Hipertensão mascarada: qual a importância da mrpa neste contexto? / Masked hypertension: how important is hbpm in this context?

A hipertensão arterial (HA) é o principal fator contributivo para as doenças cardiovasculares, as quais constituem a mais importante causa de morte prevenível no mundo. A falta de conhecimento da população acerca da doença, e consequentemente de um diagnóstico adequado, torna baixo o número de pessoas que se tratam. O aspecto silencioso da HA, e a má adesão ao tratamento proposto, dentre outros fatores, contribuem para o elevado risco de complicações. A medida da pressão arterial (PA) neste contexto apresenta grande importância não apenas no diagnóstico, mas também no acompanhamento de portadores de HA, podendo ser realizada de forma casual, em consultório, ou fora do mesmo com a utilização de outros métodos para tal. Dentre as medidas de PA, a monitorização residencial da PA (MRPA) se destaca. É um método destinado a fazer registro da PA fora do ambiente de consultório, obedecendo a um protocolo previamente estabelecido e normatizado. Além disto, a MRPA apresenta custos menores do que a monitorização ambulatorial da PA (MAPA). De acordo com a atual Diretriz Brasileira de HA, são considerados anormais valores de PA consultório ≥ 140/90 mmHg e de MRPA ≥ 130/80 mmHg. Sob esta perspectiva, a MRPA é um exame que permite que se faça o diagnóstico de HA verdadeira (PA elevada no consultório e na MRPA), normotensão verdadeira (PA normal no consultório e na MRPA), HA do avental branco (HAB) (PA elevada no consultório e normal na MRPA) e HA mascarada (HM) (PA normal no consultório e elevada na MRPA). O diagnóstico de HM é bastante relevante na prática clínica, pois em termos prognósticos, a HM apresenta um risco cardiovascular maior que a HAB e a normotensão verdadeira. Além disto, a incidência de eventos cardiovasculares na HM é similar ou até superior à da HA verdadeira.

Hypertension is the main contributing factor to cardiovascular diseases, which are the most important cause of death in the world. The lack of proper diagnosis, mainly due to the silent aspect of hypertension, makes the rate of people undergoing treatment low, contributing to the high risk of complications. The measurement of blood pressure (BP) in this context is important not only in the diagnosis, but also in the follow-up of patients with hypertension, and it can be performed casually, in the office, or outside the office, using other methods for this purpose. Home blood pressure monitoring (HBPM) is a method designed to record BP outside the office environment, following a previously established and standardized protocol and has a lower cost than ambulatory blood pressure monitoring (ABPM) According to the current Brazilian hypertension guideline, office BP values ≥ 140/90 mmHg and HBPM values ≥ 130/80 mmHg are considered abnormal. From this perspective, HBPM is a test that allows the diagnosis of true hypertension (high BP in the office and in HMBP), true normotension (normal BP in the office and in the HBPM), white coat hypertension (high BP in the office and normal BP in HBPM) and masked hypertension (normal BP in the office and high in HBPM). The diagnosis of masked hypertension is quite relevant in clinical practice, because this phenotype has greater cardiovascular risk than true normotension and white coat hypertension. On the other hand, the incidence of cardiovascular events is similar or even greater in masked hypertension in comparison with true hypertension.

Hipertensão mascarada: qual o verdadeiro risco cardiovascular? / Masked hypertension: what is the real cardiovascular risk?

Entende-se como hipertensão mascarada (HM) a existência de níveis pressóricos aumentados fora do consultório em pessoas supostamente normotensas e não tratadas. A hipertensos medicados, aplica-se a denominação de "hipertensão mascarada não controlada" (HMNC). Estas condições expõem expressivo contingente de indivíduos a um risco não identificado para eventos cardiovasculares. O presente trabalho teve como objetivo realizar uma revisão sistemática da literatura a fim de identificar os principais estudos de associação entre HM, HMNC e o risco de eventos cardiovasculares. De um total de 566 estudos, 19 foram incluídos na revisão. Dentre estes, apenas 4 não documentaram associação entre HM/HMNC e maior risco cardiovascular. Um estudo observou apenas associação com risco de infarto agudo do miocárdio (IAM) e outro apenas com o risco de acidente cerebrovascular (AVC). Os demais 13 estudos mostraram relação entre presença de HM e/ou HMNC e maior risco de eventos cardiovasculares como AVC, IAM e/ou morte. Em conclusão, existe associação entre a presença de hipertensão mascarada e o aumento no risco de eventos cardiovasculares. Alguns fenótipos especialmente vulneráveis e possíveis estratégias diagnósticas são também objeto de discussão.

Masked hypertension (MH) is defined as a normal ambulatory blood pressure, though elevated in the outpatient setting, in supposedly normotensive patients. For hypertensive patients, the term "uncontrolled masked hypertension" (MUCH) applies. Previous data suggest that subjects who present either MH or MUCH may be exposed to higher cardiovascular risk. The authors sought to carry out a systematic review of the literature regarding the association between MH, MUCH and risk of cardiovascular events. Among 566 studies retrieved,19 were included in the review. Only 4 studies did not document an association between MH/MUCH and risk of cardiovascular events. One study found an association only with the risk of acute myocardial infarction (AMI) and another with the risk of cerebrovascular events. The remaining 13 studies revealed a relationship between the presence of MH/MUCH and a higher risk of cardiovascular events such as stroke, AMI and/or death. In conclusion, there is an association between the presence of MH/MUCH and an increased risk of cardiovascular events. Some especially vulnerable phenotypes as well as possible diagnostic strategies are also discussed.

