Clinical implications of high peak nighttime home blood pressure (BP) are currently unknown. This study investigated the association between peak nighttime home systolic BP (SBP) and cardiovascular events in individuals with at least one cardiovascular risk factor. In the Japan Morning Surge-Home Blood Pressure (J-HOP) study, nighttime home BP was automatically measured three times each night for 14 days at baseline using a nighttime home BP monitoring device (HEM-5001, Omron Healthcare). Peak nighttime home SBP was defined as average of the highest three values over the 14-night measurement period. Cardiovascular events (stroke, coronary artery disease, heart failure, aortic dissection) were tracked over a mean follow-up period of 7.1 years. This analysis included 2545 individuals (mean age 63.3 ± 10.3 years, 49% male). After adjusting for covariates (including age, sex, and average office, morning, evening, and nighttime home SBP), stroke risk was significantly higher in individuals with peak nighttime home SBP in the highest quintile (≥149.0 mmHg) compared to the lowest quintile (<119.3 mmHg) (hazard ratio [HR] 4.24, 95% confidence interval [CI] 1.07-16.77; p = 0.039 overall and 8.92, 1.49-53.43; p = 0.017 in the subgroup with ≥6 nighttime home SBP measurements). This increased stroke risk remained significant after controlling for day-by-day average real variability of nighttime BP. The average peak nighttime home SBP cut-off value for predicting an increased risk of incident stroke was 136 mmHg. We propose that exaggerated peak nighttime home SBP, determined from ≥6 measurements, is a novel risk factor for stroke, independent of conventional office and home BP values. The exaggerated peak nighttime home systolic blood pressure (HSBP) determined from six or more measurements as a novel risk factor for stroke, independent of conventional office and home blood pressure (BP) values.

UNASSIGNED: The Tohoku Medical Megabank (TMM) was established for creative reconstruction from the Great East Japan Earthquake and tsunami in 2011. Two prospective genome cohort studies in Miyagi prefecture have successfully recruited approximately 127,000 participants. The health status of these individuals was evaluated at the initial recruitment, and follow-up health checkups have been conducted every 5 years. During these health checkups, unexpected critical values were encountered, which prompted us to develop an urgent notification system.
UNASSIGNED: We analyzed the frequency of critical values observed in home blood pressure (HBP) test in an urgent notification office (UNO). We returned the critical values by urgent notification before the notifications of regular results. In addition, the impact of the TMM urgent notification on the participants was evaluated.
UNASSIGNED: We issued urgent notifications of the critical values of extremely high HBP. Of the 21,061 participants who underwent HBP measurements, 256 (1.2%) met the criteria for urgent notification. It was found that abnormalities in blood sugar levels, renal function, and lipid values were frequently concurrent with the abnormal HBP readings. Annual questionnaires administered after the urgent notification, approximately 60% of those went to hospitals or clinics.
UNASSIGNED: The urgent notification system for hypertensive emergency with HBP in the TMM was well accepted by the participants and encouraged them to seek medical care. The system has been useful in addressing the prolonged healthcare problems and in promoting health care in large-scale disaster damaged areas.

BACKGROUND: Out-of-office blood pressure (BP) measurement is recommended when making a new hypertension diagnosis. In practice, however, hypertension is primarily diagnosed using clinic BP. The study objective was to understand patient attitudes about accuracy and patient-centeredness regarding hypertension diagnostic methods.
METHODS: Qualitative study within a randomized controlled diagnostic study conducted between May 2017 and March 2019 comparing the accuracy and acceptability of BP measurement methods among patients in an integrated healthcare delivery system. All participants completed 24-hour ambulatory blood pressure monitoring (ABPM), plus either clinic BP, home BP monitoring (HBPM), or kiosk BP diagnostic testing. Qualitative interviewees (aged 31-76 years, n=35) were recruited from the main study.
RESULTS: Participants who completed HBPM found it to be comfortable and low burden, and believed it produced accurate results. Participants in the clinic arm described clinic measurements as inconvenient. Participants in the kiosk arm overall did not favor kiosks due to concerns about accuracy and privacy. Participants described ABPM as the most accurate method due to repeated measurements over the 24-hour period in real-world contexts, but many found it uncomfortable and disruptive. Participants also noted methods that involved repeated measures such as HBPM and ABPM particularly influenced their understanding of whether or not they had hypertension.
CONCLUSIONS: Hypertension diagnostic methods that include more BP measurements help patients gain a deeper understanding of BP variability and the lower reliability of infrequent measurements in clinic. These findings warrant implementing strategies to enhance out-office BP diagnostic testing in primary care.

