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HONEST: Morning home BP strongly predicts CAD, stroke events
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BP taken at home in the morning is a strong predictor for future CAD and stroke events, according to new data from the HONEST study.
Because most studies of BP and CAD events have not used out-of-office BP measurements, the researchers investigated whether morning home BP could predict CAD events.
They studied 21,591 patients treated for hypertension (mean age, 64.9 years) who at 1 week, 4 weeks, 16 weeks, 6 months, 12 months, 18 months and 24 months had home BP measured twice in the morning and twice at bedtime on two different days. The outcomes of interest were stroke and CAD events. Mean follow-up was 2.02 years.
Kazuomi Kario, MD, and colleagues reported that during the study period, there were 127 stroke events (2.92/1,000 patient-years) and 121 CAD events (2.78/1,000 patient-years).
They found that stroke incidence was higher in patients with morning home systolic BP of at least 145 mm Hg compared with those with morning home systolic BP less than 125 mm Hg, and in patients with clinic systolic BP of at least 150 mm Hg compared with those with clinic systolic BP less than 130 mm Hg.
Elevated risks
Compared with people who had morning home systolic BP less than 125 mm Hg, those with morning home systolic BP of at least 155 mm Hg had a sixfold elevated risk for stroke (HR = 6.01; 95% CI, 2.85-12.68), Kario, from the division of cardiology, department of medicine, Jichi Medical University School of Medicine, Tochigi, Japan, and colleagues wrote. They found similar results for clinic systolic BP of at least 160 mm Hg vs. clinic systolic BP less than 130 mm Hg (HR = 5.82; 95% CI, 3.17-10.67), and determined that morning home systolic BP predicted stroke events with about the same accuracy as clinic systolic BP.
For CAD events, incidence was higher in those with morning home systolic BP of at least 145 mm Hg vs. those with morning home systolic BP less than 125 mm Hg, and in those with clinic systolic BP of at least 160 mm Hg vs. those with clinic systolic BP less than 130 mm Hg, according to the researchers.
Compared with those with morning systolic BP less than 125 mm Hg, those with levels of at least 155 mm Hg had more than a sixfold elevated risk for CAD events (HR = 6.24; 95% CI, 2.82-13.84), whereas the relationship between clinic systolic BP and CAD events was less strong (HR for 160 mm Hg vs. < 125 mm Hg = 3.51; 95% CI, 1.71-7.2), they wrote.
“Compared with morning [home systolic BP], [clinic systolic BP] may underestimate CAD risk,” Kario and colleagues wrote. “Goodness-of-fit analysis showed that morning [home systolic BP] predicted CAD events more strongly than [clinic systolic BP]. There does not appear to be a J-curve in the relationship between morning [home BP] and stroke or CAD events.”
Randomized trial needed
In a related editorial, Rajiv Agarwal, MD, from the Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, noted that “this study does not specifically demonstrate the value of morning home BP over the overall home BP” because “the data show that using all home BP recordings instead of just the morning ones may be easier and at least as strongly associated with stroke and [CAD].”
He added that in light of the SPRINT trial results, it is time to determine whether home BP monitoring can help patients achieve lower BP goals, and “the large pragmatic HONEST study suggests that it is time to design a randomized trial similar to SPRINT with treatment targets dictated by — not clinic BP — but home BP assessments,” which could be more cost-effective, convenient and successful in the long run. – by Erik Swain
Disclosure: The study was supported by funding from Daiichi Sankyo. Kario and four other researchers report receiving honoraria from Daiichi Sankyo. Two other researchers report being employed by Daiichi Sankyo. Agarwal reports receiving consulting and personal fees from AbbVie, Amgen, Bayer, Boehringer Ingelheim, Celgene, Daiichi Sankyo, Eli Lilly, Johnson & Johnson and Takeda.
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