Office blood pressure combined with ambulatory blood pressure monitoring in hypertension diagnosis / 预防医学

Objective@#To evaluate the effects of office blood pressure(OBP)combined with ambulatory blood pressure monitoring(ABPM)on the diagnosis of hypertension.@*Methods@#The residents aged 35-79 years without hypertension history,whose casual OBP were 120~159 mm Hg/80~99 mm Hg,were enrolled from 4 communities of Hangzhou and Zhuji from 2015 to 2018. They were performed OBP measurements on other two days in 4 weeks and ABPM in a week. There were 2 criteria of OBP as elevated OBP on the first day or in 3 different days,and 4 criteria of ABPM as elevated mean BP in 24 hours, daytime, nighttime and either of the above time. Receiver operating characteristic(ROC)curve was employed to evaluate the effects of different OBP criteria combined with ABPM criteria on the diagnosis of masked hypertension(MH)and white-coat hypertension(WCH).@* Results@#Taking 3-day-OBP as a golden standard,the 1-day-OBP with 4 ABPM criteria had the areas under the ROC curve(AUC)of 0.79-0.81,sensitivity of 57.58%-62.77% and specificity of 100.00% in MH;had the AUC of 0.95-0.98,sensitivity of 100.00% and specificity of 88.96%-96.80% in WCH. The Kappa values were all less than 0.6,known as low consistency. Taking either time of ABPM as a golden standard,24 hours,daytime and nighttime ABPM criteria with OBP had the AUC of 0.90-0.92,sensitivity of 79.17%-83.90% and specificity of 100.00% in MH(all Kappa>0.6),when with 1-day-OBP,the Kappa values were all more than 0.8,known as high consistency;had the AUC of 0.95-1.00,sensitivity of 100.00% and specificity of 89.54%-99.37% in WCH,the Kappa values of daytime ABPM were all more than 0.6,known as high consistency. @* Conclusions @# If limited by options, 1-day-OBP could be used instead of 3-day-OBP for detection of WCH or exclusion of MH yet with less accuracy; 24 hours or daytime ABPM instead of either time of ABPM was reliable.

Prevalence of Masked and White-Coat Hypertension in Pre-Hypertensive and Stage 1 Hypertensive patients with the use of TeleMRPA / Prevalência de Hipertensão Mascarada e do Avental Branco em Pré-Hipertensos e Hipertensos Estágio 1 com o uso da TeleMRPA

Abstract Background: The diagnosis of arterial hypertension based on measurements of blood pressure in the office has low accuracy. Objective: To evaluate the prevalence of masked hypertension (MH) and white-coat hypertension through home blood pressure monitoring (HBPM) in pre-hypertensive and stage 1 hypertensive patients. Method: Retrospective study, of which sample consisted of individuals with BP ≥ 120/80 mmHg and < 160/100 mmHg at the medical office without the use of antihypertensive medication and who underwent exams on the HBPM platform by telemedicine (TeleMRPA) between May 2017 and September 2018. The four-day MRPA protocol was used, with 24 measurements, using automated, validated, calibrated equipment with a memory function. Results: The sample consisted of 1,273 participants, of which 739 (58.1%) were women. The mean age was 52.4 ± 14.9 years, mean body mass index (BMI) 28.4 ± 5.1 kg/m2. The casual BP was higher than the HBPM in 7.6 mmHg for systolic blood pressure (SBP) and 5.2 mmHg for diastolic blood pressure (DBP), both with statistical significance (p < 0.001). There were 558 (43.8%) normotensive individuals; 291 (22.9%) with sustained hypertension; 145 (11.4%) with MH and 279 (21.9%) with white-coat hypertension (WCH), with a diagnostic error by casual BP in the total sample in 424 (33.3%) patients. In stage 1 hypertensive individuals, the prevalence of WCH was 48.9%; in prehypertensive patients, the prevalence of MH was 20.6%. Conclusion: MH and WCH have a high prevalence rate in the adult population; however, in prehypertensive or stage 1 hypertensive patients, the prevalence is higher. Out-of-office BP measurements in these subgroups should be performed whenever possible to prevent misdiagnosis.

