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.
In some cases this may be the result of genuine refractory
hypertension, while interesting that in others it may be simply the
consequence of an exaggerated white-coat effect. For instance,
evaluation of these patients requires BP measurements outside the
clinical environment in order to exclude the existence of the
latter.2 Monitoring ambulatory BP with a
noninvasive device3 4 provides more
representative values of BP than clinic BP does, and
the behavior of BP during the activity and sleep periods is observable.
Target-organ damage in essential hypertension correlates better with
ambulatory than with clinical BP,5 6 and for any
given value of clinical BP, target-organ damage is directly related to
the mean levels and variability of ambulatory BP. Moreover, it has been
claimed that values obtained in 24-hour monitoring are better
predictors of cardiovascular risk than data obtained in
casual measurements.7 8 9
Published consensus has established that one of the major uses for ABPM
is in the evaluation of refractory
hypertension.10 11 12 13 14 15 16 17 18 19 20 Despite agreement in the use
of ABPM with refractory hypertensive subjects, no confirmatory data
about the prognostic value of ABPM in this group have been available
until now. To establish whether ambulatory BP offers a better estimate
of cardiovascular risk than do its clinical BP
counterparts, we have conducted a prospective study assessing the
incidence of cardiovascular events over time in
patients diagnosed as having refractory hypertension.
At the beginning of the study all patients had a complete clinical
workup to rule out secondary hypertension and to assess the presence of
end-organ damage. Twenty-four ABPM were performed at the time of
entrance. End-organ damage was monitored yearly, and the incidence of
cardiovascular events during the time of follow-up was
recorded. A minimal 6-months of follow-up was required for being
included in the analysis.
Office and Ambulatory Blood Pressure Measurements
ABPM was performed with the use of an oscillometric monitor (Spacelabs
90202 or 90207) on a regular working day, during the normal intake of
the usual antihypertensive treatment. Following the standard protocol,
recording began between 8:30 and 9 AM, with
readings every 20 minutes from 6 PM until midnight and
every 30 minutes from midnight to 6 AM. Before starting the
study, reliability of BP values measured with the monitor were checked
against simultaneous measurements with a mercury
sphygmomanometer. Differences of <5 mm Hg were allowed. Those
patients with recordings showing an error rate in >25% of the
total readings were excluded from the study.
Different time periods were defined in the following manner for the
analysis of BP values obtained during monitoring: (a) the total
24 hours, (b) a day or activity period running from 8 AM
until 10 PM, (c) a night or sleep period running from
midnight to 6 AM, and (d) hourly periods over the 24 hours.
The average of SBP, DBP, and mean blood pressure were calculated for
every one of the periods. The ratio between the averages of BP during
the day period and during the night period, day/night ratio, was
calculated as an estimate of circadian variability.
Patients were divided into tertiles of average DBP during activity
according to the ABPM, with the LT <88 mm Hg (n=29), the MT 88
to 97 mm Hg (n=29), and the HT >97 mm Hg (n=28).
Clinical Score of End-Organ Damage
Follow-up of the Patients
Statistical Analysis
Event rates for new cardiovascular events, fatal plus
nonfatal, during the time of follow-up are presented as the
number of events per 100 patient-years, based on the ratio of the
observed number of events to the total number of patient-years of
exposure. Survival curves were estimated with the Kaplan-Meier
product-limit method, and differences between groups were estimated
by the log-rank test. The Cox proportional hazard model was used to
assess the effect of the prognostic factor on event-free survival. We
tested the independent significance of each ABPM tertile group. The
covariates included previous cardiovascular events
(absent, present), age (<60 years, >60 years), sex, current
smoking (absent, present), ECG criteria of left
ventricular hypertrophy (absent, present),
office BP at beginning and during follow-up, and average of daytime
ambulatory SBP as a continuous variable. Adjusted RR for the
significant Cox model factors were calculated and expressed along with
the 95% CI.
