Modeling the circadian variability of ambulatorily monitored blood pressure by multiple-component analysis

The use of a set of new end points derived from ambulatory blood pressure monitoring (ABPM), in addition to the blood pressure (BP) values themselves, has been advocated to improve the sensitivity and specificity in diagnosing hypertension and to evaluate a person's response to treatment. An adequate estimation of rhythmic parameters depends, however, on the ability to describe properly the circadian pattern of BP variability. The purpose of this study was to identify a simple model that could characterize sufficiently well the circadian pattern of BP in normotensive healthy volunteers sampled by ambulatory monitoring. We studied 278 clinically healthy Spanish adults (184 men), 22.7±3.3 yr of age, without medical history of hypertension and mean BP from ambulatory profiles always below 135/85 mmHg for systolic/diastolic BP, who underwent sequential ABPM providing a total of 1115 series of BPs and heart rates (HRs), sampled on each occasion at 0.5h intervals for 48 h. Subjects were assessed while adhering to their usual diurnal activity and nocturnal sleep routine, without restrictions but avoiding the use of medication. The circadian rhythm in BP and HR for each subject was established by multiple-component analysis. A statistically significant 24h component is documented for 97% of the BP profiles, with a significant second (12h) harmonic documented in 65% of the profiles. Other ultradian harmonic components were significant in less than 20% of the profiles. A statistically significant increase in the coefficient of determination (percent of overall variability explained by the function fitted to the data) was only obtained after including the periods of 24 and 12 h for BP, and periods of 24, 12, and 6 h for HR in the model components. Although other ultradian components can be demonstrated as statistically significant in a small percent of subjects, a rather simple model including only the two first harmonics of the 24h period describes sufficiently well, at the specified sampling rate, the circadian pattern of BP in normotensive subjects. Departure from this model could characterize overt pathology, as recently demonstrated in the diagnosis of preeclampsia.

[1]  J. Laragh,et al.  How common is white coat hypertension? , 1988, JAMA.

[2]  R. Hermida,et al.  Inferential statistical method for analysis of nonsinusoidal hybrid time series with unequidistant observations. , 1998, Chronobiology international.

[3]  G Parati,et al.  Advantages and disadvantages of non-invasive ambulatory blood pressure monitoring. , 1990, Journal of hypertension. Supplement : official journal of the International Society of Hypertension.

[4]  C. Guilleminault,et al.  Hemodynamics in sleep-induced apnea. Studies during wakefulness and sleep. , 1976, Annals of internal medicine.

[5]  R C Hermida,et al.  Chronolab: an interactive software package for chronobiologic time series analysis written for the Macintosh computer. , 1992, Chronobiology international.

[6]  R. Vandongen,et al.  Diurnal rhythms of blood pressure, plasma renin activity, angiotensin II and catecholamines in normotensive and hypertensive pregnancies. , 1983, Clinical and experimental hypertension. Part B, Hypertension in pregnancy.

[7]  Y. Imai,et al.  Altered circadian blood pressure rhythm in patients with Cushing's syndrome. , 1988, Hypertension.

[8]  R. Hermida,et al.  Diagnosing gestational hypertension and preeclampsia with the 24-hour mean of blood pressure. , 1997, Hypertension.

[9]  R. Hermida,et al.  Circadian blood pressure variability in healthy and complicated pregnancies. , 1997, Hypertension.

[10]  Detection The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) , 1997 .

[11]  J. Wilcox Observer Factors in the Measurement of Blood Pressure , 1962, Journal of the American Medical Association (JAMA).

[12]  M. Timio,et al.  Blood pressure trend and cardiovascular events in nuns in a secluded order: a 30-year follow-up study. , 1997, Blood pressure.

[13]  G. Cornelissen Instrumentation and Data Analysis Methods Needed for Blood Pressure Monitoring in Chronobiology , 1987 .

[14]  C. Goodman Association for the Advancement of Medical Instrumentation , 1988 .

[15]  T. Wiegmann,et al.  Recognition of Hypertension and Abnormal Blood Pressure Burden With Ambulatory Blood Pressure Recordings in Type I Diabetes Mellitus , 1990, Diabetes.

[16]  M Ishii,et al.  [The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, and 1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension]. , 2000, Nihon rinsho. Japanese journal of clinical medicine.

[17]  Lippincott Williams Wilkins,et al.  1993 guidelines for the management of mild hypertension. Memorandum from a World Health Organization/International Society of Hypertension meeting. Guidelines Subcommittee of the WHO/ISH Mild Hypertension Liaison Committee. , 1993, Hypertension.

[18]  H. Becker,et al.  Influence of sleep apnea on 24-hour blood pressure. , 1997, Chest.

[19]  Daniel W. Jones,et al.  The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. , 2003, JAMA.

[20]  G. Cornelissen,et al.  Chronobiologic Blood Pressure Assessment from Womb to Tomb , 1992 .

