Emergence of Home Blood Pressure-Guided Management of Hypertension Based on Global Evidence
2019; Lippincott Williams & Wilkins; Volume: 74; Issue: 2 Linguagem: Inglês
10.1161/hypertensionaha.119.12630
ISSN1524-4563
AutoresKazuomi Kario, Daichi Shimbo, Satoshi Hoshide, Ji-Guang Wang, Kei Asayama, Takayoshi Ohkubo, Yutaka Imai, Richard J. McManus, Αναστάσιος Κόλλιας, Teemu Niiranen, Gianfranco Parati, Bryan Williams, Michael A. Weber, Wanpen Vongpatanasin, Paul Muntner, George S. Stergiou,
Tópico(s)Heart Rate Variability and Autonomic Control
ResumoHomeHypertensionVol. 74, No. 2Emergence of Home Blood Pressure-Guided Management of Hypertension Based on Global Evidence Open AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessReview ArticlePDF/EPUBEmergence of Home Blood Pressure-Guided Management of Hypertension Based on Global Evidence Kazuomi Kario, Daichi Shimbo, Satoshi Hoshide, Ji-Guang Wang, Kei Asayama, Takayoshi Ohkubo, Yutaka Imai, Richard J. McManus, Anastasios Kollias, Teemu J. Niiranen, Gianfranco Parati, Bryan Williams, Michael A. Weber, Wanpen Vongpatanasin, Paul Muntner and George S. Stergiou Kazuomi KarioKazuomi Kario Correspondence to Kazuomi Kario, Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Shimotsuke, Tochigi 329-0498, Japan. Email E-mail Address: [email protected] From the Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (K.K., S.H.) Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network Tokyo, Japan (K.K., S.H., J.-G.W.) , Daichi ShimboDaichi Shimbo The Hypertension Center, Columbia University Medical Center, New York, NY (D.S.) , Satoshi HoshideSatoshi Hoshide From the Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (K.K., S.H.) Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network Tokyo, Japan (K.K., S.H., J.-G.W.) , Ji-Guang WangJi-Guang Wang Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network Tokyo, Japan (K.K., S.H., J.-G.W.) Department of Hypertension, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Shanghai Key Laboratory of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, China (J.-G.W.) , Kei AsayamaKei Asayama Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A., T.O.) , Takayoshi OhkuboTakayoshi Ohkubo Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A., T.O.) , Yutaka ImaiYutaka Imai Tohoku Institute for Management of Blood Pressure, Sendai, Japan (Y.I.) , Richard J. McManusRichard J. McManus Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom (R.J.M.) , Anastasios KolliasAnastasios Kollias Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Greece (A.K., G.S.S.) , Teemu J. NiiranenTeemu J. Niiranen National Institute for Health and Welfare, and Department of Medicine, University of Turku and Turku University Hospital, Finland (T.J.N.) , Gianfranco ParatiGianfranco Parati Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P.) Istituto Auxologico Italiano, IRCCS, Cardiology Unit and Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milano, Italy (G.P.) , Bryan WilliamsBryan Williams UCL Institute of Cardiovascular Sciences, University College London, United Kingdom (B.W.) , Michael A. WeberMichael A. Weber Division of Cardiovascular Medicine, State University of New York, Downstate College of Medicine, Brooklyn (M.A.W.) , Wanpen VongpatanasinWanpen Vongpatanasin Hypertension Section, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (W.V.) , Paul MuntnerPaul Muntner Department of Epidemiology, University of Alabama at Birmingham (P.M.). and George S. StergiouGeorge S. Stergiou Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Greece (A.K., G.S.S.) Originally published1 Jul 2019https://doi.org/10.1161/HYPERTENSIONAHA.119.12630Hypertension. 