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Supplementary Online Content
Fujiwara T, Yano Y, Hoshide S, Kanegae H, Kario K. Association of
cardiovascular outcomes with masked hypertension defined by home blood
pressure monitoring in a Japanese general practice population. JAMA Cardiol.
Published online May 23, 2018. doi:10.1001/jamacardio.2018.1233
eMethods. Methods of J-HOP Study
eTable 1. Comparison of the Baseline Characteristics of J-HOP Participants Who
Were or Were Not Included in the Current Study
eTable 2. Stroke or CHD Risk by BP Groups Using Clinic BP and Home BP
Levels Defined by the Average of Morning and Evening Home BP
eTable 3. Stroke or CHD Risk by BP Groups With Adjustment for a
Participant’s Sleep Duration
eTable 4. Stroke or CHD Risk by BP Groups With Adjustment for the BDI Test
Score
This supplementary material has been provided by the authors to give readers
additional information about their work.
© 2018 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/19/2021eMethods. Methods of J-HOP Study
J-HOP Study
The Japan Morning Surge-Home Blood Pressure (J-HOP) Study is a prospective
observational study evaluating the use of home blood pressure (BP) to predict
cardiovascular events in Japanese individuals with any of the following cardiovascular
risk factors: hypertension, impaired glucose tolerance or diabetes mellitus, dyslipidemia,
current smoking (and/or current chronic obstructive pulmonary disease), chronic kidney
disease (CKD), atrial fibrillation, metabolic syndrome, and sleep apnea syndrome. The
exclusion criteria for the J-HOP Study were a recent history of cardiovascular disease
events (within 6 months), current hemodialysis treatment, chronic inflammatory disease,
or malignancy. Diagnostic criteria of the cardiovascular risk factors were hypertension,
defined as a clinic systolic BP (SBP) of >140 mmHg and/or a diastolic BP (DBP) of
>90 mmHg, or current use of antihypertensive medication; impaired fasting glucose,
defined as a fasting glucose level of >110 mg/dl; impaired glucose tolerance, defined as
a glucose level of >140 mg/dl at 2 hours after a 75 g oral glucose tolerance test; diabetes,
defined as a fasting glucose level of >126 mg/dl and/or a casual glucose level of >200
mg/dl or treated diabetes; hyperlipidemia, defined as a total cholesterol level of >240
mg/dl or treated hyperlipidemia; CKD, defined as the presence of proteinuria or a value
of 15 events/hour by overnight sleep
polysomnography.
In Japan, there are 47 administrative divisions (prefectures). In 25 of the prefectures
(Tochigi, Aichi, Yamaguchi, Nagano, Miyazaki, Ibaraki, Hiroshima, Kumamoto,
Hyogo, Tottori, Chiba, Saitama, Niigata, Fukushima, Oosaka, Shiga, Gunma,
Kanagawa, Tokyo, Toyama, Mie, Yamagata, Gifu, Saga, Nara), a total of 75 doctors at
71 institutions (45 primary practices, 22 hospital-based outpatient clinics, and 4
specialized university hospitals) agreed with the aims of this study and collected
prospective data from individuals who agreed to participate in this project.
BP Measurements
Clinic BP was measured by physicians or nurses using an upper-arm cuff oscillometric
BP device (HEM-5001; Omron Healthcare Co., Ltd). The Omron HEM-5001 home BP
© 2018 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/19/2021device uses the same BP measurement algorithm as used in the HEM-737 home BP
device, which was validated in a previous study.3 Three clinic BP readings were taken at
15-second intervals4 in a sitting position. The analyses were performed using the mean
values of six readings obtained during two clinic visits (before and after the home BP
measurements). We advised the patients to take their morning medication as usual on
the days when they were visiting the clinic.
Self-measured home BP values were obtained using the same device (HEM-5001). The
patients were instructed to place a cuff of appropriate size on the same arm throughout
the measurements and to measure their BP in a sitting position after ≥2 minutes of rest
according to the Japanese Society of Hypertension 2004 guidelines.5 Three home BP
readings were taken at 15-second intervals in a sitting position in both the morning and
evening for 14 days. Morning BP was measured within 1 hr of waking, after urination,
before breakfast and before taking antihypertensive medication. Evening BP was
measured before going to bed, and the patients were instructed to avoid measuring their
BP just after taking a bath, drinking alcohol or smoking. The morning and evening BP
data were automatically stored in the memory of the BP device and were downloaded to
a computer by a physician or nurse during clinic visits. The data were then sent to the
study control center (Jichi Medical University, Tochigi, Japan). After exclusion of the
data from the first day, the averages of all home BP measures taken three times in the
morning (morning home BP) and three times in the evening (evening home BP) for 13
days (78 readings in total) were separately calculated by the study coordinator, who was
blinded to the clinical characteristics of the study participants.
