Correspondence: Satoshi Hoshide (hoshide@jichi.ac.jp). Division of Cardiovascular Medicine, Department of Medicine, Jichi
Medical University School of Medicine, Shimotsuke, Japan.
Initially submitted April 19, 2018; date of first revision June 5,
2018; accepted for publication August 30, 2018; online publication © American Journal of Hypertension, Ltd 2018. All rights reserved.
September 5, 2018. For Permissions, please email: journals.permissions@oup.com
compared with western populations.9 Because the IDHOCO clinic visits. In this analysis, we evaluated the morning, eve-
study analyzed a heterogeneous population from Asian and ning, and average of morning and evening home BP val-ues
western countries, it is possible that home BP is linearly asso- separately. Laboratory methods are presented in the
ciated with cardiovascular outcomes in selected Asian popu- Supplementary Data. Each participant’s history of cardiovas-
lations. Second, several studies have demonstrated that BP cular disease, including angina pectoris, myocardial infarc-
measured in the morning provided more prognostic power tion, and stroke, was ascertained at baseline.
than that measured in the evening.10–12 This observation may
also be found in patient populations aged >80 years, but to the Ascertainment of outcomes
best of our knowledge, this has never been investigated by a
stratified analysis according to morning and evening home BP Each participant’s vital status was ascertained through
levels. Third, the IDHOCO study was community-based and March 2015. As the composite cardiovascular outcome, we
not a clinical practice setting. assessed the incident composite cardiovascular outcomes
To address this gap in knowledge, we examined the during follow-up, including fatal and nonfatal coronary
All statistical analyses were performed with R software, had had pre-existing cardiovascular disease, such as angina
ver. 3.3.1 (The R Foundation for Statistical Computing, pectoris, myocardial infarction, or stroke. The mean clinic
Vienna, Austria), Stata ver. 15 software (Stata Corp, College BP (SBP/DBP) was 145.6 ± 19.2/74.4 ± 10.6 mm Hg; the
Station, TX), and SAS system, ver. 9.4 (SAS Institute, Cary, mean morning home BP and evening home BP were 146.3
NC). Two-sided P values <0.05 were defined as significant. ± 18.7/73.5 ± 10 mm Hg and 133.4 ± 17.4/67.8 ± 9.8 mm
Hg, respectively.
During a median follow-up of 3.0 years (5th to 95th percen-tile
RESULTS
interval, 1.0–6.9 years), 13 strokes and 19 nonstroke events
Table 1 provides the baseline characteristics of the 349 occurred: sudden death, n = 2; angina pectoris, n = 4; myocar-dial
patients aged >80 years. The average age was 82.8 ± 2.8 infarction, n = 3; heart failure, n = 10, and 18 noncardio-vascular
(range 80–96 years) years old. Of the 349 patients, 90% deaths occurred. Table 2 shows the HRs and 95% CIs for the
incident composite cardiovascular events according to the tertiles
were being treated with antihypertensive drugs and 17%
of morning, evening, and clinic SBP using an unadjusted Cox
Table 2. Incident composite cardiovascular events by tertiles of home and clinic SBP
Each reference was defined as the lowest number of events per 1,000 person-years. Abbreviations: BP, blood pressure; CI, confidence
inter-val; CV, cardiovascular; HR, hazard ratio; NoE, number of events; SBP, systolic blood pressure.
aNumber (95% CIs) of events per 1,000 person-years.
