Diagnostic criteria of white coat hypertension (WCH): consequences for the implications of WCH for target organs

In a sample comprising 51 normotensive subjects and 51 subjects with in-clinic arterial hypertension [blood pressures (BPs) > or = 140/90 mmHg), we investigated the prevalence of target organ damage [left ventricular hypertrophy (LVH) and retinal vasculopathy] in white coat hypertension (WCH) groups defined using: (a) the "optimal ambulatory BP" criterion of the Seventh International Consensus Conference (in-clinic BPs >140/90 mmHg, daytime mean BPs < 130/80 mmHg) and (b) the "normal ambulatory BP" criterion proposed in 1997 by Verdecchia and co-workers (in-clinic BPs >140/ 90 mmHg, daytime mean BPs < 135/85 mmHg), and we compared the results with those obtained for the normotensive group and for a WCH group defined as in a 1996 study of the same data. We found that the newer criteria did not alter the conclusions reached in 1996: namely, that WCH constitutes a state of risk intermediate between normotension and sustained hypertension, which demands in-depth evaluation and active monitoring, if not immediate therapy. We also found that when the WCH group was defined as those patients with in-clinic BPs > or = 140/90 mmHg and 24-h mean BPs < 121/78 mmHg, the prevalence of target organ damage was similar to that found in the control group. We conclude that if WCH status is to imply absence of elevated risk of target organ damage, then the ambulatory BP threshold defining WCH should be lower than the upper limit of ambulatory BPs among subjects who are normotensive in the clinic. The desirability of predicting target organ damage in both hypertensive and normotensive subjects using criteria combining in-clinic BPs, daytime mean ambulatory BPs and night-time mean ambulatory BPs is suggested.     

The Analysis of Systolic and Diastolic Time Intervals: A More Sensitive Non-Invasive Method in the Assessment of Left Ventricular Dysfunction in the Patients with Essential Hypertension

Time indices and volumetric parameters were investigated in patients with essential hypertension subdivided into three groups according to the WHO stage classification. The ratio of ejection time (ET) and pre-ejection period (PEP), ET/PEP remained within normal range in WHO-I but decreased significantly in WHO-II and reached extremely low values in WHO-III. ET did not change in WHO-I and WHO-II but became significantly reduced in WHO-III. Prolongation of PEP in WHO-II and WHO-III increased with progression of hypertensive stage. Isovolumic relaxation time (IRT) showed the same pattern as the prolongation of PEP; positive correlation between PEP and IRT was observed (r=0.55).

On the other hand, significant changes of volumetric parameters were only observed in WHO-III.

These results indicated that the time indices were a more sensitive parameter than the volumetric ones in the assessment of left ventricular dysfunction in the patients with essential hypertension.     

Sequential follow-up clinic and ambulatory blood pressure evaluation in a low risk population of white-coat hypertensive patients and in normotensives

BACKGROUND: In subjects with white-coat hypertension (WCH) it is unclear how ambulatory blood pressure (ABPM) progresses over time and whether they exhibit an increased cardiovascular risk. METHODS: We prospectively evaluated the transition of clinic and ABPM values in 39 clinic and ABPM normotensive subjects (NT) (clinic BP<140/90 mmHg and awake BP<130/85 mmHg, ages 43.4+/-2.6 y) and in 79 untreated subjects (47.2+/-2.4 y) with WCH (clinic BP>140/90, awake ABP<130/85 mmHg) with no other major cardiovascular risk factors. Ambulatory blood pressure was evaluated at baseline and on at least two further occasions during follow-up. RESULTS: At baseline all subjects were untreated and groups did not differ on values of metabolic parameters, BMI, left ventricular mass index, and ABPM values. Subjects were revaluated for ABPM half way through and at the end of follow-up, 35+/-3 and 86+/-4 months in NT and 49+/-4 and 90+/-4 months in WCH. Thirty-six WCH were on antihypertensive treatment (AH) after baseline until the end of follow-up (WCH-tr), whereas 43 WCH (WCH-untr) were free from AH throughout the study. In a similar way all groups showed a significant (p<0.01) progressive increase in 24-h ABPM systolic blood pressure (SBP)/diastolic blood pressure (DBP) from baseline throughout the follow-up in NT (+4.9/2.1+/-0.8/0.9 mmHg), average annual increase of 0.72/0.37 mmHg/y, in WCH-tr (+ 5.0/1.2+/-1.1/1.5 mmHg), average annual increase of 0.66/0.31 mmHg/y and in WCH-untr (+5.4/3.2+/-0.9/1.1 mmHg), average annual increase of 0.74/0.39 mmHg/y. During the follow-up office SBP/DBP (mmHg) significantly rose in NT (+5.7/3.9) but was reduced in WCH-tr (-7.8/5.2) and in WCH-untr (-4.7/1.1). Development of ambulatory hypertension (daytime BP >130 and/or >85 mmHg) occurred in 15.4% (6/39) of NT, in 22.7% (8/36) of WCH-tr and in 26.1% (11/43) of WCH-untr (NS). First cardiovascular events recorded were three in subjects with WCH and none in NT. CONCLUSIONS: After 7.4 years of follow-up, both the progressive increase in ABPM and the rate of transition to ambulatory hypertension in subjects with WCH (either treated or untreated), who were selected under strict criteria were similar to that of normotensive subjects. Also there was no evidence that WCH exhibited a clear higher risk of development cardiovascular events.     

