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United States and European guidelines have recommended new treatment goals for office blood pressure (BP). We examined 9784 hypertensives of the Spanish Ambulatory BP Monitoring (ABPM) registry with office BP treated to the prior goal (

The prognostic relevance of masked uncontrolled hypertension (MUCH) is incompletely clear and its global impact on cardiovascular outcomes and mortality has not been assessed. The aim of this study was to perform a meta-analysis on the prognostic value of MUCH. We searched for articles assessing outcome in patients with MUCH compared to those with controlled hypertension and reporting adjusted hazard ratio and 95% confidence interval. We identified six studies using ambulatory blood pressure monitoring (12610 patients with 933 events) and five using home blood pressure measurement (17742 patients with 394 events). The global population included 30352 patients who experienced 1327 events. Selected studies had cardiovascular outcomes and all-cause mortality as primary outcome and the main result is a composite of these events. The overall adjusted hazard ratio was 1.80 (95% confidence interval 1.57–2.06) for MUCH versus controlled hypertension. Subgroup meta-analysis showed that adjusted hazard ratio was 1.83 (95% confidence interval 1.52–2.21) in studies using ambulatory blood pressure monitoring and 1.75 (95% confidence interval 1.38–2.20) in those using home blood pressure measurement. Risk was significantly higher in MUCH than in controlled hypertension independently of follow-up length and types of studied events. MUCH was at significantly higher risk than controlled hypertension in all ethnic groups, but the highest hazard ratio was found in studies including Black patients. Risk of cardiovascular events and all-cause mortality is significantly higher in patients with MUCH than in those with controlled hypertension. MUCH detected by ambulatory or home blood pressure measurement appear to convey similar prognostic information.

Clinic blood pressure (BP) is usually higher than daytime ambulatory BP in hypertensive patients, but some recent studies have challenged this view, suggesting that this relationship is strongly influenced by age. We used the Spanish ambulatory BP monitoring cohort to examine differences between clinic and daytime BP by age among 104 639 adult hypertensive patients (office systolic/diastolic BP ≥140/90 mm Hg or treated) in usual primary-care practice, across the wide age spectrum. To assess the impact of age, cardiovascular variables, and clinic BP on the clinic–daytime BP differences, we built multivariable regression models of the average BP differences, white-coat hypertension (high clinic BP and normal daytime BP), and masked hypertension (normal clinic BP and high daytime BP). In most patients, mean clinic BP values were higher than daytime BP at all ages. Some 36.7% of patients had white-coat hypertension (amounting to 50% at clinic systolic BP of 140–159 mm Hg) and 3.9% had masked hypertension (amounting to 18% at clinic systolic BP of 130–139 mm Hg). Age explained 0.1% to 1.7% of the variance of quantitative or categorical BP differences ( P P P 40% of patients. This misclassification was not importantly influenced by age but was more evident in patients with borderline/grade 1 hypertension. These findings reinforce the importance of ambulatory BP monitoring for defining BP status in routine clinical practice.

Blood pressure variability (BPV) is recognized as an important prognostic contributor in hypertension. We asseseds differences in short-term BPV in treated patients depending on the number of drugs, drug-classes and combinations, and individual compounds. From the Spanish ABPM Registry, we selected 38188 treated patiens. BPV estimates were obtained from ABPM records, and included weighted, daytime and nighttime SD and average real variability (ARV). Comparisons (general linear models adjusted for age, gender, diabetes, dyslipidemia and CV disease) were carried out depending on the number of drugs (1, 2, 3, and more). In patients treated with monotherapy (13765), BPV estimates were compared depending on the drug classes, as well as on individual compounds inside each class. Additional comparisons were performed depending on the type of combination in patients treated with 2 (12716) and 3 drugs (7888). Systolic BPV increased from monotherapy to treatment with 4 or more drugs (p

Isolated systolic hypertension (ISH) is a clinical condition derived from increased arterial stiffness and associated with a worse cardiovascular prognosis. Increased blood pressure variability (BPV) is also associated to cardiovascular risk. We aimed to estimate short-term BPV in patients with ISH compared to those with systolic and diastolic hypertension (SDH). From the Spanish ABPM Registry database containing 63910 identified patients, we selected 20497 with ISH and 23269 with SDH. BPV estimates were obtained from ABPM records, and included standard deviation (SD), coefficient of variation (CV), weighted SD and average real variability (ARV). Comparisons were carried out by Student’s t test, and by general linear models adjusted for age, gender and office BP. Due to important differences in age between groups, a case-control matching was performed obtaining 14707 pairs matched by gender and with an age difference < 2 years. Comparisons were repeated in this dataset. Patients with ISH were older, more frequently women, with diabetes and with a previous history of CV disease. Office BP was lower (155±13/81±7 vs. 159±16/98±7 mmHg; p

