Abstract
Background
The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends ambulatory BP monitoring to exclude white coat hypertension (WCH) among adults with office systolic BP (SBP)/diastolic BP (DBP) of 130–159/80–99 mm Hg, and masked hypertension (MHT) among adults with office SBP/DBP of 120–129/75–79 mm Hg after a 3-month trial of lifestyle modification. We estimated the proportion of individuals with ideal lifestyle factors among those who meet these office BP criteria.
Methods
We analyzed data from participants not taking antihypertensive medication in the Coronary Artery Risk Development in Young Adults (CARDIA) and Jackson Heart Study (JHS) who met the office BP criteria for screening for WCH (CARDIA n = 490, JHS n = 873) and MHT (CARDIA n = 486, JHS n = 614). We estimated the prevalence of lifestyle factors including ideal body mass index (BMI), physical activity, diet, and alcohol use among participants who met office BP criteria for WCH or MHT screening.
Results
Among participants who met office BP criteria for WCH screening, 15.5% in CARDIA and 3.6% in JHS had 3 or more ideal lifestyle factors. Among participants who met office BP criteria for MHT screening, 22.6% in CARDIA and 4.7% in JHS had 3 or more ideal lifestyle factors. Ideal BMI, diet, and physical activity were present in less than half of participants in each sample.
Conclusions
Few participants who met office BP criteria for the screening of WCH or MHT had ideal lifestyle factors.
Keywords: ambulatory blood pressure monitoring, blood pressure, Coronary Artery Risk Development in Young Adults (CARDIA), hypertension, ideal lifestyle factors, Jackson Heart Study (JHS), masked hypertension, white coat hypertension
Graphical Abstract
To screen for hypertension, it is recommended to measure blood pressure (BP) in the office setting.1,2 Out-of-office BP monitoring is recommended for confirming the diagnosis of hypertension for most adults with office-measured BP above the threshold used to define hypertension and to rule out the presence of hypertension among adults with office BP below, but close to, the threshold used to define hypertension.1,2 White coat hypertension (WCH) is defined by having high office BP without high out-of-office BP, and masked hypertension (MHT) is defined as having high out-of-office BP without high office BP.1,2 For adults with an office systolic BP/diastolic BP (SBP/DBP) of 130–159/80–99 mm Hg, the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High BP in Adults recommends conducting ambulatory BP monitoring (ABPM) to assess for the presence of WCH after a 3-month trial of lifestyle modification.3 For adults with an office SBP/DBP of 120–129/75–79 mm Hg, the 2017 ACC/AHA BP guideline recommends ABPM to assess for the presence of MHT after a 3-month trial of lifestyle modification.3 However, prior studies that have evaluated the associations of WCH and MHT with cardiovascular disease (CVD) risk did not require that individuals undergo a trial of lifestyle modification prior to conducting ABPM.4–6 The proportion of adults that meet the office BP criteria for conducting ABPM to assess for WCH and MHT who would first be recommended a trial of lifestyle modification is unknown. Addressing this knowledge gap is important since there may be a delay in starting antihypertensive medication for individuals who will continue to meet the BP criteria for WCH or MHT screening after a trial of lifestyle modification and ultimately have high BP on ABPM.
The goal of the present study was to determine the proportion of adults meeting the office BP criteria in the 2017 ACC/AHA BP guideline for ABPM to assess for WCH and MHT that had ideal levels of lifestyle factors. Specifically, we determined the proportion of individuals who met office BP criteria for being recommended ABPM that had ideal levels of 4 lifestyle factors: body mass index (BMI), diet, physical activity, and alcohol intake. We also determined the proportion of adults with WCH and MHT that had ideal levels of each of these lifestyle factors. To estimate these proportions, we analyzed data from 2 cohorts, the Coronary Artery Risk Development in Young Adults (CARDIA) study and the Jackson Heart Study (JHS).
METHODS
The data that support the findings of this study are available upon reasonable request and documentation of human subject protection approval from the JHS and CARDIA Publication Committees.
