Home blood pressure measurement for hypertension management in the real world: Do not just measure, but share with your physician.

Introduction: Studies of the effectiveness of home blood pressure (BP) measurement on the treatment of hypertension in the real world are sparse, and the results are controversial. There is an efficacy-effectiveness gap in the treatment of hypertension using home BP measurements. We aimed to investigate the effect of reporting home BP to physicians on ambulatory BP control as a factor contributing to the efficacy-effectiveness gap in treating patients with hypertension. Methods: We recruited patients ≥20 years of age taking antihypertensive drugs. Office and 24-h ambulatory BP were measured. A questionnaire to the measurement of home BP was conducted. Participants were divided into an HBPM(-) group, home BP was not measured (n = 467); HBPM(+)-R(-) group, home BP was measured but not reported (n = 81); and HBPM(+)-R(+) group, home BP was measured and reported (n = 125). Results: The HBPM(+)-R(+) group had significantly lower office systolic BP (SBP, p = 0.035), 24-h SBP (p = 0.009), and daytime SBP (p = 0.016) than the HBPM(-) group, and lower nighttime SBP (p = 0.005) and diastolic BP (DBP, p = 0.008) than the HBPM(+)-R(-) group. In the multivariate analysis, the differences in 24-h SBP, daytime SBP, and nighttime DBP remained significant. There was a significant difference between groups in the target achievement rate of 24-h SBP (p = 0.046), nighttime SBP (p = 0.021), and nighttime DBP (p = 0.023). The nighttime SBP and DBP target achievement rates in the HBPM(+)-R(+) group were higher than those in the HBPM(+)-R(-) group (p = 0.006 and 0.010, respectively). Among patients measuring home BP, the adjusted odds ratio for 24-h and nighttime BP target achievement in the HBPM(+)-R(+) group were 2.233 and 3.658, respectively. Conclusion: Home BP measurements should be reported to the treating physician to effectively manage hypertension. Clinical trial registration: https://clinicaltrials.gov, identifier NCT03868384.

Home Blood Pressure-based Guidance Did Not Increase Anti-albuminuric Effects on Diagnostic Provision of Microalbuminuria in School Workers: A Miyagi Karoshi Prevention Study.

Objective We examined whether home blood pressure (BP)-based behavioural guidance had an additional anti-albuminuric effect on school workers with the simple diagnostic provision of microalbuminuria. Methods Of 169 school staff diagnosed with microalbuminuria (30-299.9 mg/gCr) in the annual 2019 health check-up, 91 agreed to receive home-BP-based guidance. Guidance comprised, for subjects with ≥135/85 mmHg, 5 days mean of home BP measurements, or encouraging medical consultation and lifestyle guidance; lifestyle guidance for subjects with BP 125-134/80-84 mmHg; and adequate lifestyle guidance for subjects BP <125/80 mmHg, if necessary. The main outcome was a change in the frequency of microalbuminuria the following year. Subjects with menstruation were excluded from analysis. Finally, there were 48 and 43 participants in guided and the non-guided groups, respectively. Results The guided and non-guided groups demonstrated similar baseline clinical data. Their prescription rates for hypertension (39.6 vs. 41.9 %) and diabetes (18.8 vs. 30.2 %) were similar. One year later, microalbuminuria was present in 31.2% and 30.2% of the guided and non-guided groups (n.s.), respectively, suggesting a ~70% risk reduction of microalbuminuria in both groups. Sensitivity analysis, excluding patients treated for hypertension or diabetes at baseline, demonstrated essentially similar results. In conclusion, the risk reduction of microalbuminuria was nearly 70% for both the home-BP-based guidance and non-guidance groups. Conclusion These data suggest that home BP-based guidance did not increase anti-albuminuric effects on simple diagnostic provision of microalbuminuria in school workers.

Expert Consensus on the Clinical Use of Pulse Wave Velocity in Asia.

