Continued 7-day/24-hour monitoring required in (MESOR-) hypertension and other VVDs (Vascular Variability Disorders)

Background. The diagnosis of hypertension by the time-unqualified conventional measurement of blood pressure (BP) in a health care office is associated with many false positive and false negative diagnoses, since a single measurement session can render the diagnosis dependent upon time of day, and even in around-the-clock profiles limited to a few days, normotensives can be hypertensive and vice-versa. Ambulatory blood pressure monitoring (ABPM) is now an available tool. Its results can be evaluated chronobiologically (C-ABPM) based on an initial record of at least 7 days while monitoring continues. It should be stopped only if no abnormality is found; if abnormality is found, monitoring continues, notably if the second 7-day record is also abnormal. There is an organismic time structure (chronome) and components of the spectral element in the chronome have physical as well as sociological environmental counterparts, in the chronomes, among others, of both societal and physical environments, including geomagnetics and the solar wind. The chronomic interpretation of the circadian and very much broader spectral element of the time structure of BP and heart rate (HR) (variability) and of its clinical relevance has now resulted in the recognition of vascular variability disorders, VVDs, including MESOR-hypertension, that is a reliably diagnosed high BP based on C-ABPM. An overswing of the within-day change, dubbed CHAT (circadian hyper-amplitude-tension), is another VVD, as is circadian ecphasia, i.e., an odd timing of the high BPs, while the HR acrophases are acceptable (to distinguish this condition from a shift in work-rest schedule such as that in shiftwork or after transmeridian flights). Further VVDs are an above-threshold pulse pressure and a below-threshold variability in HR, gauged in the standard deviation. All VVDs should be based on replication of at least a 7-day/24-hour record interpreted by C-ABPM. Design. We examined whether monitoring sessions planned to be each of 7 days, at varying intervals corresponding to sometimes casual contacts with the patient, may suffice. They do not. There is a need for much longer monitoring and for not discontinuing the completed 7-day monitoring until the record shows no longer abnormality for at least 7 days. Aim. To detect and treat VVDs based on the 7-day/24-hour C-ABPM with focus upon the diagnosis of CHAT - a higher risk of cardiovascular complications than a high blood pressure in itself. Method. The present study involves planned about (∼) 7-day BP/HR monitoring of a 40-year-old man with known type 2 diabetes mellitus and MESOR-hypertension coexisting with ischaemic heart disease. He had dyslipidemia and angiographically documented triple vessel disease. He was purely vegetarian. His BP/HR were recorded through an ambulatory BP monitor (TM-2430 from A and D, Tokyo, Japan) on five different occasions between October 2004 and November 2007 with changes in the schedule of drug therapy given by reference to awakening time. Results. The diagnosis of systolic CHAT in 3 profiles and, on one occasion, of complicating diastolic CHAT, and on still another occasion of systolic MESOR-hypertension, was made on the basis of a chronobiologic interpretation of circadian characteristics by sphygmochron, a summary of BP and HR variation with time. The patient received (at the time of the first monitoring) Metoprolol 100mg twice a day, on getting up and retiring for sleep; Ramipril 5mg in the morning, and other drugs for diabetes and heart disease. During the second recording, Ramipril 5 mg was prescribed in the evening, 12-14 hours after awakening (presumably by misunderstanding advice to the contrary from The Biosphere and the Cosmos [BIOCOS] project), while all other drugs were continued with the same timing at the 3rd, 4th and 5th monitoring. Starting during the third record, two antihypertensive drugs were added to the treatment plan in the morning. Conclusion. This case study indicates the need for continued surveillance, notably in case of CHAT complicating MESOR-hypertension. When a 7/24 profile is done, the monitoring is to be continued until the results of analysis (promptly provided by BIOCOS) are in hand. When these results are negative, BP and HR surveillance can be discontinued, but not when abnormality is found. This was not done in the case reported herein. Had this patient been monitored until the diagnosis was in hand, and then had the switching of medication, such as a beta-blocker, from a twice-a-day schedule to a full dose in the morning-only, been implemented with continued surveillance, perhaps his VVD could have been eliminated several years earlier. Whether (and, if so, how much) peripheral end organ damage occurred in the interim will have to be assessed by outcomes in clinical trials with more than single patients. But the single case suffices to emphasize the need for monitoring while 1. waiting for analyses, and if these show abnormalities, 2. further monitoring follows after changing treatment. The addition of diuretics in this case may have (possibly!) with a delay, contributed to eliminating both CHAT and MESOR-hypertension, but for how long it worked is unknown. Further monitoring is indicated.