Implementing Home Blood Pressure Into Practice

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.

sponsorship: The European Union (HEALTH-F7-2011-278249 EU-MASCARA, HEALTH-F7-305507 HOMAGE and the European Research Council Advanced Researcher Grant 294713 EPLORE) and the Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium (G.0881.13 and G.0880.13) currently support the Studies Coordinating Centre (Leuven, Belgium). (European Union|HEALTH-F7-2011-278249 EU-MASCARA, European Union|HEALTH-F7-305507 HOMAGE, European Union (European Research Council)|294713 EPLORE, Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium|G.0881.13, Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium|G.0880.13)

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 …

Recent evidence indicates that both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) are more useful than the measurement of office blood pressure for evaluating cardiovascular risks in subjects with hypertension. The major advantage of ABPM over HBPM is the ability to measure nighttime blood pressure and ambulatory blood pressure during the day. A newly developed, programmable HBPM device (HEM-5041, Omron Healthcare, [corrected] Kyoto, Japan) can record blood pressure up to 600 [corrected] times and measure nighttime blood pressure automatically. To validate the utility, feasibility, and safety of this device, we measured blood pressure by HBPM using HEM-5041 and by ABPM and compared the values in healthy volunteers. As compared with ABPM, daytime blood pressures, coefficients of variation for systolic blood pressure, diastolic blood pressure, and pulse rate, and the percentage nighttime fall in these variables were significantly lower with HBPM. However, nighttime blood pressures did not significantly differ between HBPM and ABPM. The results of a questionnaire survey indicated that the subjects were more comfortable when blood pressure was measured by HBPM than by ABPM, whereas the quality of sleep was similar. Our results suggest that HEM-5041 is useful for evaluating nighttime blood pressures as well as nighttime blood pressure falls, without causing clinically significant discomfort.

Home blood pressure–guided antihypertensive therapy in chronic kidney disease: more data are needed

Objective Abnormal nighttime blood pressure (BP) feature including early morning surge (EMS), nocturnal hypertension (NH) and non-dipping systolic blood pressure (NDSBP) are predictors for cardiovascular events (CVE) and mortality. This study aimed to try to determine which of the home blood pressure monitor (HBPM) parameters can predict abnormal BP feature. Methods The study population consisted of participants with prehypertension and stage 1 hypertension, recruited from 11 medical centers within the Taiwan Hypertension-Associated Cardiac Disease Consortium (TCHC). We selected participants who underwent both HBPM and 24-hour ambulatory blood pressure monitoring (ABPM) within a six-month period. Using machine learning, we analyzed various detailed home blood pressure measurement parameters, including morning blood pressure, evening blood pressure, morning-evening blood pressure difference, morning-evening blood pressure average, and various blood pressure variability indicators. Separate analyses were conducted for systolic blood pressure, diastolic blood pressure, pulse pressure, and mean arterial pressure to identify which home blood pressure parameters could predict nocturnal hypertension. Results A total of 1,129 patients were enrolled. For those with a history of previous cardiovascular disease (CVD), the difference between morning and evening average blood pressure was the best predictor of abnormal blood pressure features. On the other hand, for patients without a history of CVD, the maximum evening pulse pressure was the most predictive of abnormal blood pressure features. Using a machine learning-assisted model, the accuracy was 0.882, precision was 0.889, F1 score was 0.889, and AUC was 0.972. Conclusion Our results highlight the potential of machine learning-based Abnormal BP feature prediction using HBPM. The accuracy of the predictions demonstrated that HBPM feature that can predict EMS, NH and NDSBP.