Blood Pressure at the Beginning of the Study and at the End of the
Follow-up Period
The values of office BP achieved at the time of final evaluation were
significantly lower than those observed at baseline. The extent of BP
reduction, however, did not differ among the three groups for either
the SBP (LT group, 17.1 mm Hg; 95% CI, 6.3 to 27.7; MT group,
16.4 mm Hg, 95% CI, 3.8 to 29.1; HT group, 14.5 mm Hg,
95% CI, 0.6 to 28.3; P=NS) or for the DBP (LT group,
12.0 mm Hg, 95% CI, 7.6 to 16.4; MT group, 9.7 mm Hg, 95%
CI, 4.3 to 15.1; HT group, 9.4 mm Hg, 95% CI, 1.8 to 17.0;
P=NS). Office DBP persisted at >100 mm Hg for 11
(38%) of the LT group, 12 (41%) of the MT group, and 14 (50%) of the
HT group at the last evaluation.
Clinical Score at the Beginning of the Study and at the End of the
Follow-up Period
A statistically significant progression of end-organ damage was
observed for the highest ambulatory BP group (3.70, 95% CI, 2.82 to
4.58; P<.03), but not for the other groups (LT group, 2.11,
95% CI, 1.36 to 2.86; MT group, 2.93, 95% CI, 1.94 to 3.92;
P=NS).
Cardiovascular Morbidity During the
Follow-up
In the Cox analysis, the risk of cardiovascular
events was significantly higher for those patients who had previously
experienced cardiovascular events (RR, 2.47; 95% CI,
1.05 to 5.78, P<.04) and for subjects included in the HT
group (RR, 6.20; 95% CI, 1.38 to 28.1, P<.02) (Table 4
The persistence of the differences between casual and ambulatory BP
observed in this study might be ascribable to the persistence of the
so-called "white-coat effect."23 24 25 26 In this
sense, Gosse and coworkers24 retrospectively
analyzed data from 154 patients who had taken part in
therapeutic trials. These authors reported the presence of the
white-coat effect in the same percentage of patients both before and 3
months after treatment. However, the authors stressed the low
reproducibility of the magnitude of the white coat in individual
patients, where correlation coefficients of 0.45 for systolic
and 0.32 for diastolic pressure were shown. This study
demonstrated that the white-coat effect persists in hypertensive
subjects even after months of therapy and regardless of the class of
drug used.
The differences between office and ambulatory BP and the relation to
the reduction in clinical BP during antihypertensive treatment have
recently been published by Parati and coworkers25
in 266 patients treated with various antihypertensive drugs and in 116
patients treated with placebo. They have concluded that a considerable
difference persists between clinical and ambulatory BPs after several
weeks of treatment but that the magnitude of the differences is
significantly attenuated with time. Moreover, the reduction in clinical
BP during treatment was higher or lower in function to the magnitude of
initial differences between office and ambulatory BP. This observation
is in agreement with our data, although no statistically significant
differences were present among the groups. The data show that
patients in LT group, with the greatest difference between office BP
and ambulatory BP, tended to exhibit the greatest fall in office BP
over time when compared with patients in the other groups.
During the last several years, ABPM has been introduced into
hypertension research and in clinical practice on the basis of two
lines of evidence. First, that values of ambulatory BP are more
reproducible than their office BP counterparts, both in normotensive
and in hypertensive subjects, independent of the age of
subjects.27 28 Second, there is a very
consistent body of evidence from cross-sectional studies
demonstrating that ambulatory BP correlates more closely than does
office pressure with target organ damage, as represented by
left ventricular
hypertrophy5 and
microalbuminuria in either hypertensive and normotensive
type 1 diabetes mellitus.29 30 Furthermore,
Mancia et al31 in the SAMPLE study demonstrated
that for hypertensive patients with echographic left
ventricular hypertrophy and in treatment with
lisinopril, the reduction in left ventricular
mass was correlated to the fall in ambulatory BP but not to the
reduction in casual BP.