Cardiovascular prognosis of sustained and white-coat hypertension in patients with type 2 diabetes mellitus

OBJECTIVE: Cardiovascular prognosis in diabetic white-coat hypertension (WCH) has not yet been described. We designed this study to investigate the impact of WCH on cardiovascular events in patients with type 2 diabetes, compared with those having type 2 diabetes along with sustained hypertension (SH), and with nondiabetic hypertensive individuals. METHODS: We performed ambulatory blood pressure (BP) monitoring in 1207 consecutive hypertensive patients at baseline, and they were followed up for 49+/-22 months. The mean age was 70.7+/-9.8 years; 262 had type 2 diabetes; and 945 did not. They were classified as having SH with diabetes (n=210); diabetic WCH (n=52); SH alone (n=719); or WCH alone (n=226), using awake BP of 135/85 mmHg as the cutoff value. Cox regression models were used to calculate hazard ratios (HR) and 95% confidence intervals of the risk for cardiovascular events, after controlling for age, sex, body mass index, current smoking, serum creatinine, and clinical systolic BP. RESULTS: During the follow-up period, 97 cardiovascular events occurred. The incidence of cardiovascular events in the diabetic SH group was significantly higher than in the diabetic WCH, nondiabetic SH, and nondiabetic WCH (P<0.05; log-rank test) groups. In Cox regression analysis, the diabetic SH group had significantly higher risk of cardiovascular events compared with the diabetic WCH group (HR: 8.2; 95% confidence intervals: 1.09-61.8; P=0.04). Although nonsignificant, the HRs in the SH and WCH groups, relative to diabetic WCH, exceeded 3.0. CONCLUSIONS: The cardiovascular prognosis for diabetic WCH was better than that for diabetic SH during 4 years of follow-up.     

Are metabolic risk factors and target organ damage more frequent in masked hypertension than in white coat hypertension?

Patients with masked hypertension (MH) tend to have a higher risk than those with white-coat hypertension (WCH). Therefore, we evaluated the characteristics of MH and WCH in Korean patients receiving medical treatment for hypertension. We enrolled 1019 outpatients (56 ± 10 y, 488 males) with diagnosed hypertension who had not changed oral anti-hypertensive medication for 6 months. Clinic blood pressure (CBP) was checked by a nurse and doctor twice per visit. Home BP (HBP) was checked every morning and evening for 1 week. In the MH patients, mean CBP was 130/80 mmHg, whereas HBP was 137/86 mmHg. In the WCH patients, mean CBP was 149/86 mmHg by physician and 143/85 mmHg by nurse and mean HBP was 124/75 mmHg. Age and gender did not differ between the groups. Waist and hip circumferences and the level of fasting glucose were higher in patients with MH than in patients with WCH (p = 0.008, 0.016, 0.009, respectively). Metabolic risk factors were more frequent in patients with WCH, MH, and uncontrolled hypertension than in patients with controlled hypertension. The incidence of metabolic risk factors, however, did not differ between patients with WCH and MH. Heart damage was more frequent in MH than in WCH (p = 0.03). The incidence of metabolic risk factors did not differ between patients with WCH and those with MH. Target organ damage was more closely related to MH than to WCH. Home BP measurement was a useful tool for discriminating WCH and MH in patients with hypertension.     

