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      Hypertension Subtypes among Thai Hypertensives: An Analysis of Telehealth-Assisted Instrument in Home Blood Pressure Monitoring Nationwide Pilot Project

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          White-coat hypertension (HT), masked HT, HT with white-coat effect, and masked uncontrolled HT are well-recognized problems of over- and undertreatment of high blood pressure in real-life practice. However, little is known about the true prevalence in Thailand.


          To examine the prevalence and characteristics of each HT subtype defined by mean home blood pressure (HBP) and clinic blood pressure (CBP) using telemonitoring technology in Thai hypertensives.


          A multicenter, observational study included adult hypertensives who had been diagnosed for at least 3 months based on CBP without the adoption of HBP monitoring. All patients were instructed to manually measure their HBP twice a day for the duration of at least one week using the same validated automated, oscillometric telemonitoring devices (Uright model TD-3128, TaiDoc Corporation, Taiwan). The HBP, CBP, and baseline demographic data were recorded on the web-based system. HT subtypes were classified according to the treatment status, CBP (≥or <140/90 mmHg), and mean HBP (≥or <135/85 mmHg) into the following eight subtypes: in nonmedicated hypertensives, there are four subtypes that are normotension, white-coat HT, masked HT, and sustained HT; in treated hypertensives, there are four subtypes that are well-controlled HT, HT with white-coat effect, masked uncontrolled HT, and sustained HT.


          Of the 1,184 patients (mean age 58 ± 12.7 years, 59% women) from 46 hospitals, 1,040 (87.8%) were taking antihypertensive agents. The majority of them were enrolled from primary care hospitals (81%). In the nonmedicated group, the prevalence of white-coat and masked HT was 25.7% and 7.0%, respectively. Among the treated patients, the HT with white-coat effect was found in 23.3% while 46.7% had uncontrolled HBP (a combination of the masked uncontrolled HT (9.6%) and sustained HT (37.1%)). In the medicated older subgroup ( n = 487), uncontrolled HBP was more prevalent in male than in female (53.6% vs. 42.4%, p=0.013).


          This is the first nationwide study in Thailand to examine the prevalence of HT subtypes. Almost one-fourth had white-coat HT or HT with white-coat effect. Approximately half of the treated patients especially in the older males had uncontrolled HBP requiring more intensive interventions. These results emphasize the role of HBP monitoring for appropriate HT diagnosis and management. The cost-effectiveness of utilizing THAI HBPM in routine practice needs to be examined in the future study.

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          Most cited references 24

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          Prognosis of "masked" hypertension and "white-coat" hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study.

          We sought to investigate the prognosis in subjects with "white-coat" hypertension (WCHT) and "masked" hypertension (MHT), in which blood pressure (BP) is lower in clinical measurements than during ambulatory monitoring. The prognostic significance of WCHT remains controversial, and little is known about MHT. We obtained 24-h ambulatory BP and "casual" BP (i.e., obtained in clinical scenarios) values from 1,332 subjects (872 women, 460 men) > or =40 years old in a representative sample of the general population of a Japanese community. Survival and stroke morbidity were then followed up for a mean duration of 10 years. Composite risk of cardiovascular mortality and stroke morbidity examined using a Cox proportional hazards regression model for subjects with WCHT (casual BP > or =140/90 mm Hg, daytime BP or =135/85 mm Hg; RH 2.13; 95% CI 1.38 to 3.29) or sustained hypertension (casual BP > or =140/90 mm Hg, daytime BP > or =135/85 mm Hg; RH 2.26; 95% CI 1.49 to 3.41) than for subjects with sustained normal BP. Similar findings were observed for cardiovascular mortality and stroke morbidity among subgroups by gender, use of antihypertensive medication, and risk factor level (all p for heterogeneity >0.2). Conventional BP measurements may not identify some individuals at high or low risk, but these people may be identifiable by the use of ambulatory BP.
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            Prognosis of white-coat and masked hypertension: International Database of HOme blood pressure in relation to Cardiovascular Outcome.

            Home blood pressure monitoring is useful in detecting white-coat and masked hypertension and is recommended for patients with suspected or treated hypertension. The prognostic significance of white-coat and masked hypertension detected by home measurement was investigated in 6458 participants from 5 populations enrolled in the International Database of HOme blood pressure in relation to Cardiovascular Outcomes. During a median follow-up of 8.3 years, 714 fatal plus nonfatal cardiovascular events occurred. Among untreated subjects (n=5007), cardiovascular risk was higher in those with white-coat hypertension (adjusted hazard ratio 1.42; 95% CI [1.06-1.91]; P=0.02), masked hypertension (1.55; 95% CI [1.12-2.14]; P<0.01) and sustained hypertension (2.13; 95% CI [1.66-2.73]; P<0.0001) compared with normotensive subjects. Among treated patients (n=1451), the cardiovascular risk did not differ between those with high office and low home blood pressure (white-coat) and treated controlled subjects (low office and home blood pressure; 1.16; 95% CI [0.79-1.72]; P=0.45). However, treated subjects with masked hypertension (low office and high home blood pressure; 1.76; 95% CI [1.23-2.53]; P=0.002) and uncontrolled hypertension (high office and home blood pressure; 1.40; 95% CI [1.02-1.94]; P=0.04) had higher cardiovascular risk than treated controlled patients. In conclusion, white-coat hypertension assessed by home measurements is a cardiovascular risk factor in untreated but not in treated subjects probably because the latter receive effective treatment on the basis of their elevated office blood pressure. In contrast, masked uncontrolled hypertension is associated with increased cardiovascular risk in both untreated and treated patients, who are probably undertreated because of their low office blood pressure.
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              Role of Ambulatory and Home Blood Pressure Monitoring in Clinical Practice: A Narrative Review.

              Hypertension, a common risk factor for cardiovascular disease, is usually diagnosed and treated based on blood pressure readings obtained in the clinic setting. Blood pressure may differ considerably when measured inside versus outside of the clinic setting. Over the past several decades, evidence has accumulated on the following 2 approaches for measuring blood pressure outside of the clinic: ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). Both of these methods have a stronger association with cardiovascular disease outcomes than clinic blood pressure measurement. Controversy exists about whether ABPM or HBPM is superior for estimating risk for cardiovascular disease and under what circumstances these methods should be used in clinical practice for assessing blood pressure outside of the clinic. This review describes ABPM and HBPM procedures, the blood pressure phenotypic measurements that can be ascertained, and the evidence that supports the use of each approach to measuring blood pressure outside of the clinic. It also describes barriers to the successful implementation of ABPM and HBPM in clinical practice, proposes core competencies for the conduct of these procedures, and highlights important areas for future research.

                Author and article information

                Int J Hypertens
                Int J Hypertens
                International Journal of Hypertension
                9 April 2020
                : 2020
                1Division of Cardiovascular Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, 10330 Bangkok, Thailand
                2Division of Hospital and Ambulatory Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, 10330 Bangkok, Thailand
                3Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, 10330 Bangkok, Thailand
                4Pharmacy Department, King Chulalongkorn Memorial Hospital, 10330 Bangkok, Thailand
                5Department of Medicine, Siriraj Hospital, Mahidol University, 10700 Bangkok, Thailand
                6Thai Hypertension Society, 10310 Bangkok, Thailand
                Author notes

                Academic Editor: Tomohiro Katsuya

                Copyright © 2020 Sakolwat Montrivade et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Funded by: Ministry of Public Health
                Funded by: Nationwide
                Funded by: Faculty of Medicine, Chulalongkorn University
                Research Article

                Cardiovascular Medicine


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