Optimal Schedule for Assessing Home BP Variability: The Finn-Home Study.

BACKGROUND: Current guidelines make no recommendations on the optimal timing or number of measurements for assessing home blood pressure variability (HBPV). Our aim was to elucidate the optimal schedule for measuring HBPV in relation to cardiovascular risk. METHODS: In total, 1,706 Finnish adults (56.5 ± 8.5 years; 54% women) self-measured their home blood pressure (HBP) twice in the morning and evening during 7 consecutive days. The participants were followed up for cardiovascular events. We examined the association between HBPV (coefficient of variation based on 2 through 7 measurement days) and cardiovascular events using Cox regression models adjusted for HBP and other cardiovascular risk factors. RESULTS: During a follow-up of 11.8 ± 3.1 years, 216 cardiovascular events occurred. Systolic morning HBPV based on three (hazard ratio [HR], 1.039; 95% confidence interval, 1.006-1.074, model c statistic 0.737) through seven (HR, 1.057; 95% confidence interval, 1.012-1.104, model c statistic 0.737) measurement days was significantly associated with cardiovascular events. Agreement in classification to normal vs. increased morning day-to-day HBPV between consecutive measurement days became substantial (κ = 0.69 for systolic and κ = 0.68 for diastolic) after the fourth measurement day. The associations of diastolic HBPV, evening HBPV, all-day HBPV, and variability based on first measurements of each measurement occasion, with cardiovascular outcomes were nonsignificant or remained significant only after the sixth measurement day. CONCLUSIONS: Our results suggest systolic HBP should be measured twice in the morning for at least 3 days when assessing HBPV. Increasing the number of measurement days from 3 to 7 results in marginal improvement in prognostic accuracy.

Incidence rates, correlates, and prognosis of electrocardiographic P-wave abnormalities - a nationwide population-based study.

BACKGROUND: Scant data exist on incidence rates, correlates, and prognosis of electrocardiographic P-wave abnormalities in the general population. METHODS: We recorded ECG and measured conventional cardiovascular risk factors in 5667 Finns who were followed up for incident atrial fibrillation (AF). We obtained repeat ECGs from 3089 individuals 11years later. RESULTS: The incidence rates of prolonged P-wave duration, abnormal P terminal force (PTF), left P-wave axis deviation, and right P-wave axis deviation were 16.0%, 7.4%, 3.4%, and 2.2%, respectively. Older age and higher BMI were associated with incident prolonged P-wave duration and abnormal PTF (P≤0.01). Higher blood pressure was associated with incident prolonged P-wave duration and right P-wave axis deviation (P≤0.01). During follow-up, only prolonged P-wave duration predicted AF (multivariable-adjusted hazard ratio, 1.38; P=0.001). CONCLUSIONS: Modifiable risk factors associate with P-wave abnormalities that are common and may represent intermediate steps of atrial cardiomyopathy on a pathway leading to AF.

Outcome-Driven Thresholds for Increased Home Blood Pressure Variability.

Increased blood pressure (BP) variability predicts cardiovascular disease, but lack of operational thresholds limits its use in clinical practice. Our aim was to define outcome-driven thresholds for increased day-to-day home BP variability. We studied a population-based sample of 6238 individuals (mean age 60.0±12.9, 56.4% women) from Japan, Greece, and Finland. All participants self-measured their home BP on ≥3 days. We defined home BP variability as the coefficient of variation of the first morning BPs on 3 to 7 days. We assessed the association between systolic/diastolic BP variability (as a continuous variable and in deciles of coefficient of variation) and cardiovascular outcomes using Cox regression models adjusted for cohort and classical cardiovascular risk factors, including BP. During a follow-up of 9.3±3.6 years, 304 cardiovascular deaths and 715 cardiovascular events occurred. A 1 SD increase in systolic/diastolic home BP variability was associated with increased risk of cardiovascular mortality (hazard ratio, 1.17/1.22; 95% confidence interval, 1.06-1.30/1.11-1.34; P=0.003/<0.0001) and cardiovascular events (hazard ratio, 1.13/1.14; 95% confidence interval, 1.05-1.21/1.07-1.23; P=0.0007/0.0002). Compared with the average risk in the whole population, risk of cardiovascular deaths (hazard ratio, 1.66/1.84; 95% confidence interval, 1.27-2.17/1.42-2.37; P=0.0002/<0.0001) and events (hazard ratio, 1.46/1.42; 95% confidence interval, 1.21-1.76/1.17-1.71; P<0.0001/0.0004) was increased in the highest decile of systolic/diastolic BP variability (coefficient of variation>11.0/12.8). Increased home BP variability predicts cardiovascular outcomes in the general population. Individuals with a systolic/diastolic coefficient of variation of day-to-day home BP >11.0/12.8 may have an increased risk of cardiovascular disease. These findings could help physicians identify individuals who are at an increased cardiovascular disease risk.

