Clinical features and predictors of masked uncontrolled hypertension from the Korean Ambulatory Blood Pressure Monitoring Registry

Predictors Factors of Uncontrolled Masked Hypertension (MUCH) in Patients with Chronic Kidney Disease (CKD)

Background/Objectives: Masked uncontrolled hypertension (MUCH) is a blood pressure phenotype prevalent among chronic kidney disease (CKD) patients. It has been associated with an elevated risk of cardiovascular morbidity and mortality. Identifying MUCH predictor factors in this population is crucial in facilitating anticipation of adverse outcomes and complications. Methods: For a period of 7 years (2017-2023), hypertensive patients presenting CKD and in-office normotension (<140/90 mmHg) were consecutively selected. After ambulatory blood pressure monitoring (ABPM), we classified the patients into controlled hypertension (CH) or MUCH. We used epidemiological, clinical, anthropometric, and laboratory data to develop a predictor model of the MUCH phenotype. Results: From 220 participants, 109 (49.5%) had MUCH (mean age: 60 ± 16 years; 45% men; 35% with obesity). Higher diastolic BP (DBP) values were observed in the MUCH group (72 vs. 75; p = 0.01). In contrast, a higher body mass index was observed in the CH group (26 vs. 28; p < 0.01), while elevated albuminuria was observed in the MUCH group (69 vs. 275; p < 0.01). After multivariate analysis, DBP ≥75 mmHg (Odds Ratio: 1.93, 95%CI 1.03-3.64; p = 0.04), BMI ≤25 Kg/m2 (Odds Ratio: 2.21, 95%CI 1.08-4.52; p = 0.03), and albuminuria ≥ 300 mg/g (Odds Ratio: 3.26, 95%CI 1.71-6.19; p < 0.01) were identified as predictors of MUCH phenotype Conclusions: MUCH is common in patients with arterial hypertension (AH) and CKD. DBP ≥ 75 mmHg, BMI ≤ 25 Kg/m2, and albuminuria ≥ 300 mg/g were predictors of MUCH in these patients.

DCRM 2.0: Multispecialty practice recommendations for the management of diabetes, cardiorenal, and metabolic diseases

The spectrum of cardiorenal and metabolic diseases comprises many disorders, including obesity, type 2 diabetes (T2D), chronic kidney disease (CKD), atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), dyslipidemias, hypertension, and associated comorbidities such as pulmonary diseases and metabolism dysfunction-associated steatotic liver disease and metabolism dysfunction-associated steatohepatitis (MASLD and MASH, respectively, formerly known as nonalcoholic fatty liver disease and nonalcoholic steatohepatitis [NAFLD and NASH]). Because cardiorenal and metabolic diseases share pathophysiologic pathways, two or more are often present in the same individual. Findings from recent outcome trials have demonstrated benefits of various treatments across a range of conditions, suggesting a need for practice recommendations that will guide clinicians to better manage complex conditions involving diabetes, cardiorenal, and/or metabolic (DCRM) diseases. To meet this need, we formed an international volunteer task force comprising leading cardiologists, nephrologists, endocrinologists, and primary care physicians to develop the DCRM 2.0 Practice Recommendations, an updated and expanded revision of a previously published multispecialty consensus on the comprehensive management of persons living with DCRM. The recommendations are presented as 22 separate graphics covering the essentials of management to improve general health, control cardiorenal risk factors, and manage cardiorenal and metabolic comorbidities, leading to improved patient outcomes.

Exploring the prevalence, clinical spectrum, and determinants of uncontrolled hypertension in the emergency department: Insights from a hospital-based study in Somalia

BACKGROUND

Uncontrolled hypertension (UH) is a significant public health issue in both developed and developing countries. This study aimed to analyze the clinical spectrum and degrees of severity of hypertension, antihypertensive use, and factors associated with UH.

METHOD

Hospital-based cross-sectional study was conducted at the emergency-department of Mogadishu Somali Turkey Training and Research Hospital from September 2021 to August 2022. A total of 278 hypertensive patients were selected using a convenient sampling technique. Data was entered into and cleaned by Excel and exported to SPSS version-26.0 for analysis. A binary logistic regression model (AOR, 95 % CI and p-value<0.05) was used to determine the predictors of UH.

