Clinic Blood Pressure Underestimates Ambulatory Blood Pressure in an Untreated Employer-Based US Population: Results From the Masked Hypertension Study.

BACKGROUND: Ambulatory blood pressure (ABP) is consistently superior to clinic blood pressure (CBP) as a predictor of cardiovascular morbidity and mortality risk. A common perception is that ABP is usually lower than CBP. The relationship of the CBP minus ABP difference to age has not been examined in the United States. METHODS: Between 2005 and 2012, 888 healthy, employed, middle-aged (mean±SD age, 45±10.4 years) individuals (59% female, 7.4% black, 12% Hispanic) with screening BP <160/105 mm Hg and not taking antihypertensive medication completed 3 separate clinic BP assessments and a 24-hour ABP recording for the Masked Hypertension Study. The distributions of CBP, mean awake ABP (aABP), and the CBP-aABP difference in the full sample and by demographic characteristics were compared. Locally weighted scatterplot smoothing was used to model the relationship of the BP measures to age and body mass index. The prevalence of discrepancies in ABP- versus CBP-defined hypertension status-white-coat hypertension and masked hypertension-were also examined. RESULTS: Average systolic/diastolic aABP (123.0/77.4±10.3/7.4 mm Hg) was significantly higher than the average of 9 CBP readings over 3 visits (116.0/75.4±11.6/7.7 mm Hg). aABP exceeded CBP by >10 mm Hg much more frequently than CBP exceeded aABP. The difference (aABP>CBP) was most pronounced in young adults and those with normal body mass index. The systolic difference progressively diminished, but did not disappear, at older ages and higher body mass indexes. The diastolic difference vanished around age 65 and reversed (CBP>aABP) for body mass index >32.5 kg/m2. Whereas 5.3% of participants were hypertensive by CBP, 19.2% were hypertensive by aABP; 15.7% of those with nonelevated CBP had masked hypertension. CONCLUSIONS: Contrary to a widely held belief, based primarily on cohort studies of patients with elevated CBP, ABP is not usually lower than CBP, at least not among healthy, employed individuals. Furthermore, a substantial proportion of otherwise healthy individuals with nonelevated CBP have masked hypertension. Demonstrated CBP-aABP gradients, if confirmed in representative samples (eg, NHANES [National Health and Nutrition Examination Survey]), could provide guidance for primary care physicians as to when, for a given CBP, 24-hour ABP would be useful to identify or rule out masked hypertension.

Reliability of Office, Home, and Ambulatory Blood Pressure Measurements and Correlation With Left Ventricular Mass.

BACKGROUND: Determining the reliability and predictive validity of office blood pressure (OBP), ambulatory BP (ABP), and home BP (HBP) can inform which is best for diagnosing hypertension and estimating risk of cardiovascular disease. OBJECTIVES: This study aimed to assess the reliability of OBP, HBP, and ABP and evaluate their associations with left ventricular mass index (LVMI) in untreated persons. METHODS: The Improving the Detection of Hypertension (IDH) study, a community-based observational study, enrolled 408 participants who had OBP assessed at 3 visits, and completed 3 weeks of HBP, 2 24-h ABP recordings, and a 2-dimensional echocardiogram. Mean age was 41.2 ± 13.1 years, 59.5% were women, 25.5% African American, and 64.0% Hispanic. RESULTS: The reliability of 1 week of HBP, 3 office visits with mercury sphygmomanometry, and 24-h ABP were 0.938, 0.894, and 0.846 for systolic and 0.918, 0.847, and 0.843 for diastolic BP, respectively. The correlations among OBP, HBP, and ABP, corrected for regression dilution bias, were 0.74 to 0.89. After multivariable adjustment including OBP and 24-h ABP, 10 mm Hg higher systolic and diastolic HBP were associated with 5.07 (standard error [SE]: 1.48) and 3.92 (SE: 2.14) g/m2 higher LVMI, respectively. After adjustment for HBP, neither systolic or diastolic OBP nor ABP was associated with LVMI. CONCLUSIONS: OBP, HBP, and ABP assess somewhat distinct parameters. Compared with OBP (3 visits) or 24-h ABP, systolic and diastolic HBP (1 week) were more reliable and more strongly associated with LVMI. These data suggest that 1 week of HBP monitoring may be the best approach for diagnosing hypertension.

Circulating transforming growth factor-beta1 levels and the risk for kidney disease in African Americans.