Ambulatory blood pressure (BP) monitoring (ABPM) is a cornerstone in resistant hypertension (RHT) management. However, it has higher cost and lower patients' acceptance than home BP monitoring (HBPM). Our objective was to evaluate HBPM usefulness in the management of patients with RHT. A total of 240 patients were submitted to 24-hour ABPM and 5-day HBPM (triplicate morning and evening measurements). Patients with uncontrolled office BP (≥140/90mm Hg) were classified as true RHT (daytime or home BP ≥135/85mm Hg) or white-coat RHT (daytime or home BP <135/85mm Hg), and patients with controlled office BP were classified as masked RHT (daytime or home BP ≥135/85mm Hg) or controlled RHT (daytime or home BP <135/85mm Hg). Sensitivity, specificity, predictive values, and likelihood ratios for HBPM were calculated. Agreement between the procedures was evaluated using kappa coefficients and the Bland-Altman method. Mean office BP was 157±26/84±16mm Hg, mean daytime BP was 134±18/77±13mm Hg, and mean home BP was 143±20/76±14mm Hg. The ABPM and HBPM diagnoses were 35% and 48%, respectively, for true RHT; 36% and 23%, respectively, for white-coat RHT; 7% and 17%, respectively, for masked RHT; and 22% and 13%, respectively, for controlled RHT. HBPM overestimated systolic BP by 8.8 (95% confidence interval (CI) = 6.8-10.7) mm Hg and diastolic BP by 0.2 (95% CI = -1.0 to 1.4) mm Hg. The specificity, sensitivity, and positive and negative predictive values of HBPM in detecting controlled ambulatory BP were 91%, 55%, 89%, and 59%. HBPM presented good agreement with ABPM and can be used as a complementary method in the follow-up of resistant hypertensive patients, particularly in those with controlled ambulatory BPs.

An algorithm for making a differential diagnosis between sustained and white coat hypertension (WCH) has been proposed - patients with office hypertension undergo home blood pressure monitoring (HBPM) and those with normal HBP levels undergo ambulatory blood pressure monitoring (ABPM). We tested whether incorporating an upper office blood pressure (OBP) cut-off in the algorithm, higher than the traditional 140/90 mmHg, reduces the need for HBPM and ABPM. Two hundred twenty-nine normotensive and untreated mildly hypertensive participants (mean age 52.5 +/- 14.6 years, 54% female participants) underwent OBP measurements, HBPM, and 24-h ABPM. Using the algorithm, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) for sustained hypertension and WCH were assessed. We then modified the algorithm utilizing a systolic and diastolic OBP cut-off at a specificity of 95% for ambulatory hypertension - those with office hypertension but OBP levels below the upper cut-off underwent HBPM and subsequent ABPM, if appropriate. Using the original algorithm, sensitivity and PPV for sustained hypertension were 100% and 93.8%, respectively. Despite a specificity of 44.4%, NPV was 100%. These values correspond to specificity, NPV, sensitivity, and PPV for WCH, respectively. Using the modified algorithm, the diagnostic accuracy for sustained hypertension and WCH did not change. However, far fewer participants needed HBPM (29 vs. 84) and ABPM (8 vs. 15). In this sample, the original and modified algorithms are excellent at diagnosing sustained hypertension and WCH. However, the latter requires far fewer participants to undergo HBPM and ABPM. These findings have important implications for the cost-effective diagnosis of sustained hypertension and WCH.

Background: A number of studies reveal that home blood pressure variability is associated with cardiovascular risk factors. However, we do not have a consensus regarding the variability index and the frequency of measurements. Objective: The aim of the study was to assess home blood pressure variability for a period of 7 consecutive days and 24-hour ambulatory blood pressure variability using the average real variability index and to test whether home blood pressure variability represents a suitable parameter for long-term monitoring of the hypertensive patients. Material and methods: A number of 31 hypertensive patients were included in the study, 8 male, 23 female, mean age 60.19±7.35 years. At the inclusion ambulatory blood pressure monitoring was performed, home blood pressure monitoring was carried out for 7 consecutive days with 2 measurements daily. We compared ambulatory blood pressure values, variability using paired t-test. We were looking for correlations between HBP values and cardiovascular risk factors. Results: Ambulatory versus home blood pressure derived mean blood pressure was 131.38±15.2 versus 131.93±8.25, p=0.81. Ambulatory derived variability was 10.65±2.05 versus home variability 10.56±4.83, p=0.91. Home versus ambulatory pulse pressure was 51.8± 9.06 mmHg vs. 54.9±11.9 mmHg, p=0.046. We found positive correlation between HBPV and home BP values, p=0.027, r2=0.1577, (CI: 0.04967 to 0.6588). Home, as well as ambulatory derived variability were positively correlated to age p=0.043, r2=0.1377 (CI: 0.01234 to 0.6451) versus p&lt;0.0001, CI: 0.3870 to 0.8220, r2=0.4302. Conclusion: Assessment of home blood pressure monitoring and variability could represent a well-tolerated alternative for long-term follow-up of hypertension management.

