Blood pressure response with fixed-dose combination therapy

How common is isolated nocturnal hypertension?

Angiotensin-converting enzyme inhibitors combined with higher doses of hydrochlorothiazide (HCT), that is, 25 mg daily, have been recognized as an effective form of antihypertensive therapy. To evaluate the coadministration of 20 mg ramipril with 25 mg HCT, we carried out a randomized, double-blind, controlled trial with two dose schedules of ramipril (20 mg q.d. and 10 mg b.i.d.) and HCT monotherapy arms as comparators in 354 patients with stage 2 hypertension. The clinic blood pressure (BP) was assessed using a semiautomatic digital device and 24-h BP was measured using ambulatory BP recordings at baseline and after 8 weeks of therapy. At baseline, the demographics and baseline BP values were similar in the four treatment groups (age: 51-53 years, 52-58% male, 64-68% non-black, clinic BP: 155-158/103-104 mm Hg). Ramipril-HCT induced significantly greater reductions in both the clinic and ambulatory BP than the HCT and ramipril monotherapy treatments (for example, additional reductions in ambulatory BP on ramipril-HCT ranged from -7.3/-5.2 to -10.3/-7.4 mm Hg compared to the monotherapies, all P<0.001). Reductions from baseline were still numerically greater for the clinic BPs derived from device measurements than those for the BP values derived from 24-h ambulatory BP measurements (changes in clinic diastolic BP ranged from -8.5 to -15.5 mm Hg across treatment groups, whereas changes in ambulatory diastolic BP were -4.7 to -12.0 mm Hg for the same groups). Thus, these data support the use of ambulatory BP monitoring even when automated BP devices are used for the assessment of clinical BP in trials that attempt to differentiate BP responses among active comparator groups. In conclusion, based on its efficacy and tolerability profile the combination of ramipril and HCT was shown to be effective therapy for the treatment of stage 2 hypertension.

Objective. To improve blood pressure (BP) control in subjects with uncontrolled arterial hypertension treated by monotherapy with high doses of ACE inhibitors (ACEi) or angiotensin II receptor antagonists (ARA) or with the combination of ACEi or ARA with another antihypertensive agent in moderate doses. Design and methods. Forty six non-diabetic hypertensive subjects with clinic BP > 150/90 mmHg on monotherapy and > 140/90 mmHg on combination therapy with daytime ambulatory BP > 135/85 mmHg were switched to fixed-dose combination of perindopril A 10 mg/indapamide 2,5 mg for 12 weeks. Clinic and ambulatory BP measurements and laboratory evaluations were performed. Results. At baseline 39 % subjects received combination therapy, clinic BP was 162,6 ± 4,2/98 ± 3,0 mmHg, 24-h BP 146,1 ± 8,2/88,3 ± 6,0, daytime BP 147,8 ± 8,8/90,2 ± 4,2 mmHg, night-time BP 131,7 ± 5,5/81,6 ± 4,8. After 12 weeks clinic BP was 131,5 ± 4,2/82,4 ± 5,4 mmHg, target BP 135/85 mmHg) was found in 7 %. Treatment with perindopril A 10 mg/indapamide 2,5 mg was associated with significant decrease in 24-h, day- and night-time ambulatory BP, daytime systolic BP variability and morning surge, improvement of night-peaker diurnal BP pattern. No hypotensive episodes with daytime BP 5,1 mmol/l were observed. Conclusion. In uncontrolled arterial hypertension change from monotherapy with nearly to high doses of ACEi or ARA or from combination of ACEI or ARA with another antihypertensive agent to fixed dose combination of perindopril A 10 mg/indapamide 2,5 mg results in a well-tolerated significant reduction in clinic and ambulatory BP with low rate of masked uncontrolled hypertension.

