Myocardial T-Lymphocytes as a Prognostic Risk-Stratifying Marker of Dilated Cardiomyopathy　- Results of the Multicenter Registry to Investigate Inflammatory Cell Infiltration in Dilated Cardiomyopathy in Tissues of Endomyocardial Biopsy (INDICATE Study).

BACKGROUND: Dilated cardiomyopathy (DCM) associated with inflammation is diagnosed by endomyocardial biopsy; patients with this have a poorer prognosis than patients without inflammation. To date, standard diagnostic criteria have not been established.Methods and Results: This study analyzed clinical records and endomyocardial biopsy samples of 261 patients with DCM (201 males, median left ventricular ejection fraction; 28%) from 8 institutions in a multicenter retrospective study. Based on the European Society of Cardiology criteria and CD3 (T-lymphocytes) and CD68 (macrophages) immunohistochemistry, 48% of patients were categorized as having inflammatory DCM. For risk-stratification, we divided patients into 3 groups using Akaike Information Criterion/log-rank tests, which can determine multiple cut-off points: CD3+-Low, <13/mm2(n=178, 68%); CD3+-Moderate, 13-24/mm2(n=58, 22%); and CD3+-High, ≥24/mm2(n=25, 10%). The survival curves for cardiac death or left ventricular assist device implantation differed significantly among the 3 groups (10-year survival rates: CD3+-Low: 83.4%; CD3+-Moderate: 68.4%; CD3+-High: 21.1%; Log-rank P<0.001). Multivariate Cox analysis revealed CD3+count as a potent independent predictive factor for survival (fully adjusted hazard ratio: CD3+-High: 5.70, P<0.001; CD3+-Moderate: 2.64, P<0.01). CD3+-High was also associated with poor left ventricular functional and morphological recovery at short-term follow up. CONCLUSIONS: Myocardial CD3+T-lymphocyte infiltration has a significant prognostic impact in DCM and a 3-tiered risk-stratification model could be helpful to refine patient categorization.

A Case of Left Atrial Myxoma Whose Initial Symptom Was Finger Ischemic Symptom.

We experienced a 45-year-old Japanese man who was transferred to our hospital complaining of acute onset of pain and pallor in the right lower limb. Two years earlier, he had complained of repetitive pain at rest and pallor in the left third and fourth fingers. The physical exam and angiography demonstrated occlusion of finger arteries, however we could not reach final diagnosis. Acute arterial occlusive disease in the right lower limb was suspected. Transthoracic echocardiography demonstrated a gross tumor in the left atrium, which suggested left atrial myxoma. An emergency tumorectomy was successfully conducted. Pathologically, the fragile tumor and resultant thrombosis could have caused the patient's peripheral circulatory failure at least two years prior to this episode. A rigorous systemic survey is important even when the ischemic symptom is localized in peripheral circulation.

Glomerular hyperfiltration is a predictor of adverse cardiovascular outcomes.

The association between glomerular hyperfiltration and cardiovascular events is not well known. To investigate whether glomerular hyperfiltration is independently associated with risk of adverse outcome we analyzed 8794 participants, average age 52 years enrolled in 8 prospective studies. Of these, 89% had hypertension. Using the 5th and 95th percentiles of the age- and sex-specific quintiles of CKD-EPI-calculated estimated glomerular filtration rate (eGFR), we identified three participant groups with low, high and normal eGFR. The ambulatory pulse pressure interval was wider and nighttime blood pressure fall was smaller in both the low and high than in the normal eGFR participants. During a mean follow-up of 6.2 years, there were 722 cardiovascular events. Crude event rates were significantly higher for both high (1.8 per 100-person-year) and low eGFR groups (2.1 per 100 person-year) as compared with group with normal eGFR (1.2 per 100 person-year). In multivariable Cox models including age, sex, average 24-hour blood pressure, smoking, diabetes, and cholesterol, both high eGFR (hazard ratio 1.5 (95% confidence interval 1.2-2.1) and low eGFR (2.0 [1.5-2.6]) participants had a significantly higher risk of cardiovascular events as compared to those with normal eGFR. Addition of body mass index to the multivariable survival model did not change the magnitude of hazard estimates. Thus, glomerular hyperfiltration is a strong and independent predictor of cardiovascular events in a large multiethnic population of predominantly hypertensive individuals. Our findings support a U-shaped relationship between eGFR and adverse outcome.