Background: Few studies have compared accurately measured office, self-measured home, and ambulatory blood pressure (BP) for asymptomatic intracranial artery stenosis (ICAS). Relationship of day-by-day or short-term variability in BP to asymptomatic ICAS remains unclear. Objectives: To examine the association of office, home (mean value and day-by-day variability), and ambulatory BP indices (24-hour/daytime/nighttime mean values, short-term variability, nocturnal decline, and morning pressor surge) with asymptomatic ICAS. Methods: Data on office and 7-day home BP and magnetic resonance angiography to assess ICAS were obtained in 677 men (mean age, 70.0 years) from a population-based cohort. Among them, 468 underwent 24-hour ambulatory BP monitoring. Mild- or severe-ICAS was defined as 1-49% or ≥50% stenosis, respectively, and any-ICAS as either mild or severe-ICAS. Results: We observed mild- and severe-ICAS in 153 (22.6%) and 36 (5.3%) participants, respectively. In multivariable Poisson regression with robust error variance, higher systolic BP at office, home, or ambulatory BP monitoring was associated with the presence of any- or severe-ICAS. The associations with ICAS were comparable between office, home, and ambulatory systolic BP (all heterogeneity Ps &gt;0.1). Independent of mean systolic BP, greater nocturnal decline or morning pressor surge in systolic BP was associated with higher burden of any- or severe-ICAS. Conclusion: The magnitude of association of BP accurately measured at office for asymptomatic ICAS was comparable with that of BP at home or ambulatory BP monitoring. Circadian BP variation based on ambulatory BP monitoring may be considered when assessing ICAS in apparently healthy individuals.

Relative Utility of Home, Ambulatory, and Office Blood Pressures in the Prediction of End-Organ Damage