RESULTS

The prevalence of UH was 62 %(n = 172). Of the total respondents, 144(51.8 %) were males. The predominance of the respondents(n = 147, 52.9 %) were in the age group 40-69years. Almost 65.8 %(n = 183) of the participants were married. 112(40.3 %) of the participants had no formal education. The majority of the participants (n = 192, 69.1 % %) were unemployed. 225(81 %) patients had at least one or more coexisting diseases. Diabetes was the most common comorbid(47.4 %). The most common clinical manifestations observed in the study group were headache(21 %). According to the stages of hypertension, most of the patients have a Hypertensive crisis(20.9 %). Among the participants, 50 % were on calcium channel blockers(CCBs). Additionally, the majority (53.2 %) were receiving monotherapy. Patients who have no comorbidity (AOR = 0.178, 95 % CI:0.066-0.447), not performed diet control (AOR = 15.475, 95 % CI:6.666-35.929), and non-adherence to physical-activity (AOR = 5.585, 95 % CI:2.834-12.792) are independent predictors of UH.

CONCLUSION

The prevalence of UH among patients with hypertension in Somalia was high. Unhealthy lifestyles and non-adherence to physical activity were the major modifiable risk factors for UH. Regular health education during follow-up visits by nurses and physicians is crucial in preventing the issue by providing continuous information on lifestyle practices and the potential complications associated with hypertension.

When and how to use ambulatory blood pressure monitoring and home blood pressure monitoring for managing hypertension

Many individuals have different blood pressure (BP) values in the office setting compared to that outside the office setting. Therefore, confirming hypertension based on office BP (OBP) measurement alone can lead to misdiagnosis and mistreatment. The limitations of OBP measurement have led to the complementary use of out-of-office BP measurements, including 24-hour ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). This review aims to describe when and how ABPM or HBPM can be used to accurately diagnose and treat hypertension. Both methods should be performed using validated automated oscillometric devices. To minimize user errors, ABPM should be performed using standard techniques, whereas HBPM requires patient education regarding proper BP measurements. ABPM provides short-term comprehensive information on BP, including daytime, nighttime, morning, and 24-h BP. Therefore, ABPM is recommended for the initial diagnosis of hypertension, assessment of BP phenotypes and circadian patterns, and detection of nocturnal hypertension, Furthermore, ABPM plays a critical role in confirming true resistant hypertension thereby excluding pseudo-resistant hypertension. However, it is not suitable for long-term follow-up of patients with hypertension. In contrast, HBPM involves multiple BP readings taken at specific times during the day and evening over a long period. Therefore, HBPM is recommended for diagnosing hypertension and assessing BP phenotypes. However, this method has limitations in measuring nocturnal BP and circadian BP patterns. HBPM is preferred over ABPM for the long-term follow-up of patients with hypertension. This approach improves patient adherence to treatment and ultimately enhances the rate of control of hypertension. Additionally, both methods play an important role in diagnosing and treating white coat hypertension during pregnancy. Consequently, out-of-office BP measurement is essential to prevent the misdiagnosis and mistreatment of hypertension. However, these two methods offer different information regarding the BP status of an individual, and they indeed show discrepancies in the diagnosis of hypertensive phenotypes. Therefore, it is crucial to understand the advantages and limitations of both ABPM and HBPM to ensure their appropriate use in clinical practice.

Risk Factors in Optimal Management of Hypertension in Elderly Patients Following 2017 American College of Cardiology-American Heart Association Guidelines

INTRODUCTION/OBJECTIVES

The 2017 American Heart Association hypertension management guidelines recommended optimal control of blood pressure under 130/80 mmHg. We aimed to study the factors associated with suboptimal and uncontrolled hypertension in the elderly patients.

METHODS

We performed a retrospective review of suburban outpatient records of patients with hypertension, aged 65 years and older, and grouped into optimally controlled (OC; BP <130/80 mmHg), sub-optimally controlled (SOC; BP 130-139/80-89 mmHg), and uncontrolled (UC; BP≥140/90 mmHg) groups; and compared the associations of variables.

