Effective Ambulatory Blood Pressure Control in Medical Practice
2006; Lippincott Williams & Wilkins; Volume: 49; Issue: 1 Linguagem: Inglês
10.1161/01.hyp.0000250560.27738.72
ISSN1524-4563
Autores Tópico(s)Heart Rate Variability and Autonomic Control
ResumoHomeHypertensionVol. 49, No. 1Effective Ambulatory Blood Pressure Control in Medical Practice Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBEffective Ambulatory Blood Pressure Control in Medical PracticeGood News To Be Taken With Caution Giuseppe Mancia Giuseppe ManciaGiuseppe Mancia From the Clinica Medica, Dipartimento di Medicina Clinica e Prevenzione and Dipartimento di Statistica, Università Milano-Bicocca, Ospedale San Gerardo, Monza (Milan); Istituto Auxologico Italiano, Milan, Italy and Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Università di Milano, Milano-Bicocca and Pavia, Italy. Originally published6 Nov 2006https://doi.org/10.1161/01.HYP.0000250560.27738.72Hypertension. 2007;49:17–18Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 6, 2006: Previous Version 1 A large number of studies has addressed the question of how effective is blood pressure (BP) control in the hypertensive population,1–3 with a consistent and unequivocal answer. That is, BP control is disappointingly low, because only a small fraction of patients diagnosed as having a BP elevation show on-treatment BPs <140 mm Hg systolic and 90 mm Hg diastolic, which are the target values for treatment recommended by international guidelines.4,5 This is the case regardless of whether patients are followed by general practitioners or specialists6,7 and have a low or high cardiovascular risk profile,8–10 the latter condition making the need of BP control even more compelling given the imminent risk of a cardiovascular event. Reality is obviously even worse when the lower BP targets that have been shown to be additionally protective in high-risk hypertensive patients, that is, <130/80 mm Hg, are considered.4,5 In a recent study performed in Italy, for example, we have shown that in diabetic (and, thus, high risk) hypertensive patients followed by general practitioners, an on-treatment BP 2 times as large. The authors concluded that in a considerable number of treated hypertensive patients in whom BP measured by the physician remains high, daily life BPs are within the normal reference range, suggesting that the BP elevation found in the clinic environment may be a transient phenomenon (eg, a white-coat effect) and giving the problem of low BP control a more optimistic perspective.The article by Banegas et al13 has several merits that make its conclusions reliable. First, I am not aware of any other study that has examined BP control not only by office but also by a much more complex method, such as ambulatory BP monitoring, in such a large number of patients. Furthermore, selection of patients and physicians was such as to truly reflect the state of hypertension management in the country involved. Finally, the technical requirements for acceptance of ambulatory BP monitorings were such as to make the data quality adequate, a task particularly difficult to achieve in the clinical practice setting. Some considerations, however, may limit the optimistic implications of these results for BP control in the clinical practice. First, although ambulatory BP was recorded for 24 hours, data on nighttime BP values were not reported, which keeps open the possibility that in some subjects in which daytime BP was controlled, nighttime values remained above their normal limits. This may be clinically relevant, because night BP is prognostically important and its relationship with cardiovascular outcome steeper than that of daytime values.14–16 Second, the pattern characterized by an elevated office and a normal ambulatory BP may have preceded treatment because of the high prevalence (≤30%), in the untreated hypertensive population, of white-coat or isolated office hypertension.17 In other words, in at least part of the treated subjects of the study, the greater rate of ambulatory BP normality could have been present before the therapeutic intervention rather than resulting from it. Finally, there is evidence that individuals in whom ambulatory BP is normal but office BP is elevated are at greater cardiovascular risk than those in which ambulatory and office BPs are both normal.18–20 Indeed, analysis of the data obtained in the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) population shows that, compared with subjects in whom office, home, and 24-hour BPs are all normal, the 12-year rate of cardiovascular death was progressively greater when 1, 2, or all 3 of these BPs were elevated (Figure),19 the differences occurring also after adjustment for between-group discrepancies in age and gender. This supports the clinical importance of the data obtained by Banegas et al,13 because patients with an increased office BP and a normal ambulatory BP appear to be at lower risk than those in whom also ambulatory BP is elevated. It also emphasizes, however, that an uncontrolled office BP is associated with a higher-than-optimal risk and that the ideal treatment should control both "in-office" and "out-of-office" BPs. Download figureDownload PowerPointIncidence of cardiovascular fatal events in subjects of the PAMELA population sample (n=2051) followed for 148 months. Data are shown for subjects in whom: (1) clinic, home, and ambulatory BP values were all normal; (2) 1 or 2 BPs were elevated regardless whether the elevation involved clinic, home, or ambulatory values; and (3) all 3 BPs were elevated before (left) and after (right) adjustment for differences in age and gender. P values refer to trend. Data from Reference 19.The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.DisclosuresNone.FootnotesCorrespondence to Giuseppe Mancia, Clinica Medica, Ospedale San Gerardo, Via Pergolesi 33, 20052 Monza, Milan, Italy. E-mail [email protected] References 1 Kearney PM, Whelton M, Reynolds K, Whelton PK, He J. Worldwide prevalence of hypertension: a systematic review. J Hypertens. 