Published online before print February 17, 2003, doi: 10.1161/01.CIR.0000054622.45012.12
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 2003;107:1297.)
© 2003 American Heart Association, Inc.
Clinical Investigation and Reports |
Isolated Ambulatory Hypertension Predicts Cardiovascular Morbidity in Elderly Men
From the Department of Public Health & Caring Sciences/Section of Geriatrics (K.B., B.Z., H.L.) and Department of Medical Sciences (L.L., B.A.), Uppsala University, Uppsala, Sweden.
Correspondence to Kristina Björklund, Department of Public Health & Caring Sciences/Section of Geriatrics, Uppsala University, PO Box 609, Kålsängsgränd 10D, SE-751 25 Uppsala, Sweden. E-mail Kristina.Bjorklund{at}pubcare.uu.se
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background— Little is known about isolated ambulatory hypertension, a state with elevated ambulatory but normal office blood pressure (BP). This study aimed to investigate the prognostic significance of isolated ambulatory hypertension for cardiovascular morbidity in a population of elderly men.
Methods and Results— At baseline, 24-hour ambulatory BP and metabolic and cardiac risk profiles were evaluated in 578 untreated 70-year-old men, participants of a population-based cohort. Subjects with isolated ambulatory hypertension (office BP <140/90 and daytime BP 
135/85) and sustained hypertension (office BP 140/90 and daytime BP 135/85) had increased plasma glucose, body mass index, and echocardiographically determined left ventricular relative wall thickness compared with normotensive subjects (office BP <140/90 and daytime BP <135/85). Seventy-two cardiovascular morbid events (2.37 per 100 person-years at risk) occurred over 8.4 years of follow-up. The prognostic value of isolated ambulatory and sustained hypertension was assessed with Cox proportional hazard regression. Multivariate models adjusting for serum cholesterol, smoking, and diabetes demonstrated that both isolated ambulatory hypertension (hazard ratio [HR], 2.77; 95% CI, 1.15 to 6.68) and sustained hypertension (HR, 2.94; 95% CI, 1.49 to 5.82) were independent predictors of cardiovascular morbidity. In a multivariate model with continuous BP variables, ambulatory daytime systolic BP (HR for 1 SD increase, 1.47; 95% CI, 1.09 to 1.97) was associated with an adverse outcome independently of office systolic BP.
Conclusions— In the present study, isolated ambulatory hypertension as well as sustained hypertension predicted cardiovascular morbidity. The findings suggest that 24-hour ambulatory BP monitoring may disclose important prognostic information also in subjects characterized as normotensive according to office BP.
Key Words: blood pressure • hypertension • population • morbidity
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Several previous studies have indicated that 24-hour ambulatory blood pressure (BP) is a stronger predictor of cardiovascular morbidity and mortality than conventional office BP.1–4 Although 24-hour ambulatory BP recordings more accurately reflect the 24-hour BP load imposed on the vascular bed, most commonly, risk assessment in clinical practice and evaluation of antihypertensive treatment effect in clinical trials are based on conventional office BP monitoring. When there is a discrepancy between office and ambulatory BP, as in white-coat hypertension, the prognosis has been suggested to be more closely related to ambulatory BP.5 During previous years, much attention has focused on white-coat or isolated office hypertension, but despite observations that these subjects are at low risk for future morbid events,6 the prognostic significance of white-coat hypertension remains controversial.7
Using a strict upper limit of normal daytime ambulatory BP, 10% to 15% of subjects with office hypertension have normal ambulatory BP.8,9 However, less is known about the prevalence and prognostic role of the converse phenomenon, isolated ambulatory hypertension, which is characterized by elevated daytime ambulatory BP but normal office BP. Recent cross-sectional data have indicated that isolated ambulatory hypertension may be associated with metabolic risk factors and target organ abnormalities to a similar extent as sustained hypertension, a state with elevated office and ambulatory BP.10,11
The present longitudinal study, performed in a population-based cohort of elderly men, aimed to evaluate and compare the metabolic and cardiac risk profile in subjects with isolated ambulatory hypertension and sustained hypertension and to determine whether isolated ambulatory hypertension is associated with increased occurrence of cardiovascular morbid events.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Subjects