Depression is comorbid with somatic diseases; however, the relationship between depressive symptoms and hypertension (HT), a risk factor for cardiovascular events, remains unclear. Home blood pressure (BP) is more reproducible and accurately predictive of cardiovascular diseases than office BP. Therefore, we focused on home BP and investigated whether depressive symptoms contributed to the future onset of home HT. This prospective cohort study used data from the Tohoku Medical Megabank Community-Cohort Study (conducted in the Miyagi Prefecture, Japan) and included participants with home normotension (systolic blood pressure (SBP) < 135 mmHg and diastolic blood pressure (DBP) < 85 mmHg). Depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression Scale-Japanese version at the baseline survey. In the secondary survey, approximately 4 years later, the onset of home HT was evaluated (SBP ≥ 135 mmHg or DBP ≥ 85 mmHg) and was compared in participants with and without depressive symptoms. Of the 3 082 (mean age: 54.2 years; females: 80.9%) participants, 729 (23.7%) had depressive symptoms at the baseline survey. During the 3.5-year follow-up, 124 (17.0%) and 388 (16.5%) participants with and without depressive symptoms, respectively, developed home HT. Multivariable adjusted odds ratios were 1.37 (95% confidence interval (CI): 1.02-1.84), 1.18 (95% CI: 0.86-1.61), and 1.66 (95% CI: 1.17-2.36) for home, morning, and evening HT, respectively. This relationship was consistent in the subgroup analyses according to age, sex, BP pattern, and drinking habit. Depressive symptoms increased the risk of new-onset home HT, particularly evening HT, among individuals with home normotension. This prospective cohort study revealed that depressive symptoms are risk factors for new-onset home hypertension, particularly evening hypertension among individuals with home normotension. Assessing home blood pressure in individuals with depressive symptoms is important for the prevention of hypertension and concomitant cardiovascular diseases.

Adequate management of nocturnal hypertension is crucial to reduce the risk of organ damage and cardiovascular events. The EARLY-NH study was a prospective, open-label, multicenter study conducted in Japanese patients with nocturnal hypertension who received esaxerenone treatment for 12 weeks. This post hoc analysis aimed to assess (1) the relationship between changes in morning home systolic blood pressure (SBP), bedtime home SBP, and nighttime home SBP based on changes in SBP and achievement rates of target SBP levels; and (2) the correlation between nighttime home SBP measurements using brachial and wrist home BP monitoring (HBPM) devices. This analysis evaluated 82 patients who completed the 12-week treatment period. Among those who achieved target morning home SBP (<135 mmHg) and target bedtime home SBP (<135 mmHg), the brachial HBPM device showed achievement rates of 63.6% and 56.4%, respectively, for target nighttime home SBP (<120 mmHg). The wrist device showed achievement rates of 66.7% and 63.4%, respectively, for the same targets. Significant correlations were observed between both devices for nighttime home SBP measurements at baseline (r = 0.790), Week 12 (r = 0.641), and change from baseline to Week 12 (r = 0.533) (all, p < .001). In this patient population, approximately 60% of individuals who reached target morning or bedtime home SBP levels <135 mmHg exhibited well-controlled nighttime home SBP. Although nighttime home SBP measurements obtained using both brachial and wrist HBPM devices displayed a significant correlation, the wrist device needs to be examined in more detail for clinical use.

