Targeting Hypertensive Response to Exercise and the Association of Masked Hypertension With Subclinical Organ Damage: A Mini-Review and Meta-Analysis.

BACKGROUND: Emerging evidence suggests that a hypertensive response to exercise (HRE) during dynamic or isometric stress tests assessing cardiac function is predictive of hypertension and cardiovascular events such coronary artery disease, heart failure and stroke. Whether HRE represents a marker of masked hypertension (MH) in individuals with no prior history of hypertension is still unclear. This is also the case for the association between MH and hypertension-mediated organ damage (HMOD) in the HRE setting. METHODS: We addressed this issue through a review and a meta-analysis of studies providing data on this topic in normotensive individuals undergone both to dynamic or static exercise and to 24-h blood pressure monitoring (ABPM). A systematic search was performed using Pub-Med, OVID, EMBASE and Cochrane library databases from inception up to February 28th 2023. RESULTS: Six studies including a total of 1,155 untreated clinically normotensive individuals were considered for the review. Data provided by the selected studies can be summarized as follows: (i) HRE is a BP phenotype linked to a high prevalence of MH (27.3% in the pooled population); (ii) MH is, in turn, associated with a greater, consistent likelihood of echocardiographic left ventricular hypertrophy (OR: 4.93, CI: 2.16-12.2, P < 0.0001) and vascular organ damage, as assessed by pulse wave velocity, (SMD: 0.34 ±â€…0.11, CI: 0.12-0.56, P = 0002). CONCLUSIONS: On the basis of this, albeit limited, evidence, the diagnostic work-up in individuals with HRE should primarily be addressed to look for MH as well as for markers of HMOD, a highly prevalent alteration in MH.

Prevalence of Pediatric Masked Hypertension and Risk of Subclinical Cardiovascular Outcomes: A Systematic Review and Meta-Analysis.

Masked hypertension (MH) occurs when office blood pressure is normal, but hypertension is confirmed using out-of-office blood pressure measures. Hypertension is a risk factor for subclinical cardiovascular outcomes, including left ventricular hypertrophy, increased left ventricular mass index, carotid intima media thickness, and pulse wave velocity. However, the risk factors for ambulatory blood pressure monitoring defined MH and its association with subclinical cardiovascular outcomes are unclear. A systematic literature search on 9 databases included English publications from 1974 to 2023. Pediatric MH prevalence was stratified by disease comorbidities and compared with the general pediatric population. We also compared the prevalence of left ventricular hypertrophy, and mean differences in left ventricular mass index, carotid intima media thickness, and pulse wave velocity between MH versus normotensive pediatric patients. Of 2199 screened studies, 136 studies (n=28 612; ages 4-25 years) were included. The prevalence of MH in the general pediatric population was 10.4% (95% CI, 8.00-12.80). Compared with the general pediatric population, the risk ratio (RR) of MH was significantly greater in children with coarctation of the aorta (RR, 1.91), solid-organ or stem-cell transplant (RR, 2.34), chronic kidney disease (RR, 2.44), and sickle cell disease (RR, 1.33). MH patients had increased risk of subclinical cardiovascular outcomes compared with normotensive patients, including higher left ventricular mass index (mean difference, 3.86 g/m2.7 [95% CI, 2.51-5.22]), left ventricular hypertrophy (odds ratio, 2.44 [95% CI, 1.50-3.96]), and higher pulse wave velocity (mean difference, 0.30 m/s [95% CI, 0.14-0.45]). The prevalence of MH is significantly elevated among children with various comorbidities. Children with MH have evidence of subclinical cardiovascular outcomes, which increases their risk of long-term cardiovascular disease.

Masked Hypertension in Healthy Children and Adolescents: Who Should Be Screened?

