Effects of Intensive Versus Standard Office-Based Hypertension Treatment Strategy on White-Coat Effect and Masked Uncontrolled Hypertension: From the SPRINT ABPM Ancillary Study.
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SUBMITTER: Ghazi L
PROVIDER: S-EPMC7484232 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Abstract Aims The detection of white-coat hypertension/white-coat uncontrolled hypertension (WCH/WUCH) with out-of-office blood pressure (BP) monitoring is time- and resource-consuming. We aim to develop a machine learning (ML)-derived prediction model based on the characteristics of patients from a single outpatient visit. Methods and results Data from two cohorts in Taiwan were used. Cohort one (970 patients) was used for development and internal validation, and cohort two (464 patients) was used for external validation. WCH/WUCH was defined as an office BP of ≥140/90 mmHg and daytime ambulatory BP of <135/85 mmHg in treatment-naïve or treated individuals. Logistic regression, random forest (RF), eXtreme Gradient Boosting, and artificial neural network models were trained using 26 patient parameters. We used SHapley Additive exPlanations values to provide explanations for the risk factors. All models achieved great area under the receiver operating characteristic curve (AUROC), specificity, and negative predictive value in both validations (AUROC = 0.754–0.891; specificity = 0.682–0.910; negative predictive value = 0.831–0.968). The RF model was the best performing (AUROC = 0.884; sensitivity = 0.619; specificity = 0.887; negative predictive value = 0.872; accuracy = 0.819). The five most influential features of the RF model were office diastolic BP, office systolic BP, current smoker, estimated glomerular filtration rate, and fasting glucose level. Conclusion Our prediction models achieved good performance, underlining the feasibility of applying ML models to outpatient populations for the diagnosis of WCH and WUCH. Further validation with other prospective data sets should be considered in the future. Graphical Abstract Graphical Abstract Two cohorts were used for model development after splitting and external validation respectively. With oversampled training set, four algorithms were developed through the process of feature ranking with SHapley Additive exPlantions values, feature selection, and threshold tuning under five-fold cross-validation. Models were then evaluated by variant metrics. Present study demonstrated the feasibility of applying machine learning models to outpatient population for the identify of white-coat hypertension and white-coat uncontrolled hypertension. ANN, artificial neural network; AUROC, area under the receiver operating characteristic curve; DBP, diastolic blood pressure; LR, logistic regression; NPV, negative predictive value; PPV, positive predictive value; RF, random forest; ROC, receiver operating characteristic; SBP, systolic blood pressure; Sen, sensitivity; SHAP, SHapley Additive exPlanations; Spe, specificity; WCH/WUCH, white-coat hypertension/white-coat uncontrolled hypertension; XGboost, eXtreme Gradient Boosting.
| S-EPMC9779877 | biostudies-literature
Project description:Masked uncontrolled hypertension (MUCH) is diagnosed in patients treated for hypertension who are normotensive in the clinic but hypertensive outside. In this study of 333 veterans with CKD, we prospectively evaluated the prevalence of MUCH as determined by ambulatory BP monitoring using three definitions of hypertension (daytime hypertension ≥135/85 mmHg; either nighttime hypertension ≥120/70 mmHg or daytime hypertension; and 24-hour hypertension ≥130/80 mmHg) or by home BP monitoring (hypertension ≥135/85 mmHg). The prevalence of MUCH was 26.7% by daytime ambulatory BP, 32.8% by 24-hour ambulatory BP, 56.1% by daytime or night-time ambulatory BP, and 50.8% by home BP. To assess the reproducibility of the diagnosis, we repeated these measurements after 4 weeks. Agreement in MUCH diagnosis by ambulatory BP was 75-78% (κ coefficient for agreement, 0.44-0.51), depending on the definition used. In contrast, home BP showed an agreement of only 63% and a κ coefficient of 0.25. Prevalence of MUCH increased with increasing clinic systolic BP: 2% in the 90-110 mmHg group, 17% in the 110-119 mmHg group, 34% in the 120-129 mmHg group, and 66% in the 130-139 mmHg group. Clinic BP was a good determinant of MUCH (receiver operating characteristic area under the curve 0.82; 95% confidence interval 0.76-0.87). In diagnosing MUCH, home BP was not different from clinic BP. In conclusion, among people with CKD, MUCH is common and reproducible, and should be suspected when clinic BP is in the prehypertensive range. Confirmation of MUCH diagnosis should rely on ambulatory BP monitoring.
