Hiromichi Sakuma

Ambulatory blood pressure of adults in Ohasama, Japan.

We performed a cross-sectional study in a small town in northern Japan to evaluate the distribution, reference values, and daily variation in ambulatory blood pressure. A total of 705 subjects (229 men aged 61.3 +/- 13.4 years [mean +/- SD] and 476 women aged 57.5 +/- 13.3 years; 41.1% of the regional adult population, n = 1716), including those treated with antihypertensive drugs (n = 231, 66.5 +/- 9.5 years) as well as untreated subjects (n = 474, 55.0 +/- 13.5 years), participated in the study. Both ambulatory and screening blood pressures were measured in 659 subjects. Ambulatory blood pressure was measured with an automatic device (Colin ABPM-630). The 24-hour ambulatory blood pressure in the total population was 121.7 +/- 13.0/71.1 +/- 7.6 mm Hg (95th percentile value [95%] = 146/85 mm Hg). The corresponding value in the untreated subjects was 119.4 +/- 12.5/70.1 +/- 7.4 mm Hg (95% = 144/83 mm Hg). The 24-hour average ambulatory blood pressure was 118.0 +/- 11.1/69.4 +/- 6.8 mm Hg (95% = 139/81 mm Hg) in subjects identified as normotensive by their screening blood pressure (n = 448, 57.2 +/- 13.1 years) and 133.6 +/- 14.2/78.9 +/- 8.8 mm Hg in those identified as hypertensive by their screening blood pressure (n = 73, 63.1 +/- 10.6 years). Based on the mean+SD of the 24-hour ambulatory blood pressure in the normotensive subjects by their screening blood pressure (129/76 mm Hg), the 24-hour ambulatory blood pressures in 25 (34.2%) of these 73 hypertensive subjects by screening blood pressure were below this level. Nine (2%) of 448 normotensive subjects by screening blood pressure were above the mean+2 SDs (140/83 mm Hg) of the 24-hour ambulatory blood pressure in the normotensive group by screening blood pressure. Ambulatory and screening blood pressures increased with age. The age-dependent increase in ambulatory blood pressure was less apparent in men. The 24-hour average pulse rate decreased with age. The daily variation in ambulatory blood pressure (standard deviation) increased with age, whereas that of pulse rate decreased with age. Increases in blood pressure variation were observed in nighttime and daytime blood pressure values. The differences between day versus night ambulatory blood pressures decreased with age in men but not in women.(ABSTRACT TRUNCATED AT 400 WORDS)

Characteristics of a community-based distribution of home blood pressure in Ohasama in northern Japan.

Objective: To evaluate the distribution, reference values and day-to-day variation of blood pressure of untreated subjects measured at home Design: Cross-sectional study of a cohort Setting: General community in northern Japan Subjects: Blood pressure was measured in 871 subjects (mean±SD age 46.0±19.5 years, range 7-98, constituting 38.7% of the local population of Uchikawama region, Ohasama) who were not receiving antihypertensive medication Methods: Subjects measured their own blood pressure at home at least three times (mean±SD 19.718.4) each morning using a semi-automatic oscillometric blood pressure measuring device. Screening blood pressure was measured once. Main outcome measures: Distribution of home blood pressure in the study population as a whole and with respect to age and sex, and the distribution of day-to-day variation of home blood pressure were determined Results: Mean home blood pressure was 117.3±13.4/69.3±9.7mmHg (95% confidence interval 116.4-118.2/68.7-70.0). The 95th centile value was 143/85 mmHg, mean + SD 131/79 mmHg and mean + 2SD 144/89 mmHg. Mean screening blood pressure was 126.2 ±18.9/72.1 ±11.7 mmHg (95th centile 159/92 mmHg). Age- and sex-specific 95th centile values as well as mean±SD were obtained. Mean + SD, mean + 2SD and the 95th centile values obtained as reference upper limits of home blood pressure from subjects identified as normotensive by screening blood pressure (n=707) were 125/77, 137/86 and 134/83 mmHg, respectively. Home blood pressure increased gradually with increasing age in both men and women, although blood pressure was significantly higher in men until 50 years of age. Day-to-day variation of home systolic blood pressure also increased with age Conclusions: Since the distribution of home blood pressure values was affected by age and sex, age- and sex-matched reference values for home blood pressure should be established. Home blood pressure values in elderly subjects should be evaluated carefully, since these exhibit greater day-to-day variation

Clinical evaluation of semiautomatic and automatic devices for home blood pressure measurement: comparison between cuff-oscillometric and microphone methods.

