Ambulatory blood pressure monitoring. Current status and future perspectives

Ambulatory Blood Pressure Monitoring (ABPM) is considered the best method for obtaining a reliable estimation of the true blood pressure. Average values obtained during the whole 24-hour period, or during daytime and nighttime periods are better correlated with the risk of mortality and cardiovascular disease compared to clinic or office blood pressure. Indeed, nighttime blood pressure, a measure only obtained through ABPM, is the most powerful risk predictor. ABPM is complementary to clinic blood pressure measurement and allows the definition of blood pressure phenotypes, such as "white-coat or masked hypertension, when clinic and ABPM measurements show discrepancy in normal values. Additional potentially relevant features include blood pressure variability, such as nocturnal blood pressure decline, morning surge or short-term variability, as determined by standard deviation or the coefficient of variation.

[Ambulatory blood pressure monitoring, adult and pediatric population. A narrative review]

Hypertension has become a central risk factor for the development of cardiovascular disease, underscoring the importance of its accurate diagnosis. Numerous studies have established a close relationship between elevated systolic (SBP) and diastolic (DBP) blood pressure and an increased risk of cardiovascular event (CVE). Traditionally, blood pressure (BP) measurements performed in clinical settings have been the main method for diagnosing and assessing hypertension. However, in recent years, it has been recognized that BP measurements obtained outside the clinical setting, using self-monitoring blood pressure (SMBP) and ambulatory blood pressure monitoring (ABPM), offer a more realistic perspective of patients' daily lives and therefore provide more reliable results. Given the evolution of medical devices, diagnostic criteria, and the increasing relevance of certain components of ABPM in the prediction of adverse cardiovascular outcomes, a comprehensive update that is practical for daily clinical practice is required. The main objective of this article is to provide an updated review of ABPM, focusing on its importance in the evaluation of hypertension and its impact on public health in Colombia. In addition, it will discuss the implications of changes in diagnostic thresholds and provide concrete recommendations for the effective implementation of ABPM in clinical practice, allowing health professionals to make informed decisions and improve the care of their patients.

Twenty-four hour ambulatory blood pressure monitoring in patients with stable heart failure. Prevalence and associated factors

INTRODUCTION AND OBJECTIVES

Hypertension is highly common in heart failure (HF). However, there is limited information on its prevalence, circadian variation, and relationship with the various HF phenotypes. The objective of this study was to describe the prevalence of hypertension and its patterns in HF.

METHODS

This was a cross-sectional observational study of patients with optimized stable chronic HF. The patients underwent blood pressure (BP) measurement in the office and 24-hour ambulatory monitoring. We estimated the prevalence of hypertension, and its diurnal (controlled, uncontrolled, white coat, and masked) and nocturnal (dipper, nondipper, and reverse dipper) patterns. We also analyzed the factors associated with the different patterns and HF phenotypes.

RESULTS

From 2017 to 2021, 266 patients were included in the study (mean age, 72±12 years, 67% male, 46% with reduced ejection fraction). Hypertension was present in 83%: controlled in 68%, uncontrolled in 10%, white coat in 10%, and masked in 11%. Among patients with high office BP, 51% had white coat hypertension. Among those with normal office BP, 14% had masked hypertension. The prevalence of dipper, nondipper, and reverse dipper patterns was 31%, 43%, and 26%, respectively. Systolic BP was lower in HF with reduced ejection fraction than in HF with preserved ejection fraction (P <.001).

CONCLUSIONS

Ambulatory BP monitoring in HF identified white coat hypertension in more than half of patients with high office BP and masked hypertension in a relevant percentage of patients. The distribution of daytime patterns was similar to that of the population without HF in the literature, but most of the study patients had a pathological nocturnal pattern.

Evaluation of the ambulatory blood pressure monitoring in patients with retinal vein occlusion

BACKGROUND

Arterial hypertension (AHT) is the main risk factor for the development of retinal vein occlusion (RVO).

AIMS

To analyze the hypertensive profile with ambulatory blood pressure monitoring (ABPM) in patients with RVO.

PATIENTS AND METHODS

Retrospective and observational study of 66 patients with ABPM, 33 with retinal vein occlusion from a cohort of these disease and 33 controls without RVO, adjusted for age and sex.

RESULTS

Compared to controls, patients with RVO had elevated nocturnal values of SBP 130mmHg (21) vs. 119mmHg (11); P=.01 and DBP 73mmHg (11) vs. 65mmHg (9); P=.002. In addition, they presented a lower decrease in the Dipping ratio percentage 6.0% (10.4) vs. 12.3% (6.3); P=.005.

