stress, and induction of pathogenic pathways underpins the pathogenesis of many CV diseases (CVDs). Thus, shift work, late eating, sleep disturbances, and other disruptors can result in an elevated risk of heart disease and increased incidence of adverse CV events. Here, we discuss the importance of circadian rhythms for CV homeostasis, recent developments in understanding the impact of disrupted circadian rhythms on CV health and disease progression, and how understanding the interactions between circadian and CV physiology is crucial for improving interventions to mitigate CVD, especially in populations impacted by disrupted circadian rhythms.

Sleep and hypertension - up to date 2024

People spend one-third of their lives sleeping, and adequate, restful sleep is an essential component of a healthy life. Conversely, disruption of sleep has been found to cause various physical and mental health problems. Emerging research has shown that blood pressure (BP) during sleep is a stronger predictor of cardiovascular events than conventional office BP or daytime BP. Thus, management of both sleep health and nighttime BP during sleep is important for preventing cardiovascular events. However, recent studies demonstrated that nighttime BP is poorly controlled compared with office BP and daytime BP. This finding is understandable, given the challenges in monitoring BP during sleep and the multiplicity of factors related to nocturnal hypertension and BP variability. This review summarizes recent evidence and considers future perspectives for the management of sleep and hypertension.

Blood Pressure Regulation and Hypertension in Obstructive Sleep Apnea Syndrome: A Historical Perspective

In obstructive sleep apnea syndrome (OSAS), an underlying disease of secondary hypertension, repeated episodes of asphyxia due to obstructive sleep apnea (OSA), followed by arousal, lead to various cardiovascular consequences. Using a canine model of OSAS, it was found that a single load of OSA caused an abrupt increase in blood pressure (BP) (Apnea Surge in seconds), while multiple OSA episodes occurring nightly for 1-3 months led to a sustained elevation of BP during both nighttime and daytime. Epidemiological studies on 24-hour ambulatory BP measurements revealed that some hypertensive patients experienced elevated BP in the early morning (Morning Surge), which could be intensified by OSAS. The resonance of Apnea Surge in seconds and Morning Surge increases the risk of organ damage, triggers the cardiovascular events, and adversely affects the prognosis of hypertensive patients with OSAS. For ameliorating these risks, OSA should be treated with positive airway pressure properly.

Innovations in blood pressure measurement and reporting technology: International Society of Hypertension position paper endorsed by the World Hypertension League, European Society of Hypertension, Asian Pacific Society of Hypertension, and Latin American Society of Hypertension

Blood pressure (BP) is a key contributor to the lifetime risk of preclinical organ damage and cardiovascular disease. Traditional clinic-based BP readings are typically measured infrequently and under standardized/resting conditions and therefore do not capture BP values during normal everyday activity. Therefore, current hypertension guidelines emphasize the importance of incorporating out-of-office BP measurement into strategies for hypertension diagnosis and management. However, conventional home and ambulatory BP monitoring devices use the upper-arm cuff oscillometric method and only provide intermittent BP readings under static conditions or in a limited number of situations. New innovations include technologies for BP estimation based on processing of sensor signals supported by artificial intelligence tools, technologies for remote monitoring, reporting and storage of BP data, and technologies for BP data interpretation and patient interaction designed to improve hypertension management ("digital therapeutics"). The number and volume of data relating to new devices/technologies is increasing rapidly and will continue to grow. This International Society of Hypertension position paper describes the new devices/technologies, presents evidence relating to new BP measurement techniques and related indices, highlights standard for the validation of new devices/technologies, discusses the reliability and utility of novel BP monitoring devices, the association of these metrics with clinical outcomes, and the use of digital therapeutics. It also highlights the challenges and evidence gaps that need to be overcome before these new technologies can be considered as a user-friendly and accurate source of novel BP data to inform clinical hypertension management strategies.

Development of beat-by-beat blood pressure monitoring device and nocturnal sec-surge detection algorithm

The nocturnal blood pressure (BP) surge in seconds (sec-surge) is defined as a brief, acute transient BP elevation over several tens of seconds, triggered by obstructive sleep apnea (OSA) and sympathetic hyperactivity. Sec-surge imposes a significant strain on the cardiovascular system, potentially triggering cardiovascular events. Quantitative evaluation of sec-surge level could be valuable in assessing cardiovascular risks. To accurately measure the detailed sec-surge, including its shape as BP rises and falls, we developed a beat-by-beat (BbB) BP monitoring device using tonometry. In addition, we developed an automatic sec-surge detection algorithm to help identify sec-surge cases in the overnight BbB BP data. The device and algorithm successfully detected sec-surges in patients with OSA. Our results demonstrated that sec-surge was associated with left ventricular hypertrophy and arterial stiffness independently of nocturnal BP level or variability. Sec-surge would be worth monitoring for assessing cardiovascular risks, in addition to nocturnal BP level. Nocturnal blood pressure (BP) surge in seconds (sec-surge) places heavy load on the cardiovascular system and can trigger cardiovascular events. To identify sec-surges, we developed a beat-by-beat BP monitoring device and a sec-surge detection algorithm. Furthermore, sec-surge was more related to cardiovascular risks than conventional nocturnal BP parameters.

