Our aim is to determine the optimal time schedule for home blood pressure (BP) monitoring that best predicts stroke and coronary artery disease in general practice. The Japan Morning Surge-Home Blood Pressure (J-HOP) study is a nationwide practice-based study that included 4310 Japanese with a history of or risk factors for cardiovascular disease, or both (mean age, 65 years; 79% used antihypertensive medication). Home BP measures were taken twice daily (morning and evening) over 14 days at baseline. During a mean follow-up of 4 years (16 929 person-years), 74 stroke and 77 coronary artery disease events occurred. Morning systolic BP (SBP) improved the discrimination of incident stroke ( C statistics, 0.802; 95% confidence interval, 0.692–0.911) beyond traditional risk factors including office SBP (0.756; 0.646–0.866), whereas the changes were smaller with evening SBP (0.764; 0.653–0.874). The addition of evening SBP to the model (including traditional risk factors plus morning SBP) significantly reduced the discrimination of incident stroke ( C statistics difference, −0.008; 95% confidence interval: −0.015 to −0.008; P =0.03). The category-free net reclassification improvement (0.3606; 95% confidence interval, 0.1317–0.5896), absolute integrated discrimination improvement (0.015; SE, 0.005), and relative integrated discrimination improvement (58.3%; all P <0.01) with the addition of morning SBP to the model (including traditional risk factors) were greater than those with evening SBP and with combined morning and evening SBP. Neither morning nor evening SBP improved coronary artery disease risk prediction. Morning home SBP itself should be evaluated to ensure best stroke prediction in clinical practice, at least in Japan. This should be confirmed in the different ethnic groups. Clinical Trial Registration— URL: http://www.umin.ac.jp/ctr/ . Unique identifier: UMIN000000894.

Abstract-The aim of this study was to compare the effects between calcium channel blockers and diuretics when used in combination with angiotensin II receptor blocker on aortic systolic blood pressure (BP) and brachial ambulatory systolic BP. We conducted a prospective, randomized, open-label, blinded end point study in 207 hypertensive patients (mean age: 68.4 years). Patients received olmesartan monotherapy for 12 weeks, followed by additional use of azelnidipine (nϭ103) or hydrochlorothiazide (nϭ104) for 24 weeks after randomization. The central BP by radial artery tonometry, aortic pulse wave velocity, and ambulatory BP were assessed at baseline and 24 weeks later. After adjustment for baseline covariates, the extent of the reduction in central systolic BP in the olmesartan/azelnidipine group was significantly greater than that in the olmesartan/hydrochlorothiazide group (the between-group difference was 5.2 mm Hg; 95% CI: 0.3 to 10.2 mm Hg; Pϭ0.039), whereas the difference in the reduction in brachial systolic BP between the groups was not significant (2.6 mm Hg; 95% CI: Ϫ2.2 to 7.5 mm Hg; Pϭ0.29). The aortic pulse wave velocity showed a significantly greater reduction for the olmesartan/azelnidipine combination than for the olmesartan/ hydrochlorothiazide combination (0.8 m/s; 95% CI: 0.5 to 1.1 m/s; PϽ0.001) after adjustment for covariates. The extent of the reduction in brachial ambulatory systolic BP was similar between the groups. These data showed that the combination of olmesartan ( Key Words: angiotensin II receptor blocker Ⅲ calcium channel blocker Ⅲ thiazide diuretic Ⅲ central blood pressure Ⅲ pulse wave velocity Ⅲ ambulatory blood pressure R ecent clinical trials have demonstrated that strict control of blood pressure (BP) is essential to prevent target organ damage and to reduce cardiovascular mortality in hypertensive patients. 1-3 The angiotensin II receptor blocker (ARB) is one of the first-line antihypertensive drugs for most patients with hypertension, but monotherapy achieves the target BP recommended by the treatment guidelines 4,5 in only a limited number of patients, and, thus, combination therapy is required in a majority of patients. 5 A thiazide diuretic is commonly used in combination with an ARB or angiotensinconverting enzyme inhibitor (ACE-I) because it has an additive effect on BP reduction because of the complementary mechanisms of action of the components, 5 and the efficacy of these combinations has been demonstrated in clinical trials. 1,2,6 On the other hand, the combination of a dihydropyridine calcium channel blocker (CCB) with an ARB or ACE-I has also become widely used because this regimen is effective in BP control and is well tolerated. 7 Recently, the combination of an ACE-I and a CCB has been reported to be more effective than the combination of an ACE-I and a thiazide diuretic for decreasing cardiovascular events in high-risk hypertensive patients. 8 In the Anglo-Scandinavian Cardiac Outcomes Trial, 3 the CCB/ACE-I combination was more effective than a combination ...