CONCLUSIONS

Patients with RVO have an unfavorable nocturnal hypertensive profile. Recognition of this fact can help optimize their treatment.

[Ambulatory blood pressure monitoring in patients with onco-hematological diseases]

Hypertension (HT) is a frequent pathology in patients with active or surviving onco-haematological malignancies. It is estimated that the prevalence of HT in this population ranges between 30 and 70%. The relationship between cancer and HT is multifactorial: common risk factors, neoplasia that cause HT through hormonal secretion, and, especially, chemotherapy drugs that cause HT. Ambulatory blood pressure monitoring (ABPM) is a fundamental tool in the diagnosis and adequate control of blood pressure, avoiding having to suspend or reduce the dose of chemotherapy treatment. In addition, it can help in the diagnosis of autonomic dysfunction related to certain neoplastic pathologies.

[Use of 48-hour ABPM in specialist care. Experience in our centre]

Ambulatory blood pressure monitoring (ABPM) is a basic tool in the diagnosis and treatment of hypertension (HT). Validity is based on the number of readings taken and their duration. Our aim was to study in our 48-hour ABPM series whether extending the duration of ABPM to 48 hours is justified.

MATERIAL AND METHODS

Retrospective analysis of a case series comprising 81 patients with 48-hour ABPM over a 5-year period (2013 to 2018). We analysed the differences between the first and second day.

RESULTS

Eighty-one patients, 44 men, mean age of 52 years (± 18). The mean blood pressure (BP) was higher on the first day (132/77 mmHg vs. 130/76 mmHg, p ≤ .01) and there was also a greater proportion of patients with HT on the first day (59 vs. 50%; p ≤ .05). The patients with chronic kidney disease (CKD) (n = 33) had higher systolic BP (SBP) on the second night (p ≤ .05), a circadian rhythm of higher risk on the second day (dipper 13.6 vs. 86.4%, non-dipper 60.7 vs. 41.7%, and riser 30.3 vs. 18.8%; p ≤ .05), more diabetes (39%, p ≤ .01) and more left ventricular hypertrophy (LVH) (74%, p ≤ .05).

CONCLUSIONS

48-hour ABPM could determine BP readings and circadian rhythm better than 24-hour ABPM, especially in patients with CKD and diabetes, both diseases carrying high cardiovascular risk.

Latin-American Ambulatory Blood Pressure Registry (MAPA-LATAM): An urgent need

Hypertension (HT) is one of the main risk factors for cardiovascular disease (CVD). Although it is a global problem, independently of economic situation, region, race or culture, the data available on Latin America are limited. Clinical guidelines emphasise the importance of obtaining reliable blood pressure readings. For this reason, the use of ambulatory blood pressure monitoring (ABPM) is recommended. This improves precision and reproducibility, resulting in better diagnosing and therapeutic decision-making, and constitutes a better estimation of prognosis than office measurements. Unfortunately, there is no global prospective ABPM registry for all of Latin America that analyses HT prevalence, the level of knowledge about it, treatment percentage and the degree of control. Consequently, the authors of this article consider its implementation a priority.

Usefulness of ABPM and bioimpedance for the treatment and control of hypertension in patients on chronic haemodialysis

INTRODUCTION

Hypertension is very common in haemodialysis (HD) patients, and is associated with increased morbidity and mortality rates. The goals of our research were to: 1. Measure blood pressure (BP) during HD sessions; 2. Study BP in between HD sessions with 44-h Ambulatory Blood Pressure Monitoring (ABPM); 3. Evaluate changes in treatment after the ABPM; 4. Perform bioimpedance spectroscopy (BIS) on all patients and, in those hyper-hydrated or hypertensive according to ABPM, assess for changes in BP after adjusting the dry weight; 5. Identify factors associated with average systolic and diastolic BP measured by ABPM.

MATERIAL AND METHODS

Prospective observational study, which included 100 patients from our dialysis unit. We measured BP before and after the HD sessions for two weeks and then, mid-week, we attached the ABPM device to the patients for 44 h. Before starting the following dialysis session, we performed BIS. A second ABPM was performed on hyper-hydrated patients and patients hypertensive according to ABPM to evaluate changes in BP values.