Characteristics of white coat hypertension in Chinese Han patients with type 2 diabetes mellitus

Objectives: This study documented the prevalence and clinical features of white coat hypertension (WCH) among Chinese Han patients with type 2 diabetes mellitus (T₂DM). Methods: Clinic and ambulatory blood pressure (BP) measurements were compared in 856 patients with T₂DM to determine the frequency of WCH (WCH was defined as clinical blood pressure ≥140/90?mmHg and daytime blood pressure <135/85?mmHg and/or 24-h ambulatory BP (ABP) mean value of <130/80?mmHg on ambulatory BP monitoring (ABPM). Weight, waist circumference (WC), body mass index (BMI), waist to height ratio (WHtR), fasting blood glucose, glycosylated hemoglobin level and circadian BP patterns were also measured to find clinical features predictive of WCH in T₂DM. Results: The prevalence of WCH was 7.36% (63/856) in the overall population, 6.13% (29/473) in male and 8.88% (34/383) in female (p?2DM, male WC were independent protective factors, whereas female sex, smoking and alcohol consumption were independent risk factors for WCH in T₂DM. Non-dippers and reverse dippers made up larger proportion of the WCH group (p?Conclusion: WCH is relatively common among T₂DM patients, it is a unique condition distinct from essential hypertension (EH), and WCH patients also exhibit significant differences in clinical parameters.     

White coat effect in treated and untreated patients with high office blood pressure. Relationship with pulse wave velocity and left ventricular mass index.

OBJECTIVE: To evaluate in hypertensive patients whether the white coat effect is associated with target-organ damage and whether it is modified by anti-hypertensive therapy. METHODS: In a cross-sectional study we evaluated blood pressure (BP) measured in the office and by 24-h ambulatory blood pressure monitoring (ABPM), carotid-femoral pulse wave velocity (PWV) as an index of aortic stiffness, and left ventricular mass index (LVMI) in 88 subjects (aged 49 +/- 2 years) with white-coat hypertension (WCH, office BP > 140/90, daytime BP < 130/84 mmHg), 31 under antihypertensive therapy, 57 untreated, and in 115 patients with office and ambulatory hypertension (HT, aged 51 +/- 2 years, office BP > 140/90, daytime BP > 135/85), 65 under antihypertensive therapy, 50 untreated. In a longitudinal study in 15 patients with HT and in 11 patients with WCH we evaluated the influence of antihypertensive therapy (> 6 months) on office and ambulatory BP and on PWV. RESULTS: The intensity of the white coat effect (office BP-daytime BP) was greater in WCH than in HT. Taking all subjects, the white coat effect did not correlate with PWV (r = 0.08, ns) or with LVMI (r = 0.01, ns), whereas daytime BP correlated significantly with PWV (r = 0.41, p < 0.01) and with LVMI (r = 0.32, p < 0.05). WCH subjects showed lower PWV and LVMI than HT subjects. Treated and untreated WCH, with similar office and daytime BP, showed similar values of PWV and LVMI. Treated and untreated HT showed similar office BP values but treated HT showed lower daytime BP and PWV values. In the longitudinal study, antihypertensive therapy significantly reduced daytime BP and PWV values in the 15 HTs, whereas in the 11 WCH it did not alter daytime BP or PWV values. CONCLUSIONS: 1. In both WCH and HT (treated and untreated) the intensity of the white coat effect does not reflect either the severity of hypertension measured by target organ damage or the efficacy of antihypertensive treatment. 2. In WCH antihypertensive therapy does not improve either ambulatory BP values or damage to target organs.     

