Search

Objectives: Although the prognostic value of the day-night blood pressure (BP) changes is well established, the most appropriate method for definition of daytime and nighttime BP is still undefined. In a recent guidelines document of the European Society of Hypertension, there is no clear position in favor of one definition over other., Methods: In the setting of the Progetto Ipertensione Umbria Monitoraggio Ambulariale study, we analyzed the prognostic impact of the day-night BP changes by using three widely used different definitions of day and night (large fixed-clock intervals, narrow fixed-clock intervals, diary) in 2934 initially untreated participants with essential hypertension., Results: Three hundred and fifty-six cardiovascular events and 176 deaths over a median follow-up period of 7 years were observed. Nondippers showed a higher risk of total cardiovascular events and all-cause mortality than dippers regardless of the definition of day and night. Furthermore, the area under a receiver-operated characteristic curve analysis did not differ among the different definitions of day and night (large fixed-clock intervals, narrow fixed-clock intervals, diary) for total cardiovascular events and all-cause mortality (all P=NS)., Conclusion: The data suggest that the prognostic value of the diurnal BP changes is comparable when day and night are defined using large fixed-clock intervals, narrow fixed-clock intervals, or actual time spent in and out of bed.

Objective: Self-measured blood pressure (BP) and 24-hour ambulatory blood pressure (ABP) monitoring are used to define the arbitrary clinical categories of masked hypertension (MH) and white-coat hypertension (WCH). Severity of target organ damage and incidence of major cardiovascular events are greater in patients with MH than in patients whose BP is normal both inside and outside the doctor's office., Methods: We reviewed studies that addressed the prognostic impact of MH and WCH., Results: Overall, WCH was associated with a better outcome and MH to a poor outcome. We, however, need the criteria to identify the clinically normotensive patients at elevated pretest probability of MH in whom a broad use of self-measured home BP and 24-hour ambulatory BP as screening tests may be appropriate and cost effective. Clinical management of patients with MH should continue to be based on current guidelines and mostly related to target organ damage and associated clinical conditions because of the normal values of clinic BP in these patients. WCH is generally defined by the coexistence of persistently high office BP with normal daytime or 24-hour ABP. Daytime ABP normalcy has been defined by values<135/85 mmHg. Data, however, suggest that incidence of cardiovascular events tends to increase consistently above the cut-off value of 130/80 mmHg for daytime BP., Conclusion: The long-term outcome of patients with WCH remains uncertain. Data suggesting an increased risk of stroke need to be confirmed in wide-scale studies.

Objectives: To determine the accuracy of the UA-774 (UA-767Plus) blood pressure monitor developed by the A&D Company., Methods: Device evaluation was performed according to the modified British Hypertension Society (BHS) protocol released in 1993. Eighty-five subjects with characteristics outlined in the BHS protocol were recruited among those attending the outpatient clinic of the Department of Cardiovascular Disease, Hospital 'R. Silvestrini', Perugia, Italy. The A&D blood pressure monitor was evaluated according to the various steps of the protocol. Sequential readings were taken for the main validation test. Outcome was classified according to the criteria of BSH recommendations, which are based on four areas of accuracy differing from the mercury standard by 5, 10 and 15 mmHg, or more., Results: The device achieved a grade A for systolic and a grade A for diastolic blood pressure. Mean blood pressure difference (+/-1 SD) between device and observers was -1.01+/-7.14 mmHg for systolic blood pressure and -1.42+/-7.61 mmHg for diastolic blood pressure. There was no systematic change in the device-observed difference over a wide range of blood pressure values, Conclusions: These data show that the A&D UA-774 (UA-767Plus) device satisfies the BSH recommendations for accuracy for systolic and diastolic blood pressure.