Isolated Cardiac Sarcoidosis Mimicking Arrhythmogenic Right Ventricular Cardiomyopathy.

The diagnosis of cardiac sarcoidosis (CS) has become easier due to advances in imaging modalities, but we sometimes encounter difficult-to-diagnose patients. We herein report the case of a 60-year-old Japanese woman who was diagnosed with isolated CS, although she also met the diagnostic criteria of arrhythmogenic right ventricular cardiomyopathy (ARVC). A histological examination by an endomyocardial biopsy of the right ventricle revealed the typical findings of granulomatous change for CS. Although she did not show any characteristics of systemic sarcoidosis, oral prednisolone treatment was introduced, and she achieved a good response. This case shows that the characteristics of CS can overlap with the diagnostic criteria of ARVC, and that a histological examination is essential for the correct diagnosis of CS.

Life- and limb-saving endovascular therapy in a patient with acute abdominal aortic occlusion.

A 79-year-old man developed severe bilateral ischemic symptoms in the lower limbs. Chest-abdominal-pelvic contrast computed tomography (CT) showed acute occlusion involving the abdominal aorta, and endovascular therapy (EVT) was used as emergency treatment. Two self-expandable stents placed in the thrombus area resulted in restoration of blood flow to the lower limbs, despite limited stent expansion, and movement of these limbs. Follow-up CT showed good stent expansion. The patient had a favorable recovery without additional surgery. This case suggests that EVT might be an additional option for acute abdominal aortic occlusion if surgery or thrombolytic therapies are not possible.

A Cushing's syndrome patient's severe insomnia and morning blood pressure surge both improved after her left adrenal tumor resection.

Underlying mechanisms of the elevated risks of hypertension and cardiovascular disease (CVD) in Cushing's syndrome (CS) are unclear. We treated an adult woman with CS because of a cortisol-secreting adrenal tumor. After tumor resection, the 24-h blood pressure (BP) level improved from 156/91 to 131/84 mmHg; the morning BP surprisingly improved from 174/98 to 127/93 mmHg, although we reduced her antihypertensive medication. Her sleep quality (by the Pittsburgh Sleep Quality Index) improved from 7 to 2 points. Disturbed circadian BP rhythm is often observed in CS, but was reported only as altered nocturnal BP fall. This is the first report showing the disappearance of the morning BP surge evaluated by ambulatory BP monitoring with postsurgery sleep quality improvement. Poor-quality sleep, followed by exaggerated morning BP surge may thus be a cause of CS-related cardiovascular events. Sleep quality and BP circadian rhythm evaluations may clarify hypertension and high CVD risk in CS.

Effect of Intensive Salt-Restriction Education on Clinic, Home, and Ambulatory Blood Pressure Levels in Treated Hypertensive Patients During a 3-Month Education Period.

The authors tested the hypothesis that low-salt diet education by nutritionists would lower blood pressure (BP) levels in treated hypertensive patients. The amount of urinary salt excretion and clinic, home, and ambulatory BP values at baseline and at 3 months were measured in 95 patients with hypertension. After randomization to a nutritional education group (E group, n=51) or a control group (C group, n=44), the C group received conventional salt-restriction education and the E group received intensive nutritional education aimed at salt restriction to 6 g/d by nutritionists. From baseline to the end of the study, 24-hour urinary sodium excretion was significantly lowered in the E group compared with the C group (6.8±2.9 g/24 h vs 8.6±3.4 g/24 h, P<.01). Morning home systolic BP tended to be lowered in the E group (P=.051), and ambulatory 24-hour systolic BP was significantly lowered in the E group (-4.5±1.3 mm Hg) compared with the C group (2.8±1.3 mm Hg, P<.001). Intensive nutritional education by nutritionists was shown to be effective in lowering BP in treated hypertensive patients.

An adverse pregnancy-associated outcome due to overlooked primary aldosteronism.