Resumo Fundamento: O diagnóstico de hipertensão arterial baseado nas medidas do consultório tem baixa acurácia. Objetivo: Avaliar a prevalência de hipertensão mascarada (HM) e do avental branco pela monitorização residencial da pressão arterial (MRPA) em pacientes pré-hipertensos e hipertensos estágio. Método: Estudo retrospectivo com amostra constituída de indivíduos com pressão arterial (PA) na clínica ≥ 120/80 mmHg e < 160/100 mmHg sem uso de medicação anti-hipertensiva e que realizaram exames na plataforma de MRPA por telemedicina (TeleMRPA) entre maio de 2017 e setembro de 2018. Foi utilizado o protocolo MRPA de quatro dias, com 24 medidas, com equipamentos automáticos, validados, calibrados e com memória. Resultados: A amostra foi constituída de 1.273 participantes, sendo 739 (58,1%) mulheres. A idade média foi 52,4 ± 14,9 anos, índice de massa corporal (IMC) médio 28,4 ± 5,1 kg/m2. A PA casual foi maior que a MRPA em 7,6 mmHg para pressão arterial sistólica (PAS) e 5,2 mmHg para a pressão arterial diastólica (PAD), ambas com significância estatística (p < 0,001). Foram diagnosticados 558 (43,8%) normotensos; 291 (22,9%) hipertensos sustentados; 145 (11,4%) com HM e 279 (21,9%) com hipertensão do avental branco (HAB), com erro diagnóstico pela PA casual na amostra total em 424 (33,3%) pacientes. Em hipertensos estágio 1, a prevalência de HAB foi de 48,9%; nos pré-hipertensos a prevalência de HM foi de 20,6%. Conclusão: HM e HAB têm elevada prevalência na população adulta; entretanto, na população de pré-hipertensos ou hipertensos estágio 1 a prevalência é maior. Medidas da PA fora do consultório, nestes subgrupos, devem ser realizadas sempre que possível para evitar erro diagnóstico.

Ambulatory blood pressure monitoring in clinical practice

Being one of the most widely prevalent diseases throughout the world, hypertension has emerged as one of the leading causes of global premature morbidity and mortality. Hence, blood pressure (BP) measurements are essential for physicians in the diagnosis and management of hypertension. Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend initiating antihypertensive medications on the basis of office BP readings. However, office BP readings provide a snapshot evaluation of the patient's BP, which might not reflect patient's true BP, with the possibility of being falsely elevated or falsely low. Recently, there is ample evidence to show that ambulatory blood pressure monitoring (ABPM) is a better predictor of major cardiovascular events than BP measurements at clinic settings. ABPM helps in reducing the number of possible false readings, along with the added benefit of understanding the dynamic variability of BP. This article will focus on the significance of ambulatory BP, its advantages and limitations compared with the standard office BP measurement and a brief outlook on its use and interpretation to diagnose and treat hypertension.

Study on occurrence of masked hypertension and the degree of target organ damage in the population with family history of hypertension / 中国医师杂志

Objective To investigate the occurrence of masked hypertension (MH) and the degree of damage to target organs in people with family history of hypertension.Methods 987 cases of family history of hypertension who had been examined in our hospital from January 2017 to November 2017 were selected as observation group with the approval of hospital ethics committee.At the same time,987 subjects without family history of hypertension who had been examined in our hospital during the same period were selected as control group.The incidence of masked hypertension,left ventricular mass index (LVMI) and carotid intima-media thickness (IMT) were observed.Results The incidence of hypertension and masked hypertension in the observation group was significantly higher than that in the control group (P ＜ 0.05).LVMI and IMT in patients with masked hypertension were significantly higher than those in normal blood pressure group.LVMI and IMT in patients with hypertension were higher than those in patients with masked hypertension and normal blood pressure group.The LVMI and IMT of patients with family history of masked hypertension were higher than those without family history of masked hypertension.Conclusions Family history of hypertension can increase the incidence of masked hypertension and organ damage of patients.The monitoring of masked hypertension should be strengthened for those with family history of hypertension.

Study on occurrence of masked hypertension and the degree of target organ damage in the population with family history of hypertension / 中国医师杂志

Objective@#To investigate the occurrence of masked hypertension (MH) and the degree of damage to target organs in people with family history of hypertension.@*Methods@#987 cases of family history of hypertension who had been examined in our hospital from January 2017 to November 2017 were selected as observation group with the approval of hospital ethics committee. At the same time, 987 subjects without family history of hypertension who had been examined in our hospital during the same period were selected as control group. The incidence of masked hypertension, left ventricular mass index (LVMI) and carotid intima-media thickness (IMT) were observed.@*Results@#The incidence of hypertension and masked hypertension in the observation group was significantly higher than that in the control group (P<0.05). LVMI and IMT in patients with masked hypertension were significantly higher than those in normal blood pressure group. LVMI and IMT in patients with hypertension were higher than those in patients with masked hypertension and normal blood pressure group. The LVMI and IMT of patients with family history of masked hypertension were higher than those without family history of masked hypertension.@*Conclusions@#Family history of hypertension can increase the incidence of masked hypertension and organ damage of patients. The monitoring of masked hypertension should be strengthened for those with family history of hypertension.