Home versus office blood pressure: longitudinal relations with left ventricular hypertrophy: the Finn-Home study.

OBJECTIVES: Electrocardiographically assessed left-ventricular hypertrophy (ECG-LVH) is a particularly high-risk phenomenon that is a part of every hypertensive patient's initial work-up. Several cross-sectional studies have demonstrated that home blood pressure (BP) has a stronger relation to LVH than office BP. However, longitudinal evidence on the association between home BP and target organ damage is scarce to nonexistent. METHODS: We studied in a sample of 615 community-dwelling participants (mean age at baseline 53.7 ±â€Š7.2, 58% women) whether change in home BP is more strongly associated with change in ECG-LVH than change in office BP over an 11-year follow-up. RESULTS: Pearson's correlation coefficients between changes in home/office SBP and changes in Sokolow-Lyon index, Cornell voltage, Cornell product and R wave amplitude in aVL were 0.21/0.18, 0.28/0.17, 0.25/0.16, and 0.32/0.20, respectively (asterisk indicates P < 0.05 for between-method difference in correlations with Steiger's z test). For change in home/office DBP and change in the aforementioned ECG-LVH indexes, the correlations were 0.12/0.12, 0.20/0.15, 0.16/0.12, and 0.28/0.19. Multivariable-adjusted regression modelling provided similar results. No clinically significant increase in correlations between home BP and ECG-LVH indexes occurred after the fourth day of home BP measurement. CONCLUSION: Our study demonstrates for the first time the superiority of home BP over office BP in the follow-up of left ventricular mass. The results of this and previous studies underline the importance of using out-of-office BP measurements as the primary method for assessing blood pressure levels.

The association between home vs. ambulatory night-time blood pressure and end-organ damage in the general population.

OBJECTIVE: The aim of this study was to test the agreement between night-time home and night-time ambulatory blood pressure (BP) and to compare their associations with hypertensive end-organ damage for the first time in the general population. METHODS: A population sample of 248 participants underwent measurements for night-time home BP (three measurements on two nights with a timer-equipped home device), night-time ambulatory BP, pulse wave velocity (PWV), carotid intima-media thickness (IMT) and echocardiographic left ventricular mass index (LVMI). RESULTS: No significant or systematic differences were observed between mean night-time ambulatory and home BPs (systolic/diastolic difference: 0.7 ±â€Š7.6/0.2 ±â€Š6.0 mmHg, P = 0.16/0.64). All night-time home and ambulatory BPs were positively correlated with PWV, IMT and LVMI (P < 0.01 for all). No significant differences in Pearson's correlations between end-organ damage and night-time home or ambulatory BP were observed (P ≥ 0.11 for all comparisons using Dunn and Clark's Z), except for a slightly stronger correlation between PWV and ambulatory SBP than for home SBP (r = 0.57 vs. 0.50, P = 0.03). The adjusted R of all multivariable-adjusted models for PWV, IMT or LVMI that included night-time home or ambulatory SBP/DBP were within 2/1%. CONCLUSION: Our study demonstrates that night-time home and ambulatory measurements produce similar BP values that have comparable associations with end-organ damage in the general population even when a clinically feasible measurement protocol is used for measuring night-time home BP. In the future, night-time home BP measurement may offer a feasible and easily accessible alternative to ambulatory monitoring for the measurement of night-time BP.

Health 2000 score - development and validation of a novel cardiovascular risk score.