The accuracy and reliability of blood pressure (BP) values were evaluated by comparing values obtained with eight automatic or semiautomatic devices designed for home BP measurement (four microphone devices based on the Korotkoff-sound technique and four cuff-oscillometric devices) with those obtained by the auscultatory method, using a standard mercury sphygmomanometer. Systolic blood pressure (SBP) values obtained using the microphone devices coincided well with those obtained by the auscultatory method. However, these devices produced a certain proportion of errors in the measurement of diastolic blood pressure (DBP), sometimes resulting in recordings at least 25mmHg higher than those obtained by the standard method. The most frequent causes of this phenomenon were an auscultatory (silent) gap and a weak Korotkoff sound after phase IV. A microphone device using a condenser microphone built into the manometer displayed comparatively good acoustic characteristics for determining DBP. All cuff-oscillometric devices demonstrated minimal mean differences and a constant s.d. of mean difference for DBP, with no great differences from the auscultatory method. However, mean differences and s.d.s in SBP measurements using cuff-oscillometric devices were relatively greater than those obtained using some of the microphone devices. Furthermore, the direction of the mean differences in measurements from those obtained with the auscultatory method differed. The error in relation to the auscultatory method tended to be reproducible in the same subjects with both the microphone and the cuff-oscillometric devices. These results indicate that practitioners should select the most appropriate method and/or device by taking into account the factors which may cause measurement error in relation to the auscultatory method in each subject, and should then evaluate, at least once, the difference in BP values obtained using the auscultatory method and using the device. In future, home blood pressure measurement devices for determination of SBP should employ a microphone method, while a method which combines a microphone with a cuff-oscillometric device, thereby compensating for the disadvantage of the Korotkoff-sound signal with the pulse wave signal, should be recommended for measurement of DBP.

Nocturnal Blood Pressure and Silent Cerebrovascular Lesions in Elderly Japanese

BACKGROUND AND PURPOSE We conducted a cross-sectional epidemiological survey using ambulatory blood pressure monitoring and brain MRI in a cohort from northern Japan to determine whether an inappropriately low nocturnal blood pressure, or an excess fall in nocturnal blood pressure, might be responsible for silent cerebrovascular lesions in the elderly. METHODS Untreated subjects over 55 years and under 64 years of age (late middle age; 24 men and 46 women, 60% of eligible people) and over 65 years and under 75 years of age (elderly; 29 men and 52 women, 91% of eligible people) participated in the study. We evaluated the relationship between the amplitude (Daytime Average-Nighttime Average) or the rate ([Daytime Average-Nighttime Average]/Daytime Average) of the fall in nocturnal blood pressure and the incidence of silent cerebrovascular lesions on MRI (number of lacunar infarctions or extent of periventricular hyperintensity). RESULTS The amplitude or the rate of the fall in nocturnal blood pressure in elderly women with one or two lacunar infarctions was significantly higher than that in those without such infarctions. There was a significant positive correlation between the amplitude or the rate of the fall in nocturnal blood pressure and the extent of periventricular hyperintensity in the elderly women. This relationship was observed in women, but not in men, of late middle age; this was not seen in elderly men. CONCLUSIONS Results indicate that an inappropriately low nocturnal blood pressure, or an excessive fall in nocturnal blood pressure, is associated with ischemic silent cerebrovascular lesions, at least in elderly women. Treatment of hypertension in such women should be administered with care and with regard to nocturnal blood pressure.

Reproducibility of Home Blood Pressure Measurements Over a 1-Year Period

We compared the reproducibility over time of blood pressure measured at the health examinations (screening blood pressure) and blood pressure measured at home (home blood pressure). Both screening and home blood pressure were measured in subjects of a rural community. Subjects measured their own blood pressure at home once in the morning using a semiautomatic oscillometric blood pressure measuring device at least three times (on at least 3 days) in each of two 4-week periods separated by one year. Similarly, two screening blood pressure measurements were obtained from the subjects at each of two health examinations also taken 1 year apart. A total of 136 untreated subjects without cardiovascular complications (40 men and 96 women, 56 +/- 11.7 years, mean +/- SD) were analyzed in the study. The correlations between the first and second blood pressure measurements of the subjects were significantly higher for the home blood pressure measurements (systolic: r = 0.844 and diastolic: r = 0.830) than for the screening blood pressure measurements (systolic: r = 0.692 and diastolic: r = 0.570). The mean differences between the first and second home blood pressure (0.8 +/- 7.7 mm Hg for systolic BP and 0.9 +/- 5.5 mm Hg for diastolic BP) were significantly smaller than those for the screening blood pressure (-3.9 +/- 13.8 for systolic BP and -3.1 +/- 10.2 for diastolic BP) (P < .001 for both comparisons), suggesting that the reproducibility of home blood pressure over time is superior to that of screening blood pressure. Such reliable blood pressure measurements obtained at home have a clinical significance for the diagnosis and treatment of hypertension and as a tool for evaluating the efficacy of antihypertensive drugs. Home blood pressure measurements also may be more useful than screening blood pressure measurements in predicting future cardiovascular events.

