3 research outputs found
Determinants of day-night difference in blood pressure in subjects of African ancestry
Hypertension is a major risk factor for cardiovascular disease in both developed
and developing countries. Blood pressure normally decreases at night and a number of
studies have indicated that a reduced nocturnal decline in blood pressure (BP) increases
the risk for cardiovascular disease. Nocturnal decreases in BP are attenuated in subjects
of African as compared to European descent, but the mechanisms of this effect require
clarity. In the present study I attempted to identify potentially modifiable factors that
contribute toward nocturnal decreases in BP in a random sample of 171 nuclear families
comprising 438 black South Africans living in Soweto.
Prior studies have suggested that adiposity and salt intake may determine
nocturnal decreases in BP. Adiposity and salt intake were considered to be potentially
important factors to consider in the present study as 67% of the group studied were either
overweight or obese and in 291 subjects that had complete 24-hour urine collections
(used to assess salt intake) and BP measurements, Na+ and K+ intake was noted to be
considerably higher and lower respectively than the recommended daily allowance in the
majority of people. Moreover, a lack of relationship between either hypertension
awareness and treatment and Na+ and K+ intake suggested that current recommendations
for a reduced Na+ intake and increased K+ intake in hypertensives do not translate into
clinical practice in this community.
In order to assess whether adiposity or salt intake are associated with nocturnal
decreases in BP in this community, ambulatory BP monitoring was performed using
Spacelabs model 90207 oscillometric monitors. Of the 438 subjects recruited, 314 had
ambulatory BP measurements that met pre-specified quality criteria (more than 20 hours
of recordings and more than 10 and 5 readings for the computation of daytime and nighttime
means respectively). To identify whether adiposity or salt intake are associated with
a reduced nocturnal decline in BP, non-linear regression analysis was employed with
indices of adiposity and urinary Na+ and K+ excretion rates and urine Na+: K+ ratios
included in the regression model with adjustments for potential confounders. Neither
body mass index, skin-fold thickness, waist circumference, waist-to hip ratio, urinary Na+
and K+ excretion rates, nor urine Na+: K+ ratios were associated with nocturnal decreases
in systolic and diastolic BP. Indices of adiposity were however associated with 24 hour
ambulatory systolic and diastolic BP. Unexpectedly, female gender was associated with
an attenuated nocturnal decrease in BP.
In conclusion, in the first random, community-based sample with large sample
sizes conducted with ambulatory BP monitoring in Africa, I found that neither adiposity
nor salt intake are associated with a reduced nocturnal decline in BP. The lack of
association between either salt intake or adiposity and nocturnal decreases in BP was
despite a high prevalence of excessive adiposity in the community, as well as clear
evidence that current recommendations for a reduced Na+ intake and increased K+ intake
do not translate into clinical practice in this community. Thus, based on this study, the
question arises as to whether primordial prevention programs targeting excess adiposity
or inappropriate salt intake are likely to modify nocturnal decreases in BP, in urban,
developing communities of African ancestry in South Africa. However, unexpectedly I
noted that females were more likely to have an attenuated nocturnal decrease in BP. Thus
further work is required to explain this finding
Nurse versus ambulatory blood pressure measurement in a community of African descent: prevalence and significant of ``white coat`` responses.
Hypertension is a major cause of morbidity and mortality in communities of African ancestry. The most appropriate method of predicting the risk for blood pressure
(BP)-related cardiovascular events is through 24-hour ambulatory BP (ABP) monitoring.
Although the cost of monitors precludes the use of 24-hour BP measurement in groups
of African descent in Africa, the extent to which BP-related cardiovascular risk may be
underestimated by nurse-derived clinic BP measurements, and the current method of
BP-related risk assessment in these communities, is uncertain. In this regard, nursederived BP measurement is thought to be superior to other forms of in-office BP
measurement.
Ambulatory 24-hour, day and night BP (SpaceLabs, model 90207) and nursederived
clinic BP (CBP) (mean of 5 values) control rates were determined in 689
randomly selected participants (>16 years) of African ancestry in South Africa. Of the
participants 45.7% were hypertensive and 22.6% were receiving antihypertensive
medication. More participants had uncontrolled BP at night (34.0%) than during the day
(22.6%, p<0.0001). However, uncontrolled CBP was noted in 37.2% of participants,
while a much lower proportion had uncontrolled ABP (24.1%)(p<0.0001). These
differences were accounted for by a high prevalence of isolated increases in CBP (whitecoat effects)(39.4%). Thus, in communities of African descent, despite a worse BP
control at night than during the day, a high prevalence of white-coat effects translates
into a striking underestimation of BP control when employing CBP rather than ABP
measurements.