2019;74:229–236Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: July 1, 2019: Ahead of Print Recent guidelines for the management of hypertension from the 2018 European Society of Cardiology/European Society of Hypertension and the 2017 American College of Cardiology (ACC)/American Heart Association (AHA)1,2 have stressed the importance of out-of-office blood pressure (BP) measurement for hypertension management. There has been a similar emphasis on out-of-office BP monitoring for the management of hypertension in the United Kingdom, Canada, Japan, and other Asian countries.3–6 Ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) are 2 well-validated approaches for measuring out-of-office BP. In the published literature, HBPM is a term that has commonly referred to the self-measurement of BP at home, although in some studies, HBPM has been used to describe a provider or research assistant measuring an individual's BP in his/her home. ABPM and HBPM can identify white coat hypertension (diagnostic disagreement between office and out-of-office BP in untreated subjects) and white coat uncontrolled hypertension (diagnostic disagreement in treated subjects).1–8 Although ABPM has been the preferred method for out-of-office measurement, the 2017 ACC/AHA BP guideline considered HBPM to be a more practical approach in clinical practice than ABPM, particularly for individuals taking antihypertensive medication. The 2014 Japanese Society of Hypertension Guidelines for the Management of Hypertension proposed HBPM as the most effective and practical for guiding antihypertensive medication initiation and titration in clinical care, while waiting for intervention trials demonstrating better cardiovascular outcomes in patients managed based on out-of-office BP levels.3,9,10Home BP Threshold of 135/85 mm HgA commonly recommended HBPM monitoring schedule consists of performing morning and evening BP measurements twice on each occasion over a minimum of 3 days with a preferred period of 7 days.1,11 Traditionally, out-of-office BP thresholds have been determined by using the regression and outcome-derived approaches12 with data from observational studies. The threshold for high out-of-office BP corresponding to an office BP threshold of 140/90 mm Hg has been determined to be 135/85 mm Hg for both home and daytime BP on ABPM.1,3–8Associations of Home BP With Cardiovascular Disease OutcomesPrevious prospective studies have demonstrated that individuals who have higher home BP levels have an increased risk of cardiovascular disease (CVD) (Table 1). This includes several observational studies conducted among community-based and clinic-based populations.13–26Table 1. Prospective Studies of Home BP Monitoring and Cardiovascular EventsMeasurement PeriodOutcomesCommunity-based study Ohkubo et al13, Ohasama studyJapan (N=1789; age ≥40 y; mean follow-up, 6.6 y)28-d HBPM (28 readings)Relative HR of cardiovascular mortality with a BP increase of 1 mm Hg was 1.021 (95% CI, 1.001–1.041; P<0.05). Okumiya et al26, Kahoku studyJapan (N=1186; age, 73.5 y; follow-up, 4 y)5-d HBPM (20 readings)Adjusted HRs for cardiovascular mortality of each HSBP ≥135–144 mm Hg, ≥145 mm Hg compared to HSBP 125–134 mm Hg (as reference) were 2.3 (95% CI, 1.0–5.6; P<0.05), 2.1 (0.9–5.0; P<0.1), respectively. Sega et al14, PAMELA study†Italy (N=2051; age, 25–74 y; mean follow-up, 131 mo)1-d HBPM (2 readings)HR of cardiovascular mortality with a BP increase of 1 mm Hg was 1.05 (95% CI, 1.04–1.06; P<0.0001).* Hänninen et al15, Finn-Home studyFinland (N=2046; age, 44–74 y; follow-up, 7.5 y)7-d HBPM (28 readings)Adjusted HR of MH for cardiovascular events compared to normotension was 1.62 (95% CI, 0.96–2.71; P=0.07). Tientcheu et al16, Dallas Heart studyUnited States (N=3027; age, 18–65 y; median follow-up, 9 y)2 d in-home visit BP measurements (not by the self-measurement, but by trained research personnel; 10 readings)Adjusted HR of MH for composite cardiovascular events compared to normotension was 2.03 (95% CI, 1.36–3.03; P=0.0005). Ntineri et al17, Didima studyGreece (N=665; mean age, 54 y; follow-up, 19 y)3-d HBPM (12 readings)Adjusted HR of cardiovascular morbidity and mortality with an SBP increase of 10 mm Hg was 1.04 (95% CI, 0.94–1.15; P=0.45).Clinic-based study Bobrie et al18, SHEAF study‡France (4939 treated hypertensive patients; mean age, 70 y; mean follow-up, 3.2 y)4-d HBPM (baseline HBP; 24 readings)Adjusted HR of fatal or nonfatal cardiovascular events with a BP increase of 1 mm Hg was 1.02 (95% CI, 1.01–1.02; P<0.001). Fagard et al19Belgium (391 older outpatients; mean age, 71 y; follow-up, 10.9 y)1-d HBPM (baseline HBP; 3 readings; not by