To compare the reproducibility of clinic and ambulatory blood pressure measurements in elderly hypertensive subjects. Twenty-two untreated elderly hypertensives, with a clinic systolic blood pressure (SBP) > 160 mmHg and/or diastolic blood pressure (DBP) > 95 mmHg, and a mean age of 76 years (range 66-86). Following three supine clinic blood pressure readings the subjects underwent 24-h non-invasive ambulatory blood pressure monitoring, measurements being taken at 20-min intervals from 0700 to 2200 h and at 30-min intervals from 2200 to 0700 h. Measurements were repeated during a further visit at a median interval of 10 weeks (range 1-10 months). Daytime ambulatory SBP levels were 20 mmHg (95% confidence interval 14-27 mmHg, P < 0.001) lower than clinic SBP, although DBP values were similar. The mean 24-h ambulatory SBP and DBP reproducibility [assessed by the standard deviation of differences (SDD) between visits] was significantly better than that for mean clinic blood pressure (SBP 6.3 versus 17.4 mmHg, P < 0.001; DBP 4.8 versus 7.0 mmHg, respectively, P < 0.05). With daytime defined as 1000-1959 h, the SDD between visits was 12.4 mmHg for SBP and 8.3 mmHg for DBP, but with daytime defined as 0700-2159 h, the SDD fell to 6.0 mmHg for SBP and 4.8 mmHg for DBP, values almost identical to those obtained with full 24-h blood pressure monitoring. There was no difference in night-time blood pressure reproducibility, whether night-time was defined as 2400-0559 h or 2200-0659 h. Both 24-h and daytime ambulatory blood pressure monitoring significantly improve the reproducibility of blood pressure measurements compared with clinic blood pressure readings in elderly hypertensive subjects. Increasing the number of daytime blood pressure readings by 50% (from 30 to 45) reduced the variability of blood pressure measurement by 50%. Twenty-four-hour ambulatory blood pressure monitoring is of value in obtaining reproducible blood pressure measurements in elderly hypertensive subjects. However, more than 30 readings are needed during a daytime recording to significantly reduce variability compared with repeated clinic measurements, although night-time variability is not significantly affected if the number of readings is reduced to 12 over a 6-h period.

Ambulatory blood pressure (ABP) monitoring is increasingly recognized as a valuable tool to refine prediction of cardiovascular risk related to blood pressure (BP).1 After the first landmark study published by Perloff and colleagues 24 years ago,2 several longitudinal event-based studies provided unequivocal evidence of an independent association between ABP and risk of cardiovascular disease. Although experimental procedures and statistical analyses varied from study to study, ABP generally improved cardiovascular risk stratification over and beyond traditional risk factors, including clinic BP.3 The Table, obtained through an electronic search of literature using the terms “ambulatory blood pressure” and “prognosis,” shows a list of longitudinal event-based studies performed by independent groups. It is worth noting that the list of available studies is longer because each group generally published other analyses of their database. Only the first-appearing or main contribution from each group has been included in the Table. View this table: Longitudinal Event-Based Studies From Independent Groups That Addressed the Prognostic Value of ABP Article p 2145 Three aspects of available investigations deserve special mention. First, the prognostic value of ABP has been examined not only in subjects with clinical diagnosis of hypertension but also in the general population and in a variety of settings, including diabetes mellitus, renal failure, and cerebrovascular disease. Second, subjects could be untreated or treated at the time of ABP monitoring. This point may raise concerns, because drug treatment could exert unpredictable effects on 24-hour ABP profile and, consequently, interpretation and applicability of results. Third, although a continuous relation emerged in most studies between ABP and cardiovascular risk, several investigators tried to define clinical categories based on arbitrary thresholds of ABP. Although such categories are potentially useful to make diagnostic and therapeutic decisions in clinical practice, their prognostic role requires confirmation from large and independent cohort …