Transforming growth factor-beta1 (TGF-beta1) is known to induce progression of experimental renal disease. Here we determined whether there is an association between serum levels of TGF-beta1 and the risk factors for progression of clinically relevant renal disorders in 186 black and 147 white adults, none of whom had kidney disease or diabetes. Serum TGF-beta1 protein levels were positively and significantly associated with plasma renin activity along with the systolic and diastolic blood pressure in blacks but not whites after controlling for age, gender, and body mass index. These TGF-beta1 protein levels were also significantly associated with body mass index and metabolic syndrome and more predictive of microalbuminuria in blacks than in whites. The differential association between TGF-beta1 and renal disease risk factors in blacks and whites suggests an explanation for the excess burden of end-stage renal disease in the black population, but this requires validation in an independent cohort. Whether these findings show that it is the circulating levels of TGF-beta1 that contribute to renal disease progression or the findings reflect other unmeasured factors, further longitudinal studies are needed.

Trait hostility and ambulatory blood pressure among traffic enforcement agents: the effects of stressful social interactions.

This study investigated the hypothesis that trait hostility is associated with heightened cardiovascular reactivity to potentially stressful social interactions but not to nonsocial activities in the workplace. Participants were 73 (39 women) New York City traffic enforcement agents (TEAs) who patrol the streets and issue summonses for vehicular and parking violations. During their patrols, TEAs face potentially stressful interactions when they encounter motorists and pedestrians who may be angry about receiving summonses. Mood and ambulatory blood pressure were initially measured when TEAs were recently hired and attending classes at the training academy (Time 1), and were subsequently assessed again once the TEAs began independently patrolling the city streets (Time 2). Random effects regression models yielded a significant interaction of hostility and work activity on ambulatory systolic blood pressure at Time 2. For those high in hostility, but not for those low in hostility, systolic blood pressure levels were higher while interacting with members of the public than during nonsocial work activities. The findings support the notion that situational factors affect the association of hostility to cardiovascular reactivity, and that interpersonal stressors in the workplace elicit cardiovascular activation among those high in hostility.

Franz Volhard lecture: should doctors still measure blood pressure? The missing patients with masked hypertension.

The traditional reliance on blood pressure (BP) measurement in the medical setting misses a significant number of individuals with masked hypertension, who have normal clinic BP but persistently high daytime BP when measured out of the office. We suggest that masked hypertension may be a precursor of clinically recognized sustained hypertension and is associated with increased cardiovascular risk compared with consistent normotension. We discuss factors that may contribute to clinic-daytime BP differences as well as the changing relationship between these two measures over time. Anxiety at the time of BP measurement and having been diagnosed as hypertensive appear to be two possible mechanisms. The identification of individuals with masked hypertension is of great clinical importance and requires out-of-office BP screening. Ambulatory BP monitoring is the best established technique for doing this, but home monitoring may be applicable in the future.

Monitoring of the central pulse pressure is useful for detecting cardiac overload during antiadrenergic treatment: the Japan Morning Surge 1 study.

OBJECTIVE: Lowering of the central pulse pressure (PP) has been shown to contribute to an improvement of the cardiac damage beyond that of lowering the brachial PP. We assessed the hypothesis that the change in the central PP is more useful than that in the brachial PP in the assessment of the change in cardiac load. METHODS: We studied 434 treated hypertensive patients whose home systolic blood pressure was 135 mmHg or higher. They were followed for 6 months after allocation to either a control group or an added treatment group (doxazosin 1-4 mg and atenolol when needed). We measured the brachial and central (carotid) blood pressure simultaneously using a validated device, and the B-type natriuretic peptide at baseline and at the sixth month of treatment. RESULTS: In the added treatment group, the brachial systolic blood pressure was successfully reduced, but the central PP increased significantly, whereas the other blood pressure parameters did not change from the baseline. In the added treatment group, the change in the B-type natriuretic peptide was significantly correlated with the change in the brachial PP (r = 0.18), central systolic blood pressure (r = 0.18), central PP (r = 0.26), and PP amplification (r = -0.22) even after adjusting for the confounding factors. The correlation with the central PP was stronger than with the brachial PP (P = 0.018) or central systolic blood pressure (P = 0.002), and these relationships were essentially the same even after adjustment for the use of atenolol or the change in heart rate. CONCLUSION: This study showed that the central PP measurement may be more important to assess cardiac load than the brachial PP during antiadrenergic treatment.

