Mediterranean lifestyle index and 24-h systolic blood pressure and heart rate in community-dwelling older adults.

Specific foods, nutrients, dietary patterns, and physical activity are associated with lower blood pressure (BP) and heart rate (HR), but little is known about the joint effect of lifestyle factors captured in a multidimensional score. We assessed the association of a validated Mediterranean-lifestyle (MEDLIFE) index with 24-h-ambulatory BP and HR in everyday life among community-living older adults. Data were taken from 2,184 individuals (51% females, mean age: 71.4 years) from the Seniors-ENRICA-2 cohort. The MEDLIFE index consisted of 29 items arranged in three blocks: 1) Food consumption; 2) Dietary habits; and 3) Physical activity, rest, and conviviality. A higher MEDLIFE score (0-29 points) represented a better Mediterranean lifestyle adherence. 24-h-ambulatory BP and HR were obtained with validated oscillometric devices. Analyses were performed with linear regression adjusted for the main confounders. The MEDLIFE-highest quintile (vs Q1) was associated with lower nighttime systolic BP (SBP) (-3.17 mmHg [95% CI: -5.25, -1.08]; p-trend = 0.011), greater nocturnal-SBP fall (1.67% [0.51, 2.83]; p-trend = 0.052), and lower HR (-2.04 bpm [daytime], -2.33 bpm [nighttime], and -1.93 bpm [24-h]; all p-trend < 0.001). Results were similar for each of the three blocks of MEDLIFE and by hypertension status (yes/no). Among older adults, higher adherence to MEDLIFE was associated with lower nighttime SBP, greater nocturnal-SBP fall, and lower HR in their everyday life. These results suggest a synergistic BP-related protection from the components of the Mediterranean lifestyle. Future studies should determine whether these results replicate in older adults from other Mediterranean and non-Mediterranean countries.

Prevalence of office and ambulatory hypotension in treated hypertensive patients with coronary disease.

Patients with coronary heart disease (CHD) can be particularly susceptible to the adverse effects of excessive blood pressure (BP) lowering by antihypertensive treatment. The identification of hypotension is thus especially important. This study estimated the prevalence of hypotension among CHD-treated hypertensive patients undergoing ambulatory blood pressure monitoring (ABPM) in routine clinical practice. We performed a cross-sectional study with 2892 CHD-treated hypertensive patients from the Spanish ABPM Registry. Based on previous studies, hypotension was defined as systolic/diastolic BP < 120 and/or 70 mmHg according to office measurements, <115 and/or 65 mmHg according to daytime ABPM, <100 and/or 50 mmHg according to nighttime ABPM, and <110 and/or 60 mmHg according to 24 h ABPM. The participants' mean age was 67.1 years (69.8% men). A total of 19.6% of the patients had office hypotension, 26.5% had daytime hypotension, 9.0% had nighttime hypotension, and 16.1% had 24-hr ABPM hypotension. Low diastolic BP values were responsible for most cases of hypotension. Fifty-eight percent of the cases of hypotension detected by daytime ABPM did not correspond to hypotension according to office BP. The variables independently associated with daytime ambulatory systolic/diastolic hypotension and diastolic hypotension (the latter being the most frequent type of ambulatory hypotension) were age, female sex, and the number of antihypertensive medications. In conclusion, in a large ABPM registry, one out of every four CHD-treated hypertensive patients was potentially at risk because of hypotension according to daytime ABPM, and more than half of them were not identified if office BP was relied on alone. We suggest that ABPM should be performed in these patients.

How do ultrafine particles in urban air affect ambulatory blood pressure?

