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(Hypertension. 1997;30:1-6.)
© 1997 American Heart Association, Inc.
Articles |
Ambulatory and Home Blood Pressure Normality in the Elderly
Data From the PAMELA Population
From Cattedra di Medicina Interna (R.S., G.M.), Centro Studi di Patologia Cronico-Degenerativa (G.C., C.M.), and Centro di Fisiologia Clinica e Ipertensione (G.G., A.Z., G.M.), Ospedale S. Gerardo, Monza, IRCCS Ospedale Maggiore and Università di Milano; IRCCS Centro Auxologico Italiano, Milano (A.Z., G.M.); and ISTRA, Milano (R.S., G.C.), Italy.
Correspondence to Prof Giuseppe Mancia, Cattedra di Medicina Interna, Università di Milano, Ospedale S. Gerardo, via Donizetti, 20052 Monza, Italy.
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Abstract |
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Abstract To determine ambulatory blood pressure (BP) means and distributions in an elderly population, we studied a random sample of 800 subjects stratified by sex and representative of residents aged 65 to 74 years of the city of Monza. Participation was 50%. Measurements consisted of clinic BP (average of three measurements with mercury sphygmomanometry), home BP (average of morning and evening measurements with a semiautomatic device), and ambulatory BP (SpaceLabs 90207). Clinic BP was obtained before and after home and ambulatory BP measurements. In normotensive and untreated hypertensive subjects (n=248), clinic, home, and ambulatory BPs were significantly related (P<.001). The means of the clinic BPs obtained on consecutive days were very similar and markedly higher than 24-hour average BP (+25 mm Hg systolic and +10 mm Hg diastolic, P<.001). Nighttime BP was markedly less than daytime BP (-14 and -13 mm Hg, P<.001), whereas home BP values occurred approximately midway between clinic and 24-hour average BP values. Only minor differences existed between data in men and women, and the differences in clinic, home, and ambulatory BP values occurred in both normotensive and untreated hypertensive subjects. All BPs were similar in the untreated and treated hypertensive groups. Thus, as previously reported in subjects younger than 65 years, in the elderly fraction of the population, 24-hour average BP is much lower than clinic BP. The upper limit of normality for 24-hour average BP (calculated as the value corresponding to 140/90 mm Hg clinic BP) is about 120 mm Hg systolic and 76 mm Hg diastolic. At variance with data from younger subjects, home BP in the elderly is higher than 24-hour average BP. However, similar to data from younger subjects, clinic, home, and ambulatory BPs are higher in treated hypertensive than normotensive elderly subjects, indicating that in hypertensive elderly subjects, antihypertensive treatment does not commonly achieve full BP control both inside and outside the clinic environment.
Key Words: blood pressure monitoring, ambulatory • sleep • heart rate • hypertension, white coat • elderly
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Introduction |
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Ambulatory blood pressure (BP) normality has been investigated in three population studies performed in Japan, Belgium, and Italy, respectively.1 2 3 In all three populations, the upper limit of normality of ambulatory BP was found to be lower than the accepted upper limit of normality of clinic BP, ie, 140/90 mm Hg. This was particularly clear in the largest study (the PAMELA study [Pressioni Arteriose Monitorate e Loro Associazioni]3 ), which showed that the upper limits of normality of 24-hour average BP range from 120 to 130 mm Hg systolic and 75 to 81 mm Hg diastolic in men and women, respectively, aged 25 to 64 years.
No population study has so far examined ambulatory BP normality in the elderly. We have addressed this issue by recording 24-hour ambulatory BP in subjects aged 65 years or older randomly selected from the residents of the city of Monza, Italy. Because measurements included home BP, another previously unaddressed issue, ie, home BP normality in the elderly, was also examined.