Laboratory and Other Examinations
Blood and spot urine samples were collected in the morning in a fasting state at study
enrollment. The blood samples were centrifuged at 3000 ×g for 15 minutes at room
temperature. Plasma/serum samples after separation and urine samples were stored at
4°C in refrigerated containers and sent to a commercial laboratory (SRL Inc., Tokyo)
within 24 hours. Serum samples after separation were also stored at −80°C in a
refrigerator. All assays were performed within 24 hours of sample collection at a single
laboratory center (SRL Inc., Tokyo). Total cholesterol values were measured using the
cholesterol dehydrogenase-UV method. Serum high-density-lipoprotein cholesterol was
determined by the direct method using cholesterol oxidase. The urine
albumin-to-creatinine ratio was measured using an immunoturbidity kit (AutoWako
Microalbumin; Wako Pure Chemical Industries, Osaka, Japan). The plasma level of
© 2018 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/19/2021BNP (MI02 Shionogi BNP; Shionogi, Osaka, Japan) was measured by using a
chemiluminescent enzyme. Questionnaires were used to collect information on
demographics, smoking and drinking status, medical history and medication use.
Outcomes Ascertainment
Vital status was ascertained through March 2015, with an average (interquartile range)
follow-up period of 3.9 (2.4 to 4.6) years (16,875 person-years). Outcomes were
categorized as follows. (i) Fatal and nonfatal stroke, defined as sudden onset of a
neurological deficit persisting for ≥24 hours in the absence of any other disease that
could account for the symptoms. Stroke events included cerebral infarction, cerebral
hemorrhage, and subarachnoid hemorrhage based on the findings of brain computed
tomography or magnetic resonance imaging. Transient ischemic brain attacks (i.e., those
in which the neurological deficit was completely resolved within 24-hr of the onset of
symptoms) were not calculated as stroke events. (ii) Fatal and nonfatal CAD, defined as
acute myocardial infarction, angina pectoris requiring percutaneous coronary
intervention, and sudden death within 24-hr of the abrupt onset of symptoms. Criteria
for myocardial infarction included definite electrocardiographic findings (i.e., ST
elevation), typical or atypical symptoms together with electrocardiographic findings and
abnormal enzymes, or typical symptoms and abnormal cardiac enzymes with or without
electrocardiographic findings. If events occurred on ≥2 occasions, the first occurrence
was included in the analysis.
© 2018 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/19/2021References
1. Committee to Evaluate Diagnostic Standard for Metabolic Syndrome. Definition and
the Diagnostic standard for metabolic syndrome. Nippon Naika Gakkai Zasshi
2005;94:794-809. (in Japanese).
2. Matsuo S, Imai E, Horio M, et al.; Collaborators developing the Japanese equation
for estimated GFR. Revised equations for estimated GFR from serum creatinine in
Japan. Am J Kidney Dis. 2009;53(6):982-992.
3. Anwar YA, Giacco S, McCabe EJ, Tendler BE, White WB. Evaluation of the
efficacy of the Omron HEM-737 IntelliSense device for use on adults according to the
recommendations of the Association for the Advancement of Medical Instrumentation.
Blood Press Monit. 1998;3(4):261-265.
4. Yarows SA, Patel K, Brook R. Rapid oscillometric blood pressure measurement
compared to conventional oscillometric measurement. Blood Press Monit.
2001;6(3):145-147.
5. Imai Y, Otsuka K, Kawano Y, et al.; Japanese Society of Hypertension. Japanese
society of hypertension (JSH) guidelines for self-monitoring of blood pressure at home.
Hypertens Res. 2003;26(10):771-782.