A 31-year-old woman with treatment-resistant pregnancy-induced hypertension during her first pregnancy delivered a small-for-gestational-age infant (weight: 1,070 g). After delivery, she was diagnosed with primary aldosteronism (PA) associated with a left adrenal adenoma. Following a thorough examination, she underwent laparoscopic left adrenalectomy, and the diagnosis of an aldosterone-producing adenoma was confirmed based on a pathological examination. Thereafter, the patient's hypertension and hypokalemia completely disappeared. She became pregnant again and successfully delivered her second infant at the 37th week of gestation (weight: 2,720 g) without developing treatment-resistant hypertension. Secondary causes of hypertension should not be overlooked, even in young pregnant women.

Added predictive value of night-time blood pressure variability for cardiovascular events and mortality: the Ambulatory Blood Pressure-International Study.

The association of ambulatory blood pressure (BP) variability with mortality and cardiovascular events is controversial. To investigate whether BP variability predicts cardiovascular events and mortality in hypertension, we analyzed 7112 untreated hypertensive participants (3996 men) aged 52±15 years enrolled in 6 prospective studies. Median follow-up was 5.5 years. SD of night-time BP was positively associated with age, body mass index, smoking, diabetes mellitus, and average night-time BP (all P<0.001). In a multivariable Cox model, night-time BP variability was an independent predictor of all-cause mortality (systolic, P<0.001/diastolic, P<0.0001), cardiovascular mortality (P=0.008/<0.0001), and cardiovascular events (P<0.001/<0.0001). In contrast, daytime BP variability was not an independent predictor of outcomes in any model. In fully adjusted models, a night-time systolic BP SD of ≥12.2 mm Hg was associated with a 41% greater risk of cardiovascular events, a 55% greater risk of cardiovascular death, and a 59% increased risk of all-cause mortality compared with an SD of <12.2 mm Hg. The corresponding values for a diastolic BP SD of ≥7.9 mm Hg were 48%, 132%, and 77%. The addition of night-time BP variability to fully adjusted models had a significant impact on risk reclassification and integrated discrimination for all outcomes (relative integrated discrimination improvement for systolic BP variability: 9% cardiovascular events, 14.5% all-cause death, 8.5% cardiovascular death, and for diastolic BP variability: 10% cardiovascular events, 19.1% all-cause death, 23% cardiovascular death, all P<0.01). Thus, addition of BP variability to models of long-term outcomes improved the ability to stratify appropriately patients with hypertension among risk categories defined by standard clinical and laboratory variables.

Predictive value of night-time heart rate for cardiovascular events in hypertension. The ABP-International study.

BACKGROUND: Data from prospective cohort studies regarding the association between ambulatory heart rate (HR) and cardiovascular events (CVE) are conflicting. METHODS: To investigate whether ambulatory HR predicts CVE in hypertension, we performed 24-hour ambulatory blood pressure and HR monitoring in 7600 hypertensive patients aged 52 ± 16 years from Italy, U.S.A., Japan, and Australia, included in the 'ABP-International' registry. All were untreated at baseline examination. Standardized hazard ratios for ambulatory HRs were computed, stratifying for cohort, and adjusting for age, gender, blood pressure, smoking, diabetes, serum total cholesterol and serum creatinine. RESULTS: During a median follow-up of 5.0 years there were 639 fatal and nonfatal CVE. In a multivariable Cox model, night-time HR predicted fatal combined with nonfatal CVE more closely than 24h HR (p=0.007 and =0.03, respectively). Daytime HR and the night:day HR ratio were not associated with CVE (p=0.07 and =0.18, respectively). The hazard ratio of the fatal combined with nonfatal CVE for a 10-beats/min increment of the night-time HR was 1.13 (95% CI, 1.04-1.22). This relationship remained significant when subjects taking beta-blockers during the follow-up (hazard ratio, 1.15; 95% CI, 1.05-1.25) or subjects who had an event within 5 years after enrollment (hazard ratio, 1.23; 95% CI, 1.05-1.45) were excluded from analysis. CONCLUSIONS: At variance with previous data obtained from general populations, ambulatory HR added to the risk stratification for fatal combined with nonfatal CVE in the hypertensive patients from the ABP-International study. Night-time HR was a better predictor of CVE than daytime HR.

