Essential Manual of 24 Hour Blood Pressure Management

For Tomoko

Essential Manual of 24 Hour Blood Pressure ManagementFrom Morning to Nocturnal Hypertension

Kazuomi Kario MD, PhD, FACC, FACP, FAHA, FESCProfessor and Chairman, Department of Cardiovascular Medicine

Professor and Chairman, Department of Sleep and Circadian Cardiology

Jichi Medical University School of Medicine, Tochigi, Japan

Staff Visiting Professor of Medicine, UCL Institute of Cardiovascular Science

University College London, UK

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Set in 9/12pt Meridien LT Std by Aptara Inc., New Delhi, India

1 2015

v

Contents

Author biography, viii

Preface, x

Acknowledgments, xi

1 First, focusing on “morning hypertension”, 1

What is the “perfect 24‐hour blood pressure control”?, 1

Defi nition of “morning hypertension”, 4

How to assess “morning hypertension”, 5

Home BP monitoring, 7

Ambulatory BP Monitoring, 9

Feasibility of controlling morning hypertension, 12

Subtypes of morning hypertension, 14

2 Morning surge in blood pressure, 15

Defi nition of MBPS, 15

Cardiovascular events with MBPS, 16

Organ damage with MBPS, 19

Hypertensive heart disease, 20

Vascular disease and infl ammation, 21

Silent cerebrovascular disease, 22

Chronic kidney disease, 24

Determinants of MBPS, 25

Mechanism of morning risk, 28

Hemostatic abnormality and MBPS, 29

Vascular mechanism of exaggerated MBPS, 31

3 Nocturnal hypertension, 35

Circadian rhythm of BP, 35

Non‐dipper/risers of nocturnal BP, 35

Defi nition and risk of nocturnal hypertension, 38

Mechanism of nocturnal hypertension, 43

Associated conditions 44

Diabetes, 45

Chronic kidney disease, 47

vi Contents

Sleep apnea syndrome, 48

Extreme dipper—another type of disrupted circadian BP rhythm, 48

4 What is systemic hemodynamic atherothrombotic syndrome?, 50

A typical case of SHATS, 50

Clinical relevance of SHATS, 52

Pathological target of SHATS, 54

Mechanism of vicious cycle of SHATS, 57

5 Home blood pressure variability, 61

Maximum home SBP, 61

SD of morning SBP, 62

Morning orthostatic hypertension, 64

6 Development of information‐technology‐based new home blood pressure variability monitoring system, 67

Disaster cardiovascular prevention network, 67

Cutting‐edge of HBPM, 71

Basic nocturnal BP monitoring at home (Medinote), 71

“Thermosensitive hypertension” detecting home BP device, 74

Trigger nocturnal BP monitoring, 75

IT‐based trigger nocturnal pressure monitoring system, 81

Detection and management of OSAS using new IHOPE‐TNP, 82

7 Home blood‐pressure‐monitoring‐guided morning hypertension control, 88

Non-specifi c treatment, 88

Specifi c treatment, 89

8 Blood‐pressure‐lowering characteristics of antihypertensive drugs, 91

Diuretics, 91

Calcium channel blockers, 91

Amlodipine, 92

Nifedipine, 94

Cilnidipine, 95

Azelnidipine, 96

Angiotensin‐converting enzyme inhibitors, 96

Angiotensin‐receptor blockers, 98

Telmisartan, 98

Candesartan, 98

Olmesartan, 99

Azilsartan, 103

Contents vii

Alpha‐adrenergic blockers and beta‐adrenergic blockers, 104

RAS inhibitor‐based combination, 106

9 Home and ambulatory blood‐pressure‐profi le‐based combination strategy, 109

First‐line therapy, 109

Second‐line therapy, 109

Arterial stiffness type, 109

Volume retention type, 110

Third‐line therapy, 110

10 Management of resistant hypertension, 111

Evaluation of resistant hypertension, 111

Fourth‐line therapy, 111

Circadian medication, 114

11 Era of renal denervation, 115

Evidence of renal denervation, 115

Hypothesis of “perfect 24‐hour BP control” by renal denervation, 116

12 Latest evidence of controlling morning hypertension: the HONEST study, 118

Conclusion and perspectives, 122

References, 123

Index, 135

viii

Author biography

Dr. Kazuomi Kario, MD, FACC, FACP, FAHA, FESC, graduated from Jichi Medical School in 1986. He is currently Professor and Chairman of Cardiovas-

