Characteristics of Individuals with Disagreement between Home and Ambulatory Blood Pressure Measurements for the Diagnosis of Hypertension
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Abstract:
Home and ambulatory blood pressure (BP) measurements are recommended for the diagnosis of hypertension. However, the clinical characteristics of individuals showing a diagnostic disagreement between their home and ambulatory BP measurements are unclear. Of the 470 individuals who were not on antihypertensive drug treatment with a BP ≥140/90 mmHg at an outpatient clinic, 399 who had valid office, home, and ambulatory BP results were included. Hypertension was diagnosed based on an average home BP ≥135/85 mmHg and/or an average daytime ambulatory BP ≥135/85 mmHg. The participants were divided into three groups: Agree-NT (home and ambulatory BP normotension), Disagree (home BP normotension and ambulatory BP hypertension, or home BP normotension and ambulatory BP hypertension), and Agree-HT (home and ambulatory BP hypertension). Eighty-four individuals (21.1%) were classified as the Disagree group. The mean serum creatinine, triglycerides, and electrocardiogram voltage in the Disagree group were intermediate between those observed in the Agree-NT and the Agree-HT group. In the Disagree group, the mean levels of office and home diastolic BP, all of the components of ambulatory BP, the aortic systolic BP, and the BP variabilities were found to be intermediate between those of the Agree-NT and the Agree-HT groups. These results indicate that individuals showing a diagnostic disagreement between their home and ambulatory BP may have cardiovascular risks that are intermediate between those with sustained home and ambulatory normotension and hypertension.Keywords:
Masked Hypertension
2018 ESC/ESH guidelines have recommended 24-h ambulatory blood pressure monitoring to assess hypotensive therapy in many circumstances. Recommended target blood pressure in office blood pressure measurements is between 120/70 and 130/80 mmHg. Such targets for 24-h ambulatory blood pressure monitoring lacks. We aimed to define target values of blood pressure in 24-h ambulatory blood pressure monitoring in hypertensive patients. Office blood pressure measurements and 24-h ambulatory blood pressure monitoring data were collected from 1313 hypertensive patients and sorted following increasing systolic (SBP)/diastolic (DBP) blood pressure in office blood pressure measurements. The corresponding 24-h ambulatory blood pressure monitoring to office blood pressure measurements values were calculated. Values 130/80 mmHg in office blood pressure measurements correspond in 24-h ambulatory blood pressure monitoring: night-time SBP/DBP mean: 113.74/66.95 mmHg; daytime SBP/DBP mean: 135.02/81.78 mmHg and 24-h SBP/DBP mean: 130.24/78.73 mmHg. Values 120/70 mmHg in office blood pressure measurements correspond in 24-h ambulatory blood pressure monitoring: night-time SBP/DBP mean: 109.50/63.43 mmHg; daytime SBP/DBP mean: 131.01/78.47 mmHg and 24-h SBP/DBP mean: 126.36/75.31 mmHg. The proposed blood pressure target values in 24-h ambulatory blood pressure monitoring complement the therapeutic target indicated in the ESC/ESH recommendations and improves 24-h ambulatory blood pressure monitoring usefulness in clinical practice.
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Ambulatory blood pressure monitoring was compared with office blood pressure in 48 normotensive, 81 borderline hypertensives and 35 untreated hypertensives. The studied groups were chosen from a geographically defined population of middle-aged men in southern Sweden. The mean 24-h ambulatory blood pressure values for the normotensives, borderline hypertensives and untreated hypertensives were 120/76, 127/82 and 140/92 mmHg, respectively. The diurnal mean ambulatory blood pressure in the three groups was 126/80, 134/86 and 146/ 96 mmHg, respectively. The percentage of 24-h diastolic blood pressure peaks < 95 mmHg in the groups were 7%, 22% and 53%, respectively. The corresponding values <90mmHg were 16%, 38% and 69%, respectively. In the untreated hypertensive group, there was a more pronounced (P > 0.05) systolic blood pressure increase during the morning hours (0600-1000 h) than in the normotensive and borderline hypertensive groups. Fourteen per cent of the hypertensives showed normal blood pressure values during 24-h blood pressure monitoring. Fifteen per cent of the borderline hypertensives were normotensive during ambulatory blood pressure monitoring despite repeated office diastolic blood pressure < 90 mmHg. The opposite (increased blood pressure during ambulatory blood pressure monitoring and at screening but normal office blood pressure) was seen in 14% of the borderline hypertensives. Normotensives were characterized by lower mean blood pressure values, fewer blood pressure peaks and a lower systolic blood pressure increase during the morning hours than hypertensives in this study of middle-aged men. The established way of diagnosing hypertension, borderline hypertension and normotension correlated well with the results of ambulatory blood pressure monitoring.