The time course of flow-mediated vasodilation and endothelial dysfunction in patients with a cardiovascular risk factor.

The relationship between having a cardiovascular risk factor and endothelial dysfunction observed on a time-course analysis of brachial artery flow-mediated vasodilation (FMD) remains unclear. We enrolled 257 patients who had at least one cardiovascular risk factor. We measured FMD magnitude of the percentage change in peak diameter (ΔFMD), maximum FMD rate calculated as the maximum slope of dilation (FMD-MDR), and integrated FMD response calculated as the area under the dilation curve during the 60- and 120-second dilation periods (FMD-AUC60 and FMD-AUC120) using a semiautomatic edge-detection algorithm. FMD-AUC60 and FMD-AUC120 were negatively correlated with the Framingham risk score (FMD-AUC60: r = -0.15, P = .023; FMD-AUC120: r = -0.17, P = .007), whereas this association was not found in the case of either the ΔFMD or the FMR-MDR. The Framingham risk score was significantly higher in patients in the lowest tertile for FMD-AUC120 (FMD-AUC120 <5.0 mm × second) than in those in the highest tertile for FMD-AUC120 (FMD-AUC120 ≥11.0 mm × second) (12.9 ± 8.7 vs. 8.6 ± 7.8%, P = .002). The lowest tertile for FMD-AUC120 was independently associated with the Framingham risk score (ß = 0.10, P = .011), after adjustments were made for age, gender, and smoking and drinking status. FMD-AUC120 was associated with cardiovascular risk.

A case of syncope induced in the supine position.

We experienced a reproducible supine syncope followed by upper abdominal pain. A 66-year-old man was transferred to our hospital after an episode of syncope during sleep. He had a history of acute pancreatitis, diabetes, hypertension, and dyslipidemia, but no history of presyncopal attack. One night, his wife noticed he was snoring abnormally in bed, and he did not respond to her voice until after she tried many times to wake him. The same attack was reproduced three times in the same situation. One of the attacks was recorded under a continuous ECG and radial tonometry. In this case, a presyncopal attack and a sense of ill-feeling were provoked by the patient lying in a prolonged supine position. He was eventually diagnosed as metastatic liver tumor 5 months after the first attack. Because few cases of syncopal attack have been reported in the supine position, its underlying mechanisms deserve consideration.

Gestational hypertension as a subclinical preeclampsia in view of serum levels of angiogenesis-related factors.

It is controversial whether gestational hypertension (GH) and preeclampsia (PE) have the same pathophysiology. Our aim was to clarify whether the serum soluble fms-like tyrosine kinase 1 (sFlt-1)/placental growth factor (PlGF) ratio and levels of soluble endoglin (sEng) are different in women with GH and with PE. In women with GH (15 cases), hypertension preceding PE (h-PE, 10 cases) and PE in which hypertension and proteinuria occurred simultaneously (si-PE, 36 cases), blood samples were collected after disease onset. The levels of log(10)(sFlt-1/PlGF) in women with GH were significantly lower than in women with h-PE and si-PE (1.65±0.39 vs. 2.22±0.35 and 2.15±0.46). The levels of log(10)sEng in women with GH were also significantly lower than in women with h-PE and si-PE (1.51±0.43 vs. 1.87±0.21 and 1.85±0.32). The incidence rates of the sFlt-1/PlGF ratio 95th percentile of the reference value were 73, 100 and 92%, respectively, (P=0.080), and those of sEng 95th percentile were 67, 100 and 89%, respectively, (P=0.053). In conclusion, the levels of sFlt-1/PlGF ratio and sEng in women with GH were lower than in those with h-PE and with si-PE; however, the majority of women with GH showed abnormal increases of both sFlt-1/PlGF ratio and sEng, suggesting that GH may be a subclinical PE in view of serum levels of angiogenesis-related factors.

Impaired flow-mediated vasodilatation is associated with increased left ventricular mass in a multiethnic population. The Northern Manhattan Study.