PURPOSE OF REVIEW: The goal is to review masked hypertension (MH) as a relatively new phenomenon when patients have normal office BP but elevated out-of-office BP. Firstly, it was described in children in 2004. It has received increased attention in the past decade. RECENT FINDINGS: The prevalence of MH in different pediatric populations differs widely between 0 and 60% based on the population studied, definition of MH, or method of out-of-office BP measurement. The highest prevalence of MH has been demonstrated in children with chronic kidney disease (CKD), obesity, diabetes, and after heart transplantation. In healthy children but with risk factors for hypertension such as prematurity, overweight/obesity, diabetes, chronic kidney disease, or positive family history of hypertension, the prevalence of MH is 9%. In healthy children without risk factors for hypertension, the prevalence of MH is very low ranging 0-3%. In healthy children, only patients with the following clinical conditions should be screened for MH: high-normal/elevated office BP, positive family history of hypertension, and those referred for suspected hypertension who have normal office BP in the secondary/tertiary center.

Unmasking left ventricular systolic dysfunction in masked hypertension: looking at myocardial strain. A review and meta-analysis.

BACKGROUND AND AIM: A growing body of evidence supports the view that masked hypertension (MH) (i.e. normal office and elevated out-of-office BP) is a blood pressure (BP) phenotype associated with increased risk of subclinical organ damage, cardiovascular disease and death as compared to true normotension. Whether left ventricular (LV) systolic function is impaired in individuals with MH is still a poorly defined topic. Therefore, we aimed to provide a new piece of information on LV systolic dysfunction in the untreated MH setting, focusing on speckle tracking echocardiography (STE) studies investigating LV global longitudinal strain (GLS), a more sensitive index of systolic function than conventional LV ejection fraction (LVEF). METHODS: A computerized search was performed using Pub-Med, OVID, EMBASE and Cochrane library databases from inception until June 30, 2022. Full articles reporting data on LV GLS in MH, as assessed by ambulatory BP monitoring (ABPM), and normotensive controls were considered suitable for the purposes of review and meta-analysis. RESULTS: A total of 329 untreated individuals with MH and 376 normotensive controls were included in six studies. While pooled average LVEF was not different between groups [64.5 ±â€Š1.5 and 64.5 ±â€Š1.3%, respectively, standard means difference (SMD): -0.002 ±â€Š0.08, confidence interval (CI): 0.15/-0.15, P = 0.98), LV GLS was worse in MH patients than in normotensive counterparts (-18.5 ±â€Š0.70 vs. -20.0 ±â€Š0.34%, SMD: 0.68 ±â€Š0.28, CI: 0.12/1.24, P < 0.01). CONCLUSIONS: Our findings suggest that early changes in LV systolic function not detectable by conventional echocardiography in the MH setting can be unmasked by STE and that its implementation of STE in current practice may improve the detection of subclinical organ damage of adverse prognostic significance.

Accuracy of screening strategies for masked hypertension: a large-scale nationwide study based on home blood pressure monitoring.

This study compared the ability of guideline-proposed office blood pressure (OBP) screening thresholds [European Society of Hypertension (ESH) guidelines: 130/85 mmHg for individuals with an OBP < 140/90 mmHg; American College of Cardiology/American Heart Association (ACC/AHA) guidelines: 120/75 mmHg for individuals with an OBP < 130/80 mmHg] and novel screening scores to identify normotensive individuals at high risk of having masked hypertension (MH) in an office setting. We cross-sectionally evaluated untreated participants with an OBP < 140/90 mmHg (n = 22,266) and an OBP < 130/80 mmHg (n = 10,005) who underwent home blood pressure monitoring (HBPM) (derivation cohort) from 686 Brazilian sites. MH was defined according to criteria suggested by the ESH (OBP < 140/90 mmHg; HBPM ≥ 135/85 mmHg), Brazilian Society of Cardiology (BSC) (OBP < 140/90 mmHg; HBPM ≥ 130/80 mmHg) and ACC/AHA (OBP < 130/80 mmHg; HBPM ≥ 130/80 mmHg). Scores were generated from multivariable logistic regression coefficients between MH and clinical variables (OBP, age, sex, and BMI). Considering the ESH, BSC, and ACC/AHA criteria, 17.2%, 38.5%, and 21.2% of the participants had MH, respectively. Guideline-proposed OBP screening thresholds yielded area under curve (AUC) values of 0.640 (for ESH criteria), 0.641 (for BSC criteria), and 0.619 (for ACC/AHA criteria) for predicting MH, while scores presented as continuous variables or quartiles yielded AUC values of 0.700 and 0.688 (for ESH criteria), 0.720 and 0.709 (for BSC criteria), and 0.671 and 0.661 (for ACC/AHA criteria), respectively. Further analyses performed with alternative untreated participants (validation cohort; n = 2807 with an OBP < 140/90 mmHg; n = 1269 with an OBP < 130/80 mmHg) yielded similar AUC values. In conclusion, the accuracy of guideline-proposed OBP screening thresholds in identifying individuals at high risk of having MH in an office setting is limited and is inferior to that yielded by scores derived from simple clinical variables.