self-measurement, by a physician or assist physician with mercury device)Adjusted relative HR of cardiovascular events with a home BP increase of 1 SD (22.9 mm Hg) was 1.32 (95% CI, 1.06–1.64; P=0.01). Asayama et al20, HOMED-BP§Japan (3518 hypertensive patients; mean age, 59.6 y; median follow-up, 5.3 y)5-d HBPM (follow-up HBP; 5 readings)Adjusted HR of fatal or nonfatal cardiovascular events with a home BP increase of 1 SD (13.2 mm Hg) was 1.47 (95% CI, 1.23–1.75; P<0.0001). Kario et al21, HONEST study‖Japan (21 591 hypertensive patients; mean age, 64.9 y; mean follow-up, 2.02 y)2-d HBPM (follow-up HBP; 8 readings)HR of incidence of cardiovascular events for morning HSBP ≥145 mm Hg and CSBP ≥150 mm Hg compared to morning HSBP 125 mm Hg and OSBP <130 mm Hg was 3.92 (95% CI, 2.22–6.92). Hoshide et al23, J-HOP study¶Japan (4310 patients with a history of and risk factors for cardiovascular disease; mean age, 65 y; mean follow-up, 4 y)14-d HBPM (baseline HBP; 84 readings)Adjusted HR of stroke events with a home BP increase of 10 mm Hg was 1.36 (95% CI, 1.19–1.56; P<0.001).BP indicates blood pressure; HBPM, home blood pressure monitoring; HR, hazard ratio; HSBP, home systolic BP; MH, masked hypertension; OSBP, office systolic BP and SBP, systolic BP.*Calculated from presented data of β coefficient and SE in this study.†Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study‡Self-Measurement of Blood Pressure at Home in the Elderly: Assessment and Follow-up (SHEAF) study§Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP)‖Home Blood Pressure Measurement With Olmesartan Naive Patients to Establish Standard Target Blood Pressure (HONEST) study¶Japan Morning Surge-Home Blood Pressure (J-HOP) study.Community-Based StudiesThe Ohasama study was the first to demonstrate that home BP measurement had a stronger predictive value for mortality than screening office BP measurement in a general population (Table 1).13 Based on initial follow-up data from the Ohasama study in 1997, the outcome-derived reference value for hypertension based on home BP was proposed as 137/84 mm Hg, which supported the aforementioned threshold of 135/85 mm Hg.27 In another population-based study of 1186 community-dwelling elderly residents of a rural Japanese town, systolic home BP ≥135 mm Hg versus 125 to 134 mm Hg was associated with an almost 4× higher risk of mortality. Systolic home BP <125 mm Hg was also associated with an increased risk of mortality. The population-based PAMELA study (Pressioni Arteriose Monitorate E Loro Associazioni) demonstrated that the risk of death was progressively higher according to increasing home or ambulatory BP level compared to office BP level, despite only 2 home BP readings being obtained for each participant.14 In the Finn-Home Study, masked hypertension, defined as office BP <140/90 mm Hg with home BP ≥135/85 mm Hg, was associated with a statistically significantly higher age-adjusted risk of CVD events and a higher risk of all-cause mortality after adjustment for age, sex, and office BP compared with normotension (adjusted hazard ratios, 1.64; [95% CI, 1.01–2.67]; and 2.09 [95% CI, 1.17–1.34]).15 In the Dallas Heart Study, both white coat hypertension (adjusted hazard ratio, 2.09 [95% CI, 1.05–4.05]) and masked hypertension (adjusted hazard ratio, 2.03 [95% CI, 1.36–3.03]), defined using an office BP threshold of 140/90 mm Hg and home BP threshold of 135/85 mm Hg, were each associated with higher incidence of CVD events compared with normotension, even after adjustment for traditional cardiovascular risk factors.16 However, in the Dallas Heart Study, home BP readings were not self-measured but were obtained by research staff on 2 occasions at the individual's home. The Didima study, which had the longest follow-up (mean 19 years), demonstrated that compared to normotension, sustained hypertension (hypertension both in the office and in the out-of-office setting), masked hypertension, and white coat hypertension were each associated with an increased risk of death and CVD. In adjusted models, the risk of death remained statistically significantly higher for sustained hypertension, masked hypertension, and white coat