In 1970 to 1973, all 50-year-old men residing in Uppsala county were invited to a health survey aimed to identify subjects at risk for cardiovascular disease (Uppsala Longitudinal Study of Adult Men [ULSAM]),12 and 2322 of 2841 eligible subjects participated. During the following 20 years, 422 subjects died and 219 moved out of the Uppsala region. In 1991 to 1995, when the subjects were aged 70 years, 1221 of the 1681 subjects still alive and living in Uppsala took part in a reinvestigation. In this reinvestigation, representing baseline of the present study, valid 24-hour ambulatory BP recordings and data on treatment for hypertension and diabetes were available in 1057 subjects. In the present analysis, we excluded 373 subjects who were regularly taking medication with antihypertensive properties, as well as 106 individuals with normal daytime ambulatory but elevated office BP, leaving 578 men to constitute the study population. Forty subjects had previously been hospitalized because of coronary heart disease (International Classification of Diseases [ICD]-9 codes 410 to 414) and 20 because of stroke (ICD-9 codes 431 to 436), and these 60 subjects were excluded from the survival analysis, as well as 6 subjects with missing data on smoking. All measurements in the present analyses were performed at the examination at age 70 years. The Ethics Committee of Uppsala University approved the study, and all participants gave informed consent.
Follow-Up
The population was followed for up to 8.4 years since baseline investigation at age 70 years, with a mean follow-up period of 5.9±1.6 years (mean±SD) contributing to 3038 person-years at risk (PYAR). Outcome variables were defined using data from the Swedish Hospital Discharge and Cause of Death Registries (censor date December 31, 1999). End points included death from coronary heart disease (ICD-9 codes 410 to 414 or ICD-10 codes I20 to I25), stroke (ICD-9 codes 431 to 436 or ICD-10 codes I61 to I66), and peripheral vascular disease (ICD-9 codes 440 to 444 or ICD-10 codes I70 to I74) as well as first hospitalization for nonfatal coronary heart disease and stroke. A quality control by the Swedish centers of the World Health Organization MONICA study previously showed good agreement between official routine mortality statistics and registration of myocardial infarction.13
Blood Pressure Measurements
Office BP was measured in the right arm with a sphygmomanometer using the appropriate cuff size. The recordings were made to the nearest 2 mm Hg twice after 10 minutes of rest with the subject in the supine position, and the mean of the two measurements was used for the analyses. The resting heart rate was measured supine as the pulse rate during 1 minute. Twenty-four-hour ambulatory systolic BP (SBP) and diastolic BP (DBP) were recorded using the Accutracker 2 equipment (Suntech Medical Instruments Inc). Reading and data editing have been described previously.14 Short fixed-clocktime intervals were used, defining daytime as 10 AM to 8 PM and nighttime as midnight to 6 AM. We used 135/85 mm Hg as the threshold for normal daytime ambulatory BP15 and thus defined sustained hypertension as office BP 140/90 and daytime ambulatory BP 135/85 mm Hg and isolated ambulatory hypertension as office BP <140/90 and daytime ambulatory BP 135/85 mm Hg.
Anthropometric and Metabolic Measurements
The investigations took place in the morning after an overnight fast. Height was measured to the nearest whole centimeter, and body weight to the nearest 0.1 kg. Body mass index (BMI) was calculated as the ratio between weight (in kilograms) and height (in meters) squared. Waist and hip circumferences were measured in the supine position, midway between the lowest rib and the iliac crest and over the widest part of the hip, respectively. The waist to hip ratio was calculated. Cholesterol and triglyceride concentrations in serum were assayed by enzymatic techniques (Instrumentation Laboratories) in a Monarch 2000 centrifugal analyzer. An oral glucose tolerance test was performed, where the subjects ingested 75 g glucose dissolved in 300 mL of water, and blood samples for plasma glucose were drawn immediately before and 30, 60, 90, and 120 minutes after ingestion of glucose. Plasma glucose was measured by the glucose dehydrogenase method (Gluc-DH, Merck). Fasting insulin and proinsulin were analyzed with a specific two-site immunoradiometric assay technique.16 Insulin sensitivity was determined with euglycemic hyperinsulinemic clamp according to DeFronzo et al,17 slightly modified, whereby insulin was infused at a constant rate of 56 mU/(min · m2). M was calculated as the amount of glucose (mg) infused per minute per body weight (kg). We defined diabetes according to the 1985 World Health Organization criteria.18 Information on smoking habits was retrieved through interview reports.
