From the Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine (C.R.L.C., G.F.S.), Universidade Federal do Rio de Janeiro, Brazil.
Civil Engineering Program, COPPE (G.C.S.), Universidade Federal do Rio de Janeiro, Brazil.
Hypertension. 2020 May;75(5):1184-1194. doi: 10.1161/HYPERTENSIONAHA.120.14782. Epub 2020 Mar 23.
The prognostic importances of on-treatment clinic and ambulatory blood pressure (BP) levels have never been investigated in individuals with resistant hypertension. We aimed to evaluate them for the occurrence of incident cardiovascular and mortality outcomes in a prospective cohort of 1726 patients with resistant hypertension. Clinic and ambulatory BPs were measured at baseline and serially during follow-up (analyzed as time-varying and as mean cumulative BPs) and also categorized as controlled/uncontrolled as defined by the traditional and new 2017 American College of Cardiology/American Heart Association criteria. Multivariate Cox analyses examined the associations between BP parameters and the occurrence of total cardiovascular events, major adverse cardiovascular events, and cardiovascular and all-cause mortalities. C statistics and the integrated discrimination improvement indexes evaluated the improvement in risk discrimination. Over a median follow-up of 8.3 years, 417 total cardiovascular events occurred (358 major adverse cardiovascular events) and 391 individuals died (233 cardiovascular deaths). All single systolic BP (SBP) parameters significantly predicted all outcomes, but the associations were stronger for ambulatory SBPs than for clinic SBPs and for on-treatment SBPs (particularly for mean cumulative) than for baseline SBPs, and both improved risk discrimination (with increases in C statistic of up to 0.021 and integrated discrimination improvements of up to 19.7%). These findings were consistent for diastolic BPs. Uncontrolled ambulatory BPs were associated with higher risks for all outcomes, whereas uncontrolled clinic BPs were not. In conclusion, mean cumulative ambulatory BPs during follow-up were the best prognostic markers of adverse cardiovascular outcomes and mortality in patients with resistant hypertension. Serial ambulatory BP monitoring shall be more widely used in resistant hypertension management.
在抗药性高血压患者中，从未研究过治疗中诊所和动态血压（BP）水平的预后重要性。我们旨在评估 1726 例抗药性高血压患者前瞻性队列中发生心血管事件和死亡率的发生率。在基线和随访期间（分析为随时间变化和平均累积 BP）测量诊所和动态 BP，并根据传统和新的 2017 年美国心脏病学会/美国心脏协会标准将其分类为控制/未控制。多变量 Cox 分析检查了 BP 参数与总心血管事件、主要不良心血管事件以及心血管和全因死亡率发生之间的关系。C 统计量和综合鉴别改善指数评估了风险鉴别力的改善。在中位数为 8.3 年的随访期间，发生了 417 例总心血管事件（358 例主要不良心血管事件）和 391 例死亡（233 例心血管死亡）。所有单一收缩压（SBP）参数均显著预测所有结局，但动态 SBP 的相关性强于诊所 SBP，治疗中的 SBP （尤其是平均累积）比基线 SBP 更强，并且两者都改善了风险鉴别力（C 统计量最多增加 0.021，综合鉴别力改善最多增加 19.7％）。这些发现对于舒张压也是一致的。未控制的动态 BP 与所有结局的风险增加相关，而未控制的诊所 BP 则没有。总之，在抗药性高血压患者中，随访期间的平均累积动态 BP 是不良心血管结局和死亡率的最佳预后标志物。应更广泛地使用连续动态 BP 监测来管理抗药性高血压。
