Ambulatory blood pressure (BP) monitoring has become useful in the diagnosis and management of hypertensive individuals. In addition to 24-hour values, the circadian variation of BP adds prognostic significance in predicting cardiovascular outcome. However, the magnitude of circadian BP patterns in large studies has hardly been noticed. Our aims were to determine the prevalence of circadian BP patterns and to assess clinical conditions associated with the nondipping status in groups of both treated and untreated hypertensive subjects, studied separately. Clinical data and 24-hour ambulatory BP monitoring were obtained from 42,947 hypertensive patients included in the Spanish Society of Hypertension Ambulatory Blood Pressure Monitoring Registry. They were 8384 previously untreated and 34,563 treated hypertensives. Twenty-four-hour ambulatory BP monitoring was performed with an oscillometric device (SpaceLabs 90207). A nondipping pattern was defined when nocturnal systolic BP dip was <10% of daytime systolic BP. The prevalence of nondipping was 41% in the untreated group and 53% in treated patients. In both groups, advanced age, obesity, diabetes mellitus, and overt cardiovascular or renal disease were associated with a blunted nocturnal BP decline (P<0.001). In treated patients, nondipping was associated with the use of a higher number of antihypertensive drugs but not with the time of the day at which antihypertensive drugs were administered. In conclusion, a blunted nocturnal BP dip (the nondipping pattern) is common in hypertensive patients. A clinical pattern of high cardiovascular risk is associated with nondipping, suggesting that the blunted nocturnal BP dip may be merely a marker of high cardiovascular risk.

Abstract-We studied the effectiveness of blood pressure (BP) control outside the clinic by using ambulatory BP monitoring (ABPM) among a large number of hypertensive subjects treated in primary care centers across Spain. The sample consisted of 12 897 treated hypertensive subjects who had indications for ABPM. Office-based BP was calculated as the average of 2 readings. Twenty-four-hour ABPM was then performed using a SpaceLabs 90207 monitor under standardized conditions. A total of 3047 patients (23.6%) had their office BP controlled, and 6657 (51.6%) were controlled according to daytime ABPM. The proportion of office resistance or underestimation of patients' BP control by physicians in the office (office BP Ն140/90 mm Hg and average daytime ambulatory BP Ͻ135/85 mm Hg) was 33.4%, and the proportion of isolated office control or overestimation of control (office BP Ͻ140/90 mm Hg and average daytime ambulatory BP Ն135/85 mm Hg) was 5.4%. BP control was more frequently underestimated in patients who were older, female, obese, or with morning BP determination than in their counterparts. BP control was more frequently overestimated in those who were younger, male, nonobese, smokers, or with evening BP determination. Ambulatory-based hypertension control was far better than office-based hypertension control. This conveys an encouraging message to clinicians, namely that they are actually doing better than is evidenced by office-based data. However, the burden of underestimation and overestimation of BP control at the office is still remarkable. Physicians should be aware that the likelihood of misestimating BP control is higher in some hypertensive subjects. Key Words: office blood pressure Ⅲ ambulatory blood pressure Ⅲ treatment goals Ⅲ guidelines Ⅲ control A dequate control of hypertension is low in population and medical settings. 1-3 However, physicians frequently misclassify patients' blood pressure (BP) status at the office when compared with ambulatory BP monitoring (ABPM). 4 In particular, BP readings are higher in standard clinical practice than in ambulatory readings. 4,5 Nevertheless, the magnitude of the gap between office and ambulatory BP control has not been noted in large-scale studies addressing daily practice.Furthermore, the prevalence and determinants of BP conditions, such as white-coat hypertension ([WCH] ie, high office BP with normal BP outside the medical setting) and masked hypertension (normal office BP with high BP outside the medical setting) have already been studied. 6 -14 However, WCH is a term reserved for those subjects not on antihypertensive treatment 6 ; and in the case of treated hypertensive subjects, it would, therefore, be more accurate to use the term "office resistance," 6 that is, in-clinic BP readings that are both higher than goal despite treatment and higher than normotensive BP outside the clinic as demonstrated by ABPM. Likewise, we focused on "isolated office control" (BP controlled at the office but uncontrolled on ABPM despite treatment) rather than masked hyper...