The clinical significance of white-coat and masked hypertension

OBJECTIVE: Self-measured blood pressure (BP) and 24-hour ambulatory blood pressure (ABP) monitoring are used to define the arbitrary clinical categories of masked hypertension (MH) and white-coat hypertension (WCH). Severity of target organ damage and incidence of major cardiovascular events are greater in patients with MH than in patients whose BP is normal both inside and outside the doctor's office. METHODS: We reviewed studies that addressed the prognostic impact of MH and WCH. RESULTS: Overall, WCH was associated with a better outcome and MH to a poor outcome. We, however, need the criteria to identify the clinically normotensive patients at elevated pretest probability of MH in whom a broad use of self-measured home BP and 24-hour ambulatory BP as screening tests may be appropriate and cost effective. Clinical management of patients with MH should continue to be based on current guidelines and mostly related to target organ damage and associated clinical conditions because of the normal values of clinic BP in these patients. WCH is generally defined by the coexistence of persistently high office BP with normal daytime or 24-hour ABP. Daytime ABP normalcy has been defined by values<135/85 mmHg. Data, however, suggest that incidence of cardiovascular events tends to increase consistently above the cut-off value of 130/80 mmHg for daytime BP. CONCLUSION: The long-term outcome of patients with WCH remains uncertain. Data suggesting an increased risk of stroke need to be confirmed in wide-scale studies.     

Nurse-recorded and ambulatory blood pressure predicts treatment-induced reduction of left ventricular hypertrophy equally well in hypertension: results from the Swedish irbesartan left ventricular hypertrophy investigation versus atenolol (SILVHIA) study

OBJECTIVE : To compare the relationships of treatment-induced reductions of left ventricular hypertrophy to the changes in clinic and ambulatory blood pressure (BP). DESIGN : Double-blind and randomized treatment with irbesartan or atenolol for 48 weeks. PATIENTS : Patients with hypertension and left ventricular hypertrophy (n = 66) with a seated diastolic BP 90-115 mmHg (average of three measurements one minute apart by nurses). MAIN OUTCOME MEASURES : Registrations of echocardiographic left ventricular (LV) mass. Clinic and ambulatory BP. RESULTS : In the total material, nurse-measured BP was reduced by 23 +/- 15/16 +/- 7.7 mmHg and 24-h ambulatory BP fell 20 +/- 15/14 +/- 8.5 mmHg by treatment. The correlation between the change in nurse-measured BP and LV mass index (LVMI) induced by treatment was r = 0.35, P = 0.004 for systolic BP and r = 0.26, P = 0.03 for diastolic BP. Corresponding values for 24-h ambulatory BP were r = 0.29, P = 0.02 and r = 0.35, P = 0.004, respectively, with similar correlations for day- and night-time ambulatory BP. The nurse-recorded BP was slightly higher than ambulatory BP (systolic clinic - systolic 24-h ambulatory BP = 5 mmHg). Using 130/80 mmHg as a cut-off value for normal 24-h ambulatory BP, eight subjects had normal diastolic or systolic ambulatory BP, or both. Interestingly, these patients also experienced LVMI regression following treatment (low/normal ABP, -13 +/- 21 g/m2; remaining patients, -18 +/- 22 g/m2, P > 0.5). CONCLUSIONS : In patients with hypertension and left ventricular hypertrophy, ambulatory BP is not superior to carefully standardized nurse-recorded seated BP in terms of associations with treatment-induced changes in LV mass.     

White Coat Hypertension: to Treat or Not to Treat?

Definition of white coat hypertension (WCH) traditionally relies on elevated office blood pressure (BP) during repeated visits concomitant with normal out-of-office BP values, as assessed by home and/or 24-h ambulatory BP monitoring measurements. Accumulating evidence focusing on the association of WCH with target organ damage and, more importantly, with cardiovascular events indicates that the risk conveyed by this condition is intermediate between normotension and sustained hypertension. This article will review a number of issues concerning WCH with particular emphasis on the following: (1) prevalence and clinical correlates, (2) association with target organ damage and cardiovascular events, (3) therapeutic interventions. Data will refer to the original WCH definition, based on out-of-office BP determined by 24-h ambulatory BP monitoring; at variance from home BP measurement, this approach rules out the potentially confounding effect of a clinically relevant abnormal BP phenotype such as isolated nocturnal hypertension.     