Assessment of age-dependent changes in circadian blood pressure rhythm in patients with essential hypertension

The effects of age on the circadian blood pressure rhythm of patients with untreated essential hypertension (n = 133, World Health Organization stage I or II) were compared with those of normotensive subjects (n = 91). Subjects were classified into three groups by age: young (less than 40 years old), adult (40-59 years old) and old (greater than or equal to 60 years old). Blood pressure was monitored every 5 min for 24 h, using a finger volume oscillometric device under fixed external conditions. The single cosinor method was used to evaluate circadian rhythm. There was no difference in the amplitude of circadian systolic or diastolic blood pressure rhythm among the different normotensive and essentially hypertensive age groups although a wide distribution of amplitude was noted within each group. The distribution of amplitude was wider in the hypertensive than in the normotensive groups. The amplitude of circadian blood pressure rhythm was independent of the mesor level. On the other hand, the amplitude of circadian heart rate rhythm decreased with increasing age both in normotensive subjects (P less than 0.05, young versus adult or old) and hypertensive patients (P less than 0.01, young and old versus adult). The acrophase of circadian systolic blood pressure rhythm in young hypertensives was greater than that in adult or old hypertensives (P less than 0.05, for both). Such age-dependent changes were not observed in the normotensive groups. Consequently, the acrophase of circadian systolic or diastolic blood pressure rhythm in young hypertensives was larger than that in young normotensives (P less than 0.05, for both systolic and diastolic blood pressure).(ABSTRACT TRUNCATED AT 250 WORDS)

Circadian blood pressure variation in patients with renovascular hypertension or primary aldosteronism.

Circadian blood pressure (BP) variation were studied in patients with renovascular hypertension (RVH) and primary aldosteronism (PA). Ambulatory BP (ABP) was monitored every 5 min for 24 hrs in a ward setting in 23 patients with PA and 17 patients with RVH (13 patients with unilateral renal arterial stenosis and 4 with bilateral stenosis). In patients with RVH, ABP was monitored before and after treatment with a converting enzyme inhibitor or percutaneous transluminal angioplasty. Plasma renin activity (PRA) was high before percutaneous transluminal angioplasty in almost all patients with RVH and low in those with PA. Ordinary circadian BP variation, i.e. nocturnal fall and diurnal rise in BP, was confirmed in the patients with unilateral or bilateral renal artery stenosis. Percutaneous transluminal angioplasty successfully normalized both BP and PRA in those with RVH. Normal circadian BP variation was observed in those with RVH before the treatment with a converting enzyme inhibitor or percutaneous transluminal angioplasty as well as during treatment with the former and after treatment with the latter. Circadian BP variation in the patients with RVH was affected by the pathogenesis of renal artery stenosis alone, i.e, fibromuscular hyperplasia and atherosclerosis; with fibromuscular hyperplasia normal circadian BP variation was observed, while with atherosclerosis, nocturnal BP fall was restricted or eliminated. Circadian BP variation in those with PA before and after excision of adrenal adenoma was essentially similar to that in normal subjects and essential hypertensive patients. From these it seems that in patients with RVH or PA, circadian BP variation is not affected by hypertension per se or by pathogenesis of hypertension.

Muscle cramps and elevated serum creatine phosphokinase levels induced by β-adrenoceptor blockers