INTRODUCTION: Air in urban areas is usually contaminated with particle matter. High concentrations lead to a rise in the risk of cardiovascular and respiratory diseases. Some studies have reported that ultrafine particles (UFP) play a greater role in cardiovascular diseases than other particle matter, particularly regarding hypertensive crises and DBP, although in the latter such effects were described concerning clinical blood pressure (BP). In this study, we evaluate the relationship between 24-h ambulatory BP monitoring (ABPM) and atmospheric UFP concentrations in Barcelona. METHODS: An observational study of individual patients' temporal and geographical characteristics attended in Primary Care Centres and Hypertensive Units during 2009-2014 was performed. RESULTS: The participants were 521 hypertensive patients, mean age 56.8 years (SD 14.5), 52.4% were women. Mean BMI was 28.0 kg/m and the most prominent cardiovascular risk factors were diabetes (N = 66, 12.7%) and smoking (N = 79, 15.2%). We describe UFP effects at short-term and up to 1 week (from lag 0 to 7). For every 10 000 particle/cm UFP increase measured at an urban background site, a corresponding statistically significant increase of 2.7 mmHg [95% confidence interval = (0.5-4.8)] in 24-h DBP with ABPM for the following day was observed (lag 1). CONCLUSION: We have observed that a rise in UFP concentrations during the day prior to ABPM is significantly associated with an increase in 24 h and diurnal DBP. It has been increasingly demonstrated that UFP play a key role in cardiovascular risk factors and, as we have demonstrated, in good BP control.

Frequency and Prognosis of Treated Hypertensive Patients According to Prior and New Blood Pressure Goals.

United States and European guidelines have recommended new treatment goals for office blood pressure (BP). We examined 9784 hypertensives of the Spanish Ambulatory BP Monitoring (ABPM) registry with office BP treated to the prior goal (<140/90 mm Hg); and evaluated the frequency and all-cause mortality of 4 BP strata depending on whether or not they attained more conservative or new office BP goal (130-139/80-89 and <130/80 mm Hg, respectively) and whether or not BP was controlled according to ABPM criteria in the European and US guidelines (24-hour ambulatory BP <130/80 and <125/75 mm Hg, respectively). Whether achieving or not the new office BP goal, the total-mortality risk during a 5-year follow-up was only significantly higher than the reference (normal office BP and ABPM) when 24-hour ambulatory BP was above goal (hazard ratio from multivariable Cox models was in the range of 2.4-2.9; P<0.001). The frequency of patients achieving the new office BP goal was 34.4%, and the frequencies of those not achieving the ABPM goal were 31.6% and 53.7% using the 130/80 or the 125/75 ABPM goal, respectively. Mean office systolic BP was 129 mm Hg for patients not achieving the ABPM goal. In hypertensive patients controlled under prior office BP goal, the frequency of those achieving new office BP goal <130/80 was high, suggesting this goal can be attained. In addition, patients had a higher mortality risk only when ABPM was above goal despite having mean office systolic BP under control, a condition that was also common.

Chronic kidney disease in Spain: Prevalence and impact of accumulation of cardiovascular risk factors. / Prevalencia de enfermedad renal crónica en España: impacto de la acumulación de factores de riesgo cardiovascular.

BACKGROUND: Chronic kidney disease (CKD) is a public health problem worldwide. We aimed to estimate the CKD prevalence in Spain and to examine the impact of the accumulation of cardiovascular risk factors (CVRF). MATERIAL AND METHODS: We performed a nationwide, population-based survey evaluating 11,505 individuals representative of the Spanish adult population. Information was collected through standardised questionnaires, physical examination, and analysis of blood and urine samples in a central laboratory. CKD was graded according to current KDIGO definitions. The relationship between CKD and 10CVRF was assessed (age, hypertension, general obesity, abdominal obesity, smoking, high LDL-cholesterol, low HDL-cholesterol, hypertriglyceridaemia, diabetes and sedentary lifestyle). RESULTS: Prevalence of CKD was 15.1% (95%CI: 14.3-16.0%). CKD was more common in men (23.1% vs 7.3% in women), increased with age (4.8% in 18-44 age group, 17.4% in 45-64 age group, and 37.3% in ≥65), and was more common in those with than those without cardiovascular disease (39.8% vs 14.6%); all P<.001. CKD affected 4.5% of subjects with 0-1CVRF, and then progressively increased from 10.4% to 52.3% in subjects with 2 to 8-10CVRF (P trend <.001). CONCLUSIONS: CKD affects one in seven adults in Spain. The prevalence is higher than previously reported and similar to that in the United States. CKD was particularly prevalent in men, older people and people with cardiovascular disease. Prevalence of CKD increased considerably with the accumulation of CVRF, suggesting that CKD could be considered as a cardiovascular condition.

Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality.