Masked hypertension in obstructive sleep apnea syndrome

BACKGROUND: Ambulatory blood pressure (BP) monitoring (ABPM) detects subjects with normal clinic but high ambulatory 24-h BP, that is, masked hypertension. METHODS: One hundred and thirty newly diagnosed obstructive sleep apnea syndrome (OSAS) patients, free of recognized cardiovascular disease were included (111 men, age = 48 +/- 1 years, BMI = 27.6 +/- 0.4 kg/m, respiratory disturbance index (RDI = 42 +/- 2/h). Clinic BP, 24-h ABPM, baroreflex sensitivity (BRS), echocardiography and carotid intima-media thickness (IMT) were assessed. RESULTS: Forty-one patients (31.5%) were normotensive, 39 (30.0%) exhibited masked hypertension, four (3.1%) white-coat hypertension and 46 (35.4%) hypertension. Significant differences were found between normotensive, masked hypertensive and hypertensive patients in terms of BRS (10.5 +/- 0.8, 8.0 +/- 0.6 and 7.4 +/- 0.4 ms/mmHg, respectively, P < 0.001), carotid IMT (624 +/- 17, 650 +/- 20 and 705 +/- 23 microm, respectively, P = 0.04) and left ventricular mass index (37 +/- 1, 40 +/- 2 and 43 +/- 1 g/height2.7, respectively, P = 0.003). A clinic systolic BP more than 125 and a diastolic BP more than 83 mmHg led to a relative risk (RR) of 2.7 and a 90% positive predictive value for having masked hypertension. CONCLUSION: Masked hypertension is frequently underestimated in OSAS and is nearly always present when clinic BP is above 125/83 mmHg.     

ST-segment depression in hypertensive patients is linked to elevations in blood pressure,pulse pressure and double product by 24-h Cardiotens monitoring

BACKGROUND: Various statements are made concerning peaks of heart rate (HR), blood pressure (BP) and double product (product of HR and systolic BP) as triggers for ST-segment depression. The aim of the present study was to identify determinants of ST-segment depression with a new ambulatory device for simultaneous 24-h electrocardiogram (ECG) and BP monitoring. METHODS: A total of 63 treated patients (63 +/- 9 years, 33 women and 30 men) with arterial hypertension and ischemic heart disease were studied with a new ambulatory 24-h BP measurement (ABPM) device evaluated according to the BHS protocol (Cardiotens, Meditech, Hungary). This device allows simultaneous ST-segment analysis with extra BP recordings triggered by episodes of ST-segment depression. RESULTS: ST-segment (Holter ECG) depression (> 1 mm and > 60 s) was demonstrated in 26 patients with a mean duration of 4.95 +/- 2.6 min and a peak in the early morning hours. All ST-segment depressions were silent and occurred during a significant increase of BP (15 +/- 11 mmHg systolic and 10 +/- 5 mmHg diastolic, compared with the mean ABPM values) and a significant increase of the double product from 10 921 +/- 2 395 (24-h mean) to 14 515 +/- 2329 (during ST-depression). The recorded systolic and diastolic BP (SBP, DBP) values from the pre ST-event were significant higher compared with 24-h values (153 +/- 19 versus 145 +/- 22 mmHg systolic, 83 +/- 12 versus 78 +/- 14 diastolic). The mean pulse pressure (PP) value in the group with ST-depression was significantly higher than in the group without ST changes (69 +/- 16 versus 58 +/- 10 mmHg; P < 0.005). A total of 73% of patients with ST-events compared with 35% without ST-events showed a PP >or= 60 mmHg (P = 0.025). CONCLUSION: Simultaneous ABPM and ST-segment analysis identifies episodes of silent myocardial ischemia during increases of BP and HR. Hypertensive patients with ischemic heart disease and ST events show higher mean pulse pressure values than are observed in patients without events. A PP of >or= 60 mmHg is linked to an increased risk of silent myocardial ischemias.     

Clinical Implications of White Coat Hypertension

Objective: To determine the clinical implications of mild white coat hypertension (WCH).

Subjects and methods: We studied 102 subjects (54 men, 48 women). 51 of whom were normotensive and 51 slightly hypertensive. None had ever received antihypertensive therapy. An ambulatory blood pressure (ABP) record (Accutracker II), a 24-h electrocardiogram and an echocardiogram were obtained from each, and each was examined by funduscopy. WCH subjects were compared with sustained hypertension (SH) subjects and with normotensives.