Arterial stiffness is a progressive aging process that predicts cardiovascular disease. Pulse wave velocity (PWV) has emerged as a noninvasive, valid, and reliable measure of arterial stiffness and an independent risk predictor for adverse outcomes. However, up to now, PWV measurement has mostly been used as a tool for risk prediction and has not been widely used in clinical practice. This consensus paper aims to discuss multiple PWV measurements currently available in Asia and to provide evidence-based assessment together with recommendations on the clinical use of PWV. For the methodology, PWV measurement including the central elastic artery is essential and measurements including both the central elastic and peripheral muscular arteries, such as brachial-ankle PWV and cardio-ankle vascular index, can be a good alternative. As Asian populations are rapidly aging, timely detection and intervention of "early vascular aging" in terms of abnormally high PWV values are recommended. More evidence is needed to determine if a PWV-guided therapeutic approach will be beneficial to the prevention of cardiovascular diseases beyond current strategies. Large-scale randomized controlled intervention studies are needed to guide clinicians.

Effects of Isometric Handgrip Training on Home Blood Pressure Measurements in Hypertensive Patients: A Randomized Crossover Study.

Objective We aimed to examine the effects of isometric handgrip (IHG) training on home blood pressure (BP) levels in hypertensive Japanese patients undergoing treatment. Methods Fifty-three hypertensive patients (mean age, 61.7 years; 56.6% men) with a home systolic BP ≥135 mmHg and/or a home diastolic BP ≥85 mmHg were randomly assigned to either group A or B. As per the crossover design, group A performed 8 weeks of IHG training, followed by an equivalent training-free, control period, while the reverse protocol was performed by group B. The baseline characteristics were similar between both groups. The individualized daily IHG training comprised four sets of 2-min isometric contractions at 30% of the individual's maximum voluntary contraction capacity, including 1 min of rest between sets, for ≥3 days/week. The outcome measure was morning and evening home BP readings taken over the last 2 weeks of the training and control periods. Results A combined data analysis for both groups showed that IHG training was significantly associated with the lowering of both systolic and diastolic BP in the morning (137.9±9.3 vs. 135.3±9.5 mmHg, p=0.007 and 83.0±9.5 vs. 81.2±9.3 mmHg, p<0.001, respectively) and evening (130.0±10.7 vs. 127.6±10.1 mmHg, p=0.003 and 75.8±10.4 vs. 73.8±9.2 mmHg, p<0.001, respectively), while no significant change was observed after the control period. A larger increase in the maximum grip strength due to IHG training was associated with greater BP reductions. Conclusion An 8-week period of IHG training significantly lowered both the morning and evening home BP in hypertensive Japanese patients undergoing treatment.

Carotid artery intima-media thickness, HDL cholesterol levels, and gender associated with poor visual acuity in patients with branch retinal artery occlusion.

PURPOSE: To investigate factors associated with poor visual acuity (VA) in branch retinal artery occlusion (BRAO). METHODS: This was a retrospective cross-sectional study of 72 eyes with BRAO of 72 patients. For statistical comparison, we divided the patients into worse-VA (decimal VA < 0.5) and better-VA (decimal VA > = 0.5) groups. We examined the association of clinical findings, including blood biochemical test data and carotid artery ultrasound parameters, with poor VA. RESULTS: Median age, hematocrit, hemoglobin and high-density lipoprotein (HDL) differed significantly between the groups (P = 0.018, P < 0.01, P < 0.01, and P = 0.025). There was a tendency towards higher median IMT-Bmax in the worse-VA group (worse-VA vs. better-VA: 2.70 mm vs. 1.60 mm, P = 0.152). Spearman's rank correlation test revealed that logMAR VA was significantly correlated to IMT-Bmax (rs = 0.31, P < 0.01) and IMT-Cmax (rs = 0.24, P = 0.035). Furthermore, logMAR VA was significantly correlated to HDL level (rs = -0.33, P < 0.01). Multivariate logistic regression analysis revealed that IMT-Bmax (odds ratio [OR] = 2.70, P = 0.049), HDL level (OR = 0.91, P = 0.032), and female gender (OR = 15.63, P = 0.032) were independently associated with worse VA in BRAO. CONCLUSIONS: We found that increased IMT-Bmax, decreased HDL, and female sex were associated with poor VA in BRAO patients. Our findings might suggest novel risk factors for visual dysfunction in BRAO and may provide new insights into the pathomechanisms underlying BRAO.

Ankle-brachial index measured by oscillometry is predictive for cardiovascular disease and premature death in the Japanese population: An individual participant data meta-analysis.