Study population
Detailed descriptions of the CARDIA study and JHS protocols have been published.7,8 Briefly, the CARDIA study enrolled a population-based sample of 5,115 white and black adults, who were 18–30 years old in 1985–1986 at 4 centers in the United States (Birmingham, AL, Chicago, IL, Minneapolis, MN, and Oakland, CA). The JHS enrolled a community-based cohort of 5,306 black adults, 21 years and older, in 2000–2004 from the Jackson, MS metropolitan area. Institutional Review Boards at each site approved the study protocols. All participants provided written informed consent.
ABPM was conducted for a subset of participants at the Year 30 Exam for CARDIA and the baseline exam for the JHS. Therefore, we used data from these visits for the current analysis. Of the 3,358 CARDIA study participants who attended the Year 30 Exam in 2015–2016, 2,180 had complete data on lifestyle factors, office BP, and antihypertensive medication use, and were not taking antihypertensive medication. There were 5,306 JHS participants who attended Exam 1 in 2000–2004, of whom 2,259 had complete data on lifestyle factors, office BP, and antihypertensive medication use, and were not taking antihypertensive medication.
Using the office BP thresholds recommended in the 2017 ACC/AHA BP guideline,3 we categorized participants as being eligible for the analysis of WCH or MHT (Figure 1). Participants with (i) office SBP ≥130 and <160 mm Hg or office DBP ≥80 and <100 mm Hg, and (ii) office SBP <160 mm Hg and office DBP <100 mm Hg (n = 1,363) were included in the analysis of WCH. Participants with (i) office SBP ≥120 and <130 mm Hg, or office DBP ≥75 and <80 mm Hg, and (ii) office SBP <130 mm Hg and office DBP <80 mm Hg (n = 1,100) were included in the analysis of MHT. In the analysis of WCH and MHT, participants were then identified to have WCH and MHT, respectively, as defined below.
Figure 1.
Study design. Abbreviations: APBM, ambulatory blood pressure monitoring; BP, blood pressure; MHT, masked hypertension; WCH, white coat hypertension. Analyses were stratified by study cohort (Coronary Artery Risk Development in Young Adults Study [CARDIA] and Jackson Heart Study [JHS]). All study participants had complete data on lifestyle factors, office BP, and antihypertensive medication use, and were not taking antihypertensive medication.
Data collection
Demographics and CVD risk factors
For both studies, information on age, race, and sex were collected at the baseline exams. Data on education, family income, smoking status, diabetes, reduced estimated glomerular filtration rate, albuminuria, and antihypertensive medication use (Supplementary Table S1 online) were collected at the Year 30 Exam for the CARDIA study and baseline visit for JHS.
Lifestyle factors
Four health behaviors, assessed in the CARDIA study and JHS, were used in the current analysis: BMI, healthy diet, physical activity, and alcohol intake (Supplementary Table S2 online). These lifestyle factors are recommended to prevent hypertension and control BP among adults with hypertension in the 2017 ACC/AHA BP guideline.3,9–14 In each study, BMI was calculated as weight in kilograms divided by height in meters squared. In the CARDIA study, diet was assessed at the Year 20 Exam using an interviewer administered semi-quantitative food frequency questionnaire and deriving a Dietary Approaches to Stop Hypertension (DASH) diet adherence score (8–32-point scale).11 Data on the DASH diet are not available at Year 30 in the CARDIA study. We assumed the DASH diet score did not substantially change between Year 20 and 30 Exams based on a prior CARDIA study including Year 20 data in which the proportion of participants with ideal DASH diet scores was very low and not different by age.9 In JHS, diet was assessed using a 158-item food frequency questionnaire developed and validated for this cohort.10 In CARDIA, an exercise score was computed by multiplying the sum of months of infrequent activity plus 3 times the months of frequent activity by intensity of the activity, and summing over all activities, as evaluated in the CARDIA Physical Activity History Questionnaire. The score was expressed in “exercise units” (EU); 300 EU is equivalent to the US Department of Health and Human Services’ recommendation of at least 150 minutes of moderate-intensity activity per week.13 Physical activity was assessed using the JHS Physical Activity questionnaire, evaluating the duration and frequency of the 3 most common physical activities performed over the past year, and quantifying this into “number of minutes/week” spent in moderate or vigorous physical activity. Alcohol use was quantified through answers to questions on the number of drinks per week. In CARDIA, 1 drink was defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of hard liquor. In JHS, 1 drink was defined as 12 ounces of beer, 4 ounces of wine, or 1 ounce of hard liquor. Based on groupings in prior studies, each individual health behavior was categorized as being ideal or not (Supplementary Table S3 online). The total number of ideal health behaviors, 0–4, was calculated for each participant.