© 2018 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/19/2021Participants and Participating Centers
Kazuomi Kario: Jichi Medical University School of Medicine; Satoshi Hoshide: Jichi
Medical University School of Medicine; Hajime Haimoto: Haimoto Clinic; Kayo
Yamagiwa: Yamagiwa Clinic; Kiyoshi Uchiba: Oooka Clinic; Syouichirou Nagasaka:
Jichi Medical University School of Medicine; Yuichiro Yano: Nango Clinic; Kazuo
Eguchi: Jichi Medical University School of Medicine and International University of
Health and Welfare Hospital; Yoshio Matsui: Jichi Medical University and Hagi city
Mishima Clinic; Motohiro Shimizu: Ogi city Fukukawa Clinic and Heigun Clinic; Akira
Nakamura: Chukyo Clinic; Joji Ishikawa: Jichi Medical University School of Medicine
and Koga Red Cross Hospital; Shizukiyo Ishikawa: Jichi Medical University School of
Medicine and Washiya Hospital; Motoki Fukutomi: Simonoseki city Tsunoshima
Clinic; Tomoyuki Kabutoya: Jichi Medical University School of Medicine and
Ojikano Central Hospital and Chichibu Municipal Hospital; Kyousei Souda: Souda
Clinic; Michiaki Nagai: Syoubara Red Cross Hospital and Syoubara city National
Health Insurance Clinic; Seiichi Sibazaki: Ogi city Fukukawa Clinic; Hideyuki Uno:
Jichi Medical University School of Medicine and Noda Hospital; Sachiyo Ogata:
Joriku-Omiya Saiseikai Hospital; Yoshifumi Nojiri: Joetsu Community Medical Center
Hospital; Ryuji Inoue: Kanzaki General Hospital; Kazuhiko Kotani: Tottori University
Hospital; Satoshi Yamada: Yamada Clinic; Takeshi Mitsuhashi: Jichi Medical
University School of Medicine; Hiroaki Tsukao: Yamashita Clinic; Tetsuya Aoki:
Akasaki Clinic; Toshio Kuroda: Kuroda Internal Medicine and Cardiovascular Clinic;
Yutaka Nakajima: Shimonoseki city Toyota Central Hospital; Akinori Hirai: Nagahama
Red Cross Hospital; Hareaki Yamamoto: Yamamoto Clinic; Tsuneo Oowada: Oowada
Internal Medicine and Gastrointestinal Clinic; Masaru Ichida: Jichi Medical University
School of Medicine; Setsuko Katou: Katou Clinic of Internal Medicine; Takahiro
Komori: Jichi Medical University School of Medicine and Utsunomiya Social Insurance
Hospital and Kurai Kiyohiko Memorial Hospital; Sigeki Nishizawa: Nishizawa Clinic
of Internal Medicine; Kazuhiro Murata: Ooshima Clinic; Takashi Utsu: Shiga Medical
University; Toru Kato: Koyanagi Memorial Hospital; Osamu Kuwasaki: Kuwasaki
Clinic of Internal Medicine; Yutaka Shimada: Kyaranoki Care Center; Yoshihiro
Yonezawa: Yonezawa Clinic; Eiji Inoue: Inoue Clinic of Internal Medicine; Masatoshi
Matsumoto: Jichi Medical University School of Medicine; Toru Kimura: Iiduka Clinic;
Kenichi Sakakura: Kumano city Kiwa Clinic; Shingo Shikano: Ibuki Shikano Clinic;
Kazuhiro Handa: Handa Clinic; Kouichirou Abe: Abe Clinic of Internal Medicine;
Motoyuki Ishiguro: Ishiguro Clinic; Yoshio Onogaki: Onogaki Clinic; Hiroshi Kubo:
Hiro Clinic of Cardiovascular Medicine and Gastrointestinal; Kouichi Tokai: Kamihira
© 2018 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/19/2021Clinic; Ryou Touji: Touji Clinic; Akiya Nakamoto: Nakamoto Clinic of Internal
Medicine; Youichi Ehara: Yoshii Chuo Clinic; Masahiro Toshima: Kamiichi General
Hospital; Nobuyuki Adachi: Adachi Clinic of Internal Medicine; Nobuo Takahashi:
Takahashi Family Clinic; Masashi Tanaka: Manba Clinic; Fumihiko Eto: Privcare
Family Clinic; Masahisa Shinpo: Jichi Medical University School of Medicine; Katsumi
Tanaka: Youga Urban Clinic; Takeshi Takemi: Clinic Jingu-Mae; Masayuki Nagata:
Nakata Clinic; Yukihiro Hojo: Jichi Medical University School of Medicine; Yoko