Results: Fifty-three percent of the hypertensives qualified as WCH. The ultrasonographic characteristics and the ABP variables of the WCH group differed significantly from those of normotensives, but not from those of the SH group. The prevalence of left ventricilar hypertrophy (LVH) in the SH group (62.5%) did not differ significantly from its prevalence in the WCH group (40.7%). but the prevalence among normotensives (17.6%) was significantly lower than in either of the other two groups. The WCH and SH groups did not differ significantly as regards the prevalence of hypertensive retinopathy (33.3%) in the former, 58.3% in the latter). For no non-LVH, nonretinopathic subject, whether norniotensive or hypertensive, were more than 18% of daytime diastolic ABP measurements ≥90mmHg. Ultrasonographic findings were no better correlated with ABP than with in-clinic BP measurements. Fundus findings correlated well with in-clinic BP and with numerous ABP parameters. Retinopathy, with or without LVH, was efficiently predictable among hypertensives on the basis of body mass index and the 24-h maximum of systolic BP.

Conclusions: Myocardiac remodelling and vascular retinopathy develop early and in parallel in hypertensives, and both developments appear to involve determinants including body mass index and 24-h maximum systolic BP. WCH subjects, as defined by current ABP-based criteria, have cardiac and retinovascular Characteristics different to normotensive subjects. Stricter criteria are needed to discriminate between hypertensives with and without the systemic developments that constitute the immediate source of risk to the hypertensive individual.     

Prevalence of the white-coat effect at multiple visits before and during treatment

OBJECTIVE: To investigate the prevalence and persistence of the white-coat effect (WCE) and white-coat hypertension (WCH) on multiple blood pressure measurement occasions in hypertensive patients with and without treatment. DESIGN: Essential hypertensive patients in whom we took office blood pressure measurements (OBPM) at eight visits (three readings per visit) performed self blood pressure measurements (SBPM) for 1 week prior to each visit (42 readings per week) over a period of 1 year. All measurements were performed with the same automatic device (Omron 705CP). In addition, 24-h ambulatory blood pressure monitoring (ABPM) was performed at the start and at the end of the study. At the start, patients did not use any medication but on subsequent visits they were treated on the basis of their SBPM values. WCH was defined as an OBPM-value > or = 140 and/or 90 mmHg and a SBPM or daytime ABPM value < 135/85 mmHg. This definition was used irrespective of treatment. We also determined the prevalence of a substantial WCE (OBPM 20 mmHg systolic or 10 mmHg diastolic higher than SBPM or daytime ABPM). SETTING: Patients were recruited at hospital or general practice. PATIENTS: A total of 163 mild-to-moderate essential hypertensive patients with a mean age of 56 years (56% males). RESULTS: At eight blood pressure (BP) measurement occasions, 75% of all patients had a substantial WCE at least once, while 57% had WCH at least once. One-third of the patients consistently had a substantial WCE and 14% consistently had WCH on three or more occasions The magnitude of the WCE was significantly related to the height of blood pressure in treated but not in untreated patients. CONCLUSION: In some patients, WCH or a substantial WCE occurs consistently on multiple OBPM visits. Especially in untreated patients, the magnitude of the WCE varies widely among individuals. These results support the incorporation of SBPM and/or ABPM into optimal management of hypertension, not only to prevent misdiagnosis in untreated patients but also to determine the need for adjusting antihypertensive therapy in treated subjects.     

Identification of subjects with white-coat hypertension and persistently normal ambulatory blood pressure

OBJECTIVE: To assess the spontaneous changes in clinic blood pressure, ambulatory blood pressure (ABP) and left ventricular structure in untreated subjects with white-coat hypertension (WCH). DESIGN: A prospective observational study. PATIENTS AND METHODS: In 83 untreated subjects with WCH, 24 h non-invasive ABP monitoring and echocardiographic studies of the left ventricle were repeated after 0.5-6.5 years (mean 2.5) in the absence of antihypertensive drug treatment. WCH was defined by an average daytime ABP < 131/86 mmHg in women and < 136/87 mmHg in men. Ambulatory hypertension was defined by higher ABP values. RESULTS: In the whole population, the clinic blood pressure, ABP and left ventricular mass did not change from baseline to the follow-up visit, whereas the peak A: peak E ratio (where A is the velocity of transmitral blood flow after atrial contraction and E is the velocity during passive left ventricle filling) increased from 0.86 to 0.93. Sixty-three per cent of subjects remained in the WCH category at follow-up study; the remaining 37% shifted to the ambulatory hypertension category. The former group showed no changes in clinic blood pressure, ABP, left ventricular mass and peak A: peak E ratio. The clinic blood pressure of those who developed ambulatory hypertension did not change, whereas their ABP and peak A: peak E ratio increased and their left ventricular mass increased slightly but not significantly. The left ventricular mass increased from baseline to follow-up study by 6.2% in those who developed ambulatory hypertension and decreased by 1.6% in those who remained in the WCH category. The changes in left ventricular mass were associated with the changes in average 24 h systolic blood pressure, but not with the changes in clinic blood pressure. In a stepwise logistic regression analysis, average daytime diastolic blood pressure was the sole variable to enter the model and the probability of ambulatory hypertension at follow-up study was 20.0%percnt; in those with basal daytime ABP <130/80 mmHg, versus 81% in those with higher basal daytime blood pressure levels. CONCLUSION: After 0.5-6.5 years, WCH spontaneously evolved into ambulatory hypertension in 37% of subjects, with an accompanying rise in left ventricular mass. The probability of ambulatory hypertension increased with the baseline values of ABP, rather than with those of clinic blood pressure. WCH might be a prehypertensive state (particularly in subjects with higher baseline ABP levels) and should be defined by low levels of daytime ABP, possibly lower than 130/80 mmHg.     