We have assessed the propensity of β-adrenoceptor blockers to cause muscle cramps and to raise the serum creatine phosphokinase (CPK) level in 78 patients with essential hypertension. After a control period, a β-adrenoceptor blocker without intrinsic sympathomimetic activity (ISA; propranolol, metoprolol or arotinolol) was administered for three months. Thereafter, the patients were randomised to receive a β-adrenoceptor blocker with ISA (pindolol or carteolol) for three months or a β-adrenoceptor blocker without ISA for a further three months. This pattern was continued until all β-adrenoceptor blockers had been given. At the end of each period, CPK and CPK-MB levels were measured.Of the 78 subjects, muscle cramps occurred in 27 during treatment with pindolol and 32 during treatment with carteolol. No complaints were made by subjects treated with propranolol and arotinolol, but muscle cramps were reported in 2 treated with metoprolol. While muscle cramps were caused both by pindolol and carteolol in 16 subjects, they were caused by either of these drugs in the remainder of the subjects. Muscle cramp occurred mainly in the calves when the patients were in bed at night. Serum CPK and CPK-MB levels increased significantly during treatment with pindolol (control period vs pindolol, CPK=96 vs 133 IU · ml−1, CPK-MB=14 vs 18 IU · ml−1) or carteolol (CPK=117 IU · ml−1, CPK-MB=18 IU · ml−1) while the levels during treatment with propranolol, arotinolol and metoprolol did not change from those in the control period. The change in serum CPK during treatment with carteolol or pindolol was significantly correlated with the control serum CPK level. No correlation was observed between muscle cramps and serum CPK level. There were individual differences in the severity of muscle cramps, with some subjects complaining frequently of severe muscle cramps.Because muscle cramps are frequently experienced at night, they disturb sleep and lower the quality of life in patients. This problem should be considered during treatment with β-adrenoceptor blockers with ISA.

Pressor Effect of Recombinant Human Erythropoietin: Results of Ambulatory Blood Pressure Monitoring and Home Blood Pressure Measurements

We investigated whether treatment of anemic hemodialysis patients with a low dose of recombinant human erythropoietin (erythropoietin) for a short period would increase their blood pressure. Ambulatory blood pressure monitoring and home blood pressure measurements were used to detect minute increase in blood pressure. Thirty-two patients with a hematocrit of 25% or less received erythropoietin at the dose of 4500 IU/week, by the intravenous route for 8 weeks. Erythropoietin increased the hematocrit from 20.9 +/- 2.1 to 26.2 +/- 2.1%. Erythropoietin elevated mean ambulatory blood pressure by 5 mmHg or more in two-thirds of patients (n = 20; pressor group), while it elevated home mean blood pressure by 5 mmHg or more in one-third of patients (n = 11). An increase in clinic mean blood pressure by more than 5 mmHg was observed only in one-fourth of patients (n = 7). Circadian variation of blood pressure (nocturnal fall and diurnal rise) had been attenuated in the patients of the pressor group before erythropoietin treatment and erythropoietin decreased the nocturnal fall of blood pressure further more. Erythropoietin elevated nocturnal blood pressure more than diurnal blood pressure. Therefore, the increase in blood pressure induced by erythropoietin was detected more reliably by ambulatory blood pressure monitoring. There was no relation between the change in hemoglobin concentration and the increase in ambulatory blood pressure induced by erythropoietin. Erythropoietin tended to decrease cardiac output and plasma volume while it increased total peripheral resistance. It also decreased plasma norepinephrine and vasopressin levels but did not affect other humoral factors. Although the pressor effect of erythropoietin treatment for 8 weeks at the dose of 4500 IU/week was not evident on clinic blood pressure measurements, any increase in blood pressure determined by ambulatory blood pressure should be treated carefully to reduce the risk of a cardiovascular complication in patients receiving hemodialysis.

Compliance with Long-Term Dietary Salt Restriction in Hypertensive Outpatients

Eighty hypertensive outpatients were recruited for a dietary salt restriction program to examine long-term compliance. Twenty-four-hour urine samples were collected repeatedly (7.9 +/- 2.6 times, mean +/- s.d.) during a follow-up period of 6.4 +/- 1.7 years. After initial urine collection, nutritional education was carried out by dietitians to reduce dietary salt intake to 8 g/day or less. After every urine collection, the subjects were given advice by doctors on salt restriction, if necessary. The mean 24-hour urinary salt excretion (U-NaCl) and the mean urinary salt/creatinine ratio (U-NaCl/U-Cr) varied considerably both among and within individuals. U-NaCl/U-Cr, but not U-NaCl, in females was significantly higher than that in males, and in middle-aged subjects than in young subjects. U-NaCl and U-NaCl/U-Cr tended to decrease in the summer. In spite of the repeated educational effort, neither U-NaCl nor U-NaCl/U-Cr was different in the first control samples from that in the last samples. When 57 subjects were divided into three groups according to the urinary salt excretion level, U-NaCl was consistently higher during a follow-up period in the high-salt excretion group than in the mid-salt excretion group, while U-NaCl in the low-salt excretion group was initially lower than, but finally similar to, that in the mid-salt excretion group. These results suggest that: (1) multiple 24-hour urine samplings are required to assess urinary salt excretion in individuals; (2) the influence of age and sex should be taken into account in interpreting U-NaCl/U-Cr; and (3) it seems difficult to achieve long-term dietary salt restriction as a non-pharmacologic treatment of hypertension in an outpatient clinic.