Hemodynamic characterization of hypertensive patients with an exaggerated orthostatic blood pressure variation.

Exaggerated orthostatic blood pressure variation (EOV) is a poorly understood phenomenon related to high cardiovascular risk. We aimed to determine whether hypertensive patients with EOV have a distinct hemodynamic pattern, assessed through impedance cardiography. METHODS: In treated hypertensive patients, we measured the cardiac index (CI), systemic vascular resistance index (SVRI), blood pressure (BP), and heart rate (HR) in the supine and standing (after 3 minutes) positions, defining three groups according to BP variation: 1) Normal orthostatic BP variation (NOV): standing systolic BP (stSBP)-supine systolic BP (suSBP) between -20 and 20 mmHg and standing diastolic BP (stDBP)-supine diastolic BP (suDBP) between -10 and 10 mmHg; 2) orthostatic hypotension (OHypo): stSBP-suSBP≤-20 or stDBP-suDBP≤-10 mmHg; 3) orthostatic hypertension (OHyper): stSBP-suSBP≥20 or stDBP-suDBP≥10 mmHg. We performed multivariable analyses to determine the association of hemodynamic variables with EOV. RESULTS: We included 186 patients. Those with OHyper had lower suDBP and higher orthostatic SVRI variation compared to NOV. In multivariable analyses, orthostatic HR variation (OR = 1.06 (95%CI 1.01-1.13), p = 0.03) and orthostatic SVRI variation (OR = 1.16 (95%CI 1.06-1.28), p = 0.002) were independently related to OHyper. No variables were independently associated with OHypo. CONCLUSION: Patients with OHyper have a distinct hemodynamic pattern, with an exaggerated increase in SVRI and HR when standing.

Meal-induced blood pressure fall in patients with isolated morning hypertension.

We aimed to determine a possible association between isolated morning hypertension (IMH) and meal-induced blood pressure (BP) fall in adult treated hypertensive patients who underwent home BP measurements. A total of 230 patients were included, median age 73.6, 65.2% women. After adjusting for age, sex, number of antihypertensive drugs, office and home BP levels, the association between IMH and meal-induced BP fall was statistically significant. In conclusion, meal-induced BP fall and IMH detected through home blood pressure monitoring (HBPM) are independently associated in hypertensive patients. The therapeutic implications of such observation need to be clarified in large-scale prospective studies.

Predictive value of non-invasive hemodynamic measurement by means of impedance cardiography in hypertensive subjects older than 50 years of age.

The prognostic value of impedance cardiography (ICG; cardiac index [CI] and systemic vascular resistance index [SVRI] were measured) was assessed in this retrospective cohort study. A total of 1151 hypertensive outpatients >50 years with a baseline ICG were included. After median follow-up of 3.9 years, for the composite endpoint of cardiovascular events and stroke, adjusted HR for each 500 ml/min/m(2) CI increase was 0.85 (CI95% 0.73-0.9, p = 0.039), and for each 500 dynes s cm(-5) SVRI increase was 1.11 (CI95% 1.01-1.23, p = 0.046), whereas adjusted HR for all-cause mortality was not significant. ICG adds prognostic value to conventional risk factors in hypertensive patients.

Association of 24-h central hemodynamics and stiffness with cardiovascular events and all-cause mortality. The VASOTENS Registry.