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After initial management and 3 month follow-up, larger size (more than 10 mm) and a history of lung cancer are risk factors for GGO growth, and therefore should be considered when making a follow-up plan.

Abstract-The maximum office systolic blood pressure (SBP) has been shown to be a strong predictor of cardiovascular events, independently of the mean SBP level. However, the clinical implications of maximum home SBP have never been reported. We investigated the association between the maximum home SBP and target organ damage (TOD). We assessed the left ventricular mass index (LVMI) and carotid intima-media thickness (IMT) using ultrasonography and the urinary albumin/creatinine ratio (UACR) as measures of TOD in 356 never-treated hypertensive subjects. Home BP was taken in triplicate in the morning and evening, respectively, for 14 consecutive days with a memory-equipped device. The maximum home SBP was defined as the maximum mean triplicate BP reading in the 14-day period for each individual and was significantly correlated with LVMI (rϭ0.51, PϽ0.001), carotid IMT (rϭ0.40, PϽ0.001), and UACR (rϭ0.29, PϽ0.001). The correlation coefficients with LVMI and carotid IMT were significantly larger for the maximum home SBP than the mean home SBP. In multivariate regression analyses, the maximum home SBP was independently associated with LVMI and carotid IMT, regardless of the mean home BP level. In the prediction of left ventricular hypertrophy and carotid atherosclerosis, the goodness-of-fit of the model was significantly improved when the maximum home SBP was added to the sum of the mean office and home BPs (Pϭ0.002 and PϽ0.001, respectively). These findings indicate that assessment of the maximum home SBP, in addition to the mean home SBP, might increase the predictive value of hypertensive TOD in the heart and artery. Key Words: maximum home systolic blood pressure Ⅲ mean home systolic blood pressure Ⅲ left ventricular mass index Ⅲ carotid intima-media thickness Ⅲ urinary albumin/creatinine ratio Ⅲ aging Ⅲ arterial stiffness I t has been believed that transient increases in blood pressure (BP) might be construed as noise and merely an obstacle to reliable estimation of usual BP (conceived as the true underlying average BP over a period of time). In this case, such increases would result in substantial underestimation of the strength of the real association between usual BP and cardiovascular risk, a so-called "regression dilution bias." 1 Rothwell et al 2 recently showed that the maximum systolic BP (SBP) reached in an office setting was a strong predictor of cardiovascular events, independently of the mean SBP over 12 to 36 months. Ko et al 3 also showed that the maximum SBP during the first 72 hours of acute ischemic stroke was strongly associated with the development of brain hemorrhagic transformation, independently of the mean SBP level. Thus, subjects with episodic high BP might be at a high cardiovascular risk.One drawback of the use of the maximum SBP in routine clinical management of hypertension is that obtaining it requires several office visits over a period of time. One possible way to solve this is to observe the maximum SBP derived from self-measurement at home, because this selfmeasurement makes it p...

To study whether sleep blood pressure (BP) self‐measured at home is associated with organ damage, the authors analyzed the data of 2562 participants in the J‐HOP study who self‐measured sleep BP using a home BP monitoring (HBPM) device, three times during sleep (2 am, 3 am, 4 am), as well as the home morning and evening BPs. The mean sleep home systolic BPs (SBPs) were all correlated with urinary albumin/creatinine ratio (UACR), left ventricular mass index (LVMI), brachial‐ankle pulse wave velocity (baPWV), maximum carotid intima‐media thickness, and plasma N‐terminal pro‐hormone pro–brain‐type natriuretic peptide (NTproBNP) (all P<.001). After controlling for clinic SBP and home morning and evening SBPs, associations of home sleep SBP with UACR, LVMI, and baPWV remained significant (all P<.008). Even in patients with home morning BP <135/85 mm Hg, 27% exhibited masked nocturnal hypertension with home sleep SBP ≥120 mm Hg and had higher UACR and NTproBNP. Masked nocturnal hypertension, which is associated with advanced organ damage, remains unrecognized by conventional HBPM.

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Morning BP and evening BP provide equally useful information for subclinical target organ damage, yet multivariate modeling highlighted the stand-alone predictive ability of morning BP.