Increased low-grade inflammation and plasminogen-activator inhibitor-1 level in nondippers with sleep apnea syndrome.

OBJECTIVE: Patients with sleep apnea syndrome have an increased risk of cardiovascular events and frequently show a nondipper pattern (blunted nocturnal decline <10%) of systolic blood pressure. We investigated neurohumoral activation and risk factors in relation to nocturnal blood pressure dipping pattern and sleep apnea syndrome. METHODS: We conducted sleep polysomnography and ambulatory blood pressure monitoring and measured high-sensitivity C-reactive protein, tissue-type plasminogen activator inhibitor-1, and neurohumoral factors in 121 outpatients with suspected sleep apnea syndrome who were classified into four groups on the basis of the presence or the absence of dipping/nondipping and sleep apnea syndrome. RESULTS: Nondippers with sleep apnea syndrome had higher high-sensitivity C-reactive protein (overall P < 0.001), plasminogen activator inhibitor-1 (overall P = 0.004), and aldosterone levels (overall P = 0.010) than any of the other three groups. After adjustment for significant covariates such as age, sex, body mass index, waist circumference, smoking, alcohol drinking, aspirin use, presence of diabetes, and insulin, nondippers with sleep apnea syndrome still had a higher high-sensitivity C-reactive protein level than nondippers without sleep apnea syndrome (geometric mean: 1.47 vs. 0.37 mg/l, P = 0.001). In multiple linear regression analysis controlling for confounding factors related with sleep apnea syndrome, high-sensitivity C-reactive protein was significantly correlated with 3% oxygen desaturation index (P = 0.047). Plasminogen activator inhibitor-1 level was also highest in the nondippers with sleep apnea syndrome but not independent of obesity. Plasminogen activator inhibitor-1 level correlated with insulin (r = 0.32, P = 0.002) and high-sensitivity C-reactive protein levels (r = 0.26, P = 0.005). CONCLUSION: Nondipper status was associated with an increased high-sensitivity C-reactive protein level in patients who also had sleep apnea syndrome but not in those who did not. High-sensitivity C-reactive protein level was closely affected by the desaturation level. Plasminogen activator inhibitor-1 level is also increased in nondippers with sleep apnea syndrome and is related to insulin and high-sensitivity C-reactive protein levels.

Effect of doxazosin on the left ventricular structure and function in morning hypertensive patients: the Japan Morning Surge 1 study.

OBJECTIVES: Doxazosin is reported to increase the incidence of congestive heart failure. The benefits of doxazosin, for controlling morning blood pressure as well as its effect on the left ventricular structure and function, are herein examined. METHODS: In this study, 223 morning hypertensive patients were randomized into either the doxazosin group, with a once-daily bedtime dose of doxazosin, or the control group, who continued their current medication. Atenolol was added to the doxazosin group when needed. The effect of doxazosin was evaluated by measurement of echocardiographic parameters and B-type natriuretic peptide. RESULTS: The left ventricular wall thickness decreased, but the left ventricular diastolic diameter in the doxazosin group increased from the baseline. The changes in the left ventricular mass index were similar between the groups, whereas the relative wall thickness in the doxazosin group decreased more than that in the control group. The left ventricular diastolic function could deteriorate in the doxazosin group. In the doxazosin group, an increase in the left ventricular diameter was only seen in the patient who did not take diuretics throughout the study. The office and home blood pressure in the doxazosin group decreased more than that in the control group, whereas the B-type natriuretic peptide increased in the doxazosin group. Three cases of congestive heart failure were observed in the doxazosin group, but none in the control group. CONCLUSION: Although a bedtime dose of doxazosin can significantly lower the blood pressure, it can also increase left ventricular diameter, thus increasing the risk of congestive heart failure. However, the prior use of diuretics can prevent the unfavorable effects of doxazosin on the left ventricular structure.

An alpha-adrenergic blocker titrated by self-measured blood pressure recordings lowered blood pressure and microalbuminuria in patients with morning hypertension: the Japan Morning Surge-1 Study.