Prevalencia de hipertensión enmascarada en niños con factores de riesgo para el desarrollo de hipertensión arterial / Prevalence of masked hypertension among children with risk factors for arterial hypertension

Introducción. La hipertensión enmascarada (HE) en niños se define por registros de presión arterial normal en la consulta y elevados fuera de ella. El monitoreo ambulatorio de presión arterial de 24 horas (MAPA) permite su diagnóstico. Existe poca información sobre su prevalencia en nuestra población. Objetivo. Estimar la prevalencia de HE en niños con factores de riesgo para el desarrollo de hipertensión arterial. Material y método. Estudio prospectivo, observacional, corte transversal. Se incluyeron en forma consecutiva pacientes asistidos en el Hospital General de Niños P. de Elizalde entre 1/7/2015 y 1/12/2016, de 5 a 11 años, con presión arterial normal y, al menos, un factor de riesgo para hipertensión arterial. Se realizó MAPA durante 24 horas (SpaceLabs 90207/90217). Muestra estimada: 110 pacientes. Se contó con las aprobaciones pertinentes. Resultados. Se incluyeron 110 pacientes, edad de 8,7 ± 1,8 años, 60 mujeres. Tiempo de MAPA: 23,18 ± 1,8 horas. Tenían antecedentes neonatales 23 pacientes; todos tenían, al menos, un antecedente personal (los más frecuentes, ingesta aumentada de sal y obesidad); 101 tenían, al menos, un antecedente familiar. El MAPA permitió identificar a 10 pacientes con HE (9,1%; IC 95%: 5,1-15,9); 7 con hipertensión nocturna aislada (6,4%; IC 95%: 3,1-23,5) y 28, prehipertensión (25,4%; IC 95%: 18,2-34,3). Los 10 pacientes con HE fueron 7 varones, 9 obesos y con, al menos, un antecedente familiar. Conclusión. La prevalencia de HE en niños con factores de riesgo de desarrollar hipertensión arterial fue cercana al 10%.

Introduction. Masked hypertension (MH) in children is defined as normal office blood pressure values and high values outside the clinical setting. The 24-hour ambulatory blood pressure monitoring (ABPM) is helpful for diagnosis. There is little information on MH prevalence in our population. Objective. To estimate the prevalence of MH in children with risk factors for arterial hypertension. Material and method. Prospective, observational, cross-sectional study. Patients seen at Hospital General de Niños "P. de Elizalde" between July 1st, 2015 and December 1st, 2016, aged 5-11 years, with normal blood pressure and at least one risk factor for arterial hypertension were included in consecutive order. A 24-hour ABPM was done (SpaceLabs 90207/90217). Estimated sample: 110 patients. All relevant authorizations were obtained. Results. One hundred and ten patients aged 8.7 ± 1.8 years were included; 60 were girls. ABPM duration: 23.18 ± 1.8 hours. Twenty-three patients had neonatal history; all had at least one factor corresponding to personal history (the most common ones were increased salt intake and obesity); 101 had at least one factor corresponding to family history. ABPM helped to identify 10 patients with MH (9.1%; 95% confidence interval --1;CI--3;: 5.1-15.9); 7 had isolated nocturnal hypertension (6.4%; 95% CI: 3.1-23.5) and 28 had prehypertension (25.4%; 95% CI: 18.234.3). Among the 10 patients with MH, 7 were boys, 9 were obese and had at least one factor corresponding to family history. Conclusion. The prevalence of MH in children with risk factors for arterial hypertension was close to 10%.

Discussion on using ambulatory blood pressure monitoring in the diagnostic criteria of white coat and masked hypertension / 上海交通大学学报（医学版）

Objective • To investigate different methods on the diagnosis of white coat and masked phenomena in ambulatory blood pressure monitoring (ABPM). Methods • Information of clinical characteristics and laboratory data were collected, and measurements of office blood pressure (OBP) and ambulatory blood pressure (ABP) in 274 subjects were performed, including 46 persons with high normal OBP (SBP/DBP 130-139/85-89 mmHg) (1 mmHg=0.133 kPa), 187 untreated patients with grade 1 and grade 2 hypertension (SBP/DBP 140-179/90-109 mmHg), and 41 treated hypertensive patients. Differences of 95th and 5th percentile between OBP and daytime ABP, were respectively taken as the cutoff for the definition of white coat phenomenon and masked phenomenon. Results • If white coat and masked phenomenon were diagnosed according to the current hypertension guidelines, the prevalence of white coat phenomenon did not differ between untreated and treated hypertensive patients (11.2% vs 7.3%, P=0.460). In the untreated group, the prevalence of white coat phenomenon was higher in grade 2 than in grade 1 hypertension (20.0% vs 8.5%, P=0.033), whereas the prevalence of white coat hypertension did not differ (2.2% vs 7.0%, P=0.230). The prevalence of masked hypertension was 73.9% in high normal blood pressure group. The prevalence of masked uncontrolled hypertension was 4.9%. If the difference of 95th percentile (≥20.50/20.50 mmHg) and 5th percentile (≤-18.67/-6.00 mmHg) between OBP and daytime ABP were, respectively, used as the cutoff for the definition of white coat and masked phenomenon, the prevalence of white coat phenomenon did not differ between treated and untreated groups (12.2% vs 9.1%，P=0.543). In the untreated group, the prevalence of white coat phenomenon was higher in grade 2 than in grade 1 hypertension (24.4% vs 4.2%, P=0.000). The prevalence of masked phenomenon did not differ between persons with high normal OBP (15.2%) and untreated (5.9%) as well as treated hypertensive patients (12.2%) (P>0.05). Conclusion • The percentile methods may be useful for the diagnosis of white coat and masked phenomena.

