Role of Ambulatory and Home Blood Pressure Monitoring in Clinical Practice: A Narrative Review

Diagnosing Masked Hypertension Using Ambulatory Blood Pressure Monitoring, Home Blood Pressure Monitoring, or Both?

Guidelines recommend measuring out-of-clinic blood pressure (BP) to identify masked hypertension (MHT) defined by out-of-clinic BP in the hypertensive range among individuals with clinic-measured BP not in the hypertensive range. The aim of this study was to determine the overlap between ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) for the detection of MHT. We analyzed data from 333 community-dwelling adults not taking antihypertensive medication with clinic BP <140/90 mm Hg in the IDH study (Improving the Detection of Hypertension). Any MHT was defined by the presence of daytime MHT (mean daytime BP ≥135/85 mm Hg), 24-hour MHT (mean 24-hour BP ≥130/80 mm Hg), or nighttime MHT (mean nighttime BP ≥120/70 mm Hg). Home MHT was defined as mean BP ≥135/85 mm Hg on HBPM. The prevalence of MHT was 25.8% for any MHT and 11.1% for home MHT. Among participants with MHT on either ABPM or HBPM, 29.5% had MHT on both ABPM and HBPM; 61.1% had MHT only on ABPM; and 9.4% of participants had MHT only on HBPM. After multivariable adjustment and compared with participants without MHT on ABPM and HBPM, those with MHT on both ABPM and HBPM and only on ABPM had a higher left ventricular mass index (mean difference [SE], 12.7 [2.9] g/m2, P<0.001; and 4.9 [2.1] g/m2, P=0.022, respectively), whereas participants with MHT only on HBPM did not have an increased left ventricular mass index (mean difference [SE], -1.9 [4.8] g/m2, P=0.693). These data suggest that conducting ABPM will detect many individuals with MHT who have an increased cardiovascular disease risk.

Out of Office Blood Pressure Measurement in Pregnancy and the Postpartum Period

PURPOSE

Hypertensive disorders of pregnancy are increasing in prevalence and associated with significant maternal and perinatal morbidity and mortality.

RECENT FINDINGS

Increased emphasis has been placed recently on the use of out-of-office (i.e., home and ambulatory) blood pressure (BP) monitoring to diagnose and manage hypertension in the general population. Current guidelines offer limited recommendations on the use of out-of-office BP monitoring during pregnancy and postpartum. This review will discuss the recent literature on BP measurement outside of the office and its use for screening, diagnosis, and treatment in pregnancy and postpartum, and will illuminate areas for future research.

Number of Measurements Needed to Obtain a Reliable Estimate of Home Blood Pressure: Results From the Improving the Detection of Hypertension Study

Background Obtaining out-of-clinic blood pressure ( BP ) measurements to confirm a diagnosis of hypertension is recommended before initiating treatment. There are few empiric data available on the number of measurements required to reliably estimate BP on home BP monitoring ( HBPM ). Methods and Results We analyzed data from 316 community-dwelling adults not taking antihypertensive medication from the IDH (Improving the Detection of Hypertension) study who performed HBPM for 14 days. The reliability of home BP measurements was assessed using the intraclass correlation coefficient and as the percentage of participants with an absolute difference in home BP <10 mm Hg between weeks. The reliability of home hypertension status was assessed by the κ statistic. In the IDH study, 13.6% of participants had clinic hypertension and 18.0% had home hypertension. Mean home systolic and diastolic BP exhibited excellent reliability and sufficient agreement using the average of 2 morning and 2 evening BP readings for a minimum of 2 days of HBPM and a single morning and single evening or 2 morning BP readings for a minimum of 3 days. For diagnosing home hypertension, there was good agreement with a minimum of 3 days of HBPM using the average of 2 morning and 2 evening measurements or a single morning and single evening BP reading. A greater number of days was required for the other HBPM strategies. Conclusions Using the average of morning and evening readings, 3 days of HBPM are needed to reliably estimate mean home BP and diagnose out-of-clinic hypertension.

Development and Preliminary Feasibility of an Automated Hypertension Self-Management System

BACKGROUND

Uncontrolled hypertension constitutes a significant challenge throughout the world. Blood pressure measurement by patients is informative for both patients and providers but is rarely performed systematically, thereby reducing its utility. Mobile phones can be used to efficiently prompt individuals to measure blood pressure and automate data management while avoiding technology barriers to widespread adoption. Presented is the design and pilot test results of MyBP, an automated texting intervention to support blood pressure self-monitoring and patient self-management.

METHODS

Three sequential phases are described: (1) stakeholders' needs assessment, (2) preliminary design pilot (n = 10), and (3) a 6-week pilot of the redesigned comprehensive program with hypertensive patients (n = 43) recruited from 3 clinical sites (Emergency Department, Primary Care, Hypertension Center). Outcomes of interest included participant adherence, perceived importance of blood pressure monitoring, and healthy behavior change.