RESULTS

According to the ABPM, 65% of patients had daytime BP > 135/85 mmHg, 90% night-time BP > 120/70 mmHg and 76% average BP > 130/80 mmHg; 11% had a dipper pattern, 51% non-dipper and 38% riser. The average systolic and diastolic BP readings were 4.7 mmHg (3.8%) and 1.1 mmHg (1.64%) higher on the second day. The dose of antihypertensive medication had to be lowered in 6% of patients, 9% had to stop taking it, 28% needed increased doses and 17% had to add a new drug. The pre-HD diastolic BP best matched the ABPM. After performing the bioimpedance and adjusting dry weight, there was a statistically significant decrease in all BP values. The univariate analysis showed that the average systolic BP was higher in patients with a high-calcium dialysis bath, more antihypertensive drugs and higher doses of EPO. The multivariate analysis showed significant association for EPO and number of drugs (p < 0.01). The average diastolic BP was higher in younger patients and patients with lower Charlson index, lower body mass index and less diuresis, those on higher doses of EPO and non-diabetics. The linear regression study showed age (p < 0.005), body mass index (p < 0.03) and EPO (p < 0.03) as significant variables.

CONCLUSIONS

Our study shows: 1. The variability of hypertension criteria according to use of BP values from during the HD session or ABPM; 2. The variability of BP in the interdialysis period; 3. That the pre-dialysis diastolic BP best corresponds with the ABPM. 4. That the use of both BIS and ABPM improves the control of BP; 5. That the dose of EPO is the most important factor associated with hypertension in our patients.

Cardiovascular disease risk stratification by the Framigham score is markedly improved by ambulatory compared with office blood pressure

INTRODUCTION AND OBJECTIVES

Ambulatory blood pressure (BP) better predicts cardiovascular disease (CVD) outcomes than office BP measurements (OBPM). Nonetheless, current CVD risk stratification models continue to rely on exclusively daytime OBPM along with traditional factors, eg, age, sex, smoking, dyslipidemia, and/or diabetes.

METHODS

Data from 19 949 participants of the primary care-based Hygia Project assessed by 48-hour ambulatory BP monitoring (ABPM) and without prior CVD events were used to compare the diagnostic accuracy, discrimination, and performance of the original Framingham risk score (RS_OFG) and its adjusted version to the Hygia Project study population (RS_AFG) with that of a novel CVD risk stratification model constructed by replacing OBPM with ABPM-derived prognostic parameters (RS_ABPM).

RESULTS

During the follow-up, lasting up to 12.7 years, 1854 participants experienced a primary CVD outcome of CVD death, myocardial infarction, coronary revascularization, heart failure, stroke, transient ischemic attack, angina pectoris, or peripheral artery disease. Asleep systolic BP (SBP) mean and sleep-time relative SBP decline were the only joint significant ABPM-derived predictive factors of CVD risk and were therefore used to substitute for in-clinic SBP in the RS_ABPM model. The RS_ABPM model, in comparison with the RS_OFG and RS_AFG models, showed significantly improved calibration, diagnostic accuracy, discrimination, and performance (always P<.001). The RS_AFG-derived event-probabilities of 57.3% of the participants were outside the 95% confidence limits of the event probability determined by the RS_ABPM model.

CONCLUSIONS

These collective findings reveal important limitations of CVD risk stratification when based upon OBPM, as in the Framingham score, and corroborate the clinical value of around-the-clock ABPM to properly diagnose true hypertension and reliably stratify CVD vulnerability.

Usefulness of ABPM and bioimpedance for the treatment and control of hypertension in patients on chronic haemodialysis

INTRODUCTION

Hypertension is very common in haemodialysis (HD) patients, and is associated with increased morbidity and mortality rates. The goals of our research were to: 1. Measure blood pressure (BP) during HD sessions; 2. Study BP in between HD sessions with 44-hour Ambulatory Blood Pressure Monitoring (ABPM); 3. Identify differences between the BP recorded during HD and with the ABPM; 4. Evaluate changes in treatment after the ABPM; 5. Perform bioimpedance spectroscopy (BIS) on all patients and, in those hyper-hydrated or hypertensive according to ABPM, assess for changes in BP after adjusting the dry weight; 6. Identify factors associated with average systolic and diastolic BP measured by ABPM.

MATERIAL AND METHODS

Prospective observational study, which included 100 patients from our dialysis unit. We measured BP before and after the HD sessions for two weeks and then, mid-week, we attached the ABPM device to the patients for 44 hours. Before starting the following dialysis session, we performed BIS. A second ABPM was performed on hyper-hydrated patients and patients hypertensive according to ABPM to evaluate changes in BP values.

