BLOOD PRESSURE PHENOTYPES IN TREATED HYPERTENSIVE PATIENTS IN SUMMER AND WINTER: FOCUS ON MASKED UNCONTROLLED HYPERTENSION. PART 1: BLOOD PRESSURE PHENOTYPES PREVALENCE

Background. The seasonal variability of blood pressure (BP) and cardiovascular morbidity and mortality motivates researchers to search  for the new approaches of the antihypertensive treatment (AHT) efficacy assessment, including the analysis of interrelation between clinic and ambulatory BP, i.e. BP phenotypes.

Aim. To evaluate the prevalence of BP phenotypes in treated hypertensive outpatients both in winter and summer.

Material and methods. Hypertensive patients under regular AHT with available data of clinic BP and 24-hour BP monitoring both in winter and summer seasons (n=477) were selected from a outpatient database with clinic BP <160/100 mm Hg (n=1762). The BP threshold values from current guidelines were used for the BP phenotypes definition. The “controlled hypertension” phenotype was detected when  clinic and ambulatory BP levels were less than  threshold values, the “uncontrolled hypertension” – when  both levels exceeded the thresholds, the “white coat hypertension (WCH) in treated patients” – when  clinic BP was only increased, the “masked  uncontrolled hypertension” phenotype was ascertained if ambulatory BP was only elevated.

Results. The study included 232 patients examined in Ivanovo (a relatively cold region; mean  age 53.5±9.3 years; 28% men; clinic BP 121.7±7.9 mm Hg; mean  duration of hypertension 4.6±6.3 years) and 245 patients from Saratov (a relatively hot region; mean  age 58.3±10.6 years; 56.3% men; clinic BP 127.5±14.9 mmHg; mean duration of hypertension 9.2±9.2 years; р<0.0001). In the Ivanovo cohort, ratio of BP phenotypes in summer and winter did not differ; the “masked  uncontrolled hypertension” phenotype prevailed (62.1% and 63.8% in winter and summer, respectively); AHT was effective in 27.6% and 29.7% of the patients in winter and summer, respectively. The prevalence of other phenotypes was low: uncontrolled hypertension – 9.5% in winter and 6.0% in summer; WCH in treated patients – less than  1%  in both seasons. The prevalence of BP phenotypes in the patients examined in Saratov differed in winter and summer (χ²=18.127, р<0.0001); the “masked  uncontrolled hypertension” phenotype rate was higher in summer than in winter (50.2% and 32.2%, respectively); the rates of other phenotypes were higher in winter: uncontrolled hypertension – 38.8% and 27.8%, controlled hypertension – 25.3% and 20.8%, WCH – 3.7% and 1.2% in winter and summer, respectively.

Conclusion. We have found no seasonal changes in BP phenotypes prevalence in relatively younger hypertensive patients in a relatively cold region. The “masked  uncontrolled hypertension” phenotype was predominant (>60%) in this region. In contrast, the cohort  of relatively older patients with longer hypertension history examined in a relatively warmer region revealed significantly higher rate of masked uncontrolled hypertension in summer (50.2%) while prevalence of all other phenotypes – in winter.

1. Kaplan N.M. New Issues in the Treatment of Isolated Systolic Hypertension Circulation. 2000;102:1079-81. doi:10.1161/01.CIR.102.10.1079.

2. Viera A.J., Shimbo D. Ambulatory Blood Pressure Phenotypes and the Risk for Hypertension Curr Hypertens Rep. 2014;16(10):481. doi:10.1007/s11906-014-0481-5.

3. 2013 ESH/ESC Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. doi: 10.1093/eurheartj/eht151.

4. 2013 Ambulatory Blood Pressure Monitoring Recommendations for the Diagnosis of Adult Hypertension, Assessment of Cardiovascular and other Hypertension-associated Risk, and Attainment of Therapeutic Goals. Chronobiology International. 2013;30(3):355-410. doi: 10.3109/07420528.2013.750490.

5. Smirnova M.I., Oganov R.G., Gorbunov V.М. The hidden ineffectiveness of treatment of arterial hypertension: frequency and predictors. Cardiovascular Therapy and Prevention. 2011;10(6):11-7. (In Russ.) [Смирнова М.И., Оганов Р.Г., Горбунов В.М. и др. Скрытая неэффективность лечения артериальной гипертонии: частота и предикторы. Кардиоваскулярная Терапия и Профилактика. 2011;10(6):11-7].