Table 3. Composite cardiovascular events, stroke events, and nonstroke events associated with higher home and clinic SBP levels
BP measures HR (95% CI) P value HR (95% CI) P value HR (95% CI) P value
Model 1
Morning home SBP 1.22 (1.02–1.47) 0.031 1.47 (1.10–1.95) 0.009 1.07 (0.85–1.35) 0.553
Evening home SBP 1.09 (0.90–1.32) 0.384 1.18 (0.91–1.53) 0.211 1.03 (0.79–1.36) 0.823
Clinic SBP 1.02 (0.86–1.20) 0.857 1.06 (0.85–1.33) 0.588 0.98 (0.78–1.24) 0.875
Model 2
Morning home SBP 1.20 (0.99–1.45) 0.059 1.41 (1.06–1.87) 0.017 1.06 (0.83–1.34) 0.646
Evening home SBP 1.08 (0.89–1.31) 0.451 1.17 (0.90–1.51) 0.248 1.02 (0.78–1.35) 0.870
Clinic SBP 1.02 (0.88–1.19) 0.806 1.06 (0.88–1.29) 0.523 0.99 (0.79–1.23) 0.899
Model 3
Morning home SBP 1.23 (1.01–1.50) 0.044 1.47 (1.08–2.00) 0.014 1.08 (0.84–1.38) 0.569
Evening home SBP 1.09 (0.85–1.39) 0.511 1.16 (0.84–1.62) 0.364 1.04 (0.74–1.46) 0.836
Clinic SBP n/a n/a n/a n/a n/a n/a
Adjusted HRs (95% CIs) for the risk of composite cardiovascular events, stroke events, and nonstroke events with a 10 mm Hg higher morn-ing,
evening, and clinic SBP are shown. Adjusted factors for Model 2 included the 4-year cardiovascular risk scores comprising demographic variables (age
and sex) and clinical and behavioral characteristics (body mass index; smoking status; prevalence of diabetes; pre-existing angina pectoris, myocardial
infarction, or stroke; total cholesterol; high-density lipoprotein cholesterol; and statin or antihypertensive medication use). Adjustment factors for Model
3 included the 4-year cardiovascular risk scores comprising demographic variables, clinical and behavioral characteristics, and clinic SBP.
Abbreviations: BP, blood pressure; CI, confidence interval; HR, hazard ratio; SBP, systolic blood pressure.
These associations were not found in evening home BP. (PARTAGE) enrolled 1,126 subjects ≥80 years old, and the
Clinic BP measured by a similar validated device for home studys’ authors found that self-measured BP at baseline was not
BP was also not associated with cardiovascular events. associated with total mortality or cardiovascular events during the
There are 2 previous studies of the association between 2-year follow-up; however, the subjects of that study were
home BP levels and cardiovascular outcomes in a population 19 8
residents of nursing homes. Aparicio et al. selected a popu-
aged ≥80 years. The Predictive Values of Blood Pressure and lation older than 80 years of age from the IDHOCO study and
Arterial Stiffness in an Institutionalized Very Aged Population combined the dataset of a prospective study regarding home
American Journal of Hypertension 31(11) November 2018 1193
Kawauchi et al.
BP measurements from several countries; the results revealed international guidelines recommend both morning and eve-
that home BP was linearly associated with cardiovascular out- ning home BP measurement,3,6,7 the morning home BP mea-
comes in the 202 untreated patients, and a J- or U-curve as- surement might be more important. Actually, in the present
sociation between home BP and outcomes existed in the 173 study, the average of morning and evening home SBP values
treated hypertensive patients. However, the subjects of that diluted the prognostic impact for composite cardiovascular
study were enrolled from a general population. To the best of outcomes compared with morning home SBP alone.
our knowledge, the present study is the first to investigate the Although there are several findings indicating a J- or U-shaped
association between home BP levels and cardiovascular out- association between clinic DBP levels and cardiovas-cular
comes in a population aged ≥80 years in a clinical setting. 26,27
risks, the association of home DBP is limited. To the best of
The results of our present analyses demonstrated a positive our knowledge, only 1 report showed that lower home DBP
linear relationship between morning home BP and cardio-vascular tended to show an increased risk of stroke; this tendency was not
events (especially stroke events) in individuals aged ≥80 years. 28
significant. The results of the present study showed that the
The majority of the participants in our present series were being lowest tertile of evening home DBP presented a risk of composite
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Di Carlo S, Porreca E, Cuccurullo F. Morning blood pressure surge, J-shaped relation between blood pressure and stroke in treated hyper-
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Association of an abnormal blood glucose level and morning blood urement in relation to stroke morbidity: a population-based pilot study
pressure surge in elderly subjects with hypertension. Am J Hypertens in Ohasama, Japan. Hypertens Res 1997; 20:167–174.
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