The relationship of masked hypertension with autonomic dysfunction and cardiometabolic parameters: a case-control study.

OBJECTIVE: Masked hypertension (MH) is associated with cardiovascular events and mortality. Data on the association between exaggerated blood pressure response (EBPR) to exercise, heart rate recovery (HRR), which are indicators of autonomic dysfunction, and MH are lacking. This study aimed at evaluating the association between EBPR, HRR, and MH. PATIENTS AND METHODS: Between January 2020 and January 2021, 130 MH (57 male, median age = 52.8 years) and 60 healthy (28 male, median age = 40.8 years) subjects were included in this single-center, case-control, and cross-sectional study. Office blood pressure measurement, 24-hour ambulatory blood pressure monitoring, treadmill test, echocardiography, and specific biochemical parameters were evaluated. RESULTS: The frequency of blunted HRR (73 subjects, 56.2%) and EBPR (40 subjects, 30.8%) were significantly higher in patients with MH (p < 0.001). Patients with MH had higher serum uric acid levels and frequency of hyperlipidemia (p < 0.05). Diameters of the left atrium (LA), aortic root, and ascending aorta were significantly higher in MH patients (p < 0.05). Thirty-two (24.6%) patients with MH had left ventricular hypertrophy and 33 (25.4%) had diastolic dysfunction (p < 0.001). Multivariate analysis identified the presence of blunted HRR as an independent predictor factor of MH as well as smoking, hyperlipidemia, GFR, LA diameter, and aortic root diameter were other independent factors. CONCLUSIONS: The frequency of blunted HRR and EBPR were significantly higher in the MH group compared to the control group, suggesting a close relationship between MH and autonomic dysfunction.

The Role of Ambulatory Blood Pressure Monitoring in Current Clinical Practice.

Hypertension continues to be the leading modifiable risk factor for stroke, kidney disease and cardiovascular disease, and it also plays a key role in a significant proportion of preventable deaths globally. Ambulatory blood pressure monitoring (ABPM) is an underutilised tool that augments the accurate diagnosis of hypertension. Out-of-office blood pressure measurements such as ABPM, permits the diagnosis of white coat hypertension and masked hypertension as well as determining a patient's nocturnal dipping status. These common clinical phenotypes have relevance with regard to clinical outcomes and may impact management. Overall, the diagnosis and management of hypertension presents numerous challenges, requiring the complementary use of multimodal blood pressure monitoring. Familiarity with the use of ABPM is important in the optimal management of patients, particularly as it becomes more accessible with the recent introduction of a Medicare Benefits Schedule item number.

Cost-Effectiveness of Masked Hypertension Screening and Treatment in US Adults With Suspected Masked Hypertension: A Simulation Study.

BACKGROUND: Recent US blood pressure (BP) guidelines recommend using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to screen adults for masked hypertension. However, limited evidence exists of the expected long-term effects of screening for and treating masked hypertension. METHODS: We estimated the lifetime health and economic outcomes of screening for and treating masked hypertension using the Cardiovascular Disease (CVD) Policy Model, a validated microsimulation model. We simulated a cohort of 100,000 US adults aged ≥20 years with suspected masked hypertension (i.e., office BP 120-129/<80 mm Hg, not taking antihypertensive medications, without CVD history). We compared usual care only (i.e., no screening), usual care plus ABPM, and usual care plus HBPM. We projected total direct healthcare costs (2021 USD), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Future costs and QALYs were discounted 3% annually. Secondary outcomes included CVD events and serious adverse events. RESULTS: Relative to usual care, adding masked hypertension screening and treatment with ABPM and HBPM was projected to prevent 14.3 and 20.5 CVD events per 100,000 person-years, increase the proportion experiencing any treatment-related serious adverse events by 2.7 and 5.1 percentage points, and increase mean total costs by $1,076 and $1,046, respectively. Compared with usual care, adding ABPM was estimated to cost $85,164/QALY gained. HBPM resulted in lower QALYs than usual care due to increased treatment-related adverse events and pill-taking disutility. CONCLUSIONS: The results from our simulation study suggest screening with ABPM and treating masked hypertension is cost-effective in US adults with suspected masked hypertension.