BP measurement
Office BP
In the CARDIA study, BP was measured 3 times by trained and certified staff on participants’ right arm using the Omron HEM 907XL device (Omron Healthcare, Lake Forest, IL) and an appropriately sized cuff. Consistent with prior CARDIA analyses,15 office BP was defined as the mean of the second and third readings. In the JHS, 2 office SBP and DBP measurements were taken using a Hawksley random zero sphygmomanometer and an appropriately sized cuff. Office BP was defined as the mean of the 2 readings. BP measurements were calibrated using robust regression to the Omron HEM-907XL device.16
Ambulatory BP monitoring
In the CARDIA study, ABPM was conducted using a Spacelabs 90227 device following the Year 30 Exam in 781 participants. In the JHS, ABPM was conducted using the Spacelabs 90207 device following the baseline exam in 1,046 participants. SBP and DBP were measured every 30 minutes in the CARDIA study and every 20 minutes in the JHS over a 24-hour period. The times when participants were awake and asleep were determined by wrist actigraphy supplemented by self-report in the CARDIA study and by self-report only in the JHS. For JHS participants without self-reported sleep information (n = 197), the awake and asleep periods were defined as 10:00 to 20:00 and 00:00 to 06:00, respectively.17 Mean awake and asleep SBP and DBP were calculated using all available measurements during the awake and asleep periods, respectively. Mean 24-hour SBP and DBP were calculated using all available measurements during the monitoring period. In accordance with the International Database of Ambulatory Blood Pressure in relation to Cardiovascular Outcome (IDACO) criteria, a complete ABPM recording was defined by ≥10 awake and ≥5 asleep SBP and DBP measurements.18
WCH and MHT
Among participants who met the office BP criteria for screening with ABPM to detect WCH, WCH was defined as having mean awake SBP <130 mm Hg and mean awake DBP <80 mm Hg. Among participants who met the office BP criteria for screening with ABPM to detect MHT, MHT was defined as having mean awake SBP ≥130 mm Hg or mean awake DBP ≥80 mm Hg.3
Statistical analysis
A total of 10 imputed datasets were created using predictive mean matching for continuous variables and logistic or multinomial regression for categorical variables with 2 or >2 categories, respectively, to account for missing mean BP data on ABPM (Supplementary Table S4 online). Multiple imputation was conducted using the mice R package.19
Participant characteristics were computed in each cohort, among those who met the office BP criteria recommended in the 2017 ACC/AHA BP guideline for the screening of WCH and MHT. The percentage of participants with 1 or more, 2 or more, 3 or more, and 4 ideal lifestyle factors, and the percentage with each ideal lifestyle factor, was determined among those who met the office BP criteria for the screening of WCH and among those with WCH. Also, these statistics were calculated for participants who met the office BP criteria for the screening of MHT and among those with MHT. Analyses were conducted for the JHS and CARDIA study, separately, as the definitions and prevalence of ideal lifestyle factors differed between the studies.