BACKGROUND: Previous risk scores for predicting myocardial infarctions and strokes have mainly been based on conventional risk factors. We aimed to develop a novel improved risk score that would incorporate other widely available clinical variables for predicting the broadest range of endpoints, including revascularizations. METHODS: A nationwide sample of 5843 Finns underwent a clinical examination in 2000-2001. The participants were followed for a median of 11.2 years for incident cardiovascular events. Model discrimination and calibration were assessed and internal validation was performed. RESULTS: Sex, age, systolic blood pressure, total cholesterol, HDL cholesterol, smoking status, parental death from cardiovascular disease, left ventricular hypertrophy, hemoglobin A1c, and educational level remained significant predictors of cardiovascular events (p ≤ 0.005 for all). The share of participants with ≥10% estimated cardiovascular risk was 28.9%, 18.5%, 36.9% and 23.8% with the Health 2000, Finrisk, Framingham and Reynolds risk scores. The Health 2000 score (c-statistic: 0.850) showed superior discrimination to the Framingham (c-statistic improvement: 0.021) and Reynolds (c-statistic improvement: 0.007) scores (p < 0.001 for both comparisons). Model including left ventricular hypertrophy, hemoglobin A1c, and educational level improved the model prediction (c-statistic improvement: 0.006, p = 0.003). CONCLUSIONS: The Health 2000score improves cardiovascular risk prediction in the current study population. KEY MESSAGES Previous risk scores for predicting myocardial infarctions and strokes have mainly been based on conventional risk factors. We aimed to develop a novel improved risk score that would incorporate other widely available clinical variables (including left ventricular hypertrophy, hemoglobin A1c, and education level) for predicting the broadest range of endpoints, including revascularizations. The Health 2000 score improved cardiovascular risk prediction in the current study population compared with traditional cardiovascular risk prediction scores.

The impact of the day of the week on home blood pressure: the Finn-Home study.

OBJECTIVE: The impact of the day of the week on home blood pressure (BP) level and day-to-day BP profile is unknown. Our objectives were to examine (i) how the initial measurement day of the week affects 3-day and 7-day mean home BP and (ii) the BP variation between different days of the week. PARTICIPANTS AND METHODS: The study included a population sample of 1852 participants aged 44-74 years. Home BP was measured twice in the morning and evening on 7 consecutive days. The days of the week on which home BP was measured were recorded. BP means were compared with analysis of variance and the t-test. RESULTS: There were no overall differences in mean systolic/diastolic BPs initiated on various days of the week (3-day means: P=0.15/0.66; 7-day means: P=0.11/0.55). Within-subject systolic/diastolic BP variation between different days of the week was small but significant (128.7±19.2-130.4±19.8/79.5±9.8-80.6±9.9 mmHg; P<0.001/<0.001). Systolic/diastolic BP was lowest during the weekend (Saturday-Sunday: 129.0±18.9/79.6±9.6 mmHg) and highest on Monday (130.4±19.8/80.6±9.9 mmHg), irrespective of the initial measurement day of the week (P for systolic/diastolic difference <0.001/<0.001). In subgroup analyses, the systolic/diastolic BP increase was greater from Saturday-Sunday to Monday among the employed than among the unemployed (1.8/1.3 vs. 0.8/0.7 mmHg; P=0.02/0.01). CONCLUSION: Seven-day home BP measurement can be initiated on any given day of the week. However, if a 3-day measurement is taken, it is recommended to keep in mind that BP is usually the lowest during the weekend, and highest at the beginning of the week, especially among the employed.

Comparison of Acceptability of Traditional and Novel Blood Pressure Measurement Methods.