Over the past 5 years, numerous hypertension treatment trials have been completed and reported.1-8 A majority of these trials were initiated to distinguish one therapy from another in reducing cardiovascular (CV) events. Some were blinded and appropriately randomized prospective trials; others were unblinded or prospective cohort studies. Various populations have been studied, and results have differed. Statistical manipulations have often been carried out to prove a point if trial results were different than the investigators had anticipated. An ongoing question remains: “What really matters in determining therapy?” Is it the lowering of blood pressure (BP) that reduces CV events, or does the use of specific medications account for differing results? A meta-analysis of the clinical trials has determined that it is the degree of BP lowering that makes the major difference in outcome, and not specific medical therapy.9 Many individual trials appear to confirm this conclusion. For example, the Verapamil in Hypertension Atherosclerosis Study (VHAS)10 reported no difference in outcome between a diuretic and verapamil. The Controlled Onset Verapamil Investigation of Cardiovascular End Points (CONVINCE)8 study reported no differences between a verapamil-based treatment and usual care, i.e., a diuretic plus a β blocker and other drugs, and the United Kingdom Prospective Diabetes Study (UKPDS)11 in type 2 diabetics reported no difference in outcome between a β-blocker-based and an angiotensin-converting enzyme inhibitor (ACEI)-based treatment program if Bps were lowered to an equivalent degree. In the latter study, which included an 8.5-year follow-up of more than 1100 patients, a difference of only 10/5 mm Hg accounted for a significant decrease in macrovascular and microvascular CV events in diabetics in the group of patients who achieved the lower levels of BP.11 In the Swedish Trial in Old Patients with Hypertension (STOP-2) study,12 both systolic and diastolic Bps were reduced to an equivalent degree with calcium channel blockers (CCBs) and ACEIs compared with diuretics and β blockers. There was also no significant difference in overall outcomes. In this study, however, patients on ACEIs had fewer myocardial infarctions (MIs) and less congestive heart failure than patients receiving a CCB. This finding had also been noted in several other smaller studies when a CCB-based regimen was compared with an ACEI-based treatment program.13, 14 In the Blood Pressure Lowering Treatment Trialists' Collaboration meta-analysis, however, these differences were not noted,9 and more recent studies have reported that CCB-based therapy appears to result in CV outcomes similar to those with ACEI- or angiotensin receptor blocker (ARB)-based regimens. It appears, therefore, that abundant data confirm that BP lowering accounts for most of the benefit noted in the clinical trials. In some high-risk patients, however, results have been somewhat different. In the Heart Outcomes Prevention Evaluation (HOPE),7 the Irbesartan Diabetic Nephropathy Trial (IDNT),15 the Irbesartan Microalbuminuria Type 2 Diabetes in Hypertensive Patients (IRMA) study,16 the Reduction in Endpoints in Noninsulin-Dependent Diabetes Mellitus with the Angiotensin II Antagonist Losartan (RENAAL),6 and the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE)5 studies, the use of an ACEI or angiotensin receptor blocker (ARB), usually given with a diuretic, reduced CV events to a greater degree than a regimen that did not include these medications. In these studies, it appeared that specific medications made a difference in CV event outcome, especially in patients with diabetes and renal disease. Thus, while most trial results confirm the conclusions of the meta-analyses, others indicate that there are instances where specific medications may be more effective than others. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT),1 a randomized, double-blind, multicenter, non-industry-sponsored clinical trial, reported that >60% of hypertensive patients with a mean age of 67 years could be controlled with Bps lower than 140/90 mm Hg if goal Bps were vigorously pursued.17 Primary outcomes (fatal and nonfatal coronary heart disease) showed no difference when a diuretic (chlorthalidone)-based treatment regimen was compared with an ACEI (lisinopril) or a CCB (amlodipine)-based program. When further analyses were done, however, diuretic-treated patients had fewer strokes than ACEI subjects and fewer episodes of heart failure compared with either ACEI- or CCB-treated patients. Some investigators were quick to note that black patients and patients over 65 years of age experienced a greater BP decrease on the diuretic than with other medications, especially when the ACEI was compared with the diuretic. A 4-mm Hg systolic BP difference was noted in black subjects; a 3-mm Hg systolic BP difference was noted in the over-65 group. This may have accounted for at least some of the significant differences in stroke outcome. Specific actions of one medication may, therefore, not have accounted for differences in benefit between groups. In this trial, as in all the others, multiple medications were necessary to achieve goal Bps in a majority of patients. The ALLHAT investigators concluded that a diuretic should be the first-choice drug in most patients but also concluded that a majority of hypertensive patients required more than one drug to achieve goal Bps. The Second Australian National Blood Pressure study (ANBP-2),2 which was not blinded, compared an ACEI-based to a diuretic-based regimen in elderly patients over 5 years. The ACEI-treated patients experienced a marginally better long-term outcome; the benefit, however, was noted only in male patients. Some physicians concluded that the ASNBP-2 results, which were different from ALLHAT, should be the ones to guide therapy—that an ACEI-based treatment program was more beneficial in reducing CV events than a diuretic-based regimen. In the Valsartan Antihypertension Long-Term Evaluation (VALUE),3 Bps were lowered, especially during the first 6 months, to a greater degree with amlodipine than an ARB (valsartan). The occurrence of Mis was lower in the CCB group. Statistical calculations were done to demonstrate that in people with the same achieved BP there was no difference in outcome, but the question of whether it was the achieved BP or a specific treatment that made the difference was not settled. VALUE, like ALLHAT and ASNBP-2, was a trial of multiple-drug therapy and did not completely settle the question of one medication's superiority over another in reducing CV events. The LIFE study,5 which compared the results of an ARB (losartan)- to a β-blocker (atenolol)-based program in hypertensives with left ventricular hypertrophy, demonstrated that strokes were significantly reduced in the ARB group despite essentially similar Bps in both groups at the end of the trial. This trial suggested that specific therapy did make a difference in outcome, at least in some patient subgroups. It was not surprising that outcome was better with therapy other than a β blocker; this had been demonstrated many years ago in the Medical Research Council trial18 in the elderly. When a diuretic was compared with a β blocker and a placebo, the use of a diuretic resulted in a significantly greater decrease in coronary heart disease events compared with the β blocker, but in this trial BP was reduced to a greater degree and in more patients with the diuretic. Other studies, such as RENAAL6 and HOPE,7 suggest that there is some difference in outcome with certain agents compared with other medications with equivalent decreases in BP. But in some of these trials, especially the HOPE trial, there is still a question of whether or not it was BP lowering or medication that made the difference in outcome. Finally, the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) trial,4 which included 77% males and more than 90% Caucasians, concluded that a CCB-based (plus an ACEI) regimen reduced mortality and strokes more than a β-blocker-based (plus a diuretic) program. But, as in the ALLHAT trial, the primary outcome (MI) was similar with both therapies.4, 19 Basically, ASCOT compared a CCB titrated upward to a β blocker titrated upward regimen within the first few months of the study. There was a difference of 5.9/2 mm Hg in BP control in the first few months; this may conceivably have resulted in the better outcome with the CCB. The ASCOT investigators concluded that, based on secondary end points, national guidelines should be changed and that so-called “contemporary” therapy (i.e., CCBs and ACEIs) was superior to older therapy (β blockers and diuretics). The results regarding the use of β blockers as initial therapy may be applicable to elderly Caucasian males but, based on ASCOT, cannot be applied to other gender and ethnic groups. It is also inappropriate, based on the results of ALLHAT and other trials in which diuretics were used as initial therapy, to suggest that the current recommendations for use of these agents be changed. The ASCOT results should not influence guidelines such as those of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)20 that suggested diuretics as initial therapy in most patients and suggested as early as 1998 in JNC VI21 that β blocker monotherapy was not preferred initial therapy in the elderly. ASCOT has confirmed, however, what other trials had reported—multiple medications are necessary to reduce BP. Thus, there are meta-analyses that indicate that it is the BP level that makes the difference in outcome, but also some confusion from several of the trials that suggest specific benefits of various medications over and above the effects of BP lowering. When the data are carefully considered, two conclusions, which may actually not be confusing, can be reached22: 1) the “my drug is better than your drug” argument may be moot—multiple medications are necessary to achieve goal Bps in most cases—and none of the recent trials which have been so highly promoted were trials of monotherapy; and 2) most of the benefit achieved in the treatment trials results from more effective BP control, with exceptions in the cases of patients with diabetes or renal disease. An additional confusing message relates to the occurrence of NOD as a result of treatment in some hypertensive patients. This has recently been reviewed.23, 24 It is well known that diabetes is more common in hypertensives than in normotensives.25 There is, however, a <1% increase in NOD with diuretics and β blockers in placebo-controlled hypertensive treatment trials. In chart reviews, no difference has been found in NOD among diuretics, ACEIs, and CCBs, but an increase has been noted with β blockers.25, 26 In comparative trials, a 1%–3.5% absolute increase in NOD has been reported with a diureticbased compared with an ACEI-based treatment program and about a 1% increase when compared with CCBs.27 The clinical significance of this finding has been questioned; further studies are needed to decide whether or not CV outcome is affected. Data are conflicting. One study with a small number of events suggests that NOD has a similar prognosis as pretreatment diabetes; another does not.28, 29 Both studies report that, while there appears to be a relationship between NOD and the use of diureticbased treatments, there does not appear to be an independent relationship to CV outcome. At present, the data do not indicate that the findings of NOD should lead to a change in the JNC 7 recommendation for diuretics as initial therapy for most patients. The results of some of the recent trials and the NOD data do suggest, however, that the use of β blockers (without vasodilator or α-blocking actions) may not be preferred as initial antihypertensive therapy, especially in obese patients or subjects with findings of the metabolic syndrome. These medications are indicated, however, in patients with angina, heart failure, and post-MI. They should also continue to be used in combination with a diuretic, if necessary, to reduce BP to goal levels.27 Despite all of the expense and effort expended to convince physicians that one therapy is superior to another, the bottom line remains: reduce the BP to as low as possible without interfering with the enjoyment of life, and CV outcome will improve. The choice of medication, with the exception of certain subgroups of patients, appears to be less important than achieving goal BP; medications with differing actions will be necessary in most patients to achieve goal Bps.