Hoshide: Satou Clinic; Fumihiko Yasuma: Suzuka National Hospital; Hajime
Yanagisawa: Sudou Hospital; Yukitaka Anraku: Omocyanomachi Internal Medicine
Clinic; Shuichi Ueno: Jichi Medical University School of Medicine; Ryousuke Kusaba:
Saitama Tsukuba Hospital; Naoshi Suzuki: Washiya Hospital; Nobuyuki Maki:
Kamogawa City National Health Insurance Hospital
(75 physicians and 71 institutes)
© 2018 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/19/2021eTable 1. Comparison of the Baseline Characteristics of J-HOP Participants Who Were or Were
Not Included in the Current Study
Included (n=4,261) Not included
(n=49) P Value
Age, years 64.9±10.9 63.4±11.1 0.33
Men, % 46.8 65.3 0.014
2
Body mass index, kg/m 24.3±3.5 24.7±3.8 0.42
Current smoker, % 12.2 18.4 0.19
Daily drinker, % 27.4 38.8 0.08
Diabetes mellitus, % 24.4 30.6 0.32
Statin use, % 23.6 24.5 0.87
History of CVD, % 12.7 14.3 0.67
Fasting glucose, mg/dL 107.4±27.6 111.6±22.6 0.35
Total cholesterol, mg/dL 202.4±32.9 208.6±34.9 0.19
High-density lipoprotein cholesterol, mg/dL 57.6±15.3 54.8±13.0 0.20
Antihypertensive medication use, % 79.2 73.5 0.38
BP measures
Clinic SBP, mmHg 141.3±16.4 141.1±19.5 0.94
Clinic DBP, mmHg 81.2±10.6 83.2±11.8 0.20
Morning home SBP, mmHg 138.4±15.8 140.9±19.4 0.26
Morning home DBP, mmHg 79.1±10.0 82.0±9.9 0.043
Evening home SBP, mmHg 130.1±14.9 132.6±17.2 0.24
Evening home DBP, mmHg 72.6±9.7 76.1±9.7 0.014
Mean morning and evening home SBP, mmHg 134.2±14.3 136.8±17.6 0.22
Mean morning and evening home DBP, mmHg 75.9±9.3 79.0±9.2 0.018
© 2018 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 11/19/2021Cardiovascular end-organ damage
Urine albumin-to-creatinine ratio, mg/g Cr 13.2 (7.2-30.8) 11.9 (7.5-48.8) 0.92
Brain natriuretic peptide, pg/mL 18.7 (9.3-38.5) 12.5 (5.3-29.0) 0.028
Data are expressed as means+SD, median (interquartile range), or percentage. Unpaired Student’s t-test (for continuous variables) or Fisher’s exact
tests (for categorical variables) were performed. Mann-Whitney U test was used for comparing differences in BNP and UACR because of their
skewed distribution. Statistical significance was defined as PeTable 2. Stroke or CHD Risk by BP Groups Using Clinic BP and Home BP Levels Defined by the Average of Morning and Evening Home BP
Controlled White-coat Masked Sustained
BP hypertension hypertension hypertension
(n=1,433) (n=905) (n=554) (n=1,369)
Number of stroke events, (per 1,000 person-years; 95% CIs) 13, (2.3; 1.3-3.9) 11, (3.1; 1.8-5.6) 13, (5.7; 3.3-9.7) 37, (6.9; 5.0-9.6)
Model 1 (unadjusted) 1.00 1.38 (0.62-3.08) 2.44 (1.13-5.27) 3.04 (1.61-5.71)
Model 2 1.00 1.38 (0.62-3.08) 2.27 (1.05-4.90) 2.65 (1.40-5.01)
Model 3 1.00 1.40 (0.63-3.12) 2.29 (1.06-4.95) 2.51 (1.32-4.77)
Number of CHD events, (per 1,000 person-years; 95% CIs) 26, (4.5; 3.1-6.7) 12, (3.4; 2.0-6.0) 12, (5.2; 3.0-9.1) 27, (5.1; 3.5-7.4)
Model 1 (unadjusted) 1.00 0.74 (0.37-1.47) 1.18 (0.60-2.35) 1.11 (0.65-1.91)
Model 2 1.00 0.73 (0.37-1.44) 1.05 (0.53-2.07) 0.93 (0.54-1.61)
Model 3 1.00 0.74 (0.38-1.47) 1.08 (0.55-2.15) 0.90 (0.51-1.57)
The adjusted HR (95% CIs) associated with each BP group is shown. Adjusted factors for Model 2 included the 4-year cardiovascular risk scores comprising demographic variables (age and sex) and clinical and
behavioral characteristics (body mass index; smoking status; prevalence of diabetes; pre-existing angina pectoris, myocardial infarction, or stroke; total cholesterol; high-density lipoprotein cholesterol; and statin or
