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© The Author 2017. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd. BACKGROUND: Interarm differences (IADs) ≥10 mm Hg in systolic blood pressure (BP) are associated with greater incidence of cardiovascular disease. The effect of ethnicity and the white coat effect (WCE) on significant systolic IADs (ssIADs) are not well understood.METHODS: Differences in BP by ethnicity for different methods of BP measurement were examined in 770 people (300 White British, 241 South Asian, 229 African-Caribbean). Repeated clinic measurements were obtained simultaneously in the right and left arm using 2 BPTru monitors and comparisons made between the first reading, mean of second and third and mean of second to sixth readings for patients with, and without known hypertension. All patients had ambulatory BP monitoring (ABPM). WCE was defined as systolic clinic BP ≥10 mm Hg higher than daytime ABPM.RESULTS: No significant differences were seen in the prevalence of ssIAD between ethnicities whichever combinations of BP measurement were used and regardless of hypertensive status. ssIADs fell between the 1st measurement (161, 22%), 2nd/3rd (113, 16%), and 2nd-6th (78, 11%) (1st vs. 2nd/3rd and 2nd-6th, P < 0.001). Hypertensives with a WCE were more likely to have ssIADs on 1st, (odds ratio [OR] 1.73 (95% confidence interval 1.04-2.86); 2nd/3rd, (OR 3.05 (1.68-5.53); and 2nd-6th measurements, (OR 2.58 (1.22-5.44). Nonhypertensive participants with a WCE were more likely to have a ssIAD on their first measurement (OR 3.82 (1.77 to -8.25) only.CONCLUSIONS: ssIAD prevalence does not vary with ethnicity regardless of hypertensive status but is affected by the number of readings, suggesting the influence of WCE. Multiple readings should be used to confirm ssIADs.

BACKGROUND Urinary albumin levels and hypertension (HTN) are independently associated with an increased risk of all-cause mortality. The effect of albuminuria on mortality in the absence or presence of HTN is uncertain. This study aimed to evaluate the effect of albuminuria and HTN on all-cause and cardiovascular disease (CVD) mortality. METHODS Mortality outcomes for 32,653 Koreans enrolled in a health screening including measurements of the urinary albumin/creatinine ratio (UACR) at baseline and median follow-up of 5.13 years. Receiver operating characteristic curve analyses were performed in UACR and the cut-point was 5.42 mg/g. The participants for UACR at the cut-point of 5.42 μg/mg were categorized into UACR < 5.42 or UACR ≥ 5.42. HTN status was categorized as No HTN or HTN (defined as the absence or presence HTN). RESULTS The median (interquartile) baseline UACRs were higher in those who died than in survivors. Subjects with a UACR ≥ 5.42 mg/g without or with HTN showed a similar increased risk for all-cause mortality and CVD mortality, even after adjusting for known CVD risk factors compared to those with no HTN/UACR < 5.42 (reference), (all-cause mortality; hazard ratio [HR] 1.48; 95% confidence interval [CI] 1.02–2.15: HR 1.47; 95% CI 0.94–2.32, respectively), (CVD mortality; HR 5.75; 95% CI 1.54–21.47: HR 5.87; 95% CI 1.36–25.29) CONCLUSIONS The presence of urinary albumin and HTN is a significant determinant of CVD and death. Urinary albumin might be more attributable to CVD and all-cause mortality than HTN.

© The Author 2015. Published by Oxford University Press on behalf of the American Journal of Hypertension. BACKGROUND: Patients may have lower (white coat hypertension) or higher (masked hypertension) blood pressure (BP) at home compared to the clinic, resulting in misdiagnosis and suboptimal management of hypertension. This study aimed to systematically review the literature and establish the most important predictors of the home-clinic BP difference. METHODS: A systematic review was conducted using a MEDLINE search strategy, adapted for use in 6 literature databases. Studies examining factors that predict the home-clinic BP difference were included in the review. Odds ratios (ORs) describing the association between patient characteristics and white coat or masked hypertension were extracted and entered into a random-effects meta-analysis. RESULTS: The search strategy identified 3,743 articles of which 70 were eligible for this review. Studies examined a total of 86,167 patients (47% female) and reported a total of 60 significant predictors of the home-clinic BP difference. Masked hypertension was associated with male sex (OR 1.47, 95% confidence interval (CI) 1.18-1.75), body mass index (BMI, per kg/m2increase, OR 1.07, 95% CI 1.01-1.14), current smoking status (OR 1.32, 95% CI 1.13-1.50), and systolic clinic BP (per mm Hg increase, OR 1.10, 95% CI 1.01-1.19). Female sex was the only significant predictor of white coat hypertension (OR 3.38, 95% CI 1.64-6.96). CONCLUSIONS: There are a number of common patient characteristics that predict the home-clinic BP difference, in particular for people with masked hypertension. There is scope to incorporate such predictors into a clinical prediction tool which could be used to identify those patients displaying a significant masked or white coat effect in routine clinical practice.