We performed 2 sensitivity analyses. First, the analyses were conducted using alternative definitions of WCH and MHT based on 24-hour BP, and separately, awake, 24-hour, and asleep BP (Supplementary Table S5 online).1,2 Second, the analyses were conducted after restricting the analysis to participants with complete ABPM data including 106 participants in CARDIA and 159 participants in JHS who met the office BP criteria for the screening of WCH, and 121 participants in CARDIA and 109 participants in JHS who met the office BP criteria for the screening of MHT. Analyses were conducted using SAS 9.4 (SAS Institute, Cary, NC) and R version 4.0.2 (Vienna, Austria).
RESULTS
Characteristics
Among participants who met the office BP criteria recommended in the 2017 ACC/AHA BP guideline for the screening of WCH, the mean ± SD age was 55.1 ± 3.6 years in CARDIA and 52.9 ± 11.7 years in JHS; 54.3% and 51.9% were female and 53.7% and 100.0% were black, in CARDIA and JHS, respectively (Table 1). Among participants who met the office BP criteria recommended in the 2017 ACC/AHA BP guideline for the screening of MHT, the mean ± SD age was 54.9 ± 3.5 years in CARDIA and 49.6 ± 12.1 years in JHS; 52.9% and 58.6% were female, and 44.9% and 100.0% were black, in CARDIA and JHS, respectively.
Table 1.
Characteristics of participants who met the office blood pressure criteria for screening of white coat hypertension and masked hypertension, overall and by study cohort
| Characteristic | Met the office BP criteria for screening of white coat hypertension | Met the office BP criteria for screening of masked hypertension | ||||
|---|---|---|---|---|---|---|
| Overall (N = 1,363) |
CARDIA (N = 490) |
JHS (N = 873) |
Overall (N = 1,100) |
CARDIA (N = 486) |
JHS (N = 614) |
|
| Age | 53.7 (9.6) | 55.1 (3.6) | 52.9 (11.7) | 51.9 (9.7) | 54.9 (3.5) | 49.6 (12.1) |
| Female sex, % | 52.8% | 54.3% | 51.9% | 56.1% | 52.9% | 58.6% |
| Black, % | 83.3% | 53.7% | 100.0% | 75.6% | 44.9% | 100.0% |
| Education | ||||||
| Attended vocational, trade school, or college | 69.4% | 76.9% | 65.2% | 73.6% | 74.9% | 72.6% |
| High school graduate/GED | 19.9% | 21.0% | 19.2% | 19.0% | 21.2% | 17.3% |
| Less than high school | 10.7% | 2.0% | 15.6% | 7.4% | 3.9% | 10.1% |
| Family income <$25,000, % | 26.9% | 15.7% | 34.3% | 21.7% | 14.7% | 28.0% |
| Smoking status | ||||||
| Current smoker, % | 16.4% | 15.7% | 16.7% | 13.4% | 14.7% | 12.4% |
| Past smoker, % | 18.6% | 22.9% | 16.2% | 18.7% | 23.9% | 14.5% |
| Never smoker, % | 65.1% | 61.4% | 67.1% | 67.9% | 61.4% | 73.1% |
| Diabetes, % | 12.2% | 10.4% | 13.2% | 9.4% | 6.7% | 11.5% |
| Reduced eGFR, % | 1.5% | 1.9% | 1.3% | 1.7% | 1.9% | 1.5% |
| Albuminuria, % | 9.5% | 9.6% | 9.4% | 4.8% | 5.0% | 4.6% |
| Lifestyle factors | ||||||
| BMI, kg/m2 | 31.4 (7.1) | 31.7 (6.6) | 31.3 (7.3) | 30.1 (6.5) | 29.9 (6.4) | 30.3 (6.5) |
| Ideal diet scorea, % | 9.9% | 25.9% | 0.9% | 13.4% | 29.0% | 1.0% |
| Ideal physical activityb, % | 26.6% | 41.8% | 18.0% | 33.7% | 47.1% | 23.1% |
| Alcohol use | ||||||
| None, % | 47.0% | 38.8% | 51.7% | 44.2% | 41.6% | 46.3% |
