Ambulatory Blood Pressure Thresholds for Diagnosis of Hypertension in Patients With and Without Type 2 Diabetes Based on Cardiovascular Outcomes

Hypertension in Women: The Current Understanding and Future Goals

Hypertension is one of the major contributing risk factor of cardiovascular diseases. Despite enormous advances in the preventive cardiology, hypertension remains the leading cause of death and disability in women. The article aims to focus on the gender specific differences in hypertension, and existing gaps in the current understanding of high blood pressure (BP) in women. Apart from epidemiological differences, hypertension in men and women has distinct pathophysiological mechanisms, impact on cardiovascular system, awareness and control. Prevalence of hypertension is higher in men than women till menopause; following this the prevalence rises steeply in women, and exceeds that of men above 75 years of age. Women with their estrogenic environment are relatively protected from high BP as their hormonal/chromosomal profile govern expression of alternate renin angiotensin axis (RAS) pathway and anti-inflammatory, vasodilatory, anti-proliferative immune cells whereas in males, classical RAS driven inflammatory, pro-hypertensive and proliferative milieu confers higher risk of hypertension. Thus, immunotherapy can have a potential therapeutic role in the treatment of hypertension in future. Cardiovascular consequences of high BP are worse in women than men in majority of trials. Women are now getting more aware of hypertension but the control of BP still remains poorer than men, especially in older age group. There are some noteworthy pharmacokinetic and pharmacogenomics gender differences in response to various antihypertensive drugs, which can be taken into consideration while choosing a particular class of drugs in female population. Standard treatment guidelines recommend same BP targets and management strategies in both the genders, but the trials so far have not been designed in a way to draw women specific conclusions on optimal cut-offs for diagnosis and treatment of BP due to under representation of women in majority of trials. More women centered analysis in future hypertension research projects can provide better scientific insights in various clinical aspects of hypertension.

Asleep blood pressure: significant prognostic marker of vascular risk and therapeutic target for prevention

Aims

Sleep-time blood pressure (BP) is a stronger risk factor for cardiovascular disease (CVD) events than awake and 24 h BP means, but the potential role of asleep BP as therapeutic target for diminishing CVD risk is uncertain. We investigated whether CVD risk reduction is most associated with progressive decrease of either office or ambulatory awake or asleep BP mean.

Methods and results

We prospectively evaluated 18 078 individuals with baseline ambulatory BP ranging from normotension to hypertension. At inclusion and at scheduled visits (mainly annually) during follow-up, ambulatory BP was measured for 48 consecutive hours. During the 5.1-year median follow-up, 2311 individuals had events, including 1209 experiencing the primary outcome (composite of CVD death, myocardial infarction, coronary revascularization, heart failure, and stroke). The asleep systolic blood pressure (SBP) mean was the most significant BP-derived risk factor for the primary outcome [hazard ratio 1.29 (95% CI) 1.22-1.35 per SD elevation, P < 0.001], regardless of office [1.03 (0.97-1.09), P = 0.32], and awake SBP [1.02 (0.94-1.10), P = 0.68]. Most important, the progressive attenuation of asleep SBP was the most significant marker of event-free survival [0.75 (95% CI 0.69-0.82) per SD decrease, P < 0.001], regardless of changes in office [1.07 (0.97-1.17), P = 0.18], or awake SBP mean [0.96 (0.85-1.08), P = 0.47] during follow-up.

Conclusion

Asleep SBP is the most significant BP-derived risk factor for CVD events. Furthermore, treatment-induced decrease of asleep, but not awake SBP, a novel hypertension therapeutic target requiring periodic patient evaluation by ambulatory monitoring, is associated with significantly lower risk for CVD morbidity and mortality.

Nocturnal blood pressure is associated with the progression of microvascular complications and hypertension in patients with type 1 diabetes mellitus

AIMS

To evaluate relationships between early alterations in blood pressure and the progression of microvascular complications of diabetes in clinically-normotensive patients with type 1 diabetes (T1DM).

METHODS

In a prospective observational study of 85 normotensive T1DM patients without microalbuminuria, blood pressure (BP) was monitored over 24h using the ambulatory blood pressure monitoring (ABPM) system at baseline and 7years later. Development or progression of microalbuminuria, retinopathy and hypertension was evaluated.

RESULTS

Initially, 20 patients (24%) were diagnosed with masked hypertension and 31 (37%) with non-dipper pattern as the only pathological findings. At 7years: 1) twenty-seven patients (32%) had progression of retinopathy related to the nocturnal diastolic blood pressure (BPD) (OR:1.122; p=0.034) and final non-dipper pattern (OR:5.857; p=0.005); 2) seven patients (10%) developed microalbuminuria for which nocturnal systolic blood pressure (BPS) was a risk factor (OR:1.129; p=0.007); 3) five of the normotensive patients (9%) progressed to hypertension; historic HbA1c (OR:2.767; p=0.046) and nocturnal BPD (OR:1.243; p=0.046) being the related risk factors. BPD level ≥65mmHg was associated with an increase in progression of retinopathy and hypertension.

CONCLUSIONS

In T1DM patients there is an elevated prevalence of BP alterations, detected using ABPM. Alterations in nocturnal BP predispose to development/progression of microvascular complications and overt hypertension.