OBJECTIVES: In hemodialysis patients, central hemodynamics, stiffness, and wave reflections assessed through ambulatory blood pressure monitoring (ABPM) showed superior prognostic value for cardiovascular (CV) events than peripheral blood pressures (BPs). No such evidence is available for lower-risk hypertensive patients. METHODS: In 591 hypertensive patients (mean age 58 ±â€Š14 years, 49% males), ambulatory brachial and central BP, pulse wave velocity (PWV), and augmentation index (AIx) were obtained with a validated upper arm cuff-based pulse wave analysis technology. Information on treatment for hypertension (73% of patients), dyslipidemia (27%), diabetes (8%), CV disease history (25%), was collected. Patients were censored for CV events or all-cause death over 4.2 years. RESULTS: One hundred and four events (24 fatal) were recorded. Advanced age [hazard ratio and 95% confidence interval: 1.03 (1.01, 1.05), P  = 0.0001], female sex [1.57 (1.05, 2.33), P  = 0.027], CV disease [2.22 (1.50, 3.29), P  = 0.0001], increased 24-h central pulse pressure (PP) [1.56 (1.05, 2.31), P  = 0.027], PWV [1.59 (1.07, 2.36), P  = 0.022], or AIx [1.59 (1.08, 2.36), P  = 0.020] were significantly associated with a worse prognosis (univariate Cox regression analysis). The prognostic power of peripheral and central BPs was lower. However, PWV [1.02 (0.64, 1.63), P  = 0.924], AIx [1.06 (0.66, 1.69), P  = 0.823], and central PP [1.18 (0.76, 1.82), P  = 0.471], were not significant predictors in multivariate analyses. CONCLUSIONS: In hypertensive patients, ambulatory central PP, PWV, and AIx are associated with an increased risk of CV morbidity and all-cause mortality. However, this association is not independent of other patient characteristics.

Prevalence and clinical profile of resistant hypertension among treated hypertensive subjects.

We assessed prevalence and clinical characteristics of resistant hypertension (RH) and prevalence of false RH (white-coat effect [WCE] by home blood pressure [BP] monitoring), among a population of 302 treated hypertensive patients, mean age 66.6 (± 13.8), 67.5% women. Resistant hypertension was defined according to the American Heart Association criteria. Prevalence of RH was 10%, and the following five variables were independently associated with it: body mass index, diabetes, isolated systolic hypertension, orthostatic hypotension, and use of beta-blockers. Prevalence of WCE among subjects with office-RH was 27.6%. Our study identified easily measurable parameters related to RH. Standing BP should be systematically measured in individuals with RH.

[Reproducibility and reliability of a 4-day HBPM protocol with and without first day measurements]. / Reproducibilidad y confiabilidad de un protocolo de 4 días de monitoreo domiciliario de presión arterial con y sin exclusión del primer día.

HBPM guidelines state that morning and evening measurements should be recorded and, to improve stability, the first day of measurements should be discarded. Our objective was to assess the reproducibility and reliability of a 4-day HBPM protocol with and without first day measurements. We analyzed a retrospective cohort of ambulatory patients who required a HBPM for diagnostic purposes or evaluation of treatment efficacy. A 4-day protocol was implemented, with daily duplicate measurements in the morning, afternoon and evening, using an OMRON 705 CP validated equipment. HBPM reproducibility was quantified by test-re-test correlations and standard deviation of differences (SDD) between BP measurements obtained during the entire 4 days, with and without exclusion of the first day. The reliability criterion was the stabilization of the mean and standard deviation (SD). We included 353 subjects with a total of 8224 BP recordings (median of 24 recordings per patient). We found a strong test-re-test correlation between days 1 to 4, which improved when we excluded the first day (p<0.001). We also found a reduction of the mean BP when we increased the number of days and a reduction of SDD when we excluded day 1. Therefore, we conclude that the exclusion of the first day of measurements improves the reproducibility and reliability of a 4-day protocol, and such two factors are not affected by the inclusion of afternoon measurements.

The Influence of Resting Heart Rate on Central Pulse Pressure is Age-Dependent.