BACKGROUND AND AIMS: The ankle-brachial index (ABI) is a predictor of cardiovascular disease (CVD) and premature death. However, few studies on this marker are available in the general Asian populations. This study aimed to investigate the association between ABI measured with oscillometry and the risk of these outcomes. METHODS: We conducted an individual participant data meta-analysis in 10,679 community-dwelling Japanese individuals without a history of CVD. The primary outcome was a composite of CVD events and all-cause mortality. RESULTS: During an average of 7.8 years of follow-up, 720 participants experienced the primary outcome. The multivariable-adjusted hazard ratios (HRs) of the primary outcome significantly increased with a lower ABI. The HRs were 1.07 (95% confidence interval [CI] 0.91-1.27) for ABI of 1.00-1.09, HR 1.37 (95% CI 1.04-1.81) for ABI of 0.91-0.99, and HR 1.60 (95% CI 1.06-2.41) for ABI of ≤0.90, compared with ABI of 1.10-1.19. Furthermore, a high ABI (≥1.30) was associated with a greater risk of outcome (HR 2.42 [95% CI 1.14-5.13]). Similar tendencies were observed for CVD events alone and all-cause mortality alone. Addition of ABI to a model with the Framingham risk score marginally improved the c-statistics (p = 0.08) and integrated discrimination improvement (p < 0.05) for the primary outcome. CONCLUSIONS: The present study suggests that lower and higher ABI are significantly associated with an increased risk of CVD and all-cause mortality in the Japanese population. The ABI, which is easily measured by oscillometry, may be incorporated into daily clinical practice to identify high-risk populations.

Clinical significance of stress-related increase in blood pressure: current evidence in office and out-of-office settings.

High blood pressure is the most significant risk factor of cardiovascular and cerebrovascular diseases worldwide. Blood pressure and its variability are recognized as risk factors. Thus, hypertension control should focus not only on maintaining optimal levels but also on achieving less variability in blood pressure. Psychosocial stress is known to contribute to the development and worsening of hypertension. Stress is perceived by the brain and induces neuroendocrine responses in either a rapid or long-term manner. Moreover, endothelial dysfunction and inflammation might be further involved in the modulation of blood pressure elevation associated with stress. White-coat hypertension, defined as high clinic blood pressure but normal out-of-office blood pressure, is the most popular stress-related blood pressure response. Careful follow-up is necessary for this type of hypertensive patients because some show organ damage or a worse prognosis. On the other hand, masked hypertension, defined as high out-of-office blood pressure but normal office blood pressure, has received considerable interest as a poor prognostic condition. The cause of masked hypertension is complex, but evidence suggests that chronic stress at the workplace or home could be involved. Chronic psychological stress could be associated with distorted lifestyle and mental distress as well as long-lasting allostatic load, contributing to the maintenance of blood pressure elevation. Stress issues are common in patients in modern society. Considering psychosocial stress as the pathogenesis of blood pressure elevation is useful for achieving an individual-focused approach and 24-h blood pressure control.

Simultaneously Measured Interarm Blood Pressure Difference and Stroke: An Individual Participants Data Meta-Analysis.

We conducted individual participant data meta-analysis to examine the validity of interarm blood pressure difference in simultaneous measurement as a marker to identify subjects with ankle-brachial pressure index <0.90 and to predict future cardiovascular events. We collected individual participant data on 13 317 Japanese subjects from 10 cohorts (general population-based cohorts, cohorts of patients with past history of cardiovascular events, and those with cardiovascular risk factors). Binary logistic regression analysis with adjustments identified interarm blood pressure difference >5 mm Hg as being associated with a significant odds ratio for the presence of ankle-brachial pressure index <0.90 (odds ratio, 2.19; 95% confidence interval, 1.60-3.03; P<0.01). Among 11 726 subjects without a past history of cardiovascular disease, 249 developed stroke during the average follow-up period of 7.4 years. Interarm blood pressure difference >15 mm Hg was associated with a significant Cox stratified adjusted hazard ratio for subsequent stroke (hazard ratio, 2.42; 95% confidence interval, 1.27-4.60; P<0.01). Therefore, interarm blood pressure differences, measured simultaneously in both arms, may be associated with vascular damage in the systemic arterial tree. These differences may be useful for identifying subjects with an ankle-brachial pressure index of <0.90 in the overall study population, and also a reliable predictor of future stroke in subjects without a past history of cardiovascular disease. These findings support the recommendation to measure blood pressure in both arms at the first visit.