BACKGROUND: The impact on microalbuminuria of strict treatment aimed at lowering of self-measured morning blood pressure using an adrenergic blockade is unclear. METHODS: We conducted an open-label multicenter trial, the Japan Morning Surge-1 Study, that enrolled 611 hypertensive patients, whose self-measured morning systolic blood pressure levels were more than 135 mmHg while taking antihypertensive drugs. These were randomly allocated to an experimental group, whose members received bedtime administration of 1-4 mg doxazosin (doxazosin group) or a control group whose members continued without any add-on medication (control group). The urinary albumin/creatinine ratio was investigated at the baseline and 6 months after the randomization. RESULTS: Both the morning and evening blood pressures and urinary albumin/creatinine ratio (-3.4 vs. 0.0 mg/gCr for urinary albumin/creatinine ratio; P < 0.001) were more markedly reduced in the doxazosin group than in the control group. This difference in the urinary albumin/creatinine ratio between the two groups was more marked in the patients with microalbuminuria (n = 238, -27.9 vs. -8.1 mg/gCr, P < 0.001). The reduction of urinary albumin/creatinine ratio was significantly associated with the use of doxazosin, and the change in all self-measured blood pressures (morning, evening, the average morning-evening), and these associations were independent of each other (P < 0.001). CONCLUSION: Adding a bedtime dose of an alpha-adrenergic blocker titrated by self-measured morning blood pressure in treated hypertensive patients with uncontrolled morning hypertension significantly reduced blood pressure and urinary albumin excretion rate, particularly in those with microalbuminuria.

Sleep duration associated with mortality in elderly, but not middle-aged, adults in a large US sample.

STUDY OBJECTIVES: To explore age differences in the relationship between sleep duration and mortality by conducting analyses stratified by age. Both short and long sleep durations have been found to be associated with mortality. Short sleep duration is associated with negative health outcomes, but there is little evidence that long sleep duration has adverse health effects. No epidemiologic studies have published multivariate analyses stratified by age, even though life expectancy is 75 years and the majority of deaths occur in the elderly. DESIGN: Multivariate longitudinal analyses of the first National Health and Nutrition Examination Survey using Cox proportional hazards models. SETTING: Probability sample (n = 9789) of the civilian noninstitutionalized population of the United States between 1982 and 1992. PARTICIPANTS: Subjects aged 32 to 86 years. MEASUREMENTS AND RESULTS: In multivariate analyses controlling for many covariates, no relationship was found in middle-aged subjects between short sleep of 5 hours or less and mortality (hazards ratio [HR] = 0.67, 95% confidence interval [CI] 0.43-1.05) or long sleep of 9 hours or more and mortality (HR = 1.04, 95% CI 0.66-1.65). A U-shaped relationship was found only in elderly subjects, with both short sleep duration (HR = 1.27, 95% CI 1.06-1.53) and long sleep duration (HR = 1.36, 95% CI 1.15-1.60) having significantly higher HRs. CONCLUSIONS: The relationship between sleep duration and mortality is largely influenced by deaths in elderly subjects and by the measurement of sleep durations closely before death. Long sleep duration is unlikely to contribute toward mortality but, rather, is a consequence of medical conditions and age-related sleep changes.

Racism and ambulatory blood pressure in a community sample.

OBJECTIVE: Racism has been identified as a psychosocial stressor that may contribute to disparities in the prevalence of cardiovascular disease. The goal of the present article was to investigate the relationship of perceived racism to ambulatory blood pressure (ABP) in a sample of American-born Blacks and Latinos. METHODS: Participants included English-speaking Black or Latino(a) adults between the ages of 24 and 65. They completed daily mood diaries and measures of perceived racism, socioeconomic status, and hostility. Participants were outfitted with ABP monitors; 357 provided data on waking hours only, and 245 provided data on both waking and nocturnal ABP. RESULTS: Perceived racism was positively associated with nocturnal ABP even when controlling for personality factors and socioeconomic status. CONCLUSIONS: The results suggest that racism may influence cardiovascular disease risk through its effects on nocturnal BP recovery.

Effect of social support on nocturnal blood pressure dipping.