RESULTS

According to the ABPM, 65% of patients had daytime BP > 135/85 mmHg, 90% night-time BP > 120/70 mmHg and 76% average BP > 130/80 mmHg; 11% had a dipper pattern, 51% non-dipper and 38% riser. The average systolic and diastolic BP readings were 4.7 mmHg (3.8%) and 1.1 mmHg (1.64%) higher on the second day. The dose of antihypertensive medication had to be lowered in 6% of patients, 9% had to stop taking it, 28% needed increased doses and 17% had to add a new drug. The pre-HD diastolic BP best matched the ABPM. After performing the bioimpedance and adjusting dry weight, there was a statistically significant decrease in all BP values. The univariate analysis showed that the average systolic BP was higher in patients with a high-calcium dialysis bath, more antihypertensive drugs and higher doses of EPO. The multivariate analysis showed significant association for EPO and number of drugs (p < 0.01). The average diastolic BP was higher in younger patients and patients with lower Charlson index, lower body mass index and less diuresis, those on higher doses of EPO and non-diabetics. The linear regression study showed age (p < 0.005), body mass index (p < 0.03) and EPO (p < 0.03) as significant variables.

CONCLUSIONS

Our study shows: 1. The variability of hypertension criteria according to use of BP values from during the HD session or ABPM; 2. The variability of BP in the interdialysis period; 3. That the pre-dialysis diastolic BP best corresponds with the ABPM. 4. That the use of both BIS and ABPM improves the control of BP; 5. That the dose of EPO is the most important factor associated with hypertension in our patients.

Chronotherapy for reduction of cardiovascular risk

Numerous prospective studies establish that elevated asleep blood pressure (BP) constitutes a significant cardiovascular disease (CVD) risk factor, irrespective of daytime office BP measurements or awake and 24h BP measurements. Moreover, except for a small number of studies with flawed methodology, multiple clinical trials of high consistency document significantly better BP-lowering efficacy of hypertension medication and their combinations when ingested at bedtime compared to upon awakening as is customary. Additionally, recent trials conclude bedtime hypertension chronotherapy markedly reduces CVD risk not only in the general population, but also in more vulnerable patients of advanced age, with kidney disease, diabetes, or resistant hypertension. Collectively, these results call for a new definition of true arterial hypertension and its proper diagnosis and management.

[Diagnostic accuracy of blood pressure determination in clinics in control of hypertension: Proposal of new cut-off values]

AIM

This study seeks to determine the optimal cut-off values for the determination of the blood pressure in the clinic as a follow-up test in Primary Care practice.

DESIGN

A total of 153 hypertensive patients under 80years of age who met inclusion and exclusion criteria for the study, were subjected to ambulatory monitoring of their blood pressure for 24hours (ABPM). After which two clinic-based measurements were obtained. With the results obtained from the clinic, and taking the ABMP as a reference, the ROC curve was calculated choose the optimal cut-off point. The agreement between both measurements was determined by the intraclass correlation coefficient and the Bland-Altman equation. A validation study was then carried out with the objective of diagnosing whether or not the hypertensive patient was in control.

RESULTS

The optimal cut-off values were 137mmHg for systolic BP (sensitivity: 89.3%; specificity: 72.2%) and 84mmHg for diastolic blood pressure (sensitivity: 79.4%; specificity: 72.3%). The agreement in the diagnosis of control between clinic-based measurement and ABPM was 58.9% (Kappa: 0.418).

CONCLUSION

The optimal cut-off value of the diastolic BP for follow-up is lower than the values currently established.

[Ambulatory blood pressure monitoring for hypertension diagnosis?]

The early and accurate diagnosis of hypertension is essential given its importance in the development of cardiovascular disease. The boundaries between normal blood pressure (BP) and hypertension are arbitrary and based on the benefits of treating exceeding those of not treating. Conventional BP measurement at the clinic only offers information of a particular time and presents multiple biases dependent on inherent variability of BP and measurement technique itself. Multiple studies have demonstrated the prognosis superiority in the development of cardiovascular disease of ambulatory blood pressure monitoring (ABPM), allows detection of white coat hypertension, avoiding overdiagnosis and overtreatment, and the detection of patients with masked hypertension who are at risk of underdetection and undertreatment. ABPM also assess nightime BP and circadian variability, providing additional prognostic value. ABPM is recognized in the diagnosis of hypertension in 2011 British NICE Guidelines, very argued at the 2013 European Society of Hypertension guidelines, and recommended in the US Preventive Services Task Force in 2015, 2016 Canadian Guidelines and the 2016 Spanish Program of Preventive Activities and Health Promotion (PAPPS). Its generalization is likely to be only a matter of time.

