Morning, smooth ambulatory BP control ‘rarely achieved’ in general practice

Most patients receiving treatment for hypertension do not have their morning blood pressure (BP) levels controlled, and do not achieve smooth daytime control, researchers report.

Their study of over 3000 patients, from nine countries, found that less than half achieved morning, daytime, and 24-hour ambulatory BP (ABP) control.

Furthermore, control rates were lower among patients with diabetes or left ventricular hypertrophy (LVH) and those at high cardiovascular risk.

A team led by Gianfranco Parati (University of Milano-Bicocca, Italy) examined ABP levels, recorded every 15 minutes during the day and every 20 minutes during the night over a 2-week period, among 3312 patients with uncontrolled clinic BP (>140/90 mmHg).

Patients were enrolled in Argentina, Chile, the Czech Republic, Denmark, Ecuador, France, Lebanon, Mexico, and Portugal, countries that were selected at random "to represent an international community of typical centers treating patients with hypertension," the authors note.

The majority (73%) of patients were on medication; all took their medication once daily, in the morning, and the most common antihypertensive agents used were beta blockers and ACE inhibitors.

Results showed that the mean morning (06:00-11:59 hours) ABP among treated patients was 135/81 mmHg, with only 45.2% achieving morning ABP control (<135/85 mmHg).

Similarly, the mean daytime (10:00-22:00 hours) ABP was 135/80 mmHg in treated patients, but only 47.4% achieved control levels (<135/85 mmHg).

And the mean 24-hour ABP was 131/77 mmHg, but 24-hour ABP control was only achieved in 34.6% of patients according to European Society of Hypertension-European Society of Cardiology criteria (<125/80 mmHg) and in 44.7% of patients by US guidelines (<130/80 mmHg).

Subgroup analysis indicated that morning ABP control rates were slightly lower in patients with diabetes or LVH (45.1% and 43.6%, respectively), while 24-hour ABP control was much lower (31.9% and 32.1% by European guidelines). Furthermore, only 42.3% of patients deemed at high or very high cardiovascular risk achieved morning ABP control.

Of note, the team found only poor agreement between patients' clinic BP control and morning and daytime ABP control, indicating that "the clinic BP value obtained does not reflect measures at other times of the day."

"Low 24-hour ABP control, especially in the morning, may be due in part to the use of agents that cannot sustain 24-hour control. This may further increase the risk of cardiovascular events, particularly in high-risk patients, an issue to be addressed in further studies," conclude the authors in the Journal of Hypertension.

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