This study was aimed at evaluating the antihypertensive effect of lisinopril and hydrochlorothiazide administered in the fixed combination of 20 and 12.5 mg, respectively, on clinic and 24-h blood pressure in elderly patients (age, 68.8 +/- 5.8 years, mean +/- SD) with mild-to-moderate essential systodiastolic or isolated systolic hypertension. After a washout period of 4 weeks, patients received once daily lisinopril combined with hydrochlorothiazide for a 6-week period. At the end of the washout and treatment periods, clinic blood pressure was assessed 24 h after dosing, and 24-h ambulatory blood pressure was monitored, taking blood pressure readings every 15 min. Pretreatment clinic blood pressure was 171.3 +/- 14.0/103.7 +/- 5.1 mm Hg (systolic/diastolic) in the group with systodiastolic hypertension (n = 405) and 179.6 +/- 9.4/83.6 +/- 5.4 mm Hg in the group with isolated systolic hypertension (n = 165). The corresponding 24-h average blood pressures were 144.1 +/- 13.9/88.7 +/- 8.4 mm Hg (n = 114) and 150.7 +/- 15.5/80.8 +/- 9.4 mm Hg (n = 40). Clinic blood pressure was significantly reduced by treatment in both groups. This was the case also for ambulatory blood pressure, which was reduced by 9.6 +/- 0.9%/9.9 +/- 0.9% in systodiastolic and by 11.8 +/- 1.3%/8.5 +/- 1.5% in isolated patients with systolic hypertension (p < 0.05 at least for all differences). The antihypertensive effect was similar in patients older and younger than 70 years. In all groups, it was manifest both during the day and the nighttime and was still significant after 24 h. Thus single daily administration of combined lisinopril-hydrochlorothiazide effectively reduces blood pressure in elderly patients with hypertension.