hypertension, whereas the risk for CVD remained statistically significant only for white coat hypertension.17Clinic-Based Studies Exploring the Role of Office and Out-of-Office BP in Patients Treated for HypertensionA prospective study conducted among older French adults taking antihypertensive medication reported that those with masked uncontrolled hypertension, defined as office BP <140/90 mm Hg and home BP ≥135/85 mm Hg, had a statistically significantly higher risk of CVD events (hazard ratio, 2.06 [95% CI, 1.22–3.47]) compared to participants who had controlled hypertension, defined as office BP <140/90 mm Hg and home BP <135/85 mm Hg (Table 1). The risk of CVD events associated with masked uncontrolled hypertension was similar to that of uncontrolled hypertension (hazard ratio, 1.96 [95% CI, 1.27–3.02]), defined as office BP ≥140/90 mm Hg and home BP ≥135/85 mm Hg.18 In a registry consisting of older adults, aged ≥60 years, the prognostic value of home BP was superior to that of office BP, and was similar to or better than daytime systolic BP (SBP) and daytime diastolic BP, respectively.19 The multicenter HOMED BP (Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure) demonstrated that the 5-year risk of CVD events was low (≤1%) if on-treatment home SBP was <131.6 mm Hg.20 The HONEST (Home Blood Pressure Measurement With Olmesartan Naive Patients to Establish Standard Target Blood Pressure) Study, the largest prospective study (n=21 591) of home BP conducted to date, demonstrated that higher on-treatment morning home BP was associated with a statistically significant increased risk for CVD events. In this study, cardiovascular risk was increased in participants with morning home SBP ≥145 mm Hg and office SBP <130 mm Hg (hazard ratio, 2.47 [95% CI, 1.20–5.08]) compared with morning home SBP <125 mm Hg and office SBP <130 mm Hg. Using a spline regression analysis, the morning home SBP level associated with the lowest CVD risk was 124 mm Hg.21 Morning home SBP was more closely associated with the risk of both stroke and coronary artery disease events compared with office SBP.22 The J-HOP study (Japan Morning Surge-Home Blood Pressure), a nationwide practice-based study, demonstrated that morning home SBP ≥135 mm Hg was associated with a statistically significant higher stroke risk than morning home SBP <135 mm Hg, and morning SBP improved the discrimination of incident stroke (C statistic, 0.802) beyond traditional risk factors including office SBP (C statistic, 0.756). Better discrimination of incident stroke was present for morning versus evening SBP (C statistic, 0.802 versus 0.764).23 In J-HOP, masked uncontrolled hypertension, defined as office BP <140/90 mm Hg and home BP ≥135/85 mm Hg was associated with increased stroke risk.24Moreover, in a recent post hoc analysis, a home SBP <125 mm Hg was associated with the lowest risk of CVD events in high-risk individuals with hypertension and diabetes mellitus or a history of stroke.25 These data suggest that patients may receive additional CVD risk reduction benefits by achieving a home BP of <125 mm Hg, especially among high-risk individuals with hypertension. However, on-treatment home BP targets should be evaluated in large randomized controlled outcome trials.Trial Evidence for Improved Hypertension Control With Self-Monitoring of Home BPThere is now a large body of empirical evidence indicating better BP control with HBPM.28 Uhlig et al29 conducted a systematic review and meta-analysis of 52 studies that compared HBPM to usual care. The results showed that HBPM alone without co-interventions (ie, one-to-one counseling, remote telemonitoring, and educational classes) to be associated with lower BP at 6 months but not 12 months compared with usual care. However, compared with usual care, HBPM when given with co-interventions was associated with a reduction in BP at 12 months. In a more recent systematic review and meta-analysis, Tucker et al28 identified 25 trials that compared HBPM to usual care. HBPM was more effective than usual care at lowering BP at 12 months, but this effect was strongly influenced by whether co-interventions were given. There was no difference