The Norwegian office-, home-, and ambulatory blood pressure study (NOHA).

Omvik P, Gerhardsen G.

Institute of Internal Medicine, Department of Cardiology, Haukeland University Hospital, Bergen, Norway. Per.Omvik med.uib.no

OBJECTIVES: To evaluate the use of ambulatory blood pressure monitoring in comparison with home and office blood pressure in every-day general practice. METHODS: In a multicenter survey sixty-two practitioners previously unfamiliar with ambulatory blood pressure monitoring performed a total of 1162 (mean 18 +/- 16; range 3-94) 24-h ambulatory- and home blood pressure measurements in normotensive subjects or patients with untreated or treated hypertension. RESULTS: In subjects with office blood pressure <140/90 mmHg average 24-h ambulatory blood pressure (Tenso 24 monitors) was 126/79 mmHg, home blood pressure (Tenso Plus semiautomatic sphygmomanometers) was 128/ 84 mmHg, and office blood pressure (standard sphygmomanometer) was 130/82 mmHg. Patients with office blood pressure > or = 140/90 mmHg had 24-h ambulatory blood pressure averaging 141/88 mmHg, home blood pressure 149/93 mmHg, and office blood pressure 157/95 mmHg. The difference between office-, home-, and ambulatory blood pressure increased with age. Expected differences were found between the three blood pressure modalities according to indication of examination (borderline -, "white-coat" -, and therapy refractory hypertension). Indices of hypertension related end-organ damage were positively correlated with home and ambulatory blood pressure but not with office blood pressure. Overall the performance of home- and ambulatory blood pressure in this general practice setting was similar to that seen by specialized blood pressure units. CONCLUSION: This study demonstrates the practical utility of home- and ambulatory blood pressure measurement in every-day general practice. Both methods are easy to introduce and the quality of blood pressure data obtained in every-day general practice are comparable to those obtained in hypertension clinics and trial centers.

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Effects of autogenic training and antihypertensive agents on circadian and circaseptan variation of blood pressure.

Watanabe Y, Cornelissen G, Watanabe M, Watanabe F, Otsuka K, Ohkawa S, Kikuchi T, Halberg F.

Tokyo Women's Medical University, Tokyo, Japan. yoshi-w jd5.so-net.ne.jp

Even when the daily blood pressure mean is acceptable, too large a circadian amplitude of blood pressure largely increases cardiovascular disease risk. Autogenic training (N = 11), a non-pharmacologic intervention capable of lowering an excessive blood pressure variability, may be well-suited for MESOR-normotensive patients diagnosed with circadian-hyper-amplitude-tension (CHAT). Not all anti-hypertensive drugs affect blood pressure variability. Accordingly, long-acting carteolol (N = 11) and/or atenolol (N = 8) may be preferred to captopril retard (N = 13), nilvadipine (N = 8), or amlodipine (N = 7) for midline-estimating statistic of rhythm (MESOR)-hypertensive patients with CHAT. Prospective outcome studies are needed to assess whether the relative merits of these treatments are in keeping with their effects on blood pressure and blood pressure variability.

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Plasma homocysteine, hypertension incidence, and blood pressure tracking: the Framingham Heart Study.

Sundstrom J, Sullivan L, D'Agostino RB, Jacques PF, Selhub J, Rosenberg IH, Wilson PW, Levy D, Vasan RS.

Framingham Heart Study, Framingham, Mass 01702-5803, USA.

Plasma homocysteine is cross-sectionally associated with blood pressure in large, community-based studies. It is unknown whether elevated plasma homocysteine predicts hypertension incidence. We investigated the relations of baseline plasma total homocysteine levels to hypertension incidence and blood pressure tracking in 2104 Framingham Heart Study participants (mean age, 57 years; 58% women), who were free of hypertension, myocardial infarction, heart failure, atrial fibrillation, or renal failure at baseline. Baseline mean+/-SD plasma homocysteine was 10.1+/-3.7 micromol/L. On follow-up 4 years from baseline, 360 persons (17.1%) had developed hypertension, and 878 persons (41.7%) had progressed to a higher blood pressure stage. In unadjusted analyses, a 1-SD higher log homocysteine value was associated with increased odds of developing hypertension (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.05 to 1.32) and increased odds of blood pressure progression (OR, 1.17; 95% CI, 1.07 to 1.27). The relations of plasma homocysteine to the incidence of hypertension or blood pressure progression were statistically nonsignificant in age- and sex-adjusted logistic regression models (OR, 0.98; 95% CI, 0.87 to 1.11 and OR, 1.05; 95% CI, 0.96 to 1.16, respectively) and in multivariable models adjusted for age, sex, body mass index, diabetes, interim weight change, smoking, serum creatinine, baseline blood pressure, and blood pressure category (OR, 0.92; 95% CI, 0.81 to 1.06 and OR, 1.07; 95% CI, 0.97 to 1.18, respectively). In conclusion, we found no major relation of baseline plasma homocysteine levels to hypertension incidence or longitudinal blood pressure progression in a large, community-based cohort of nonhypertensive individuals after adjustment for age, sex, and other important covariates.