Prospective data relating ambulatory BP to
cardiovascular prognosis have been limited to two
articles. The first, published by Perloff and
coworkers,7 included 751 patients and evaluated
daytime ambulatory BP as well as clinical BP measurements during a
follow-up of 5 years. This study showed that the combination of
ambulatory and clinical BP values was a better predictor of the
incidence of cardiovascular events than was clinical BP
alone. Although criticized on several grounds, this was the first
approach to the prognostic value of ABPM. The second was published by
Verdecchia and coworkers,8 who followed 1187
hypertensive and 205 normotensive men an women for an average of 3.2
years. The event rate observed was similar in the normotensive and
white-coat hypertensives and was significantly higher in the sustained
hypertensives. The present study adds further information as to the
prognostic value of ABPM, in this case in patients with refractory
hypertension, a group with high cardiovascular
risk.2
The results of this study deserve some commentary. First of all, the
averages of ambulatory BP at the beginning are a better prognostic
marker of cardiovascular events than are such other
well-known markers of risk as office BP during
follow-up32 and left ventricular
hypertrophy.33 The persistence of a
marked white-coat effect throughout the study and the high prevalence
of left ventricular hypertrophy explains this
result in our study population. Second, the prognostic value of
ambulatory BP predicted not only the incidence of
cardiovascular events but also other end-organ damage.
Occurrence of left ventricular hypertrophy
and/or proteinuria and the increment of plasma creatinine
values were more frequently in the HT group than in the other groups
during the observation period (Table 3
It should be pointed out that the present study has several its
limitations. To begin with, the number of subjects was relatively
small, although as the subjects studied are a group with high
cardiovascular risk, the number of events recorded
is high enough to allow for comparisons between groups. Second,
antihypertensive drugs and their combinations were variable during
the follow-up because of the special characteristics of the study
group. The maintenance of the same treatment during large
periods could raise ethical conflicts. Additionally, a lipid profile
might help to explain our findings. Nonetheless, only a small number of
patients needed lipid-lowering drugs, 3 in each group, and no
differences in the values of total cholesterol or
triglycerides were present among the groups at the time
of inclusion. Finally, one aspect not covered in the study was the
performance of regular ABPM during the follow-up to further
assess the prognostic value of this technique. It is known that
lowering elevated BP results in a remarkable reduction of
hypertension-induced morbidity and mortality and that the benefits of
treatment are greatest for those patients whose BP had been reduced the
most.32 Whether or not ambulatory BP values
throughout a long follow-up period represent a more accurate
prognostic tool than office BP in evaluating refractory hypertensive
patients needs to be assessed in future studies.
In conclusion, higher values of ambulatory BP result in a more
accurate prognosis of future cardiovascular events in
patients with refractory hypertension than do casual BP values.
Although more studies are needed to better assess the prognostic value
of ambulatory BP, the present data support the Consensus Meetings'
recommendation that ABPM be used to stratify
cardiovascular risk in patients with refractory
hypertension.
Received August 4, 1997;
first decision September 2, 1997;
accepted September 29, 1997.
© 1998 American Heart Association, Inc.
Scientific Contributions
Prognostic Value of Ambulatory Blood Pressure Monitoring in Refractory Hypertension
A Prospective Study
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
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.
Key Words: blood pressure monitoring, ambulatory • hypertension, refractory • cardiovascular risk • prognosis
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Hypertensive patients
whose clinical BP remains persistently high despite being prescribed
appropriate multiple medications present a relatively common
clinical problem. These patients, so-called resistant or
refractory, account for 10% of hypertensive subjects referred to
specialized clinics and frequently have changes in their medications,
including the addition of other antihypertensive
drugs.1 Attempts have been made to classify
refractory hypertension according to its cause. It may be due to a
specific identifiable disorder (secondary hypertension) associated with
exogenous substances that raise BP or interfere with the action of
antihypertensive agents (ie, nonsteroidal anti-inflammatory drugs),
attributable to complicating biological factors (obesity and
hyperinsulinemia), ascribable to inappropriate or
inadequate treatment, or due to noncompliance with a prescribed medical
regimen. In many cases, however, it is not possible to find a
potentially correctable cause of the elevated BP, even though the
patient's compliance to medication seems to be
adequate.1
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Selection of Study Participants
A group of 86 patients were included in the study. Patients were
recruited from the outpatient clinic of two hospitals (Hospital of
Sagunto and Hospital 12 de Octubre, Madrid) over a 68 month period
(January 1989 to December 1994). All patients who fulfilled the
inclusion criteria were invited to participate, and written consent was
obtained. The inclusion criteria were the following: (a) clinical
diastolic BP >100 mm Hg (Korotkoff phase V, sitting
position) for three visits at 1-month intervals during the same
antihypertensive treatment, which included three or more
antihypertensive drugs, one of them being a diuretic; (b)
preserved renal function, glomerular filtration rate
estimated by endogenous creatinine clearance
>60 mL/min per 1.73 m2. Patients with diabetes
mellitus or with secondary hypertension were excluded. The presence of
previous cardiovascular events did not constitute an
exclusion criteria in subjects maintaining their normal physical and
work activities.
