Medline ® Abstracts for References 20,27,41,42
of 'Ambulatory and home blood pressure monitoring and white coat hypertension in adults'
Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study.
Dolan E, Stanton A, Thijs L, Hinedi K, Atkins N, McClory S, Den Hond E, McCormack P, Staessen JA, O'Brien E
Hypertension. 2005;46(1):156. Epub 2005 Jun 6.
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.
ADAPT Centre, Beaumont Hospital, Department of Clinical Pharmacology, Royal College of Surgeons, Dublin, Ireland.
Prognostic value of ambulatory blood-pressure recordings in patients with treated hypertension.
Clement DL, De Buyzere ML, De Bacquer DA, de Leeuw PW, Duprez DA, Fagard RH, Gheeraert PJ, Missault LH, Braun JJ, Six RO, Van Der Niepen P, O'Brien E, Office versus Ambulatory Pressure Study Investigators
N Engl J Med. 2003;348(24):2407.
BACKGROUND: It is uncertain whether ambulatory blood-pressure measurements recorded for 24 hours in patients with treated hypertension predict cardiovascular events independently of blood-pressure measurements obtained in the physician's office and other cardiovascular risk factors.
METHODS: We assessed the association between base-line ambulatory blood pressures in treated patients and subsequent cardiovascular events among 1963 patients with a median follow-up of 5 years (range, 1 to 66 months).
RESULTS: We documented new cardiovascular events in 157 patients. In a Cox proportional-hazards model with adjustment for age, sex, smoking status, presence or absence of diabetes mellitus, serum cholesterol concentration, body-mass index, use or nonuse of lipid-lowering drugs, and presence or absence of a history of cardiovascular events, as well as blood pressure measured at the physician's office, higher mean values for 24-hour ambulatory systolic and diastolic blood pressure were independent risk factors for new cardiovascular events. The adjusted relative risk of cardiovascular events associated with a 1-SD increment in blood pressure was 1.34 (95 percent confidence interval, 1.11 to 1.62) for 24-hour ambulatory systolic blood pressure, 1.30 (95 percent confidence interval, 1.08 to 1.58) for ambulatory systolic blood pressure during the daytime, and 1.27 (95 percent confidence interval, 1.07 to 1.57) for ambulatory systolic blood pressure during the nighttime. For ambulatory diastolic blood pressure, the corresponding relative risks of cardiovascular events associated with a 1-SD increment were 1.21 (95 percent confidence interval, 1.01 to 1.46), 1.24 (95 percent confidence interval, 1.03 to 1.49), and 1.18 (95 percent confidence interval, 0.98 to 1.40).
CONCLUSIONS: In patients with treated hypertension, a higher ambulatory systolic or diastolic blood pressure predicts cardiovascular events even after adjustment for classic risk factors including office measurements of blood pressure.
Department of Cardiovascular Diseases, Ghent University, Ghent, Belgium. firstname.lastname@example.org
Cardiovascular prognosis of "masked hypertension" detected by blood pressure self-measurement in elderly treated hypertensive patients.
Bobrie G, Chatellier G, Genes N, Clerson P, Vaur L, Vaisse B, Menard J, Mallion JM
CONTEXT: Blood pressure (BP) measurement in clinicians' offices with a mercury sphygmomanometer has numerous drawbacks. In contrast, the use of home BP measurement improves measurement precision and reproducibility. However, data about its prognostic value are lacking.
OBJECTIVE: To assess the prognostic value of home vs office BP measurement by general practitioners in a European population of elderly patients being treated for hypertension.
DESIGN, SETTING, AND PARTICIPANTS: Office and home BP and cardiac risk factors were measured at baseline in a cohort of 4939 treated hypertensive patients (mean age, 70 [SD, 6.5]years; 48.9% men) who were recruited and followed up by their usual general practitioners without specific recommendations about their management. The cohort was then followed up for a mean of 3.2 (SD, 0.5) years. The thresholds defining uncontrolled hypertension were at least 140/90 mm Hg for office BP and 135/85 mm Hg for home BP.
MAIN OUTCOME MEASURES: The primary end point was cardiovascular mortality. Secondary end points were total mortality and the combination of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, transient ischemic attack, hospitalization for angina or heart failure, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery.
RESULTS: At the end of follow-up, clinical status was known for 99.9% of patients. At least 1 cardiovascular event had occurred in 324 (incidence, 22.2/1000 patient-years). For BP self-measurement at home, each 10-mm Hg increase in systolic BP increased the risk of a cardiovascular event by 17.2% (95% confidence interval [CI], 11.0%-23.8%) and each 5-mm Hg increase in diastolic BP increased that risk by 11.7% (95% CI, 5.7%-18.1%). Conversely, for the same increase in BP observed using office measurement, there was no significant increase in the risk of a cardiovascular event. In a multivariable model with patients having controlled hypertension (normal home and office BP) as the referent, the hazard ratio of cardiovascular events was 1.96 (95% CI, 1.27-3.02) in patients with uncontrolled hypertension (high BP with both measurement methods), 2.06 (95% CI, 1.22-3.47) in patients with normal office BP and elevated home BP, and 1.18 (95% CI, 0.67-2.10) in patients with elevated office BP and normal home BP.
CONCLUSIONS: Our findings suggest that home BP measurement has a better prognostic accuracy than office BP measurement. Blood pressure should systematically be measured at home in patients receiving treatment for hypertension.
Service d'Hypertension Artérielle, Hôpital Européen Georges Pompidou, Paris, France. email@example.com
Prognosis of "masked" hypertension and "white-coat" hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study.
Ohkubo T, Kikuya M, Metoki H, Asayama K, Obara T, Hashimoto J, Totsune K, Hoshi H, Satoh H, Imai Y
J Am Coll Cardiol. 2005;46(3):508.
OBJECTIVES: We sought to investigate the prognosis in subjects with "white-coat" hypertension (WCHT) and "masked" hypertension (MHT), in which blood pressure (BP) is lower in clinical measurements than during ambulatory monitoring.
BACKGROUND: The prognostic significance of WCHT remains controversial, and little is known about MHT.
METHODS: We obtained 24-h ambulatory BP and "casual" BP (i.e., obtained in clinical scenarios) values from 1,332 subjects (872 women, 460 men)>or =40 years old in a representative sample of the general population of a Japanese community. Survival and stroke morbidity were then followed up for a mean duration of 10 years.
RESULTS: Composite risk of cardiovascular mortality and stroke morbidity examined using a Cox proportional hazards regression model for subjects with WCHT (casual BP>or =140/90 mm Hg, daytime BP<135/85 mm Hg; relative hazards [RH])1.28; 95% confidence interval [CI]0.76 to 2.14) was no different from risk for subjects with sustained normal BP (casual BP<140/90 mm Hg, daytime BP<135/85 mm Hg). However, risk was significantly higher for subjects with MHT (casual BP<140/90 mm Hg, daytime BP>or =135/85 mm Hg; RH 2.13; 95% CI 1.38 to 3.29) or sustained hypertension (casual BP>or =140/90 mm Hg, daytime BP>or =135/85 mm Hg; RH 2.26; 95% CI 1.49 to 3.41) than for subjects with sustained normal BP. Similar findings were observed for cardiovascular mortality and stroke morbidity among subgroups by gender, use of antihypertensive medication, and risk factor level (all p for heterogeneity>0.2).
CONCLUSIONS: Conventional BP measurements may not identify some individuals at high or low risk, but these people may be identifiable by the use of ambulatory BP.
Department of Planning for Drug Development and Clinical Evaluation, Sendai, Japan. firstname.lastname@example.org