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Methods |
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The present study was an extension of the PAMELA study, which had been performed on Monza residents aged 25 to 64 years. The methods used were identical to those described in detail previously.3 Briefly, a sample of 800 subjects of both sexes was randomly selected from city residents aged 65 to 74 years, according to the criteria of the World Health Organization's MONICA project (Monitoring Trends and Determinants in Cardiovascular Disease).4 The patients were informed of their selection by letters and phone calls. Then they visited in the morning of a working day (Monday through Friday) an outpatient clinic established at the Monza Hospital for this purpose. A comprehensive medical history, physical examination, and three "clinic" BP measurements via a mercury sphygmomanometer (auscultatory method) with the subject in the sitting position were obtained during the visit. The measurements (which were followed by heart rate assessment via pulse palpation) were collected first 5 minutes after assumption of the sitting posture, then about 10 minutes after the beginning of the medical visit, and finally before application of the ambulatory BP-monitoring device (SpaceLabs 90207), which provided automatic sphygmomanometric BP readings at 20-minute intervals (oscillometric method). The subject was asked to pursue his or her normal activities during the monitoring period (the only precaution being to hold the arm immobile at the time of each BP reading) and to return to the hospital the following morning so that the device could be removed and three additional sitting BP and heart rate measurements obtained. The subject was also asked to self-measure BP at home with a semiautomatic sphygmomanometric device (oscillometric method) (model HP 5331, Philips) at approximately 7 PM and 7 AM, in the sitting position and using the arm contralateral to the one used for BP monitoring. During the initial medical visit, sitting BP was also measured by a random-zero mercury sphygmomanometer (auscultatory method) (Hawksley & Sons) approximately at the time of the second BP measurement by the physician. This was done to obtain a "clinic" BP value devoid of the physician's bias. As reported for the PAMELA study,3 the physicians involved in the study were trained and certified according to the MONICA criteria.4 The accuracy of both the ambulatory and home BP-measuring devices was checked by multiple comparisons with sphygmomanometric BP values before their use in individual subjects and at monthly intervals.
As done for the PAMELA study,3 in each subject, averages
were separately obtained of the three initial "clinic" BPs, the
two home BPs, and the three "clinic" BPs collected after
termination of 24-hour ambulatory BP monitoring. Ambulatory BP data
were edited for artifacts5 and averaged for the 24-hour
period, the daytime (7 AM to 11 PM), the
nighttime (11 PM to 7 AM), and each single
hour. Heart rate was analyzed as BP was, and data from
individual subjects were averaged and expressed as mean±SD for all
subjects except those who reported to be under antihypertensive
treatment. This was done to avoid the confounding effect of an external
intervention on the population values. Data from normotensive subjects,
"untreated" hypertensive subjects (ie, subjects with clinic
systolic BP 
140 mm Hg and/or clinic
diastolic BP 90 mm Hg who had no awareness of their
hypertensive condition or were not under antihypertensive treatment
during at least the previous 15 days), and "treated" hypertensive
subjects (subjects with a history of hypertension reporting current
antihypertensive treatment) were also averaged separately. Data were
separately analyzed for men and women. The linear correlations
between the various BPs collected in the study were also calculated.
Statistical evaluation of the average data was performed by two-way
ANOVA, using Duncan's or an unpaired t test to establish
the statistical significance (P<.05) of the differences.
Data were compared also with those collected in the younger PAMELA
population,3 which consisted of subjects 25 to 64 years
old.
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Results |
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Clinic, home, and BP measurements were obtained in 400 subjects, ie, in 50% of the randomly selected sample. The attendance rate was lower than that of the PAMELA study in subjects aged 64 years or less, but the collected sample retained the sex representativeness of the original sample. There were no differences between participants and nonparticipants in the study concerning hypertension awareness and treatment, smoking habits, body weight, prevalence of known cardiovascular diseases, and use of cardiovascular drugs (telephone interviews). Mean age of the sample was 69.0±2.3 years. Valid ambulatory BP readings were 94.1±2.3% of the planned readings (72 readings over the 24 hours), with a homogeneously high distribution for each hour of the monitoring period, ie, 2.8 of the 3 planned hourly readings, with minimal and maximal values of 2.6 and 2.9, respectively.
Clinic, Home, and Ambulatory Average BP and Heart Rate
Values
Demographic characteristics of the study subjects are shown in
Table 1
. As shown in Table 2, in
normotensive and untreated hypertensive subjects (n=248), clinic
systolic BP was similar, whereas clinic diastolic
BP was slightly greater, on day 2 than day 1. Random-zero BP was
slightly although significantly (systolic) higher than clinic
BP. Home BP, although significantly lower than clinic BP, was
noticeably higher than 24-hour average BP, which was thus markedly
lower (-25 mm Hg systolic and -10 mm Hg
diastolic) than clinic BP. Daytime average BP was greater
than 24-hour average BP but still significantly and markedly less than
clinic BP. Nighttime average BP was markedly and significantly less
than both day and 24-hour average BPs. Home and 24-hour average heart
rates were slightly greater than clinic heart rate, whereas daytime and
nighttime average heart rates were markedly greater and smaller,
respectively, than the clinic, home, and 24-hour average heart rate
values. Both BP and heart rate values showed small or no differences
between men (n=128) and women (n=120).
