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White-coat and masked hypertension diagnoses in chronic kidney disease patients
Henrique Pereira1, Alessandra Bonilha1, Pasqual Barretti1
1Department of Internal Medicine, Botucatu Medical School, São Paulo State University (Unesp), Botucatu, Brazil.
Insights
The old criterion for diagnosing masked hypertension (MH) and white-coat hypertension (WCH) using daytime ambulatory blood pressure measurement (ABPM) better predicted mortality in chronic kidney disease (CKD) patients. This suggests daytime ABPM is crucial for identifying at-risk CKD individuals.
Area of Science:
- Nephrology
- Cardiology
- Hypertension Research
Background:
- Masked hypertension (MH) and white-coat hypertension (WCH) are significant in chronic kidney disease (CKD) patients, impacting prognosis.
- Accurate diagnosis of MH and WCH is crucial for risk stratification and management in CKD.
- Current diagnostic criteria for MH and WCH using ambulatory blood pressure measurement (ABPM) vary, necessitating analysis of their predictive value.
Purpose of the Study:
- To analyze which 24-hour ABPM parameters are most effective for diagnosing MH and WCH in non-dialysis CKD patients.
- To compare the predictive capacity of different WCH and MH definitions regarding mortality outcomes.
- To identify the optimal ABPM criteria for distinguishing different hypertension phenotypes in CKD.
Main Methods:
- Observational study of 367 non-dialysis CKD patients undergoing 24-hour ABPM.
- Evaluation of two sets of WCH and MH definitions: an 'old criterion' (daytime ABPM) and a 'new criterion' (24-hour, daytime, and nighttime ABPM).
- Cox regression analysis adjusted for eGFR, age, diabetes, and smoking, with cardiovascular and all-cause mortality as outcomes.
Main Results:
- The 'old criterion,' relying solely on daytime ABPM, was the only definition to distinguish sustained hypertension from WCH concerning all-cause mortality (adjusted HR: 3.730; P=.039).
- The 'old criterion' also uniquely differentiated normotension from MH regarding cardiovascular mortality (adjusted HR: 7.641; P=.026).
- These findings indicate that daytime ABPM parameters are more effective in predicting mortality in this CKD cohort.
Conclusions:
- Definitions of WCH and MH based exclusively on daytime ABPM values (old criterion) demonstrated superior ability to predict mortality in the studied CKD cohort.
- The findings support the use of daytime ABPM as a key parameter for diagnosing MH and WCH in CKD patients.
- This emphasizes the importance of specific ABPM parameters for accurate risk assessment in individuals with chronic kidney disease.
Abstract:
The purpose of this study was to analyze which 24-hour ambulatory blood pressure measurement (ABPM) parameters should be used on masked hypertension (MH) and white-coat hypertension (WCH) diagnoses in chronic kidney disease (CKD) patients. Non-dialysis CKD patients underwent 24-hour ABPM examination between 01/27/2004 and 02/16/2012. They were followed from the 24-hour ABPM to January/2014 in an observational study. The WCH definitions tested were as follows: (a) office blood pressure (BP) ≥ 140/90 mm Hg and daytime ABPM BP ≤ 135/85 mm Hg (old criterion); and (b) office BP ≥ 140/90 mm Hg and 24-hour ABPM BP ≤ 130/80 mm Hg, daytime ABPM BP ≤ 135/85 mm Hg, and nighttime ABPM BP ≤ 120/70 mm Hg (new criterion). The MH definitions tested were as follows: (a) office BP < 140/90 mm Hg and daytime ABPM BP > 135/85 mm Hg (old criterion); and (b) office BP < 140/90 mm Hg and 24-hour ABPM BP > 130/80 mm Hg or daytime ABPM BP > 135/85 mm Hg or nighttime ABPM BP > 120/70 mm Hg (new criterion). The two definitions' predictive capacity was compared, regarding both WCH and MH. Cardiovascular mortality was the primary and all-cause mortality was the secondary outcome. Cox regression was adjusted to the variables: glomerular filtration rate, age, diabetes mellitus, and active smoking. There were 367 patients studied. The old criterion (exclusive mean daytime ABPM BP) was the only to distinguish sustained hypertension from WCH (adjusted HR: 3.730; 95% CI: 1.068-13.029; P = .039), regarding all-cause mortality. Additionally, the old criterion was the only one to distinguish normotension and MH, regarding cardiovascular mortality (adjusted HR: 7.641; 95% CI: 1.277-45.738; P = .026). Therefore, WCH and MH definitions based exclusively on daytime ABPM BP values (old criterion) were able to better distinguish mortality in this studied CKD cohort.
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