BP was measured in a quiet environment with a mercury
sphygmomanometer with the patient in a sitting position after 5 minutes
of rest, following the recommendations of the British Hypertension
Society.21 SBP and DBP (Korotkoff phase I and
phase V, respectively) represented in each visit the mean
of three different readings measured at 5-minute intervals.
The presence of end-organ damage attributed to hypertension,
estimated at the beginning of the study and yearly, was reported as a
modification of a previously published score.22
This score was calculated with the use of data derived from each
patient's history, physical examination, and laboratory investigations
such as ECG, chest radiograph, fundus oculi, urinalysis, and plasma
creatinine. History questions were asked to establish the
presence (1 point) or absence (0 points) of ischemic heart
disease, heart failure, cerebrovascular insufficiency, and
peripheral arterial disease. The following ECG
abnormalities were considered evidence of target-organ damage: (a) left
ventricular hypertrophy (Sokolow criteria)
without (1 point) or with strain (2 points); (b) other ECG
abnormalities, such as signs of infarction, resting ischemia,
left bundle-branch block, ventricular arrhythmias,
and atrial fibrillation in absence of other possible causes (1 point).
Abnormalities on chest radiograph considered evidence of target-organ
damage were (a) moderate, cardiothoracic index 0.50 to 055, (1 point)
or (b) marked cardiac enlargement, cardiothoracic index >0.55 (2
points). The abnormalities of the fundus were classified according to
the Keith-Wagener criteria: grade II (1 point) and grade III or IV (2
points). Serum creatinine >132 mmol/L (1.5 mg/dL)
and/or proteinuria >1 g/24 hours scored 1 additional point. The total
score for an individual patient was the sum all item scores and ranged
from a minimum of 0 to a maximum of 12.
After the initial evaluation, patients were followed in one of
the outpatient clinics and when needed during hospitalization periods
by one of the authors. Antihypertensive treatment was monitored by
means of frequent office BP measurements, and when appropriate changes
in the number, class, and dose of antihypertensive drugs
(diuretics, ß-blockers, 
-blockers, calcium channel
blockers, angiotensin-converting enzyme
inhibitors, and vasodilators) were made according to
clinical criteria (goal of BP control <140/90 mm Hg) in spite of
whether treating physicians were or were not aware of the ABPM results.
A comparison of the incidence of new cardiovascular
events, fatal and nonfatal, between patient groups was made during the
follow-up. In subjects experiencing multiple nonfatal events, the
analysis included only the first event.
Cardiovascular events included myocardial infarction,
angina pectoris, coronary
revascularization, stroke, transient
ischemic attack, sudden death, aortoiliac occlusive disease,
progressive heart failure, and hypertensive emergency. Myocardial
infarction was diagnosed on the basis of at least two of three standard
criteria (typical chest pain, ECG QRS changes, and transient elevation
of myocardial enzymes by more than twofold the upper normal laboratory
limits). Angina pectoris was defined as chest pain accompanied by
typical ischemic changes in the ECG. Stroke was diagnosed on
the basis of rapid onset of localizing neurological deficit lasting 24
hours or longer in the absence of any other process that could explain
the symptoms. Transient ischemic attack was defined as any
sudden focal neurological deficit that cleared completely in less than
24 hours, based on a diagnosis made by a physician. Sudden death was
defined as a witnessed death that occurred within 1 hour after the
onset of acute symptoms, with no history of violence or accident
playing a role in the fatal outcome. Progressive heart failure was
defined as symptoms when appearing during the follow-up in patients
without previous heart failure symptoms. Hypertensive emergency was
defined as, and only considered applicable, when symptoms were
accompanied by papilledema in funduscopic examination.
For each variable, values are expressed as mean±SD.
Differences between groups were sought by using ANOVA for continuous
variables and 
2 for discontinuous
variables. Two-way ANOVA was used to analyze changes in the
variables (BP and score) over time in the two group of
patients.
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
General Characteristics
Eighty-six patients (27 men and 59 women; mean age, 53±9 years),
all white, who met the inclusion criteria, were included in the study.
The principal clinical characteristics and BP values of the patients in
each group are shown in Table 1
. No
differences in age, sex, or body mass index were observed between
groups. Five patients (17%) in the LT group, 6 (21%) in the MT group,
and 7 (25%) in the HT group had had at least one previous
cardiovascular event.
View this table:
[in a new window]
Table 1. General Characteristics: Office and Ambulatory BPs
in Hypertensive Subjects Grouped by Ambulatory BP
Office and ambulatory BP values are shown in Table 1
. No
differences in office SBP and DBP were present among the groups.
Not only the mean values of both 24-hour ambulatory SBP and DBP, but
also those values obtained during day and night periods were
significantly higher in the HT group (P<.001) than in the
other groups. Differences between office BP and the average of daytime
ambulatory BP were 29.1±24.1 mm Hg for SBP and 15.4±12.2
mm Hg for DBP. Only 6 (8.3%) of the subjects had a daytime ambulatory
BP higher than their office BP. The circadian pattern of BP in the
three groups is shown in Fig 1. The
highest tertile group exhibited the greatest average values of hourly
SBP and DBP throughout the day and night periods when compared with the
other groups (P<.01 for all hourly periods). No differences
in the day/night ratio as an estimate of circadian variability were
observed among the groups.
View larger version (33K):
[in a new window]
Figure 1. Twenty-four-hour circadian BP profile in patients
with resistant hypertension grouped by ambulatory BP: LT group
( 
, average of ambulatory during the activity DBP <88 mm Hg,
n=29), MT group (
, average of ambulatory during the activity DBP 88
to 97 mm Hg, n=29), and HT group (
, average of ambulatory
during the activity DBP >97 mm Hg, n=29). There are significant
differences in all hourly averages among groups. Values are
mean±SE.
At baseline, mean value of the clinical score was higher in the HT
group than in the other groups; however, this difference did not attain
statistical significance (LT group, 2.30, 95% CI, 1.45 to 3.14; MT
group, 2.41, 95% CI, 1.50 to 3.33; and HT group, 2.64, 95% CI, 1.82
to 3.47; respectively, P=NS).
Mean time of observation was 49 months, ranging from 6 to 96
months (median, 45 months). During the follow-up, 21 patients had a new
cardiovascular event (11 with coronary heart
disease, myocardial infarction, or angina pectoris; 5 with
cerebrovascular disease, stroke, or transient ischemic attack;
4 with progressive heart failure; 1 with hypertensive emergency). While
no statistically significant difference between the two groups with
highest ambulatory BP, incidence of events was significantly lower for
the LT group (LT group, 2 events, 2.2 per 100 patient-years; MT group,
9 events, 9.5 per 100 patient-years; HT group, 10 events, 13.6 per 100
patient-years). Similar results were observed when the comparison
between groups was performed by excluding patients with previous
cardiovascular events (LT group, 1 event, 1.3 per 100
patient-years; MT group, 6 events, 8.4 per 100 patient-years; HT group,
7 events, 12.1 per 100 patient-years). The probability of event-free
survival is shown in Fig 2. The
comparison of survival curves among the groups for the overall
population shows significant differences between the LT and MT groups
(log-rank P<.04), and between the LT and HT groups
(log-rank P<.006). No differences between MT and HT groups
were observed (log-rank P<.26). When only patients without
previous cardiovascular events were considered,
differences among groups remain (LT versus MT, P<.05; LT
versus HT, P<.02; MT versus HT, P<.37).
View larger version (12K):
[in a new window]
Figure 2. Probability of event-free survival in patients
with resistant hypertension grouped by ambulatory BP: LT group
(average of ambulatory during the activity DBP <88 mm Hg, n=29),
MT group (average of ambulatory during the activity DBP 88 to 97
mm Hg, n=29), and HT group (average of ambulatory during the activity
DBP >97 mm Hg, n=29). The comparison of survival curves between
the groups shows significant differences between LT and MT groups
(log-rank P<.04) and LT and HT groups (log-rank
P<.006). No differences between MT and HT groups were
observed (log-rank P<.26). ).