Echocardiography
M-mode, 2-dimensional, and Doppler echocardiographic examinations were performed in the first 583 consecutive subjects in the original study population,19 leaving 234 of the men in the present analysis. The measurements included interventricular septal thickness (IVS), posterior wall thickness (PW), and left ventricular diameter at the end of diastole (LVEDD). Left ventricular mass (LVM) was determined using the M-mode formula of Troy according to recommendations of the American Society of Echocardiography.20 LVM was divided with body surface area to obtain LVM index (LVMI). Relative wall thickness (RWT) was calculated using the formula ((IVS+PW)/LVEDD).
Statistical Analysis
Distributions were tested for normality by Shapiro-Wilk’s W test. Skewed variables were logarithmically transformed. We used ANOVA to calculate differences in means, and comparisons between subgroups were performed if the overall F-test was significant. Two-tailed significance values were given, with P<0.05 regarded as significant. Cox proportional hazard regression was used to calculate crude and multivariate-adjusted hazard ratios of cardiovascular morbidity and their 95% confidence intervals (CIs) for baseline hypertensive category or 1 SD increase in office and daytime ambulatory SBP, respectively. In multivariate models, adjustments were made for serum cholesterol (1 SD), smoking (yes, no), diabetes (yes, no), and BMI (1 SD). The statistical software package Stata 6.0 (Stata Corporation, College Station, USA) was used.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Of the 578 subjects, 188 (33%) were identified as normotensive according to both office and ambulatory daytime BP. Eighty-two subjects (14%) showed a normal office but elevated daytime BP and were thus considered to have isolated ambulatory hypertension, whereas 308 (53%) subjects had sustained hypertension.
Metabolic Characteristics
Office and ambulatory BP and heart rate measured at baseline are presented in Table 1. Daytime and nighttime BPs were significantly higher in isolated ambulatory hypertensive than in normotensive subjects. Office SBP was slightly but significantly elevated in isolated ambulatory hypertensive compared with normotensive subjects, whereas office DBP did not differ between these two groups. All BPs were lower in isolated ambulatory hypertensive than in sustained hypertensive subjects (Table 1). Baseline demographics and metabolic parameters are shown in Table 2. The proportion of smokers was similar in the 3 subgroups, but the prevalence of diabetes was significantly higher in sustained hypertensive than in normotensive subjects. BMI, waist circumference, and waist to hip ratio were increased in both hypertensive subgroups compared with normotensive subjects (P<0.05, Table 2). Serum concentrations of triglycerides and cholesterol did not differ between the groups. Both isolated ambulatory and sustained hypertensive subjects showed increased plasma glucose levels during an oral glucose tolerance test and an impaired insulin sensitivity, expressed as the M-value at clamp, compared with normotensive patients. Fasting insulin and proinsulin were significantly higher in sustained hypertensive than in normotensive subjects (Table 2).
|
|
Echocardiographic Characteristics
Data from the echocardiographic investigation were obtained in a subset of subjects with normotension (n=74), isolated ambulatory hypertension (n=21), and sustained hypertension (n=139). Subjects with isolated ambulatory hypertension showed a similar LVMI as normotensive subjects, whereas sustained hypertensive subjects had increased LVMI (Figure 1a). In contrast, RWT was increased in both subjects with sustained and isolated ambulatory hypertension compared with normotensive subjects (Figure 1b).
