From the Hypertension Clinic, Hospital Clínico, University of
Valencia (Spain) (J.R., M.L.N.); Hypertension Clinic, 12 de Octubre Hospital,
Madrid (C.C., J.L.R., L.M.R.); and Internal Medicine, Hospital of Sagunto
(Spain) (J.M.P.).
Correspondence to Josep Redon, MD, Hypertension Clinic, Internal Medicine, Hospital Clinico, University of Valencia, Avda Blasco Ibañez 10, 46010 Valencia, Spain.
Abstract—The objective of this study
was to establish whether ambulatory blood pressure offers a better
estimate of cardiovascular risk than does its clinical
blood pressure counterpart in refractory hypertension. This prospective
study assessed the incidence of cardiovascular events
over time during an average follow-up of 49 months (range, 6 to 96).
Patients were referred to specialized hypertension clinics (86
essential hypertension patients who had diastolic blood
pressure >100 mm Hg during antihypertensive treatment that
included three or more antihypertensive drugs, one being a
diuretic). Twenty-four-hour ambulatory blood pressure
monitoring (ABPM) was performed at the time of entrance. End-organ
damage was monitored yearly, and the incidence of
cardiovascular events was recorded. Patients were
divided into tertiles of average diastolic blood pressure
during activity according to the ABPM, with the lowest tertile
<88 mm Hg (LT, n=29), the middle tertile 88 to 97 mm Hg
(MT, n=29), and the highest tertile >97 mm Hg (HT, n=28). While
significant differences in systolic and diastolic
ambulatory blood pressures were observed among groups, no differences
were observed at either the beginning or at the time of the last
evaluation for office blood pressure. During the last evaluation, a
progression in the end-organ damage score was observed for the HT group
but not for the two other groups. Twenty-one of the patients had a new
cardiovascular event; the incidence of events was
significantly lower for the LT group (2.2 per 100 patient-years) than
it was for the MT group (9.5 per 100 patient-years) or for the HT group
(13.6 per 100 patient-years). The probability of event-free survival
was also significantly different when comparing the LT group with the
other two groups (LT versus MT log-rank, P<.04; LT
versus HT log-rank, P<.006). The HT group was an
independent risk factor for the incidence of
cardiovascular events (relative risk, 6.20; 95%
confidence interval, 1.38 to 28.1, P<.02). Higher
values of ambulatory blood pressure result in a worse prognosis in
patients with refractory hypertension, supporting the recommendation
that ABPM is useful in stratifying the cardiovascular
risk in patients with refractory hypertension.
© 1998 American Heart Association, Inc.
Scientific Contributions
Prognostic Value of Ambulatory Blood Pressure Monitoring in Refractory Hypertension
A Prospective Study
Key Words: blood pressure monitoring, ambulatory • hypertension, refractory • cardiovascular risk • prognosis
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