INTRODUCTION: Low resting heart rate (RHR) increases augmentation pressure (AP) and central pulse pressure (central PP) and decreases peripheral pressure wave amplification. Given that the contribution of AP to central PP increases with age we hypothesized that the influence of RHR on AP, central PP and peripheral amplification varies with age. AIM: To evaluate the interaction between age and RHR on the forward and backward components of central PP. METHODS: A cohort of 1249 ambulatory hypertensive patients with good quality radial wave recordings was stratified into age groups and quartiles of RHR (< 61, 61-68, 69-76 and > 76 bpm). Central aortic pressure was estimated from radial applanation tonometry. RESULTS: Forward wave (FW) and AP showed opposite changes until midlife, mutually canceling their effect on central PP, whereas both components of central PP increased in parallel after the fifth decade. The initial fall in FW was expressed in the brachial artery as a corresponding decrease in PP and in peripheral amplification. After midlife there was a further decrease in peripheral amplification at the expense of the rise in central PP. A lower RHR exaggerated the age-related increase in left ventricular ejection time (LVET), AP, central PP, and the decrease in peripheral amplification (P < 0.001, for all the interactions between decades and quartiles of RHR). Multivariable regression analyses (n = 1249) confirmed a significant interaction between age and RHR on central PP (P < 0.001), AP (P < 0.001), LVET (P < 0.001), AIx (P < 0.035), and peripheral amplification (P < 0.001). Multivariable regression analyses stratified by age groups (< 30, 30-59 and ≥ 60 years) showed an increasing strength in the relationship of RHR with AP, independently of sex, mean arterial pressure, pulse wave velocity and beta-blockers use. The average increase in AP for a decrease in 10 bpm was 1.4 mmHg before age < 30 years; 2.5 mmHg between age 30-59 years; and 5.4 mmHg at 60 years and older. CONCLUSIONS: A lower heart rate exaggerated AP and central PP in an age dependent fashion, being the effect particularly relevant in older patients.

Comparing Office, Central, Home and Ambulatory Blood Pressure in Predicting Left Ventricular Mass.

The blood pressure measurement method that more accurately predicts a left ventricular mass is controversial, and the evidence suggesting superiority of central over brachial measurements is contradictory. The aim of this study was to compare the relationship between the different clinic and out-of-clinic blood pressure measurements methods with left ventricular mass in patients who attended a specialised hypertension centre for a central blood pressure measurement. An analysis was performed on the correlations between left ventricular mass and central and brachial blood pressure measurements made in the clinic, and home, as well as 24-h systolic blood pressure measurements. A linear regression analysis was then performed to assess the independent relationship of each blood pressure measurement with left ventricular mass. The results on 824 treated and 123 untreated patients showed no significant differences between correlations, although home readings tended to have the best correlations. In regression adjusted models, for each 10 mmHg increase in systolic home blood pressure the left ventricular mass increased 10 g/m2 (95% CI; 3.7-27, p=.01, adjR2 0.38), and for 24-h ambulatory systolic blood pressure it increased 2.3 g/m2 (95% CI 0.76-3.9, p<.01, adjR2 0.15) in treated and untreated patients, respectively. The association of systolic blood pressure with left ventricular mass was better explained by home and 24-h ambulatory monitoring than to clinic-based measurements in treated and untreated patients, respectively. In the clinic, however, the central measurement was not superior to brachial blood pressure.

Validation of a new piezoelectric device for noninvasive measurement of central aortic systolic blood pressure.

OBJECTIVE: The objective of this study was to compare the aortic piezoelectric device for noninvasive measurement of central aortic systolic blood pressure (cSBP) with the SphygmoCor. PARTICIPANTS AND METHODS: A total of 85 participants from both sexes, aged 18-80 years, were stratified into three age groups (<30, 30-60, >60 years), with an equal number of healthy volunteers and hypertensive patients. We performed three cSBP measurements with each device, in an alternate manner, using the Bland-Altman method to determine the level of agreement. The standard of the Association for the Advancement of Medical Instrumentation for brachial blood pressure evaluation was used for the comparison. RESULTS: The mean cSBPs were 109.3±12.05 and 109.0±12.2 mmHg with the SphygmoCor and the Aortic device, respectively, showing a strong correlation (r=0.98, P<0.001). A mean difference of 0.35±2.43 mmHg (95% confidence interval: 0.17-0.87, P=NS) was obtained with the Bland-Altman method. The 95% limits of agreement was -4.4 to +5.1 mmHg. CONCLUSION: Complying with the Association for the Advancement of Medical Instrumentation criteria, cSBP measurements obtained with the Aortic and the SphygmoCor devices are equivalent.