Writing Committee on behalf of the COM99 Study Group* Background-Medication nonadherence is common and results in preventable disease complications. This study assessed the effectiveness of a multifactorial intervention to improve both medication adherence and blood pressure control and to reduce cardiovascular events. Methods and Results-In this multicenter, cluster-randomized trial, physicians from hospital-based hypertension clinics and primary care centers across Spain were randomized to receive and provide the intervention to their high-risk patients. Eligible patients were Ն50 years of age, had uncontrolled hypertension, and had an estimated 10-year cardiovascular risk greater than 30%. Physicians randomized to the intervention group counted patients' pills, designated a family member to support adherence behavior, and provided educational information to patients. The primary outcome was blood pressure control at 6 months. Secondary outcomes included both medication adherence and a composite end point of all-cause mortality and cardiovascular-related hospitalizations. Seventy-nine physicians and 877 patients participated in the trial. The mean duration of follow-up was 39 months. Intervention patients were less likely to have an uncontrolled systolic blood pressure (odds ratio 0.62, 95% confidence interval 0.50 to 0.78) and were more likely to be adherent (odds ratio 1.91, 95% confidence interval 1.19 to 3.05) than control group patients at 6 months. After 5 years, 16% of the patients in the intervention group and 19% in the control group met the composite end point (hazard ratio 0.97, 95% confidence interval 0.67 to 1.39). Conclusions-A multifactorial intervention to improve adherence to antihypertensive medication was effective in improving both adherence and blood pressure control, but it did not appear to improve long-term cardiovascular events. Clinical Trial Registration-URL: http://www.controlled-trials.com. Unique identifier: ISRCTN35208258. Key Words: hypertension Ⅲ medication adherence Ⅲ blood pressure Ⅲ intervention studies H ypertension is a major but modifiable contributory factor to cardiovascular diseases such as stroke and coronary heart disease. 1,2 According to the Seventh Report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure in the United States, the percentage of patients whose blood pressure (BP) is under control (ie, Ͻ140/90 mm Hg) increased from 10% in 1976 -1980 to 34% in the period 1999 -2000.Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz. Received October 30, 2009; accepted July 14, 2010 Editorial see p 1141 Clinical Perspective on p 1191A major modifiable reason for the lack of BP control is medication nonadherence, where adherence is defined as the extent to which a person's behavior corresponds with the recommendations of their healthcare provider. 7 In general, poor adherence to medications is associated with the development of complications, disease pr...

There was a remarkable discrepancy between office and ambulatory BP in high-risk hypertensive patients. The prevalence of a non-dipper BP pattern was almost 60%. In the lowest levels of ambulatory BP, high-risk patients showed a higher prevalence of non-dipping BP than lower-risk cases. These observations support the recommendation of a wider use of ABPM in high-risk hypertensive patients.

Abstract-It has been reported that both the DD genotype of the angiotensin converting enzyme (ACE) gene and the presence of cerebral white matter lesions (WML) may represent risk factors for the development of stroke. The present study investigates a possible association between 3 different genetic polymorphisms of the renin-angiotensin system and the presence of WML in 60 never-treated essential hypertensive patients (36 men, 24 women), aged 50 to 60 years, without clinical evidence of target organ damage. Although their pathogenesis is poorly understood, various studies have shown that age, hypertension, diabetes mellitus, and a history of stroke or heart disease are the most important factors related to the presence of WML. 1 In addition, a recent study of elderly twins indicated that susceptibility to white matter hyperintensities was largely determined by genetic factors. 2 The identification of hereditary factors is important because the presence of WML is an important prognostic factor for the development of stroke 3-5 and also for cognitive impairment. 6 -11 The association between the presence of WML and arterial hypertension 1 suggests that genes involved in the regulation of blood pressure (BP) may also contribute to the development of this cerebral abnormality. Essential hypertension has a well-known familial aggregation, and it has been calculated that BP variation is approximately 40% genetically determined. 12 The renin-angiotensin system (RAS) plays a central role in the regulation of BP, 13 and the genes involved in the activity of this enzyme cascade are potential candidates for essential hypertension and some associated clinical conditions.In the past decade, several authors have investigated RAS polymorphisms as genetic determinants of essential hypertension and cardiovascular complications, with controversial results. Evidence implicating the insertion/deletion (I/D) angiotensin-converting enzyme (ACE) gene, the M235T angiotensinogen (AGT) gene, and the A1166C angiotensin II type 1 (AT 1 ) receptor gene polymorphisms in essential hypertension has been reported in some studies 14 -16 but not in others. 17,18 A recent meta-analysis by Staessen et al 17 reported that the D allele of the ACE gene was not related to hypertension but seemed to be associated with a higher risk of atherosclerotic complications (coronary heart disease, miocardial infarction, and stroke). Conversely, the same group also reported that the T allele of the AGT gene was not associated with atherosclerotic complications but seemed to be related to hypertension. 19 With respect to possible inter-