Management of morning hypertension: a consensus statement of an Asian expert panel.

Morning blood pressure (BP) surge is an important aspect of hypertension research. Morning BP monitoring could be a clinically relevant concept in the therapeutic management of hypertension and in the prevention of cardiovascular complications by defining and treating morning hypertension. Because antihypertensive medication is often taken in the morning, uncontrolled morning BP during the trough effect hours could be a hallmark of inadequate choice of antihypertensive regimen, such as the use of short- or intermediate-acting drugs, underdosing of drugs, or no use or underuse of combination therapy. To improve the management of hypertension in general and morning hypertension in particular, long-acting antihypertensive drugs should be used in appropriate, often full dosages and in proper combinations. The clinical usefulness of antihypertensive drugs with specific mechanisms for morning BP or split or timed dosing of long-acting drugs in controlling morning BP remains under investigation.

Relationship between subtle urinary albumin excretion and risk of incident hypertension: modification by glomerular filtration rate.

It has been reported that an increase in urinary albumin excretion (UAE) within the normal range could be a risk factor for incident hypertension. However, it remains unclear how the subtle increases in UAE and renal function interact in the development of hypertension. We examined the modification of UAE as a risk factor for incident hypertension by glomerular filtration rate (GFR) in the Japanese population. We prospectively followed 1281 normotensive individuals from Watari town (34.3% men; mean age, 58.0±12.3 years old) whose UAE was <30 mg g-1· Cr. Hypertension was diagnosed as a systolic blood pressure (BP)⩾140 mm Hg and/or a diastolic BP⩾90 mm Hg, or antihypertensive medication use. The relationship between sex-specific quartiles of UAE and incident hypertension was examined with Cox proportional hazard analysis. During a mean follow-up of 3.7 years, 315 individuals developed hypertension. Multivariate Cox proportional hazard analysis revealed that a subtle increase in UAE was a risk factor for incident hypertension, but there was a significant interaction between UAE and estimated GFR (eGFR) (P=0.018). The risk of incident hypertension dose dependently increased in the highest eGFR quartile (⩾90 ml min-1 per 1.73 m2). Decline in renal function alone increased the risk of incident hypertension but the increased risk with a subtle increase in UAE became smaller and less clear in the lower eGFR quartiles. The present data suggest that UAE as a risk factor for incident hypertension is largely dependent on eGFR levels.

Increased double product on Monday morning during work.

It has been reported that cardiovascular events often occur on Monday morning, especially in the young working population. Because hypertension is a major cardiovascular risk, we examined whether blood pressure was elevated on Monday, especially in the morning during work. However, there were no weekly rhythms in blood pressure itself. Instead, we found significant interactions between the double product (systolic blood pressure × heart rate) and weekly (high on Monday) and circadian (high in the morning) rhythms. Further studies are required to determine whether Monday morning preference in cardiovascular events is caused by increased double product.

Proposed Cutoff Value of Brachial-Ankle Pulse Wave Velocity for the Management of Hypertension.

BACKGROUND: The optimal cutoff values of the brachial-ankle pulse wave velocity (baPWV) for predicting cardiovascular disease (CVD) were examined in patients with hypertension.Methods and Results:A total of 7,656 participants were followed prospectively. The hazard ratio for the development of CVD increased significantly as the baPWV increased, independent of conventional risk factors. The receiver-operating characteristic curve analysis showed that the optimal cutoff values for predicting CVD was 18.3 m/s. This cutoff value significantly predicted THE incidence of CVD. CONCLUSIONS: The present analysis suggests that the optimal cutoff value for CVD in patients with hypertension is 18.3 m/s.

Gender Differences in Lifestyle Factors Associated with Metabolic Syndrome and Preliminary Metabolic Syndrome in the General Population: The Watari Study.