[21]  COMPUTATION OF MODEL-DEPENDENT TOLERANCE BANDS FOR AMBULATORILY MONITORED BLOOD PRESSURE , 2000, Chronobiology international.

[22]  E B Raftery,et al.  Circadian variation of blood pressure in autonomic failure. , 1983, Circulation.

[23]  D. Sander,et al.  Changes of Orcadian Blood Pressure Patterns After Hemodynamic and Thromboembolic Brain Infarction , 1994, Stroke.

[24]  M. Knapp,et al.  Variations of bloodpressure in hypertensives during sleep. , 1963, Lancet.

[25]  K. Shimada,et al.  Diurnal blood pressure variations and silent cerebrovascular damage in elderly patients with hypertension. , 1992, Journal of hypertension.

[26]  Coats,et al.  Benefits of ambulatory blood pressure monitoring in the design of antihypertensive drug trials. , 1996, Blood pressure monitoring.

[27]  V. Spallone,et al.  Factors determining the 24-h blood pressure profile in normotensive patients with type 1 and type 2 diabetes , 2001, Journal of Human Hypertension.

[28]  W. White,et al.  Clinical evaluation of the Colin ABPM 630 at rest and during exercise: an ambulatory blood pressure monitor with gas-powered cuff inflation. , 1989, Journal of hypertension.

[29]  S. Ancoli-Israel,et al.  Sleep quality and blood pressure dipping in obstructive sleep apnea. , 2001, American journal of hypertension.

[30]  T. Ogihara,et al.  Absence of Nocturnal Fall in Blood Pressure in Elderly Persons with Alzheimer‐Type Dementia , 1990, Journal of the American Geriatrics Society.

[31]  W. A. Littler,et al.  CIRCADIAN VARIATION IN BLOOD-PRESSURE , 1978, The Lancet.

[32]  R. Hornung,et al.  Ambulatory Blood Pressure and Heart Rate in Diabetic Patients: an Assessment of Autonomic Function , 1989, Diabetic medicine : a journal of the British Diabetic Association.

[33]  E. O’Brien,et al.  Defining normal ambulatory blood pressure. , 1993, American journal of hypertension.

[34]  F Halberg,et al.  Chronobiologic assessment of deviant human blood pressure: an invitation for improvements. , 1990, Progress in clinical and biological research.

[35]  K. Shimada,et al.  Silent Cerebrovascular Disease in the Elderly Correlation With Ambulatory Pressure , 1990, Hypertension.

[36]  G. Parati,et al.  Ambulatory blood pressure monitoring in the design of studies on antihypertensive drug efficacy. , 1993, American Journal of Hypertension.

[37]  G. Parati,et al.  Direct and surrogate measures of the white-coat effect: methodological aspects and clinical relevance. , 2000, Journal of hypertension.

[38]  R C Hermida,et al.  Time-qualified reference values for 24 h ambulatory blood pressure monitoring. , 1999, Blood pressure monitoring.

[39]  J L Grashuis,et al.  A new model for diurnal blood pressure profiling. Square wave fit compared with conventional methods. , 1992, Hypertension.

[40]  F Halberg,et al.  Methods for cosinor-rhythmometry. , 1979, Chronobiologia.

[41]  J. Baguet,et al.  Clinical value of ambulatory blood pressure monitoring. , 1999, Journal of hypertension.

[42]  R. Hermida,et al.  Time-Qualified Reference Values for Ambulatory Blood Pressure Monitoring in Pregnancy , 2001, Hypertension.

[43]  G. Parati,et al.  Task force IV: Clinical use of ambulatory blood pressure monitoring. Participants of the 1999 Consensus Conference on Ambulatory Blood Pressure Monitoring. , 1999, Blood pressure monitoring.

[44]  H. Kinoshita,et al.  Disparate circadian variations of blood pressure and body temperature in bedridden elderly patients with cerebral atrophy. , 1995, American journal of hypertension.

[45]  W. Keane,et al.  Correlation of office and ambulatory blood pressure measurements with urinary albumin and N-acetyl-beta-D-glucosaminidase excretions in essential hypertension. , 1988, American journal of hypertension.

[46]  R. Hermida,et al.  Reproducibility of the hyperbaric index as a measure of blood pressure excess. , 2000, Hypertension.

[47]  E. Sforza,et al.  Diurnal blood pressure variation and hormonal correlates in fatal familial insomnia. , 1994, Hypertension.

[48]  J. Staessen,et al.  Ambulatory Blood Pressure Monitoring in Clinical Trials , 1996, Journal of hypertension. Supplement : official journal of the International Society of Hypertension.

[49]  T. Pickering,et al.  The influence of behavioral factors on the daily variation of blood pressure. , 1993, American journal of hypertension.