in BP comparing HBPM alone without co-interventions (web/phone feedback, education, in-person counseling or telecounseling) versus usual care. In contrast, there was a reduction in BP when HBPM was combined with co-interventions, with the reduction increasing with the intensity of co-intervention. The results of both systematic reviews and meta-analyses suggest that the benefits of HBPM on BP control are greatest when given with interventions.More recent studies using 135/85 mm Hg as the home BP target have shown better BP control with HBPM with or without telemonitoring versus usual care.30,31 Similar or better BP lowering has been observed in individuals titrating their own antihypertensive medication using HBPM under medical supervision.32,33 Two studies showed that treatment titration aiming at achieving home BP levels <135/85 mm Hg improved indices of subclinical organ damage.34,35 Stergiou et al36 showed that compared to a strategy combining ABPM and office BP monitoring, HBPM resulted in similar outcomes in terms of end-organ damage regression. Longer-term follow-up of self-BP monitoring trials suggests that these benefits are sustained.37 The benefits of HBPM may be mediated through the optimization of antihypertensive therapy (eg, reduction of clinical inertia) combined with increased medication adherence.38Taken together, these results provide strong evidence suggesting that the use of HBPM to guide antihypertensive management may lead to better BP control, particularly when accompanied by co-interventions. Finally, data indicate that HBPM with or without telemonitoring is cost-effective when compared to office BP measurement or usual care in individuals with hypertension.39–43Home BP Threshold of 130/80 mm HgThe 2017 ACC/AHA BP Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults2 suggested lower BP thresholds (ie, office BP goal of 130/80 mm Hg) with the aim of preventing organ damage and CVD events.44 At lower BP levels, the differences between office and home or daytime ambulatory BP values are smaller.45 Data from observational studies using the regression and outcome-derived approaches suggest that the BP threshold for having high BP corresponding to an office BP of 130/80 mm Hg is 130/80 mm Hg for home and daytime BP on ABPM.12The 2017 ACC/AHA BP guideline definition for hypertension status (office BP ≥130/80 mm Hg and home BP ≥130/80 mm Hg) has markedly changed the prevalence of hypertension subtypes compared to prior thresholds (ie, office BP ≥140/90 mm Hg and home BP ≥135/85 mm Hg). In the J-HOP study,44 a general practice-based national registry of home BP, the prevalence of normotension, white coat uncontrolled hypertension, masked uncontrolled hypertension, and sustained hypertension was 31%, 15%, 19%, and 36%, respectively according to the thresholds (ie, 140/90 mm Hg for office BP and 135/85 mm Hg for home BP) proposed by the previous Joint National Committee 7 and the 2018 European Society of Cardiology/European Society of Hypertension guidelines. The prevalence of normotension, white coat uncontrolled hypertension, masked uncontrolled hypertension, and sustained hypertension was 14%, 17%, 10%, and 58%, respectively, according to the 2017 ACC/AHA BP guideline threshold definitions (ie, 130/80 mm Hg for both office BP and home BP).44 Thus, the greatest impact of the reclassification of hypertension is an increased prevalence of sustained hypertension and lower prevalence of normotension. The population-based Ohasama study also demonstrated similar changes in the distribution of these 4 hypertension subtypes.46,47A recent analysis of the Ohasama study demonstrated that partial masked hypertension, defined as having masked hypertension on HBPM but not ABPM or alternatively on ABPM but not HBPM, and complete masked hypertension, defined as having masked hypertension on both ABPM and HBPM, were associated with a similar risk for stroke events, when masked hypertension was defined using the BP thresholds of either the 2017 ACC/AHA BP guideline or the 2018 European Society of Cardiology/European Society of Hypertension guideline.46A recent analysis of the Dallas Heart Study (n=5768) and the North