BACKGROUND: Evidence for the influence of ambulatory blood pressure on prognosis derives mainly from population-based studies and a few relatively small clinical investigations. This study examined the associations of blood pressure measured in the clinic (clinic blood pressure) and 24-hour ambulatory blood pressure with all-cause and cardiovascular mortality in a large cohort of patients in primary care. METHODS: We analyzed data from a registry-based, multicenter, national cohort that included 63,910 adults recruited from 2004 through 2014 in Spain. Clinic and 24-hour ambulatory blood-pressure data were examined in the following categories: sustained hypertension (elevated clinic and elevated 24-hour ambulatory blood pressure), "white-coat" hypertension (elevated clinic and normal 24-hour ambulatory blood pressure), masked hypertension (normal clinic and elevated 24-hour ambulatory blood pressure), and normotension (normal clinic and normal 24-hour ambulatory blood pressure). Analyses were conducted with Cox regression models, adjusted for clinic and 24-hour ambulatory blood pressures and for confounders. RESULTS: During a median follow-up of 4.7 years, 3808 patients died from any cause, and 1295 of these patients died from cardiovascular causes. In a model that included both 24-hour and clinic measurements, 24-hour systolic pressure was more strongly associated with all-cause mortality (hazard ratio, 1.58 per 1-SD increase in pressure; 95% confidence interval [CI], 1.56 to 1.60, after adjustment for clinic blood pressure) than the clinic systolic pressure (hazard ratio, 1.02; 95% CI, 1.00 to 1.04, after adjustment for 24-hour blood pressure). Corresponding hazard ratios per 1-SD increase in pressure were 1.55 (95% CI, 1.53 to 1.57, after adjustment for clinic and daytime blood pressures) for nighttime ambulatory systolic pressure and 1.54 (95% CI, 1.52 to 1.56, after adjustment for clinic and nighttime blood pressures) for daytime ambulatory systolic pressure. These relationships were consistent across subgroups of age, sex, and status with respect to obesity, diabetes, cardiovascular disease, and antihypertensive treatment. Masked hypertension was more strongly associated with all-cause mortality (hazard ratio, 2.83; 95% CI, 2.12 to 3.79) than sustained hypertension (hazard ratio, 1.80; 95% CI, 1.41 to 2.31) or white-coat hypertension (hazard ratio, 1.79; 95% CI, 1.38 to 2.32). Results for cardiovascular mortality were similar to those for all-cause mortality. CONCLUSIONS: Ambulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. White-coat hypertension was not benign, and masked hypertension was associated with a greater risk of death than sustained hypertension. (Funded by the Spanish Society of Hypertension and others.).

Antihypertensive drug use in resistant and nonresistant hypertension and in controlled and uncontrolled resistant hypertension.

BACKGROUND AND AIM: Treatment-resistant hypertension (TRH) is associated with particular clinical features, nonadherence, and suboptimal treatment. We assessed possible associations of antihypertensive drug classes, specific agents inside each class, and types of combinations, with the presence of non-TRH vs. TRH, and with controlled vs. uncontrolled TRH. METHODS: Comparisons were done in 14 264 patients treated with three drugs (non-TRH: 2988; TRH: 11 276) and in 6974 treated with at least four drugs (controlled TRH: 1383; uncontrolled TRH: 5591). Associations were adjusted for age, sex, and previous cardiovascular event. RESULTS: In both groups of patients treated with three or with at least four drugs, aldosterone antagonists among drug classes [adjusted odds ratio (OR): 1.82 and 1.41, respectively], and ramipril (OR: 1.28 and 1.30), olmesartan (OR: 1.31 and 1.37), and amlodipine (OR: 1.11 and 1.41) inside each class were significantly associated with blood pressure control (non-TRH or controlled TRH). In patients treated with three drugs, non-TRH was also associated with the use of chlorthalidone (OR: 1.50) and bisoprolol (OR: 1.19), whereas in patients treated with at least four drugs, controlled TRH was significantly associated with the triple combination of a renin-angiotensin system blocker, a calcium channel blocker, and a diuretic (OR: 1.17). CONCLUSION: The use of aldosterone antagonists is associated with blood pressure control in patients treated with three or more drugs. Similar results are observed with specific agents inside each class, being ramipril, olmesartan, chlorthalidone, amlodipine, and bisoprolol those exhibiting significant results. An increased use of these drugs might probably reduce the burden of TRH.

Blood pressure variability increases with advancing chronic kidney disease stage: a cross-sectional analysis of 16 546 hypertensive patients.