Arterial Stiffness in Treated Hypertensive Patients With White-Coat Hypertension.

Arterial stiffness, assessed through pulse wave velocity (PWV), independently predicts cardiovascular outcomes. In untreated persons, white-coat hypertension (WCH) has been related to arterial stiffness, but data in treated patients with WCH are scarce. The authors aimed to determine a possible association between WCH and arterial stiffness in this population. Adult treated hypertensive patients underwent home blood pressure monitoring and PWV assessment. Variables associated with PWV in univariable analyses were entered into a multivariable linear regression model. The study included 121 patients, 33.9% men, median age 67.9 (interquartile range 18.4) years, 5.8% with diabetes, and 3.3% with a history of cardiovascular or cerebrovascular disease. In multivariable analysis, WCH in treated hypertensive patients remained a determinant of PWV: ß=1.1 (95% confidence interval, 0.1-2.1 [P=.037]; adjusted R2 0.49). In conclusion, WCH is independently associated with arterial stiffness in treated hypertensive patients. Whether this high-risk association is offset by antihypertensive treatment should be further investigated.

Alerting Reaction in Office Blood Pressure and Target Organ Damage: An Innocent Phenomenon?

BACKGROUND: An alerting reaction is a physician-induced phenomenon which produces a transient blood pressure rise in the office. OBJECTIVE: To determine its relationship with target organ damage in treated hypertensives. METHOD: We used three different indexes for calculating alerting reaction depending on the first, second or third office blood pressure measurement. We correlated these indexes with glomerular filtration rate, left ventricular mass index and pulse wave velocity. Thereafter, for multivariate analysis, we selected the index which better correlated with each target organ damage subtype. RESULTS: We included 174 adults, mean age 67(±13.7) years. 75% of the patients had some degree of blood pressure fall between measurements 1-3. In multivariate linear regression models, after adjusting for classic risk factors, two out of the three systolic alerting reaction indexes showed an independent association with target organ damage. After further adjusting for office blood pressure and white coat effect (calculated with standardized home blood pressure monitoring), left ventricular mass index maintained a statistically significant association. CONCLUSION: A higher alerting reaction in the office seems to be related to increased target organ damage in treated hypertensives and should not be considered an innocent phenomenon.

[Variations between 2 ECG as predictors of atrial fibrillation: Cohort study]. / Diferencias entre 2 electrocardiogramas sinusales como predictoras de fibrilación auricular: estudio de cohorte.

OBJETIVE: To evaluate the association between delta variations in the parameters of 2 sinusal ECG with atrial fibrillation (AF) onset. METHOD: Retrospective cohort of 9,975 adult patients and members of the prepaid system at Hospital Italiano de Buenos Aires from Argentina, who had at least 2 sinusal ECG between 2006 and 2011. Population was followed up for detection of AF. All measurements and electrocardiographic deltas (differences between the 2 ECG) were standardized. Hazard ratio (HR) was estimated for the development of AF for each delta of the different ECG parameters using a Cox regression model. RESULTS: During a median follow up of 3.5 years, 189 patients (1.89%) developed AF. Heart rate delta, ST interval delta and P wave amplitude were predictors of AF. Hazard ratio Adjusted for clinical characteristics and ECGbasal values was 0,86 (CI95%: 0.75-0.98, p=0.024) for heart rate delta, 1.12 (CI95%: 0.98-1.27, p=0.082) for ST interval delta and 1.21 (CI95%: 1.05-1.38, p=0.006) for P wave amplitude delta. CONCLUSION: Differences of heart rate and P wave amplitude between ECG's measurements may predict AF, independently of clinical features and ECGbasal values.

Home blood pressure profile in very elderly hypertensives: should we use the same thresholds as in younger patients?