The SPRINT trial has demonstrated the benefit of intensive BP reduction in hypertensive patients at high cardiovascular risk. Values of ABPM are of potential interest in such patients to better select those who will benefit of a lower BP target. We aimed to evaluate ABPM values in a large cohort of patients potentially candidates (meeting inclusion criteria) for the SPRINT trial. Moreover, in patients on antihypertensive therapy who also fulfill SPRINT criteria, except for clinic SBP ≥ 130 mmHg, we evaluated 24-hour SBP values among those who had clinic SBP < 120; between 120 and 139, or ≥ 140. From the database of the Spanish ABPM Registry containing 115708 patients, we identified 39132 (34%, 51% women, mean age 65 years) who fulfill both inclusion and exclusion criteria of the SPRINT trial. Mean values of clinic SBP were 151±11 mmHg, whereas corresponding values for 24-h SBP were 130±13 mmHg. Overall, 52% of patients had 24-h SBP below 130 mmHg. The proportion varied from 69% in those with clinic BP 130-139 to 34% in those with clinic BP ≥ 170 mmHg. Among 34328 treated patients who fulfilled SPRINT inclusion criteria (except for clinic BP ≥ 130), 1014 (3%) had clinic SBP < 120 mmHg, and 5330 (16%) values between 120 and 139 mmHg. The remaining 27984 patients were not controlled and had clinic SBP ≥ 140 mmHg. Values of 24 h SBP below 130 mmHg were seen in 88% of those with clinic BP < 120, in 74% of those with clinic BP 120-139, and in 47% of those with clinic BP ≥ 140 mmHg. The corresponding proportion of patients having 24-h SBP < 100 mmHg were 7.7%, 1.1%, and 0.6%. We conclude that ABPM assessment could be necessary in the evaluation of hypertensive patients at high CV risk before targeting the BP goal, as roughly half of them may have normal values of 24-h SBP (< 130 mmHg). In addition, targeting clinic BP below 120 mmHg is accompanied by 8% of patients with 24-h SBP below 100 mmHg.

Despite the importance of achieving cardiometabolic goals beyond blood pressure, in the health of hypertensives, no comprehensive assessment of these characteristics has been performed in whole countries. We studied in 2008–2010 a total of 11 957 individuals representative of the Spanish population aged ≥18 years. Information on cardiometabolic characteristics was collected at the participants’ homes, through structured questionnaires, physical examination, and fasting blood samples. A total of 3983 individuals (33.3%) had hypertension (≥140/90 mm Hg or current antihypertensive drug treatment), 59.4% were aware of their condition, 78.8% treated among those aware, and 48.5% controlled among those aware and treated (22.7% of all hypertensives). Of the aware hypertensives, 13.8% had a body mass index 2 , 38.6% consumed

We aimed to estimate the prevalence of resistant hypertension through both office and ambulatory blood pressure monitoring in a large cohort of treated hypertensive patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. In addition, we also compared clinical features of patients with true or white-coat–resistant hypertension. In December 2009, we identified 68 045 treated patients with complete information for this analysis. Among them, 8295 (12.2% of the database) had resistant hypertension (office blood pressure ≥140 and/or 90 mm Hg while being treated with ≥3 antihypertensive drugs, 1 of them being a diuretic). After ambulatory blood pressure monitoring, 62.5% of patients were classified as true resistant hypertensives, the remaining 37.5% having white-coat resistance. The former group was younger, more frequently men, with a longer duration of hypertension and a worse cardiovascular risk profile. The group included larger proportions of smokers, diabetics, target organ damage (including left ventricular hypertrophy, impaired renal function, and microalbuminuria), and documented cardiovascular disease. Moreover, true resistant hypertensives exhibited in a greater proportion a riser pattern (22% versus 18%; P

We studied the effectiveness of blood pressure (BP) control outside the clinic by using ambulatory BP monitoring (ABPM) among a large number of hypertensive subjects treated in primary care centers across Spain. The sample consisted of 12 897 treated hypertensive subjects who had indications for ABPM. Office-based BP was calculated as the average of 2 readings. Twenty-four–hour ABPM was then performed using a SpaceLabs 90207 monitor under standardized conditions. A total of 3047 patients (23.6%) had their office BP controlled, and 6657 (51.6%) were controlled according to daytime ABPM. The proportion of office resistance or underestimation of patients’ BP control by physicians in the office (office BP ≥140/90 mm Hg and average daytime ambulatory BP