Prehypertension
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Home measurement and ambulatory 24-hour monitoring of blood pressure (BP) have many advantages over conventional office BP measurement and are increasingly used in clinical practice. However, their effect on the treatment of hypertension requires additional study. We assessed the hypothesis that the adjustment of antihypertensive treatment based on home BP instead of ambulatory BP would lead to equivalent BP control. After a 4-week wash-out period with placebo, a total of 110 patients whose daytime diastolic ambulatory BP averaged 85 mmHg or higher were randomized to either ambulatory BP or home BP groups. Antihypertensive treatment was then adjusted in a stepwise fashion at 6-week intervals according to the mean daytime ambulatory diastolic BP or the mean home diastolic BP during the preceding week, depending on the patient's randomization group. Both ambulatory BP monitoring and home BP measurement were performed on all patients during the study. If the diastolic BP guiding treatment was above 80 mmHg, a physician blinded to the randomization intensified hypertensive treatment; if equal to or below 80 mmHg the treatment was left unchanged. A total of 98 patients completed the study; 52 in the home BP group (age 54±1.4 y, 37% men) and 46 in the ambulatory BP group (age 54±1.0 y, 50% men). After a 24-week follow-up period BP was significantly reduced within both groups (p<0.01). The between-group differences in systolic and diastolic BP changes were statistically nonsignificant (p>0.05). An equal share of patients had progressed to multiple-drug treatment in the home and ambulatory BP groups (65.4% vs. 67.4%, p=0.83). We conclude that the adjustment of antihypertensive treatment based on home BP measurement instead of 24-hour ambulatory BP monitoring led to equally intensive drug treatment with preservation of BP control. (See Table) Changes in BPs After a 24-week Follow-up Values expressed as mean ± SEM. SBP, systolic blood pressure; DBP, diastolic blood pressure. Changes in BPs After a 24-week Follow-up Values expressed as mean ± SEM. SBP, systolic blood pressure; DBP, diastolic blood pressure.
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SUMMARY 1. The diagnosis of isolated systolic hypertension, diastolic hypertension and normotension in elderly subjects, as defined by casual office blood pressure measurement, was compared with 24 h ambulatory blood pressure monitoring using an Accutracker II. 2. Mean day‐time ambulatory blood pressure monitoring underestimated the casual systolic blood pressure in all three clinical groups. Diastolic pressure was not underestimated to the same extent. 3. Ambulatory blood pressure monitoring best reflected casual blood pressure determination for normotensive subjects. In subjects with isolated systolic hypertension ambulatory blood pressures were only consistent with that diagnosis for 8% of the day time period. For 34% of the day time, their ambulatory blood pressures were consistent with diastolic/ mixed hypertension. 4. It is concluded that isolated systolic hypertension may not be a sustained condition, but rather an isolated response to office measurement of blood pressure.
Prehypertension
Isolated systolic hypertension
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Masked Hypertension
White coat hypertension
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In the past, the diagnosis and management of hypertension has been based on office blood pressure. However, office blood pressure is not always a true reflection of a patient's blood pressure profile. Since ambulatory blood pressure monitoring permits a large number of readings to be taken in the patient's usual environment, it may provide a more representative blood pressure profile. Indeed, ambulatory blood pressure has been better correlated than office blood pressure with the target-organ complications of hypertension. Office or white-coat hypertension (elevated blood pressure only when measured in the physician's office) has been reported in 12-21% of patients in mildly hypertensive sample populations. While office blood pressure and daytime ambulatory blood pressure values are reported to be similar in normotensive subjects, ambulatory systolic and diastolic readings in hypertensive subjects have been reported as, respectively, 4-15 mmHg and 3-10 mmHg lower than office blood pressure readings. In estimating a patient's mean blood pressure and diagnosing hypertension, the greater the number of recording hours the more accurate the estimate is likely to be; in addition, increasing the number of measurements per hour also improves accuracy and increases the sensitivity of the readings. An increased frequency and severity of target-organ damage has been associated with higher 24-h blood pressure variability. Although the diagnosis of hypertension should not be based on ambulatory blood pressure alone, there are many clinical problems for which ambulatory blood pressure can be useful.
