Research ArticleHypotension based on office and ambulatory monitoring blood pressure. Prevalence and clinical profile among a cohort of 70,997 treated hypertensives
Introduction
Hypertension is the most important risk factor for the development of cardiovascular disease and is the first cause of mortality and disability worldwide.1 Importantly, it has been reported that around 60%–80% of patients with established cardiovascular disease, 50% of diabetics and more than 50% of patients >65 years old have hypertension.2, 3, 4 There is a direct relationship between increased blood pressure (BP) levels and cardiovascular morbidity and mortality, without any evidence of a threshold down to at least 115/75 mm Hg.1 In addition, reducing BP with antihypertensive treatment decreases cardiovascular events by 30%–50%, particularly in those patients at higher risk.5 Therefore, pharmacologic therapy is mandatory to attain the BP targets recommended by the International Scientific Societies.
With regard to BP goals, previous guidelines had suggested “the lower the better,” particularly in patients at higher risk. However, these recommendations also reported that an excessive BP reduction with antihypertensive treatment could be harmful in some patients. The reappraisal of the European Society of Hypertension published in 2009 recommended lowering BP to values within the range 130–139/80–85 mm Hg.6 Later, the meta-analysis of Bangalore et al7 suggested a beneficial effect of reducing systolic BP below <130 mm Hg in patients with coronary artery disease, but with a significant increase in the risk of hypotension. More recently, the SPRINT8 trial showed in hypertensive patients at high risk that cardiovascular risk was reduced in those patients assigned to stricter BP goal (<120 mm Hg) but with a significant but infrequent risk of severe hypotension and syncope.
The existence of a J-curve remains controversial. The J-curve implies that in hypertensive patients, both high and excessively low levels of BP with antihypertensive treatment are associated with an increased cardiovascular risk. Thus, it seems that there is a lowest value of BP (nadir), which represents a point at which BP is too low to maintain an adequate perfusion of vital organs, leading to an increase of cardiovascular morbidity and mortality. This is particularly important regarding diastolic BP and in patients with coronary artery disease.9, 10, 11, 12 Although it has not been clearly established, the PROVE IT-TIMI13 study showed that BP levels below 110/70 mm Hg could be harmful in patients with coronary artery disease. Other studies,14 but not all,15 have reported similar results. A number of studies have shown that the J-curve could be different according to the type of organ damage.16 For example, with regard to stroke prevention, the TNT,10 ONTARGET,17, 18 and ACCORD19 studies did not demonstrate the presence of a J-curve. In addition, other studies have questioned the existence of a J-curve.20, 21
Hypotension related with antihypertensive treatment has not been clearly defined. To the best of our knowledge, no studies have specifically analyzed the prevalence of hypotension based on office and ambulatory BP monitoring (ABPM) in hypertensive treated patients. It would be useful to ascertain the magnitude of the problem, which factors may be associated with an excessive BP reduction and whether the presence of hypotension is associated with different clinical conditions. It is uncertain whether the J-curve is the cause or the consequence in some patients.
The main objective of this study was to determine the prevalence of hypotension using both clinic and ABPM in hypertensive treated patients and the factors associated with its presence.
Section snippets
Design of the Study
In this descriptive study that included patients from the ABPM Spanish Registry, a total of 1000 ABPM devices were used in primary care setting and hypertension units all around Spain. The recruitment started in 2004. The characteristics of investigators, the recruitment of patients, and the characteristics of the ABPM Spanish Registry have been previously reported.22, 23, 24 All investigators were specifically trained for the use of ABPM. ABPM registries and data of patients were sent to an
Study Population and Prevalence of Hypotension
Of the 135,500 ABPM registries available, 115,708 were considered valid for the analysis (85.4%). In this study, only data from treated hypertensive patients were analyzed (n = 70,997). Mean age was 61.8 ± 12.8 years, and 52.5% were men.
The prevalence of hypotension was 8.2% (7.1% in men and 9.5% in women, P < .0001) with office BP, 12.2% (7.7% vs. 17.1%, respectively, P < .001) with daytime ABPM, 3.9% (2.3% vs. 5.8%, respectively, P < .001) with nighttime ABPM, and 6.8% (3.9% vs. 10%,
Discussion
In this large clinical study, the prevalence of hypotension in treated hypertensive patients based on office BP and ABPM as well as factors associated with the presence of hypotension was determined.
Scientific Societies have not clearly defined hypotension in hypertensive patients. In addition, despite different clinical trials performed in hypertensive population included symptomatic hypotension as a side effect related with antihypertensive treatment, BP values defining hypotension were not
Conclusions
The prevalence of hypotension, particularly in elderly patients as well as in those with cardiovascular disease, is relatively high. One out of 5–6 elderly patients or with cardiovascular disease is at risk of hypotension. More than half of patients with hypotension detected with ABPM do not have hypotension according to office BP. As a result, in those patients with a higher risk of hypotension, such as the elderly those with cardiovascular disease, with low body weight or women, the use of
Acknowledgments
The authors thank all investigators of the Spanish ABPM Registry. Their names are available at http://www.cardiorisk.com.
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2021, International Journal of Hygiene and Environmental HealthCitation Excerpt :It should be noted that the observed acute lowering of BP may be harmful. Hypotension and BP below a nadir in treated hypertensives, especially with the presence of coronary artery disease, are associated with myocardial ischemic events (Divisón-Garrote et al., 2016; Divisón-Garrote et al., 2020; Messerli et al., 2006; Messerli and Panjrath, 2009; Owens and O'Brien, 1999). Furthermore, previous systemic reviews conclude that decrease in SBP during exercise stress testing is associated with increased risks of multiple cardiovascular events (Barlow et al., 2014; Schultz et al., 2017).
Magnitude of Hypotension Based on Office and Ambulatory Blood Pressure Monitoring: Results From a Cohort of 5066 Treated Hypertensive Patients Aged 80 Years and Older
2017, Journal of the American Medical Directors AssociationCitation Excerpt :The evidence of the existence of the J-curve is more evident in this population.18–20,26,38,39 Previous data from the Spanish Registry of ABPM showed in treated hypertensive patients aged 18 years or older a prevalence of hypotension (12% with daytime ABPM) that was lower than that reported in our study.40 The greater prevalence of hypotension in elderly patients or in patients with cardiovascular disease suggests that hypotension could be more a consequence than the cause of the higher risk.
From the Editor
2016, Journal of the American Society of HypertensionPosition statement on ambulatory blood pressure monitoring (ABPM) by the Spanish Society of Hypertension (2019)
2019, Hipertension y Riesgo Vascular
The Spanish ABPM Registry was initiated and is maintained by an unrestricted grant from Lacer Laboratories, Spain, and the Spanish Society of Hypertension. Specific funding for this analysis was obtained from FIS grant PI13/02321 and by the “Cátedra UAM de Epidemiología y Control del Riesgo Cardiovascular.” The funding agencies had no role in study design, data extraction, data analysis, data interpretation, writing of the report, or in the decision to submit it for publication.
Conflict of interest: None.