Audit of the treatment of arterial hypertension in specialized consultation]

The objective of the study was to estimate the control of elevated blood pressure (BP) among patients regularly followed-up and to analyse physicians attitudes in patients having uncontrolled BP. Two hundred and fifty-eight consecutive patients (mean age 56 years, 58% of males) with essential hypertension attending the outpatient department of a specialised hypertension clinic, having at least a 6-month follow-up at the clinic and at least 3 prior visits, were included in the study. Twelve different physicians were in charge of these patients. Data were collected [1] from the structured computerised record called ARTEMIS and [2] from a structured questionnaire filled up by the physician after each visit, where he/she explained the reasons for his/her decisions. BP was measured by a nurse using an automatic device (oscillometric method) and then by a physician using a mercury sphygmomanometer. During follow-up, mean physician's BP fell from 179/107 to 148/91 mmHg and mean nurse BP fell from 164/96 to 143/83 mmHg. Percentages of patients having a controlled hypertension (BP < 140/90 mmHg) were 27% (physician's BP) and 45% (nurse BP). Physicians did not modify treatment in 59% of patients among whom they measured a BP > or = 140/90 mmHg. The 3 main reasons given by physicians for not modifying treatment were: BP controlled when using other BP measurement methods (nurse, home or ambulatory BP), 44%; BP control considered as satisfactory, 29%; systolic hypertension in the elderly, 8%. The person (physician or nurse) who measures BP and the measurement method have dramatic consequences on BP control level. Reasons for not modifying treatment in uncontrolled patients (physician's BP > or = 140/90 mmHg) were based on opinions rather than evidence, for example when isolated systolic hypertension in the elderly is concerned.     

Relations of pulse pressure and other components of blood pressure to preclinical echocardiographic abnormalities

OBJECTIVE : To evaluate the extent to which pulse pressure (PP) is associated with echocardiographic abnormalities, and in particular to whether PP is related to LV hypertrophy taking into account other blood pressure (BP) components. DESIGN : Cross-sectional. SETTING : University hospital, hypertension outpatient unit. PARTICIPANTS : A total of 275 adults (mean age 47 years, range 19-69, 3% aged > or = 65) with essential hypertension. Overt coronary artery disease, valvular disease and secondary hypertension were exclusion criteria. Subjects were divided in two groups with PP < or = 50 or PP > 50 mmHg. OUTCOME MEASURES : Left ventricular (LV) mass, hypertrophy, LV systolic dysfunction. RESULTS : Prevalence of LV hypertrophy was higher in subjects with clinic PP > 50 mmHg. Subjects with PP > 50 mmHg had higher clinic and ambulatory systolic than subjects with PP < or = 50 mmHg while diastolic BP did not differ between groups. PP and systolic BP, either clinic or ambulatory, showed similar correlation to LV hypertrophy in separate logistic multivariate models. Using different methodologies, PP was not related to LV mass index or hypertrophy when the effect of its component systolic BP was taken into account. In separate analyses, PP was not significantly related to ejection fraction or midwall mechanics. CONCLUSION : Middle-aged clinically healthy hypertensives with PP > 50 mmHg had two-fold higher prevalence of LV hypertrophy than those with PP < or = 50 mmHg, which may contribute to the higher cardiovascular risk in subjects with higher PP. However, in our sample, PP was not related to LV hypertrophy independently of systolic BP, suggesting that systolic BP is the explanatory link of the relation between PP and LV hypertrophy.     