Controversies in Hypertension I: The Optimal Assessment of Blood Pressure Load and Implications for Treatment.

The most important factor in treating hypertension is assessing an individual patient's true blood pressure load, the cornerstone being research-grade office determination. Office blood pressure should be supplemented with out-of-office measurement, including home and ambulatory monitoring (if available), which we consider complementary and not interchangeable. Controversy remains for initiation of treatment of white coat hypertension, where cardiovascular risk lies between normotension and sustained hypertension; antihypertensive therapy should be considered unless low cardiovascular risk, wherein pressures should be followed for progression to sustained hypertension. Available data do not support intensification of therapy for the white coat effect due to the similar cardiovascular risk to controlled hypertension. Given the higher cardiovascular risk of the masked effect, initiation of therapy for masked hypertension and intensification for masked uncontrolled hypertension are indicated, acknowledging the dearth of supporting data. Optimally, randomized controlled trials are needed to determine the benefit of treating the 4 incongruous phenotypes between office and out-of-office measurements, that is, those with white coat or masked effects. We make no recommendations regarding chronotherapy pending results of ongoing trials.

Artificial intelligence measuring the aortic diameter assist in identifying adverse blood pressure status including masked hypertension.

INTRODUCTION AND OBJECTIVES: Artificial intelligence (AI) made it achievable that aortic dilation could be measured in CT images indirectly, while aortic diameter (AD) has the certain relationship with blood pressure. It was potential that the blood pressure condition be determined by AD measurement using the data obtained from a CT scanning especially in identifying masked hypertension and predicting the risk of poor control of blood pressure (BP) which was easy to elude diagnosis in clinic. We aimed to evaluate the possibility of utilizing AD by AI for predicting the risk of adverse BP status (including masked hypertension or poor BP control) and the optimal thoracic aortic position in measurement as well as the cutoff value for predicting the risk. METHODS: Eight hundred and one patients were enrolled in our study. AI-Rad Companion Cardiovascular (K183268 FDA approved) was used to perform automatic aorta measurement in thoracic CT images at nine key positions based on AHA guidelines. Data was post processed by software from AI-Rad Companion undergone rigorous clinical validation by both FDA and CE as verification of its efficacy and usability. The AD's risk and diagnostic value was assessed in identifying hypertension in the general population, in identifying the poor BP controlled in the hypertension population, and in screening masked hypertension in the general population respectively by multiple regression analysis and receiver operating curve analysis. RESULTS: AD measured by AI was a risk factor for adverse BP status after clinical covariates adjustment (OR = 1.02 ~ 1.26). The AD at mid descending aorta was mostly affected by BP particularly, which is optimal indicator in identifying hypertension in the general population (AUC = 0.73) and for screening masked hypertension (AUC = 0.78). CONCLUSION: Using AI to measure the AD of the aorta, particularly at the position of mid descending aorta, is greatly valuable for identifying people with poor BP status. It will be possible to reveal more clinical information reflected by ordinary CT images and enrich the screening methods for hypertension, especially masked hypertension.PLAIN LANGUAGE SUMMARYHTN has a significant adverse effect on arterial deformation. BP and arterial dilation promote each other in a vicious circle. Arterial dilation may not be restricted by apparent fluctuations in BP and is objective evidence of an undesirable BP state. The accuracy of AD measurements by AI on chest CT images has been verified. There has not been the application of AD measurement by AI in the scene of poor BP status in clinical practice.In this study, we applied AI to measure the diameter of the aorta in nine consecutive positions. We explored the association between AD at various positions and BP levels and the possibility that AD in identifying poor BP status in different populations. We found that the AD at the MD is of great value in screening MH and evaluating the control state of BP in HTN. It will be possible to significantly expand the clinical information reflected by ordinary CT images and enrich the screening methods for HTN, especially MH.