[Position statement on ambulatory blood pressure monitoring (ABPM) by the Spanish Society of Hypertension (2019)]

Conventional blood pressure (BP) measurement in clinical practice is the most used procedure for the diagnosis and treatment of hypertension (HT), but is subject to considerable inaccuracies due to, on the one hand, the inherent variability of the BP itself and, on the other hand biases arising from the measurement technique and conditions, Some studies have demonstrated the prognosis superiority in the development of cardiovascular disease using ambulatory blood pressure monitoring (ABPM). It can also detect "white coat" hypertension, avoiding over-diagnosis and over-treatment in many cases, as well detecting of masked hypertension, avoiding under-detection and under-treatment. ABPM is recognised in the diagnosis and management of HT in most of international guidelines on hypertension. The present document, taking the recommendations of the European Society of Hypertension as a reference, aims to review the more recent evidence on ABPM, and to serve as guidelines for health professionals in their clinical practice and to encourage ABPM use in the diagnosis and follow-up of hypertensive subjects. Requirements, procedure, and clinical indications for using ABPM are provided. An analysis is also made of the main contributions of ABPM in the diagnosis of "white coat" and masked HT phenotypes, short term BP variability patterns, its use in high risk and resistant hypertension, as well as its the role in special population groups like children, pregnancy and elderly. Finally, some aspects about the current situation of the Spanish ABPM Registry and future perspectives in research and potential ABPM generalisation in clinical practice are also discussed.

[Diagnostic validity of the isolated measurement of blood pressure in the community pharmacy. Optimum cut-off points]

INTRODUCTION AND OBJECTIVES

The aim of this study is to determine the diagnostic validity of blood pressure measurement in the community pharmacy (CPBP), and to set the cut-off points in systolic blood pressure (SBP) and diastolic blood pressure (DBP) in order to maximise the aforementioned validity, using 24 hour ambulatory blood pressure monitoring (ABPM) as the reference method.

MATERIAL AND METHODS

A cross-sectional study with consecutive selection of patient users of the community pharmacy in Andalusia. The CPBP was measured, followed by 24-hour ABPM, which assessed the diagnostic validity of the CPBP. The AUC of the ROC curve was also calculated for SBP and DBP, along with the positive and negative predictive values, for different prevalences and the variation of sensitivity and specificity for the different cut-off points for SBP/DBP.

RESULTS

A total of 167 community pharmacy participated with 1,170 patients, of which 1,110 were valid. The CPBP showed a sensitivity of 60.41% (95% CI: 56.40-64.29), and a specificity of the 79.77% (95% CI: 76.12-82.99), a positive predictive values of 76.96% (95% CI: 72.89-80.57), and a negative predictive values of 64.31% (95% CI: 60.55%-67.90%). By using the ROC curve method, the optimal cut-off points are 134/81mm Hg, the point where the sensitivity and specificity and are balanced and the Youden index is maximised.

CONCLUSIONS

The sensitivity is relatively low. To improve it tends to lower the cut-off points of SBP and DBP. The calculated optimum is 134/81mm Hg. This provides data on the desirability to review the current cut-off points (140/90), as proposed by the ACC/AHA 2017.

The value of ABPM and subclinical target organ damage parameters in diagnosis of resistant hypertension

INTRODUCTION

We aimed to assess the effectiveness of ambulatory blood pressure monitoring (ABPM) and subclinical target organ damage parameters for diagnosis of resistant hypertension (RH).

METHODS

We assessed demographic and anthropometric variables, the incidence of cardiovascular events and subclinical target organ damage (n=112). We also studied the relationship between these variables and the ABPM results.

RESULTS

Of the 112 patients referred from primary care with a diagnosis of RH, 69 (61.6%) were confirmed by ABPM. We found statistically significant differences (P<.001) between patients with RH and pseudo-resistant hypertension in the appearance of subclinical target organ damage. A percentage of 84 of the patients had microalbuminuria: 66.25±30.7mg/dl); 44.9% had stage 3 chronic kidney disease: the average glomerular filtration was 59ml/min/1.73m²; and 56.5% had left ventricular hypertrophy on echocardiography. Fundoscopy revealed that 64% of the patients had hypertensive retinopathy. Three variables were associated with an increased HR risk: microalbuminuria, hypertensive retinopathy and left ventricular hypertrophy (OR 5.7, 6.2 and 11.2, respectively).

CONCLUSIONS

This study shows that the systematic testing for target organ damage, particularly in terms of albuminuria, is a simple and inexpensive tool, with a high predictive value for RH (85%), which could be useful for prioritising patients who need ABPM.