Levels of hypertension treatment and control have been noted to vary between Europe and North America, although direct comparisons with similar methods have not been undertaken. In this study, we sought to estimate the relative impact of hypertension treatment strategies in Germany, Sweden, England, Spain, Italy, Canada, and the United States by using sample surveys conducted in the 1990s. Hypertension was defined as a blood pressure of 160/95 mm Hg or 140/90 mm Hg, plus persons taking antihypertensive medication. “Controlled hypertension” was defined as a blood pressure less than threshold among persons taking antihypertensive medications. Among persons 35 to 64 years, 66% of hypertensives in the United States had their blood pressure controlled at 160/95 mm Hg, compared with 49% in Canada and 23% to 38% in Europe. Similar discrepancies were apparent at the 140/90 mm Hg threshold, at which 29% of hypertensives in the United States, 17% in Canada, and ≤10% in European countries had their blood pressure controlled. At the 140/90 mm Hg cutpoint, two thirds to three quarters of the hypertensives in Canada and Europe were untreated compared with slightly less than half in the United States. Although guidelines vary among countries, resulting in different case definitions, this does not account entirely for the varying success of different national control efforts. Low treatment and control rates in Europe, combined with a higher prevalence of hypertension, could contribute to a higher burden of cardiovascular disease risk attributable to elevated blood pressure compared with that in North America.

We have read with interest the letter from Ayala et al1 concerning our article on resistant hypertension (RH).2 The first comment concerns a possible overestimation of white-coat RH by using 24-hour blood pressure (BP) as the criteria for definition of true and white-coat RH. Ayala et al1 stated that patients on ≥4 medications were true RH, and they should not be considered as having white-coat RH, even if 24-hour BP was normal. As contained in the American Heart Association definition, RH is a condition where patients remain above BP target despite the use of ≥3 medications.3 The inclusion in the definition of patients on ≥4 medications with normal clinic BP understands that these patients have been uptitrated to 4 medications because of …

We thank Thomopoulos and Tsioufis1 for their interest in our article2 and also for their positive feedback and criticism. We will try to answer directly to the 3 points raised in their letter. First, we would like to clarify our analyses regarding treatment posology. Although, in the protocol of the Spanish Ambulatory Blood Pressure Monitoring Registry, details of treatment posology were collected on a 3-category scheme, results from this cohort of patients with resistant hypertension indicated that only 41 patients (0.5% of the cohort) received part of their …

We thank Almirall et al1 for their interest in our article.2 In the present answer to their letter, we provide data from the Spanish Ambulatory Blood Pressure Monitoring Registry regarding clinical differences among patients depending on the time that they received their medication (Table). As shown, several differences were evident among groups, with respect to age, duration of hypertension, prevalence of diabetes mellitus, and history of …

We thank Ben-Dov and Bursztyn for their interest in our article1 and also for their positive feedback and criticism.2 We would like to try to answer directly to the 3 points raised in their letter. First, is siesta influencing the nocturnal BP dip? In the Spanish ambulatory blood pressure monitoring registry, the daytime period was calculated from the time of wake-up in the morning to the time of going to bed in the evening. However, in our opinion, 2 aspects minimize a possible …

We thank Martinez-Moya et al1 for their interest in our article.2 First, we congratulate that their findings are consistent with ours in that ambulatory blood pressure (BP) control among treated patients with hypertension is much better than that based on office BP measurements. Second, following the suggestion of Ben-Dov and Bursztyn in a previous letter,3 Martinez-Moya et al1 have suggested that the influence of the nap in the BP diurnal average perhaps can present erroneously higher rates of daytime BP control than real. …

We thank Obara et al1 for their interest in our article.2 We agree with them that given that many antihypertensive drugs do not seem to encompass a full 24-hour period and that a high percentage of subjects with hypertension in our study were on a morning-only therapeutic regimen, BP at nighttime would be expected to be less sufficiently controlled than that in the daytime. In our study on 12 897 treated patients with hypertension in a primary care setting in Spain, office systolic blood pressure (BP)/diastolic …

We thank Ben-Dov and Bursztyn for their interest in our article1 and criticism.1,2 As discussed in our article,1 there are large differences in the prevalence of office resistance and isolated office control depending on many factors, for example, age. White-coat hypertension increases with age, and the opposite is true for masked hypertension, and mean age in our sample was 61.9±12.3 years. But our results are not unique. Methodologic differences aside, in our study, as in the Pressione Arteriose Monitorate E Loro Associazioni Study in Italy, the white-coat condition was much more common than the reversed phenomenon. …