A possible cause of epistaxis: increased masked hypertension prevalence in patients with epistaxis / Uma possível causa de epistaxe: maior prevalência de hipertensão mascarada em pacientes com epistaxe

Abstract Introduction Epistaxis and hypertension are frequent conditions in the adult population. Masked hypertension is defined as a clinical condition in which a patient's office blood pressure level is <140/90 mmHg, but the ambulatory or home blood pressure readings are in the hypertensive range. Many studies have proved that hypertension is one of the most important causes of epistaxis. The prevalence of this condition in patients with epistaxis is not well defined. Objective This study aimed to evaluate the prevalence of masked hypertension using the results of office blood pressure measurement compared with the results of ambulatory blood pressure monitoring. Methods Sixty patients with epistaxis and 60 control subjects were enrolled in the study. All patients with epistaxis and controls without history of hypertension underwent physical examination, including office blood pressure measurement, ambulatory or home blood pressure, and measurement of anthropometric parameters. Results Mean age was similar between the epistaxis group and the controls – 21–68 years (mean 42.9) for the epistaxis group and 18–71 years (mean 42.2) for the control group. A total of 20 patients (33.3%) in the epistaxis group and 7 patients (11.7%) in the control group (p = 0.004) had masked hypertension. Night-time systolic blood pressure was significantly higher in patients with epistaxis than in the control group (p < 0.005). However, no significant difference was found in daytime systolic blood pressure between the control group and the patients with epistaxis (p = 0.517). Conclusion This study demonstrates increased masked hypertension prevalence in patients with epistaxis. We suggest that all patients with epistaxis should undergo ambulatory or home blood pressure to detect masked hypertension, which could be a possible cause of epistaxis.

Resumo Introdução Epistaxe e hipertensão são condições frequentes na população adulta. Hipertensão mascarada é definida como uma condição clínica em que o nível da pressão arterial do paciente no consultório é < 140/90 mm Hg, mas as leituras da pressão arterial ambulatorial ou em casa se encontram na faixa hipertensiva. Muitos estudos demonstraram que a hipertensão é uma das causas mais importantes de epistaxe. Ainda não está devidamente definida a prevalência dessa condição em pacientes com epistaxe. Objetivo Avaliar a prevalência de HM com o uso dos resultados de mensurações da pressão arterial no consultório, em comparação com os resultados da MAPA. Método Foram recrutados 60 pacientes com epistaxe e 60 indivíduos para controle. Todos os pacientes com epistaxe e os controles sem histórico de hipertensão passaram por exame físico, inclusive determinação da pressão arterial no consultório, MAPA e mensuração dos parâmetros antropométricos. Resultados A média de idade foi similar entre o grupo com epistaxe e os controles: de 21 a 68 (média 42,9) anos para o grupo com epistaxe e de 18 a 71 (média 42,2) anos para o grupo controle. No total, 20 pacientes (33,3%) no grupo com epistaxe e sete (11,7%) no grupo controle (p = 0,004) apresentaram hipertensão mascarada. A pressão arterial sistólica noturna foi significantemente mais alta em pacientes com epistaxe, em comparação com o grupo controle (p < 0,005). No entanto, não foi observada diferença significante na pressão arterial sistólica obtida durante o dia entre o grupo controle e os pacientes com epistaxe (p = 0,517). Conclusão O presente estudo demonstra maior prevalência de hipertensão mascarada em pacientes com epistaxe. Sugerimos que todos os pacientes com epistaxe devam ser submetidos à monitoração da pressão arterial caseira ou em consultório com o objetivo de detectar hipertensão mascarada, que pode ser uma causa possível de epistaxe.

Discrepancies in Clinic and Ambulatory Blood Pressure in Korean Chronic Kidney Disease Patients

Blood pressure (BP) control is considered the most important treatment for preventing chronic kidney disease (CKD) progression and associated cardiovascular complications. However, clinic BP is insufficient to diagnose hypertension (HT) and to monitor overall BP control because it does not correlate well with ambulatory blood pressure monitoring (ABPM). We enrolled 387 hypertensive CKD patients (stages G1–G4, 58.4% male with median age 61 years) from 3 hospitals in Korea. HT of clinic BP and ABPM was classified as ≥ 140/90 and ≥ 130/80 mmHg, respectively. Clinic BP control rate was 60.2%. The median 24-hour systolic blood pressures (SBPs) of CKD G3b and CKD G4 were significantly higher than those of CKD G1–2 and CKD G3a. However, the median 24-hour SBPs were not different between CKD G1–2 and CKD G3a or between CKD G3b and CKD G4. Of all patients, 5.7%, 38.0%. 42.3%, and 14.0% were extreme-dippers, dippers, non-dippers, and reverse-dippers, respectively. Non-/reverse-dippers independently correlated with higher Ca × P product, higher intact parathyroid hormone (iPTH), and lower albumin. Normal BP was 33.3%, and sustained, masked, and white-coat HT were 29.7%, 26.9%, and 10.1%, respectively. White-coat HT independently correlated with age ≥ 61 years and masked HT independently correlated with CKD G3b/G4. In conclusion, ABPM revealed a high prevalence of non-/reverse-dippers and sustained/masked HT in Korean CKD patients. Clinicians should try to obtain a CKD patient's ABPM, especially among those who are older or who have advanced CKD as well as those with abnormal Ca × P product, iPTH, and albumin.