OBJECTIVE: Increased BP-variability predicts cardiovascular morbidity and mortality in hypertensives. This study aimed to examine short-term BP-variability according to renal function stage. METHODS: We included 16 546 patients [10 270 (62.1%) without/6276 (38.9%) with CKD Stage 1-5] from the Spanish Ambulatory-Blood-Pressure Monitoring (ABPM) Registry. Stages of CKD were defined according to K/DIGO criteria, based on estimated glomerular filtration rate calculated with the CKD-EPI equation and albumin-to-creatine ratio. BP-variability was assessed with standard deviation (SD), weighted SD (wSD), coefficient of variation (CV), and average real variability (ARV). RESULTS: Compared with those without CKD, a lower proportion of CKD patients were dippers (51.9 versus 39.6%; P < 0.001). Across CKD stages, a progressive decrease in dipper (from 39.1 to 20.4%; P < 0.001) and increase in riser proportion (from 12.3 to 36.7%; P < 0.001) were noted. Patients with CKD had significantly higher SBP SD, wSD, CV and ARV and lower DBP SD compared with those without CKD (P < 0.001). Within CKD Stages, an increasing trend from Stage 1 towards Stage 5 was observed for SBP SD (from 13.8 ±â€Š3.7 to 15.6 ±â€Š5.4 mmHg), wSD (from 12.0 ±â€Š3.2 to 13.9 ±â€Š5.1 mmHg), CV (from 10.4 ±â€Š2.7 to 11.5 ±â€Š4.1%), ARV (from 9.9 ±â€Š2.3 to 11.4 ±â€Š3.2 mmHg); P < 0.001 for all comparisons. DBP SD (P < 0.001), wSD and ARV (P = 0.002) were slightly decreasing, whereas DBP CV increased from Stage 1 to Stage 4 (P < 0.001). In multivariate analysis, male gender, older age, abdominal obesity, diabetes, number of antihypertensive medications, and clinic SBP were independent factors for higher SBP 24-h ARV in CKD. CONCLUSION: An increase in short-term SBP-variability was present with advancing CKD stages in a large cohort. This increased SBP-variability may be involved in the sharp elevation of cardiovascular risk with worsening renal function.

Prevalence and clinical characteristics of white-coat hypertension based on different definition criteria in untreated and treated patients.

BACKGROUND AND AIM: The prevalence and associated risks of white-coat hypertension (WCH) are still a matter of debate. We aimed to assess differences in prevalence and associated conditions of WCH defined on the basis of the normality of all daytime, night-time, and 24-h blood pressure (BP), only daytime, or only 24-h BP. METHODS: We selected 115 708 patients (45 020 untreated and 70 688 treated) from the Spanish Ambulatory BP Monitoring Registry. WCH was estimated in patients with elevated office BP (≥140 and/or 90 mmHg) by using normal daytime (<135/85) BP, normal 24-h BP (<130/80), or normal daytime, night-time (<120/70) and 24-h BP. Demographic and clinical data (associated risk factors and organ damage) were compared among groups. RESULTS: Prevalence of WCH was 41.3, 35.2, and 26.1% in untreated, and 45.8, 38.9, and 27.2% in treated patients with elevated office BP, by using the criteria of daytime, 24-h, or all ambulatory periods. Compared with the normotensive group, WCH defined by normal daytime, night-time, and 24-h BP did not significantly differ in terms of other cardiovascular risk factors or organ damage. In contrast, patients from other groups (either only normal daytime BP or 24-h BP) had significantly more prevalence of diabetes, dyslipidaemia, microalbuminuria, left ventricular hypertrophy, reduced renal function, and previous history of cardiovascular disease. CONCLUSION: Prevalence of WCH is dependent on definition criteria. Only diagnostic criteria which considers the normality of all ambulatory periods identifies patients with cardiovascular risk similar to normotensive patients. These results support using such criteria for a more accurate definition of WCH.

Magnitude of Hypotension Based on Office and Ambulatory Blood Pressure Monitoring: Results From a Cohort of 5066 Treated Hypertensive Patients Aged 80 Years and Older.