The coexistence of persistently high office blood pressure with normal blood pressujre outside the medical setting is often referred to as 'white-coat', 'office' or 'isolated clinic' hypertension. The definition of normal blood pressure outside the medical setting is controversial. In our experience, not only the prevalence of white-coat hypertension, but also left ventricular mass measured echocardiographically and the prevalence of left ventricular hypertrophy in this condition markedly vary on going from more restrictive (lower) to more liberal (higher) limits of ambulatory blood pressure normalcy over quite a narrow range. In a prospective study, cardiovascular morbidities of healthy normotensive controls and subjects with white-coat hypertension did not differ. A more recent analysis of our database supports the use of qujite a restrictive definition of white-coat hypertension (average daytime blood pressure < 130/80 mmHg) in order to identify the minority of subjects who have a low risk of cardiovascular morbid events during the subsequent years. A recent document published by the American Society of Hypertension suggests that slightly higher upper limits of ambulatory blood pressure normalcy (i.e. average daytime blood pressure < 135 mmHg systolic and 85 mmHg diastolic) should be used. In a follow-up study by our group, 37% of subjects with white-coat hypertension spontaneously evolved into cases of ambulatory hypertension, with accompanying increases in left ventricular mass. In that study, the probability of a subject developing ambulatory hypertension increased with the baseline values of ambulatory blood pressure and it was quite low (20%) for those with daytime blood pressures below 130/80 mmHg. In two recent controlled studies, the rate of development of ambulatory hypertension over time for untreated subjects did not differ between the normotensive control group and the group with white-coat hypertension. A final answer regarding the clinical significance of white-coat hypertension will come from very large surveys of the natural history of this condition in the long term. For now, we suggest a verdict of innocence for white-coat hypertension when low values of daytime ambulatory blood pressure (i.e. < 130/80 mmHg) and absence of organ lesions and other risk factors coexist.

BACKGROUND: In a previous analysis of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale we found a higher rate of cardiovascular morbid events among hypertensive nondippers than we did among dippers (5.86 versus 1.18 events per 100 person-years, P = 0.0002) for women, whereas the difference between the two groups was smaller and not statistically significant for men (4.15 versus 2.48 events per 100 person-years). These differences held in a multivariate analysis after adjustment for several confounders including average 24 h ambulatory blood pressure. In another analysis, the rate of occurrence of cardiovascular end-points was higher among nondippers than it was among dippers regardless of the definition of day and night (0600-2200 h and 2200-0600 h, awake and asleep, and 1000-2000 h and 2400-0600 h) and of the dividing line between dippers and nondippers (10 versus 0% day-night difference in blood pressure). OBJECTIVE: To test in a subsequent analysis based on a larger sample and a longer follow-up period, for both sexes, the prognostic value of a blunted diurnal rhythm of blood pressure. METHOD: We used the night: day ratio of ambulatory blood pressure, a continuous and normally distributed variable. RESULTS: A night: day systolic blood pressure ratio > 0.899 for men and > 0.909 for women (upper tertiles of distributions) identified a subset of subjects with greater than normal cardiovascular risk for any level of concomitant risk factors, wherease the hight:day diastolic blood pressure ratio was not statistically significant as an independent predictor. The excess risk for subjects in the upper tertile of the night: day systolic blood pressure ratio held after adjustment for several risk markers, including average 24 h ambulatory blood pressure. CONCLUSION: These data suggest that a blunted reduction in blood pressure from day to night predicts an increased cardiovascular morbidity at any level of concomitant risk factors including average 24 h ambulatory blood pressure. Nondippers can be defined in terms of a night: day ambulatory systolic blood pressure ratio > 0.899 for men and > 0.909 for women, regardless of the diastolic blood pressure profile.

