High prevalence of masked uncontrolled hypertension in people with treated hypertension

Banegas, José R.; Ruilope, Luís M.; Sierra, Alejandro de la; Cruz, Juan; Gorostidi, Manuel; Segura, Julián; Martell, Nieves; García-Puig, Juan; Deanfield, John; Williams, Bryan

doi:10.1093/eurheartj/ehu016

Cited by 199 publications

(178 citation statements)

References 32 publications

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“…Although echocardiography and PWV measurements were available in most ABPM participants, they were not necessarily obtained concurrently, and the sequence of ABPM and these measures was not uniform across all participants; this further limits our ability to assess causality. We did not distinguish between masked hypertension and masked uncontrolled hypertension, although .90% of participants received antihypertensive medications (45). Additionally, the outcomes assessed in this paper, although clearly important, are still surrogates for clinical cardiovascular disease.…”

Section: Discussionmentioning

confidence: 97%

Masked Hypertension and Elevated Nighttime Blood Pressure in CKD

Drawz¹,

Alper²,

Anderson³

et al. 2016

Clinical Journal of the American Society of Nephrology

173

118

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Background and objectives Masked hypertension and elevated nighttime BP are associated with increased risk of hypertensive target organ damage and adverse cardiovascular and renal outcomes in patients with normal kidney function. The significance of masked hypertension for these risks in patients with CKD is less well defined. The objective of this study was to evaluate the association between masked hypertension and kidney function and markers of cardiovascular target organ damage, and to determine whether this relationship was consistent among those with and without elevated nighttime BP.Design, setting, participants, & measurements This was a cross-sectional study. We performed 24-hour ambulatory BP in 1492 men and women with CKD enrolled in the Chronic Renal Insufficiency Cohort Study. We categorized participants into controlled BP, white-coat, masked, and sustained hypertension on the basis of clinic and 24-hour ambulatory BP. We obtained echocardiograms and measured pulse wave velocity in 1278 and 1394 participants, respectively. ResultsThe percentages of participants with controlled BP, white-coat, masked, and sustained hypertension were 49.3%, 4.1%, 27.8%, and 18.8%, respectively. Compared with controlled BP, masked hypertension independently associated with low eGFR (23.2 ml/min per 1.73 m 2 ; 95% confidence interval, 25.5 to 20.9), higher proteinuria (+0.9 unit higher in log 2 urine protein; 95% confidence interval, 0.7 to 1.1), and higher left ventricular mass index (+2.52 g/m 2.7 ; 95% confidence interval, 0.9 to 4.1), and pulse wave velocity (+0.92 m/s; 95% confidence interval, 0.5 to 1.3). Participants with masked hypertension had lower eGFR only in the presence of elevated nighttime BP (23.6 ml/min per 1.73 m 2 ; 95% confidence interval, 26.1 to 21.1; versus 21.4 ml/min per 1.73 m 2 ; 95% confidence interval, 26.9 to 4.0, among those with nighttime BP ,120/70 mmHg; P value for interaction with nighttime systolic BP 0.002).Conclusions Masked hypertension is common in patients with CKD and associated with lower eGFR, proteinuria, and cardiovascular target organ damage. In patients with CKD, ambulatory BP characterizes the relationship between BP and target organ damage better than BP measured in the clinic alone.

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Section: Discussionmentioning

confidence: 97%

Masked Hypertension and Elevated Nighttime Blood Pressure in CKD

Drawz¹,

Alper²,

Anderson³

et al. 2016

Clinical Journal of the American Society of Nephrology

173

118

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“…Albuminuria is expressed as mg/g. in order to assess the appropriateness of nighttime BP control, ABPM performance is required in patients with albuminuria because elevated nighttime BP could be present in patients with an apparently adequate BP control in the office (42).…”

Section: Discussionmentioning

confidence: 99%

Association Between High and Very High Albuminuria and Nighttime Blood Pressure: Influence of Diabetes and Chronic Kidney Disease