RESULTS

Among 1311 patients, there were 610 (46.5%) patients in OC, 391 (29.9%) in SOC, and 310 (23.6%) in UC groups. Mean ages were comparable (OC = 78 ± 8.1, SOC = 77 ± 7.4, UC = 78 ± 7.3 years; P = .760). In all groups, the majority of patients were White followed by BIPOC (Black-indigenous-and-other-people-of-color; OC = 78.5% vs 21.5%, SOC = 78.3% vs 21.7%, and UC = 71% vs 29%, respectively). There were more BIPOC patients in UC compared to OC group (29.0% vs 21.5%; P = .011). Mean body-mass-index (BMI) of patients in SOC and UC groups were greater than OC group (27.9 ± 6.3 vs 26.9 ± 6.3 kg/m2; P = .047; 28.1 ± 6.3 vs 26.9 ± 6.3 kg/m2; P = .027; respectively). There were significantly higher associations of certain comorbidities in SOC compared to OC group, such as transient ischemic attack (12.3% vs 3.6%; P < .001), hyperlipidemia (72.4% vs 56.2%; P < .001), atrial fibrillation (19.2% vs 11%; P < .001), HFpEF (5.4% vs 1.5%; P < .001), osteoarthritis (38.9% vs 30.5%; P = .006), malignancy (32.2% vs 19.5%; P < .001), and left ventricular hypertrophy (LVH; 27.4% vs 15.9%; P < .001). Logistic regression analysis showed that when compared to BIPOC, White race had lower odds of UC (OR = 0.63, 95% CI = 0.45-0.90). For every unit increase in BMI, there were greater odds of SOC (OR = 1.04, 95% CI = 1.01-1.06) and UC (OR = 1.04, 95% CI = 1.01-1.16). Patients with hyperlipidemia and LVH had greater odds of SOC (OR = 1.72, CI = 95% 1.25-2.37; and OR = 2.13, 95% CI = 1.02-4.43; respectively).

CONCLUSION

In patients with sub-optimal and uncontrolled hypertension, there is a significantly higher association of BIPOC race, elevated BMI, hyperlipidemia, and left ventricular hypertrophy.

Comparison of Office Blood Pressure, Automated Unattended Office Blood Pressure, Home Blood Pressure, and 24-Hour Ambulatory Blood Pressure Measurements

BACKGROUND

Although previous studies have reported differences of blood pressure (BP) according to BP measurement methods, studies in Korean population were scarce. This study aimed to compare BP differences according to different BP measurement methods and assess hypertension phenotype.

METHODS

This prospective study recruited 183 individuals (mean 55.9 years; 51.4% males). The BP measurements included office BP (auscultatory attended office BP [ausAOBP], automated attended office BP [aAOBP], and automated unattended office BP [aUAOBP]) and out-of-office BP (home BP [HBP] and ambulatory BP [ABP]) measurements taken within one week of each other.

RESULTS

The mean systolic/diastolic BP differences between ausAOBP and other BPs according to different BP measurement methods were 3.5/2.3 mmHg for aAOBP; 6.1/2.9 mmHg for aUAOBP; 15.0/7.3 mmHg for daytime ABP; and 10.6/3.4 mmHg for average HBP. The increasing disparity between ausAOBP and other BPs in multivariable regression analysis was significantly associated with increasing BP. The prevalence of white-coat hypertension and masked hypertension in 107 individuals not taking antihypertensive medication was 25.4-26.8% and 30.6-33.3% based on ausAOBP, daytime ABP, and average HBP, respectively. The prevalence of white-coat uncontrolled hypertension and masked uncontrolled hypertension in 76 of those taking antihypertensive medication was 31.7-34.1% and 17.1-37.1%, respectively.

CONCLUSION

This study showed a large disparity between office BP and out-of-office BP which became more pronounced when office BP by auscultation increased, suggesting that various BP measurement methods should be used to more accurately assess BP status.