BACKGROUND AND OBJECTIVE: Elderly patients can be particularly susceptible to the adverse effects of excessive blood pressure (BP) lowering by antihypertensive treatment. The identification of hypotension is thus especially important. Ambulatory BP monitoring (ABPM) is a more accurate technique than office for classifying BP status. This study examined the prevalence of hypotension and associated demographic and clinical factors among very old treated hypertensive patients undergoing ABPM. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study in which 5066 patients aged 80 years and older with treated hypertension drawn from the Spanish ABPM Registry were included. MEASUREMENTS: Office BP and 24-hour ambulatory BP were determined using validated devices under standardized conditions. Based on previous studies, hypotension was defined as systolic/diastolic BP <110 and/or 70 mmHg with office measurement, <105 and/or 65 mmHg with daytime ABPM, <90 and/or 50 mmHg with nighttime ABPM, and <100 and/or 60 mmHg with 24-hour ABPM. RESULTS: Participants' mean age was 83.2 ± 3.1 years (64.4% women). Overall, 22.8% of patients had office hypotension, 33.7% daytime hypotension, 9.2% nighttime hypotension, and 20.5% 24-hour ABPM hypotension. Low diastolic BP values were responsible for 90% of cases of hypotension. In addition, 59.1% of the cases of hypotension detected by daytime ABPM did not correspond to hypotension according to office BP. The variables independently associated with office and ABPM hypotension were diabetes, coronary heart disease, and a higher number of antihypertensive medications. CONCLUSIONS: One in 3 very elderly treated hypertensive patients attended in usual clinical practice were potentially at risk of having hypotension according to daytime ABPM. More than half of them had masked hypotension; that is, they were not identified if relying on office BP alone. Thus, ABPM could be especially helpful for identifying ambulatory hypotension and avoiding overtreatment, in particular, in patients with diabetes, heart disease, or on antihypertensive polytherapy.

Clinic Versus Daytime Ambulatory Blood Pressure Difference in Hypertensive Patients: The Impact of Age and Clinic Blood Pressure.

Clinic blood pressure (BP) is usually higher than daytime ambulatory BP in hypertensive patients, but some recent studies have challenged this view, suggesting that this relationship is strongly influenced by age. We used the Spanish ambulatory BP monitoring cohort to examine differences between clinic and daytime BP by age among 104 639 adult hypertensive patients (office systolic/diastolic BP ≥140/90 mm Hg or treated) in usual primary-care practice, across the wide age spectrum. To assess the impact of age, cardiovascular variables, and clinic BP on the clinic-daytime BP differences, we built multivariable regression models of the average BP differences, white-coat hypertension (high clinic BP and normal daytime BP), and masked hypertension (normal clinic BP and high daytime BP). In most patients, mean clinic BP values were higher than daytime BP at all ages. Some 36.7% of patients had white-coat hypertension (amounting to 50% at clinic systolic BP of 140-159 mm Hg) and 3.9% had masked hypertension (amounting to 18% at clinic systolic BP of 130-139 mm Hg). Age explained 0.1% to 1.7% of the variance of quantitative or categorical BP differences (P<0.001). Cardiovascular variables explained an additional 1.6% to 3.4% of the variance (P<0.001). Finally, clinic BP generally explained ≥20% more of the variance (P<0.01). In this large study in usual clinical practice, clinic BP misclassified hypertension status in >40% of patients. This misclassification was not importantly influenced by age but was more evident in patients with borderline/grade 1 hypertension. These findings reinforce the importance of ambulatory BP monitoring for defining BP status in routine clinical practice.

Ambulatory blood pressure in hypertensive patients with inclusion criteria for the SPRINT trial.

We aimed to characterize 24-hour blood pressure (BP) values and categories in patients with inclusion/exclusion criteria of the Systolic Blood Pressure Intervention (SPRINT) trial from the Spanish ABPM Registry. We selected patients older than 50 years, with office systolic BP (SBP) above 130 mm Hg and at high cardiovascular risk, but without diabetes, previous stroke, or symptomatic heart failure. Ambulatory BP was compared among BP categories. A total of 39,132 patients (34%) fulfilled inclusion criteria of SPRINT trial. Ambulatory SBP was considerably lower than office BP, with 42% of patients having daytime values below 130 mm Hg and 21% 24-hour values below 120 mm Hg. In conclusion, more than one-third of the hypertensive population included in the Spanish ABPM Registry can be considered as SPRINT candidates, although one out of five have values of 24-hour SBP below 120 mm Hg. These data suggest that knowledge of ABPM values could be helpful when planning a treatment intensification in high-risk patients.

