Original article
Morning Home Blood Pressure and Cardiovascular
Events in a Japanese General Practice Population Over
80 Years Old: The J-HOP Study
Dai Kawauchi, Satoshi Hoshide, and Kazuomi Kario
BACKGROUND
Home blood pressure (BP) measurement has been well accepted for
use in the diagnosis and treatment of hypertension. However, data
regarding the association between home BP levels and cardiovascular
events in a general practice population aged ≥80 years are sparse.
METHODS
We analyzed the cases of 349 patients ≥80 years old from the Japan
Morning Surge-Home Blood Pressure (J-HOP) Study, a nationwide prac-
tice-based study of 4,310 Japanese with a history of and/or risk factors for
cardiovascular disease. Home BP measurements were performed twice
daily (morning and evening) over 14 consecutive days at baseline.
RESULTS
During a median follow-up of 3.0 years, 32 composite cardiovascular
events (13 strokes and 19 nonstroke events) occurred. Higher morning
systolic BP (SBP) was a significant risk factor for composite cardiovas-
cular events (hazard ratio (HR) per 10 mm Hg, 1.23; 95% confidence
Hypertension is both a common disease in elderly people and
a leading cause of cardiovascular events.1 The National
Health and Nutrition Examination Survey (NHANES)
reported that the prevalence of hypertension was 76% in
adults aged 65–74 years and 82% in adults aged ≥75 years, 2
when hypertension was defined as clinic systolic blood pres-
sure (SBP) ≥130 mm Hg and/or diastolic blood pressure
(DBP) ≥80 mm Hg in keeping with a recently revised guide-
line (the 2017 American College of Cardiology/American
Heart Association (ACC/AHA) Guideline).3
The Hypertension in the Very Elderly Trial (HYVET) dem-
onstrated that antihypertensive treatment for targeting clinic
blood pressure (BP) <150/80 mm Hg reduced cardiovascular
mortality compared with a placebo group among hyperten-
sive patients aged ≥80 years.4 The effect of lowering BP was
also observed in the Systolic Blood Pressure Intervention Trial
(SPRINT), the subject group of which was approximately
30% patients aged ≥75 years. In SPRINT, the strict clinic SBP
con-trol group (<120 mm Hg) showed a reduced incidence of
car-diovascular events and increased adverse events compared
with the standard SBP control group (<140 mm Hg). 5 Thus,
Correspondence: Satoshi Hoshide (hoshide@jichi.ac.jp).
Initially submitted April 19, 2018; date of first revision June 5,
2018; accepted for publication August 30, 2018; online publication
September 5, 2018.
1190 American Journal of Hypertension 31(11) November 2018
Downloaded from https://academic.oup.com/ajh/article-
interval (CI): 1.01–1.50) and stroke events (HR per 10 mm Hg, 1.47;
95% CI: 1.08–2.00) after adjustment by the 4-year cardiovascular risk
scores and clinic SBP. In the adjusted model, morning diastolic BP
also tended to be a significant risk factor of stroke events (HR per 5
mm Hg, 1.43; 95% CI: 1.00–2.05). However, these associations were
not found for eve-ning BP or clinic BP.
CONCLUSIONS
Morning home BP showed a positive linear association with cardiovas-cular
events, especially with stroke. This association was not observed for clinic
BP or evening home BP. Based on these results, in very elderly Asian
populations, measuring morning home BP might be important in clinical
practice regardless of the individual’s office BP level.
Keywords: blood pressure; cardiovascular event; elderly; home
blood pressure; hypertension; morning; stroke.
doi:10.1093/ajh/hpy116
abstract/31/11/1190/5090996 by guest on 25 October 2018
in elderly hypertensive patients, clinic BP control has been
shown to achieve a reduction in cardiovascular events.
The use of home BP measurement has been well accepted
as a tool contributing to the diagnosis and treatment of
hypertension, based on accumulated findings that home BP
measurement provides reproducibility of BP measurement
comparable with that by clinic BP and may even exceed clinic
BP in its association with organ damage and cardiovascular
outcomes.3,6,7 However, data are lacking regarding the asso-
ciation between home BP levels and cardiovascular events in
very elderly populations. In a population aged ≥80 years from
the International Database on Home Blood Pressure in
Relation to Cardiovascular Outcome (IDHOCO), a J- or U-
curve association between home BP levels and cardiovas-cular
events was observed, especially in the population with
antihypertensive treatment.8 Accordingly, that study raised
concerns about the benefit of lowering the home BP level in
very elderly individuals. However, that study had important
limitations that evoke several questions.
First, Asian populations have provided more evidence re-
garding the contribution of BP to cardiovascular outcomes
Division of Cardiovascular Medicine, Department of Medicine, Jichi
Medical University School of Medicine, Shimotsuke, Japan.
© American Journal of Hypertension, Ltd 2018. All rights reserved.
For Permissions, please email: journals.permissions@oup.com