The significance of blood pressure variation and metabolic risk factors in patients with different stages of hypertension / 고신대학교의과대학학술지

OBJECTIVES: Blood pressure variation (BPV) and metabolic syndrome is an independent risk factor for cardiovascular events. Ambulatory blood Pressure (ABP) has been shown to be more closely related to cardiovascular events in hypertensive patients than conventional office BP (OBP). Using both OBP and ABP, 4 groups of patients were identified: (1) normotensive patients (NT); (2) white coat hypertensives (WCHT); (3) masked hypertensives (MHT); and (4) sustainedhypertensives (SHT). We investigated the significance of BPV and metabolic risks of these 4 groups. METHODS: This study is a retrospective analysis of patients between January 2008 and May 2013. Echocardiography and 24 hour ABP monitoring were performed. RESULTS: BMI was significantly higher in the MHT compared with the NT. There were progressive increases in fasting glucose level from NT to WCHT, MHT, and SHT.MHT and SHT had higher 24h and nighttime BPV than NT.MHT was significantly related with BMI (r = 0.139, P = 0.010), creatinine (r = 0.144, P = 0.018), fasting glucose (r = 0.128, P = 0.046), daytime systolic BPV (r = 0.130, P = 0.017), and daytime diastolic BPV (r = 0.130, P = 0.017). Dyslipidemia (r = 0.110, P = 0.043), nighttime systolic BPV (r = 0.241, P < 0.001) and nighttime diastolic BPV (r = 0.143, P = 0.009) shown correlation with SHT. In multivariate logistic regression, MHT was independently associated with Body mass index (OR 1.086, 95% CI 1.005–1.174, P = 0.038) and creatinine (OR 1.005, 95% CI 1.001–1.010, P = 0.045). CONCLUSIONS: BPV and metabolic risk factors were found to be greater in MHT and SHT compared with NT and WCHT. This suggests that BPV and metabolic risks may contribute to the elevated cardiovascular risk observed in patients with MHT and SHT.

Aspectos clínicos actuales del monitoreo ambulatorio de presión arterial / Current clinical aspects of ambulatory blood pressure monitoring

Resumen La hipertensión arterial sistémica es la enfermedad de mayor prevalencia a nivel mundial que incrementa de forma importante el riesgo cardiovascular. Un diagnóstico temprano, junto al logro de metas, disminuye de forma importante el riesgo de complicaciones. Recientemente se han actualizado los criterios diagnósticos para la hipertensión, así como la introducción del monitoreo ambulatorio de presión arterial. La introducción en la práctica clínica del monitoreo ambulatorio de presión arterial fue para ayudar al diagnóstico de la "hipertensión de bata blanca" y la "hipertensión enmascarada". En la actualidad también se ha demostrado que el monitoreo ambulatorio de presión arterial es superior al método tradicional de registro de presión arterial en el consultorio, tanto para el diagnóstico como para el adecuado control y ajuste del tratamiento farmacológico. Además se han introducido nuevos conceptos de suma importancia como la hipertensión arterial nocturna aislada, la elevación matutina alterada de la presión arterial y los patrones alterados de descenso nocturno de la presión arterial; los cuales se han asociado a un incremento de riesgo cardiovascular. Varios estudios han mostrado relevante valor pronóstico en algunas poblaciones. Aún existen otros conceptos en los cuales hace falta un mayor estudio para establecer adecuadamente su introducción en la práctica clínica como la carga hipertensiva, la variabilidad, la presión de pulso y la rigidez arterial; además de establecer valores de acuerdo a más estudios clínicos en poblaciones como pacientes geriátricos y niños.

Abstract Systemic arterial hypertension is the prevalentest disease worldwide that significantly increases cardiovascular risk. An early diagnosis together to achieve goals decreases the risk of complications significatly. Recently have been updated the diagnostic criteria for hypertension and the introduction of ambulatory blood pressure monitoring. The introduction into clinical practice of ambulatory blood pressure monitoring was to assist the diagnosis of "white coat hypertension" and "masked hypertension". Today has also shown that ambulatory blood pressure monitoring is better than the traditional method of recording blood pressure in the office, to the diagnosis and to adequate control and adjustment of drug treatment. Also there have been introduced important new concepts such as isloted nocturnal hypertension, morning blood pressure elevation altered and altered patterns of nocturnal dip in blood pressure; which have been associated with increased cardiovascular risk. Several studies have shown significant prognostic value in some stocks. There are still other concepts on which further study is needed to properly establish their introduction to clinical practice as hypertensive load variability, pulse pressure and arterial stiffness. In addition to setting values according to further clinical studies in populations such as elderly and children.