| Moderate, % | 43.6% | 42.9% | 44.0% | 47.3% | 43.6% | 50.2% |
| Heavy, % | 9.4% | 18.4% | 4.4% | 8.5% | 14.8% | 3.6% |
| SBP | ||||||
| Office SBP, mm Hg | 134.1 (10.0) | 134.5 (9.5) | 133.9 (10.4) | 120.6 (6.0) | 121.5 (5.4) | 119.9 (6.3) |
| Awake SBP, mm Hg | 136.3 (14.3) | 141.7 (15.7) | 132.5 (12.0) | 126.7 (10.7) | 130.0 (10.7) | 123.2 (9.4) |
| Asleep SBP, mm Hg | 122.0 (13.7) | 121.4 (15.3) | 122.4 (12.6) | 113.7 (11.7) | 112.6 (11.6) | 114.9 (11.7) |
| 24-Hour SBP, mm Hg | 131.4 (13.2) | 135.5 (14.6) | 128.7 (11.5) | 122.2 (9.9) | 124.0 (10.0) | 120.2 (9.4) |
| DBP | ||||||
| Office DBP, mm Hg | 82.3 (6.7) | 83.8 (6.2) | 81.5 (6.8) | 74.7 (4.3) | 74.9 (4.1) | 74.6 (4.5) |
| Awake DBP, mm Hg | 83.6 (8.7) | 87.1 (7.7) | 81.3 (8.5) | 79.2 (8.0) | 81.8 (7.1) | 76.2 (7.9) |
| Asleep DBP, mm Hg | 71.2 (8.3) | 71.9 (8.2) | 70.7 (8.3) | 67.6 (7.6) | 67.9 (7.1) | 67.1 (8.1) |
| 24-Hour DBP, mm Hg | 79.3 (8.0) | 82.3 (6.8) | 77.2 (8.1) | 75.0 (7.1) | 77.1 (6.4) | 72.7 (7.1) |
Data are expressed as mean (SD) or percentage. Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; BMI, body mass index; BP, blood pressure; CARDIA, Coronary Artery Risk Development in Young Adults study; DASH, Dietary Approaches to Stop Hypertension; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate; JHS, Jackson Heart Study; SBP, systolic blood pressure.
aDASH diet adherence score in CARDIA study (8–32-point scale), and number of components of the American Heart Association 2020 Strategic Impact Goals for healthy diet in the JHS (0–5-point scale). In the CARDIA study, ideal diet score was defined as the top quartile from DASH diet adherence score. In the JHS, ideal diet score was defined as having 4–5 components of the American Heart Association 2020 Strategic Impact Goals for healthy diet.
bExercise units for CARDIA study and number of minutes of moderate and/or vigorous physical activity per week for JHS. In the CARDIA study, ideal physical activity as defined as ≥300 exercise units. In the JHS, ideal physical activity was defined as >150 minutes of moderate physical activity, ≥75 minutes of vigorous physical activity, or ≥150 minutes of combined moderate and vigorous physical activity.
White coat hypertension
Overall, 15.5% of participants in CARDIA and 3.6% of participants in JHS who met the office BP criteria for the screening of WCH had 3 or more ideal lifestyle factors (Table 2). Among those with WCH defined using awake BP, 15.6% of participants in CARDIA and 4.3% in JHS had 3 or more ideal lifestyle factors. Among participants who met the office BP criteria for the screening of WCH, 13.3% in CARDIA and 16.4% in JHS had ideal BMI, 25.9% in CARDIA and 0.92% in JHS had ideal diet, and 41.8% in CARDIA and 18.0% in JHS had ideal physical activity, and 81.6% in CARDIA and 95.6% in JHS had ideal alcohol intake. Among those with WCH, 10.4% in CARDIA and 13.1% in JHS had ideal BMI, 26.5% in CARDIA and 0.81% in JHS had ideal diet, and 36.0% in CARDIA and 20.6% in JHS had ideal physical activity, and 90.0% in CARDIA and 93.5% in JHS had ideal alcohol intake.