BACKGROUND: Increased left ventricular (LV) mass and endothelial dysfunction are important risk factors for cardiovascular mortality and morbidity. However, it is not clear whether endothelial dysfunction is associated with increased LV mass. We tested the hypothesis that impaired flow-mediated vasodilatation (FMD) is associated with increased LV mass in a population-based multiethnic cohort. METHODS: As a part of the Northern Manhattan Study (NOMAS), we performed two-dimensional echocardiography and FMD assessment during reactive hyperemia by high-resolution ultrasonography in 867 stroke-free community participants. LV mass was calculated according to an established method. LV hypertrophy was defined as the 90th percentile of sex-specific LV mass indexed for body surface area among normal subjects. Multivariable models were used to test the association of FMD with LV mass. RESULTS: In multiple linear regression analysis adjusting for age, sex, body mass index, systolic blood pressure, antihypertensive medications, low-density lipoprotein cholesterol, diabetes, smoking, hematocrit, and race-ethnicity, FMD was inversely associated with LV mass (beta = -1.21 +/- 0.56, P = 0.03). The association persisted after further adjustment for any component of blood pressure (systolic, mean, and pulse pressure). In univariate logistic regression analysis, each 1% decrease in FMD was associated with an 8% higher risk of LV hypertrophy (odds ratio 1.08, 95% confidence interval 1.03-1.13 per each FMD point P < 0.01). CONCLUSIONS: Impaired FMD is associated with LV mass, independent of other factors associated with increased LV mass. Endothelial dysfunction might be a potential risk factor for LV hypertrophy.

Association between the morning-evening difference in home blood pressure and cardiac damage in untreated hypertensive patients.

OBJECTIVES: The present study investigated whether the morning-evening difference in self-measured blood pressure (BP) (MEdif) can be an independent determinant of cardiac damage in untreated hypertensive patients. METHODS: In a cross-sectional study, the left ventricular (LV) mass, relative wall thickness, and diastolic function using echocardiography were assessed in 356 untreated hypertensive patients. Home BP measurements were taken in triplicate in the morning and evening, respectively, for 14 consecutive days with a memory-equipped device. Thereafter, the association between the MEdif in systolic BP (SBP) and the echocardiographic parameters was assessed. RESULTS: The MEdif in SBP was significantly correlated with LV mass index (r = 0.28, P < 0.001), relative wall thickness (r = 0.21, P < 0.001), ratio of E-wave to A-wave (r = -0.24, P < 0.001), and the deceleration time of the E-wave velocity (r = 0.23, P < 0.001). In a multivariable regression analysis, the MEdif in SBP was a significant determinant of these parameters, independent of age, sex, duration of hypertension, current smoking, habitual drinking, diabetes mellitus, the average of morning and evening SBP, and the heart rate at echo. When the MEdif in SBP was divided into quartiles, the highest quartile had increased likelihood of LV concentric hypertrophy (odds ratio = 2.63, 95% confidence interval = 1.20-5.87, P = 0.008) in comparison with the lowest quartile after adjusting for confounding factors. CONCLUSION: The MEdif is a significant determinant of LV hypertrophy, LV geometry, and diastolic function, and therefore, evaluation of the MEdif combined with the average of morning and evening SBP might be useful in the early stage assessment of hypertensive patients.

Soluble tumor necrosis factor receptor 1 level is associated with left ventricular hypertrophy: the northern Manhattan study.

BACKGROUND: Although inflammatory markers may be associated with risk of cardiovascular events, few data are available regarding these markers and their association with left ventricular hypertrophy (LVH). We sought to evaluate whether inflammatory markers were independently associated with LVH in a multiethnic population in northern Manhattan. METHODS: A population-based cross-sectional study was conducted in 660 participants without stroke, who had undergone both transthoracic echocardiography and testing for soluble tumor necrosis factor receptor (sTNFR) 1, interleukin (IL)-6, and high-sensitivity C-reactive protein (hsCRP). LV mass was calculated according to an established formula. LVH was defined as LV mass >90th percentile of the participants. RESULTS: The mean age was 67.4 +/- 8.8 years, 35.5% were men, 61.7% were Hispanic, 19.7% were black, and 18.6% were white. In univariate analyses, hsCRP, IL-6, and sTNFR1 were significantly associated with LV mass. Multiple linear regression analyses demonstrated that sTNFR1 (P = 0.0008) was associated with LV mass after adjusting for demographic and medical risk factors, but hsCRP and IL-6 were not. When all markers were included in the same model, sTNFR1 remained significant, but hsCRP and IL-6 did not. Compared with the lowest quartile of sTNFR1, those in the highest quartile were more likely to have LVH (odds ratio = 1.84, 95% confidence interval, 0.97-3.64, P = 0.06). CONCLUSIONS: sTNFR1, but not hsCRP nor IL-6, is independently associated with increased LV mass. Chronic subclinical inflammation including the TNFR1-associated system may contribute to LVH.

