Office measurement vs. ambulatory blood pressure monitoring: associations with mortality in patients with or without diabetes.

BACKGROUND AND AIMS: Guidelines suggest similar blood pressure (BP) targets in patients with and without diabetes and recommend ambulatory BP monitoring (ABPM) to diagnose and classify hypertension. It was explored whether different levels of ambulatory and office BP and different hypertension phenotypes associate with differences of risk in diabetes and no diabetes. METHODS: This analysis assessed outcome data from the Spanish ABPM Registry in 59 124 patients with complete available data. The associations between office, mean, daytime, and nighttime ambulatory BP with the risk in patients with or without diabetes were explored. The effects of diabetes on mortality in different hypertension phenotypes, i.e. sustained hypertension, white-coat hypertension, and masked hypertension, compared with normotension were studied. Analyses were done with Cox regression analyses and adjusted for demographic and clinical confounders. RESULTS: A total of 59 124 patients were recruited from 223 primary care centres in Spain. The majority had an office systolic BP >140 mmHg (36 700 patients), and 23 128 (40.6%) patients were untreated. Diabetes was diagnosed in 11 391 patients (19.2%). Concomitant cardiovascular (CV) disease was present in 2521 patients (23.1%) with diabetes and 4616 (10.0%) without diabetes. Twenty-four-hour mean, daytime, and nighttime ambulatory BP were associated with increased risk in diabetes and no diabetes, while in office BP, there was no clear association with no differences with and without diabetes. While the relative association of BP to CV death risk was similar in diabetes compared with no diabetes (mean interaction P = .80, daytime interaction P = .97, and nighttime interaction P = .32), increased event rates occurred in diabetes for all ABPM parameters for CV death and all-cause death. White-coat hypertension was not associated with risk for CV death (hazard ratio 0.86; 95% confidence interval 0.72-1.03) and slightly reduced risk for all-cause death in no diabetes (hazard ratio 0.89; confidence interval 0.81-0.98) but without significant interaction between diabetes and no diabetes. Sustained hypertension and masked hypertension in diabetes and no diabetes were associated with even higher risk. There were no significant interactions in hypertensive phenotypes between diabetes and no diabetes and CV death risk (interaction P = .26), while some interaction was present for all-cause death (interaction P = .043) and non-CV death (interaction P = .053). CONCLUSIONS: Diabetes increased the risk for all-cause death, CV, and non-CV death at every level of office and ambulatory BP. Masked and sustained hypertension confer to the highest risk, while white-coat hypertension appears grossly neutral without interaction of relative risk between diabetes and no diabetes. These results support recommendations of international guidelines for strict BP control and using ABPM for classification and assessment of risk and control of hypertension, particularly in patients with diabetes. CLINICAL TRIAL REGISTRATION: Not applicable.

Changes in quality of life, depression, general anxiety, and heart-focused anxiety after defibrillator implantation.

AIMS: The Anxiety-CHF (Anxiety in patients with Chronic Heart Failure) study investigated heart-focused anxiety (HFA, with the dimensions fear, attention, and avoidance of physical activity), general anxiety, depression, and quality of life (QoL) in patients with heart failure. Psychological measures were assessed before and up to 2 years after the implantation of an implantable cardioverter defibrillator (ICD) with or without cardiac resynchronization therapy defibrillator (CRT-D). METHODS AND RESULTS: One hundred thirty-two patients were enrolled in this monocentric prospective study (44/88 CRT-D/ICD, mean age 61 ± 14 years, mean left ventricular ejection fraction 31 ± 9%, and 29% women). Psychological assessment was performed before device implantation as well as after 5, 12, and 24 months. After device implantation, mean total HFA, HFA-fear, HFA-attention, general anxiety, and QoL improved significantly. Depression and HFA-related avoidance of physical activity did not change. CRT-D patients compared with ICD recipients and women compared with men reported worse QoL at baseline. Younger patients (

Predictors of heart-focused anxiety in patients with stable heart failure.

BACKGROUND: It has been shown that heart-focused anxiety raises the risk of adverse outcomes in patients with heart disease. Yet, there is a lack of studies investigating this association. We aim at identifying predictors of heart-focused anxiety in patients with stable heart failure to facilitate the identification of individuals with increased risk for adverse outcomes. METHODS: We assessed heart-focused anxiety and a set of psychological, demographic/lifestyle, and medical/laboratory variables in a sample of 107 patients with stable chronic heart failure to identify predictors of heart-focused anxiety. RESULTS: Heart-focused anxiety was best predicted by self-reported anxiety and quality of life. Moreover, the personality dimension conscientiousness as well as physical activity, and the laboratory value of renal function, the estimated glomerular filtration rate (eGFR), had predictive validity for heart-focused anxiety. LIMITATIONS: The present findings should be replicated in a longitudinal design with a less selective sample including more women and participants with more divers ethnical backgrounds. CONCLUSION: Heart-focused anxiety is predictable by psychological and lifestyle variables. eGFR, as a laboratory marker for renal function, showed also predictive validity. The awareness of such predictors may help detecting comorbid underlying heart-focused anxiety and thus identify patients with an increased need for psychological care.

Association of clinic and ambulatory heart rate parameters with mortality in hypertension.

OBJECTIVES: Resting heart rate (HR) taken in the office has been shown to be associated with cardiovascular outcomes in the general population, hypertension and heart failure. It is unknown whether 24-h oscillographic pulse rate measurement as an approximation of HR derived from ambulatory blood pressure monitoring (ABPM) associates with cardiovascular outcomes in hypertensive patients. METHODS: We evaluated ABPM recordings from 56 901 patients with complete 3373 421 HR measures entering the final analysis from the Spanish Blood Pressure Monitoring Registry for a median follow-up time of 5.1 years. We explored the association of office HR, mean 24-h HR, mean day HR, mean night HR as well as day-night HR differences, morning mean HR, morning HR surge and night peak HR to all-cause death, cardiovascular death and noncardiovascular death. Data were analyzed by Cox regression analysis, analysis of variance and chi-square test. RESULTS: The Spanish ABPM Registry recorded data in 223 primary care centers in Spain from 2004 until 31 December 2014 at the end of recruitment. Office HR was 3.5 bpm higher than mean 24-h HR, office mean HR versus mean night was 10.4 bpm higher and mean day versus mean night HR 9.3 bpm higher, while there were no relevant difference between office and mean day HR. Office mean, 24-h day and night HR more than 90 bpm were associated with an increased risk for all-cause and noncardiovascular death, whereas for cardiovascular death only mean night HR was predictive. The strongest association to all-cause death was observed with mean night HR [hazard ratio 3.80 (2.87-5.03)], mean 24-h HR [2.85 (2.30-3.54)] and mean day HR [2.22 (1.83-2.70)]. Day-night dipping of more than 8 bpm was associated with a 20% lesser risk on all-cause, cardiovascular and noncardiovascular death. Results were robust after adjusting for relevant risk indicators. CONCLUSION: HR parameters derived from ABPM provide important information, in particular association with death by mean night HR, mean 24-h HR and reduced day-night HR dipping less than 8 bpm superior to office HR.