Frequency of masked hypertension in patients with nonfunctioning adrenal incidentalomas with normal and high normal blood pressure.

OBJECTIVES: Nonfunctioning adrenal incidentalomas (NFAIs) are associated with increased cardiovascular risk, but the frequency of masked hypertension (MH) is uncertain in these patients. This study aimed to evaluate the prevalence of MH by ambulatory blood pressure monitoring in patients with NFAIs. METHODS: The study included a total of 85 individuals: 43 patients with NFAIs and 42 controls of similar age, gender, BMI, smoking, and diabetes. The office BP and ABPM parameters of the NFAI and controls were measured. Biochemical, hormonal, and radiological data were obtained retrospectively in the NFAI group. RESULTS: There were no statistically significant difference between the NFAI and control groups in relation to the office SBP (134.4 ± 37.2 mmHg vs 133.1 ± 35.8 mmHg, p = 0.273) and office DBP (87.4 ± 14.5 mmHg vs 86.8 ± 13.7 mmHg, p = 0.318). Besides, normal (28% vs 28.6%, p = 0.176) and high normal blood pressure (72% vs 71.4%, p = 0.332) rates were similar. The prevalence of MH was significantly higher in patients with NFAI than in controls (25.5% vs 9.5%, p = 0.037). MH was significantly associated with diabetes odds ratio (OR) = 2.07, p = 0.044, office SBP (OR = 1.41, p = 0.046), smoking (OR = 1.46, p = 0.031), BMI (OR = 1.17, p = 0.037), and morning cortisol (OR = 1.21, p = 0.039). CONCLUSION: The prevalence of MH in the NFAI patient's was higher than in the control group. Patients with NFAI with high normal blood pressure should be evaluated for MH.

Comparison of ambulatory blood pressure monitoring and office blood pressure in primary health care of populations at a high risk of hypertension.

Introduction: Current studies have found that the incidence of masked hypertension is high in Asian countries, but the use of ambulatory blood pressure monitoring (ABPM) in Asian countries is very limited, especially in primary health care. We compared the ABPM and office blood pressure (OBP) in primary health care of a high-risk population of hypertension. Methods: The study included participants with at least one risk factor for hypertension who received primary health care. Demographic data, present medical history, personal history, and family history were collected by questionnaire. Results: A total of 823 subjects were included in the study. There were 531 (64.5%) subjects with hypertension by ABPM and 316 patients (38.4%) by OBP. A paired chi-square test showed that the positive rate of ABPM in the diagnosis of hypertension was significantly higher than that of OBP (chi-square value 174.129, P < 0.0001). There were 24 (2.9%) patients with white coat hypertension, 239 (29.0%) with masked hypertension, 504 (52.9%) with a non-dipping pattern, 135 (16.9%) with nocturnal hypertension and 18 (2.2%) with high ambulatory BP variability. Concordance correlation coefficient showed there was a poor correlation between OBP and awake average BP. Scatter plot displayed there was a positive correlation between OBP and awake average BP, but the degree of fitting was not high. The Bland Altman plot showed that OBP and awake average BP were consistent. Conclusions: Although OBP and ABPM have some consistency, ABPM can screen for masked hypertension and nocturnal hypertension in primary care of populations at high risk of hypertension. Therefore, ABPM is necessary in the primary health care of populations at high risk of hypertension and can be used as a routine screening.

Nomogram based on clinical features at a single outpatient visit to predict masked hypertension and masked uncontrolled hypertension: A study of diagnostic accuracy.