| S-EPMC4769206 | biostudies-literature
Project description:ObjectiveWe investigated factors associated with masked and white-coat hypertension in a Swiss population-based sample.MethodsThe Swiss Kidney Project on Genes in Hypertension is a family-based cross-sectional study. Office and 24-hour ambulatory blood pressure were measured using validated devices. Masked hypertension was defined as office blood pressure<140/90 mmHg and daytime ambulatory blood pressure?135/85 mmHg. White-coat hypertension was defined as office blood pressure?140/90 mmHg and daytime ambulatory blood pressure<135/85 mmHg. Mixed-effect logistic regression was used to examine the relationship of masked and white-coat hypertension with associated factors, while taking familial correlations into account. High-normal office blood pressure was defined as systolic/diastolic blood pressure within the 130-139/85-89 mmHg range.ResultsAmong the 652 participants included in this analysis, 51% were female. Mean age (±SD) was 48 (±18) years. The proportion of participants with masked and white coat hypertension was respectively 15.8% and 2.6%. Masked hypertension was associated with age (odds ratio (OR)?=?1.02, p?=?0.012), high-normal office blood pressure (OR?=?6.68, p<0.001), and obesity (OR?=?3.63, p?=?0.001). White-coat hypertension was significantly associated with age (OR?=?1.07, p<0.001) but not with education, family history of hypertension, or physical activity.ConclusionsOur findings suggest that physicians should consider ambulatory blood pressure monitoring for older individuals with high-normal office blood pressure and/or who are obese.
| S-EPMC3963885 | biostudies-literature
Project description:Objective: This study aimed to develop machine learning-based prediction models to predict masked hypertension and masked uncontrolled hypertension using the clinical characteristics of patients at a single outpatient visit. Methods: Data were derived from two cohorts in Taiwan. The first cohort included 970 hypertensive patients recruited from six medical centers between 2004 and 2005, which were split into a training set (n = 679), a validation set (n = 146), and a test set (n = 145) for model development and internal validation. The second cohort included 416 hypertensive patients recruited from a single medical center between 2012 and 2020, which was used for external validation. We used 33 clinical characteristics as candidate variables to develop models based on logistic regression (LR), random forest (RF), eXtreme Gradient Boosting (XGboost), and artificial neural network (ANN). Results: The four models featured high sensitivity and high negative predictive value (NPV) in internal validation (sensitivity = 0.914-1.000; NPV = 0.853-1.000) and external validation (sensitivity = 0.950-1.000; NPV = 0.875-1.000). The RF, XGboost, and ANN models showed much higher area under the receiver operating characteristic curve (AUC) (0.799-0.851 in internal validation, 0.672-0.837 in external validation) than the LR model. Among the models, the RF model, composed of 6 predictor variables, had the best overall performance in both internal and external validation (AUC = 0.851 and 0.837; sensitivity = 1.000 and 1.000; specificity = 0.609 and 0.580; NPV = 1.000 and 1.000; accuracy = 0.766 and 0.721, respectively). Conclusion: An effective machine learning-based predictive model that requires data from a single clinic visit may help to identify masked hypertension and masked uncontrolled hypertension.
| S-EPMC8639874 | biostudies-literature
Project description:The prognostic relevance of masked uncontrolled hypertension (MUCH) is incompletely clear, and its global impact on cardiovascular outcomes and mortality has not been assessed. The aim of this study was to perform a meta-analysis on the prognostic value of MUCH. We searched for articles assessing outcome in patients with MUCH compared with those with controlled hypertension (CH) and reporting adjusted hazard ratio and 95% CI. We identified 6 studies using ambulatory blood pressure monitoring (12?610 patients with 933 events) and 5 using home blood pressure measurement (17?742 patients with 394 events). The global population included 30?352 patients who experienced 1327 events. Selected studies had cardiovascular outcomes and all-cause mortality as primary outcome, and the main result is a composite of these events. The overall adjusted hazard ratio was 1.80 (95% CI, 1.57-2.06) for MUCH versus CH. Subgroup meta-analysis showed that adjusted hazard ratio was 1.83 (95% CI, 1.52-2.21) in studies using ambulatory blood pressure monitoring and 1.75 (95% CI, 1.38-2.20) in those using home blood pressure measurement. Risk was significantly higher in MUCH than in CH independently of follow-up length and types of studied events. MUCH was at significantly higher risk than CH in all ethnic groups, but the highest hazard ratio was found in studies, including black patients. Risk of cardiovascular events and all-cause mortality is significantly higher in patients with MUCH than in those with CH. MUCH detected by ambulatory or home blood pressure measurement seems to convey similar prognostic information.