We aimed to determine the characteristics of home blood pressure (BP) in very elderly hypertensives. A total of 485 treated hypertensive patients ≥18 years (median age, 70.8 [interquartile range, 18]; 67.2% women) underwent home BP measurements. Characteristics of patients ≥80 and <80 years of age and prevalence of office and home uncontrolled hypertension, isolated morning (IMH), isolated evening, isolated office, and masked hypertension were compared. Very elderly subjects had higher levels of systolic and lower levels of diastolic BP at home, a higher prevalence of home uncontrolled hypertension (68.5% vs. 37.7%; P < .001), masked hypertension (30.6% vs. 14.9%; P = .02), and IMH (19.4% vs. 10.9%; P = .02), and a lower prevalence of isolated office hypertension (8.3% vs. 18.8%; P = .01). When using differential home BP thresholds in the very elderly, determined through the percentile method, statistical differences disappeared, except for IMH. The very elderly depict a particular home BP profile. Benefit from using differential home BP thresholds should be determined in prospective studies.

Comparison of atenolol versus bisoprolol with noninvasive hemodynamic and pulse wave assessment.

We aimed to compare atenolol versus bisoprolol regarding general hemodynamics, central-peripheral blood pressure (BP), pulse wave parameters, and arterial stiffness. In this open-label, crossover study, we recruited 19 hypertensives, untreated or with stable monotherapy. Patients were randomized to receive atenolol (25-50 mg) or bisoprolol (2.5-5 mg), and then switched medications after 4 weeks. Studies were performed at baseline and after each drug period. In pulse wave analyses, both drugs significantly increased augmentation index (P < .01) and ejection duration (P < .02), and reduced heart rate (P < .001), brachial systolic BP (P ≤ .01), brachial diastolic BP (P ≤ .001), and central diastolic BP (P ≤ .001), but not central systolic BP (P ≥ .06). Impedance cardiographic assessment showed a significantly increased stroke volume (P ≤ .02). There were no significant differences in the effects between drugs. In conclusion, atenolol and bisoprolol show similar hemodynamic characteristics. Failure to decrease central systolic BP results from bradycardia with increased stroke volume and an earlier reflected aortic wave.

Defining thresholds for home blood pressure monitoring in octogenarians.

To generate outcome-driven thresholds for home blood pressure (BP) in the elderly, we analyzed 375 octogenarians (60.3% women; 83.0 years [mean]) enrolled in the International Database on home BP in relation to cardiovascular outcome. Over 5.5 years (median), 155 participants died, 76 from cardiovascular causes, whereas 104, 55, 36, and 51 experienced a cardiovascular, cardiac, coronary, or cerebrovascular event, respectively. In 202 untreated participants, home diastolic in the lowest fifth of the distribution (≤65.1 mm Hg) compared with the multivariable-adjusted average risk was associated with increased risk of cardiovascular mortality and morbidity (hazard ratios [HRs], ≥1.96; P≤0.022), whereas the HR for cardiovascular mortality in the top fifth (≥82.0 mm Hg) was 0.37 (P=0.034). Among 173 participants treated for hypertension, the HR for total mortality in the lowest fifth of systolic home BP (<126.9 mm Hg) was 2.09 (P=0.020). In further analyses of home BP as continuous variable (per 1-SD increment), higher diastolic BP predicted lower cardiovascular mortality and morbidity and cardiac and coronary risk (HR≤0.65; P≤0.039) in untreated participants. In those treated, cardiovascular morbidity was curvilinearly associated with systolic home BP with nadir at 148.6 mm Hg and with a 1.45 HR (P=0.046) for a 1-SD decrease below this threshold. In conclusion, in untreated octogenarians, systolic home BP ≥152.4 and diastolic BP ≤65.1 mm Hg entails increased cardiovascular risk, whereas diastolic home BP ≥82 mm Hg minimizes risk. In those treated, systolic home BP <126.9 mm Hg was associated with increased total mortality with lowest risk at 148.6 mm Hg.

Postprandial hypotension detected through home blood pressure monitoring: a frequent phenomenon in elderly hypertensive patients.