Clinical and life style factors related to the nighttime blood pressure, nighttime dipping and their phenotypes in Korean hypertensive patients

BACKGROUND

Non-dipping or reverse dipping patterns are known to be associated with adverse cardiovascular prognosis among the general population and clinical cohort. Few large sized studies have explored factors including sleep duration and sleep quality related to nighttime blood pressure (BP) and nocturnal dipping patterns.

METHODS

Among 5,360 patients enrolled  in Korean multicenter nationwide prospective Registry of ambulatory BP monitoring (KORABP), 981 subjects with complete data on sleep duration, sleep quality assessed using a 4-point Likert scale, and clinical variables were included in the analysis. Phenotypes of nighttime BP pattern were categorized as extreme dipper, dipper, non-dipper, and reverse dipper. Hypertension was defined as a 24-h ambulatory BPs were 130/80 mmHg or higher.

RESULTS

Among 981 subjects, 221 were normotensive, 359 were untreated hypertensive, and 401 were treated hypertensive. Age of the participants were 53.87 ± 14.02 years and 47.1% were female. In overall patients, sleep duration was 431.99 ± 107.61 min, and one to four points of sleep quality were observed in 15.5%, 30.0%, 30.4%, and 24.2%, respectively. Of the 760 hypertensive patients, extreme dipper, dipper, non-dipper, and reverse dipper were observed in 58 (7.63%), 277 (36.45%), 325 (42.76%), and 100 (13.16%), respectively. In multiple linear regression analysis, sleep duration (β = 0.0105, p < 0.001) and sleep quality (β = -0.8093, p < 0.001) were associated with nighttime systolic BP and sleep quality was associated with extent of nighttime systolic BP dipping (β = 0.7622, p < 0.001) in hypertensive patients. In addition, sleep quality showed positive association with dipper pattern (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.03-1.30) and showed negative association with reverse dipper pattern (OR = 0.73, 95% CI = 0.62-0.86) in multiple logistic regression analyses.

CONCLUSION

When adjusted covariates, less sleep duration and poor sleep quality were positively associated with nighttime systolic BP. Additionally, sleep quality was the independent associated factor for dipper and reverse dipper phenotypes. The study also found that male sex, low estimated glomerular filtration rate, high ambulatory BP, low office BP, and poor sleep quality were associated with blunted nighttime SBP dipping.

The 2022 focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension

Hypertension is the leading cause of death in human being, which shows high prevalence and associated complications that increase the mortality and morbidity. Controlling blood pressure (BP) is very important because it is well known that lowering high BP effectively improves patients' prognosis. This review aims to provide a focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension. The importance of ambulatory BP and home BP monitoring was further emphasized not only for the diagnosis but also for treatment target. By adopting corresponding BPs, the updated guideline recommended out-of-office BP targets for both standard and intensive treatment. Based on the consensus on corresponding BPs and Systolic Blood Pressure Intervention Trial (SPRINT) revisit, the updated guidelines recommended target BP in high-risk patients below 130/80 mmHg and it applies to hypertensive patients with three or more additional cardiovascular risk factors, one or more risk factors with diabetes, or hypertensive patients with subclinical organ damages, coronary or vascular diseases, heart failure, chronic kidney disease with proteinuria, and cerebral lacunar infarction. Cerebral infarction and chronic kidney disease are also high-risk factors for cardiovascular disease. However, due to lack of evidence, the target BP was generally determined at < 140/90 mmHg in patients with those conditions as well as in the elderly. Updated contents regarding the management of hypertension in special situations are also discussed.

Prediction of Masked Uncontrolled Hypertension Detected by Ambulatory Blood Pressure Monitoring