Table 2.
Distribution of the number of ideal lifestyle factors (upper panel) and each ideal lifestyle factor (lower panel) among participants who met the 2017 ACC/AHA guideline office blood pressure criteria for screening of white coat hypertension, and the subgroup with white coat hypertension, defined using awake blood pressure
| Number of ideal lifestyle factorsa (%) | ||||
|---|---|---|---|---|
| 1 or more | 2 or more | 3 or more | 4 | |
| Among participants who met the office BP criteria for screening of white coat hypertensionb | ||||
| CARDIA | 93.3 | 50.8 | 15.5 | 3.1 |
| JHS | 97.4 | 29.9 | 3.6 | 0.11 |
| Among participants with white coat hypertensionc | ||||
| CARDIA | 97.6 | 46.5 | 15.6 | 3.1 |
| JHS | 95.8 | 28.0 | 4.3 | 0.03 |
| Individual lifestyle factors (%) | ||||
| Ideal BMI | Ideal diet | Ideal physical activity | Ideal alcohol intake | |
| Among participants who met the office BP criteria for screening of white coat hypertensionb | ||||
| CARDIA | 13.3 | 25.9 | 41.8 | 81.6 |
| JHS | 16.4 | 0.92 | 18.0 | 95.6 |
| Among participants with white coat hypertensionc | ||||
| CARDIA | 10.4 | 26.5 | 36.0 | 90.0 |
| JHS | 13.1 | 0.81 | 20.6 | 93.5 |
Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; BMI, body mass index; BP, blood pressure; CARDIA, Coronary Artery Risk Development in Young Adults Study; DBP, diastolic blood pressure; JHS, Jackson Heart Study; SBP, systolic blood pressure.
aIdeal lifestyle factors were based on ideal levels of body mass index, diet score, physical activity, and alcohol intake.
bOffice BP criteria for screening of white coat hypertension as recommended in the 2017 ACC/AHA guideline: SBP 130–159 or DBP 80–99 mm Hg.
cDefined using awake blood pressure on ambulatory blood pressure monitoring as having mean awake SBP <130 mm Hg and mean awake DBP <80 mm Hg.
Masked hypertension
Overall, 22.6% of participants in CARDIA and 4.7% of participants in JHS who met the office BP criteria for the screening of MHT had 3 or more ideal lifestyle factors (Table 3). Among the subgroup of participants with MHT defined using awake BP, 21.8% in CARDIA and 6.2% in JHS had 3 or more ideal lifestyle factors. Among participants who met the office BP criteria for the screening of MHT, 21.4% in CARDIA and 19.2% in JHS had ideal BMI, 29.0% in CARDIA and 0.98% in JHS had ideal diet, and 47.1% in CARDIA and 23.1% in JHS had ideal physical activity, and 85.2% in CARDIA and 96.4% in JHS had ideal alcohol intake. Among those with MHT, 21.7% in CARDIA and 21.9% in JHS had ideal BMI, 26.6% in CARDIA and 0.91% in JHS had ideal diet, and 49.0% in CARDIA and 24.7% in JHS had ideal physical activity, and 84.4% in CARDIA and 97.7% in JHS had ideal alcohol intake.
Table 3.