Home blood pressure-centered approach - from digital health to medical practice: HOPE Asia Network consensus statement 2023

Recent innovations in digital technology have enabled the simultaneous accumulation, and the linking and analysis of time-series big data relating to several factors that influence blood pressure (BP), including biological indicators, physical activity, and environmental information. Various approaches can be used to monitor BP: in the office/clinic; at home; 24-h ambulatory recording; or with wearable and cuffless devices. Of these, home BP monitoring is a reliable and convenient method, and is recommended for hypertension management by current national and international guidelines. This recommendation is based on evidence showing that home BP is an important predictor of cardiovascular, cerebrovascular and kidney disease in patients with hypertension. In addition, lifetime personalized health record (PHR)-based home BP with telemonitoring combined with co-interventions has been shown to lower BP more effectively than the traditional approach based on office BP. Thus, home BP represents a key metric for personalized anticipation medicine, from digital healthcare to digital medicine. This paper summarizes the latest evidence on home BP monitoring and proposes a Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network consensus on a home BP-centered approach to the management of hypertension.

Digital hypertension towards to the anticipation medicine

"Digital Hypertension" is a new research field proposed by the Japanese Society of Hypertension that integrates digital technology into hypertension management and proactively promotes research activities. This novel approach includes the development of new technologies for better BP management, such as sensors for detecting environmental factors that affect BP, information processing, and machine learning. To facilitate "Digital Hypertension," a more sophisticated BP monitoring system capable of measuring an individual's BP more frequently in various situations would be required. With the use of these technologies, hypertension management could shift from the current "dots" management based on office BP readings during clinic visits to a "line" management system based on seamless home BP or individual BP data taken by a wearable BP monitoring device. DTx is the innovation to change hypertension management from "dots" to "line", completely achieved by wearable BP.

Blood pressure variability: methodological aspects, clinical relevance and practical indications for management - a European Society of Hypertension position paper ∗

Blood pressure is not a static parameter, but rather undergoes continuous fluctuations over time, as a result of the interaction between environmental and behavioural factors on one side and intrinsic cardiovascular regulatory mechanisms on the other side. Increased blood pressure variability (BPV) may indicate an impaired cardiovascular regulation and may represent a cardiovascular risk factor itself, having been associated with increased all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia incidence. Nonetheless, BPV was considered only a research issue in previous hypertension management guidelines, because the available evidence on its clinical relevance presents several gaps and is based on heterogeneous studies with limited standardization of methods for BPV assessment. The aim of this position paper, with contributions from members of the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability and from a number of international experts, is to summarize the available evidence in the field of BPV assessment methodology and clinical applications and to provide practical indications on how to measure and interpret BPV in research and clinical settings based on currently available data. Pending issues and clinical and methodological recommendations supported by available evidence are also reported. The information provided by this paper should contribute to a better standardization of future studies on BPV, but should also provide clinicians with some indications on how BPV can be managed based on currently available data.

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

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

Long-term stability of over-the-counter cuffless blood pressure monitors: a proposal

Blood pressure is an important cardiovascular parameter. Currently, the cuff-based sphygmomanometer is a popular, reliable, measurement method, but blood pressure monitors without cuffs have become popular and are now available without a prescription. Blood pressure monitors must be approved by regulatory authorities. Current cuffless blood pressure (CL-BP) monitors are not suitable for at-home management and prevention of hypertension. This paper proposes simple criteria for over-the-counter CL-BP monitoring. First, the history of the sphygmomanometer and current standard blood pressure protocol are reviewed. The main components of CL-BP monitoring are accuracy during the resting condition, accuracy during dynamic blood pressure changes, and long-term stability. In this proposal we recommend intermittent measurement to ensure that active measurement accuracy mirrors resting condition accuracy. A new experimental protocol is proposed to maintain long-term stability. A medically approved automated sphygmomanometer was used as the standard device in this study. The long-term accuracy of the test device is based on the definition of propagation error, i.e., for an oscillometric automated sphygmomanometer (5 ± 8 mmHg) ± the error for the test device static accuracy (-0.12 ± 5.49 mmHg for systolic blood pressure and - 1.17 ± 5.06 mmHg for diastolic blood pressure). Thus, the long-term stabilities were - 3.38 ± 7.1 mmHg and - 1.38 ± 5.4 mmHg, which satisfied propagation error. Further research and discussion are necessary to create standards for use by manufacturers; such standards should be readily evaluated and ensure high-quality evidence.

Supplementary information

The online version contains supplementary material available at 10.1007/s12553-023-00726-6.

Update on Hypertension Research in 2021

In 2021, 217 excellent manuscripts were published in Hypertension Research. Editorial teams greatly appreciate the authors' contribution to hypertension research progress. Here, our editorial members have summarized twelve topics from published work and discussed current topics in depth. We hope you enjoy our special feature, "Update on Hypertension Research in 2021".