BACKGROUND: Blood pressure (BP) monitor technology has developed significantly over the past years with the introduction of smaller and quieter home and ambulatory monitors that can both measure BP at night. The acceptability of different BP measurement methods using modern monitors is currently unknown. The purpose of this study was to compare patients' acceptability of traditional and novel BP measurement methods using up-to-date monitors. METHODS: A population sample of 223 participants underwent 4 office measurements on 2 occasions, a 24-hour ambulatory monitoring and 4 home measurements on 7 consecutive days with home nighttime (home-night) measurements on 2 nights. The acceptability of each method was evaluated with a questionnaire. Analysis of variance with post hoc Bonferroni correction was used to compare mean acceptability scores. RESULTS: Mean acceptability score, with a lower score indicating better acceptability, decreased from ambulatory (3.11±0.93) to home-night (2.74±0.81) to home (2.20±0.70) to office (1.95±0.63) measurements (P < 0.001 for all between-method comparisons). The largest between-method differences were observed in comfort of use and disturbance of everyday activities (P < 0.001). 73.1%, 31.8%, 1.3%, and 2.2% rated office, home, home-night, and ambulatory measurements as the most acceptable method, respectively. CONCLUSIONS: In the general population and under a research setting, office BP measurement was the method most preferred by the participants while home measurement was the second most preferred. Home-night measurement was slightly more preferred than ambulatory monitoring. However, before home-night BP measurement can be widely promoted as an alternative method for measuring nighttime BP, more evidence of its prognostic significance is needed.

Agreement between ambulatory, home, and office blood pressure variability.

OBJECTIVE: Ambulatory, home, and office blood pressure (BP) variability are often treated as a single entity. Our aim was to assess the agreement between these three methods for measuring BP variability. METHODS: Twenty-four-hour ambulatory BP monitoring, 28 home BP measurements, and eight office BP measurements were performed on 461 population-based or hypertensive participants. Five variability indices were calculated for all measurement methods: SD, coefficient of variation, maximum-minimum difference, variability independent of the mean, and average real variability. Pearson's correlation coefficients were calculated for indices measured with different methods. The agreement between different measurement methods on the diagnoses of extreme BP variability (participants in the highest decile of variability) was assessed with kappa (κ) coefficients. RESULTS: SBP/DBP variability was greater in daytime (coefficient of variation: 9.8 ±â€Š2.9/11.9 ±â€Š3.6) and night-time ambulatory measurements (coefficient of variation: 8.6 ±â€Š3.4/12.1 ±â€Š4.5) than in home (coefficient of variation: 4.4 ±â€Š1.8/4.7 ±â€Š1.9) and office (coefficient of variation: 4.6 ±â€Š2.4/5.2 ±â€Š2.6) measurements (P < 0.001/0.001 for all). Pearson's correlation coefficients for systolic/diastolic daytime or night-time ambulatory-home, ambulatory-office, and home-office variability indices ranged between 0.07-0.25/0.12-0.23, 0.13-0.26/0.03-0.22 and 0.13-0.24/0.10-0.19, respectively, indicating, at most, a weak positive (r < 0.3) relationship. The agreement between measurement methods on diagnoses of extreme SBP/DBP variability was only slight (κ < 0.2), with the κ coefficients for daytime and night-time ambulatory-home, ambulatory-office, and home-office agreement varying between-0.014-0.20/0.061-0.15, 0.037-0.18/0.082-0.15, and 0.082-0.13/0.045-0.15, respectively. CONCLUSION: Shorter-term and longer-term BP variability assessed by different methods of BP measurement seem to correlate only weakly with each other. Our study suggests that BP variability measured by different methods and timeframes may reflect different phenomena, not a single entity.

Insulin resistance is associated with poorer verbal fluency performance in women.

AIMS/HYPOTHESIS: Type 2 diabetes is an independent risk factor for cognitive decline. Insulin resistance occurring during midlife may increase the risk of cognitive decline later in life. We hypothesised that insulin resistance is associated with poorer cognitive performance and that sex and APOE*E4 might modulate this association. METHODS: The association of insulin resistance and APOE*E4 genotype on cognitive function was evaluated in a nationwide Finnish population-based study (n = 5,935, mean age 52.5 years, range 30-97 years). HOMA-IR was used to measure insulin resistance. Cognitive function was tested by word-list learning, word-list delayed-recall, categorical verbal fluency and simple and visual-choice reaction-time tests. Linear regression analysis was used to determine the association between HOMA-IR and the results of the cognitive tests. RESULTS: Higher HOMA-IR was associated with poorer verbal fluency in women (p < 0.0001) but not in men (p = 0.56). Higher HOMA-IR was also associated with poorer verbal fluency in APOE*E4 -negative individuals (p = 0.0003), but not in APOE*E4 carriers (p = 0.28). Furthermore, higher HOMA-IR was associated with a slower simple reaction time in the whole study group (p = 0.02). CONCLUSIONS/INTERPRETATION: To our knowledge, this is the first comprehensive, population-based study, including both young and middle-aged adults, to report that female sex impacts the association of HOMA-IR with verbal fluency. Our study was cross-sectional, so causal effects of HOMA-IR on cognition could not be evaluated. However, our results suggest that HOMA-IR could be an early marker for an increased risk of cognitive decline in women.