Introduction For practical reasons, blood pressure values measured by physicians or nurses in a medical environment remain the clinical basis of the diagnosis and management of arterial hypertension around the world as recommended by all guidelines [1–4]. Nevertheless, measurements of blood pressure outside the office have gained an increasing popularity over the last decades not only to ascertain the diagnosis of hypertension but also to follow the impact of therapeutic interventions. Out-of-office blood pressure measurements can be obtained either by 24-h ambulatory blood pressure monitoring or by home blood pressure monitoring. As reviewed recently [5], both sets of out-of-office blood pressure offer undeniable advantages when compared to office blood pressure. First, both ambulatory blood pressure and home blood pressure monitoring provide more reliable and reproducible information on blood pressure. Second, blood pressure values obtained by ambulatory blood pressure and home blood pressure monitoring appear to be more closely related to target organ damage than office blood pressure and hence have a greater prognostic relevance than office blood pressure. Third, certain diagnosis such as white coat hypertension and masked hypertension can only be diagnosed using out-of-office blood pressure measurements. Fourth, when used in the clinical follow-up of treated hypertensive patients to evaluate the impact of drug treatment, ambulatory blood pressure monitoring as well as home blood pressure monitoring has the advantage of not being affected by a placebo effect. Finally, evidence has been provided that treatment-induced reduction in 24-h blood pressure may predict better than office blood pressure the regression of end organ damage (particularly the cardiac one) induced by antihypertensive drug. Many of these information have been achieved during the past two decades by a number of studies carried out in different populations around the world, including the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study [6–10]. When should out-office blood pressure be measured? Despite their advantages, ambulatory blood pressure monitoring as well as home blood pressure monitoring is not regarded as a routine procedure that should be applied to all hypertensive patients essentially for economical reasons. However, this issue is debated because the clinical information gathered with these measurements may potentially result in financial savings when applied adequately. The European and American guidelines for the management of hypertension have defined some indications for the use of ambulatory blood pressure monitoring in hypertension [1,2]. These include patients with resistant hypertension, patients with a high variability of office blood pressure, low-risk patients with a high blood pressure, patients with suspected episodes of hypotension, patients with a large discrepancy between office and home blood pressures, and finally patients with special clinical conditions such as pregnancy or sleep apnea syndrome. Outside these indications, the use of ambulatory blood pressure monitoring could be discussed both in terms of feasibility and economics. Theoretically, a measurement of out-of-office blood pressure could be recommended to all new patients with as suspected hypertension to confirm the diagnosis of hypertension and to refine the patient's cardiovascular risk profile. Therefore, ambulatory blood pressure monitoring could be recommended to all high cardiovascular risk patients before starting any treatment and later under therapy to ascertain the adequacy of the control of blood pressure. Ambulatory blood pressure values in diabetic patients In this issue of the Journal of Hypertension, Leitao et al.[11] report the results of a cross-sectional study performed to estimate the daytime ambulatory blood pressure monitoring values corresponding to the target office blood pressure of 130/80 mmHg for diabetic (as defined by the American Diabetes Association) and to assess which diabetic patients may actually benefit from ambulatory blood pressure monitoring. They included 554 patients in this analysis. Regression analyses were performed to analyze the ambulatory blood pressure monitoring values corresponding to office blood pressure and receiver operating characteristics (ROC) curves were used to assess the sensitivity and specificity of office blood pressure in diagnosing daytime ambulatory blood pressure monitoring hypertension. According to their regression equations, the daytime ambulatory blood pressure monitoring corresponding to the target office blood pressure of 130/80 mmHg was 129/79 mmHg and the daytime ambulatory blood pressure monitoring value corresponding to 140/90 mmHg at the office was 134/82 mmHg. As expected, discrepancies between ambulatory blood pressure monitoring and office blood pressure were due essentially to masked hypertension (about 10% of cases) and white coat hypertension (between 19% for systolic blood pressure and 26% for diastolic blood pressure). Interestingly, when office blood pressure was lower than 120 mmHg systolic and 70 mmHg diastolic, the sensitivity to rule out hypertension using ambulatory blood pressure monitoring was 90%. Similarly, when office blood pressure was more than 145 mmHg systolic and more than 90 mmHg diastolic the sensitivity to confirm hypertension using ambulatory blood pressure monitoring was 90%. Within these two sets of limits, 38% of patients would be misclassified if only office blood pressure values would be considered for the diagnosis. Thus, using the cut-off values of less than 120/70 mmHg and more than 140/90 mmHg at the office, 56% of the population sample would need an ambulatory blood pressure monitoring to confirm the diagnosis of hypertension. According to these results, only diabetics with an office blood pressure between 120 and 140 mmHg systolic and/or a diastolic blood pressure between 70 and 90 mmHg would really benefit from an out-office assessment of blood pressure. This would limit the use of ambulatory blood pressure monitoring to only 50% of the diabetic patients. Studies implications and limitations The results of this provide interesting practical information on the use of ambulatory blood pressure monitoring in diabetic patients. However, they also have some limitations. The first one is the fact that the entire analysis is based on daytime ambulatory blood pressure only. Although the authors have measured 24-h blood pressure, they have not considered the nighttime blood pressure. This is unfortunate because there is increasing evidence that nighttime is a better predictor of cardiovascular risk than daytime blood pressure. Moreover, diabetic patients are often characterized by an absence of the physiological fall in blood pressure reflecting a nondipping pattern at night. Diabetes may even be the cause of a reverse dipping, that is an increase in blood pressure at night. Both the nondipping and the reverse dipping pattern of blood pressure have been associated with an increased risk of developing target organ damages such as left ventricular hypertrophy, microalbuminuria, renal dysfunction, and cerebral vascular lesions [5,12]. Thus, when assessing the cardiovascular risk profile linked to hypertension in diabetic patients, nighttime blood pressure should be included. Indeed, it is not uncommon in diabetes that daytime normotensive patients exhibit a nocturnal hypertension. This type of patients would be misdiagnosed using the algorithm proposed by the authors. Recently, the results of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial have shown that in diabetic patients the reduction of cardiovascular morbidity and mortality obtained by lowering office blood pressure below 120 mmHg systolic is not greater than that seen reducing blood pressure below 130 mmHg [13]. On the contrary, a systolic blood pressure below 120 mmHg may result in an increased risk of developing cardiac complications, as suggested by the recent post hoc analysis of diabetic patients with coronary heart diseases having participated in the INternational VErapamil SR-Trandolapril (INVEST) Study [14]. If a low blood pressure increases the risk of cardiac complications in diabetics, one might have to reconsider the necessity to perform an ambulatory blood pressure monitoring in diabetic patients with a blood pressure <120/70 mmHg in contrast to the proposals of Leitao et al. Indeed, in treated diabetic patients with a low office blood pressure, ambulatory blood pressure monitoring could be of importance to diagnosis episodes of asymptomatic hypotension episodes which might increase their cardiac risk. Thus, in the analysis of daytime and nighttime blood pressure values, it would be of interest to assess whether the percentage of ambulatory blood pressure values below a certain level is indeed associated with an increased risk of some cardiovascular complications. In this respect, it is important to mention that the analysis presented by Leitao et al. does not provide any information on the presence in this particular patients population of cardiac organ damage. The study also does not provide any data such on the occurrence of cardiovascular events and deaths, as it was not a prospective cohort study. Both these two sets of information should be thus provided by future clinical trials.