Sleep-time ambulatory blood pressure as a prognostic marker of vascular and other risks and therapeutic target for prevention by hypertension chronotherapy: Rationale and design of the Hygia Project

This article describes the rationale, objectives, design and conduct of the ambulatory blood pressure monitoring (ABPM)-based Hygia Project. Given the substantial evidence of the significantly better prognostic value of ABPM compared to clinic BP measurements, several international guidelines now propose ABPM as a requirement to confirm the office diagnosis of hypertension. Nonetheless, all previous ABPM outcome investigations, except the Monitorización Ambulatoria para Predicción de Eventos Cardiovasculares study (MAPEC) study, relied upon only a single, low-reproducible 24 h ABPM assessment per participant done at study inclusion, thus precluding the opportunity to explore the potential reduction in cardiovascular disease (CVD) risk associated with modification of prognostic ABPM-derived parameters by hypertension therapy. The findings of the single-center MAPEC study, based upon periodic systematic 48 h ABPM evaluation of all participants during a median follow-up of 5.6 years, constitute the first proof-of-concept evidence that the progressive reduction of the asleep systolic blood pressure (SBP) mean and correction of the sleep-time relative SBP decline toward the normal dipper BP profile, most efficiently accomplished by a bedtime hypertension treatment strategy, best attenuates the risk of CVD, stroke and development of new-onset diabetes. The Hygia Project, primarily designed to extend the use of ABPM in primary care as a requirement for diagnosis of hypertension, evaluation of response to treatment and individualized assessment of CVD and other risks, is a research network presently composed of 40 clinical sites and 292 investigators. Its main objectives are to (i) investigate whether specific treatment-induced changes in ABPM-derived parameters reduce risk of CVD events, stroke, new-onset diabetes and/or development of chronic kidney disease (CKD); and (ii) test the hypothesis that bedtime chronotherapy entailing the entire daily dose of ≥1 conventional hypertension medications exerts better ambulatory BP control and CVD, metabolic and renal risk reduction than all such medications ingested in the morning upon awakening. Between 2007 and 2015, investigators recruited 18 078 persons [9769 men/8309 women, 59.1 ± 14.3 years of age (mean ± SD)], including 15 764 with hypertension according to ABPM criteria as participants in the prospective randomized chronotherapy trial. The initial evaluation includes 48 h ABPM, detailed medical history and screening laboratory blood and urine tests. The same evaluation procedure is scheduled annually, or more frequently when treatment adjustment is required for proper ambulatory BP control, targeting a median follow-up of >5 years. The primary CVD outcome end point is the composite of CVD death, myocardial infarction, coronary revascularization, heart failure, ischemic stroke and hemorrhagic stroke. The independent Hygia Project Events Committee periodically evaluates blinded clinical reports to ascertain and certify every documented event. Beyond the potential findings resulting from testing the main hypotheses, the Hygia Project has already demonstrated, as proof of concept, that the routine diagnosis of hypertension and individualized assessment of CVD and other risks by ABPM, as currently recommended, is fully viable in the primary care setting, where most people with either hypertension, dyslipidemia, type 2 diabetes or CKD receive routine medical attention.

Ambulatory Blood Pressure Monitoring (ABPM) as the reference standard for diagnosis of hypertension and assessment of vascular risk in adults

New information has become available since the ISC, AAMCC, and SECAC released their first extensive guidedelines to improve the diagnosis and treatment of adult arterial hypertension. A critical assessment of evidence and a comparison of what international guidelines now propose are the basis for the following statements, which update the recommendations first issued in 2013. Office blood pressure (BP) measurements should no longer be considered to be the "gold standard" for the diagnosis of hypertension and assessment of cardiovascular risk. Relying on office BP, even when supplemented with at-home wake-time self-measurements, to identify high-risk individuals, disregarding circadian BP patterning and asleep BP level, leads to potential misclassification of 50% of all evaluated persons. Accordingly, ambulatory BP monitoring is the recommended reference standard for the diagnosis of true hypertension and accurate assessment of cardiovascular risk in all adults ≥18 yrs of age, regardless of whether office BP is normal or elevated. Asleep systolic BP mean is the most significant independent predictor of cardiovascular events. The sleep-time relative SBP decline adds prognostic value to the statistical model that already includes the asleep systolic BP mean and corrected for relevant confounding variables. Accordingly, the asleep systolic BP mean is the recommended protocol to diagnose hypertension, assess cardiovascular risk, and predict cardiovascular event-free interval. In men, and in the absence of compelling clinical conditions, reference thresholds for diagnosing hypertension are 120/70 mmHg for the asleep systolic/diastolic BP means derived from ambulatory BP monitoring. However, in women, in the absence of complicating co-morbidities, the same thresholds are lower by 10/5 mmHg, i.e., 110/65 mmHg for the asleep means. In high-risk patients, including those diagnosed with diabetes or chronic kidney disease, and/or those having experienced past cardiovascular events, the thresholds are even lower by 15/10 mmHg, i.e., 105/60 mmHg. Bedtime treatment with the full daily dose of ≥1 hypertension medications is recommended as a cost-effective means to improve the management of hypertension and reduce hypertension-associated risk. Bedtime treatment entailing the full daily dose of ≥1 conventional hypertension medications must be the therapeutic regimen of choice for the elderly and those with diabetes, resistant and secondary hypertension, chronic kidney disease, obstructive sleep apnea, and medical history of past cardiovascular events, among others, given their documented high prevalence of sleep-time hypertension.