|
Cardiovascular Morbidity
A total of 72 events (2.37 of 100 PYAR) occurred during the follow-up period, including 48 coronary events, 8 of which were fatal, 20 strokes, 2 of which were fatal, and 4 peripheral vascular deaths. The event rate (per 100 PYAR) was 3.14 in sustained hypertensive subjects, 2.74 in isolated ambulatory hypertensive subjects, and 0.99 in normotensive subjects (Figure 2). Table 3 shows the probability of cardiovascular events evaluated in a univariate Cox proportional hazard regression analysis. Both isolated ambulatory hypertension and sustained hypertension were significant predictors of cardiovascular morbidity. Office and ambulatory BP as continuous variables, smoking, diabetes, and BMI were also associated with a significantly increased probability of cardiovascular events, whereas serum cholesterol did not predict outcome (Table 3). In extended multivariate Cox models (Table 4), adjusting for serum cholesterol, smoking, and diabetes, both isolated ambulatory hypertension (adjusted HR, 2.77 [95% CI, 1.15 to 6.68]) and sustained hypertension (HR, 2.94 [95% CI, 1.49 to 5.82]) remained significant predictors of cardiovascular morbidity. The increased risk in subjects with isolated ambulatory hypertension was independent of office SBP level (multivariate adjusted HR for isolated ambulatory hypertension, 2.62; 95% CI, 1.08 to 6.35; for office SBP 1.21, 95% CI, 0.86 to 1.70). In a multivariate model with continuous BP variables, daytime ambulatory SBP was a significant predictor of cardiovascular events, whereas office SBP lost its predictive value (Table 4). An additional adjustment for BMI did not alter the results substantially (data not shown).
|
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Isolated ambulatory hypertension, characterized by a normal office but elevated daytime ambulatory BP, was associated with a nearly 3-fold increased risk of cardiovascular morbidity in this longitudinal population-based study. Furthermore, plasma glucose levels, measures of abdominal obesity, and echocardiographically determined left ventricular RWT were increased at baseline in subjects with isolated ambulatory hypertension. Metabolic disturbances may aggravate the atherosclerotic process in hypertensive subjects, but isolated ambulatory hypertension was a predictor of cardiovascular events independent of established risk factors such as smoking, serum cholesterol, and diabetes, and the risk was similar to that observed for sustained hypertension.
Average ambulatory BP is, more than office BP, representative of the true BP. The independent prognostic value of ambulatory BP, which was also confirmed in the present study, has been demonstrated by several previous investigators.1–4 However, ambulatory BP monitoring is primarily used to evaluate risk in subjects with known office hypertension. Whereas white-coat hypertension has been subject to numerous investigations during previous years, the knowledge about the opposite phenomenon, isolated ambulatory hypertension, is limited. It has been recognized that 
10% to 20% of a population with office normotension have elevated BPs during daytime and that these individuals show metabolic and cardiac structural abnormalities compared with sustained normotensive individuals.10,11 However, until now, longitudinal data regarding cardiovascular outcome for this potential high-risk group have not been available.21
Among possible mechanisms responsible for an increased daytime but normal office BP, smoking has been shown to elicit such an effect,22 and in a recent study, an ambulatory BP greater than office BP in elderly patients was related to previous antihypertensive treatment.23 In our study population, smoking habits did not differ between normotensive, isolated ambulatory hypertensive, and sustained hypertensive subjects, and the subjects were previously untreated. Different kinds of activity and behavior in daily life such as working conditions may affect average daytime BP. In the present study, a questionnaire that was part of the baseline examination revealed no differences in self-reported leisure-time physical activity between the 3 groups when physical activity was described on a 4-level scale ranging from sedentary to athletic category (data not shown). Although work-related factors were not applicable in the present study population of senior citizens, they may be of importance in other age groups. It is also possible that the subjects we identified as isolated ambulatory hypertensive in fact represent borderline hypertensive subjects whose resting blood pressure has not yet been stabilized on an elevated level.