Patients with masked hypertension (MH) and masked uncontrolled hypertension (MUCH) are easily overlooked, and both cause target organ damage. We propose a prediction model for MH and MUCH patients based on clinical features at a single outpatient visit. Data collection was planned before the index test and reference standard were after. Thus, we retrospectively collect analyzed 804 subjects who underwent ambulatory blood pressure monitoring (ABPM) at Renmin Hospital of Wuhan University. These patients were divided into normotension/controlled hypertension group (n = 121), MH/MUCH (n = 347), and sustained hypertension (SH)/sustained uncontrolled hypertension group (SUCH) (n = 302) for baseline characteristic analysis. Models were constructed by logistic regression, a nomogram was visualized, and internal validation by bootstrapping. All groups were performed according to the definition proposed by the Chinese Hypertension Association. Compared with normotension/controlled hypertension, patients with MH/MUCH had higher office blood pressure (BP) and were more likely to have poor liver and kidney function, metabolic disorder and myocardial damage. By analysis, [office systolic blood pressure (OSBP)] (P = .004) and [office diastolic blood pressure (ODBP)] (P = .007) were independent predictors of MH and MUCH. By logistic regression backward stepping method, office BP, body mass index (BMI), total cholesterol (Tch), high-density lipoprotein cholesterol (HDL-C), and left ventricular mass index are contained in this model [area under curve (AUC) = 0.755] and its mean absolute error is 0.015. Therefore, the prediction model established by the clinical characteristics or relevant data obtained from a single outpatient clinic can accurately predict MH and MUCH.

Diagnosis of hypertension: Ambulatory pediatric American Heart Association/European Society of Hypertension versus blood pressure load thresholds.

The agreement between the traditionally-used ambulatory blood pressure (ABP)-load thresholds in children and recently-recommended pediatric American Heart Association (AHA)/European Society of Hypertension (ESH) ABP thresholds for diagnosing ambulatory hypertension (AH), white coat hypertension (WCH), and masked hypertension (MH) has not been evaluated. In this cross-sectional study on 450 outpatient participants, the authors evaluated the agreement between previously used ABP-load 25%, 30%, 40%, 50% thresholds and the AHA/ESH thresholds for diagnosing AH, WCH, and MH. The American Academy of Pediatrics thresholds were used to diagnose office hypertension. The AHA threshold diagnosed ambulatory normotension/hypertension closest to ABP load 50% in 88% (95% CI 0.79, 0.96) participants (k 0.67, 95% CI 0.59, 0.75) and the ESH threshold diagnosed ambulatory normotension/hypertension closest to ABP load 40% in 86% (95% CI 0.77, 0.94) participants (k 0.66, 95% CI 0.59, 0.74). In contrast, the AHA/ESH thresholds had a relatively weaker agreement with ABP load 25%/30%. Therefore, the diagnosis of AH was closest between the AHA threshold and ABP load 50% (difference 3%, 95% CI -2.6%, 8.6%, p = .29) and between the ESH threshold and ABP load 40% (difference 4%, 95% CI -2.1%, 10.1%, p = .19) than between the AHA/ESH and ABP load 25%/30% thresholds. A similar agreement pattern persisted between the AHA/ESH and various ABP load thresholds for diagnosing WCH and MH. The AHA and ESH thresholds diagnosed AH, WCH, and MH closest to ABP load 40%/50% than ABP load 25%/30%. Future outcome-based studies are needed to guide the optimal use of these ABP thresholds in clinical practice.

Prevalence and characteristics of isolated nocturnal hypertension in the general population.

BACKGROUND/AIMS: Ascertaining the prevalence of isolated nocturnal hypertension (INHT) in the general population and identifying the characteristics of patients with INHT may be important to determine patients who should receive 24- hour ambulatory blood pressure (BP) measurements. This study aimed to evaluate the prevalence and characteristics of INHT in the general population. METHODS: Of 1,128 participants (aged 20 to 70 years), we analyzed 823 who had valid 24-hour ambulatory BP measurements and were not on antihypertensive drug treatment. RESULTS: The prevalence of INHT in the study was 22.8%. Individuals with INHT had a higher office, 24-hour, and daytime and nighttime ambulatory systolic and diastolic BPs compared to individuals with sustained day-night normotension. INHT was more prevalent in individuals with masked hypertension (MH) than in those with sustained hypertension (59.8% vs. 15.6%, p < 0.001). Among individuals with INHT, 92.6% had MH. Among individuals with office BP-based prehypertension, 34.5% had both INHT and MH. The prevalence of INHT was highest in individuals with office BP-based prehypertension. INHT was an independent determinant of MH after adjustment for age, sex, body mass index, diabetes, low-density-lipoprotein cholesterol, 24-hour systolic and diastolic BP, systolic and diastolic BP dipping, and systolic and diastolic BP non-dipping. CONCLUSION: The present study showed that INHT is not uncommon and is a major determinant of MH. Our findings strongly suggest the use of 24-hour ambulatory BP measurement for individuals within the prehypertension range of office BP owing to the high prevalence of INHT and MH in this population.