Guidelines recommend measuring out-of-clinic blood pressure (BP) to identify masked hypertension (MHT) defined by out-of-clinic BP in the hypertensive range among individuals with clinic-measured BP not in the hypertensive range. The aim of this study was to determine the overlap between ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) for the detection of MHT. We analyzed data from 333 community-dwelling adults not taking antihypertensive medication with clinic BP <140/90 mm Hg in the IDH study (Improving the Detection of Hypertension). Any MHT was defined by the presence of daytime MHT (mean daytime BP ≥135/85 mm Hg), 24-hour MHT (mean 24-hour BP ≥130/80 mm Hg), or nighttime MHT (mean nighttime BP ≥120/70 mm Hg). Home MHT was defined as mean BP ≥135/85 mm Hg on HBPM. The prevalence of MHT was 25.8% for any MHT and 11.1% for home MHT. Among participants with MHT on either ABPM or HBPM, 29.5% had MHT on both ABPM and HBPM; 61.1% had MHT only on ABPM; and 9.4% of participants had MHT only on HBPM. After multivariable adjustment and compared with participants without MHT on ABPM and HBPM, those with MHT on both ABPM and HBPM and only on ABPM had a higher left ventricular mass index (mean difference [SE], 12.7 [2.9] g/m2, P<0.001; and 4.9 [2.1] g/m2, P=0.022, respectively), whereas participants with MHT only on HBPM did not have an increased left ventricular mass index (mean difference [SE], -1.9 [4.8] g/m2, P=0.693). These data suggest that conducting ABPM will detect many individuals with MHT who have an increased cardiovascular disease risk.