OBJECTIVE: To determine if nocturnal blood pressure (BP) dipping among non-Hispanic blacks is influenced by social support. Non-Hispanic blacks have higher rates of cardiovascular morbidity and mortality from hypertension and are more likely to have ambulatory blood pressure (ABP) that remains high at night (nondipping). METHODS: A total of 68 non-Hispanic black normotensive and 13 untreated hypertensive participants (age 72 +/- 10 years, 48% female) free of clinical cardiovascular disease completed 24-hour ABP monitoring and a questionnaire that included a modified version of the CARDIA Study Social Support Scale (CSSS). Nondipping was defined as a decrease of <10% in the ratio between average awake and average asleep systolic BP. Analyses were adjusted for age, gender, and systolic BP. RESULTS: The prevalence of nondipping was 26.8% in subjects in the highest CSSS tertile versus 41.1% in the lowest CSSS tertile (p = .009). On adjusted analysis, CSSS was analyzed as a continuous variable and remained independently and inversely associated with nondipping (odds ratio 0.27, 95% Confidence Interval 0.08-0.94, p = .04). CONCLUSIONS: Social support may be an important predictor of BP dipping at night. These findings suggest that social support may have positive health affects through physiologic (autonomic) pathways.

Ambulatory blood pressure is a better marker than clinic blood pressure in predicting cardiovascular events in patients with/without type 2 diabetes.

BACKGROUND: The prognostic significance of ambulatory blood pressure (ABP) has not been established in patients with type 2 diabetes (T2DM). METHODS: In order to clarify the impact of ABP on cardiovascular prognosis in patients with or without T2DM, we performed ABP monitoring (ABPM) in 1,268 subjects recruited from nine sites in Japan, who were being evaluated for hypertension. The mean age of the patients was 70.4 +/- 9.9 years, and 301 of them had diabetes. The patients were followed up for 50 +/- 23 months. We investigated the relation between incidence of cardiovascular diseases (CVDs) and different measures of ABP, including three categories of awake systolic blood pressure (SBP <135, 135-150, and >150 mm Hg), sleep SBP (<120, 120-135, and >135 mm Hg), and dipping trends in nocturnal blood pressure (BP) (dippers, nondippers, and risers). Cox regression models were used in order to control for classic risk factors. RESULTS: Higher awake and sleep SBPs predicted higher incidence of CVD in patients with and without diabetes. In multivariable analyses, elevated SBPs while awake and asleep predicted increased risk of CVD more accurately than clinic BP did, in both groups of patients. The relationships between ABP level and CVD were similar in both groups. In Kaplan-Meier analyses, the incidence of CVD in nondippers was similar to that in dippers, but risers experienced the highest risk of CVD in both groups (P < 0.01). The riser pattern was associated with a approximately 150% increase in risk of CVD, in both groups. CONCLUSIONS: These findings suggest that ABPM is a better predictor of cardiovascular risk than clinic BP, and that this holds true for patients with or without T2DM.

Plasma tissue inhibitor of matrix metalloproteinase-1 level is increased in normotensive non-dippers in association with impaired glucose metabolism.

Non-dipping (nocturnal blood pressure [BP] decrease<10%) is related to accelerated urinary salt excretion (u-NaCl), and increased risk of left ventricular hypertrophy (LVH) and cardiovascular events. We evaluated whether non-dippers exhibit an advanced extracellular matrix fibrosis, in relation to increased u-NaCl, among normotensive subjects. We measured plasma tissue inhibitor of matrix metalloproteinase-1 (TIMP-1), a marker of collagen fibrosis in extracellular matrix, to evaluate the relationship between non-dipping and u-NaCl in 73 normotensive subjects (no antihypertensive medications, clinic BP<140/90 mmHg and/or 24-h ambulatory BP<125/80 mmHg). Non-dippers had a significantly higher percentage of subjects with impaired fasting glucose (IFG) or diabetes mellitus (DM), and had a greater left ventricular mass index (LVMI), plasma TIMP-1 level and u-NaCl than dippers (IFG or DM: 24.0 vs. 6.3%, p=0.029; LVMI: 118+/-31 vs. 103+/-26 g/m(2), p=0.039; TIMP-1: 168+/-35 vs. 151+/-30 pg/mL, p=0.035; u-NaCl: 5.1+/-1.7 vs. 3.9+/-1.7 g/12 h, p=0.005). In logistic regression analysis, non-dipping was independently associated with u-NaCl and TIMP-1. u-NaCl was correlated with non-dipping (r=0.35, p=0.003) and serum glucose level (r=0.26, p=0.027). On the other hand, TIMP-1 level was significantly correlated with the presence of IFG or DM (r=0.23, p=0.046), but not with u-NaCl. In conclusion, plasma TIMP-1 level, a measure of cardiovascular fibrosis in extracellular matrix, is greater in normotensive non-dippers than in dippers; however, the increased TIMP-1 level may be related to impaired glucose metabolism, and non-dipping may be related to increased u-NaCl associated with high serum glucose levels in normotensive subjects. (Hypertens Res 2008; 31: 2045-2051).

