PEDER AF GEIJERSTAM - Home blood pressure in health and disease

Project description

Background

Hypertension is the major preventable cause of premature all-cause mortality globally, mainly by cardiovascular disease (CVD). Hypertension and diabetes mellitus often co-exist, and both increase the risk of CVD so that the total risk is the combined or even multiplicative risk of each disease. [1] [2] Lowering blood pressure (BP) reduces morbidity and mortality.[3]

BP can be measured at a clinic (office BP) or outside the clinic (out-of-office BP). Out-of-office BP can be further classified into ambulatory blood pressure monitoring in which an automatic reader measures the BP at regular intervals over 24 hours, and home blood pressure monitoring (HBPM) in which patients themselves record their BP multiple times per day for several days.[1, 3]

HBPM measurements significantly predict cardiovascular mortality, which office BP measurements do not.[4] Furthermore, the combination of office and out-of-office BP measurements allows for the diagnosis of the intermediate hypertension phenotypes white coat hypertension and masked hypertension.[5] The latter is more prevalent amongst certain cohorts, including those with obesity and diabetes mellitus.[6] Several guidelines consider out-of-office BP pivotal in the diagnosis of hypertension,[7] but some only recommend it if logistically and economically feasible.[3]

Aim

To study the discrepancy between office BP and HBPM in relationship to dysglycaemia as well as markers of inflammation previously shown to correlate with the disease spectrum of the metabolic syndrome. Furthermore, to investigate the effect on blood pressure discrepancies of two common antidiabetics.

Method

The first, second and third studies will analyze data from the Swedish CardioPulmonary bioImage Study (SCAPIS), a national cohort study of 30 000 participants, of which 5045 participated in a sub-study which included HBPM. In the first study, we will analyse the relationship between the white coat effect and HbA1c and glycaemic status respectively. In the second study, we will analyse the relationship between the white coat effect and four inflammatory markers (leptin, selectin, interleukin 6 and interleukin 18) and obesity. In the third study, we will return to the results of the first study and investigate clinical outcome measures, including CVD and all-cause mortality.

The fourth study will be based on a subset of participants in the SGLT2-inhibitor or Metformin as Standard Treatment in Early Stage Type 2 Diabetes (SMARTEST) study. This national study involves the randomization to either SGLT2 inhibitors or metformin as the standard treatment of early T2DM, and for this subset of participants HBPM will also be obtained. The aim of the study is to compare and quantify the BP reduction that these two different antidiabetics result in.

Relevance

Despite current guidelines and knowledge in how hypertension is diagnosed and monitored, the correlation between BP measurements and glycaemic status is still not fully understood. Increased knowledge could help to further refine both methods of diagnosis, follow-up and treatment of hypertension in patients with dysglycaemia and/or the metabolic syndrome. Furthermore, the fourth study could have direct implications on clinical treatment recommendations for type 2 diabetes mellitus, particularly for patients with co-existing hypertension.

References

1. Cosentino, F., et al., 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J, 2020. 41(2): p. 255-323.
2. Franklin, S.S., et al., Masked hypertension in diabetes mellitus: treatment implications for clinical practice. Hypertension, 2013. 61(5): p. 964-71.
3. Williams, B., et al., 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens, 2018. 36(10): p. 1953-2041.
4. Ward, A.M., et al., Home measurement of blood pressure and cardiovascular disease: systematic review and meta-analysis of prospective studies. J Hypertens, 2012. 30(3): p. 449-56.
5. Stergiou, G.S., et al., Home blood pressure monitoring in the 21st century. J Clin Hypertens (Greenwich), 2018. 20(7): p. 1116-1121.
6. Franklin, S.S., et al., Masked hypertension: a phenomenon of measurement. Hypertension, 2015. 65(1): p. 16-20.
7. Whelton, P.K., et al., 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 2018. 71(6): p. 1269-1324.