Masked Hypertension
White coat hypertension
Prehypertension
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Patients with elevated clinic blood pressure and normal ambulatory blood pressure have a better prognosis than patients with sustained ambulatory hypertension, and may not have to be treated with antihypertensive drugs. On the contrary, current guidelines emphasize repeated clinic blood pressure measurements for the initiation of antihypertensive therapy.To examine the relationship between ambulatory blood pressure at baseline and clinic blood pressure after 6 months of follow-up in untreated hypertensive patients, and the relationships of these pressures with the subsequent incidence of cardiovascular events.Patients who were > or = 60 years old, with systolic clinic blood pressure of 160-219 mmHg and diastolic pressure < 95 mmHg, participated in the Systolic Hypertension in Europe trial. The relationship between ambulatory blood pressure at baseline and clinic blood pressure after 6 months of follow-up was examined in 295 patients enrolled in the Ambulatory Blood Pressure Monitoring substudy and randomized to the placebo arm, and who were still on double-blind treatment and not taking other antihypertensive drugs after 6 months follow-up.Age averaged 70 +/- 6 years, 41% were men, and baseline daytime ambulatory blood pressure was 152 +/- 16/84 +/- 10 mmHg; clinic blood pressure decreased from 173 +/- 10/86 +/- 6 mmHg at baseline to 163 +/- 20/85 +/- 9 mmHg at month 6. Systolic daytime ambulatory blood pressure at baseline and systolic clinic blood pressure at month 6 were considered normal if < 140 mmHg. Of the 74 patients with normal systolic daytime ambulatory blood pressure at baseline, only seven (9.5%) had a normal systolic clinic blood pressure during follow-up. Conversely, of the 24 patients with normal follow-up clinic blood pressure, only seven (29%) had a normal systolic daytime ambulatory blood pressure at baseline. The incidence of cardiovascular events beyond the 6-month visit was significantly related to baseline ambulatory blood pressure but not to follow-up clinic pressure.Baseline daytime ambulatory blood pressure and follow-up clinic blood pressure do not identify the same patients for antihypertensive treatment. Baseline ambulatory pressure is a better predictor of cardiovascular events than follow-up clinic pressure.
Isolated systolic hypertension
Systolic hypertension
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The purpose of this study was to compare home and ambulatory blood pressure (BP) in the adjustment of antihypertensive treatment. After a 4-week washout period, patients whose untreated daytime diastolic ambulatory BP averaged ≥85 mm Hg were randomized to be treated according to their ambulatory or home BP. Antihypertensive treatment was adjusted at 6-week intervals according to the mean daytime ambulatory diastolic BP or the mean home diastolic BP, depending on the patient's randomization group. If the diastolic BP stayed above 80 mm Hg, the physician blinded to randomization intensified hypertensive treatment. Ninety-eight patients completed the study. During the 24-week follow-up period both systolic and diastolic BP decreased significantly within both groups (P < .001). At the end of the study, the systolic/diastolic differences between ambulatory (n = 46) and home (n = 52) BP groups in home, daytime ambulatory, night-time ambulatory, and 24-h ambulatory BP changes averaged 2.6/2.6 mm Hg, 0.6/1.7 mm Hg, 1.0/1.4 mm Hg, and 0.6/1.5 mm Hg, respectively (P range .06 to .75) A nonsignificant trend to more intensive drug therapy in the ambulatory BP group and a nonsignificant trend to larger share of patients reaching (57.7% v 43.5%, P = .16) the target pressure in the home BP group was observed due to the 3.8 mm Hg difference in ambulatory and home diastolic BP at randomization. The adjustment of antihypertensive treatment based on either ambulatory or home BP measurement led to good BP control. No significant between-group differences in BP changes were seen at the end of the study. Additional research is needed to provide more conclusive results.
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Masked Hypertension
White coat hypertension
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Objective To investigate the characteristics of ambulatory blood pressure levels and circadian rhythm in the youth with essential hypertension(EH) before and after treatment.Methods 95 young patients with EH were treated with antihypertensive drugs.Four indexes of 24-hour ambulatory blood pressure monitor were measured and compared before and after treatment,including mean blood pressure,mean pulse pressure,blood pressure load and blood pressure circadian rhythm.Results Systolic pressure and diastolic pressure in EH patients were all higher than the normal value in the whole day but decreased obviously(P 0.05) after the treatment.Before the treatment,the systolic pressure load was 30%and the diastolic pressure load was 36%in daytime;which was 28%and 32%at night.After the treatment,the systolic pressure load decreased to 4%in daytime and 3%at night;the diastolic pressure load decreased to 3%in daytime and 4%at night.The differences were statistically significant(P 0.01).The patients with abnormity in circadian rhythm of blood pressure(nondipper) account for 81.1%(77/95 ) before the treatment.The decrease rates of systolic pressure and diastolic pressure during the night were all increased obviously(P 0.05) after the treatment.However,there was only 19.5%(15/77) nondipper blood pressure circadian rhythms changing into dippers.Conclusion After treatments young EH patients had much lower mean blood pressure and blood pressure load in the whole day.Decrease rate of blood pressure during the night increased obviously,whereas only a part of patients recovered to normal blood pressure circadian rhythms.
Essential hypertension
Pulse pressure
Dipper
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