Beat-to-beat, ambulatory hour-to-hour, and home day-to-day variabilities in blood pressure, pulse pressure, and heart rate in comparison with each other and with target-organ damage.

OBJECTIVE: The objective was to compare beat-to-beat, ambulatory hour-to-hour, and home day-to-day variability in blood pressure (BP), pulse pressure (PP), and heart rate (HR) with each other and with target-organ damage. METHODS: We studied a population-based sample of Finnish adults including 150 healthy participants aged between 35 and 64 years. Variability in BP and HR was assessed using self-measured morning and evening recordings from seven consecutive days and 24-h ambulatory recordings. Frequency domain measures of beat-to-beat BP variability and baroreflex sensitivity were determined from 5-min time series. The study participants underwent clinical examination, a clinical interview, measurement of urine albumin levels, and echocardiographic examination. RESULTS: Home BP/PP variability parameters and low frequency (LF) power of beat-to-beat BP/PP variability were mainly associated with left ventricular mass index (LVMI) in models adjusted for age, sex, and BP/PP level. The associations of LVMI with PP variability parameters were stronger than the corresponding associations with BP parameters. The associations of PP variability parameters with LVMI were stronger in old than in young individuals. Home BP/PP variability parameters were mainly associated with the LF power of beat-to-beat BP/PP variability in models adjusted for age, sex, and beat-to-beat BP/PP level and the associations were stronger in old than in young individuals. Home HR variability parameters and 24-h hour-to-hour HR variability were mainly associated with LF/high-frequency powers of beat-to-beat HR variability. CONCLUSION: Reading-to-reading BP/PP variability parameters and their corresponding beat-to-beat variability parameters are partially connected, possibly to common regulatory mechanisms. Their prognostic significance in relation to cardiovascular outcome needs further investigation.

Risk assessment of echocardiographic left ventricular hypertrophy with electrocardiography, body mass index and blood pressure.

AIMS: Electrocardiography (ECG) has a high specificity but unfortunately low sensitivity to detect anatomic left ventricular hypertrophy (LVH). In this study, ECG amplitude and products were examined as continuous variables together with blood pressure (BP) and body mass index (BMI) to find out a simple method to predict echocardiographic (ECHO)-LVH. An age- and gender-stratified population-based sample of men (n = 121) and women (n = 135) aged 35-64 years enriched with newly diagnosed untreated hypertensive men (n = 138) and women (n = 97) in the Turku area in south-western Finland was studied. MAJOR FINDINGS: Cornell voltage (or Cornell product), systolic BP (SBP) and BMI were all independent determinants of ECHO-LVH and left ventricular mass (LVM) indexed by height (LVMI). According to multivariate regression analyses with Cornell voltage (Cornell product), BMI and BP as explanatory variables, the three determinants explained 46-48% (47-49%) of the variation in LVMI among men and 50-54% (52-57%) among women. Score tables were constructed to estimate the probability of LVH. The estimated probability of ECHO-LVH increased in men gradually from 0% to 81% (79%) along with increased Cornell voltage (Cornell product) tertiles and in women respectively from 0% to 95% (97%). CONCLUSION: The sensitivity of ECG to detect ECHO-LVH can be markedly enhanced by using ECG amplitudes and products as continuous variables. The risk tables using Cornell voltages or products, BMI and SBP enable an easy and effective way to estimate the probability of ECHO-LVH.

Oscillometric and auscultatory blood pressure measurement in the assessment of blood pressure and target organ damage.