Rationale and Methodology of the SARAH Trial: Long-Term Cardiovascular Outcomes in Patients With Resistant Hypertension and Obstructive Sleep Apnea

INTRODUCTION

Patients with resistant hypertension (RH) have a high risk of developing cardiovascular events; therefore, new therapeutic approaches to better control blood pressure may be useful in improving cardiovascular outcomes. The prevalence of obstructive sleep apnea (OSA) is very high among patients with RH. Continuous positive airway pressure (CPAP) has been shown to be an effective treatment for reducing blood pressure in patients with RH. Nevertheless, the long-term effect of CPAP treatment on cardiovascular outcomes has not been explored. The main objective of the SARAH study is to assess the impact of OSA and its treatment on cardiovascular outcomes (morbidity and mortality) in patients with RH.

METHODS

This study is a multi-center, prospective, observational cohort study. A total of 1371 patients with RH will be enrolled in the study and followed once a year for five years. At inclusion, ambulatory blood pressure monitoring (ABPM) and a sleep study will be performed in all subjects. Socio-demographic, clinical and cardiovascular variables will be collected at baseline and follow-up. Subsequently, subjects with OSA will be managed according to local standard practice. Based on the OSA diagnosis and its treatment, three cohorts of subjects with RH will be defined: non-OSA, treated OSA and non-treated OSA.

CONCLUSIONS

This study will contribute to elucidating the long-term impact of OSA treatments on blood pressure control and cardiovascular outcomes in patients with RH. These results will contribute to improve the cardiovascular prognosis of patients with RH.

[Ambulatory blood pressure monitoring is a useful tool for all patients]

Clinical blood pressure measurement (BP) is an occasional and imperfect way of estimating this biological variable. Ambulatory blood pressure monitoring (ABPM) is by far the best clinical tool for measuring an individual's blood pressure. Mean values over 24h, through the daytime and at night all make it more possible to predict organic damage and the future development of the disorder. ABPM enables the detection of white-coat hypertension and masked hypertension in both the diagnosis and follow-up of treated patients. Although some of the advantages of ABPM can be reproduced by more automated measurement without the presence of an observer in the clinic or self-measurement at home, there are some other elements of great interest that are unique to ABPM, such as seeing what happens to a patient's BP at night, the night time dipping pattern and short-term variability, all of which relate equally to the patient's prognosis. There is no scientific or clinical justification for denying these advantages, and ABPM should form part of the evaluation and follow-up of practically all hypertensive patients. Rather than continuing unhelpful discussions as to its availability and acceptability, we should concentrate our efforts on ensuring its universal availability and clearly explaining its advantages to both doctors and patients.

Ambulatory blood pressure monitoring in diabetes for the assessment and control of vascular risk

The diagnosis of hypertension and the clinical decisions regarding its treatment are usually based on daytime clinic blood pressure (BP) measurements. However, the correlation between BP levels and target organ damage, cardiovascular (CV) risk, and long-term prognosis, is higher for ambulatory (ABPM) than clinic measurements, both in the general population as well as in patients with diabetes. Moreover, there is consistent evidence in numerous studies that the asleep BP better predicts CV events than either the awake or 24h means. The prevalence of abnormal BP pattern and sleep-time hypertension is extensive in diabetes, often leading to inaccurate diagnoses of hypertension and its therapeutic control in the absence of complete and careful assessment of the entire 24h, i.e., daytime and night-time, BP pattern. Accordingly, ABPM should be the preferred method to comprehensively assess and decide the optimal clinical management of patients with diabetes directed to properly reduce elevated sleep-time BP, which might also lead to a significant reduction of CV events.

[Differences in the reduction of blood pressure according to drug administration at activity hours or rest hours]

BACKGROUND AND OBJECTIVE

In this study, 123 recordings of blood pressure (BP) obtained by ambulatory BP monitoring were analyzed. These recordings were measured in 2011 in patients from a Spanish tertiary university hospital. All participating patients were treated with 2, 3 or 4 anti-hypertensive drugs. The main aim of this study was to determine differences in BP control, if any, depending on the medication schedule. Thus, BP levels were studied at 3 periods of the day: activity hours, rest hours and 24h.

PATIENTS AND METHOD

We compared subjects taking all anti-hypertensive agents during the day (n=70, group 1) with those taking at least one at night (n=53, group 2).

RESULTS

Significant differences were found on diastolic BP, where group 2 patients had lower levels at activity, 24h periods and sleep-time. Even if it was not statistically significant, lower levels of systolic BP from group 2 were also observed at activity and 24h periods as well as lower levels of systolic, diastolic and mean BP at rest hours periods. There were also significant group differences in relation to the number of prescribed agents (with the mean being higher for group 2) and the type of agent (beta-blockers and calcium antagonists were more prevalent in group 2). Nevertheless, the multivariate regression analysis done taking into account these variables did not change the observed statistical significance.