et al. 2016

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OBJECTIVENighttime blood pressure (BP) and albuminuria are two important and independent predictors of cardiovascular morbidity and mortality. Here, we examined the quantitative differences in nighttime systolic BP (SBP) across albuminuria levels in patients with and without diabetes and chronic kidney disease. RESEARCH DESIGN AND METHODSA total of 16,546 patients from the Spanish Ambulatory Blood Pressure Monitoring Registry cohort (mean age 59.6 years, 54.9% men) were analyzed. Patients were classified according to estimated glomerular filtration rate (eGFR), as ‡60 or <60 mL/min/1.73 m 2 (low eGFR), and urine albumin-to-creatinine ratio, as normoalbuminuria (<30 mg/g), high albuminuria (30-300 mg/g), or very high albuminuria (>300 mg/g). Office and 24-h BP were determined with standardized methods and conditions. RESULTSHigh albuminuria was associated with a statistically significant and clinically substantial higher nighttime SBP (6.8 mmHg higher than with normoalbuminuria, P < 0.001). This association was particularly striking at very high albuminuria among patients with diabetes and low eGFR (16.5 mmHg, P < 0.001). Generalized linear models showed that after full adjustment for demographic, lifestyles, and clinical characteristics, nighttime SBP was 4.8 mmHg higher in patients with high albuminuria than in those with normoalbuminuria (P < 0.001), and patients with very high albuminuria had a 6.1 mmHg greater nighttime SBP than those with high albuminuria (P < 0.001). These differences were 3.8 and 3.1 mmHg, respectively, among patients without diabetes, and 6.5 and 8 mmHg among patients with diabetes (P < 0.001). CONCLUSIONSAlbuminuria in hypertensive patients is accompanied by quantitatively striking higher nighttime SBP, particularly in those with diabetes with very high albuminuria and low eGFR.

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“…77 Home BP measurement could be useful in the diagnosis and in the prognostic stratification, also for the nocturnal period, 78 but ABPM seems to be the best method to make an accurate diagnosis. 79,80 In addition, the Ohasama study demonstrated, in a cohort of 843 subjects of the general population who performed ABPM, that the nocturnal BP values were the best predictor of future chronic kidney disease. 81 In the Japan Morning Surge Home Blood Pressure (J-HOP) Study, Kario et al developed a more comfortable device with respect to traditional ABPM device focused on the night time BP values of 02:00, 03:00, 04:00 a.m., which showed in 2562 subjects a strict correlation between nighttime BP values and TOD.…”

Section: Clinical Consequencesmentioning

confidence: 99%

White-coat hypertension and masked hypertension: an update

2015

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The precise quantification of blood pressure (BP) is an essential step to reach the largest number of correct diagnosis of arterial hypertension (AH) and consequently to optimize the anti-hypertensive therapy. Since the invention of the first sphygmomanometer in 1896, Riva-Rocci observed the inaccuracy of that method for a correct BP determination: 1 the simple appearance of a doctor was accompanied by an immediate rise in BP in some patients. Years later Pickering called this phenomenon white coat hypertension (WCHT). 2 The introduction of fully-automated BP measurement during the 24 h (ambulatory blood pressure monitoring, ABPM) allowed to observe the entire circadian BP profile, highlighting how BP could be normal in physician office and elevated at home, especially during the nocturnal period. 3 This last observation was named masked hypertension (MHT). 4 WCHT is defined as office BP persistently ≥140 mmHg systolic, ≥90 mmHG diastolic, or both, whereas out-of-office BP is within normal (<130/80 mmHg for 24-h mean BP, or <135/85 mmHG for home BP). 5-7 Medical environment triggers this alarm reaction, 8 through the hyperactivation of sympathetic nervous system. 9 It peaked 2-4 min after the start of the visit and continued throughout the duration of the physician's visit. 10 For this reason, international guidelines recommended to record at least two ABPM to confirm the diagnosis of WCHT and to determine the possible development of sustained hypertension. 11 Further WCHT can be divided into true WCH, when both home BP values and ABPM values are normal, and partial WCHT, when only one of these out-of-office measurements is normal. 5 If WCHT can determinate an overdiagnosis of AH, on the other hand some subjects present normal office BP values in contrast to pathological 24-h BP profile on ABPM or altered home BP. This reverse white-coat effect or MHT 12,13 is related to a worse cardiovascular (CV) prognosis 14 and also to the development of a target organ damage (TOD) comparable to sustained hypertension patients 15 (Table 1). Both WCHT and MHT are examples of how the correct evaluation of BP profile is a difficult challenge and how their better knowledge can lead to a more precise diagnosis and consequently to a proper treatment of AH. EpidemiologyThe prevalence of WCHT and MHT is not completely clear. AS a confounding factor several studies showed different values for normal BP. Regarding White-coat hypertension and masked hypertension: an update ABSTRACTWhite coat hypertension and masked hypertension are two conditions with a controversial role in the beginning and the progression of the cardiovascular disease. We focused our attention on the definition, the epidemiology, the pathophysiology and the clinical consequences of these two conditions, with an attention also on the management. This review was based on the papers found on PubMed and MEDLINE up to August 2015. The search terms used were white coat hypertension, masked hypertension in combination with epidemiology, management and pathophysiology.

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High prevalence of masked uncontrolled hypertension in people with treated hypertension

Cited by 199 publications

References 32 publications

Masked Hypertension and Elevated Nighttime Blood Pressure in CKD

Masked Hypertension and Elevated Nighttime Blood Pressure in CKD

Association Between High and Very High Albuminuria and Nighttime Blood Pressure: Influence of Diabetes and Chronic Kidney Disease

White-coat hypertension and masked hypertension: an update

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