Prevalence of Masked Hypertension: a Population-Based Survey in a Large City by Using 24-Hour Ambulatory Blood Pressure Monitoring

BACKGROUND AND OBJECTIVES: We estimated the prevalence of hypertension and hypertension subtypes in a large semi-urban city in Korea, using 24-hour ambulatory blood pressure monitoring (ABPM) in a randomly selected sample population. SUBJECTS AND METHODS: A random sample (aged 20-65 years) from a city with an adult population of approximately 600000 was selected by using a list-assisted random digit dialing method. The 24-hour ABPM and conventional blood pressure measurement (CBPM) of these individuals were obtained. RESULTS: Among the 496 participants, valid 24-hour ABPM and CBPM were obtained from 462 (93%) individuals. The estimated prevalence of hypertension in Goyang was 17.54% by CBPM and 32.70% by 24-hour ABPM (p<0.01). In the age stratified analysis, both CBPM and 24-hour ABPM showed increased prevalence of hypertension with age. The estimated prevalence of masked hypertension was 16.22% and that of white-coat hypertension was 1.08%. Men had a higher prevalence of masked hypertension than women (20.79% vs. 11.86%, p=0.0295). The estimated prevalence of masked hypertension was 17.5%, 20.58%, 24.34%, and 13.29% in the age categories of 30s, 40s, 50s, and 60s, respectively. The estimated prevalence of masked uncontrolled hypertension was 26.79% in patients with hypertension who were taking antihypertensive medications. CONCLUSION: The estimated prevalence of hypertension by 24-hour ABPM was higher than that by CBPM, revealing high prevalence of masked hypertension. The high prevalence of masked hypertension supports the adoption of ABPM in the national population survey and clinical practice to improve public health and reduce health care costs.

Systemic Hemodynamic Atherothrombotic Syndrome and Resonance Hypothesis of Blood Pressure Variability: Triggering Cardiovascular Events

Blood pressure (BP) exhibits different variabilities and surges with different time phases, from the shortest beat-by-beat to longest yearly changes. We hypothesized that the synergistic resonance of these BP variabilites generates an extraordinarily large dynamic surge in BP and triggers cardiovascular events (the resonance hypothesis). The power of pulses is transmitted to the peripheral sites without attenuation by the large arteries, in individuals with stiffened arteries. Thus, the effect of a BP surge on cardiovascular risk would be especially exaggerated in high-risk patients with vascular disease. Based on this concept, our group recently proposed a new theory of systemic hemodynamic atherothromboltic syndrome (SHATS), a vicious cycle of hemodynamic stress and vascular disease that advances organ damage and triggers cardiovascular disease. Clinical phenotypes of SHATS are large-artery atherothombotic diseases such as stroke, coronary artery disease, and aortic and pheripheral artery disease; small-artery diseases, and microcirculation-related disease such as vascular cognitive dysfunction, heart failure, and chronic kidney disease. The careful consideration of BP variability and vascular diseases such as SHATS, and the early detection and management of SHATS, will achieve more effective individualized cardiovascular protection. In the near future, information and communication technology-based 'anticipation medicine' predicted by the changes of individual BP values could be a promising approach to achieving zero cardiovascular events.

Systemic Hemodynamic Atherothrombotic Syndrome and Resonance Hypothesis of Blood Pressure Variability: Triggering Cardiovascular Events

Blood pressure (BP) exhibits different variabilities and surges with different time phases, from the shortest beat-by-beat to longest yearly changes. We hypothesized that the synergistic resonance of these BP variabilites generates an extraordinarily large dynamic surge in BP and triggers cardiovascular events (the resonance hypothesis). The power of pulses is transmitted to the peripheral sites without attenuation by the large arteries, in individuals with stiffened arteries. Thus, the effect of a BP surge on cardiovascular risk would be especially exaggerated in high-risk patients with vascular disease. Based on this concept, our group recently proposed a new theory of systemic hemodynamic atherothromboltic syndrome (SHATS), a vicious cycle of hemodynamic stress and vascular disease that advances organ damage and triggers cardiovascular disease. Clinical phenotypes of SHATS are large-artery atherothombotic diseases such as stroke, coronary artery disease, and aortic and pheripheral artery disease; small-artery diseases, and microcirculation-related disease such as vascular cognitive dysfunction, heart failure, and chronic kidney disease. The careful consideration of BP variability and vascular diseases such as SHATS, and the early detection and management of SHATS, will achieve more effective individualized cardiovascular protection. In the near future, information and communication technology-based 'anticipation medicine' predicted by the changes of individual BP values could be a promising approach to achieving zero cardiovascular events.