Which is responsible for target organ damage in masked hypertension? Is it an increase in blood pressure or a disruption of the circadian rhythm?

OBJECTIVE: Masked hypertension (MH) and non-dipping pattern are conditions associated with target organ damage and cardiovascular risk, which are frequently observed together. We aimed to show the relationship between the target organ damage observed in MH and the deterioration in the dipping pattern. METHODS: Patients who underwent ambulatory blood pressure monitoring (ABPM) and office blood pressure (BP) <140/90 mmHg were retrospectively screened. In ABPM data, those with daytime BP ≥135/85 mmHg and night BP ≥120/70 mmHg were included in the MH group, while the others were included in the normotensive group. The patients were grouped as dipper, non-dipper and reverse-dipper according to ABPM results. Left ventricular mass index (LVMI), glomerular filtration rate (GFR) and serum creatinine levels were used to determine target organ damage. RESULTS: 289 patients [mean age 46.6 ± 12.4 years, 136 (47.1%) males], 154 (53.3%) of whom had MH were included in our study. GFR value was found to be significantly lower, serum creatinine levels and LVMI were significantly higher in patients with MH compared to normotensives (p < .05, for all). When the subgroups were examined, it was found that this difference was associated with the disruption in the dipping pattern. In patients with MH, dipping pattern disruption without change in systolic BP was independently associated with an increase in LVMI (p < .05, for both). CONCLUSION: Target organ damage seen in MH may be due to the deterioration of the dipping pattern.

The prevalence of masked hypertension in a group of young healthy soldiers.

BACKGROUND: To assess the prevalence of masked hypertension (MH) in young Saudi National Guard soldiers based on 24h ambulatory blood pressure monitoring (ABPM). METHODS: A prospective study of 196 soldiers, aged between 21-50 years, without a history of hypertension or antihypertensive medication use. Each participant was fitted with a 24h-ABPM. Patients were considered to have MH if the office blood pressure (OBP) was <140/90 mm Hg and the 24h-ABPM average was ≥130/80 mmHg. RESULTS: The mean age of the MH group was 34.5 years compared to 32.4 years of the normotensive group. By pairing the average OBP with the 24h-ABPM, the prevalence of MH was estimated to be 29/196 (14.8%), with the SBP (systolic blood pressure) and DPB MH (diastolic BP) prevalence 12.8% and 7.7%, respectively. For the systolic BP, the OBP compared with the 24h-ABPM was 120.0±8.1 vs. 134.7±4.5 (P<0.001) and for the diastolic BP, 70.7±7.0 vs. 79.9±4.2 (P<0.001). CONCLUSIONS: The prevalence of MH among this sample of healthy military soldiers was 14.8%. It is important not to rely solely on the OBP and to consider MH when screening for hypertension in apparently healthy individuals.

Contribution of single office aortic systolic blood pressure measurements to the detection of masked hypertension: data from two separate cohorts.

Masked hypertension (MH) and masked uncontrolled hypertension (MUH) remain largely underdiagnosed with no efficient detection algorithm. We recently proposed a novel classification of office systolic hypertension phenotypes defined on the basis of both brachial and aortic systolic blood pressure (bSBP/aSBP) and showed that type III ("isolated high office aSBP" phenotype: normal office bSBP but high office aSBP) has higher hypertension-mediated organ damage (HMOD). We tested whether MH/MUH (1) can be detected with the "isolated high office aSBP" phenotype and (2) if it is associated with elevated office aSBP with respect to normotension. We classified two separate and quite different cohorts (n = 391 and 956, respectively) on the basis of both bSBP and aSBP into four different phenotypes. Participants were classified as sustained hypertensives, masked hypertensives/masked uncontrolled hypertensives (MHs/MUHs), white coat hypertensives, and normotensives according to their office and out-of-office BP readings. The majority (more than 60% in cohort A and more than 50% in cohort B) of type III individuals were MHs/MUHs. Almost 35% of MHs/MUHs had optimal office bSBP rather than high normal bSBP. In both cohorts, the detection of more than 40% of MH/MUH was feasible with the type III phenotype. MHs/MUHs had higher office aSBP than individuals with sustained normotension (p < 0.05). In conclusion, in the absence of an efficient screening test, the diagnosis of MH/MUH can be assisted by the detection of the "isolated high office aSBP" phenotype, which can be measured in a single office visit. MHs/MUHs have increased aSBP relative to normotensives, further explaining the increased mortality of MH/MUH.