Over the last decades, 2 main techniques for measuring blood pressure (BP) out of the physician’s office have gained increasing importance in the clinical approach to arterial hypertension, both being supported by recent international hypertension management guidelines.1,2 These techniques are home BP monitoring (HBPM) and 24-hour ambulatory BP monitoring (ABPM). Their diffusion in clinical practice has been favored by a number of factors, including on one side technical progress and wider availability of accurate HBPM and ABPM devices and on the other side the increasing awareness of the limitations of office BP (Table 1).3,4 Office BP is in fact characterized by a random error affecting casual BP readings and by a systematic error related to the patient’s alerting reaction to the measurement procedure and setting, known as “white coat effect.”1,3 Both ABPM and HBPM are devoid of these limitations and, thus, provide more stable and reproducible information on BP values,5 which is also of greater prognostic relevance6–21 (Table 2). Furthermore, office BP readings are unable to collect information on BP during a subject’s usual activities and over a long period of time,22 an important limitation in everyday management of hypertensive subjects that can be overcome by out-of-office BP monitoring. View this table: Table 1. Comparison of Main Features of 3 Main Methods of BP Measurement View this table: Table 2. Home BP Measurements and Outcome ABPM was initially confined to specialized hypertension centers because of its relatively high cost, but over the years its availability has steadily increased. HBPM, on the other hand, has been used rather reluctantly by physicians in routine management of hypertensive patients. Although its potential usefulness in clinical practice was acknowledged many years ago,23 its application has been limited until the end of last century by the need to use auscultatory measurements, an approach …

BACKGROUND An exaggerated morning blood pressure surge (MBPS) may be associated with stroke and other cardiovascular events, but the threshold at which an MBPS becomes pathological is unclear. This study aimed to systematically review the existing literature and establish the most appropriate definition of pathological MBPS. METHODS A MEDLINE search strategy was adapted for a range of literature databases to identify all prospective studies relating an exaggerated MBPS to cardiovascular endpoints. Hazard ratios (HRs) were extracted and synthesized using random-effects meta-analysis. RESULTS The search strategy identified 2,964 unique articles, of which 17 were eligible for the study. Seven different definitions of MBPS were identified; the most common was a prewaking surge (mean blood pressure for 2 hours after wake-up minus mean blood pressure for 2 hours before wake-up; n = 6 studies). Summary meta-analysis gave no clear evidence that prewaking MBPS (defined by a predetermined threshold: >25–55mm Hg) was associated with all cardiovascular events (n = 2 studies; HR = 0.94, 95% confidence interval (CI) = 0.39–2.28) or stroke (n = 2 studies; HR = 1.26, 95% CI = 0.92–1.71). However, using a continuous scale, which has more power to detect an association, there was evidence that a 10 mm Hg increase in MBPS was related to an increased risk of stroke (n = 3 studies; HR = 1.11, 95% CI = 1.03–1.20). CONCLUSIONS These findings suggest that when measured and analyzed as a continuous variable, increasing levels of MBPS may be associated with increased risk of stroke. Large, protocol-driven individual patient data analyses are needed to accurately define this relationship further.

The objective of this study is to construct an International Database of HOme blood pressure in relation to Cardiovascular Outcome (IDHOCO). The main goal of this database is to determine outcome-based diagnostic thresholds for the self-measured home blood pressure (BP). Secondary objectives include investigating the predictive value of white-coat and masked hypertension, morning and evening BP, BP and heart rate variability, and the home arterial stiffness index. We also aim to determine an optimal schedule for home BP measurements that provides the most accurate risk stratification. Eligible studies are population-based, have fatal as well as nonfatal outcomes available for analysis, comply with ethical standards, and have been previously published in peer-reviewed journals. In a meta-analysis based on individual subject data, composite and cause-specific cardiovascular events will be related to various indexes derived by home BP measurement. The analyses will be stratified by a cohort and adjusted for the clinic BP and established cardiovascular risk factors. The database includes 6753 subjects from five cohorts recruited in Ohasama, Japan (n=2777); Finland (n=2075); Tsurugaya, Japan (n=836); Didima, Greece (n=665); and Montevideo, Uruguay (n=400). In these five cohorts, during a total of 62 106 person-years of follow-up (mean 9.2 years), 852 subjects died and 740 participants experienced a fatal or nonfatal cardiovascular event. IDHOCO provides a unique opportunity to investigate several hypotheses that could not reliably be studied in individual studies. The results of these analyses should be of help to clinicians involved in the management of patients with suspected or established hypertension.Hypertension Research advance online publication, 5 July 2012; doi:10.1038/hr.2012.97. ispartof: Hypertension Research vol:35 issue:11 pages:1072-1079 ispartof: location:England status: published

Background: Previous studies have shown that in the treated fraction of the hypertensive population, blood pressure (BP) control is less common for systolic BP (SBP) than for diastolic BP (DBP) as measured in the physician’s office. Whether this phenomenon is artifactually attributable to a temporary increase in BP owing to a “white-coat” effect or represents a true rarity of SBP control in daily life is unknown. Methods: Data were obtained from the PAMELA (Pressioni Arteriose Monitorate E Loro Associazioni) study population, which involved individuals ranging in age from 25 to 74 years who were representative of the residents of Monza (a city near Milan, Italy) and who were stratified according to sex. Office (an average of 3 sphygmomanometric measurements), home (an average of morning and evening self-measurements using a semiautomatic device), and 24-hour ambulatory (average of measurements performed every 20 minutes during the day and at night) BP values were obtained in all study subjects. In the treated hypertensive patients, BP was regarded as controlled if office values were less than 140 (SBP) or 90 (DBP) mm Hg. Home and 24-hour average SBP and DBP were regarded as controlled if the values were lower than 132/83 and 125/79 mm Hg, respectively. Results: In the study participants (n=2051), the number of patients with hypertension who were receiving antihypertensive treatment was 398, or approximately 42% of all individuals with hypertension. In-office SBP control by treatment was less frequent than DBP control (29.9% vs 41.5%, P.05). This was also the case when home and 24-hour SBP and DBP control was considered (38.3% vs 54.6% and 50.8 vs 64.9%, respectively, P.05 for both). Conclusions: In the PAMELA population, SBP control by treatment was much less frequent than DBP control by treatment. This was the case not only for office BP values but also for home and 24-hour BP values, demonstrating that inadequate SBP control is not limited to artificial BP-measuring methods but occurs in daily life. Arch Intern Med. 2002;162:582-586