Objective In Japan, metabolic syndrome (MetS) and preliminary metabolic syndrome (preMetS) are more prevalent in men; however, it remains unclear whether the relationship between these metabolic disorders and lifestyle factors is similar between genders. Methods We examined waist circumference, blood pressure, fasting blood, and various lifestyle factors in 3,166 individuals aged from 30-79 years of age from the Japanese general population. MetS was diagnosed on the basis of central obesity - assessed by waist circumference - plus two or more of the following cardio-metabolic risks according to Japanese criteria: high blood pressure, hyperglycemia, and lipid abnormality. Central obesity plus one of the risks was defined as preMetS. Results Men had a significantly higher prevalence of MetS (23.3% vs. 8.7%, p<0.001) and preMetS (21.2% vs. 10.2%, p<0.001) than women. An age-adjusted logistic regression analysis revealed that heavy drinkers were associated with an increased probability of MetS (odds ratio, 1.91: 95% confidence interval, 1.29-2.83) and preMetS (1.69: 1.11-2.58); fast eaters were also related to preMetS (1.83: 1.33-2.55) and MetS (1.55: 1.12-2.15) in men. Lacking regular exercise was significantly associated with preMetS (1.38: 1.03-1.85), but not MetS. In women, preMetS was significantly associated with fast eaters and lacking regular exercise (1.44: 1.01-2.07 and 1.41: 1.02-1.96, respectively); a stepwise increase in each odds ratio (2.02: 1.40-2.91 and 1.47: 1.03-2.09, respectively) was also observed for MetS. Conclusion The relationships between lifestyle factors and MetS or preMetS differed between men and women, which suggests the need for gender-specific lifestyle modification to effectively prevent MetS.

Cardiovascular Responses Associated with the Moving Beans Task: Influence of Psychological Characteristics.

BACKGROUND AND OBJECTIVE: High blood pressure (BP) after stroke is associated with a poor outcome. However, exercise training or speech therapy for patients with stroke can raise the BP. The aim of this study was to examine cardiovascular responses during the moving beans task (MBT) used in occupational therapy and to study the influence of psychological characteristics on cardiovascular responses during this task in healthy subjects. MATERIALS AND METHODS: In 34 healthy volunteers, the BP and the heart rate (HR) were continuously measured during the baseline period, the 5-minute MBT, and the 1-minute cold pressor test (CPT). All subjects completed self-reported questionnaires, including the Center for Epidemiologic Studies Depression Scale (CES-D), the State Trait Anxiety Inventory Y-2, and the Japanese version of the 20-item Toronto Alexithymia Scale (TAS-20). RESULTS: The systolic blood pressure (SBP), the diastolic blood pressure (DBP), and the mean blood pressure (MBP) significantly increased during the MBT and the CPT compared with the baseline values. SBP, DBP, and MBP responses during the MBT significantly correlated with the TAS-20 scores. Moreover, DBP response during the MBT correlated with the CES-D scores. CONCLUSIONS: The MBT significantly raised BP without increasing the HR. BP responses during this task were influenced by the psychological characteristics of depression and alexithymia.

Brachial-Ankle Pulse Wave Velocity and the Risk Prediction of Cardiovascular Disease: An Individual Participant Data Meta-Analysis.

An individual participant data meta-analysis was conducted in the data of 14 673 Japanese participants without a history of cardiovascular disease (CVD) to examine the association of the brachial-ankle pulse wave velocity (baPWV) with the risk of development of CVD. During the average 6.4-year follow-up period, 687 participants died and 735 developed cardiovascular events. A higher baPWV was significantly associated with a higher risk of CVD, even after adjustments for conventional risk factors (P for trend <0.001). When the baPWV values were classified into quintiles, the multivariable-adjusted hazard ratio for CVD increased significantly as the baPWV quintile increased. The hazard ratio in the subjects with baPWV values in quintile 5 versus that in those with the values in quintile 1 was 3.50 (2.14-5.74; P<0.001). Every 1 SD increase of the baPWV was associated with a 1.19-fold (1.10-1.29; P<0.001) increase in the risk of CVD. Moreover, addition of baPWV to a model incorporating the Framingham risk score significantly increased the C statistics from 0.8026 to 0.8131 (P<0.001) and also improved the category-free net reclassification (0.247; P<0.001). The present meta-analysis clearly established baPWV as an independent predictor of the risk of development of CVD in Japanese subjects without preexisting CVD. Thus, measurement of the baPWV could enhance the efficacy of prediction of the risk of development of CVD over that of the Framingham risk score, which is based on the traditional cardiovascular risk factors.