Prevalence and determinants of prehypertension in a Japanese general population: the Jichi Medical School Cohort Study.

It has been reported that subjects with prehypertension (pre-HT) (systolic blood pressure [SBP] 120-139 mmHg and/or diastolic blood pressure [DBP] 80-89 mmHg) have an increased risk of cardiovascular disease (CVD). We evaluated the prevalence and determinants of pre-HT in a Japanese general population. We enrolled 4,706 males and 7,342 females aged 18 to 90 years whose BPs were measured at baseline. The subjects' BPs were classified as follows: normotension (NT: SPB/DBP < 120/80 mmHg), pre-HT (120/80-139/89 mmHg), and hypertension (HT: > or = 140/90 mmHg or treated hypertension). The prevalence of pre-HT was 34.8% (males), and 31.8% (females). Body mass index (BMI) of more than 23.0 kg/m2 was the strongest determinant of pre-HT (Males--BMI: 23.0-24.9 kg/m2, odds ratio [OR] = 1.47, 95% confidence interval [CI] = 1.21-1.79; BMI: 25.0-26.9 kg/m2, OR = 2.20, 95% CI =1.68-2.87; BMI: 27.0-29.9 kg/m2, OR = 2.75, 95% CI = 1.80-4.19; BMI: > or = 30.0 kg/m2, OR = 3.39, 95% CI = 1.21-9.46. Females--BMI: 23.0-24.9 kg/m2, OR = 1.67, 95% CI = 1.42-1.95; BMI: 25.0-26.9 kg/m2, OR = 1.79, 95% CI = 1.46-2.19; BMI: 27.0-29.9 kg/m2, OR = 3.65, 95% CI = 2.73-4.89; BMI: > or = 30.0 kg/m2, OR = 4.23, 95% CI = 2.33-7.70). The other determinants of pre-HT were hyperlipidemia (Males: OR = 1.25; Females: OR = 1.43), and aging (by 10 years; Males: OR = 1.12; Females: OR = 1.48). Determinants of pre-HT in females were impaired glucose tolerance (OR = 1.41, 95% CI = 1.03-1.94), diabetes (OR = 2.01, 95% CI = 1.16-3.47) and a family history of HT in both parents (OR = 1.90, 95% CI = 1.38-2.62), whereas in males the only other predictor was alcohol drinking (OR = 1.45, 95% CI = 1.23-1.70). In conclusion, even subjects with a mild increase of BMI (23.0-24.9 kg/m2) had an increased risk of pre-HT in a Japanese population, and the level of BMI associated with pre-HT was lower than that in Western countries. Additionally, there were gender differences in the determinants of pre-HT.

Orthostatic hypertension detected by self-measured home blood pressure monitoring: a new cardiovascular risk factor for elderly hypertensives.

Orthostatic blood pressure (BP) dysregulation is a risk factor for both falls and cardiovascular events. Self-measured BP, carried out at home, is both highly reproducible and useful for evaluating antihypertensive treatment. However, there have been a few reports on the clinical implications of orthostatic BP changes in home BP monitoring (HBPM). In the baseline examination for the Japan Morning Surge-1 Study, a multicenter randomized control trial, we evaluated 605 hypertensive outpatients who had a morning systolic BP above 135 mmHg. The plasma brain natriuretic peptide (BNP) level and urinary albumin excretion were measured. When the patients were divided into 10 groups, according to orthostatic BP change evaluated by HBPM, after adjusting for age, gender, body mass index and sitting home BP level, those in the top decile (n=60, orthostatic BP increase>7.8 mmHg) had a higher urinary albumin/creatinine ratio (UAR) than the lowest decile group (geometric mean [SEM range]: 209.1 [134.7-318.7] vs. 34.1 [20.1-56.2] mg/g creatinine [Cr], p=0.003) and the pooled second to ninth decile groups (n=485, 209.1 [134.7-318.7] vs. 39.7 [33.2-47.3] mg/g Cr, p<0.02). Additionally, patients in the top decile had a higher BNP level than the second to ninth decile groups (75.7 [55.0-103.1] vs. 23.6 [20.8-26.6] pg/mL, p=0.003). Evaluation of orthostatic hypertension at home might be a high-risk factor for cardiovascular events in hypertensive subjects with increased levels of BNP and a higher UAR, independent of the home sitting BP level.