Whatever the reasons may be for this phenomenon, the present findings suggest that almost 15% of the subjects in an elderly untreated population have elevated daytime BP despite being normotensive according to office measurements and that these subjects are exposed to an increased cardiovascular risk. Confirming previous studies,10,11 we found that isolated ambulatory hypertension was characterized by a metabolic and cardiac risk profile. The echocardiographic findings of an increased RWT but normal LVMI in subjects with isolated ambulatory hypertension indicate that these subjects have a higher prevalence of concentric remodeling rather than left ventricular hypertrophy. Concentric remodeling has been suggested to represent an early stage in the development of concentric left ventricular hypertrophy and was associated with an increased cardiovascular risk in a previous study.24
We were somewhat surprised to find that only one third of untreated 70-year-old men from the general population were normotensive according to both office and ambulatory BP and that even mild hypertension, which apparently had not been considered in need of treatment, may increase the risk of a cardiovascular event considerably in the elderly. It is known that hypertension becomes increasingly prevalent with age,25 and in randomized controlled trials, antihypertensive treatment has been shown to efficiently reduce the incidence of stroke and coronary heart disease in elderly subjects with moderate to severe hypertension or systolic hypertension.26–28 Despite the development of strict treatment guidelines, BP is still inadequately controlled in a large proportion of treated hypertensives.29,30 The present study confirms a high prevalence of mild hypertension in the elderly and additionally illustrates the risk associated with a moderately elevated BP (mean BP in the sustained hypertensive group, 155/87 mm Hg).
A possible limitation of the present study is the lack of follow-up visits with repeated office BP readings, which may have increased the number of subjects correctly identified as hypertensive by office BP. Furthermore, data regarding initiation of antihypertensive treatment during follow-up were not available for entry in the survival analysis. The relatively small study size may have influenced the findings, and the results therefore need to be reproduced. Moreover, extrapolation of these results to women should be done with caution. Categorizing subjects into subgroups on the basis of ambulatory and office BP may constitute another limitation, because it assumes an arbitrary dichotomization of a continuous variable. However, grouping of subjects may be clinically useful and, for the particular aim of this study, inevitable. Individuals with white-coat hypertension were excluded from this study, because the particular aim was to highlight isolated ambulatory hypertension. The threshold for elevated ambulatory daytime BP in this study (135/85 mm Hg) has been proposed based on previous studies of ambulatory BP normality in different populations15,31 and is also close to the daytime ambulatory BP (137/83 mm Hg) that by linear regression corresponded to an office BP of 140/90 in the present study population.14
In conclusion, the present study in an elderly population showed for the first time that isolated ambulatory hypertension was a predictor of increased cardiovascular morbidity, independent of office BP and other established cardiovascular risk factors. The findings suggest that important prognostic information may be undetected when BP is measured only in the clinical setting.
|
Acknowledgments |
|---|
This study was supported by grants from the Medical Faculty at Uppsala University, the Swedish Medical Research Council (grant No. 5446), the Foundation for Geriatric Research, the Swedish National Association against Heart and Lung Disease, the Uppsala Geriatric Fund, the Swedish Council for Planning and Coordination of Research, and the Thuréus Foundation.
Received October 15, 2002; revision received December 5, 2002; accepted December 5, 2002.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1. Perloff D, Sokolow M, Cowan R. The prognostic value of ambulatory blood pressures. JAMA. 1983; 249: 2792–2788.
2. Verdecchia P, Porcellati C, Schillaci G, et al. Ambulatory blood pressure: an independent predictor of prognosis in essential hypertension. Hypertension. 1994; 24: 793–801.
3. Ohkubo T, Imai Y, Tsuji I, et al. Prediction of mortality by ambulatory blood pressure monitoring versus screening blood pressure measurements: a pilot study in Ohasama. J Hypertens. 1997; 15: 357–364.[CrossRef][Medline] [Order article via Infotrieve]
4. Staessen JA, Thijs L, Fagard R, et al. 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.
5. Pickering TG, Coats A, Mallion JM, et al. Blood Pressure Monitoring: task force V.White-coat hypertension. Blood Press Monit. 1999; 4: 333–341.[Medline] [Order article via Infotrieve]
6. Verdecchia P, Schillaci G, Borgioni C, et al. White-coat hypertension. Lancet. 1996; 348: 1444–1445.[Medline] [Order article via Infotrieve]
7. Mancia G, Parati G. Ambulatory blood pressure monitoring and organ damage. Hypertension. 2000; 36: 894–900.
8. Verdecchia P, Schillaci G, Boldrini F, et al. Variability between current definitions of "normal" ambulatory blood pressure: implications in the assessment of white coat hypertension. Hypertension. 1992; 20: 555–562.