OBJECTIVE: To assess the spontaneous changes in clinic blood pressure, ambulatory blood pressure (ABP) and left ventricular structure in untreated subjects with white-coat hypertension (WCH). DESIGN: A prospective observational study. PATIENTS AND METHODS: In 83 untreated subjects with WCH, 24 h non-invasive ABP monitoring and echocardiographic studies of the left ventricle were repeated after 0.5-6.5 years (mean 2.5) in the absence of antihypertensive drug treatment. WCH was defined by an average daytime ABP < 131/86 mmHg in women and < 136/87 mmHg in men. Ambulatory hypertension was defined by higher ABP values. RESULTS: In the whole population, the clinic blood pressure, ABP and left ventricular mass did not change from baseline to the follow-up visit, whereas the peak A: peak E ratio (where A is the velocity of transmitral blood flow after atrial contraction and E is the velocity during passive left ventricle filling) increased from 0.86 to 0.93. Sixty-three per cent of subjects remained in the WCH category at follow-up study; the remaining 37% shifted to the ambulatory hypertension category. The former group showed no changes in clinic blood pressure, ABP, left ventricular mass and peak A: peak E ratio. The clinic blood pressure of those who developed ambulatory hypertension did not change, whereas their ABP and peak A: peak E ratio increased and their left ventricular mass increased slightly but not significantly. The left ventricular mass increased from baseline to follow-up study by 6.2% in those who developed ambulatory hypertension and decreased by 1.6% in those who remained in the WCH category. The changes in left ventricular mass were associated with the changes in average 24 h systolic blood pressure, but not with the changes in clinic blood pressure. In a stepwise logistic regression analysis, average daytime diastolic blood pressure was the sole variable to enter the model and the probability of ambulatory hypertension at follow-up study was 20.0%percnt; in those with basal daytime ABP <130/80 mmHg, versus 81% in those with higher basal daytime blood pressure levels. CONCLUSION: After 0.5-6.5 years, WCH spontaneously evolved into ambulatory hypertension in 37% of subjects, with an accompanying rise in left ventricular mass. The probability of ambulatory hypertension increased with the baseline values of ABP, rather than with those of clinic blood pressure. WCH might be a prehypertensive state (particularly in subjects with higher baseline ABP levels) and should be defined by low levels of daytime ABP, possibly lower than 130/80 mmHg.

BACKGROUND: Blood pressure variability is a determinant of target organ damage in essential hypertension, but its independent prognostic significance has not yet been assessed in prospective studies of cardiovascular morbidity and mortality. OBJECTIVE: To assess the relationship between blood pressure variability, assessed non-invasively using 24 h ambulatory blood pressure monitoring and subsequent incidence of cardiovascular morbid events in persons with essential hypertension. DESIGN: Prospective observational study. PATIENTS AND METHODS: We followed for up to 8.6 years (mean 2.92) 1372 individuals with essential hypertension whose initial off-therapy diagnostic work-up included 24 h non-invasive ambulatory blood pressure monitoring. Those with a standard deviation of daytime or night-time blood pressure below or above the group mean were classified as having low or high blood pressure variability, respectively. One hundred and eighty-two participants underwent repeated ambulatory blood pressure monitoring and echocardiography during follow-up, 2.7 years later. RESULTS: Target organ damage score was greater in the participants with high variability of daytime (P = 0.004) and night-time (P = 0.011) systolic blood pressure than in those with low blood pressure variability. In those who underwent repeated echocardiography, for every quartile of baseline ambulatory blood pressure, left ventricular mass at follow-up was greater (all P < 0.05) in those with high baseline blood pressure variability than in those with low baseline variability. During follow-up there were 106 major cardiovascular morbid events. Event rate was 1.99 and 3.26 events per 100 patient-years, respectively, in participants with low and high variability of daytime systolic pressure and 1.98 and 3.38 events per 100 patient-years, respectively, in those with low and high variability of night-time systolic pressure (log-rank test: both P < 0.05). However, in a Cox multivariate analysis, the variability score for daytime and night-time systolic pressure failed to enter the model (age, diabetes mellitus, previous cardiovascular events and average night-time systolic pressure were independently associated with cardiovascular events). CONCLUSION: Increased blood pressure variability, assessed with non-invasive monitoring, is associated with a higher incidence of cardiovascular morbid complications of hypertension, but also with a higher blood pressure, older age and a higher prevalence of diabetes mellitus. Because of the relevant predictive effect of these associated factors, the adverse prognostic significance of increased blood pressure variability is no longer detectable in multivariate analysis.