2004; 22: 11–19.CrossrefMedlineGoogle Scholar2 Primatesta P, Brookes M, Poulter NR. Improved hypertension management and control: results from the health survey for England 1998. Hypertension. 2001; 38: 827–832.LinkGoogle Scholar3 Mancia G, Grassi G. Rationale for the use of fixed combination in the treatment of hypertension. Eur Heart J. 1999; 1 (suppl): L14–L19.Google Scholar4 Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens. 2003; 21: 1011–1053.CrossrefMedlineGoogle Scholar5 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ and the National High Blood Pressure Education Program Coordinating Committee. 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Hypertension. 1995; 26: 60–69.CrossrefMedlineGoogle Scholar13 Banegas JR, Segura J, Sobrino J, Rodriguez-Artalejo F, de la Sierra A, de la Cruz JJ, Gorostidi M, Sarría A, Ruilope LM. for the Spanish Society of Hypertension Ambulatory Blood Pressure Monitoring Registry Investigators. Effectiveness of blood pressure control outside the medical setting. Hypertension. 2007; 49: 62–68.LinkGoogle Scholar14 Sega R, Facchetti R, Bombelli M, Cesana G, Corrao G, Grassi G, Mancia G. Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation. 2005; 111: 1777–1783.LinkGoogle Scholar15 Staessen JA, Thijs L, Fagard R, O'Brien ET, Clement D, de Leeuw PW, Mancia G, Nachev C, Palatini P, Parati G, Tuomilehto J, Webster J. Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. Systolic Hypertension in Europe Trial Investigators. JAMA. 1999; 282: 539–546.CrossrefMedlineGoogle Scholar16 Kario K, Pickering TG. White-coat hypertension or white-coat hypertension syndrome: which is accompanied by target organ damage? Arch Intern Med. 2000; 160: 3497–3498.CrossrefMedlineGoogle Scholar17 Pickering TG, Coats A, Mallion JM, Mancia G, Verdecchia P. Blood Pressure Monitoring Task Force V: White-coat hypertension. Blood Press Monit. 1999; 4: 333–341.MedlineGoogle Scholar18 Gustavsen PH, Hoegholm A, Bang LE, Kristensen KS. White-coat hypertension is a cardiovascular risk factor: a 10-year follow-up study. J Hum Hypertens. 2003; 17: 811–817.CrossrefMedlineGoogle Scholar19 Mancia G, Facchetti R, Bombelli M, Grassi G, Sega R. Long-term risk of mortality associated with selective and combined elevation in office, home, and ambulatory blood pressure. 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Souza G, Libardi C, Rocha Jr. J, Madruga V and Chacon-Mikahil M (2012) Efeito do treinamento concorrente nos componentes da síndrome metabólica de homens de meia-idade, Fisioterapia em Movimento, 10.1590/S0103-51502012000300020, 25:3, (649-658), Online publication date: 1-Sep-2012. Mancia G, Bombelli M, Seravalle G and Grassi G (2011) Diagnosis and management of patients with white-coat and masked hypertension, Nature Reviews Cardiology, 10.1038/nrcardio.2011.115, 8:12, (686-693), Online publication date: 1-Dec-2011. Segura J and Gorostidi M (2010) Evidencias generadas por el proyecto CARDIORISC, Hipertensión y Riesgo Vascular, 10.1016/S1889-1837(10)70002-7, 27, (4-8), Online publication date: 1-Jan-2010. Gorostidi M and Ruilope L (2010) Aportaciones del proyecto CARDIORISC. Introducción, Hipertensión y Riesgo Vascular, 10.1016/S1889-1837(10)70001-5, 27, (1-3), Online publication date: 1-Jan-2010. Mancia G, Bombelli M, Facchetti R, Madotto F, Quarti-Trevano F, Friz H, Grassi G and Sega R (2009) Response to Long-Term Risk in Subjects With White-Coat Hypertension, Hypertension, 54:5, (e134-e134), Online publication date: 1-Nov-2009. Mancia G, Giannattasio C, Seravalle G, Quarti-Trevano F and Grassi G (2009) Protective effects of renin–angiotensin blockade beyond blood pressure control, Journal of Human Hypertension, 10.1038/jhh.2008.171, 23:9, (570-577), Online publication date: 1-Sep-2009. O'Brien E (2009) Ambulatory blood pressure measurement is indispensable to good clinical practice, Hipertensión y Riesgo Vascular, 10.1016/j.hipert.2009.02.002, 26:5, (213-217), Online publication date: 1-Sep-2009. Kronborg C, Hallas J and Jacobsen I (2009) Prevalence, awareness, and control of arterial hypertension in Denmark, Journal of the American Society of Hypertension, 10.1016/j.jash.2008.08.001, 3:1, (19-24.e2), Online publication date: 1-Jan-2009. Mancia G (2008) The broadening landscape for hypertension management, Journal of the American Society of Hypertension, 10.1016/j.jash.2008.03.003, 2:4, (S3-S9), Online publication date: 1-Jul-2008. O'Brien E (2008) Ambulatory Blood Pressure Measurement, Hypertension, 51:6, (1435-1441), Online publication date: 1-Jun-2008. January 2007Vol 49, Issue 1 Advertisement Article InformationMetrics https://doi.org/10.1161/01.HYP.0000250560.27738.72PMID: 17088450 Originally publishedNovember 6, 2006 PDF download Advertisement SubjectsClinical Studies
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