[50]  M. Massobrio,et al.  Blood Pressure Patterns in Normal Pregnancy and in Pregnancy‐Induced Hypertension, Preeclampsia, and Chronic Hypertension , 1996, Obstetrics and gynecology.

[51]  R. Fogari,et al.  Ambulatory blood pressure monitoring in normotensive and hypertensive type 2 diabetes. Prevalence of impaired diurnal blood pressure patterns. , 1993, American journal of hypertension.

[52]  K. Bailey,et al.  Blood pressure load--a better determinant of hypertension. , 1988, Mayo Clinic proceedings.

[53]  S. Miyamoto,et al.  Circadian rhythm of plasma atrial natriuretic peptide, aldosterone, and blood pressure during the third trimester in normal and preeclamptic pregnancies , 1988, American journal of obstetrics and gynecology.

[54]  R. Hermida,et al.  Blood pressure excess for the early identification of gestational hypertension and preeclampsia. , 1998, Hypertension.

[55]  M. Smolensky,et al.  Circadian Rhythm and Environmental Determinants of Blood Pressure Regulation in Normal and Hypertensive Conditions , 2001 .

[56]  Pierre Corvol,et al.  Influence of observer's expectation on the placebo effect in blood pressure trials , 1987 .

[57]  M. Boscaro,et al.  24-hour blood pressure profile in Addison's disease. , 1994, American journal of hypertension.

[58]  I. Kuwajima,et al.  Diminished nocturnal decline in blood pressure in elderly hypertensive patients with left ventricular hypertrophy. , 1992, American heart journal.

[59]  H. Tohgi,et al.  Twenty-four-hour variation of blood pressure in vascular dementia of the Binswanger type. , 1991, Stroke.

[60]  M. Rutter,et al.  Increased left ventricular mass index and nocturnal systolic blood pressure in patients with Type 2 diabetes mellitus and microalbuminuria , 2000, Diabetic medicine : a journal of the British Diabetic Association.

[61]  F Halberg,et al.  Inferential statistical methods for estimating and comparing cosinor parameters. , 1982, Chronobiologia.

[62]  R. Hermida,et al.  Computation of time-specified tolerance intervals for ambulatorily monitored blood pressure. , 1996, Biomedical instrumentation & technology.

[63]  B. Lemmer Cardiovascular Chronobiology and Chronopharmacology , 2001 .

[64]  P Whelton,et al.  Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988-1991. , 1995, Hypertension.

[65]  B. Waeber,et al.  Clinical value of ambulatory blood pressure monitoring in the assessment of antihypertensive therapy. , 1999, Blood pressure monitoring.

[66]  R. Hermida,et al.  Computer-based medical system for the computation of blood pressure excess in the diagnosis of hypertension. , 1996, Biomedical instrumentation & technology.

[67]  E. O’Brien,et al.  Normotension and hypertension defined by 24-hour ambulatory blood pressure monitoring. , 1995, Blood pressure.

[68]  R. Hermida,et al.  Evaluation of the Blood Pressure Load in the Diagnosis of Hypertension in Pregnancy , 2001, Hypertension.

[69]  G. Schillaci,et al.  Circadian blood pressure changes and left ventricular hypertrophy in essential hypertension. , 1990, Circulation.

[70]  P. Baumgart,et al.  Circadian rhythm of blood pressure: internal and external time triggers. , 1991, Chronobiology international.

[71]  Lance C. LaMotte,et al.  Blood Pressure Monitoring in Cardiovascular Medicine and Therapeutics , 2001 .

[72]  E. O’Brien,et al.  Techniques for measuring blood pressure and their interpretation , 1990 .

[73]  C. Redman,et al.  Reversed diurnal blood pressure rhythm in hypertensive pregnancies. , 1976, Clinical science and molecular medicine. Supplement.

[74]  Dawn K. Wilson,et al.  Sodium, Potassium, the Sympathetic Nervous System, and the Renin-Angiotensin System: Impact on the Circadian Variability in Blood Pressure , 2000 .

[75]  A. J. Honour,et al.  Direct arterial pressure, heart rate, and electrocardiogram in unrestricted patients before and after removal of a phaeochromocyoma. , 1974, The Quarterly journal of medicine.

[76]  H R Patterson,et al.  Sources of error in recording the blood pressure of patients with hypertension in general practice. , 1984, British medical journal.

[77]  A. J. Man in 't Veld,et al.  The Second Sir George Pickering Memorial Lecture What Regulates Whole Body Autoregulation? Clinical Observations , 1985, Journal of hypertension.

[78]  J. Sowers,et al.  Relationship between arterial blood pressure and plasma norepinephrine levels in a patient with neurogenic hypertension. , 1986, The American journal of medicine.

[79]  R. Hermida,et al.  Blood pressure patterns in normal pregnancy, gestational hypertension, and preeclampsia. , 2000, Hypertension.