Association Between High and Very High Albuminuria and Nighttime Blood Pressure: Influence of Diabetes and Chronic Kidney Disease.

OBJECTIVE: Nighttime blood pressure (BP) and albuminuria are two important and independent predictors of cardiovascular morbidity and mortality. Here, we examined the quantitative differences in nighttime systolic BP (SBP) across albuminuria levels in patients with and without diabetes and chronic kidney disease. RESEARCH DESIGN AND METHODS: A total of 16,546 patients from the Spanish Ambulatory Blood Pressure Monitoring Registry cohort (mean age 59.6 years, 54.9% men) were analyzed. Patients were classified according to estimated glomerular filtration rate (eGFR), as ≥60 or <60 mL/min/1.73 m(2) (low eGFR), and urine albumin-to-creatinine ratio, as normoalbuminuria (<30 mg/g), high albuminuria (30-300 mg/g), or very high albuminuria (>300 mg/g). Office and 24-h BP were determined with standardized methods and conditions. RESULTS: High albuminuria was associated with a statistically significant and clinically substantial higher nighttime SBP (6.8 mmHg higher than with normoalbuminuria, P < 0.001). This association was particularly striking at very high albuminuria among patients with diabetes and low eGFR (16.5 mmHg, P < 0.001). Generalized linear models showed that after full adjustment for demographic, lifestyles, and clinical characteristics, nighttime SBP was 4.8 mmHg higher in patients with high albuminuria than in those with normoalbuminuria (P < 0.001), and patients with very high albuminuria had a 6.1 mmHg greater nighttime SBP than those with high albuminuria (P < 0.001). These differences were 3.8 and 3.1 mmHg, respectively, among patients without diabetes, and 6.5 and 8 mmHg among patients with diabetes (P < 0.001). CONCLUSIONS: Albuminuria in hypertensive patients is accompanied by quantitatively striking higher nighttime SBP, particularly in those with diabetes with very high albuminuria and low eGFR.

Hypotension based on office and ambulatory monitoring blood pressure. Prevalence and clinical profile among a cohort of 70,997 treated hypertensives.

We aimed to determine the prevalence of hypotension and factors associated with the presence of this condition in treated hypertensive patients undergoing ambulatory blood pressure monitoring (ABPM). Data were taken from the Spanish ABPM Registry. Office blood pressure (BP) and ABPM were determined using validated devices under standardized conditions. Based on previous studies, hypotension was defined as office systolic/diastolic BP <110 and/or 70 mm Hg, daytime ABPM <105 and/or 65 mm Hg, nighttime ABPM <90 and/or 50 mm Hg, and 24-hour ABPM <100 and/or 60 mm Hg. Multivariable logistic regression was performed to determine the variables associated with the presence of hypotension. A total of 70,997 hypertensive patients on treatment (mean age 61.8 years, 52.5% men) were included in the study. The prevalence of hypotension was 8.2% with office BP, 12.2% with daytime ABPM, 3.9% with nighttime ABPM, and 6.8% with 24-hour ABPM. Low diastolic BP values were responsible for the majority of cases of hypotension. Some 68% of the hypotension cases detected by daytime ABPM did not correspond to hypotension according to office BP. The variables independently and consistently associated with higher likelihood of office, daytime, and 24 hour-based hypotension were age, female gender, history of ischemic heart disease, and body mass index <30 kg/m(2) (P < .05). In conclusion, in this large cohort of patients in usual daily practice, one in eight treated hypertensive patients are at risk of hypotension according to daytime BP. Two-thirds of them are not adequately identified with office BP. ABPM could be especially helpful for identifying ambulatory hypotension, in particular in patients who are older, women, or with previous ischemic heart disease where antihypertensive treatment should be especially individualized and cautious.

Office and ambulatory blood pressure control in hypertensive patients treated with different two-drug and three-drug combinations.