OBJECTIVE: The objective of this study was to elucidate the usefulness of both the oscillometric blood pressure (OBP) and auscultatory blood pressure (ABP) measurement technique in the assessment of blood pressure (BP) and target organ damage in the general population. METHODS: We studied a sample of the Finnish adult population aged 25-74 years. Four hundred and eighty-four study participants underwent a health examination including measurements of 24-h urine albumin, echocardiographic variables of the left ventricle, intima media thickness and pulse wave velocity. OBP and ABP were measured simultaneously four times by beginning the OBP measurements in random order from the right or left arm and by switching the devices between hands after two measurements. RESULTS: The mean OBP was 126.7/77.4 mmHg and the mean ABP was 124.5/78.0 mmHg. Systolic difference between OBP compared with ABP was large in men. Male sex, higher arm circumference and lower systolic BP were independent determinants explaining the greater difference between systolic OBP compared with ABP. Diabetes, higher arm circumference and higher pulse wave velocity were independent determinants explaining greater difference between diastolic OBP compared with ABP. The correlations of target organ damage between OBP and ABP were equally good. CONCLUSION: At population level OBP and ABP measurements yielded similar results in relation to BP level and the indicators of target organ damage, probably due to the simultaneous and controlled measurement protocol, and to the sample of participants from the general population. It is, however, recommendable to use either OBP or ABP measurements for individual patients to avoid unnecessary interdevice variability.

Interarm blood pressure difference and target organ damage in the general population.

OBJECTIVE: The objective of the study was to investigate interarm differences of blood pressure (BP) and its determinants, and to clarify whether both arms are equally good in assessing BP and target organ damage in the general population. METHODS: We studied a representative sample of Finnish adult population with 484 study participants, ages 25-74 years. BP was measured twice by an oscillometric monitor simultaneously on both arms. Study participants underwent a clinical examination including measurements of serum lipids, glucose and indicators of target organ damage. RESULTS: BP was 2.3/0.2 mmHg higher on right than on left arm (P < 0.001/P = 0.15 for SBP/DBP differences). SBP and DBP measured on right and left arms correlated equally with left ventricular mass index (LVMI), interventricular septal thickness (IVST), posterior wall thickness (PWT), pulse wave velocity (PWV) and albuminuria. Higher SBP level was an independent determinant of both greater systolic and diastolic interarm BP difference. Exaggerated absolute diastolic interarm BP difference (>5 mmHg) was associated with higher BMI, arm circumference, LVMI, IVST and PWT, whereas exaggerated absolute systolic interarm BP difference (>10 mmHg) was not associated with any clinical variables. CONCLUSION: There was only a small difference in BP between arms in a healthy general population. Both arms are equally good determinants of target organ damage. BP should be measured at least once on both arms and prefer the arm with higher BP readings in the future BP measurements.

A study to promote breast feeding in the Helsinki Metropolitan area in Finland.

OBJECTIVE: the aim of this study was to assess the impact of providing intensified support for breast feeding during the perinatal period. DESIGN: a quasi-experimental design with non-equivalent control group. SETTING: three public maternity hospitals (two study, one control) in the Helsinki Metropolitan area in Finland. PARTICIPANTS: a convenience sample of 705 mothers (431 in the intervention group, 274 in the control group). METHODS AND INTERVENTION: in this study, families in the intervention group had access to intensified breast feeding support from midpregnancy, whereas those in the control group had access to normal care. Intensified support included lectures and workshops to health professionals, and families in the intervention group had access to more intensive support and counselling for breast feeding and a breast feeding outpatient clinic. Additionally, an internet-based intervention was only used in the intervention group, but not in the control group. Mothers in the control group received normal care from the midwifery and nursing professionals who were to continue their work normally. The data were analysed statistically. FINDINGS: altogether 705 women participated in the study. In the intervention group (n=431), 76% of the women breast fed exclusively throughout the hospital stay, compared to 66% of the mothers in the control group (n=274). In multivariate analysis, the likelihood of exclusive breast feeding at the time of responding (at hospital discharge or after that at home) was increased by the mother not being treated for an underlying illness or medical problem during pregnancy, being in the intervention group, having normal vaginal childbirth, high breast feeding confidence, positive attitude towards breast feeding, good coping with breast feeding, and 24-hour presence of the infant's father in the ward. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the low exclusive breast feeding rates of newborns could be increased by using intensified breast feeding support. Mothers' health problems during pregnancy can decrease exclusive breast feeding. Mothers with health problems or other than normal childbirth should receive extra breast feeding support, and the presence of fathers in the ward should be encouraged. Intensified breast feeding counselling and support helps mothers to breast feed exclusively. This support should be available in a variety of forms, so that mothers can choose the type of support they need. As breast feeding counselling and support is intensified, more mothers succeed with exclusive breast feeding.