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Effect of blood pressure on early decline in kidney function among hypertensive men.

Vupputuri S, Batuman V, Muntner P, Bazzano LA, Lefante JJ, Whelton PK, He J.

Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, La, USA. suma email.unc.edu

Few cohort studies have examined the longitudinal association between change in blood pressure and decline in kidney function among treated hypertensive patients without chronic kidney disease. We conducted a nonconcurrent cohort study to examine the effects of blood pressure on estimated glomerular filtration rate and early kidney function decline (rise in serum creatinine > or =0.6 mg/dL during follow-up) among 504 African-American and 218 white hypertensive patients. Our results showed that each standard deviation higher treated systolic (18 mm Hg) and diastolic (10 mm Hg) blood pressure was associated with an average annual decline (95% confidence interval [CI]) in estimated glomerular filtration rate of -0.92 ([-1.49 to -0.36] P=0.001) and -0.83 ([-1.38 to -0.28] P=0.003) mL x min(-1) x 1.73 m(-2), respectively, after adjustment for race, age, education, income, use of antihypertensive drugs, body mass index, and history of diabetes and dyslipidemia. Likewise, each standard deviation higher systolic and diastolic blood pressure was associated with relative risks (95% CIs) of 1.81 ([1.29 to 2.55] P<0.001) and 1.55 ([1.08 to 2.22] P=0.046), respectively, for early kidney function decline. Compared with patients with a blood pressure level <140/90 mm Hg, those with a blood pressure level > or =160/95 mm Hg had a -2.67 ([-4.01 to -1.32] P<0.001) mL x min(-1) x 1.73 m(-2) greater annual decline in estimated glomerular filtration rate and a 5.21-fold ([2.06 to 13.21] P<0.001) greater risk of early kidney function decline. Our study found that higher levels of treated blood pressure were positively and significantly related to early decline in kidney function among hypertensive men. These results indicate that better blood pressure control might prevent the onset of chronic kidney disease among hypertensives.

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A comparison of awake-sleep blood pressure variation between normotensive Japanese-American and Caucasian women in Hawaii.

Brown DE, James GD, Aki SL, Mills PS, Etrata MB.

Department of Anthropology, University of Hawaii at Hilo, Hilo, Hawaii 96720, USA. dbrown hawaii.edu

OBJECTIVE: To compare awake-sleep ambulatory blood pressure variation between Japanese-American and Caucasian women in Hawaii, specifically determining whether Japanese-Americans have reduced dipping of blood pressure during sleep, as is found in comparisons of Japanese and US samples. METHODS: Normotensive school teachers from East Hawaii who were either of Japanese-American (n = 70) or Caucasian (n = 48) ethnicity were recruited. They wore an ambulatory blood pressure monitor (Spacelabs 90207) that took measurements every 15 min during waking hours and every 30 min during sleep for a 24-h period on a normal workday. All subjects provided demographic information and underwent a series of anthropometric measurements the day before monitoring. Japanese-American subjects also answered questionnaires relating to cultural identity and migration history. RESULTS: The Japanese-American women had significantly higher mean diastolic (P < 0.01) blood pressure during sleep. These ethnic differences in sleep blood pressure persisted when analyses controlled for age, body mass index, and the waist-hip circumference ratio. There were also significant differences in the proportion by which blood pressure dipped from waking to sleeping, with the Japanese-American women dipping significantly less than the Caucasian women (P < 0.05 systolic, P < 0.001 diastolic). CONCLUSIONS: Normotensive Japanese-American women have higher sleep pressure, and a smaller awake-sleep dip, in pressure than Caucasian women. The relative elevation of blood pressure in Japanese-American women during sleep, but not at other times of the day, is similar to the pattern seen among Japanese women in Japan.

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Prognostic significance of post-exercise blood pressure response in patients with dilated cardiomyopathy.

Kitaoka H, Hitomi N, Okawa M, Furuno T, Doi Y.

Department of Medicine and Geriatrics, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505.