Cardiovascular prognosis of sustained and white-coat hypertension in patients with type 2 diabetes mellitus.

OBJECTIVE: Cardiovascular prognosis in diabetic white-coat hypertension (WCH) has not yet been described. We designed this study to investigate the impact of WCH on cardiovascular events in patients with type 2 diabetes, compared with those having type 2 diabetes along with sustained hypertension (SH), and with nondiabetic hypertensive individuals. METHODS: We performed ambulatory blood pressure (BP) monitoring in 1207 consecutive hypertensive patients at baseline, and they were followed up for 49+/-22 months. The mean age was 70.7+/-9.8 years; 262 had type 2 diabetes; and 945 did not. They were classified as having SH with diabetes (n=210); diabetic WCH (n=52); SH alone (n=719); or WCH alone (n=226), using awake BP of 135/85 mmHg as the cutoff value. Cox regression models were used to calculate hazard ratios (HR) and 95% confidence intervals of the risk for cardiovascular events, after controlling for age, sex, body mass index, current smoking, serum creatinine, and clinical systolic BP. RESULTS: During the follow-up period, 97 cardiovascular events occurred. The incidence of cardiovascular events in the diabetic SH group was significantly higher than in the diabetic WCH, nondiabetic SH, and nondiabetic WCH (P<0.05; log-rank test) groups. In Cox regression analysis, the diabetic SH group had significantly higher risk of cardiovascular events compared with the diabetic WCH group (HR: 8.2; 95% confidence intervals: 1.09-61.8; P=0.04). Although nonsignificant, the HRs in the SH and WCH groups, relative to diabetic WCH, exceeded 3.0. CONCLUSIONS: The cardiovascular prognosis for diabetic WCH was better than that for diabetic SH during 4 years of follow-up.

Paroxysmal hypertension: the role of stress and psychological factors.

This paper reviews the limited literature on paroxysmal hypertension. A case report describes the clinical picture frequently seen in specialty hypertension practice, a patient with paroxysmal or intermittent hypertension who proves not to have a pheochromocytoma. The variety of diagnostic labels given to these patients is reviewed, including pseudopheochromocytoma, panic attacks, and hyperventilation syndrome. The clinical features, pathology, diagnosis, and treatment of these syndromes are outlined. It is proposed that successful management of these patients may be best achieved by collaborative care between a hypertension specialist and a psychiatrist or clinical psychologist with expertise in cognitive-behavioral panic management, stress-reduction techniques including controlled breathing, and treating health anxiety. The use of drugs effective for treatment of panic disorder can also be helpful in managing these patients.

Cardiovascular risks of dipping status and chronic kidney disease in elderly Japanese hypertensive patients.

Chronic kidney disease (CKD) increases the risk of cardiovascular events and is often associated with the nondipping pattern of blood pressure (BP). We evaluated ambulatory BP, CKD, and the incidence of cardiovascular events in 811 older hypertensive patients. CKD and the dipping pattern increased the risk of cardiovascular events independent of the 24-hour systolic BP level (CKD: hazard ratio [HR], 2.37; 95% confidence interval [CI], 1.24-4.54; nondippers: HR, 2.16; 95% CI, 1.19-3.91; extreme dippers: HR, 2.38; 95% CI, 1.17-4.83). However, after adjustment for covariates that included CKD, the risk in nondippers was insignificant (HR, 1.83; 95% CI, 0.998-3.34; P=.051), while the risk in extreme dippers remained (HR, 2.59; 95% CI, 1.26-5.32; P=.009) (CKD: HR, 1.81; 95% CI, 0.93-3.54; P=.081). Patients with CKD have an increased risk of cardiovascular events. CKD and other cardiovascular risk factors may account for some of the increased risk in nondippers, but it does not explain the higher risk in extreme dippers.

Call to action on use and reimbursement for home blood pressure monitoring: Executive Summary. A joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association.

Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (class IIa; level of evidence A). This call-to-action article makes the following recommendations: (1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; (3) Two to 3 readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of > or =12 readings are recommended for making clinical decisions; (4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; (5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; (6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; (7) The target HBPM goal for treatment is <135/85 mm Hg or <130/80 mm Hg in high-risk patients; (8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; (9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; (10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and (11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed.