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Long-term followup of untreated white-coat hypertensive patients
AIR-APRIL 1995-VOL.8, NO.4, PART 2
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SELF·MEMlVRED BLOOD PRESSURE VI ABPM IN THE DIAGNOlS'S OF HYPERTENSION.ll..Hglm, 1. Steurer, W. Veller·,Department of Internal Medicine, University Hospital, Zurich, SwilZCrland. Both, ambulatory blood pressure (ABPM) and blood pressure self· measurement (8M) are used in Ibediagnostic worle·up of hypertension. Inthepresent study \hevalidity of 8Mwas compared with ADPM. 79 patlenlS wilb mUd hypertension were Included. ABPM was performed by using a Space-Labs device (90207), 8Mwl\h a semiautomatic escillometric device (VlsQmat OZ2). In group I patients (11=48) performed 1 single daily morning SM (6a.m.-Sam.) andIngroup 2 (n=31) 2 8Min ihe morning (6 a.m.·8 am.) and2 in the evening (6p.m.·8p.m.). In each group SM values oC day 1·3 and 4·7(8) were pooled. ADPM was performed atday 1 and day 7.Dipping was defined as 11 decrease in mean nigbt systolic andlor diastolic blood pressure of ~ 10%. In group 1 mean SM blood pressure values were 143,t14In lhefltstand 142,tlS mmHg systolic In the second period and 92:1:11 and 9O;t.ll mmHg diastoUc,1n group 2 142±19 and 139±17 mmHg systolic and9O±12 and 89,t12 mmHg diastolic. Respective values for ADPM·day were In group1 141±11 at day I and 142:1:12 mmHg systolic at day 7 and91:1:8 and 91:t;9 mmHg diastolic. Only 3 oCLbe 71 (4.2%) cases showed a nondipping 24h·ABPM profile. In SM thestandard devlatlon of themean difference (SOD) dccreascd from group I togroup 2 from 'J.9 to7mmHg systolic and 6 to5 mmHg diastolic. InADPM nodecrease was observed InSOD: 5.3 and7.3 mmHg systolic and 4.8and SmmHg diastolic. In 8M correlations coefficients (r) between thefirst and thesecond period Increased from 0.58 to0.86systolic and from 0.7 to 0.85 diastolic. In ADPM therespective values were 0.18 and 0,6 systolic and 0.68 and 0.67 diastolic. ThefollOWing conclusions am be drawn from ourresults 1. The nearly identical values in mean blood pressure, SDO and correlations demonstrate, that 8M is as precise as ABPM when multiple dally measurements are performed. 2. ABPM is the only method to detcet non-dipping. However, in our pallenls witb mild uncomplicaled bypertenslon this pbenomen was very rare. 3. Because of the easier application of SM in general praetJre and its I:lgber acceptance in patients, 8M Is a good candidate in replacing ABPM in the routine diagnostic werk-upofhypertension. ~ey
POSTERS: PatientEvaluation and Management 85A
Words: Hypel1ension, self·measurement. ABPM
MICROALBUMINURIA, LEFT VENTRICUlAR MASS AND AMBlAATORY BLOOD PRESSURE IN ESSENTIAL HYPERTENSION. ~ E Baldo, V Bertolln, JV Lozono, A Mlrallae, JM Pa&CUal. Hyportlll1slon Clinic. Depautmlnl 01 Medlclno, Hoapll8l 01 SagunlD, SplIIn. Mlcroarbl/mlnurla (MALS) I, a polenlllli marker 01 risk In .sDP:lVlII hypertonslon. Previously WI describe a relatlonahlp belWHn MALO Ind lell venlrlcular milS (LVM) Illdel*ldenl 01 olllc;e BP vllull. ~ : To alMU II thl relatlolllhip belwltn MALB and L'IM llindeptndent 01 a more repreMnlatlVl BP valul. al luch the ambulalo!)' BP. !2I,lgn ..11
IlIllIlJgJ!t.PaUlnts wtlh lI/lInllal hyperten~on, -eed 25to60 yllll old. ",Vlll' trelted wUh lIlIllllypertenslYO drugl,Wllre Incfuded Inthl ItUcty. Thllnclullon criteria ~'II: I) able~(jl d1lbelll, renoJ dlNaM orurfnal)llrlC'llnllCtlon:
b) ed1ocardlography aullablu lor mellluremBflI 01 LVMi 0) Urfllllt)' l1Wmln excradon (UAE) Wli estimated Inurine 0124 hour In two Mparalldclayl and d) goodquality ambulalo!)' blood prellura monllorlng dUring 24 hoUri. LVM WlS calculated by the 09VereauM formula and lelor8d toheight (LVMI gtm). UAE was mellBIJred using II ImmUflOnephelomelrlo IIssay (Behring InstlluI) and MALS WI'considered MIen UAQ30mgl24h In tho twoday•• "MBPWIlD performed uslng anonellomllrlo device (Spacellbt 90202«90207) during I . " r working day. Readingl IWlll ptogrammed l'ifry 20 min betNHn 6 n to midnight andtherealter eVlii/ 30mIn. Mean 01 24hoUri, llWlke and a/lep periodl lor systolic and dlll.lol/C bloodpl8saure wa", calculltgd. £IilIIItl. an. hundrod Il1d ftlthy one padentc (96 mIle. mean '118 3718 yr. 8MI ';.T.7t3.7 gfm2) were Included. Tho mllllll Vllues of UAE wae 3O.tt62.3 mlf
1:==r---,~..,..
UAE
n III
mgl24h..
.... III
•.or_ _
II
a
2 Tel111as LVMI Conclusions. Patlenls wllhIlsHntlalhypertllnslon and MALB hadhigher LV mass lIthe same diastolic BP values. AsslSsment 01 MALB can beuselul for slTlIllfietollon of risk on hypel10nslves mlcroelb~mlnurle,
,.ft
".ntrlel/ln hvp.rtrophV. '1'l1t'ul.tory blood pr
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LONG·TERM FOLLOWllP OF UNTREATED WHITE· COATHYPERTENSIVE PATIENTS, William B. White. $ Wendy Susser. Ellen J. McCabe, andGeorge A Mansoor, Section of Hypertension and Vascular Diseases, University of Connecticut Health Center. Farmington, CT Recent cross-sectional and prognostic studies of white-coat hypertension (WCH) have suggested that an office BP > 140/90 mmHg is not predictive of hypertensive morbidity when the awake ambulatory BP is < 135/85 mmHg. To evaluate the longterm changes in office and ambulatory BP, and the white-coat effect (office-awake BPJ. we restudied untreated WCH patients (office BP> 140/90 mmHg withawake BP < 135/85 mmHg and white-coat effect> 20 mmHg systolic or IO mmHg diastolic) who had their first ambulatory BP recording> J2 months previously and had not been treated with antihypertensive drug therapy. Recordings were perfonned with either Accutracker or QuietTrak recorders under the same environmental conditions. Patients with substantial changes in employment status (e.g, retirement), weight/exercise (> IO % change), or drugs that might affect BPwere excluded. Studies were performed 37 ± 26 months (range, 15-]J9 months) apart: fawndtt Study I ...S1JI.Ih1 p.yalUf OrflCcSBP (mmfig) 148±13 149± 12 .647 Office DBP (mmHg) 99 ± 6 96 ± 7 ,115 24·hSBP (rnmHg) 120 ± 5 123 ± 7 . MS ~ 24-h DBP(mmHg) 73± 5 77 ± 7 .009' AwakcSDP(mmlfg) t26:t 6 t28:t 9 .336 Awake DBP (mmHg) 78 ± 5 81 ± 8 .05t· SleepSBP(mmHg) tM± 7 106± 7 .200 Sleep DBP (mmHg) 62 ± 6 66 ± 6 .004' While~oal cffccl'(%) 1!Xl'h 95 % ,919 'whilecoaleffecl(office-awake BP> 20mmHIl sap or 10rnrnHl!: DBP)
lnly five (12.5%) of the WeH patients developed one or more criteria for ambulatory hypertension (awake BP > 135/85 mmHg or BP IOi!d > 30%). Age, duration of hypertension, body mass index, baseline office and ambulatory BPs, and time I~psed between studies didnotpredict thechange illambulatory BP over time. These datashow that 88% of patients withWCH remain as WCH overtime and 95% continue to display a white·coat effect. The small subgroup who did become hypertensive over time werenot predicted byoffice BP,ambulatory BP,or age. Key Words:
whi!c.coat hvpertension, ambulatory BP. white·coat effed, outcomes
INAPPROPRIATE PHYSICIAN PRESCRIBING HABITS OF ORAL NIFEDIPINE CAPSULES IN HOSPITALIZED PATIENTS. Faiz RebwAn. George A, Mansoor, and William B. White,. Section of Hypertension and Vascular Diseases, University of Connecticut School of Medicine, Farmington, Connecticut. Despite the absence of an approved FDA indication, the use of oral/sublingual nifcdipine for 'acute' hypertension has become a widespread practice among physicians. To assess the clinical circumstances for which the drugwas being prescribed, dosing of oral niferlipine capsules was studied prospectively in threecentral Connecticut hospitals (private-nonteaching, university, and community-teaching). Through evaluation of computerized pharmacy and medical records, data werecollected on diagnostic reasons for ordering nifedipine, pre- and post-treatment BPs, dosing frequency, clinical documentation associated with drug prescription, and adverse events. Physicians and nurses at the respective hospitals were unaware cf theconduct of thestudy. The prevalence of nifedipine capsule administration for all 3 hospitals was 3.4% (I52 dosings/4498 hospitalized patients/2 months). Practice habits and BPchanges did notdiffer among hospitals. Ten mg WaS the most common dose prescribed (96%). however, multiple doses were given in 63% of cases. Sixty-three per cent of nifedipine orders were given over the phone for arbitrary and asymptomatic BP elevations and ~ of orders lacked bedside patient evaluation. Followup of BP was performed within 1hourin 51% of patients. 24% in 2 hours while in 25%, there Was no docu!llentatioll of folJowup until 2-6 hours afternifedipine dosing. Mean pretreatment DPwas 186/94 ±20/16 mm Hg, (range, 150/50 to 250/125 mrnHg). Blood pressure fell-321-16 ± 22/16 rom Hg (range, -92/-90 to +8/+28 mmHg) and was related to the level of pretreatment BP (r = 0.53, P < 0.0001 for systolic BP, and r = 0.49, P < 0.0001 for diastolic BP). Large, asymptomatic BP reductions were common (prevalence> 30/15mmHg =66%). One hypertensive patient with angina experienced severe hypotension accompanied by myocardial infarction. These data demonstrate inappropriate prescribing habits of oral nifedipine in hospitalized patients characterized by lack of proper assessment prior to drug dosing, highly arbitary treatment parameters that were wrinen wilhout regard for symptoms, andslow followup forevaluation of clinical respons~, Key Words: nifedipine capsules, hypertensive urgency, physician practice habits, hospitalized patients
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SELF·MEMlVRED BLOOD PRESSURE VI ABPM IN THE DIAGNOlS'S OF HYPERTENSION.ll..Hglm, 1. Steurer, W. Veller·,Department of Internal Medicine, University Hospital, Zurich, SwilZCrland. Both, ambulatory blood pressure (ABPM) and blood pressure self· measurement (8M) are used in Ibediagnostic worle·up of hypertension. Inthepresent study \hevalidity of 8Mwas compared with ADPM. 79 patlenlS wilb mUd hypertension were Included. ABPM was performed by using a Space-Labs device (90207), 8Mwl\h a semiautomatic escillometric device (VlsQmat OZ2). In group I patients (11=48) performed 1 single daily morning SM (6a.m.-Sam.) andIngroup 2 (n=31) 2 8Min ihe morning (6 a.m.·8 am.) and2 in the evening (6p.m.·8p.m.). In each group SM values oC day 1·3 and 4·7(8) were pooled. ADPM was performed atday 1 and day 7.Dipping was defined as 11 decrease in mean nigbt systolic andlor diastolic blood pressure of ~ 10%. In group 1 mean SM blood pressure values were 143,t14In lhefltstand 142,tlS mmHg systolic In the second period and 92:1:11 and 9O;t.ll mmHg diastoUc,1n group 2 142±19 and 139±17 mmHg systolic and9O±12 and 89,t12 mmHg diastolic. Respective values for ADPM·day were In group1 141±11 at day I and 142:1:12 mmHg systolic at day 7 and91:1:8 and 91:t;9 mmHg diastolic. Only 3 oCLbe 71 (4.2%) cases showed a nondipping 24h·ABPM profile. In SM thestandard devlatlon of themean difference (SOD) dccreascd from group I togroup 2 from 'J.9 to7mmHg systolic and 6 to5 mmHg diastolic. InADPM nodecrease was observed InSOD: 5.3 and7.3 mmHg systolic and 4.8and SmmHg diastolic. In 8M correlations coefficients (r) between thefirst and thesecond period Increased from 0.58 to0.86systolic and from 0.7 to 0.85 diastolic. In ADPM therespective values were 0.18 and 0,6 systolic and 0.68 and 0.67 diastolic. ThefollOWing conclusions am be drawn from ourresults 1. The nearly identical values in mean blood pressure, SDO and correlations demonstrate, that 8M is as precise as ABPM when multiple dally measurements are performed. 2. ABPM is the only method to detcet non-dipping. However, in our pallenls witb mild uncomplicaled bypertenslon this pbenomen was very rare. 3. Because of the easier application of SM in general praetJre and its I:lgber acceptance in patients, 8M Is a good candidate in replacing ABPM in the routine diagnostic werk-upofhypertension. ~ey
POSTERS: PatientEvaluation and Management 85A
Words: Hypel1ension, self·measurement. ABPM
MICROALBUMINURIA, LEFT VENTRICUlAR MASS AND AMBlAATORY BLOOD PRESSURE IN ESSENTIAL HYPERTENSION. ~ E Baldo, V Bertolln, JV Lozono, A Mlrallae, JM Pa&CUal. Hyportlll1slon Clinic. Depautmlnl 01 Medlclno, Hoapll8l 01 SagunlD, SplIIn. Mlcroarbl/mlnurla (MALS) I, a polenlllli marker 01 risk In .sDP:lVlII hypertonslon. Previously WI describe a relatlonahlp belWHn MALO Ind lell venlrlcular milS (LVM) Illdel*ldenl 01 olllc;e BP vllull. ~ : To alMU II thl relatlolllhip belwltn MALB and L'IM llindeptndent 01 a more repreMnlatlVl BP valul. al luch the ambulalo!)' BP. !2I,lgn ..11
IlIllIlJgJ!t.PaUlnts wtlh lI/lInllal hyperten~on, -eed 25to60 yllll old. ",Vlll' trelted wUh lIlIllllypertenslYO drugl,Wllre Incfuded Inthl ItUcty. Thllnclullon criteria ~'II: I) able~(jl d1lbelll, renoJ dlNaM orurfnal)llrlC'llnllCtlon:
b) ed1ocardlography aullablu lor mellluremBflI 01 LVMi 0) Urfllllt)' l1Wmln excradon (UAE) Wli estimated Inurine 0124 hour In two Mparalldclayl and d) goodquality ambulalo!)' blood prellura monllorlng dUring 24 hoUri. LVM WlS calculated by the 09VereauM formula and lelor8d toheight (LVMI gtm). UAE was mellBIJred using II ImmUflOnephelomelrlo IIssay (Behring InstlluI) and MALS WI'considered MIen UAQ30mgl24h In tho twoday•• "MBPWIlD performed uslng anonellomllrlo device (Spacellbt 90202«90207) during I . " r working day. Readingl IWlll ptogrammed l'ifry 20 min betNHn 6 n to midnight andtherealter eVlii/ 30mIn. Mean 01 24hoUri, llWlke and a/lep periodl lor systolic and dlll.lol/C bloodpl8saure wa", calculltgd. £IilIIItl. an. hundrod Il1d ftlthy one padentc (96 mIle. mean '118 3718 yr. 8MI ';.T.7t3.7 gfm2) were Included. Tho mllllll Vllues of UAE wae 3O.tt62.3 mlf
1:==r---,~..,..
UAE
n III
mgl24h..