Distribution of the number of ideal lifestyle factors (upper panel) and each ideal lifestyle factor (lower panel) among participants who met the 2017 ACC/AHA guideline office blood pressure criteria for screening of masked hypertension, and the subgroup with masked hypertension, defined using awake blood pressure
| Number of ideal lifestyle factorsa (%) | ||||
|---|---|---|---|---|
| 1 or more | 2 or more | 3 or more | 4 | |
| Among participants who met the office BP criteria for screening of masked hypertensionb | ||||
| CARDIA | 95.9 | 60.3 | 22.6 | 3.9 |
| JHS | 97.9 | 37.1 | 4.7 | 0.00 |
| Among participants with masked hypertensionc | ||||
| CARDIA | 95.7 | 60.8 | 21.8 | 3.3 |
| JHS | 98.7 | 40.4 | 6.2 | 0.00 |
| Individual lifestyle factors (%) | ||||
| Ideal BMI | Ideal diet | Ideal physical activity | Ideal alcohol intake | |
| Among participants who met the office BP criteria for screening of masked hypertensionb | ||||
| CARDIA | 21.4 | 29.0 | 47.1 | 85.2 |
| JHS | 19.2 | 0.98 | 23.1 | 96.4 |
| Among participants with masked hypertensionc | ||||
| CARDIA | 21.7 | 26.6 | 49.0 | 84.4 |
| JHS | 21.9 | 0.91 | 24.7 | 97.7 |
Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; BMI, body mass index; BP, blood pressure; CARDIA, Coronary Artery Risk Development in Young Adults Study; DBP, diastolic blood pressure; JHS, Jackson Heart Study; SBP, systolic blood pressure.
aIdeal lifestyle factors were based on ideal levels of body mass index, diet score, physical activity, and alcohol intake.
bOffice BP criteria for screening of masked hypertension as recommended in the 2017 ACC/AHA guideline: SBP 120–129 or DBP 75–79 mm Hg.
cDefined using awake blood pressure on ambulatory blood pressure monitoring as mean awake SBP ≥130 mm Hg or mean awake DBP ≥80 mm Hg.
Sensitivity analyses
Results using 24-hour BP and awake, asleep and 24-hour BP to define WCH and MHT are shown in Supplementary Tables S6 and S7 online, respectively. Analyses conducted among participants with complete ABPM data are shown in Supplementary Table S8 online for WCH and Supplementary Table S9 online for MHT.
Discussion
A small proportion of CARDIA and JHS participants who met the office BP criteria in the 2017 ACC/AHA BP guideline for the screening of WCH and MHT had 3 or more ideal lifestyle factors, and had ideal BMI, ideal diet, and ideal physical activity. Further, a small proportion of participants with WCH and MHT on ABPM had 3 or more ideal lifestyle factors, and had ideal BMI, ideal diet, and ideal physical activity. The results were consistent after defining WCH and MHT using 24-hour BP and alternatively, awake, 24-hour, and asleep BP instead of awake BP.
Studies have demonstrated that adults with WCH have a lower risk for CVD events compared with their counterparts with sustained hypertension, defined as having high office BP and high out-of-office BP.20 Further, studies have demonstrated that adults with MHT have a substantially increased CVD risk compared with their counterparts with sustained normotension, defined as not having high office BP despite having high out-of-office BP.2,4 Therefore, out-of-office BP monitoring is useful for distinguishing between individuals with WCH vs. sustained hypertension among those with high office BP, and between individuals with MHT vs. sustained normotension among those without high office BP.
In the 2017 ACC/AHA BP guideline, a 3-month trial of lifestyle modification is recommended for adults with elevated BP (SBP/DBP 120–129/<80 mm Hg) and those with hypertension (SBP/DBP ≥130/80 mm Hg), which is supported by a high quality level of evidence.3 A 3-month trial of lifestyle modification is also recommended prior to screening with ABPM to exclude WCH and MHT.3 Other recent guidelines, including the 2018 European Society of Cardiology and European Society of Hypertension guidelines on hypertension21 and the 2018 Hypertension Canadian guidelines,22 recommend lifestyle modification for the prevention and treatment of hypertension. In 2019, the Centers for Medicare & Medicaid Services revised ABPM coverage criteria to include screening for both WCH and MHT but did not require that lifestyle modification be conducted prior to ABPM.23 The results of the current study indicate that most individuals who meet the office BP criteria for WCH and MHT screening according to the ACC/AHA BP guideline have few ideal lifestyle factors. These individuals should be referred for a 3-month trial of lifestyle modification prior to completing ABPM. Ideally, lifestyle modification would reduce their office BP, so that those who meet screening office BP criteria for WCH or MHT initially would no longer be recommended ABPM. However, many individuals will have difficulty making lifestyle changes, and there may be little change in their BP during this 3-month period. Waiting may be harmful for individuals who have sustained hypertension and MHT, as they have increased risk for CVD events compared with those with sustained normotension. While a CVD event may be unlikely to occur during this time period, continued exposure to high BP may increase their long-term CVD risk. A 3-month delay in conducting ABPM may also create a burden on both healthcare providers and patients to attend additional office visits to obtain a diagnosis and eventual treatment plan. Clinical inertia for conducting ABPM may occur among providers and some patients may not attend a follow-up healthcare visit.