Target organ damage and masked hypertension in the general population: the Finn-Home study.

BACKGROUND: The relation of masked hypertension to target organ damage has very seldom been investigated in a general population. METHODS: An unselected population cohort (n = 1989 of which 1540 were not treated for hypertension) underwent office (duplicate measurements on one visit by a nurse) and home (duplicate measurements on 7 days) blood pressure (BP) measurements and evaluation of electrocardiographic left ventricular hypertrophy (ECG-LVH, n = 1989/1540), carotid intima-media thickness (cIMT, n = 758/592), and pulse wave velocity (PWV, n = 237/158). ECG-LVH was diagnosed using Cornell voltage criteria. PWV was measured using whole-body impedance cardiography. Masked hypertension was defined as office BP less than 140/90 mmHg with home BP at least 135/85 mmHg and white-coat hypertension as office BP at least 140/90 mmHg and home BP less than 135/85 mmHg. RESULTS: Masked and sustained hypertensive individuals had significantly higher age-adjusted and sex-adjusted Cornell voltage, cIMT, and PWV than normotensive individuals. White-coat hypertensive patients had higher age-adjusted and sex-adjusted Cornell voltage than normotensive individuals but significantly lower Cornell voltage and PWV than sustained hypertensive patients. The differences in Cornell voltage and PWV remained significant after adjustment for confounding factors. However, all differences became nonsignificant after adjustment for systolic home BP. CONCLUSION: Masked and sustained hypertension is accompanied by increased risk for hypertensive target organ damage, whereas white-coat hypertension seems to be a more benign phenomenon.

Prognostic significance of masked and white-coat hypertension in the general population: the Finn-Home Study.

OBJECTIVE: The clinical significance of masked and white-coat hypertension is still somewhat controversial. The aim of the present study was to investigate the prognosis of masked and white-coat hypertension using home blood pressure (BP) measurement. DESIGN AND METHODS: A nationwide population sample (n = 2046, age 44-74 years) underwent office (duplicate measurements on one visit by a nurse) and home (duplicate measurements on 7 days) BP measurements and risk factor evaluation. During the follow-up of 7.5 years, 221 fatal and nonfatal cardiovascular events and 142 all-cause deaths occurred. Masked hypertension was defined as office BP less than 140/90 mmHg with home BP at least 135/85 mmHg. RESULTS: The prevalence of baseline risk factors and the incidence of cardiovascular events and all-cause deaths increased from normotension to white-coat, masked and sustained hypertension. Unadjusted hazard ratios for white-coat hypertension were 1.18 (P = 0.5) for cardiovascular events and 1.23 (P = 0.5) for all-cause deaths. Masked hypertension had a significantly higher age-adjusted risk of cardiovascular events and a higher risk of all-cause mortality after adjustment for age, sex and office BP than normotension (hazard ratios 1.64, P = 0.05, and 2.09, P = 0.01). Masked hypertension lost its predictive significance after adjustment for home BP or concomitant other cardiovascular risk factors. CONCLUSION: Neither masked nor white-coat hypertension was an independent predictor of cardiovascular risk or all-cause mortality when concomitant other risk factors or baseline home BP levels were taken into account. The present study suggests that home BP level, along with other traditional risk factors, may be enough to stratify cardiovascular risk.

Prognostic value of the variability in home-measured blood pressure and heart rate: the Finn-Home Study.