Assessment of Achieved Clinic and Ambulatory Blood Pressure Recordings and Outcomes During Treatment in Hypertensive Patients With CKD: A Multicenter Prospective Cohort Study

Ambulatory blood pressure monitoring and endothelium-dependent vasodilation in the elderly athletes

This study investigated clinic and ambulatory blood pressure (BP) responses after a single bout of low-intensity resistance exercise in normotensive subjects. Fifteen healthy subjects underwent 2 experimental sessions: control-40 minutes of seated rest, and exercise-6 resistance exercises, with 3 sets of as many repetitions as possible until moderate fatigue, with an intensity of 50% of 1-repetition maximum (1RM). Before and for 60 minutes after interventions, clinic BP was measured by auscultatory and oscillometric methods. Postintervention ambulatory BP levels were also measured for 24 hours. In comparison with preintervention values, clinic systolic BP, as measured by the auscultatory method, did not change in the control group, but it decreased after exercise (-3.7 +/- 1.6 mm Hg, p < 0.05). Diastolic and mean BP levels increased after intervention in the control group (+3.4 +/- 1.0 and +3.0 +/- 0.8 mm Hg, respectively, p < 0.05) and decreased in the exercise group (-3.6 +/- 1.7 and -3.4 +/- 1.4 mm Hg, respectively, p < 0.05). Systolic and mean oscillometric BP levels did not change after interventions either in the control or exercise sessions, whereas diastolic BP increased after intervention in the control group (+5.0 +/- 1.7 mm Hg, p < 0.05) but not change after exercise. Ambulatory BP behaviors after interventions were similar in the control and exercise sessions. Significant and positive correlations were observed between preexercise values and postexercise clinic and ambulatory BP decreases. In conclusion, in the whole sample, a single bout of low-intensity resistance exercise decreased postexercise BP under clinic, but not ambulatory, conditions. However, considering individual responses, postexercise clinic and ambulatory hypotensive effects were greater in subjects with higher preexercise BP levels.

To assess the additional diagnostic precision conferred by ambulatory blood pressure monitoring on clinic blood pressure measurement in evaluating the severity of isolated systolic hypertension. The association between left ventricular size as determined by ECG voltages [R-wave voltages in lead V5 (RV5) and S-wave voltages in lead V1 (SV1)] and blood pressure as assessed by clinic measurements and ambulatory blood pressure monitoring was studied in 97 elderly patients included in the placebo run-in phase of the Syst-Eur trial. The additional diagnostic precision conferred by ambulatory monitoring on clinic blood pressure measurements was assessed by relating the residual ambulatory blood pressure level to the ECG-left ventricular size. The residual ambulatory blood pressure level was calculated by subtracting the predicted ambulatory blood pressure level for each patient (using the linear regression equation relating both techniques for the group) from the observed ambulatory blood pressure. Clinic systolic blood pressure was on average 20 mmHg higher (P < 0.001) than daytime ambulatory blood pressure while diastolic blood pressure was similar with both techniques. The sum of SV1 + RV5 was significantly related to clinic systolic pressure (r = 0.25), and 24-h (systolic, r = 0.37; diastolic, r = 0.29), daytime (systolic, r = 0.30; diastolic, r = 0.19) and night-time (systolic, r = 0.33; diastolic, r = 0.28) ambulatory blood pressure levels. These findings were not affected by adjustment for gender, age and the body mass index. The sum of SV1 + RV5 was significantly related to the residual 24-h (systolic, r = 0.30; diastolic, r = 0.31), daytime systolic (r = 0.20) and night-time (systolic, r = 0.31; diastolic, r = 0.29) ambulatory blood pressure monitoring levels. Ambulatory blood pressure monitoring adds to the diagnostic precision of clinic blood pressure measurement in assessing the severity of hypertension in this population. The ongoing side project on ambulatory blood pressure monitoring in the Syst-Eur study should establish whether these findings hold true for morbidity and mortality.

