Research Article
Hypotension based on office and ambulatory monitoring blood pressure. Prevalence and clinical profile among a cohort of 70,997 treated hypertensives

https://doi.org/10.1016/j.jash.2016.06.035Get rights and content

Highlights

  • Hypotension is not necessarily an innocent phenomenon in treated patients.

  • Eight percentage of treated hypertensives may be at high cardiovascular risk due to hypotension.

  • Sixty-eight percentage of hypotension cases identified outside the office are missed in the office.

  • Ambulatory BP monitoring helps identify hypotension cases outside the office.

Abstract

We aimed to determine the prevalence of hypotension and factors associated with the presence of this condition in treated hypertensive patients undergoing ambulatory blood pressure monitoring (ABPM). Data were taken from the Spanish ABPM Registry. Office blood pressure (BP) and ABPM were determined using validated devices under standardized conditions. Based on previous studies, hypotension was defined as office systolic/diastolic BP <110 and/or 70 mm Hg, daytime ABPM <105 and/or 65 mm Hg, nighttime ABPM <90 and/or 50 mm Hg, and 24-hour ABPM <100 and/or 60 mm Hg. Multivariable logistic regression was performed to determine the variables associated with the presence of hypotension. A total of 70,997 hypertensive patients on treatment (mean age 61.8 years, 52.5% men) were included in the study. The prevalence of hypotension was 8.2% with office BP, 12.2% with daytime ABPM, 3.9% with nighttime ABPM, and 6.8% with 24-hour ABPM. Low diastolic BP values were responsible for the majority of cases of hypotension. Some 68% of the hypotension cases detected by daytime ABPM did not correspond to hypotension according to office BP. The variables independently and consistently associated with higher likelihood of office, daytime, and 24 hour–based hypotension were age, female gender, history of ischemic heart disease, and body mass index <30 kg/m2 (P < .05). In conclusion, in this large cohort of patients in usual daily practice, one in eight treated hypertensive patients are at risk of hypotension according to daytime BP. Two-thirds of them are not adequately identified with office BP. ABPM could be especially helpful for identifying ambulatory hypotension, in particular in patients who are older, women, or with previous ischemic heart disease where antihypertensive treatment should be especially individualized and cautious.

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.

References (51)

  • S. Bangalore et al.

    Blood pressure targets in patients with coronary artery disease: observations from traditional and Bayesian random effects meta-analysis of randomized trials

    Heart

    (2013)
  • J.T. Wright et al.

    A randomized trial of intensive versus standard blood pressure control

    N Engl J Med

    (2015)
  • C.J. Pepine et al.

    A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial

    JAMA

    (2003)
  • S. Bangalore et al.

    Treating to New Targets Steering Committee and Investigators. J curse revisited: an analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial

    Eur Heart J

    (2010)
  • M. Banach et al.

    Blood pressure J curve: current concepts

    Curr Hypertens Rep

    (2012)
  • E.P. Tsika et al.

    The J-curve in arterial hypertension: fact or fallacy?

    Cardiology

    (2014)
  • S. Bangalore et al.

    What is the optimal blood pressure in patients after acute coronary syndromes? Relationship of blood pressure and cardiovascular events in the PRavastatin OR atorVastatin Evaluation and Infection Therapy. Thrombolysis In Myocardial Infarction (PROVE IT-TIMI) 22 trial

    Circulation

    (2010)
  • E.P. Vamos et al.

    Association of systolic and diastolic blood pressure and all cause mortality in people with newly diagnosed type 2 diabetes: retrospective cohort study

    BMJ

    (2012)
  • P. Verdecchia et al.

    Systolic and diastolic blood pressure changes in relation with myocardial infarction and stroke in patients with coronary artery disease

    Hypertension

    (2015)
  • M.S. Tanna et al.

    Antihypertensive therapy and the curve J: fact or fiction?

    Curr Hypertens Rep

    (2015)
  • S. Yusuf et al.

    Telmisartan, ramipril os both in patients at high risk for vascular events

    N Engl J Med

    (2008)
  • G. Mancia et al.

    Blood pressure targets recommended by guidelines and incidence of cardiovascular and renal events in ONTARGET

    Circulation

    (2011)
  • W.C. Cushman et al.

    Effects of intensive blood pressure control in type 2 diabetes mellitus

    N Engl J Med

    (2010)
  • W. Xu et al.

    Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study

    BMJ

    (2015)
  • M. Gorostidi et al.

    Ambulatory blood pressure monitoring in hypertensive patients with high cardiovascular risk: a cross-sectional analysis of a 20,000-patient database in Spain

    J Hypertens

    (2007)
  • Cited by (26)

    • Orthostatic hypotension

      2023, FMC Formacion Medica Continuada en Atencion Primaria
    • Acute cardiovascular responses of wildland firefighters to working at prescribed burn

      2021, International Journal of Hygiene and Environmental Health
      Citation 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 Association
      Citation 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 Hypertension
    View all citing articles on Scopus

    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.

    View full text