| S-EPMC6205750 | biostudies-literature
Project description:Background: White coat hypertension (WCH) and masked hypertension (MH) can increase the risk of target organ damage. Home blood pressure monitoring is an important method for detecting WCH and MH. However, the prevalence and related factors of WCH and MH in China have been rarely reported. Objective: To explore the prevalence and related factors associated with white coat hypertension (WCH) and masked hypertension (MH) in Shunde District, Southern China. Methods: This study recruited subjects from the Physical Examination Center in Shunde Hospital, Southern Medical University. Office blood pressure and home blood pressure values were collected using the home blood pressure monitor with telemedicine device and office blood pressure monitor, and the prevalence of WCH and MH was calculated by the values. Multivariate logistic regression was used to explore the related factors for WCH and MH. Results: Four-hundred and sixty-one participants (61% male), with an average age of 49 years, were included. The prevalence of WCH and MH was 5.1 and 15.2%, respectively. Multivariate logistic regression analysis showed that smoking (OR = 4.71, 95% CI = 1.05-21.15) and family history of coronary heart disease (OR = 4.51, 95% CI = 1.08-18.93) were associated with higher odds of WCH. The associated factors for higher odds of MH were smoking (OR = 2.83, 95% CI = 1.11-7.23), family history of hypertension (OR = 2.17, 95% CI = 1.11-4.26) and family history of coronary heart disease (OR = 2.82, 95% CI = 1.07-7.45). Conclusion: WCH and MH are highly prevalent in the Physical Examination Center in Shunde Hospital, Southern Medical University. We found smoking and family history of coronary heart disease were related factors for WCH, and smoking, family history of hypertension and coronary heart disease were associated with the odds of MH. Home blood pressure monitoring with a telemedicine device should be recommended to identity abnormal BP phenotype.
| S-EPMC9283833 | biostudies-literature
Project description:Data on masked hypertension (MH) and white-coat hypertension (WCH) in African populations are needed to estimate the true prevalence of hypertension in these populations because they have the highest burden of the disease. We conducted the first systematic review and meta-analysis that summarized available data on the prevalence of WCH and MH in Africa. We searched PubMed and Scopus to identify all the articles published on MH and WCH in populations living in Africa from inception to November 30, 2017. We reviewed each study for methodological quality. A random-effects model was used to estimate the prevalence of WCH and MH across studies. Eleven studies were included, all having a low-risk of bias. The prevalence of masked hypertension was 11% (95% CI: 4.7-19.3; 10 studies) in a pooled sample of 7789 individuals. The prevalence of WCH was 14.8% (95% CI: 9.4-21.1; 8 studies) in a pooled sample of 4451 individuals. There was no difference on the prevalence of WCH and MH between studies in which participants were recruited from the community and the hospital. The prevalence of MH was higher in urban areas compared to rural ones; there was no difference for WCH. WHC and MH seem to be frequent in African populations, suggesting the importance of out-of-clinic BP measurement in the diagnosis and management of patients with hypertension in Africa, especially in urban areas for MH.
| S-EPMC8031123 | biostudies-literature
Project description:The 2017 American College of Cardiology/American Heart Association blood pressure (BP) Hypertension Clinical Practice Guidelines recommends ambulatory BP monitoring to detect masked hypertension. Data on the short-term reproducibility of masked hypertension are scarce. The IDH study (Improving the Detection of Hypertension) enrolled 408 adults not taking antihypertensive medication from 2011 to 2013. Office BP and 24-hour ambulatory BP monitoring were performed on 2 occasions, a median of 29 days apart. After excluding participants with office hypertension (mean systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg), the analytical sample included 254 participants. Using the κ statistic, we evaluated the reproducibility of masked awake hypertension (awake systolic/diastolic BP ≥130/80 mm Hg) defined by the 2017 BP guideline thresholds, as well as masked 24-hour (24-hour systolic/diastolic BP ≥125/75 mm Hg), masked asleep (asleep systolic/diastolic BP ≥110/65 mm Hg), and any masked hypertension (high awake, 24-hour, and asleep BP). The mean (SD) age of participants was 38.0 (12.3) years and 65.7% were female. Based on the first and second ambulatory BP recordings, 24.0% and 26.4% of participants, respectively, had masked awake hypertension. The κ statistic (95% CI) was 0.50 (0.38-0.62) for masked awake, 0.57 (0.46-0.69) for masked 24-hour, 0.57 (0.47-0.68) for masked asleep, and 0.58 (0.47-0.68) for any masked hypertension. Clinicians should consider the moderate short-term reproducibility of masked hypertension when interpreting the results from a single ambulatory BP recording.