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As illustrated in Fig 1, clinic BP showed a steep
progressive increase from the PAMELA subjects aged 25 to 34 years to
the PAMELA subjects aged 65 to 74 years. To a lesser extent, this was
the case also for home BP, whereas 24-hour average BP showed a much
flatter age-dependent change. Clinic, home, and 24-hour average heart
rates did not show any substantial age-related differences. Nocturnal
bradycardia and hypotension were similar in the oldest decade compared
with the younger ones. This was the case also when men and women were
separately analyzed (Fig 2).
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As reported for younger PAMELA subjects,3 in the older
subjects of the PAMELA study, clinic BP showed a positive correlation
with home and ambulatory BPs, which were also correlated with each
other (Fig 3).
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Upper Limit of Home and Ambulatory BP Normality
As in the previous PAMELA study,3 in the present
study, the upper limits of normality of home and ambulatory BPs were
calculated as the values corresponding on the regression lines
traceable in Fig 3
to clinic BP values of 140/90 mm Hg. This was
preferred to other methods of expressing the upper limit of home and
ambulatory BP normality, ie, the 90% confidence limit, the 95%
confidence limit, or ±2 SD of the mean,6 for several
reasons extensively discussed in the previous PAMELA
study.3 One of these reasons is that the other methods
provide more a statistical than a clinic upper limit of normality and
include in the normality range a large fraction of individuals in whom,
on the basis of clinic BP, there is a BP-related increase in
cardiovascular risk. An additional reason is that this
method allows comparison with the PAMELA data in the younger
population. As shown in Table 3, the upper limits of
normality were 133/82 mm Hg
(systolic/diastolic) for home and 120/76
mm Hg for 24-hour average BPs; that is, they were markedly lower than
the upper limit of normality of clinic BP.
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Comparison Between Normotensive, Untreated Hypertensive, and
Treated Hypertensive Individuals
Fig 4 shows the results obtained in the 110
normotensive subjects (clinic BP <140/90 mm Hg), the 138
"untreated" hypertensive subjects (clinic BP 140/90
mm Hg), and the 152 "treated" hypertensive subjects. In
the latter group, treatment consisted of diuretics (n=43),
calcium antagonists (n=13), ACE inhibitors
(n=35), a combination of two drugs (n=51), or other treatments (n=10),
ie, central agents, vasodilators, etc. Among the 138 "untreated"
hypertensive subjects, 96 had only a systolic BP elevation and
42 a combined systolic and diastolic BP
elevation. As in the younger decades of the PAMELA study (G.M. et al,
unpublished data, 1996), clinic BP, although obviously greater in the
untreated hypertensive than the normotensive group, did not differ
substantially between "treated" and "untreated"
hypertensive subjects. Home and 24-hour average BPs were lower than
clinic BPs in all three groups but again were similar in
"treated" and "untreated" hypertensive subjects. This was
the case also for daytime and nighttime BPs (Fig 5). In
the normotensive subjects taking nitrates for angina pectoris (n=26),
24-hour average BP was not lower than in subjects not taking nitrates
(123.8±12.1/72.6±6.5 versus 123.1±12.0/72.8±7.4 mm Hg).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Our study provides the first population-based data on ambulatory and home BP values in subjects aged between 65 and 74 years. The most important findings are that in this group of aged subjects, 24-hour average, daytime average, and home systolic and diastolic BPs were all significantly and markedly less than clinic BPs. Thus, similarly to what occurs at younger ages,1 2 3 in elderly subjects the upper limit of normality of ambulatory and home BPs is located well below 140 mm Hg systolic and 90 mm Hg diastolic BP. If this is not taken into account, an ambulatory or home BP elevation will be missed in a large number of elderly individuals.