Associação entre valores de carga pressórica noturna na MAPA com o diagnóstico de apneia do sono / Association between sleep load pressure values with sleep apnea diagnosis

Fundamentos: A apneia do sono é fator de risco para várias condições cardiovasculares e, sendo assim, o seudiagnóstico é essencial.Objetivo: Verificar em pacientes portadores de hipertensão arterial sistêmica e apneia do sono, se há associaçãoentre esses diagnósticos.Métodos: Estudo retrospectivo, realizado com pacientes adultos, de ambos os sexos, provenientes do banco dedados da Clínica Paulista de Doenças Cardiovasculares, diagnosticados com hipertensão arterial sistêmica eapneia do sono, no período de janeiro de 2011 a janeiro de 2015. Utilizados dados da monitorização ambulatorialda pressão arterial (MAPA) e da polissonografia associados para verificar a presença de aumento da cargapressórica e ausência de descenso durante o sono e a presença de episódios obstrutivos que diagnosticaram apneiado sono. Os pacientes também foram avaliados em relação aos fatores de risco cardiovascular: sedentarismo,obesidade, tabagismo, nível glicêmico e perfil lipídico.Resultados: Foram avaliados 59 pacientes, sendo que 32 (54,2%) pacientes apresentaram na MAPA manutençãoou aumento da carga pressórica com ausência de descenso durante o sono, quando comparados à vigília. Dessespacientes, 31 (96,9%) apresentaram apneia do sono na polissonografia, mostrando uma associação de 97,0%.Conclusão: Neste estudo, observou-se forte associação entre hipertensão arterial sistêmica e apneia do sono.

Background: Sleep apnea is a risk factor for many cardiovascular conditions, therefore, its diagnosis is essential.Objective: To check in patients with systemic arterial hypertension and sleep apnea whether there is an association between thesediagnoses.Methods: Retrospective study with adult patients of both sexes from the database of Clínica Paulista de Doenças Cardiovascularesdiagnosed with systemic arterial hypertension and sleep apnea from January 2011 to January 2015. Data from ambulatory bloodpressure monitoring (ABPM) and polysomnography associated for the presence of increased pressure load and no pressure decreaseduring sleep and the presence of obstructive episodes that diagnosed sleep apnea. Patients were also evaluated for cardiovascularrisk factors: physical inactivity, obesity, smoking, glucose level and lipid profile.Results: Altogether, 59 patients have been evaluated, 32 of which (54.2%) presented, during ABPM, stable or increased pressureload with no decline during sleep compared to wakefulness. Of these patients, 31 (96.9%) had sleep apnea in polysomnography,showing an association of 97.0%.Conclusion: In this study, we observed a strong association between systemic arterial hypertension and sleep apnea.

Hypertension and Masked Hypertension in a Small Town in Central Italy Revealed Using Ambulatory Blood Pressure Monitoring: A Descriptive Observational Study.

Objective: To evaluate the anamnestic prevalence of hypertension and the number of subjects with high blood pressure independently by clinical history; quantify how many subjects are in our population with masked hypertension. Design: Descriptive observational study with simple random sampling of residents in Santarcangelo di Romagna. Setting and Participants: From February 2011 to February 2013 we carried out the prospective evaluation of 127 participants: 59 females and 68 males, whose average age was 64 years (range 51 - 80). We performed office blood pressure, ambulatory blood pressure monitoring (ABPM) and recorded clinical history. Results and Conclusion: Our population was made of 62 cases with anamnesis of high blood pressure (the anti-hypertensive treatment works only in 79% cases) and of 65 persons without anamnestic hypertension. In this sub-population in 9 cases the office measurement performed before ABPM was normal, but ABPM found high values of blood pressure night time, and an increased average value, condition compatible with a MH diagnosis. The implications are that there is a substantial number of people in the general population who has untreated hypertension and an increased risk of cardiovascular disease that requires serious consideration. The results obtained in this work, in our opinion, suggest a more intensive use of ABPM in the management of patients with high blood pressure or without hypertension but with organ damage difficult to explain, particularly in diabetics and smokers.

Discordance between ambulatory versus clinic blood pressure according to global cardiovascular risk group

BACKGROUND/AIMS: The detection of white coat hypertension (WCH), treated normalized hypertension, and masked hypertension (MH) is important to improve the effectiveness of hypertension management. However, whether global cardiovascular risk (GCR) profile has any effect on the discordance between ambulatory blood pressure (ABP) and clinic blood pressure (CBP) is unknown. METHODS: Data from 1,916 subjects, taken from the Korean Multicenter Registry for ABP monitoring, were grouped according to diagnostic and therapeutic thresholds for CBP and ABP (140/90 and 135/85 mmHg, respectively). GCR was assessed using European Society of Hypertension 2007 guidelines. RESULTS: The mean subject age was 54.1 ± 14.9 years, and 48.9% of patients were female. The discordancy rate between ABP and CBP in the untreated and treated patients was 32.5% and 26.5%, respectively (p = 0.02). The prevalence of WCH or treated normalized hypertension and MH was 14.4% and 16.0%, respectively. Discordance between ABP and CBP was lower in the very high added-risk group compared to the moderate added-risk group (odds ratio [OR], 0.649; 95% confidence interval [CI], 0.487 to 0.863; p = 0.003). The prevalence of WCH or treated normalized hypertension was also lower in the very high added-risk group (OR, 0.451; 95% CI, 0.311 to 0.655). CONCLUSIONS: Discordance between ABP and CBP was observed more frequently in untreated subjects than in treated subjects, and less frequently in the very high added-risk group, which was due mainly to the lower prevalence of WCH or treated normalized hypertension.