| S-EPMC7490832 | biostudies-literature
Project description:Masked uncontrolled hypertension (MUCH) in treated hypertensive patients is defined as controlled automated office blood pressure (BP; <135/85 mm Hg) in-clinic but uncontrolled out-of-clinic BP by ambulatory BP monitoring (awake [daytime] readings ≥135/85 mm Hg or 24-hour readings ≥130/80 mm Hg). To determine whether MUCH is attributable to antihypertensive medication nonadherence. One hundred eighty-four enrolled patients were confirmed to have controlled office BP; of these, 167 patients were with adequate 24-hour ambulatory BP recordings. Of 167 patients, 86 were controlled by in-clinic BP assessment but had uncontrolled ambulatory awake BP, indicative of MUCH. The remaining 81 had controlled in-clinic and ambulatory awake BP, consistent with true controlled hypertension. After exclusion of 9 patients with missing 24-hour urine collections, antihypertensive medication adherence was determined based on the detection of urinary drugs or drug metabolites by high-performance liquid chromatography-tandem mass spectrometry. Of the 81 patients with MUCH, 69 (85.2%) were fully adherent and 12 (14.8%) were partially adherent (fewer medications detected than prescribed). Of the 77 patients with true controlled hypertension, 69 (89.6%) were fully adherent with prescribed antihypertensive medications and 8 (10.4%) were partially adherent. None of the patients in either group were fully nonadherent. There was no statistically significant difference in complete or partial adherence between the MUCH and true controlled groups (P=0.403). Measurement of urinary drug and drug metabolite levels demonstrates a similarly high level of antihypertensive medication adherence in both MUCH and truly controlled hypertensive patients. These findings indicate that MUCH is not attributable to antihypertensive medication nonadherence.
| S-EPMC6687528 | biostudies-literature
Project description:IntroductionMasked uncontrolled hypertension (MUCH) carries an increased risk of cardiovascular (CV) complications and can be identified through combined use of office (O) and ambulatory (A) blood pressure (BP) monitoring (M) in treated patients. However, it is still debated whether the information carried by ABPM should be considered for MUCH management. Aim of the MASked-unconTrolled hypERtension management based on OBP or on ambulatory blood pressure measurement (MASTER) Study is to assess the impact on outcome of MUCH management based on OBPM or ABPM.Methods and analysisMASTER is a 4-year prospective, randomised, open-label, blinded-endpoint investigation. A total of 1240 treated hypertensive patients from about 40 secondary care clinical centres worldwide will be included -upon confirming presence of MUCH (repeated on treatment OBP <140/90 mm Hg, and at least one of the following: daytime ABP ≥135/85 mm Hg; night-time ABP ≥120/70 mm Hg; 24 hour ABP ≥130/80 mm Hg), and will be randomised to a management strategy based on OBPM (group 1) or on ABPM (group 2). Patients in group 1 will have OBP measured at 0, 3, 6, 12, 18, 24, 30, 36, 42 and 48 months and taken as a guide for treatment; ABPM will be performed at randomisation and at 12, 24, 36 and 48 months but will not be used to take treatment decisions. Patients randomised to group 2 will have ABPM performed at randomisation and all scheduled visits as a guide to antihypertensive treatment. The effects of MUCH management strategy based on ABPM or on OBPM on CV and renal intermediate outcomes (changing left ventricular mass and microalbuminuria, coprimary outcomes) at 1 year and on CV events at 4 years and on changes in BP-related variables will be assessed.Ethics and disseminationMASTER study protocol has received approval by the ethical review board of Istituto Auxologico Italiano. The procedures set out in this protocol are in accordance with principles of Declaration of Helsinki and Good Clinical Practice guidelines. Results will be published in accordance with the CONSORT statement in a peer-reviewed scientific journal.Trial registration numberNCT02804074; Pre-results.
| S-EPMC6303603 | biostudies-literature