Two other similarities between the findings obtained in the present study and those reported in younger populations1 2 3 should be mentioned. First, in subjects aged 65 years or older, nighttime BP and heart rate values were lower than daytime values and to the same extent as in younger subjects taken from the same population. Thus, nocturnal hypotension and bradycardia are not blunted in the elderly fraction of the population, presumably because the autonomic mechanisms responsible for cardiovascular adjustments to sleep (sympathetic deactivation and vagal stimulation7 8 9 ) do not undergo an important age-dependent impairment. Second, in subjects aged 65 years or older, the difference between clinic and 24-hour or daytime average BPs was greater than in younger subjects and continued the progressive increase already observed in the PAMELA population when progressing from each age decade to the subsequent one in the age range from 25 to 64 years. However, the increasing clinic-ambulatory BP difference was not paralleled by an increase in clinic-ambulatory heart rate difference. Indeed, in elderly individuals, daytime (and to a lesser extent 24-hour) average heart rate was greater than clinic heart rate. This provides further support for arguments against the interpretation of clinic-ambulatory BP differences as a measure of the alerting reaction to clinic BP measurements, ie, as a measure of the phenomenon known as the white coat effect.10 If this were the case, one should find greater clinic than ambulatory heart rate values because the alerting response to clinic BP measurements is characterized by a tachycardic as well as a pressor response.11 12 13 One should probably also find an exaggerated tachycardia and pressor response to a variety of emotional stimuli, which is not in line with available data from previous studies.11 12 13 The large difference between clinic and ambulatory BP occurring in elderly subjects is thus likely to be accounted for, at least in part, by factors other than the effect of emotion on clinic BP. We can speculate that behaviors which in the elderly lower daily life BP (eg, orthostatism, physical activity, digestion14 ) are involved, ie, that an age-dependent hypotensive influence is responsible for the difference. However, in the earlier PAMELA data,3 the clinic-ambulatory BP difference increased in parallel with the increase in clinic BP, and this factor rather than the age per se accounted for its greater value in the elderly (and more frequently hypertensive) individuals. Thus, the explanation resides in clinic rather than ambulatory BP, one obvious possibility being that the former is not subjected to a regression to the mean, which magnifies values located at the extremes of the range.
Our study also shows that a major difference exists between elderly, middle-aged, and young subjects of the PAMELA study.3 Although in younger subjects home and 24-hour average BPs were similar, in middle-aged and particularly in elderly subjects home BP was greater than ambulatory BP because of a steeper age-dependent increase. Also in this instance, however, this was not due to age per se but to the fact that the home-ambulatory difference tends to increase with increasing BP values,3 as could be seen also by the different increase in the home-daytime BP difference when plotted versus home BP values in the elderly subjects of the present study (for systolic BP, P<.001). The factors responsible for this phenomenon (which has been confirmed by recent measurements of clinic, home, and ambulatory BPs in the hypertensive patients of the Study on Ambulatory Monitoring of Pressure and Lisinopril Evaluation [SAMPLE]15 ) are unknown. In practical terms, however, this means that home BP offers an approximate (and inexpensive) index of the prevailing 24-hour BP in normotensive but not in hypertensive population strata, ie, in the strata in which this index is more needed.
Two other points need to be mentioned. First, at variance with the data reported in the Allied Irish Bank Study,16 in the elderly subjects of the present study there were only minor differences between ambulatory BP values in men and women. We have no explanation for this discrepancy except for pointing out that since the Allied Irish Bank Study was not a population-based study, lack of randomization in patient selection may have produced some selection bias. Second, in many subjects of the present study, clinic systolic BP was above 140 mm Hg and/or diastolic BP above 90 mm Hg. This is in line with the high prevalence of hypertension in elderly populations17 and with epidemiological data from the same geographical area obtained in the MONICA study.18 The present study additionally shows, however, that in elderly hypertensive subjects under antihypertensive treatment, (1) clinic BP values were still much higher than in the normotensive population and not less than in the untreated hypertensive fraction of the population, and (2) this is not due to an alerting reaction that raises clinic BP temporarily above 140/90 mm Hg, because home and ambulatory BP values, ie, values taken outside the clinic environment and devoid of the white coat effect, were also similar in untreated and treated hypertensive subjects.19 This may not mean the complete ineffectiveness of treatment because in treated hypertensive subjects, pretreatment BPs may have been greater than in untreated hypertensive subjects. It means, however, that in line with results obtained in various populations,3 18 20 21 22 in elderly hypertensive subjects, treatment leaves BP at levels that are much higher than those of the normotensive population and that this is the case also when daily life values devoid of an alerting response are considered. Poor compliance with treatment is likely to be responsible for this phenomenon.23
Finally, it should be emphasized that our data refer to subjects aged up to 74 years and that no inference can be made as to the home BP normality, 24-hour BP normality, and magnitude of nocturnal hypotension in populations aged 75 years or older. This should be a goal of future population studies on home and ambulatory BPs.
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Acknowledgments |
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This study has been partly supported by a research grant from Glaxo, Italy, and by CNR, Italy (Progetto FATMA n. 41.115.02280).
Received July 5, 1996; first decision August 2, 1996; accepted November 29, 1996.
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