The prognostic value of ambulatory BP as an independent risk factor
remains even when patients who had suffered previous
cardiovascular events were removed from the
analysis (RR, 8.76; 95% CI, 1.07 to 71.8, P=.05).
In contrast, age, sex, left ventricular
hypertrophy in the ECG, SBP, and DBP office BP at the
beginning and at the time of the last evaluation and daytime ambulatory
SBP were not independent risk factors for morbid
cardiovascular events.
View this table:
[in a new window]
Table 4. Relative Risks for Cardiovascular
Morbid Events Assessed by Cox Proportional Hazards Model
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
In a group of 86 hypertensive patients with refractory
hypertension, defined as the finding of an office DBP 
100 mm Hg
during the administration of an adequate combination of three or more
antihypertensive drugs, 21 cardiovascular events were
recorded during a mean follow-up of 49 months. The risk of a
cardiovascular event was significantly higher for the
patients who previously had experienced a
cardiovascular event and for patients who had a higher
ambulatory BP at the time of inclusion. The risk in relation to
ambulatory BP values seems to increase progressively from lowest values
to highest. Whatever the case, in the absence or in presence of a
previous cardiovascular event, ambulatory BP was an
independent marker of risk for new events. The data of the present
study show that ABPM is useful in stratifying the risk in patients with
refractory hypertension according to office BP measurements, supporting
the recommendations from the National and International Consensus
Meetings.10 11 12 13 14 15 16 17 18 19 20 ). Finally, ambulatory BP
day/night ratio as an estimate of circadian variability was not an
independent marker of risk among patients with refractory hypertension.
A higher cardiovascular risk has been reported in women
with low BP circadian variability, "nondippers," than the risk in
those with "normal" BP circadian variability,
"dippers."8 The high BP values maintained
during the night, despite the presence of a "normal" nocturnal BP
fall, overcome the importance of the extent of BP fall in refractory
hypertensives.
View this table:
[in a new window]
Table 3. End-Organ Damage and Cardiovascular
Events Developed During the Follow-up Period in Hypertensive Subjects
Grouped by Ambulatory BP
Selected Abbreviations and Acronyms
ABPM
=
ambulatory blood pressure monitoring
BP
=
blood pressure
CI
=
confidence interval
DBP
=
diastolic blood pressure
ECG
=
electrocardiograph
HT
=
highest tertile
LT
=
lowest tertile
MT
=
middle tertile
RR
=
relative risk
SBP
=
systolic blood pressure
View this table:
[in a new window]
Table 2. Baseline Clinical End-Organ Damage in Hypertensive
Subjects Grouped by Ambulatory BP
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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I. Z. Ben-Dov, J. D. Kark, D. Ben-Ishay, J. Mekler, L. Ben-Arie, and M. Bursztyn Predictors of All-Cause Mortality in Clinical Ambulatory Monitoring: Unique Aspects of Blood Pressure During Sleep Hypertension, June 1, 2007; 49(6): 1235 - 1241. [Abstract] [Full Text] [PDF]
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 M. A. Martinez-Garcia, R. Gomez-Aldaravi, J-J. Soler-Cataluna, T. G. Martinez, B. Bernacer-Alpera, and P. Roman-Sanchez Positive effect of CPAP treatment on the control of difficult-to-treat hypertension Eur. Respir. J., May 1, 2007; 29(5): 951 - 957. [Abstract] [Full Text] [PDF]
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 D Erdogan, H Gullu, M Caliskan, I Yildirim, D Tok, and H Muderrisoglu Coronary flow reserve is preserved in white-coat hypertension Heart, August 1, 2006; 92(8): 1109 - 1112. [Abstract] [Full Text] [PDF]
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 T. G. Pickering, D. Shimbo, and D. Haas Ambulatory blood-pressure monitoring. N. Engl. J. Med., June 1, 2006; 354(22): 2368 - 2374. [Full Text] [PDF]