6. Smirnova M.I., Platonova E.M., Britov A.N., et al. The rate and characters of masked arterial hypertension and masked ineffectiveness of hypertension treatment in industrial workers according to the preventive examination. Rational Pharmacotherapy in Cardiology. 2014;10(5):481-7. (In Russ.) [Смирнова М.И., Платонова Е.М., Бритов А.Н. и др. Частота и маркеры скрытой артериальной гипертонии и скрытой неэффективности лечения артериальной гипертонии у работников промышленного предприятия по данным профилактического осмотра. Рациональная Фармакотерапия в Кардиологии. 2014;10(5):481-7]. doi: 10.20996/1819-6446-2014-10-5-481-487.

7. Stergiou G.S., Asayama K., Thijs L., et al. Prognosis of white coat and masked hypertension: International Database of HOme blood pressure in relation to Cardiovascular Outcome. Hypertension. 2014;63(4):675-82. doi: 10.1161/HYPERTENSIONAHA.113.02741.

8. Banegas J.R., Ruilope L.M., de la Sierra A., et al. High prevalence of masked uncontrolled hypertension in people with treated hypertension. Eur Heart J. 2014;35(46):3304-12. doi: 10.1093/eurheartj/ehu016.

9. Brook R.D., Weder A.B., Rajagopalan S. “Environmental hypertensionology” the effects of environmental factors on blood pressure in clinical practice and research. J Clin Hypertens (Greenwich). 2011;13:836-842. doi: 10.1111/j.1751-7176.2011.00543.x.

10. Sega R., Cesana G., Bombelli M. et al. Seasonal variations in home and ambulatory blood pressure in the PAMELA population. J Hypertens. 1998;16:1585-92.

11. Modesti P.A., Morabito M., Bertolozzi I. et al. Weather-related changes in 24-hour blood pressure profile. Effects of age and implications for hypertension management. Hypertension. 2006;47:155-61. doi: 10.1161/01.HYP.0000199192.17126.d4.

12. Modesti P.A., Morabito M., Massetti L. et al. Seasonal blood pressure changes: an independent relationship with temperature and daylight hours. Hypertension. 2013;61(4):908-14. doi: 10.1161/HYPERTENSIONAHA.111.00315.

13. Smirnova M.I., Gorbunov V.M., Volkov D.A. Seasonal changes in hemodynamic parameters in patients with controlled arterial hypertension and high normal arterial pressure in two regions of the Russian Federation with different climatic characteristics. Part 3. Main results of the study of 1630 patients. Profilakticheskaya Meditsina. 2015;6:78-86. (In Russ.) [Смирнова М.И., Горбунов В.М., Волков Д.А. и др. Сезонные изменения гемодинамических параметров у больных с контролируемой артериальной гипертонией и высоким нормальным артериальным давлением в двух регионах Российской Федерации с различными климатическими характеристиками. Часть 3. Основные результаты исследования 1630 пациентов. Профилактическая Медицина. 2015;6:78-86]. doi:10.17116/profmed201518678-86

14. Boulay F., Berthier F., Sisteron O. et al. Seasonal variation in chronic heart failure hospitalizations and mortality in France. Circulation.1999;100:280-6. doi: 10.1161/01.CIR.100.3.280/

15. Dilaveris P., Synetos A., Giannopoulos G., et al. CLimate Impacts on Myocardial infarction deaths in the Athens TErritory: the CLIMATE study. Heart. 2006;92:1747-51. doi: 10.1136/hrt.2006.091884/

16. Fomina N.V., Altarev S.S., Barbarash O.L. Annual biological rhythms as an additional risk factor for death in patients with ischemic heart disease. Circulation Pathology and Surgery. 2007;(1):44-7. (In Russ.) [Фомина Н.В., Алтарев С.С., Барбараш О.Л. Годовые биологические ритмы как дополнительный фактор риска смерти при ишемической болезни сердца. Патология Кровообращения и Кардиохирургия. 2007; (1):44-7].

17. Rocklöv J., Forsberg B. The effect of temperature on mortality in Stockholm 1998-2003: A study of lag structures and heatwave effects. Scandinav J Pub Health. 2008;36:516-23. doi: 10.1177/1403494807088458.

18. Revich B.A., Shaposhnikov D.A. Extreme temperature episodes and mortality in Yakutsk, East Siberia. Rural and Remote Health. 2010;10:1338.