Carolina Masked Hypertension study (n=420) used the regression-based approach to determine home BP thresholds corresponding to office BP of 130/80 mm Hg. Home BP was measured by research staff visiting the participants' home in the Dallas Heart Study, whereas home BP was self-measured in the North Carolina Masked Hypertension study. In these studies, home BP thresholds were 129/80 mm Hg in black participants, 130/80 mm Hg in white participants, and 126/78 mm Hg in Hispanic participants.48 According to an outcome-derived approach based on the composite of CVD events or all-cause mortality over 11 years of follow-up of Dallas Heart Study participants, the home SBP thresholds corresponding to office SBP of 130 mm Hg were 130 mm Hg in black participants, 129 mm Hg in white participants, and 131 mm Hg in Hispanic participants. Home BP thresholds were identified using the outcomes-based approach for SBP only as home diastolic BP was not associated with outcomes. Both the regression-derived and outcome-derived approaches in these studies support a home BP threshold of 130/80 mm Hg for hypertension status in several racial/ethnic groups.48 As these data are supported primarily by observational studies, randomized controlled trials should examine whether lowering of home BP leads to a reduction in cardiovascular events and also determine the optimal BP thresholds to define hypertension.49There are several ongoing studies based on use of out-of-office BP in hypertension management. The INFINITY (Intensive Versus Standard Blood Pressure Lowering to Prevent Functional Decline in Older People Trial) recently demonstrated that intensive BP reduction to target 24-hour ambulatory SBP to <130 mm Hg resulted in slower progression of subcortical white matter disease in hypertensive adults of 75 years or older. However, no benefit in the cognitive or functional outcome was observed. The HIPAC trial ([Hypertension, Intracranial Pulsatility, and Brain A-Beta Accumulation in Older Adults], URL: http://www.clinicaltrials.gov. Unique identifier: NCT03354143) and MASTER ([Masked-Uncontrolled Hypertension Management Based on Office BP or on Ambulatory Blood Pressure Measurement] study, URL: http://www.clinicaltrials.gov. Unique identifier: NCT02804074)50 will further clarify its role in the management of hypertension and prevention of target organ complications.The Asia [email protected] study, the first study designed to investigate home BP control status in different Asian countries/regions using standardized home BP measurements taken with the same validated HBPM device, which has data memory capabilities, demonstrated that home BP is relatively well controlled at hypertension specialist centers.51 However, almost half of all patients had uncontrolled morning BP according to the 2017 ACC/AHA BP guideline, with significant country/regional differences. In a study that enrolled 1443 patients taking antihypertensive medication from 15 Asian specialist centers in 11 countries/regions between April 2017 and March 2018, BP was controlled in 68.2% of patients using a morning home SBP normality cutoff of <135 mm Hg, and in 55.1% of patients using an office SBP cutoff of <140 mm Hg. However, when the cutoff values were changed to the 2017 ACC/AHA BP guideline threshold (SBP <130 mm Hg), only 53.6% of patients had controlled morning home SBP.51Morning and Nocturnal Home BPThere are 3 subtypes of masked hypertension: morning hypertension, daytime hypertension, and nocturnal hypertension.44 Although the current reference standard for identifying all 3 types of masked hypertension is ABPM,52 HBPM can also be used.Four studies conducted in Asia (Ohasama, J-HOP, HOMED BP, and HONEST) demonstrated that morning home BP was a predictor of future CVD events.13,20–23 The measurement of home BP during the morning period has been recommended before taking medications in several guidelines.1–3 The 2018 European Society of Cardiology/European Society of Hypertension guidelines recommend HBPM being performed during the morning and evening, with the latter being measured before dinner. However, in Asian countries, individuals usually eat dinner before returning home