Arterial stiffness in children and adolescents with masked and sustained hypertension.

This study recruited 85 healthy children and adolescents, aged 6-18 years, from a school-based blood pressure (BP) screening study and performed office BP measurements, 24-h ambulatory blood pressure monitoring (24-h ABPM) and 24-h pulse wave analysis. Prevalence of BP phenotypes was assessed, factors that may predict hypertension (HTN) in ABPM were examined and the effect of BP phenotypes, as well as school, office, and ambulatory BP parameters on pulse wave velocity (PWV), was investigated. Forty-five (54.9%) of the children were normotensives, 8 (9.7%) were white coat hypertensives (WCH), 19 (23.2%) had masked hypertension (MH), and 10 (12.2%) had sustained HTN. Estimated adjusted marginal means for 24-h PWV were 4.79 m/s (95% CI 4.65-4.94) for sustained hypertensives, 4.72 m/s (95% CI 4.62-4.82) for MH, 4.38 m/s (95% CI 4.23-4.54) for WCH, and 4.33 m/s (95% CI 4.26-4.40) for normotensives (sustained hypertensives versus normotensives and WCH, p < 0.001, MH versus normotensives and WCH, p < 0.005). Neither body mass index (BMI) z-score nor school systolic BP (SBP) z-score could predict HTN by ABPM. Office SBP z-score was associated with 1.74 times increased odds ratio to have HTN in ABPM. Sustained HTN and MH were independent predictors of 24-h PWV after adjustment for age, sex, and BMI z-score. In conclusion, arterial stiffness in children and adolescents was assessed by 24-h PWV associates with mean ambulatory BP. Both school and office BP measurements could not predict HTN in ABPM or increasing PWV. HTN in ABPM was independently associated with the risk of higher PWV compared with normotensive and WCH phenotype.

Diagnosis of Pediatric Hypertension: European Society of Hypertension-Recommended 24-Hour vs. 24-Hour-Day-Night Ambulatory Blood Pressure Thresholds.

BACKGROUND: The impact of diagnosing pediatric hypertension based on all three-24-hour, day and night ambulatory blood pressure (ABP) thresholds (combined ABP threshold) vs. conventionally used 24-hour ABP threshold is not known. METHODS: In this cross-sectional, retrospective study from a tertiary care outpatient clinic, we evaluated the diagnosis of hypertension based on the 24-hour European Society of Hypertension (ESH) and combined ESH ABP thresholds in untreated children with essential hypertension. The American Academy of Pediatrics (AAP) and Fourth Report thresholds were used to classify office blood pressure (OBP). RESULTS: In 159 children, aged 5-18 years, the 24-hour ESH and combined ESH thresholds classified 82% (95th confidence interval (CI) 0.68, 0.97) ABP similarly with the area under the curve (AUC) of 0.86 (95th CI 0.80, 0.91). However, the AUC of the 2 ABP thresholds was significantly higher in the participants with office hypertension than office normotension, with OBP classified by the AAP (AUC 0.93, 95th CI 0.84, 0.98 vs. 0.80, 95th CI 0.71, 0.88) or Fourth Report (AUC 0.93, 95th CI 0.83, 0.98 vs. 0.81, 95th CI 0.73, 0.88) threshold. With OBP classified by the either OBP threshold, the combined ESH threshold diagnosed significantly more masked hypertension (MH) (difference 15%, 95th CI 4.9, 24.7; P = 0.00); however, the diagnosis of white coat hypertension (WCH) by the 2 ABP thresholds did not differ significantly (difference 4%, 95th CI 1.8, 10; P = 0.16). CONCLUSIONS: In children with essential hypertension, the 24-hour and combined ESH thresholds have a stronger agreement for diagnosing WCH than MH.