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Ambulatory BP measurements strong predictors of mortality
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Ambulatory BP measurements were better predictors of CV and all-cause mortality compared with clinic BP measurements, according to a study published in The New England Journal of Medicine.
In addition, researchers found that masked hypertension conferred worse mortality outcomes than sustained hypertension.
J.R. Banegas, MD, professor at Universidad Autónoma de Madrid, and colleagues analyzed data from 63,910 adults (mean age, 58 years; 58% men) who were recommended according to guidelines for ambulatory BP monitoring from March 2004 to December 2014. Both clinic and ambulatory BP measurements were reviewed. Interviews and physical examinations were performed to collect patient data.
Phenotypes of hypertension were also assessed, including white-coat hypertension, sustained hypertension, masked hypertension and normotension.
Patients were followed up for a median of 4.7 years, and follow-up was conducted from the date of recruitment until death or Dec. 31, 2014, whichever occurred first.
During follow-up, 3,808 patients died, 1,295 from CV causes. There was a stronger association with all-cause mortality and 24-hour ambulatory systolic BP (HR after adjustment for clinic BP = 1.58 per 1-standard-deviation increase in pressure; 95% CI, 1.56-1.6) compared with clinic systolic BP (HR after adjustment for 24-hour BP = 1.02; 95% CI, 1-1.04).
Each 1-standard-deviation increase in nighttime ambulatory systolic BP was associated with an HR of 1.55 (95% CI, 1.53-1.57). The corresponding HR was 1.54 for daytime ambulatory systolic pressure (95% CI, 1.52-1.56). Findings were similar in analyses that stratified by sex, age and status regarding diabetes, obesity, CVD and antihypertensive treatment.
There was a stronger link between all-cause mortality and masked hypertension (HR = 2.83; 95% CI, 2.12-3.79) compared with white-coat hypertension (HR = 1.79; 95% CI, 1.38-2.32) and sustained hypertension (HR = 1.8; 95% CI, 1.41-2.31).
All results were similar in CV mortality.
“In our study, unlike most previous studies, we observed consistently greater mortality associated with masked hypertension than with sustained hypertension, which might be due to the delayed detection of masked hypertension in patients, who consequently could have more organ damage and cardiovascular disease than patients with sustained hypertension,” Banegas and colleagues wrote. – by Darlene Dobkowski
Disclosures: The study was supported by an unrestricted grant from Lacer Laboratories. Banegas reports he received grants from Fondo de Investigación Sanitaria and personal fees from Lacer. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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George L. Bakris, MD
This is an important study for many reasons. First, it adds to our knowledge that 24-hour ambulatory BP measurement is a better predictor of outcomes than office BP. Second, it confirms what has been shown in other studies regarding the increased CV event rate among those with white-coat hypertension.
What is relatively new is the contribution of masked hypertension having the strongest relationship with all-cause mortality, stronger than sustained hypertension. Masked hypertension is impossible to detect by office BP and difficult to assess with home monitoring. Thus, patients whose BP their physicians believe is well-controlled by office reading may be at much higher risk than appreciated based on these findings.
The suggestion a few years ago to perform an ambulatory BP measurement on all patients with an initial diagnosis of hypertension now takes on even more importance to ascertain not only white-coat hypertension, but masked hypertension. While not practical, however, since most physicians do not own such machines and may not be skilled at reading them, home BP monitors may be used to assess BP at different times of the workday or evening as appropriate.
People with masked hypertension are usually involved in highly analytical jobs such as stock traders, accounts, engineers, etc. or have jobs that are psychologically stressful or may have a stressful situation at home. It would be nice to better characterize patients with masked hypertension and use agents with different pharmacological half-lives to have peak activity when under work stress, at least. We have done this in our clinic for those referred to us with masked hypertension. Such an approach minimizes adverse effects and blunts the BPs from going too high. It would be good to identify a cadre of such patients and evaluate the outcomes.
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