from work, and in Japan, adults usually take an evening bath. For this reason, evening home BP measurement just before bedtime is recommended,3–6 and in the absence of evening home BP measurement, morning home BP measurement alone may be sufficient for identifying hypertension as a first step toward home BP-guided management and has been successful in self-titration studies.4,5,32,33 An additional advantage of conducting morning BP measurements before taking medications is the ability to detect through BP levels among individuals taking antihypertensive medications in the morning.53In addition to controlling morning and evening home BP, the control of nocturnal BP should be considered since evidence suggests it is the most important aspect of the 24-hour BP profile for predicting the risk for CVD outcomes.54,55 In the past, nighttime BP could only be measured with ABPM, but more recently, new HBPM devices have been developed that measure nighttime BP.56,57 These devices automatically measure and store BP readings at preprogrammed times (eg, 2 am, 3 am, and 4 am) or at a fixed time period after going to bed (eg, 2, 3, and 4 hours after going to bed). The device is removed by the person the next morning, after awakening. The minimum number of readings and the interval for obtaining a reliable estimate of nocturnal home BP have not been determined.58 Nocturnal hypertension is common among high-risk patients, including those with diabetes mellitus, chronic kidney disease, or sleep apnea. The J-HOP study showed that nocturnal home BP was more closely associated with hypertensive organ damage than office, morning home, and evening home BP. Among individuals with controlled morning home BP (<135/85 mm Hg), uncontrolled nocturnal BP (≥120/70 mm Hg) has been associated with increased urinary albumin/creatinine ratio and plasma NT-proBNP (N-terminal pro-B-type natriuretic peptide).59 In the J-HOP study, nocturnal home SBP was a stronger predictor of CVD events than office and morning home SBP measurements.60 It has been shown that there is good agreement between HBPM and ABPM for detecting nondippers.61 A recent meta-analysis showed that ABPM and nocturnal HBPM provide similar BP values and associations with target organ damage.62 Thus, either ABPM or nocturnal HBPM may be useful for detecting nocturnal hypertension and nondippers and for the management of uncontrolled nocturnal BP.In prior studies, an office BP of 140/90 mm Hg has corresponded with a nighttime BP of 120/70 mm Hg and a home BP and daytime BP on ABPM of 135/85 mm Hg (Table 2). Also, for an office BP of 130/80 mm Hg, which corresponds to a 130/80 mm Hg threshold for home BP and daytime BP on ABPM, the 2017 ACC/AHA BP guideline recommends a nighttime BP threshold of 110/65 mm Hg for having nocturnal hypertension (Table 2). A large proportion of patients with controlled morning home SBP have uncontrolled nighttime SBP: 30% using a 120 mm Hg threshold for nighttime SBP; and 56% using a 110 mm Hg threshold for nighttime SBP.63 Thus, nocturnal HBPM may identify individuals with controlled morning BP who have high nighttime SBP and residual CVD risk, especially among those who at increased risk for having nocturnal hypertension (eg, those with CKD, sleep apnea, or diabetes mellitus).Table 2. Corresponding Values of Clinic, Home, Daytime, Nighttime, and 24-Hour BP Measurements (2017 American College of Cardiology/American Heart Association Guidelines)ClinicHBPMDaytime ABPMNighttime ABPM24-Hour ABPM120/80120/80120/80100/65115/75130/80130/80130/80110/65125/75140/90135/85135/85120/70130/80160/100145/90145/90140/85145/90ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring.Additional Measures on HBPMAdditional information provided by HBPM should also be investigated for possible clinical relevance. In particular, increased day-by-day BP variability on HBPM has been reported to be associated with increased CVD risk, independent of average home BP level in both general and clinical populations.17,64–66 Further, large seasonal home BP variation and inverse seasonal home BP changes (ie, an increase in home BP during the summ
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