The purpose of this study was to determine if ambulatory blood pressure measurement predicted total and cardiovascular mortality over and beyond clinic blood pressure measurement and other cardiovascular risk factors; 5292 untreated hypertensive patients referred to a single blood pressure clinic who had clinic and ambulatory blood pressure measurement at baseline were followed up in a prospective study of mortality outcome. Multiple Cox regression was used to model time to total and cause-specific mortality for ambulatory blood pressure measurement while adjusting for clinic blood pressure measurement and other risk factors at baseline. There were 646 deaths (of which 389 were cardiovascular) during a median follow-up period of 8.4 years. With adjustment for gender, age, risk indices, and clinic blood pressure, higher mean values of ambulatory blood pressure were independent predictors for cardiovascular mortality. The relative hazard ratio for each 10-mm Hg increase in systolic blood pressure was 1.12 (1.06 to 1.18; P<0.001) for daytime and 1.21 (1.15 to 1.27; P<0.001) for nighttime systolic blood pressure. The hazard ratios for each 5-mm Hg increase in diastolic blood pressure were 1.02 (0.99 to 1.07; P=NS) for daytime and 1.09 (1.04 to 1.13; P<0.01) for nighttime diastolic pressures. The hazard ratios for nighttime ambulatory blood pressure remained significant after adjustment for daytime ambulatory blood pressure. These results have 2 important clinical messages: ambulatory measurement of blood pressure is superior to clinic measurement in predicting cardiovascular mortality, and nighttime blood pressure is the most potent predictor of outcome.

Aim. To compare the effectiveness of three variants of long-term combination antihypertensive therapy (AHT), based on two methods of renin-angiotensinaldosterone system (RAAS) inhibition (angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor antagonists (ARAII)) or on calcium channel blockade with a dihydropyridine calcium channel blocker (CCB), all of which were administered in order to achieve target levels of blood pressure (BP). To develop an algorithm for differential administration of combination AHT in patients with arterial hypertension (AH) and Type 2 diabetes mellitus (DM-2). Material and methods. The study included 71 patients (mean age 56,8±6,5 years) with AH and DM-2, but without clinically manifested nephroangopathy. The therapy course (30–32 weeks) was completed by 69 patients. All participants were randomised into three groups. The ACEI+CCB group (n=22) received perindopril (5–10 mg/d), indapamide SR (1,5 mg/d), and amlodipine (5–10 mg). The ARAII+CCB group (n=25) was administered valsartan (80–160 mg/d), indapamide SR, and amlodipine. The CCB+BAB group (n=22) received amlodipine (5–10 mg/d), indapamide SR, and metoprolol succinate (50–100 mg/d). The doses of AHT were increased stepwise. At baseline and after 30–32 weeks of the treatment, 24-hour BP monitoring (BPM), renal artery ultrasound and Doppler ultrasound, carbohydrate and lipid metabolism assessment, and 24-hour albumin excretion measurement were performed. Results. Target BP levels were achieved in the majority of patients from all three groups. For the two-component combination AHT, target BP levels were achieved more often with the combination of RAAS inhibitors and indapamide SR, compared to the combination of CCB and indapamide SR. Most patients receiving the latter combination required additional administration of a third medication, in order to achieve adequate BP control. The combination of CCB and BAB increased intrarenal vascular resistance and less effectively controlled night-time systolic AH, compared to the combination of RAAS inhibitors and CCB. The combination of ACEI and CCB, compared to the ARAII+CCB combination, was associated with improved glycemic control, effective reduction of the duration of night-time diastolic AH and night-time heart rate, and normalisation of initially elevated intrarenal vascular resistance at the level of segmental intrarenal arteries. These findings were used for the development of the algorithm for differential administration of combination AHT in patients with AH and DM-2. Conclusion. In DM-2 patients, long-term combination AHR with ACEI and CCB demonstrates more beneficial effects on the metabolic and neurohumoral regulation processes, compared to the combination of ARAII and CCB. These benefits are particularly pronounced in patients with inadequate glycemic control and increased intrarenal vascular resistance. The combination of CCB and BAB inadequately controls night-time systolic AH and does not improve renal hemodynamics.