CONCLUSION

The administration of anti-hypertensive drugs at night could be associated with lower BP levels.

Prevalence of Atherogenic Dyslipidemia in Spanish Hypertensive Patients and Its Relationship With Blood Pressure Control and Silent Organ Damage

INTRODUCTION AND OBJECTIVES

To assess the prevalence of atherogenic dyslipidemia in hypertensive patients and its relationship with risk profile and blood pressure control.

METHODS

The study included 24 351 hypertensive patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. Atherogenic dyslipidemia was defined as the presence of hypertriglyceridemia (> 150mg/dL) and low levels of high-density lipoprotein cholesterol (< 40mg/dL in men and < 46mg/dL in women). Blood pressure control was assessed by office and ambulatory monitoring.

RESULTS

Atherogenic dyslipidemia was present in 2705 patients (11.1%). Of these, 30% had hypertriglyceridemia and 21.7% had low levels of high-density lipoprotein cholesterol. Compared with patients without these risk factors, the former group were more often male (60% vs 52%), younger (57 years vs 59 years), had other risk factors and organ damage (microalbuminuria, reduced estimated glomerular filtration rate, and left ventricular hypertrophy), worse office, diurnal, and nocturnal blood pressure values (odds ratio 1.09, 1.06, and 1.10, respectively), and the lowest nocturnal blood pressure reduction (odds ratio=1.07), despite the greater use of antihypertensive drugs.

CONCLUSIONS

Atherogenic dyslipidemia is present in more than 10% of hypertensive patients and is associated with other risk factors, organ damage, and poorer blood pressure control. Greater therapeutic effort is needed to reduce overall risk in these patients.

Validity and applicability of a new recording method for hypertension

INTRODUCTION AND OBJECTIVES

Blood pressure measurement methods and conditions are determinants of hypertension diagnosis. A recent British guideline recommends systematic 24-h ambulatory blood pressure monitoring. However, these devices are not available at all health centers and they can only be used by 1 patient per day. The aim of this study was to test a new blood pressure recording method to see if it gave the same diagnostic results as 24-h blood pressure monitoring.

METHODS

One-hour blood pressure monitoring under routine clinical practice conditions was compared with standard method of day time recording by analyzing the coefficient of correlation and Bland-Altman plots. The Kappa index was used to calculate degree of agreement. Method sensitivity and specificity were also analyzed.

RESULTS

Of the 102 participants, 89 (87.3%) obtained the same diagnosis regardless of method, with high between-method agreement (κ= 0.81; 95% confidence interval, 0.71-0.91). We observed robust correlations between diastolic (r=0.85) and systolic blood pressure (r=0.76) readings. Sensitivity and specificity for the new method for diagnosing white coat hypertension were 85.2% (95% confidence interval 67.5%-94.1%) and 92% (95% confidence interval, 83.6%-96.3%), respectively.

CONCLUSIONS

One-hour blood pressure monitoring is a valid and reliable method for diagnosing hypertension and for classifying hypertension subpopulations, especially in white coat hypertension and refractory hypertension. This also leads to a more productive use of monitoring instruments.

[Descriptive study of ambulatory blood pressure monitoring in the Primary Care Nursing clinic]

OBJECTIVE

To analyze the clinical characteristics and the circadian patterns of patients who received ambulatory blood pressure monitoring (ABPM) by a Primary Care Team.

METHOD

A descriptive, observational, cross-sectional study at community level. People older than 18 years on ABPM (2007-2011).

VARIABLES

demographic, cardiovascular disease, diabetes mellitus, cardiovascular risk factors, any type of arterial hypertension and circadian pattern. Intruments of measurement: 2 validated instruments with comparable results were used.

PROCEDURE

The instruments for ABPM were placed during the nursing visit. The instruments were then removed after 24h, and the data was retrieved and recorded in the computerized clinical history.

RESULTS

A total of 326 people were studied, with a mean age of 60.53±12.96 years, of whom 56.7% were male. According to ABPM the patient results showed that: 38.5% had «white coat» arterial hypertension, 36.2% were classified as poorly controlled arterial hypertension, 17.2% had masked hypertension, and 8% with isolated hypertension. Dipper circadian patterns were present in 39.6% of patients and non- dipper in 60.4%.

CONCLUSIONS

ABPM allows to Primary Health Care professionals to check the actual situation of the blood pressure over 24h and analyze the circadian pattern. In clinical practice this involves having a comprehensive care strategy on life style, as well as adherence to treatment.