Association of an abnormal blood glucose level and morning blood pressure surge in elderly subjects with hypertension.

BACKGROUND: We previously reported that morning blood pressure (BP) surge (MBPS) was an independent risk factor for stroke. We evaluated the determinants of MBPS in hypertensive patients. METHODS: We analyzed 24-h ambulatory BP monitoring (ABPM) records in 458 hypertensive patients (mean: 72.2 +/- 8.5 years). The MBPS was calculated as the mean systolic BP (SBP) over 2 h after waking minus mean SBP during the hour of sleep that included the lowest nighttime BP. The cutoff value for identifying the top decile (the MBPS group) was defined as > or =55 mm Hg. RESULTS: The MBPS was associated with age, fasting plasma glucose, and 24-h SBP, and they were independent and significant determinants of MBPS in multivariate analysis (age, P = 0.01; fasting plasma glucose, P < 0.01; 24-h SBP, P = 0.04) after adjustment for confounding factors of gender, body mass index (BMI), and smoking status. The subjects in the MBPS group (n = 45) were older in age (76.4 years vs. 71.8 years, P < 0.01) and had higher fasting plasma glucose (97.6 mg/dl vs. 91.4 mg/dl, P = 0.04) than those in the non-MBPS group. In logistic regression analysis, the MBPS group was associated with older age (10 years older: odds ratio (OR) 1.85, 95% confidence interval (CI) 1.26-2.72, P < 0.01) and higher fasting plasma glucose (10-mg/dl increase: OR 1.16, 95% CI 1.01-1.33, P = 0.03). CONCLUSION: In addition to older age and higher mean 24-h SBP, higher fasting plasma glucose was associated with MBPS.

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.

Determinants of self-measured pulse rate profile in medicated hypertensives: the Jichi Morning Surge-1 (JMS-1) study.

BACKGROUND: Recently, it was reported that high pulse rate (PR), which was measured using by self-measured blood pressure (BP) monitoring at home, was associated with cardiovascular risk. However, the predictor of high PR at home in treated hypertensives is unknown. In this study, we studied the predictor of high PR and evaluated pulse rate variability (PRV). METHODS: In the JMS-1 study, 611 hypertensive outpatients were recruited. Self-measured BP monitoring was conducted consecutively twice in the morning and evening for three days. PR analysis was conducted using the average of these two measurements for three days (six readings in total). We defined home PR as the mean of these six readings. Home PRV was defined as the standard deviation of these six readings. RESULTS: Multivariate linear regression analysis demonstrated that current smoking (beta = 0.12, p = 0.002), diabetes (beta = 0.16, p < 0.001), lack of angiotensin-converting enzyme (ACE) inhibitor use (beta = 0.10, p = 0.008), decreased brain-type natriuretic peptide (BNP; beta = 0.17, p < 0.001), and elevated home diastolic blood pressure (beta = 0.14, p = 0.009) were determinants of high PR. Determinants of decreased home PRV were female gender (beta = 0.10, p < 0.03) and increased hemoglobin A1c (HbA1c; beta = 0.15, p < 0.001). When we divided the patients into four groups according to home PR and its variability, hypertensives whose home PR was high and variability was low were found to have high HbA1c (ANOVA, p > 0.05). CONCLUSIONS: Smoking habit, diabetes, lack of ACE inhibitor use, and low BNP value were determinants of home PR, and female gender and higher HbA1c were significantly associated with its low variability. Home PR and its variability may be useful for detecting high-risk hypertensive patients, particularly with autonomic neuropathy.