Postprandial hypotension (PPH) is a frequently under-recognized entity associated with increased morbidity and mortality. The prevalence of PPH detected through home blood pressure monitoring (HBPM) is unknown. To determine the prevalence and clinical predictors of PPH in hypertensive patients assessed through HBPM. Hypertensive patients of 18 years or older underwent home blood pressure (BP) measurements (duplicate measurements for 4 days: in the morning, 1 h before and 1 h after their usual lunch, and in the evening; OMRON 705 CP). PPH was defined as a meal-induced systolic BP decrease of ≥20 mm Hg. Variables identified as relevant predictors of PPH were entered into a multivariate logistic regression analysis. In total, 230 patients were included in the analysis, with a median age of 73.6 (interquartile range 16.9) years, and 65.2% were female. The prevalence of PPH (at least one episode) was 27.4%. Four variables were independently associated with PPH: age of 80 years or older (odds ratio (OR) 3.45, 95% confidence interval (CI) 1.35-8.82), body mass index (BMI) (OR 0.88, 95%CI 0.81-0.96), office systolic BP (OR 1.03, 95%CI 1.01-1.05) and a history of cerebrovascular disease (OR 3.29, 95%CI 1.03-10.53). PPH after a typical meal is a frequent phenomenon that can be detected through HBPM. Easily measurable parameters in the office such as older age, higher systolic BP, lower BMI and a history of cerebrovascular disease may help to detect patients at risk of PPH who would benefit from HBPM.

Determinants of the Morning-Evening Home Blood Pressure Difference in Treated Hypertensives: The HIBA-Home Study.

Background. The morning home blood pressure (BP) rise is a significant asymptomatic target organ damage predictor in hypertensives. Our aim was to evaluate determinants of home-based morning-evening difference (MEdiff) in Argentine patients. Methods. Treated hypertensive patients aged ≥18 years participated in a cross-sectional study, after performing home morning and evening BP measurement. MEdiff was morning minus evening home average results. Variables identified as relevant predictors were entered into a multivariable linear regression analysis model. Results. Three hundred sixty-seven medicated hypertensives were included. Mean age was 66.2 (14.5), BMI 28.1 (4.5), total cholesterol 4.89 (1.0) mmol/L, 65.9% women, 11.7% smokers, and 10.6% diabetics. Mean MEdiff was 1.1 (12.5) mmHg systolic and 2.3 (6.1) mmHg diastolic, respectively. Mean self-recorded BP was 131.5 (14.1) mmHg systolic and 73.8 (7.6) mmHg diastolic, respectively. Mean morning and evening home BPs were 133.1 (16.5) versus 132 (15.7) systolic and 75.8 (8.4) versus 73.5 (8.2) diastolic, respectively. Significant beta-coefficient values were found in systolic MEdiff for age and smoking and in diastolic MEdiff for age, smoking, total cholesterol, and calcium-channel blockers. Conclusions. In a cohort of Argentine medicated patients, older age, smoking, total cholesterol, and use of calcium channel blockers were independent determinants of home-based MEdiff.

[Morning rise in home blood pressure and target organ damage in hypertensive patients]. / Incremento matutino de la presión arterial domiciliaria y daño de organo blanco en paciente hippertensos.

UNLABELLED: The morning blood pressure (BP) rise entails a higher cardiovascular risk. Studies evaluating the association between home BP morning rise and target organ damage are scarce and almost exclusively based on Asians. The aim of our study was to characterize hypertensive patients with morning rise in home BP and to establish a possible association with left ventricular hypertrophy (LVH). METHODS: treated hypertensive patients ≥ 18 years underwent home BP measurements (duplicate measurements for 4 days in the morning, afternoon and evening), and completed a questionnaire regarding risk factors and history of cardiovascular disease. Medical records were reviewed to extract data from grams. A morning rise in systolic home BP was defined as a difference between morning and evening systolic BP averages ≥15 mmHg. Subjects were considered to have LVH if the left ventricular mass index was >95 g/m2 in women and >115 g/m2 in men. Variables identified as relevant predictors of home BP morning rise were entered into a multivariable logistic regression analysis model. RESULTS: 216 patients were included, mean age 68 (+13.3), 69.4% women and 99.1% Caucasians. The prevalence of BP morning rise was 13.4% and independently associated factors were LVH (OR 3.5; 95%CI 1.1-11.4), age (OR 1.05; 95%CI 1.003-1.1) and a history of cerebrovascular disease (OR 3.9; 95%CI 1.1-14.2). In conclusion, a morning rise in systolic BP detected through home BP monitoring is independently associated with LVH, age and a history of cerebrovascular disease. The therapeutic implications of this observation need to be clarified in large-scale prospective studies.