19. Kontsevaya A.V., Lukyanov M.M., Khudyakov M.B. Seasonal and monthly changes of mortality in Russian Federation regions with different climate and geographic variables. Rossiyskiy Kardiologicheskiy Zhurnal. 2014;11:25-30. (In Russ.) [Концевая А.В., Лукьянов М.М., Худяков М.Б. Сезонные и помесячные изменения смертности в регионах Российский Федерации с различными климато-географическими характеристиками. Российский Кардиологический Журнал. 2014;11:25-30]. doi: 10.15829/1560-4071-2014-11-25-30.

20. Kontsevaya A.V., Balanova J.A., Loukianov M.M., Khudyakov M.B., Belova O.A., Romanchuk S.V. Excess winter cardiovascular morbidity in Ivanovo Region in 2009-2013 years. Rational Pharmacotherapy in Cardiology. 2015;11(5):450-8. (In Russ.) [Концевая А.В., Баланова Ю.А., Лукьянов М.М., Худяков М.Б., Белова О.А., Романчук С.В. Избыточная заболеваемость сердечно-сосудистыми заболеваниями в зимнии период в Ивановскои области в 2009-2013 гг. Рациональная Фармакотерапия в Кардиологии. 2015;11(5):450-8. doi:10.20996/1819-6446-2015-11-5-450-458.

21. Kontsevaia A.V., Lukyanov M.M., Balanova Iu.A. et al. Social and economic burden caused by excess winter cardiovascular deaths in the Russian Federation''s regions with different climatic and geographic characteristics. Profilakticheskaya Meditsina. 2014;6:21-5. (In Russ.) [Концевая А.В., Лукьянов М.М., Баланова Ю.А. и др. Социально-экономический ущерб, вызванный избыточной смертностью от сердечно-сосудистых заболеваний в зимний период в регионах Российской Федерации с различными климато-географическими характеристиками. Профилактическая Медицина. 2014;6:21-5].

22. Smirnova M.I., Gorbunov V.M., Boytsov S.A. Seasonal changes in hemodynamic parameters in patients with controlled arterial hypertension and high normal arterial pressure in two regions of the Russian Federation with different climatic characteristics. Part 1. Design and preliminary results. Profilakticheskaya Meditsina. 2013;6:71-8. (In Russ.) [Смирнова М.И., Горбунов В.М., Бойцов С.А. и др. Сезонные изменения гемодинамических параметров у больных с контролируемой артериальной гипертонией и высоким нормальным артериальным давлением в двух регионах Российской Федерации с различными климатическими характеристиками. Часть 1. Дизайн и предварительные результаты. Профилактическая Медицина. 2013;6:71-8].

23. Diagnosis and treatment of hypertension. National clinical recommendations. Sistemnye Gipertenzii. 2010; 3: 5-26. (In Russ.) [Диагностика и лечение артериальной гипертензии. Национальные клинические рекомендации. Системные Гипертензии. 2010; 3: 5-26].

24. Perloff D., Sokolow M., Cowan R. The prognostic value of ambulatory blood pressures. JAMA. 1983;249:2792-8. doi:10.1001/jama.1983.03330440030027.

25. Dolan E., Stanton A., Thijs L., et al. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality. The Dublin outcome study. Hypertension. 2005; 46: 156-161. doi: 10.1161/01.HYP.0000170138.56903.7a.

26. Pierdominico S.D., Cuccurillo F. Prognostic value of white coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an update meta-analysis. Am J Hypertens. 2011; 24:52-8. doi: 10.1038/ajh.2010.203.

27. Grassi G., Mancia G. The PAMELA study results and perspectives. Council for Cardiology Practice. 2011; 10(5). Available at: https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-10/The-PAMELA-study-results-and-perspectives. Checked by Sep 16, 2017.

28. Bobrie G., Clerson P., Menard J. et al. Masked hypertension: a systematic review. J Hypertens. 2008,26:1715-25. doi: 10.1097/HJH.0b013e3282fbcedf.

29. Satoh M., Asayama K., Kikuya M. et al. Long-Term Stroke Risk Due to Partial White Coat or Masked Hypertension Based on Home and Ambulatory Blood Pressure Measurements. The Ohasama Study. Hypertension. 2016;67:48-55. doi: 10.1161/HYPERTENSIONAHA.115.06461.

30. Ishikava J., Kario K., Eguchi K. et al. Regular alcohol drinking is a determinant of masked morning hypertension detected by home blood pressure monitoring in medicated hypertensive patients with wellcontrolled clinic blood pressure: the Jichi Morning Hypertension Research (J-MORE) study. Hypertens Res. 2006;29:679-86. doi: 10.1291/hypres.29.679.