compared with western populations.9 Because the IDHOCO
study analyzed a heterogeneous population from Asian and
western countries, it is possible that home BP is linearly asso-
ciated with cardiovascular outcomes in selected Asian popu-
lations. Second, several studies have demonstrated that BP
measured in the morning provided more prognostic power
than that measured in the evening.10–12 This observation may
also be found in patient populations aged >80 years, but to the
best of our knowledge, this has never been investigated by a
stratified analysis according to morning and evening home BP
levels. Third, the IDHOCO study was community-based and
not a clinical practice setting.
To address this gap in knowledge, we examined the
associ-ation between home BP levels and cardiovascular
outcomes in a Japanese general practice population aged
≥80 years from the Japan Morning Surge-Home Blood
Pressure (J-HOP) study.
METHODS
Study design
This study was a post-hoc analysis of the J-HOP study,
which is a prospective observational study (University
Hospital Medical Information Network Clinical Trials
Registry, UMIN000000894) of 4,310 patients with a
history of and/or risk factors for cardiovascular disease
who were recruited between 2005 and 2012 and followed-
up through March 2015 from primary clinical practices and
university hospitals.11 The details of the J-HOP study
design and meth-ods are described in the Supplementary
Data. The present study included 349 patients ≥80 years
old from the J-HOP study. All participants provided
written informed consent, and the Institutional Review
Board of Jichi Medical School approved the study.
BP and other measurements
Further details of the present study’s methods are described
in the Supplementary Data. Briefly, 3 clinic BP readings were
taken at 15-second intervals on 2 different occasions, and their
mean (6 readings) was used as the clinic BP. Self-measured
home BP values were obtained accord-ing to the Japanese
Society of Hypertension guidelines for self-monitoring of BP
at home.13 Three home BP readings were taken at 15-second
intervals with the subject in a seated position in both the
morning (within 1 hour of waking and before taking
antihypertensive medication) and the eve-ning (before going
to bed). All participants were instructed to measure home BP
for 14 consecutive days. After the first day’s home BP
measurements were excluded, the final aver-ages of the
remaining measurements in this study were 10.9 ± 3.0 days
and 10.7 ± 3.1 days in morning and evening home BP,
respectively.
Clinic and home BP values were measured using the
same validated, automatic, and oscillometric device (HEM-
5001; Omron Healthcare, Kyoto, Japan). 14 In addition, to
avoid reporting bias, BP data were automatically stored in
the memory of the BP device and were downloaded to a
computer by a physician or nurse during a participant’s
American Journal of Hypertension 31(11) November 2018
Home Blood Pressure in an Elderly GP Population
clinic visits. In this analysis, we evaluated the morning, eve-
ning, and average of morning and evening home BP val-ues
separately. Laboratory methods are presented in the
Supplementary Data. Each participant’s history of cardiovas-
cular disease, including angina pectoris, myocardial infarc-
tion, and stroke, was ascertained at baseline.
Ascertainment of outcomes
Each participant’s vital status was ascertained through
March 2015. As the composite cardiovascular outcome, we
assessed the incident composite cardiovascular outcomes
during follow-up, including fatal and nonfatal coronary
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artery disease and sudden death within 24 hours of the
abrupt onset of symptoms, stroke (fatal and nonfatal)
events, heart failure (fatal and hospitalized), and aortic
dissection. In the J-HOP study, we observed that higher
home BP was associated with an increased risk for stroke
but not for cor-onary artery disease.11 We therefore
evaluated stroke and nonstroke events separately.
Additional details are given in the Supplementary Data.
Statistical analyses
Descriptive statistics are presented as the mean ± SD and/or
proportions. We separately analyzed the association between
home BP and the composite cardiovascular outcome and the
association of stroke and nonstroke incidence. We performed
using the Fine and Gray model to take into account the com-
peting risk from death15 because a very elderly population is
at high risk for fatal events besides cardiovascular complica-
tions. Using Cox proportional hazards models, we calculated
the hazard ratios (HRs) and 95% confidence intervals (CIs) of
composite cardiovascular events, stroke, and nonstroke events
associated with the tertiles of BP category and BP lev-els as a
continuous variable. When we analyzed the associa-tion
between the tertiles of BP category and cardiovascular
outcomes, we defined the reference as the lowest number of
events per 1,000 person-years. The proportionality assump-
tion for the Cox analyses was confirmed graphically and via
the inclusion of a time-by-BP interaction.
To analyze the association between BP levels as a continu-
ous variable and cardiovascular outcomes, we calculated the
HRs in an unadjusted model (Model 1) and after adjusting for
a composite risk score (Model 2) and clinic SBP or DBP
(Model 3). Composite risk scores are a useful approach to
controlling for confounders when there are a limited num-ber
of outcomes.16 A composite risk score was created in the
overall J-HOP population in the current study by determin-ing
the 4-year predicted probabilities for cardiovascular out-comes
using Cox regression models including the covariates
demographic variables (age and sex) and clinical and behav-
ioral characteristics at baseline (body mass index; smoking
status; prevalent diabetes; prevalent angina pectoris, myo-
cardial infarction, or stroke; total cholesterol; high-density
lipoprotein cholesterol; and statin or antihypertensive med-
ication use). These covariates were selected a priori because
they have been reported to show correlations with both BP 17
and cardiovascular risk18 and could potentially confound the
association between BP and cardiovascular risk.
1191
Kawauchi et al.