antihypertensive medication use). Adjustment factors for Model 3 included the 4-year cardiovascular risk scores comprising demographic variables, clinical and behavioral characteristics, log-transformed UACR, and
log-transformed BNP. Statistical significance was defined as PeTable 3. Stroke or CHD Risk by BP Groups With Adjustment for a Participant’s Sleep Duration
Controlled White-coat Masked Sustained
BP hypertension hypertension hypertension
(n=1,079) (n=559) (n=675) (n=1,459)
Number of stroke events, (per 1,000 person-years; 95% CIs) 6, (1.4; 0.6-3.1) 3, (1.4; 0.5-4.0) 17, (6.4; 4.0-10.2) 36, (6.2; 4.5-8.6)
Model 1 (unadjusted) 1.00 1.02 (0.25-4.06) 4.26 (1.68-10.81) 4.42 (1.86-10.49)
Model 2 1.00 0.99 (0.25-3.94) 3.79 (1.49-9.62) 3.64 (1.52-8.71)
Model 3 1.00 0.97 (0.24-3.88) 3.73 (1.47-9.48) 3.58 (1.50-8.57)
Number of CHD events, (per 1,000 person-years; 95% CIs) 24, (5.6; 3.8-8.4) 8, (3.6; 1.8-7.1) 12, (4.5; 2.6-7.9) 25, (4.3; 2.9-6.4)
Model 1 (unadjusted) 1.00 0.66 (0.30-1.47) 0.79 (0.39-1.57) 0.78 (0.45-1.37)
Model 2 1.00 0.64 (0.29-1.43) 0.69 (0.35-1.39) 0.62 (0.35-1.11)
Model 3 1.00 0.65 (0.29-1.45) 0.70 (0.35-1.40) 0.63 (0.35-1.13)
The adjusted HR (95% CIs) associated with each BP group is shown. Adjusted factors for Model 2 included the 4-year cardiovascular risk scores, comprising demographic variables (age and sex) and clinical and
behavioral characteristics (body mass index; smoking status; prevalence of diabetes; pre-existing angina pectoris, myocardial infarction, or stroke; total cholesterol; high-density lipoprotein cholesterol; and statin or
antihypertensive medication use), log-transformed UACR, and log-transformed BNP. Adjustment factors for Model 3 included sleep duration and the 4-year cardiovascular risk scores, comprising demographic
variables, clinical and behavioral characteristics, log-transformed UACR, and log-transformed BNP. Statistical significance was defined as PeTable 4. Stroke or CHD Risk by BP Groups With Adjustment for the BDI Test Score
Controlled White-coat Masked Sustained
BP hypertension hypertension hypertension
(n=1,119) (n=581) (n=737) (n=1,564)
Number of stroke events, (per 1,000 person-years; 95% CIs) 6, (1.4; 0.6-3.0) 3, (1.3; 0.4-3.8) 15, (5.1; 3.1-8.5) 37, (6.0; 4.3-8.2)
Model 1 (unadjusted) 1.00 1.00 (0.25-3.98) 3.57 (1.39-9.20) 4.42 (1.86-10.46)
Model 2 1.00 0.98 (0.24-3.91) 3.21 (1.25-8.29) 3.64 (1.52-8.70)
Model 3 1.00 1.02 (0.25-4.07) 3.19 (1.24-8.22) 3.72 (1.56-8.89)
Number of CHD events, (per 1,000 person-years; 95% CIs) 24, (5.4; 3.6-8.1) 8, (3.5; 1.8-6.9) 12, (4.1; 2.4-7.2) 27, (4.4; 3.0-6.3)
Model 1 (unadjusted) 1.00 0.65 (0.29-1.45) 0.75 (0.37-1.49) 0.82 (0.47-1.42)
Model 2 1.00 0.64 (0.29-1.42) 0.66 (0.33-1.33) 0.65 (0.37-1.15)
Model 3 1.00 0.64 (0.29-1.42) 0.66 (0.33-1.33) 0.65 (0.37-1.15)
The adjusted HR (95% CIs) associated with each BP group is shown. Adjusted factors for Model 2 included the 4-year cardiovascular risk scores, comprising demographic variables (age and sex) and clinical and
behavioral characteristics (body mass index; smoking status; prevalence of diabetes; pre-existing angina pectoris, myocardial infarction, or stroke; total cholesterol; high-density lipoprotein cholesterol; and statin or
antihypertensive medication use), log-transformed UACR, and log-transformed BNP. Adjustment factors for Model 3 included the BDI test score and the 4-year cardiovascular risk scores, comprising demographic
variables, clinical and behavioral characteristics, log-transformed UACR, and log-transformed BNP. Statistical significance was defined as PYou can also read