[Blood pressure control in hospital units in Spain]

BACKGROUND AND OBJECTIVE

Blood pressure (BP) control has been extensively studied in patients attended in primary care but reports in the hospital setting, which includes referral units, are scarce. The aim was to evaluate the degree of BP control in hypertensive patients attended in referral units.

PATIENTS AND METHODS

We studied 1,550 hypertensive subjects (41.5% women) with a mean age of 64 (12) years, who were receiving antihypertensive drugs. The degree of BP control was estimated in a single visit by the proportion of patients with BP below 140/90 mm Hg.

RESULTS

BP was controlled in 653 patients (42%). In comparison, those whose BP was not controlled were more frequently women (odds ratio [OR] 1.57; 95% confidence interval [95%CI]: 1.23-1.99), obese (OR 1.28; 95%CI 1.00-1.63), smokers (OR 1.78; 95%CI 1.36-2.34), had left ventricular hypertrophy (OR 1.86; 95%CI 1.46-2.36) and elevated values of total serum cholesterol (OR 1.50; 95%CI 1.19-1.90) and triglycerides (OR 1.63; 95%CI 1.29-2.07). Therapeutical inertia was observed in 39% of uncontrolled patients. In a subgroup of patients who underwent ambulatory BP monitoring, discordance between measurements was only present in 23% (9.8 with isolated clinic hypertension and 13.1% with masked hypertension).

CONCLUSION

The degree of BP control in patients attended in referral units is estimated in 42% and has not been modified in the last decade. Although therapeutical effort and inertia have improved, this only compensates the increased risk and comorbidities of attended patients, making more difficult the control of BP values.

[2013 Ambulatory blood pressure monitoring recommendations for the diagnosis of adult hypertension, assessment of cardiovascular and other hypertension-associated risk, and attainment of therapeutic goals (summary). Joint recommendations from the International Society for Chronobiology (ISC), American Association of Medical Chronobiology and Chronotherapeutics (AAMCC), Spanish Society of Applied Chronobiology, Chronotherapy, and Vascular Risk (SECAC), Spanish Society of Atherosclerosis (SEA), and Romanian Society of Internal Medicine (RSIM)]

Correlation between systolic (SBP) and diastolic (DBP) blood pressure (BP) level and target organ damage, cardiovascular disease (CVD) risk, and long-term prognosis is much greater for ambulatory BP monitoring (ABPM) than daytime office measurements. The 2013 ABPM guidelines specified herein are based on ABPM patient outcomes studies and constitute a substantial revision of current knowledge. The asleep SBP mean and sleep-time relative SBP decline are the most significant predictors of CVD events, both individually as well as jointly when combined with other ABPM-derived prognostic markers. Thus, they should be preferably used to diagnose hypertension and assess CVD and other associated risks. Progressive decrease by therapeutic intervention in the asleep BP mean is the most significant predictor of CVD event-free interval. The 24 h BP mean is not recommended to diagnose hypertension because it disregards the more valuable clinical information pertaining to the features of the 24 h BP pattern. Persons with the same 24 h BP mean may display radically different 24 h BP patterns, ranging from extreme-dipper to riser types, representative of markedly different risk states. Classification of individuals by comparing office with either the 24 h or awake BP mean as "masked normotensives" (elevated clinic BP but normal ABPM), which should replace the terms of "isolated office" or "white-coat hypertension", and "masked hypertensives" (normal clinic BP but elevated ABPM) is misleading and should be avoided because it disregards the clinical significance of the asleep BP mean. Outcome-based ABPM reference thresholds for men, which in the absence of compelling clinical conditions are 135/85 mmHg for the awake and 120/70 mmHg for the asleep SBP/DBP means, are lower by 10/5 mmHg for SBP/DBP in uncomplicated, low-CVD risk, women and lower by 15/10 mmHg for SBP/DBP in male and female high-risk patients, e.g., with diabetes, chronic kidney disease (CKD), and/or past CVD events. In the adult population, the combined prevalence of masked normotension and masked hypertension is >35%. Moreover, >20% of "normotensive" adults have a non-dipper BP profile and, thus, are at relatively high CVD risk. Clinic BP measurements, even if supplemented with home self-measurements, are unable to quantify 24 h BP patterning and asleep BP level, resulting in potential misclassification of up to 50% of all evaluated adults. ABPM should be viewed as the new gold standard to diagnose true hypertension, accurately assess consequent tissue/organ, maternal/fetal, and CVD risk, and individualize hypertension chronotherapy. ABPM should be a priority for persons likely to have a blunted nighttime BP decline and elevated CVD risk, i.e., those who are elderly and obese, those with secondary or resistant hypertension, and those diagnosed with diabetes, CKD, metabolic syndrome, and sleep disorders.