El incremento matutino de la presión arterial (IMPA) aumenta el riesgo cardiovascular. Los estudios que evalúan la asociación entre IMPA domiciliaria y daño de órgano blanco son escasos y casi exclusivamente basados en población asiática. Nuestro objetivo fue caracterizar a los pacientes hipertensos con IMPA domiciliaria y establecer una posible asociación con la presencia de hipertrofia ventricular izquierda (HVI). Métodos: se incluyeron hipertensos medicados ≥18 años que realizaron mediciones de PA domiciliaria (4 días de mediciones por duplicado, a la mañana, tarde y noche) y completaron un cuestionario acerca de sus factores de riesgo y antecedentes de enfermedad cardiovascular. Se revisaron las historias clínicas para extraer datos ecocardiográficos. Se definió como IMPA a una diferencia entre el promedio de PA sistólica domiciliaria matutina ­ vespertina ≥15 mmHg. Se consideró que los pacientes tenían HVI si el índice de masa ventricular era >95 g/m2 en mujeres y >115 g/m2 en varones. Las variables identificadas como predictores relevantes de IMPA fueron introducidos en un modelo multivariado de regresión logística. Resultados: se incluyeron 216 pacientes, con una edad media de 68 (+13,3) años, 69,4% mujeres y 99,1% caucásicos. La prevalencia de IMPA fue de 13,4% y las variables independientemente asociadas fueron HVI (OR 3,5; 95%CI 1,1-11,4), edad (OR 1,05; 95%CI 1,003-1,1) y antecedente de enfermedad cerebrovascular (OR 3,9; 95%CI 1,1-14,2). En conclusión, el IMPA evaluado por monitoreo domiciliario presenta asociación independiente con HVI, edad y antecedentes de enfermedad cerebrovascular, debiendo esclarecerse las implicancias terapéuticas de esta observación en estudios prospectivos a gran escala.

Reference frame for home pulse pressure based on cardiovascular risk in 6470 subjects from 5 populations.

The absence of an outcome-driven reference frame for self-measured pulse pressure (PP) limits its clinical applicability. In an attempt to derive an operational threshold for self-measured PP, we analyzed 6470 participants (mean age 59.3 years; 56.9% women; 22.5% on antihypertensive treatment) from 5 general population cohorts included in the International Database on HOme blood pressure in relation to Cardiovascular Outcome. During 8.3 years of follow-up (median), 294 cardiovascular deaths, 393 strokes and 336 cardiac events occurred. In 3285 younger subjects (<60 years), home PP only predicted all-cause and cardiovascular mortality (P⩽0.036), whereas in 3185 older subjects (⩾60 years) PP predicted total and cardiovascular mortality (P⩽0.0067) and all cardiovascular and coronary events (P⩽0.044). However, PP did not substantially refine risk prediction based on classical risk factors including mean blood pressure (generalized R(2) statistic ⩽0.20%). In older subjects, the adjusted hazard ratios expressing the risk in the upper decile of home PP (⩾76 mm Hg) versus the average risk in whole population were 1.41 (95% confidence interval, 1.09-1.81; P=0.0081) for all-cause mortality, 1.62 (1.11-2.35; P=0.012) for cardiovascular mortality and 1.31 (1.00-1.70; P=0.047) for all fatal and nonfatal cardiovascular end points combined. The low number of events precluded an analysis by tenths of the PP distribution in younger participants. In conclusion, a home PP of ⩾76 mm Hg predicted cardiovascular outcomes in the elderly with the exception of stroke, whereas in younger subjects no threshold could be established.