The objective of the study was to assess the prognostic value of variability in home-measured blood pressure (BP) and heart rate (HR) in a general population. We studied a representative sample of the Finnish adult population with 1866 study subjects aged 45-74 years. BP and HR self-measurements were performed on 7 consecutive days. The variabilities of BP and HR were defined as the SDs of morning minus evening, day-by-day, and first minus second measurements. The primary end point was incidence of a cardiovascular event. The secondary end point was total mortality. During a follow-up of 7.8 years, 179 subjects had experienced a cardiovascular event, and 130 subjects had died. In Cox proportional hazard models adjusted for age, sex, BP/HR, and other cardiovascular risk factors, morning-evening home BP variability (systolic/diastolic relative hazard: 1.04/1.10 [95% CI: 1.01-1.07/1.05-1.15] per 1-mm Hg increase in BP variability) and morning day-by-day home BP variability (relative hazard: 1.04/1.10 [95% CI: 1.00-1.07/1.04-1.16] per 1-mm Hg increase in BP variability) were predictive of cardiovascular events. Morning-evening home HR variability (relative hazard: 1.07 [95% CI: 1.02-1.12] per 1-bpm increase in HR variability) and morning day-by-day home HR variability (relative hazard: 1.11 [95% CI: 1.05-1.17] per 1-bpm increase in HR variability) were also independent predictors of cardiovascular events. Greater variabilities of morning home BP and HR are independent predictors of cardiovascular events. Because the variabilities of home BP and HR are easily acquired in conjunction with home BP and HR level, they should be used as the additive information in the assessment of cardiovascular risk.

Determinants of masked hypertension in the general population: the Finn-Home study.

INTRODUCTION: Home blood pressure (BP) measurement has allowed the identification of individuals with normal office and elevated out-of-office BP (masked hypertension). It is, however, not feasible to measure home BP on all office normotensive individuals. The objective of the present study was to identify demographic, lifestyle, clinical and psychological characteristics suggestive of masked hypertension. METHODS: Study population was drawn from the participants of a multidisciplinary epidemiological survey, the Health 2000 Study. The untreated nationwide population sample (n = 1459, age 45-74 years) underwent office (duplicate measurements on one visit) and home (duplicate measurements on 7 days) BP measurements and risk factor evaluation. Psychometric tests assessed psychological distress, hypochondriasis, depression and alexithymia. Masked hypertension was defined as normal office BP (<140/90 mmHg) with elevated home BP (≥135/85 mmHg). RESULTS: The prevalence of masked hypertension was 8.1% in the untreated Finnish adult population. The cardiovascular risk profile of masked hypertensive patients resembled that of sustained hypertensive patients. High-normal systolic and diastolic office BP, older age, greater BMI, current smoking, excessive alcohol consumption, diabetes and electrocardiographic left-ventricular hypertrophy were independent determinants of masked hypertension in multivariate logistic regression analysis. Masked hypertension was also independently associated with hypochondria. CONCLUSION: Masked hypertension is a common phenomenon in an untreated adult population. Physicians should consider home BP measurement if a patient has high-normal office BP, diabetes, left-ventricular hypertrophy, or several other conventional cardiovascular risk factors.

Factors affecting the difference between morning and evening home blood pressure: the Finn-Home study.

OBJECTIVE: The aim of this study was to assess the determinants of home morning and evening blood pressure (BP) differences in general population. METHODS: We studied a representative sample of the general Finnish adult population with 1919 study subjects, aged 41-74 years. Study subjects underwent a clinical interview, clinical examination and home BP measurement (28 measurements performed twice in the morning and in the evening during 7 consecutive days). RESULTS: In untreated hypertensive subjects, systolic home BP was lower in the morning than in the evening while no difference was detected for diastolic home BP (137.7/85.1 vs 141.5/85.2 mmHg, p < 0.001/0.64). In treated hypertensive subjects, the difference between systolic morning and evening BP was smaller (136.2 vs 137.1 mmHg, p = 0.023) and diastolic morning BP was even higher than evening BP (83.3 vs 82.1 mmHg, p < 0.001). In the univariate analysis, higher home BP and higher body mass index were associated with relatively higher morning BP compared with evening BP. In addition, men, excessive alcohol users, subjects with cardiovascular disease, sleep apnea and subjects using antihypertensive medication had relatively higher morning BP compared with evening BP. In the multivariate analysis, male gender, excessive alcohol consumption, cardiovascular disease, sleep apnea and use of antihypertensive medication were independent determinants of elevated morning BP compared with evening BP. CONCLUSION: Knowledge of the underlying causes affecting morning and evening home BP difference in patients facilitates physicians to make rational antihypertensive medication and lifestyle adjustments, such as examining probable sleep disorder, and give alcohol and cardiovascular disease prevention counseling.