Nurse-derived BP measurements are often as closely associated with organ
damage as ABP. However, the extent to which relationships between nurse-derived BP
measurements and organ damage reflect a white-coat effect (isolated increase in inoffice
BP) as opposed to the adverse effects of BP per se are unknown. In 750
participants from a community sample, target organ changes were determined from
carotid-femoral pulse wave velocity (PWV) (applanation tonometry and SphygmoCor
software) (n=662) and left ventricular mass indexed to height2.7 (LVMI)
(echocardiography)(n=463). Nurse-derived CBP was associated with organ changes
independent of 24-hour BP (LVMI; partial r=0.15, p<0.005, PWV; partial r=0.21,
p<0.0001) and day BP. However, in both unadjusted (p<0.0001 for both) and
multivariate adjusted models (including adjustments for 24-hour BP)(LVMI; partial
r=0.14, p<0.01, PWV; partial r=0.21, p<0.0001) nurse office-day SBP (an index of
isolated increases in in-office BP) was associated with target organ changes
independent of ambulatory BP and additional confounders. Thus, nurse-elicited whitecoat
effects account for a significant proportion of the relationship between nursederived
CBP and target organ changes independent of ambulatory BP. Therefore, high
quality nurse-derived BP measurements do not approximate the impact of BP effects per
se on cardiovascular damage.
In 750 participants from a community sample I evaluated whether nurse officeday
BP is inversely related to day-night BP (BP dipping) and whether this relationship
may in-part explain the independent association between office-day BP and organ
damage. Nurse office-day systolic BP (SBP) was correlated with % night/day SBP
(r=0.22, p<0.0001) and night SBP (r=0.14, p=0.0001). Although unadjusted and
multivariate adjusted (including for day SBP) nurse office-day SBP was associated with
LVMI (partial r=0.15, p<0.01) and PWV (partial r=0.22, p<0.0001), neither day-night SBP
(LVMI; partial r=-0.01, p=0.88, PWV: partial r=-0.04, p=0.30) nor % night/day SBP
(LVMI; partial r=0.01, p=0.91, PWV: partial r=0.04, p=0.37) were independently related
to target organ changes. Moreover, the relationships between nurse office-day SBP and
target organ changes persisted with adjustments for either day-night SBP (p<0.05-
p<0.0001) or night SBP (p<0.01-p=0.0001). Thus, although nurse office-day SBP, an
index of an alerting response, is independently associated with an atttenuation of
nocturnal decreases in SBP, neither a decreased BP dipping, nor nocturnal BP explain
the independent relationship between nurse office-day SBP and target organ changes.
Whether nurse office-day BP is affected by antihypertensive therapy, is
uncertain. In the present study the effect of antihypertensive therapy on nurse office-day
BP was assessed in 173 patients whom, off treatment, had a daytime diastolic BP
ranging from 90 to 114 mm Hg. Over the treatment period marked decreases in BP
occurred (p<0.0001). However, neither nurse office-day systolic (baseline=16.5±15.8
mm Hg, 4 months=15.3±18.9 mm Hg, p=0.49), nor diastolic (baseline=0.9±9.3 mm Hg, 4
months=4.3±10.7 mm Hg, p<0.005) BP decreased significantly from baseline. Thus,
despite producing marked decreases in nurse-derived in-office and out-of-office
ambulatory BP, antihypertensive therapy produces no change in nurse-elicited isolated
increases in in-office BP (white coat-effects) in a group of African descent.
In conclusion, the results of the present thesis indicate that in an urban,
developing community of African descent, as compared to 24-hour BP measurements,
nurse-derived BP measurements elicit a significant in-office increase in BP which
translates into a marked underestimation of BP control at a community level; is strongly
associated with organ damage through effects that cannot be attributed to 24-hour BP or
to relationships with an attenuated decline in nocturnal BP; and which cannot be treated
with antihypertensive therapy. Further work is required to assess the most cost-effective
approach to excluding nurse-elicited isolated increases in in-office BP before initiating
antihypertensive therapy to groups of African descent