UNASSIGNED: Hypertension guidelines recommend using home blood pressure (HBP) to diagnose, treat and monitor hypertension. This study aimed to explore the challenges primary care physicians (PCPs) face in using HBP to manage patients with hypertension.
UNASSIGNED: A qualitative study was conducted in 2022 at five primary care clinics in Singapore. An experienced qualitative researcher conducted individual in-depth interviews with 17 PCPs using a semi-structured interview guide. PCPs were purposively recruited based on their clinical roles and seniority until data saturation. The interviews were audio-recorded, transcribed verbatim and managed using NVivo qualitative data management software. Analysis was performed using thematic analysis.
UNASSIGNED: PCPs identified variations in patients\' HBP monitoring practices and inconsistencies in recording them. Access to HBP records relied on patients bringing their records to the clinic visit. A lack of seamless transfer of HBP records to the EMR resulted in an inconsistency in documentation and additional workload for PCPs. PCPs struggled to interpret the HBP readings, especially when there were BP fluctuations; this made treatment decisions difficult.
UNASSIGNED: Despite strong recommendations to use HBP to inform hypertension management, PCPs still faced challenges accessing and interpreting HBP readings; this makes clinical decision-making difficult. Future research should explore effective ways to enhance patient self-efficacy in HBP monitoring and support healthcare providers in documenting and interpreting HBP.

OBJECTIVE: To compare clinic and home blood pressure readings in higher risk pregnancies in the antenatal period from 20 weeks gestation, and to evaluate differences between the two modalities.
METHODS: A cohort study comprising a secondary analysis of a large randomised controlled trial (BUMP 1).
METHODS: Normotensive women at higher risk of pregnancy hypertension randomised to self-monitoring of blood pressure.
METHODS: The primary outcome was the overall mean difference between clinic and home readings for systolic blood pressure (sBP) and diastolic blood pressure (dBP). Blood pressure readings were averaged across each gestational week for each participant and compared within the same gestational week. Calculations of the overall differences were based on the average difference for each week for each participant.
RESULTS: The cohort comprised 925 participants. In total, 92 (10 %) developed a hypertensive disorder during the pregnancy. A significant difference in the overall mean sBP (clinic - home) of 1.1 mmHg (0.5-1.6 95 %CI) was noted, whereas no significant difference for the overall mean dBP was found (0.0 mmHg (-0.4-0.4 95 %CI)). No tendency of proportional bias was noted based on Bland-Altman plots. Increasing body mass index in general increased the difference (clinic - home) for both sBP and dBP in a multivariate analysis.
CONCLUSIONS: No clinically significant difference was found between clinic and home blood pressure readings in normotensive higher risk pregnancies from gestational week 20+0 until 40+0. Clinic and home blood pressure readings might be considered equal during pregnancy in women who are normotensive at baseline.

BACKGROUND: White coat effect (WCE) and white coat hypertension (WCH) are hardly both compared in primary care.
OBJECTIVE: To assess the usefulness of repeated measures of systolic blood pressure (SBP) to dissociate various forms of white-coat interactions.
METHODS: An open cross-sectional study on consecutive patients treated or not for high blood pressure was made in family physicians\' offices. SBP was measured 5 times by an electronic device. Measurements were performed before (SBP1) and after (SBP5) the office visit by a lay assistant and at the beginning (SBP2), middle (SBP3) and end (SBP4) of visit, by the family physician. Home BP (HBPM) was measured from 3 consecutive days by the patient. WCE and office WCE tail (OWCET) were defined, respectively, as a 10 mmHg SBP increase or decrease between SBP2-SBP1 or SBP4-SBP2. WCH was considered when HBPM was normal (SBP < 135 mmHg) at home and high during the SBP2 office visit.
RESULTS: Two hundred five patients (134 women versus 71 men, ratio 1.9, aged 59.8±15.7 years) were recruited. In categorical terms, there were 51 patients (25%) who presented with WCE, OWCET was seen in 121 patients (62%) and 47 patients (23%) had WCH. Only 36 patients (18%) presented both OWCET and WCE and 32 (16%) had both OWCET and WCH. The receiver operating characteristic curves (ROCs) of OWCET in diagnosing WCE or WCH were respectively 0.67 (p<0.0001) and 0.53 (NS).
CONCLUSIONS: Thus, OWCET was predictive of WCE and not of WCH and it is worthwhile to be measured in the family physician office.