Recent advances in blood pressure measurement technology: normalized blood pressure measurement with a double-cuff sphygmotonometer

BACKGROUND: In our previous studies of 24-h blood pressure measurement, basal blood pressure (minimum sleep-time blood pressure) showed the strongest correlation with hypertensive target-organ damage. We have currently devised a new accurate method of blood pressure measurement that entails recording casual blood pressure waves by means of a double-cuff sphygmotonometer, and attempted to normalize casual blood pressure to basal blood pressure. METHODS: The double-cuff sphygmotonometer records the arterial pressure wave, from which, using the formula (P0 = phi(-1)(i) x Pi), we attempted a normalization of casual blood pressure (Pi) to values close to those of the basal blood pressure (P0). True basal blood pressure was measured by an indirect ambulatory blood pressure monitoring device (TM2425, A&D Co. Ltd., Tokyo, Japan). The subjects were 54 normotensive volunteers and 156 out-patients with essential hypertension [63 with World Health Organization (WHO)-II stage and 93 with WHO-I stage, including 47 subjects with white-coat hypertension] not receiving medication. RESULTS: The coefficient of correlation (r) between normalized diastolic blood pressure (Pd0') and true diastolic basal blood pressure (Pd0) was 0.82 (mean difference = 1 +/- 9.8 mmHg), that between normalized systolic blood pressure (Ps0') and true systolic basal blood pressure (Ps0) being 0.78 (1 +/- 13 mmHg) in 210 subjects. When an office mean blood pressure (MBP) of 116 mmHg was taken as the standard for identifying the WHO-I group, the sensitivity was 70% (65/93) and the specificity 67% (42/63), but when an MBP0 [MBP0' = (Ps0'-Pd0')/3 + Pd0'] of 89 mmHg was the standard, the sensitivity was 82% (76/93) and the specificity 90% (57/63), both significantly higher than the corresponding values for office MBP (P < 0.05). CONCLUSION: We devised a new double-cuff sphygmotonometer and normalizing function (phi(-1)) and, using these methods, calculated the normalized blood pressure in hypertensive out-patients, which may make it possible to identify degrees of severity of hypertension in terms of WHO stages.     

Antihypertensive efficacy of night-time graded-release diltiazem versus morning amlodipine in African Americans

BACKGROUND: The effect of a once daily night-time (10 pm) graded-release diltiazem (GRD) on early morning blood pressure (BP), heart rate (HR), and rate-pressure product (RPP) were compared with the effect of morning (8 am) amlodipine in 262 African American individuals with hypertension. METHODS: The multicenter, randomized, double-blind, parallel-group, dose-to-effect trial evaluated changes from baseline in BP, HR, and RPP (HR x systolic BP) by ambulatory BP monitoring during the first 4 h after awakening (diastolic BP = primary), between 6 am and 12 noon, and over a 24-h period. Patients were randomized to night-time GRD 360 mg (n = 132) or morning amlodipine 5 mg (n = 130) for 6 weeks, and were titrated to GRD 540 mg or amlodipine 10 mg after 6 weeks if clinic systolic BP/diastolic BP (SBP/DBP) was > or = 130/85 mm Hg. RESULTS: Compared with amlodipine, GRD showed significantly greater DBP reductions of 3.5 mm Hg (P < .0049) and 3.2 mm Hg (P < .0019) during the first 4 h after awakening and between 6 am and 12 noon respectively, as well as comparable reduction for the 24-h mean DBP. The SBP reductions during the morning periods were comparable, but the reduction in the 24-h mean SBP was 3.4 mm Hg greater (P < .0022) for amlodipine. Mean reductions in HR and RPP were significantly greater (P < or = .0008) for GRD during all intervals; amlodipine increased whereas diltiazem reduced HR with mean differences of 6.7 to 9.3 beats/min. Both treatments were well tolerated. CONCLUSIONS: Night-time GRD was more effective than morning amlodipine in reducing early morning DBP, HR, and RPP, as well as 24-h HR and RPP in African American individuals with hypertension. Amlodipine was more effective in reducing SBP over the 24-h period.