All statistical analyses were performed with R software,
ver. 3.3.1 (The R Foundation for Statistical Computing,
Vienna, Austria), Stata ver. 15 software (Stata Corp, College
Station, TX), and SAS system, ver. 9.4 (SAS Institute, Cary,
NC). Two-sided P values <0.05 were defined as significant.
RESULTS
Table 1 provides the baseline characteristics of the 349
patients aged >80 years. The average age was 82.8 ± 2.8
(range 80–96 years) years old. Of the 349 patients, 90%
were being treated with antihypertensive drugs and 17%
had had pre-existing cardiovascular disease, such as angina
pectoris, myocardial infarction, or stroke. The mean clinic
BP (SBP/DBP) was 145.6 ± 19.2/74.4 ± 10.6 mm Hg; the
mean morning home BP and evening home BP were 146.3
± 18.7/73.5 ± 10 mm Hg and 133.4 ± 17.4/67.8 ± 9.8 mm
Hg, respectively.
During a median follow-up of 3.0 years (5th to 95th percen-tile
interval, 1.0–6.9 years), 13 strokes and 19 nonstroke events
occurred: sudden death, n = 2; angina pectoris, n = 4; myocar-dial
infarction, n = 3; heart failure, n = 10, and 18 noncardio-vascular
deaths occurred. Table 2 shows the HRs and 95% CIs for the
incident composite cardiovascular events according to the tertiles
of morning, evening, and clinic SBP using an unadjusted Cox