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E. Dolan, L. Thijs, Y. Li, N. Atkins, P. McCormack, S. McClory, E. O'Brien, J. A. Staessen, and A. V. Stanton Ambulatory Arterial Stiffness Index as a Predictor of Cardiovascular Mortality in the Dublin Outcome Study Hypertension, March 1, 2006; 47(3): 365 - 370. [Abstract] [Full Text] [PDF]
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G. Salles, S. Leocadio, K. Bloch, A. R. Nogueira, and E. Muxfeldt Combined QT Interval and Voltage Criteria Improve Left Ventricular Hypertrophy Detection in Resistant Hypertension Hypertension, November 1, 2005; 46(5): 1207 - 1212. [Abstract] [Full Text] [PDF]
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R. C. Hermida, D. E. Ayala, C. Calvo, J. E. Lopez, A. Mojon, M. J. Fontao, R. Soler, and J. R. Fernandez Effects of Time of Day of Treatment on Ambulatory Blood Pressure Pattern of Patients With Resistant Hypertension Hypertension, October 1, 2005; 46(4): 1053 - 1059. [Abstract] [Full Text] [PDF]
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P. Verdecchia and F. Angeli How Can We Use the Results of Ambulatory Blood Pressure Monitoring in Clinical Practice? Hypertension, July 1, 2005; 46(1): 25 - 26. [Full Text] [PDF]
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E. Dolan, A. Stanton, L. Thijs, K. Hinedi, N. Atkins, S. McClory, E. D. Hond, P. McCormack, J. A. Staessen, and E. O'Brien Superiority of Ambulatory Over Clinic Blood Pressure Measurement in Predicting Mortality: The Dublin Outcome Study Hypertension, July 1, 2005; 46(1): 156 - 161. [Abstract] [Full Text] [PDF]
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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]
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M. G. Myers Ambulatory Blood Pressure Monitoring for Routine Clinical Practice Hypertension, April 1, 2005; 45(4): 483 - 484. [Full Text] [PDF]
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T. G. Pickering, J. E. Hall, L. J. Appel, B. E. Falkner, J. Graves, M. N. Hill, D. W. Jones, T. Kurtz, S. G. Sheps, and E. J. Roccella Recommendations for Blood Pressure Measurement in Humans and Experimental Animals: Part 1: Blood Pressure Measurement in Humans: A Statement for Professionals From the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research Circulation, February 8, 2005; 111(5): 697 - 716. [Abstract] [Full Text] [PDF]
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T. G. Pickering, J. E. Hall, L. J. Appel, B. E. Falkner, J. Graves, M. N. Hill, D. W. Jones, T. Kurtz, S. G. Sheps, and E. J. Roccella Recommendations for Blood Pressure Measurement in Humans and Experimental Animals: Part 1: Blood Pressure Measurement in Humans: A Statement for Professionals From the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research Hypertension, January 1, 2005; 45(1): 142 - 161. [Abstract] [Full Text] [PDF]
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 S. J. Howell, J. W. Sear, and P. Foex Hypertension, hypertensive heart disease and perioperative cardiac risk{dagger} Br. J. Anaesth., April 1, 2004; 92(4): 570 - 583. [Abstract] [Full Text] [PDF]
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 P. Verdecchia, F. Angeli, and R. Gattobigio Clinical Usefulness of Ambulatory Blood Pressure Monitoring J. Am. Soc. Nephrol., January 1, 2004; 15(90010): S30 - 33. [Abstract] [Full Text]
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D. L. Clement, M. L. De Buyzere, D. A. De Bacquer, P. W. de Leeuw, D. A. Duprez, R. H. Fagard, P. J. Gheeraert, L. H. Missault, J. J. Braun, R. O. Six, et al. Prognostic Value of Ambulatory Blood-Pressure Recordings in Patients with Treated Hypertension N. Engl. J. Med., June 12, 2003; 348(24): 2407 - 2415. [Abstract] [Full Text] [PDF]
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 L. Poulsen Blood pressure and cardiac autonomic function in relation to risk factors and treatment perspectives in Type 1 diabetes Journal of Renin-Angiotensin-Aldosterone System, December 1, 2002; 3(4): 222 - 242. [Abstract] [PDF]
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