.... III
•.or_ _
II
a
2 Tel111as LVMI Conclusions. Patlenls wllhIlsHntlalhypertllnslon and MALB hadhigher LV mass lIthe same diastolic BP values. AsslSsment 01 MALB can beuselul for slTlIllfietollon of risk on hypel10nslves mlcroelb~mlnurle,
,.ft
".ntrlel/ln hvp.rtrophV. '1'l1t'ul.tory blood pr
G15
G16
LONG·TERM FOLLOWllP OF UNTREATED WHITE· COATHYPERTENSIVE PATIENTS, William B. White. $ Wendy Susser. Ellen J. McCabe, andGeorge A Mansoor, Section of Hypertension and Vascular Diseases, University of Connecticut Health Center. Farmington, CT Recent cross-sectional and prognostic studies of white-coat hypertension (WCH) have suggested that an office BP > 140/90 mmHg is not predictive of hypertensive morbidity when the awake ambulatory BP is < 135/85 mmHg. To evaluate the longterm changes in office and ambulatory BP, and the white-coat effect (office-awake BPJ. we restudied untreated WCH patients (office BP> 140/90 mmHg withawake BP < 135/85 mmHg and white-coat effect> 20 mmHg systolic or IO mmHg diastolic) who had their first ambulatory BP recording> J2 months previously and had not been treated with antihypertensive drug therapy. Recordings were perfonned with either Accutracker or QuietTrak recorders under the same environmental conditions. Patients with substantial changes in employment status (e.g, retirement), weight/exercise (> IO % change), or drugs that might affect BPwere excluded. Studies were performed 37 ± 26 months (range, 15-]J9 months) apart: fawndtt Study I ...S1JI.Ih1 p.yalUf OrflCcSBP (mmfig) 148±13 149± 12 .647 Office DBP (mmHg) 99 ± 6 96 ± 7 ,115 24·hSBP (rnmHg) 120 ± 5 123 ± 7 . MS ~ 24-h DBP(mmHg) 73± 5 77 ± 7 .009' AwakcSDP(mmlfg) t26:t 6 t28:t 9 .336 Awake DBP (mmHg) 78 ± 5 81 ± 8 .05t· SleepSBP(mmHg) tM± 7 106± 7 .200 Sleep DBP (mmHg) 62 ± 6 66 ± 6 .004' While~oal cffccl'(%) 1!Xl'h 95 % ,919 'whilecoaleffecl(office-awake BP> 20mmHIl sap or 10rnrnHl!: DBP)
lnly five (12.5%) of the WeH patients developed one or more criteria for ambulatory hypertension (awake BP > 135/85 mmHg or BP IOi!d > 30%). Age, duration of hypertension, body mass index, baseline office and ambulatory BPs, and time I~psed between studies didnotpredict thechange illambulatory BP over time. These datashow that 88% of patients withWCH remain as WCH overtime and 95% continue to display a white·coat effect. The small subgroup who did become hypertensive over time werenot predicted byoffice BP,ambulatory BP,or age. Key Words:
whi!c.coat hvpertension, ambulatory BP. white·coat effed, outcomes
INAPPROPRIATE PHYSICIAN PRESCRIBING HABITS OF ORAL NIFEDIPINE CAPSULES IN HOSPITALIZED PATIENTS. Faiz RebwAn. George A, Mansoor, and William B. White,. Section of Hypertension and Vascular Diseases, University of Connecticut School of Medicine, Farmington, Connecticut. Despite the absence of an approved FDA indication, the use of oral/sublingual nifcdipine for 'acute' hypertension has become a widespread practice among physicians. To assess the clinical circumstances for which the drugwas being prescribed, dosing of oral niferlipine capsules was studied prospectively in threecentral Connecticut hospitals (private-nonteaching, university, and community-teaching). Through evaluation of computerized pharmacy and medical records, data werecollected on diagnostic reasons for ordering nifedipine, pre- and post-treatment BPs, dosing frequency, clinical documentation associated with drug prescription, and adverse events. Physicians and nurses at the respective hospitals were unaware cf theconduct of thestudy. The prevalence of nifedipine capsule administration for all 3 hospitals was 3.4% (I52 dosings/4498 hospitalized patients/2 months). Practice habits and BPchanges did notdiffer among hospitals. Ten mg WaS the most common dose prescribed (96%). however, multiple doses were given in 63% of cases. Sixty-three per cent of nifedipine orders were given over the phone for arbitrary and asymptomatic BP elevations and ~ of orders lacked bedside patient evaluation. Followup of BP was performed within 1hourin 51% of patients. 24% in 2 hours while in 25%, there Was no docu!llentatioll of folJowup until 2-6 hours afternifedipine dosing. Mean pretreatment DPwas 186/94 ±20/16 mm Hg, (range, 150/50 to 250/125 mrnHg). Blood pressure fell-321-16 ± 22/16 rom Hg (range, -92/-90 to +8/+28 mmHg) and was related to the level of pretreatment BP (r = 0.53, P < 0.0001 for systolic BP, and r = 0.49, P < 0.0001 for diastolic BP). Large, asymptomatic BP reductions were common (prevalence> 30/15mmHg =66%). One hypertensive patient with angina experienced severe hypotension accompanied by myocardial infarction. These data demonstrate inappropriate prescribing habits of oral nifedipine in hospitalized patients characterized by lack of proper assessment prior to drug dosing, highly arbitary treatment parameters that were wrinen wilhout regard for symptoms, andslow followup forevaluation of clinical respons~, Key Words: nifedipine capsules, hypertensive urgency, physician practice habits, hospitalized patients