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hazard model. Supplementary Table S1 shows the prevalence of
Table 1. Clinical characteristics of the study cohort (n = 349) stroke or nonstroke events and SBP indexes. There were no
Descriptive variable
findings indicating a J- or U-shaped association between all the
SBP indexes and incident composite cardio-vascular events,
Age, years 82.8 ± 2.8 stroke, and nonstroke events.
Men, % 40.0 In the unadjusted model, higher morning SBP was a sig-
nificant risk of composite cardiovascular and stroke events
Body mass index, kg/m2 23.1 ± 3.0 (Model 1 in Table 3). This association largely remained after
Current smoker, % 5.0 adjustment by the 4-year cardiovascular risk scores (Model 2
Daily drinker, % 19.0 in Table 3) and after adjustment by the 4-year cardiovascular
Antihypertensive medication, % 90.0 risk scores and clinic SBP (Model 3 in Table 3).
Concerning the association between the tertiles of morn-
Calcium channel blockers 64.0
ing, evening, and clinic DBP and outcome, there were find-
Angiotensin-converting enzyme inhibitors 7.0 ings indicating a J- or U-shaped association between
Angiotensin receptor blockers 64.0 evening DBP and incident composite cardiovascular or
Diuretics 34.0
nonstroke events (Supplementary Tables S2 and S3).
Higher morning DBP as continuous variable tended to be
α-Blockers 6.0 associated with a significant risk of stroke events in the
β-Blockers 11.0 unadjusted model (Supplementary Table S4). This associa-
Diabetes mellitus, % 20.0 tion remained after adjustment by the 4-year cardiovascular
risk scores and after adjustment by the 4-year cardiovascular
Statin use, % 22.0
risk scores and clinic DBP (Supplementary Table S4).
Pre-existing cardiovascular disease, % 17.0 Placement in the top tertile of average home SBP and DBP
Total cholesterol, mg/dl 194.0 tended to confer a risk of composite cardiovascular events
High-density lipoprotein, mg/dl 56.8 ± 14.6 (Supplementary Table S5). There was no difference in the
prevalence of stroke and nonstroke events among the tertiles
BP parameters, mm Hg
of average home SBP and DBP (Supplementary Table S6).
Clinic SBP 145.6 ± 19.2 Higher average home SBP as continuous variable tended to be
Clinic DBP 74.4 ± 10.6 associated with composite cardiovascular events in unad-
Clinic PR 70.5 ± 16.8 justed model (Supplementary Table S7). Concerning stroke
events, higher average home SBP was a significant risk even
Morning home SBP 146.3 ± 18.7
after adjustment by the 4-year cardiovascular risk scores and
Morning home DBP 73.5 ± 10.0 clinic SBP, whereas this association in average home DBP
Morning home PR 72.8 ± 15.8 was marginal (Supplementary Table S7).
Evening home SBP 133.4 ± 17.4
Evening home DBP 67.8 ± 9.8 DISCUSSION
Evening home PR 66.2 ± 14.0
In the J-HOP study, a nationwide practice-based study of
Average home SBP 140.2 ± 16.7 4,310 Japanese with a prior history of and/or risk fac-tors for
Average home DBP 70.5 ± 9.4 cardiovascular disease, 8.1% of the participants were ≥80
Average home PR 69.1 ± 15.0
years of age and underwent a median follow-up of 3.0 years.
Our present findings showed that in a Japanese general
Data are the means ± SD or percentages. Average home SBP, DBP, practice population aged ≥80 years, an increased morning
and PR are the average of morning and evening SBP, DBP, and PR, home SBP level was independently associated with composite
respectively. Abbreviations: BP, blood pressure; DBP, dias-tolic blood cardiovascular events and stroke events, and morning home
pressure; PR, pulse rate; SBP, systolic blood pressure. DBP was also associated with stroke events.