BACKGROUND: The objective of the PERSONAL-CovidBP (Personalised Electronic Record Supported Optimisation When Alone for Patients With Hypertension: Pilot Study for Remote Medical Management of Hypertension During the COVID-19 Pandemic) trial was to assess the efficacy and safety of smartphone-enabled remote precision dosing of amlodipine to control blood pressure (BP) in participants with primary hypertension during the COVID-19 pandemic.
RESULTS: This was an open-label, remote, dose titration trial using daily home self-monitoring of BP, drug dose, and side effects with linked smartphone app and telemonitoring. Participants aged ≥18 years with uncontrolled hypertension (5-7 day baseline mean ≥135 mm Hg systolic BP or ≥85 mm Hg diastolic BP) received personalized amlodipine dose titration using novel (1, 2, 3, 4, 6, 7, 8, 9 mg) and standard (5 and 10 mg) doses daily over 14 weeks. The primary outcome of the trial was mean change in systolic BP from baseline to end of treatment. A total of 205 participants were enrolled and mean BP fell from 142/87 (systolic BP/diastolic BP) to 131/81 mm Hg (a reduction of 11 (95% CI, 10-12)/7 (95% CI, 6-7) mm Hg, P<0.001). The majority of participants achieved BP control on novel doses (84%); of those participants, 35% were controlled by 1 mg daily. The majority (88%) controlled on novel doses had no peripheral edema. Adherence to BP recording and reported adherence to medication was 84% and 94%, respectively. Patient retention was 96% (196/205). Treatment was well tolerated with no withdrawals from adverse events.
CONCLUSIONS: Personalized dose titration with amlodipine was safe, well tolerated, and efficacious in treating primary hypertension. The majority of participants achieved BP control on novel doses, and with personalization of dose there were no trial discontinuations due to drug intolerance. App-assisted remote clinician dose titration may better balance BP control and adverse effects and help optimize long-term care.
BACKGROUND: URL: clinicaltrials.gov. Identifier: NCT04559074.

Licorice, through the effects of glycyrrhizic acid (GA), raises blood pressure (BP). The World Health Organization has suggested that 100 mg GA/d would be unlikely to cause adverse effects, but of 13 previously published studies none have been randomized and controlled and independently quantified the GA content.
Our aim was to analyze the effects on home BP of a daily licorice intake containing 100 mg GA.
Healthy volunteers were randomly assigned to start with either licorice or a control product in a nonblinded, 2 × 2 crossover study. Home BP was measured daily, and blood samples were collected at the end of each 2-wk period.
There were 28 participants and no dropouts. The median age was 24.0 y (interquartile range 22.8-27.0 y). During the licorice compared with control intake period, the systolic home BP increased [mean difference: 3.1 mm Hg (95% confidence interval [CI]: 0.8, 5.4 mm Hg) compared with -0.3 mm Hg (95% CI: -1.8, 1.3 mm Hg); P = 0.018] and renin and aldosterone were suppressed [mean change: -30.0% (95% CI: -56.7%, -3.3%) compared with 15.8% (95% CI: -12.8%, 44.4%); P = 0.003; and -45.1% (95% CI: -61.5%, -28.7%) compared with 8.2% (95% CI: -14.7%, 31.1%); P <0.001, respectively]. In the quartile of participants with the most pronounced suppression of renin and aldosterone, N-terminal prohormone of brain natriuretic peptide concentration increased during the licorice compared with control period [mean change: 204.1% (95% CI: -11.6%, 419.7%) compared with 72.4% (95% CI: -52.2%, 197.1%); P = 0.016].
We found licorice to be more potent than previously known, with significant increases in BP, after a daily intake of only 100 mg GA. Thus, the safe limit of intake of this substance might need to be reconsidered. This trial was registered at clinicaltrials.gov as NCT05661721 (https://clinicaltrials.gov/study/NCT05661721).