There are several strengths of the study. Data were obtained from established cohorts with rigorous quality control procedures. We also examined a racially diverse population with a high number of black participants who underwent ABPM. Despite these strengths, the results should be interpreted in the context of potential limitations. We did not pool the data from JHS and CARDIA due to differences in the data collection and how ideal lifestyle factors were defined. Diet history was not collected at the time of ABPM in CARDIA (Year 30 Exam), so we had to use dietary data from Year 20. For both the CARDIA study and the JHS, only a single 24-hour ABPM was performed. In addition, data on diet, physical activity, and alcohol intake were self-reported. Finally, ABPM was conducted only in a subset of CARDIA and JHS participants, and therefore, we relied on data imputation to increase the analytical sample size. However, the imputed results are consistent with those from the complete-case analysis.
In conclusion, the 2017 ACC/AHA BP guideline recommends ABPM to exclude the presence of WCH among adults who have an office SBP/DBP of 130–159/80–99 mm Hg, and the presence of MHT among adults who have an office SBP/DBP of 120–129/75–79 mm Hg after both groups have undertaken a 3-month trial of lifestyle modification. The findings of the current study indicate that a small proportion of individuals who have an office SBP/DBP of 130–159/80–99 and 120–129/75–79 mm Hg had ideal lifestyle factors. Ideal lifestyle factors were also uncommon among those with WCH and MHT. Therefore, most adults are likely to be recommended a 3-month trial of lifestyle modification prior to conducting ABPM. A requirement for a 3-month trial of lifestyle modification may lead to a delay in the detection of WCH and MHT for individuals without ideal lifestyle factors.
Supplementary Material
Acknowledgments
The authors wish to thank the staffs and participants of the CARDIA study and the JHS.
Funding
The Jackson Heart Study (JHS) is supported and conducted in collaboration with Jackson State University (HHSN268201800013I), Tougaloo College (HHSN268201800014I), the Mississippi State Department of Health (HHSN268201800015I/HHSN26800001), and the University of Mississippi Medical Center (HHSN268201800010I, HHSN268201800011I, and HHSN268201800012I) contracts from the National Heart, Lung, and Blood Institute (NHLBI) and the National Institute for Minority Health and Health Disparities (NIMHD). The authors also wish to thank the staffs and participants of the JHS. The Coronary Artery Risk Development in Young Adults Study (CARDIA) is supported by contracts HHSN268201800003I, HHSN268201800004I, HHSN268201800005I, HHSN268201800006I, and HHSN268201800007I from the National Heart, Lung, and Blood Institute (NHLBI). The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the U.S. Department of Health and Human Services. The current study is also supported by R01-HL117323 and K24-HL125704 from NHLBI. Dr Cohen received funding from National Institutes of Health grant T32-HL007343-38. Dr Langford received funding from NHLBI grant K01-HL135467. Dr. Abdalla receives support through 18AMFDP34380732 from the American Heart Association and the NIH/NHLBI (K23HL141682-01A1 and R01HL146636-01A1).
DISCLOSURE
The authors declared no conflict of interest.
This manuscript was sent to Guest Editor, Hillel W. Cohen, MPH, DrPH for editorial handling and final disposition.
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