1192 American Journal of Hypertension 31(11) November 2018

 Home Blood Pressure in an Elderly GP Population

Table 2. Incident composite cardiovascular events by tertiles of home and clinic SBP

Composite cardiovascular events (n = 32)

Number of No (95% CIs)

BP range non-CV deaths NoE of eventsa HR (95% CI) P value

Morning home SBP
Tertile 1 (n = 116) 88.2–136.1 10 8 20.1 (10.2–39.6) Reference n/a
Tertile 2 (n = 116) 136.2–153.0 3 9 22.4 (11.8–42.6) 1.15 (0.45–2.97) 0.769
Tertile 3 (n = 117) 153.1–207.5 5 15 37.9 (23.0–62.5) 1.91 (0.81–4.51) 0.141

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Evening home SBP
Tertile 1 (n = 115) 90.8–125.1 9 9 20.8 (11.0–39.6) Reference n/a
Tertile 2 (n = 117) 125.2–140.8 2 12 32.2 (18.4–56.2) 1.55 (0.66–3.59) 0.313
Tertile 3 (n = 117) 140.9–185.4 7 11 28.1 (15.7–50.3) 1.37 (0.58–3.24) 0.474
Clinic SBP
Tertile 1 (n = 116) 86.3–137.0 4 7 16.0 (7.7–33.0) Reference n/a
Tertile 2 (n = 115) 137.1–150.8 6 15 39.0 (23.6–64.3) 2.33 (0.96–5.64) 0.061
Tertile 3 (n = 118) 151.0–202.5 8 10 26.7 (14.5–49.1) 1.64 (0.63–4.25) 0.314

Each reference was defined as the lowest number of events per 1,000 person-years. Abbreviations: BP, blood pressure; CI, confidence
inter-val; CV, cardiovascular; HR, hazard ratio; NoE, number of events; SBP, systolic blood pressure.
aNumber (95% CIs) of events per 1,000 person-years.

Table 3. Composite cardiovascular events, stroke events, and nonstroke events associated with higher home and clinic SBP levels

Composite cardiovascular events

(n = 32) Stroke events (n = 13) Nonstroke events (n = 19)

BP measures HR (95% CI) P value HR (95% CI) P value HR (95% CI) P value

Model 1
Morning home SBP 1.22 (1.02–1.47) 0.031 1.47 (1.10–1.95) 0.009 1.07 (0.85–1.35) 0.553
Evening home SBP 1.09 (0.90–1.32) 0.384 1.18 (0.91–1.53) 0.211 1.03 (0.79–1.36) 0.823
Clinic SBP 1.02 (0.86–1.20) 0.857 1.06 (0.85–1.33) 0.588 0.98 (0.78–1.24) 0.875
Model 2
Morning home SBP 1.20 (0.99–1.45) 0.059 1.41 (1.06–1.87) 0.017 1.06 (0.83–1.34) 0.646
Evening home SBP 1.08 (0.89–1.31) 0.451 1.17 (0.90–1.51) 0.248 1.02 (0.78–1.35) 0.870
Clinic SBP 1.02 (0.88–1.19) 0.806 1.06 (0.88–1.29) 0.523 0.99 (0.79–1.23) 0.899
Model 3
Morning home SBP 1.23 (1.01–1.50) 0.044 1.47 (1.08–2.00) 0.014 1.08 (0.84–1.38) 0.569
Evening home SBP 1.09 (0.85–1.39) 0.511 1.16 (0.84–1.62) 0.364 1.04 (0.74–1.46) 0.836
Clinic SBP n/a n/a n/a n/a n/a n/a