9. Mancia G, Zanchetti A. White-coat hypertension: misnomers, misconceptions and misunderstandings. What should we do next? J Hypertens. 1996; 14: 1049–1052.[Medline] [Order article via Infotrieve]
10. Liu JE, Roman MJ, Pini R, et al. Cardiac and arterial target organ damage in adults with elevated ambulatory and normal office blood pressure. Ann Intern Med. 1999; 131: 564–572.
11. Sega R, Trocino G, Lanzarotti A, et al. Alterations of cardiac structure in patients with isolated office, ambulatory, or home hypertension: data from the general population (Pressione Arteriose Monitorate E Loro Associazioni [PAMELA] Study). Circulation. 2001; 104: 1385–1392.
12. Hedstrand H. A study of middle-aged men with particular reference to risk factors for cardiovascular disease. Ups J Med Sci Suppl. 1975; 19: 1–61.[Medline] [Order article via Infotrieve]
13. Tunstall-Pedoe H, Kuulasmaa K, Amouyel P, et al. Myocardial infarction and coronary deaths in the World Health Organization MONICA Project: registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation. 1994; 90: 583–612.
14. Bjorklund K, Lind L, Lithell H. Twenty-four hour ambulatory blood pressure in a population of elderly men. J Intern Med. 2000; 248: 501–510.[CrossRef][Medline] [Order article via Infotrieve]
15. Pickering T. Recommendations for the use of home (self) and ambulatory blood pressure monitoring: American Society of Hypertension Ad Hoc Panel. Am J Hypertens. 1996; 9: 1–11.[CrossRef][Medline] [Order article via Infotrieve]
16. Sobey WJ, Beer SF, Carrington CA, et al. Sensitive and specific two-site immunoradiometric assays for human insulin, proinsulin, 65–66 split and 32–33 split proinsulins. Biochem J. 1989; 260: 535–541.[Medline] [Order article via Infotrieve]
17. DeFronzo RA, Tobin JD, Andres R. Glucose clamp technique: a method for quantifying insulin secretion and resistance. Am J Physiol. 1979; 237: E214–E223.[Medline] [Order article via Infotrieve]
18. World Health Organization. Diabetes mellitus: report of a WHO study group. Geneva: WHO; 1985. Technical Report Series 727.
19. Andren B, Lind L, Hedenstierna G, et al. Left ventricular hypertrophy and geometry in a population sample of elderly males. Eur Heart J. 1996; 17: 1800–1807.
20. Devereux RB, Alonso DR, Lutas EM, et al. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol. 1986; 57: 450–458.[CrossRef][Medline] [Order article via Infotrieve]
21. Mancia G. Reversed white-coat hypertension: definition, mechanisms and prognostic implications. J Hypertens. 2002; 20: 579–581.[CrossRef][Medline] [Order article via Infotrieve]
22. Mann SJ, James GD, Wang RS, et al. Elevation of ambulatory systolic blood pressure in hypertensive smokers: a case-control study. JAMA. 1991; 265: 2226–2228.
23. Wing LM, Brown MA, Beilin LJ, et al. "Reverse white-coat hypertension" in older hypertensives. J Hypertens. 2002; 20: 639–644.[CrossRef][Medline] [Order article via Infotrieve]
24. Verdecchia P, Schillaci G, Borgioni C, et al. Adverse prognostic significance of concentric remodeling of the left ventricle in hypertensive patients with normal left ventricular mass. J Am Coll Cardiol. 1995; 25: 871–878.[Abstract]
25. Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988–1991. Hypertension. 1995; 25: 305–313.
26. Dahlof B, Lindholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet. 1991; 338: 1281–1285.[CrossRef][Medline] [Order article via Infotrieve]
27. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension:final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA. 1991; 265: 3255–3264.
28. Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension: the Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997; 350: 757–764.[CrossRef][Medline] [Order article via Infotrieve]
29. Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998; 339: 1957–1963.
30. Mancia G, Bombelli M, Lanzarotti A, et al. Systolic vs diastolic blood pressure control in the hypertensive patients of the PAMELA population: Pressioni Arteriose Monitorate E Loro Associazioni. Arch Intern Med. 2002; 162: 582–586.
31. O’Brien E, Staessen J. Normotension and hypertension defined by 24-hour ambulatory blood pressure monitoring. Blood Press. 1995; 4: 266–282.[Medline] [Order article via Infotrieve]
This article has been cited by other articles:
 |
|
 |
|
  P. Verdecchia, F. Angeli, G. Mazzotta, G. Gentile, and G. Reboldi Home Blood Pressure Measurements Will Not Replace 24-Hour Ambulatory Blood Pressure Monitoring Hypertension, August 1, 2009; 54(2): 188 - 195. [Full Text] [PDF]
|
|
|
|
 |
|
 S. E. Kjeldsen, T. A. Aksnes, R. H. Fagard, and G. Mancia CHAPTER 13 Hypertension ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Ogedegbe, T. G. Pickering, L. Clemow, W. Chaplin, T. M. Spruill, G. M. Albanese, K. Eguchi, M. Burg, and W. Gerin The Misdiagnosis of Hypertension: The Role of Patient Anxiety Arch Intern Med, December 8, 2008; 168(22): 2459 - 2465. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Urbina, B. Alpert, J. Flynn, L. Hayman, G. A. Harshfield, M. Jacobson, L. Mahoney, B. McCrindle, M. Mietus-Snyder, J. Steinberger, et al. Ambulatory Blood Pressure Monitoring in Children and Adolescents: Recommendations for Standard Assessment: A Scientific Statement From the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young and the Council for High Blood Pressure Research Hypertension, September 1, 2008; 52(3): 433 - 451. [Full Text] [PDF]
|
|
|
|
|
|
T. G. Pickering, N. H. Miller, G. Ogedegbe, L. R. Krakoff, N. T. Artinian, and D. Goff Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring: A Joint Scientific Statement From the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association Hypertension, July 1, 2008; 52(1): 10 - 29. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Authors/Task Force Members:, G. Mancia, G. De Backer, A. Dominiczak, R. Cifkova, R. Fagard, G. Germano, G. Grassi, A. M. Heagerty, S. E. Kjeldsen, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) Eur. Heart J., June 11, 2007; (2007) ehm236v1. [Full Text] [PDF]
|
|
|
|
 |
|
 M. Kikuya, T. W. Hansen, L. Thijs, K. Bjorklund-Bodegard, T. Kuznetsova, T. Ohkubo, T. Richart, C. Torp-Pedersen, L. Lind, H. Ibsen, et al. Diagnostic Thresholds for Ambulatory Blood Pressure Monitoring Based on 10-Year Cardiovascular Risk Circulation, April 24, 2007; 115(16): 2145 - 2152. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Kikuya, J. A. Staessen, T. Ohkubo, L. Thijs, H. Metoki, K. Asayama, T. Obara, R. Inoue, Y. Li, E. Dolan, et al. Ambulatory Arterial Stiffness Index and 24-Hour Ambulatory Pulse Pressure as Predictors of Mortality in Ohasama, Japan Stroke, April 1, 2007; 38(4): 1161 - 1166. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Inoue, T. Ohkubo, M. Kikuya, H. Metoki, K. Asayama, T. Obara, H. Hoshi, J. Hashimoto, K. Totsune, H. Satoh, et al. Predicting Stroke Using 4 Ambulatory Blood Pressure Monitoring-Derived Blood Pressure Indices: The Ohasama Study Hypertension, November 1, 2006; 48(5): 877 - 882. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Mancia, R. Facchetti, M. Bombelli, G. Grassi, and R. Sega Long-Term Risk of Mortality Associated With Selective and Combined Elevation in Office, Home, and Ambulatory Blood Pressure Hypertension, May 1, 2006; 47(5): 846 - 853. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Ohkubo, M. Kikuya, H. Metoki, K. Asayama, T. Obara, J. Hashimoto, K. Totsune, H. Hoshi, H. Satoh, and Y. Imai Prognosis of "Masked" Hypertension and "White-Coat" Hypertension Detected by 24-h Ambulatory Blood Pressure Monitoring: 10-Year Follow-Up From the Ohasama Study J. Am. Coll. Cardiol., August 2, 2005; 46(3): 508 - 515. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Sega, R. Facchetti, M. Bombelli, G. Cesana, G. Corrao, G. Grassi, and G. Mancia 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, April 12, 2005; 111(14): 1777 - 1783. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. O'Brien Unmasking Hypertension Hypertension, April 1, 2005; 45(4): 481 - 482. [Full Text] [PDF]
|
|
|
|
|
|
E. Lurbe, I. Torro, V. Alvarez, T. Nawrot, R. Paya, J. Redon, and J. A. Staessen Prevalence, Persistence, and Clinical Significance of Masked Hypertension in Youth Hypertension, April 1, 2005; 45(4): 493 - 498. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. G. Myers Ambulatory Blood Pressure Monitoring for Routine Clinical Practice Hypertension, April 1, 2005; 45(4): 483 - 484. [Full Text] [PDF]
|
|
|
|
|
|
M. Kikuya, T. Ohkubo, K. Asayama, H. Metoki, T. Obara, S. Saito, J. Hashimoto, K. Totsune, H. Hoshi, H. Satoh, et al. Ambulatory Blood Pressure and 10-Year Risk of Cardiovascular and Noncardiovascular Mortality: The Ohasama Study Hypertension, February 1, 2005; 45(2): 240 - 245. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. R. Sowers, W. B. White, B. Pitt, A. Whelton, L. S. Simon, N. Winer, A. Kivitz, H. van Ingen, T. Brabant, J. G. Fort, et al. The Effects of Cyclooxygenase-2 Inhibitors and Nonsteroidal Anti-inflammatory Therapy on 24-Hour Blood Pressure in Patients With Hypertension, Osteoarthritis, and Type 2 Diabetes Mellitus Arch Intern Med, January 24, 2005; 165(2): 161 - 168. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Palatini, M. Winnicki, M. Santonastaso, L. Mos, D. Longo, V. Zaetta, M. D. Follo, T. Biasion, and A. C. Pessina Prevalence and Clinical Significance of Isolated Ambulatory Hypertension in Young Subjects Screened for Stage 1 Hypertension Hypertension, August 1, 2004; 44(2): 170 - 174. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Bobrie, G. Chatellier, N. Genes, P. Clerson, L. Vaur, B. Vaisse, J. Menard, and J.-M. Mallion Cardiovascular Prognosis of "Masked Hypertension" Detected by Blood Pressure Self-measurement in Elderly Treated Hypertensive Patients JAMA, March 17, 2004; 291(11): 1342 - 1349. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G Vaudo, S Marchesi, R Gerli, R Allegrucci, A Giordano, D Siepi, M Pirro, Y Shoenfeld, G Schillaci, and E Mannarino Endothelial dysfunction in young patients with rheumatoid arthritis and low disease activity Ann Rheum Dis, January 1, 2004; 63(1): 31 - 35. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Manfredini, B. Boari, F. Portaluppi, K. Kario, K. Eguchi, Y. Umeda, S. Hoshide, Y. Hoshide, M. Morinari, M. Murata, et al. Morning Surge in Blood Pressure as a Predictor of Silent and Clinical Cerebrovascular Disease in Elderly Hypertensives * Response Circulation, September 9, 2003; 108 (10): e72 - e73. [Full Text] [PDF]
|
|
|
|
 |
|
 S. C. Textor, S. J. Taler, T. S. Larson, M. Prieto, M. Griffin, J. Gloor, S. Nyberg, J. Velosa, T. Schwab, and M. Stegall Blood Pressure Evaluation among Older Living Kidney Donors J. Am. Soc. Nephrol., August 1, 2003; 14(8): 2159 - 2167. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||