The aim of this study was to provide prediction models for masked uncontrolled hypertension (MUCH) detected by ambulatory blood pressure (BP) monitoring in an Italian population. We studied 738 treated hypertensive patients with normal clinic BPs classified as having controlled hypertension (CH) or MUCH if their daytime BP was < or ≥135/85 mmHg regardless of nighttime BP, respectively, or CH or MUCH if their 24-h BP was < or ≥130/80 mmHg regardless of daytime or nighttime BP, respectively. We detected 215 (29%) and 275 (37%) patients with MUCH using daytime and 24-h BP thresholds, respectively. Multivariate logistic regression analysis showed that males, those with a smoking habit, left ventricular hypertrophy (LVH), and a clinic systolic BP between 130−139 mmHg and/or clinic diastolic BP between 85−89 mmHg were associated with MUCH. The area under the receiver operating characteristic curve showed good accuracy at 0.78 (95% CI 0.75−0.81, p < 0.0001) and 0.77 (95% CI 0.73−0.80, p < 0.0001) for MUCH defined by daytime and 24 h BP, respectively. Internal validation suggested a good predictive performance of the models. Males, those with a smoking habit, LVH, and high-normal clinic BP are indicators of MUCH and models including these factors provide good diagnostic accuracy in identifying this ambulatory BP phenotype.

Nomogram based on clinical features at a single outpatient visit to predict masked hypertension and masked uncontrolled hypertension: A study of diagnostic accuracy

Patients with masked hypertension (MH) and masked uncontrolled hypertension (MUCH) are easily overlooked, and both cause target organ damage. We propose a prediction model for MH and MUCH patients based on clinical features at a single outpatient visit. Data collection was planned before the index test and reference standard were after. Thus, we retrospectively collect analyzed 804 subjects who underwent ambulatory blood pressure monitoring (ABPM) at Renmin Hospital of Wuhan University. These patients were divided into normotension/controlled hypertension group (n = 121), MH/MUCH (n = 347), and sustained hypertension (SH)/sustained uncontrolled hypertension group (SUCH) (n = 302) for baseline characteristic analysis. Models were constructed by logistic regression, a nomogram was visualized, and internal validation by bootstrapping. All groups were performed according to the definition proposed by the Chinese Hypertension Association. Compared with normotension/controlled hypertension, patients with MH/MUCH had higher office blood pressure (BP) and were more likely to have poor liver and kidney function, metabolic disorder and myocardial damage. By analysis, [office systolic blood pressure (OSBP)] (P = .004) and [office diastolic blood pressure (ODBP)] (P = .007) were independent predictors of MH and MUCH. By logistic regression backward stepping method, office BP, body mass index (BMI), total cholesterol (Tch), high-density lipoprotein cholesterol (HDL-C), and left ventricular mass index are contained in this model [area under curve (AUC) = 0.755] and its mean absolute error is 0.015. Therefore, the prediction model established by the clinical characteristics or relevant data obtained from a single outpatient clinic can accurately predict MH and MUCH.

DCRM Multispecialty Practice Recommendations for the management of diabetes, cardiorenal, and metabolic diseases

Type 2 diabetes (T2D), chronic kidney disease (CKD), atherosclerotic cardiovascular disease (ASCVD), and heart failure (HF)-along with their associated risk factors-have overlapping etiologies, and two or more of these conditions frequently occur in the same patient. Many recent cardiovascular outcome trials (CVOTs) have demonstrated the benefits of agents originally developed to control T2D, ASCVD, or CKD risk factors, and these agents have transcended their primary indications to confer benefits across a range of conditions. This evolution in CVOT evidence calls for practice recommendations that are not constrained by a single discipline to help clinicians manage patients with complex conditions involving diabetes, cardiorenal, and/or metabolic (DCRM) diseases. The ultimate goal for these recommendations is to be comprehensive yet succinct and easy to follow by the nonexpert-whether a specialist or a primary care clinician. To meet this need, we formed a volunteer task force comprising leading cardiologists, nephrologists, endocrinologists, and primary care physicians to develop the DCRM Practice Recommendations, a multispecialty consensus on the comprehensive management of the patient with complicated metabolic disease. The task force recommendations are based on strong evidence and incorporate practical guidance that is clinically relevant and simple to implement, with the aim of improving outcomes in patients with DCRM. The recommendations are presented as 18 separate graphics covering lifestyle therapy, patient self-management education, technology for DCRM management, prediabetes, cognitive dysfunction, vaccinations, clinical tests, lipids, hypertension, anticoagulation and antiplatelet therapy, antihyperglycemic therapy, hypoglycemia, nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), ASCVD, HF, CKD, and comorbid HF and CKD, as well as a graphical summary of medications used for DCRM.