https://immattersacp.org/weekly/archives/2016/03/29/4.htm

Morning home blood pressure strongly predicts coronary artery disease, stroke events, study finds

Patients in the study were instructed in guideline-directed home blood pressure (BP) measurement technique and were asked to measure BP twice in the morning on 2 different days for each measurement point.


Morning home blood pressure (BP) readings appear to be a strong predictor of future stroke and coronary artery disease (CAD) events, according to a recent analysis.

Researchers used data from the HONEST (Home blood pressure measurement with Olmesartan Naive patients to Establish Standard Target blood pressure) study to analyze the relationship between morning home BP and the incidence of stroke and CAD events. Results were published online on March 28 by the Journal of the American College of Cardiology.

The analysis included 21,591 Japanese patients treated for hypertension (51% women; mean age, 64.9 years; mean follow-up, 2.02 years); all patients in the study were on antihypertensive therapy, and there was no control group. Within this population, there were a total of 127 strokes (2.92 per 1,000 patient-years) and 121 CAD events (2.78 per 1,000 patient-years). A total of 21,345 patients experienced neither event.

Patients in the study were instructed in guideline-directed home BP measurement technique and were asked to measure BP twice in the morning on 2 different days for each measurement point. Measurements were taken at 1, 4, and 16 weeks, and at 6, 12, 18, and 24 months during the follow-up period. The day's 2 blood pressures were averaged, as was each 2-day period, and average value of all BPs taken during the follow-up period was used in the analysis. For purposes of comparison, home systolic BPs were categorized as <125 mm Hg, 125 to <135 mm Hg, 135 to <145 mm Hg, 145 to <155 mm Hg, and ≥155 mm Hg. Clinic BPs were determined using standard methods, and average systolic BPs during follow-up were used for analysis, categorized as <130 mm Hg, 130 to <140 mm Hg, 140 to <150 mm Hg, 150 to <160 mm Hg, and ≥160 mm Hg.

The incidence of stroke events was significantly higher in patients with a morning home systolic BP ≥145 mm Hg compared to <125 mm Hg and in those with a clinic systolic BP ≥150 mm Hg compared to <130 mm Hg. Patients with morning home systolic BP ≥155 mm Hg had a stroke hazard ratio of 6.01 (95% CI, 2.85 to 12.68) compared to those with BP <125 mm Hg. For those with clinic systolic BP ≥160 mm Hg, the HR was 5.82 (95% CI, 3.17 to 10.67) compared to patients with BP <130 mm Hg.

Morning home systolic BP predicted stroke events similarly to clinic systolic BP but predicted CAD events more strongly. The incidence of CAD events was significantly higher in patients with morning home systolic BP ≥145 mm Hg compared to <125 mm Hg and in patients with clinic systolic BP ≥160 mm Hg compared to <130 mm Hg. The HR was 6.24 (95% CI, 2.82 to 13.84) for morning home systolic BP ≥155 mm Hg and 3.51 (95% CI, 1.71 to 7.20) for clinic systolic BP ≥160 mm Hg.

Limitations of the analysis include the nonrandomized, noncontrolled study design, which is not able to demonstrate causality between morning BPs and study outcomes and also allows for potential confounding effects, such as the ability of the individual treating physician to determine BP targets and no restriction on the use of combination therapy.

The results of this study and the recent Systolic Blood Pressure Intervention Trial (SPRINT) raise the question of whether lower BP goals can be achieved by home monitoring, according to an accompanying editorial. “Several randomized trials suggest that this is feasible, and the large pragmatic HONEST study suggests that it is time to design a randomized trial similar to SPRINT with treatment targets dictated by—not clinic BP—but home BP assessments,” the editorialist wrote.