cular Medicine, and Professor of the Department of Sleep and Circadian Cardiology, Jichi Medi-cal University School of Medicine, Japan, and is Staff Visiting Professor, Institute of Cardiovascu-lar Science, University College London, UK. Dr. Kario and his team were the fi rst to demonstrate “morning surge” in blood pressure (BP) as an independent risk factor for cardiovascular disease in 2003 [1, 2]. He fi rst used “morning hyperten-sion” with the defi nition of morning BP >135/85 mmHg regardless of clinic BP and stressed its clinical relevance in his book, Clinician’s Manual on Early Morning Risk Management in Hypertension in 2004 (Science Press, London, UK, 2004) [3]. He has recently proposed a novel disease entity,

systemic hemodynamic atherothrombotic syndrome (SHATS), which is charac-terized by synergistic risk of exaggerated hemodynamic stress (exaggerated vari-ability of BP and blood fl ow) and vascular disease, not only for advancing organ damage but also for triggering cardiovascular events [4].

His research includes the development of new technology‐based BP monitor-ing such as “IT‐based home nocturnal BP monitoring” and “hypoxia‐triggered home sleep BP monitoring (TSP)” to clarify the clinical relevance of 24‐hour BP control [5, 6]. He is the principal investigator of several clinical studies, such as Japan Morning Surge‐Home Blood Pressure (J‐HOP) study, Japan Ambulatory BP Monitoring (JAMP) study, Country‐based Ambulatory BP Registry in Asia 2010 (CARE Asia), and Sleep BP and disordered breathing in REsistant hypertension And cardiovascular Disease (SPREAD), and the Home BP measurement with Olmesartan Naive patients to Establish Standard Target blood pressure (HONEST) study, the largest prospective observational study involving >20  000 patients receiving angiotensin receptor blocker (ARB)‐based antihypertensive treatment for 2 years [7].

He has served as Editor‐in‐Chief of Current Hypertension Reviews and is the past Executive Editor of Hypertension Research. He is an editorial board member of more than 15 international journals, including Hypertension, Journal of Hypertension, Circulation Journal, Journal of Clinical Hypertension, Journal of the American Society

Author biography ix

of Hypertension, American Journal of Hypertension, Blood Pressure Monitoring, Current Hypertension Reports, and Current Cardiology Reviews. Dr. Kario has published more than 600 academic papers during his distinguished career.

References

1 Kario K, Pickering TG, Umeda Y, Hoshide S, Hoshide Y, Morinari M, Murata M, Kuroda

T, Schwartz JE, Shimada K. Morning surge in blood pressure as a predictor of silent and

clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation.

2003;107:1401–1406.

2 Kario K, Ishikawa J, Pickering TG, Hoshide S, Eguchi K, Morinari M, Hoshide Y, Kuroda

T, Shimada K. Morning hypertension: the strongest independent risk factor for stroke in

elderly hypertensive patients. Hypertens Res. 2006;29:581–587.

3 Kario K. Clinician's Manual on Early Morning Risk Management in Hypertension. Science

Press, London, UK, pp. 1–68, 2004.

4 Kario K. Orthostatic hypertension—a new haemodynamic cardiovascular risk factor.

Nat Rev Nephrol. 2013;9:726–738.

5 Kario K. Proposal of a new strategy for ambulatory blood pressure profi le‐based

management of resistant hypertension in the era of renal denervation. Hypertens Res.

2013;36:478–484.