Adjusted HRs (95% CIs) for the risk of composite cardiovascular events, stroke events, and nonstroke events with a 10 mm Hg higher morn-ing,
evening, and clinic SBP are 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, and clinic SBP.
Abbreviations: BP, blood pressure; CI, confidence interval; HR, hazard ratio; SBP, systolic blood pressure.
These associations were not found in evening home BP. (PARTAGE) enrolled 1,126 subjects ≥80 years old, and the
Clinic BP measured by a similar validated device for home studys’ authors found that self-measured BP at baseline was not
BP was also not associated with cardiovascular events. associated with total mortality or cardiovascular events during the
There are 2 previous studies of the association between 2-year follow-up; however, the subjects of that study were
home BP levels and cardiovascular outcomes in a population 19 8
residents of nursing homes. Aparicio et al. selected a popu-
aged ≥80 years. The Predictive Values of Blood Pressure and lation older than 80 years of age from the IDHOCO study and
Arterial Stiffness in an Institutionalized Very Aged Population combined the dataset of a prospective study regarding home
American Journal of Hypertension 31(11) November 2018 1193
Kawauchi et al.
BP measurements from several countries; the results revealed
that home BP was linearly associated with cardiovascular out-
comes in the 202 untreated patients, and a J- or U-curve as-
sociation between home BP and outcomes existed in the 173
treated hypertensive patients. However, the subjects of that
study were enrolled from a general population. To the best of
our knowledge, the present study is the first to investigate the
association between home BP levels and cardiovascular out-
comes in a population aged ≥80 years in a clinical setting.
The results of our present analyses demonstrated a positive
linear relationship between morning home BP and cardio-vascular
events (especially stroke events) in individuals aged ≥80 years.
The majority of the participants in our present series were being
treated for hypertension (90%). Although the IDHOCO study
demonstrated, in a treated hypertensive population, that the
association between home SBP and car-diovascular outcome
8
shows a J- or U-curve relationship, the differing characteristics
of the populations under study might explain this diversity. The
population of the IDHOCO study was drawn from several
countries, including Japan, Greece, and Argentina. The
prevalence of cardiovascular risk and events has been reported to
differ depending on countries or races. In Japanese individuals in
particular, stroke events are more common than coronary
20
events. In addition, a difference has been observed in the
contribution of cardiovascular risk to cardiovascular events.
9
Perkovic et al. reported that the contri-bution of BP to
cardiovascular events in an Asian population was steeper than
that in a western population regardless of age. Therefore, the
possibility that the variation in results among studies might have
depended on different racial characteristics and contributions of
cardiovascular risk should be carefully considered. A previous
study also supports our findings. The morning BP surge evaluated
by ambulatory BP monitoring has been reported to be an
21–23
independent cardiovascular disease risk factor, and its
24
incidence increased with aging.
In the present study, morning home BP was clearly associ-
ated with cardiovascular outcomes, whereas clinic BP was
not. Two previous studies, the PARTAGE and IDHOCO
investigations, did not explore the prognostic difference
between clinic BP and home BP.8,19 The present study is the
first to explore the impact on cardiovascular outcomes
between office and home BP in a clinical population aged >80
years. Although out-of-clinic BP measurements are rec-
ommended in international guidelines,3,6,7 clinic BP mea-
surement has still been the golden standard method for the
management of hypertension. Our present findings suggest
that home BP measurement might be beneficial compared
with clinic BP measurement in very elderly individuals.
The data indicating no association between evening home
BP and cardiovascular outcomes in this study were consistent
with previous results. In the entire population of the J-HOP
study, evening BP was not linearly associated with stroke or
coronary events.11 Although the PARTAGE and IDHOCO
studies performed measurement of not only morning but also
evening home BP, the studies’ authors did not present the
results stratified by morning and evening home BP. 8,19 Home
BP measurement has shown superior reproducibility and
reliability compared with office BP measurement. However,
we observed that evening home BP had inferior reliability
compared with morning home BP during the day. 25 Although
1194 American Journal of Hypertension 31(11) November 2018
international guidelines recommend both morning and eve-
ning home BP measurement,3,6,7 the morning home BP mea-
surement might be more important. Actually, in the present
study, the average of morning and evening home SBP values
diluted the prognostic impact for composite cardiovascular
outcomes compared with morning home SBP alone.
Although there are several findings indicating a J- or U-shaped
association between clinic DBP levels and cardiovas-cular
26,27
risks, the association of home DBP is limited. To the best of
our knowledge, only 1 report showed that lower home DBP
tended to show an increased risk of stroke; this tendency was not
28
significant. The results of the present study showed that the
lowest tertile of evening home DBP presented a risk of composite
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cardiovascular and nonstroke events. Further stud-ies will be
needed to investigate the association between home DBP
measurement and the risk of each phenotype of cardio-vascular
outcome in very old individuals in a clinical setting.
There are several limitations in this study. First, the fol-
low-up period was relatively short compared with previous
studies, but for investigations of the prognostic power of BP
for cardiovascular outcomes in very elderly populations, a
short-term follow-up might be superior to a long-term follow-
up. A recent study showed that the mean office BP decreased
for more than a decade before death in patients aged ≥60
years, independently of hypertension treatment. 29 Therefore, a
long-term follow-up of very elderly individu-als might
underestimate the real contribution of BP to car-diovascular
outcomes. Second, the sample size was small because it was
difficult to recruit very elderly individuals from clinical
settings who were able to perform self-mea-sured home BP
(the ≥80-year-old patients were 8.1% of the entire J-HOP
population). This tendency was consistent with other general
population studies (Ohasama study, 5.2%; Didima study,
5.4%).8 Third, especially for the elderly, a dif-ferential
association between BP and cardiovascular events has been
observed when stratified according to physical inactivity,30
but information on physical inactivity was not available in this
analysis. Fourth, given the small number of events, our results
are not sufficient to make any definitive statements. Finally,
whether our findings can be generalized to other populations
or races remains to be determined.
In conclusion, we showed the association between home BP
and cardiovascular events in a very elderly Japanese popu-
lation drawn from clinical settings. Morning home BP showed
a positive linear association with cardiovascular events, espe-
cially stroke incidence, whereas this association was not found
in clinic BP or evening home BP. Based on these results, in
very elderly Asian individuals, measuring morning home BP
might be important in clinical settings regardless of the indi-
viduals’ clinic BP levels. Further study is needed to determine
whether hypertensive treatment titrated by morning home BP
reduces the risk of cardiovascular outcomes, taking adverse
events into consideration for very elderly people.
SUPPLEMENTARY DATA
Supplementary data are available at American Journal of
Hypertension online.