Objective The aim of this study was to assess the long-term effects of low-dose oral hormone replacement therapy (HRT) on 24-h blood pressure in hypertensive postmenopausal women.Study design In this 12-month, prospective study, 66 postmenopausal women with mild or moderate hypertension were randomly assigned to receive either HRT with 1 mg/day micronized 17β-estradiol sequentially combined with 10 mg/day dydrogesterone for 14 days of each 28-day cycle, or no therapy. Ambulatory blood pressure measurements were recorded for a 24-h period at baseline and after 12 months of treatment or follow-up.Results Blood pressure did not differ significantly between the groups at baseline. After 12 months, there were falls in 24-h systolic, diastolic and mean arterial blood pressure in both the HRT and control groups; only the fall in mean arterial blood pressure in the HRT group achieved statistical significance (−2.0 ± 0.8 mmHg, p < 0.01). While there was no significant decrease in daytime systolic or mean arterial blood pressure in either group, a significant decrease in diastolic blood pressure (−1.8 ± 10 mmHg, p < 0.001) was observed in the HRT group. Night-time systolic and mean arterial blood pressure also decreased significantly (p < 0.001) in the HRT group (−3.0 ± 1.5 mmHg and −2.2 ± 0.6 mmHg, respectively), but no significant change was observed in the control group.Conclusion Low-dose oral HRT caused significant falls in both daytime and night-time ambulatory blood pressure in postmenopausal women with mild or moderate hypertension.

The prognostic importance of tight clinic blood pressure (BP) control is controversial in diabetic patients. The objective was to investigate the prognostic impact of clinic and ambulatory BPs for cardiovascular morbidity and mortality in type 2 diabetes. In a prospective cohort study, 565 type 2 diabetic patients had clinical, laboratory and ambulatory BP monitoring (ABPM) data obtained at baseline and during follow-up. The primary endpoints were a composite of fatal and nonfatal cardiovascular events and all-cause mortality. Multivariable Cox survival and splines regression analyses assessed associations between each BP component [SBP, DBP and pulse pressure (PP)] and the endpoints. After a median follow-up of 5.75 years, 88 total cardiovascular events and 70 all-cause deaths occurred. After adjustments for cardiovascular risk factors, clinic SBP and DBPs were predictive of the composite endpoint but not of all-cause mortality, whereas all ambulatory BP components were predictors of both endpoints. Ambulatory systolic and PPs were the strongest predictors and achieved ambulatory BPs during follow-up improved risk prediction in relation to baseline values. When categorized at clinically relevant cut-off values, risk began only at clinic BPs at least 140/90 mmHg, whereas for ambulatory BPs it began at lower values (≥120/75 mmHg for the 24-h period). ABPM provides more valuable information regarding cardiovascular risk stratification than office BPs and should be performed, if possible, in every high-risk type 2 diabetic patient. Achieved 24-h ambulatory BPs less than 120/75 mmHg are associated with significant cardiovascular protection and, if confirmed by other studies, may be considered as BP treatment targets.