6 Kario K, Kuwabara M, Hoshide S, Nagai M, Shimpo M. Effects of nighttime single‐dose

administration of vasodilating vs sympatholytic antihypertensive agents on sleep

blood pressure in hypertensive patients with sleep apnea syndrome. J Clin Hypertens

(Greenwich). 2014;16(6):459–466.

7 Kario K, Saito I, Kushiro T, Teramukai S, Ishikawa Y, Mori Y, Kobayashi F, Shimada K.

Home blood pressure and cardiovascular outcomes in patients during antihypertensive

therapy: primary results of HONEST, a large‐scale prospective, real‐world observational

study. Hypertension. 2014;64:989–996.

x

Preface 

“Home blood pressure‐guided individual management of morning hyper-tension, as the fi rst step of “perfect” 24‐hour blood pressure control.”

The essential benefi t of the management of hypertension is derived from blood pressure (BP) lowering per se, indicating the importance of BP throughout 24 hours. Recent guidelines stressed the importance of home BP for the diagnosis and management of hypertension.

It is well known that cardiovascular events occur more frequently in the morning; BP levels have been shown to increase during the period from night to early morning. In recent years, clinical research using ambulatory blood pressure monitoring (ABPM) or home BP monitoring (HBPM) has clarifi ed that morning BP and BP surge are more closely related to the cardiovascular risk than clinic BP. Also, in hypertensive patients treated with antihypertensive medication, even patients whose clinic BP is well controlled, morning BP level prior to taking med-ication frequently remains high.

In addition, nocturnal hypertension, frequently found in high‐risk hyperten-sives with diabetes, chronic kidney disease (CKD), and sleep apnea syndrome (SAS), are closely associated with organ damage and risk of cardiovascular events. We have recently developed an information technology (IT)‐based home noctur-nal BP pressure monitoring system (ITNP) [1]. This may be useful for assessing the risk during sleep in high‐risk patients.

In this Essential Manual, I would like to show the recent evidence on “morn-ing hypertension” and “nocturnal hypertension,” the technology which will support the home BP‐guided individual approach. I believe the “perfect 24‐hour BP control” by changing the dose, the class, and timing of administration of antihypertensive drugs will achieve the most effective cardiovascular and renal protection. I hope this book will provide good practical advice for the treatment of hypertension on a day‐to‐day basis.

Reference

1 Kario K. Proposal of a new strategy for ambulatory blood pressure profi le‐based

management of resistant hypertension in the era of renal denervation. Hypertens Res.

2013;36:478–484.

xi

Acknowledgments

I would particularly like to thank the three academic fathers of my research, Kazuyuki Shimada, Takefumi Matsuo, and the late Thomas G. Pickering, who continuously supported me. I would also like to thank other senior research-ers in this fi eld and my colleagues who provided many helpful academic com-ments and criticism on the contents of this book. They include Bryan Williams, Gianfranco Parati, George Stergiou, Jiguang Wang, Satoshi Hoshide, Kazuo Eguchi, Yoshio Matsui, Yuichiro Yano, Joji Ishikawa, Michiaki Nagai, Tomoyuki Kabutoya, Mitsunori Sugiyama, Yusuke Ishikawa, Toshikazu Shiga, and Mitsuo Kuwabara. And my particular thanks are due to Ayako Okura, Editorial coordi-nator in the Department of Cardiovascular Medicine, Jichi Medical University School of Medicine, Yosuke Sato, Wiley Publishing Japan K.K. and the UK editors of Wiley, without whom this book would not have been possible.

Kazuomi Kario, MD, PhD, FACC, FACP, FAHA, FESC

1

Essential Manual of 24 Hour Blood Pressure Management, First Edition. By Kazuomi Kario.

© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd.