Comparison of Office, Home, and Ambulatory Blood Pressure in Heart Transplant Recipients

Hypertension is highly prevalent in Japan, affecting up to 60% of males and 45% of females. Stroke is the main adverse cardiovascular event, occurring at a higher rate than acute myocardial infarction. Reducing blood pressure (BP) therefore has an important role to play in decreasing morbidity and mortality. The high use of home BP monitoring (HBPM) in Japan is a positive, and home BP is a better predictor of cardiovascular event occurrence than office BP. New 2019 Japanese Society of Hypertension Guidelines strongly recommend the use of HBPM to facilitate control of hypertension to new lower target BP levels (office BP<130/80mmHg and home BP<125/75mmHg). Lifestyle modifications, especially reducing salt intake, are also an important part of hypertension management strategies in Japan. The most commonly used antihypertensive agents are calcium channel blockers followed by angiotensin receptor blockers, and the combination of agents from these two classes is the most popular combination therapy. These agents are appropriate choices in South East Asian countries given that they have been shown to reduce stroke more effectively than other antihypertensives. Morning hypertension, nocturnal hypertension, and BP variability are important targets for antihypertensive therapy based on their association with target organ damage and cardiovascular events. Use of home and ambulatory BP monitoring techniques is needed to monitor these important hypertension phenotypes. Information and communication technology-based monitoring platforms and wearable devices are expected to facilitate better management of hypertension in Japan in the future.