BACKGROUND AND OBJECTIVES: The occurrence of an abnormal cardiovascular response during exercise in patients with chronic heart failure is well known. Post-exercise blood pressure response is also useful in assessing the severity of heart failure and impaired exercise capacity. This study evaluated the prognostic significance of post-exercise blood pressure response in patients with dilated cardiomyopathy. METHODS: Thirty patients with dilated cardiomyopathy (left ventricular ejection fraction: 32 +/- 9%) were studied and the relationship between post-exercise blood pressure response and cardiac events (sudden death, heart failure death and readmission for heart failure) were evaluated. The post-exercise blood pressure response was defined as PBP3 (systolic blood pressure at 3 min after exercise divided by peak systolic blood pressure during exercise). RESULTS: Seven cardiac events (one sudden death, two deaths for heart failure and four readmissions from heart failure) were observed during the follow-up period (3.3 +/- 1.8 years). The PBP3 in patients with these cardiac events was higher than that in patients without cardiac events (0.95 +/- 0.09 vs 0.84 +/- 0.10, p < 0.05). The area under the curve for the receiver-operating characteristic curve with PBP3 used to predict the cardiovascular events was 0.79 (95% confidence interval: 0.62-0.97, p = 0.02). CONCLUSIONS: Post-exercise blood pressure response is a simple and useful predictor of adverse cardiac events in patients with dilated cardiomyopathy.

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Is ambulatory blood pressure monitoring cost-effective in the routine surveillance of treated hypertensive patients in primary care?

Lorgelly P, Siatis I, Brooks A, Slinn B, Millar-Craig MW, Donnelly R, Manning G.

School of Medicine, Health Policy and Practice, University of East Anglia, Norwich.

Achieving target levels of office and/or ambulatory blood pressure readings among treated hypertensive patients is an important aspect of cardiovascular disease prevention. Although office blood pressure measurement is simple and convenient, ambulatory blood pressure monitoring is especially useful for identifying patients with 'white coat' hypertension, in whom falsely raised office blood pressure recordings often lead to unnecessary return visits and additional treatment. Office and ambulatory blood pressure control was compared in 374 treated hypertensive patients in a single general practice, and the costs of performing annual ambulatory blood pressure measurements were compared with potential clinical savings. Ambulatory blood pressure monitoring detected 115 (31%) patients who fulfilled the British Hypertension Society target for ambulatory but not office blood pressure, i.e. white coat hypertension, and 21 patients apparently controlled by office but not ambulatory blood pressure criteria. In economic modelling, the capital, maintenance and user costs of ambulatory blood pressure monitoring (13,790 Pounds per year) were partly offset by fewer follow-up visits and second-line treatments in the group with white coat hypertension (there were modelled savings of 10,178 Pounds). Thus, ambulatory blood pressure monitoring identified a much larger number of treated hypertensive patients with adequate blood pressure control at an extra net cost of 3612 Pounds per year.

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The association between birthweight and current blood pressure: a cross-sectional study in an Australian Aboriginal community.

Singh GR, Hoy WE.

Department of Public Health and Chronic Disease, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0811, Australia. gurmeet menzies.edu.au

OBJECTIVES: To study the relationship of blood pressure to birthweight and current body mass index in a population with high rates of low birthweight (< 2.5 kg). DESIGN: A cross-sectional population screening program conducted between 1992 and 1998, with retrospective retrieval of birthweights. SETTING: A remote coastal Australian Aboriginal community with a high prevalence of diabetes, cardiovascular and renal disease. PARTICIPANTS: Eighty-two per cent of the community members (1473/1805) were screened. Birthweights were available for 767 (71%) of the screened participants aged 7-43 years. MAIN OUTCOME MEASURES: The association between birthweight and current blood pressure, accounting for current body mass index. RESULTS: Mean birthweights were low, and 18% of children and 35% of adults had been low-birthweight babies. In children (7-17 years), blood pressure was not correlated with birthweight, but in adults there was an inverse correlation - a 1 kg increase in birthweight was associated with a 2.9 mmHg (95% CI, 0.3-5.5 mmHg) decrease in systolic blood pressure, after adjusting for age, sex and current weight. Overweight adults with low birthweight had the highest blood pressures. CONCLUSIONS: Low birthweight is significantly associated with higher blood pressure in adult life, and the effect is amplified by higher current weight. Given the high rates of low birthweight in Aboriginal people in remote areas, and the detrimental effect of higher blood pressures on chronic diseases (currently present in epidemic proportions), interventions should focus on improving birthweights and on weight control in adolescents and adults. Special attention should be paid to children with low birthweight to avoid their becoming overweight in adult life.

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