There is scarce information regarding ambulatory blood pressure (BP) achieved in daily practice with a wide range of antihypertensive drug combinations. We looked for differences in office and ambulatory BP among major drug combinations of two and three antihypertensive agents from a different drugs class. A total of 17187 patients treated with six types of two-drug combinations and 9724 treated with six types of three-drug combinations from the Spanish ABPM Registry were analyzed. We compared achieved office and ambulatory BP, as well as office (< 140/90 mmHg) and ambulatory (24-hour BP < 130/80; day BP < 135/85, and night BP < 120/70 mmHg) BP control among groups. The combination of renin-angiotensin system (RAS) blockers with diuretics and the triple combination of RAS blockers with diuretics and calcium channel blockers (CCB) were associated with lower values of 24-hour, daytime and nighttime BP, as well as more pronounced nocturnal BP dip. Compared with such combinations (reference), other double combinations had lower rates of ambulatory BP control. Moreover, triple combinations containing alpha blockers also had lower rates of ambulatory BP control. We conclude that even with similar office BP control, differences exist among antihypertensive two-drug and three-drug combinations with respect to ambulatory BP control achieved during treatment, with RAS blockers/diuretics and RAS blockers/CCBs/diuretics obtaining better control rates. This can help physicians choose among drug combinations in order to obtain further ambulatory BP reductions.

Short-Term and Long-Term Reproducibility of Hypertension Phenotypes Obtained by Office and Ambulatory Blood Pressure Measurements.

The authors aimed to assess the reproducibility of normotension and white-coat, masked, and sustained hypertension in 839 untreated patients who underwent two separate assessments (median, 3; interquartile range, 0-13 months) by both office and ambulatory blood pressure (BP) monitoring (ABPM). The proportion of patients falling into the same category in the two assessments was: 52% normotension and 55% white-coat, 47% masked, and 82% sustained hypertension. The most frequent switch was to sustained hypertension (26% of white-coat and 33% of masked hypertension). No clinical factors predicted the change in category, except for higher office diastolic BP in patients with masked hypertension who developed sustained hypertension, compared with those who remained with masked hypertension (84±4 mm Hg vs 80±5 mm Hg; P=.006). The reproducibility of hypertension phenotypes was highly dependent on the time between assessments. The authors conclude that white-coat and masked hypertension phenotypes are only reproducible in the short-term, while they frequently shift towards sustained hypertension in the long-term.

Ambulatory Blood Pressures in Hypertensive Patients Treated With One Antihypertensive Agent: Differences Among Drug Classes and Among Drugs Belonging to the Same Class.

The authors investigated the differences in office and ambulatory blood pressure (BP) among major antihypertensive drug classes and among frequently used drugs in each class in 22,617 patients treated with monotherapy from the Spanish ABPM Registry. Using thiazides as the reference group, patients treated with calcium channel blockers have significantly (P<.01) elevated ambulatory BP and less ambulatory control after adjusting for confounders. Inside each class, no significant differences were observed among thiazides or angiotensin receptor blockers. Atenolol and bisoprolol among ß-blockers, amlodipine among calcium channel blockers, and lisinopril and enalapril among angiotensin-converting enzyme inhibitors exhibited lower ambulatory BP and better control than other agents. Differences exist among antihypertensive drug classes and among different compounds in each class with respect to ambulatory BP control. This can help physicians choose among drug classes and among compounds in each class if BP reduction is the main objective of treatment.

Impact of Ambulatory Blood Pressure Monitoring on Reclassification of Hypertension Prevalence and Control in Older People in Spain.

Ambulatory blood pressure monitoring (ABPM) accurately classifies blood pressure (BP) status but its impact on the prevalence and control of hypertension is little known. The authors conducted a cross-sectional study in 2012 among 1047 individuals 60 years and older from the follow-up of a population cohort in Spain. Three casual BP measurements and 24-hour ABPM were performed under standardized conditions. Approximately 68.8% patients were hypertensive based on casual BP (≥140/90 mm Hg or current BP medication use) and 62.1% based on 24-hour ABPM (≥130/80 mm Hg or current BP medication use) (P=.009). The proportion of patients with treatment-eligible hypertension who met BP goals increased from 37.4% based on the casual BP target to 54.1% based on the 24-hour BP target (absolute difference, 16.7%; P<.01). These results were consistent across alternative BP thresholds. Therefore, compared with casual BP, 24-hour ABPM led to a reduction in the proportion of older patients recommended for hypertension treatment and a substantial increase in the proportion of those with hypertension control.