ACKNOWLEDGMENTS
This study was financially supported, in part, by a grant
from the 21st Century Center of Excellence Project run by
Japan’s Ministry of Education, Culture, Sports, Science, and
Technology; a grant from the Foundation for Development of
the Community (Tochigi); a grant from Omron Healthcare
Co., Ltd., a Grant-in-Aid for Scientific Research
(B) (21390247) from The Ministry of Education, Culture,
Sports, Science and Technology (MEXT) of Japan, 2009–
2013; and funds from the MEXT-Supported Program for
the Strategic Research Foundation at Private Universities,
2011– 2015 Cooperative Basic and Clinical Research on
Circadian Medicine (S1101022) to K.K. Funding sponsors
had no role in forming the study design or conducting the
study; the collection, management, analysis, and
interpretation of the data; the preparation of the article; or
the decision to submit the article for publication.
DISCLOSURES
K.K. has received research grants from Teijin Pharma,
Ltd., Novartis Pharma K.K., Takeda Pharmaceutical Co.,
Ltd., Omron Healthcare Co., Ltd., and Fukuda Denshi and
honoraria from Mochida Pharmaceutical Co., Ltd., Takeda
Pharmaceutical Co., Ltd., Daiichi Sankyo Co., Ltd., and
Sumitomo Dainippon Pharma Co., Ltd.
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