CHAPTER 1

First, focusing on “morning hypertension”  

The morning is the most important period for cardiovascular diseases [ 1, 2 ]. Cardi-ovascular events occur most frequently in the morning just after awakening, at the time of the peak ambulatory blood pressure (BP) (Figure 1.1 ) [ 2 ]. Exaggerated morning BP surge (MBPS) and morning hypertension are a risk for cardiovascular events (Figure 1.2 ), and are associated with advanced organ damage (Figure 1.3 ) [ 3–7 ]. Morning BP level is more closely associated with organ damage to brain, heart, and kidney, and the risk of cardiovascular and cerebrovascular events (Fig-ure 1.4 ) and disability in the elderly than clinic BP both in hypertensive patients and community‐based normotensive populations [ 8, 9 ]. Finally, recent evidence demonstrates that uncontrolled morning hypertension on medication is a strong predictor of cardiovascular events [ 10 ].

What is the “perfect 24‐hour blood pressure control”?

The management of “morning hypertension” is the most effective fi rst step to achieve “perfect 24‐hour BP control” [ 1 ]. The majority of the benefi t of antihy-pertensive treatment is derived from BP control per se. There is robust evidence that indicates BP control throughout 24 hours is essentially important for lower-ing the risk of organ damage and cardiovascular events. However, not only strict reduction of the 24‐hour BP level (amount of 24‐hour BP lowering), but also restoring disrupted circadian BP rhythms, and reducing exaggerated BP variability (quality of 24‐hour BP lowering), are required to achieve “perfect 24‐hour BP control” (Figure 1.5 ) [ 11 ].

Recent guidelines such as the Japanese Society of Hypertension (JSH2014) Guidelines [ 12 ], European Society of Hypertension/European Society of Cardiol-ogy (ESH/ESC2013) Guidelines [ 13 ], and NICE 2011 Guidelines (UK) [ 14 ] recom-mend the practical use of the out‐of‐offi ce BP for the diagnosis and management of hypertension. Clinically, two methods are available to measure our BP in clini-cal practice. One is ambulatory BP monitoring (ABPM), and the other is home BP monitoring (HBPM) (Figure 1.6 ). Figure 1.7 demonstrates the different thresholds of clinic, home, and ambulatory BPs for the defi nition of hypertension [ 11–13 ].

2 Essential Manual of 24 Hour Blood Pressure Management

Figure  1.1 Onset time of cardiovascular events. Source: Muller et al. 1989 [ 2 ].

120

Sudden cardiac death40

Ischemic strokeNumber

Number

Number

30

60

90

10

20

30

00

TimeTime

30

40

50 Acute myocardial infarctionmmHg

BP150

100

10

2050

0 10 12 14 16 182 20 224 6 8

0 10 12 14 16 182 20 224 6 8 0 10 12 14 16 182 20 224 6 8

0 09 10111213141516171819202122232487654321

TimeTime

Figure  1.2 Morning BP surge and stroke risk in hypertension (matching for age and 24‐hour systolic BP). Source: Kario et al. 2003 [ 3 ].

JMU ABPM Wave 1 study

Arising Silent cerebral infarcts(Prevalence, detected by brain MRI)(%)

Stroke

p < 0.05

Awake

Morning BP

Sleep

60

70

Morning surgeBP 20

25

events(Incidence)

p < 0.05

(%)

2. 7 times

Nighttimelowest

54%

37%

17%

40

50(sleep-trough) 15

20

BP37%

7.0%

30 5

10

Morning surge group

Non-surgegroup

20 0Morning surge group

Non-surgegroup

(n = 46) (n = 46)Morning surge group (Top 10%: MS >55 mmHg)group (n = 145)(n = 145)

Masked hypertension is defi ned as normotension for offi ce BP and hypertension for out‐of‐offi ce BP, while white‐coat hypertension is defi ned as normotension for out‐of‐offi ce BP and hypertension for offi ce BP [ 15 ]. There are three subtypes of masked hypertension, namely morning hypertension, daytime (stress‐induced) hypertension, and nocturnal hypertension (Figure 1.8 ). Among these masked hypertension subtypes, only morning hypertension could be defi nitively detected by the conventional measurement of HBPM.