RESULTS

Median adherence to MyBP prompts over 6 weeks was 79% (72% emergency department, 84% primary care, and 96% hypertension center, H[2] = 5.56, P = .06). Adherence did not vary by age, sex, education, or baseline use of texting but was lowest among patients recruited from the emergency department (χ[2]2 = 6.66, P = .04). In the exit survey, MyBP was associated with increased importance of blood pressure self-monitoring and particularly motivated primary care and emergency department groups to improve dietary habits, increase daily physical activity, and focus on stress reduction. The majority of participants (88%) indicated interest in using the program for 6 months.

CONCLUSIONS

Automated mobile-phone-based blood pressure self-monitoring using MyBP is feasible, acceptable, and scalable, and may improve self-management and support clinical care.

The Role of Out-of-Clinic Blood Pressure Measurements in Preventing Hypertension

PURPOSE OF REVIEW

One of the possible strategies for preventing hypertension is identifying high-risk people and then implementing lifestyle modifications or therapeutic interventions. Out-of-clinic blood pressure measurements, either home or ambulatory blood pressure monitoring, may identify people with early blood pressure elevation or white-coat or masked hypertension and potentially help prevent hypertension. In this review, we will summarize the evidence on the role of out-of-clinic blood pressure measurements in preventing hypertension either from prehypertension or high normal or elevated blood pressure, or from white-coat or masked hypertension.

RECENT FINDINGS

Early blood pressure elevation, either termed as prehypertension or as high normal or elevated blood pressure, identified by home blood pressure monitoring was associated with a 3- to 5-fold risk of sustained hypertension. White-coat and masked hypertension, identified by either home or ambulatory blood pressure monitoring, was associated with a 2- to 4-fold risk of sustained hypertension. Out-of-office blood pressure measurements may potentially help prevent hypertension. However, to prove reversibility, controlled clinical trials are required.

Patient Barriers and Facilitators to Ambulatory and Home Blood Pressure Monitoring: A Qualitative Study

BACKGROUND

Guidelines recommend that patients with newly elevated office blood pressure undergo ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to rule-out white coat hypertension before being diagnosed with hypertension. We explored patients' perspectives of the barriers and facilitators to undergoing ABPM or HBPM.

METHODS

Focus groups were conducted with twenty English- and Spanish-speaking individuals from underserved communities in New York City. Two researchers analyzed transcripts using a conventional content analysis to identify barriers and facilitators to participation in ABPM and HBPM.

RESULTS

Participants described favorable attitudes toward testing including readily understanding white coat hypertension, agreeing with the rationale for out-of-office testing, and believing that testing would benefit patients. Regarding ABPM, participants expressed concerns over the representativeness of the day the test was performed and the intrusiveness of the frequent readings. Regarding HBPM, participants expressed concerns over the validity of the monitoring method and the reliability of home blood pressure devices. For both tests, participants noted that out-of-pocket costs may deter patient participation and felt that patients would require detailed information about the test itself before deciding to participate. Participants overwhelmingly believed that out-of-office testing benefits outweighed testing barriers, were confident that they could successfully complete either testing if recommended by their provider, and described the rationale for their testing preference.

CONCLUSIONS

Participants identified dominant barriers and facilitators to ABPM and HBPM testing, articulated testing preferences, and believed that they could successfully complete out-of-office testing if recommended by their provider.

The importance of using 24-hour and nighttime blood pressure for the identification of white coat hypertension: Data from the Jackson Heart Study

We calculated the prevalence of white coat hypertension (WCH) using out-of-clinic blood pressure (BP) in the daytime period; daytime and 24-hour periods; and daytime, 24-hour, and nighttime periods among 199 African Americans with clinic-measured systolic/diastolic BP ≥140/90 mm Hg in the Jackson Heart Study. Left ventricular mass index (LVMI) was measured among participants with WCH and 374 participants with sustained normotension (ie, non-hypertensive clinic, daytime, 24-hour, and nighttime BP). The prevalence of WCH was 29.6%, 21.1%, and 10.6% using daytime BP; daytime and 24-hour BP; and daytime, 24-hour, and nighttime BP, respectively. Compared with sustained normotension, LVMI was higher when WCH was defined using daytime BP (adjusted mean difference [95% CI] 5.0 [-0.2, 10.1] g/m2 ), but not when defined using daytime and 24-hour BP or daytime, 24-hour, and nighttime BP (adjusted mean difference [95% CI] 3.9 [-1.9, 9.7] and 0.4 [-7.3,8.2] g/m2 , respectively). Using only daytime BP overestimates the prevalence of WCH among African Americans.

A Comparison of the Diagnostic Accuracy of Common Office Blood Pressure Measurement Protocols

BACKGROUND

The optimal approach to measuring office blood pressure (BP) is uncertain. We aimed to compare BP measurement protocols that differed based on numbers of readings within and between visits and by assessment method.

METHODS

We enrolled a sample of 707 employees without known hypertension or cardiovascular disease, and obtained 6 standardized BP readings during each of 3 office visits at least 1 week apart, using mercury sphygmomanometer and BpTRU oscillometric devices (18 readings per participant) for a total of 12,645 readings. We used confirmatory factor analysis to develop a model estimating "true" office BP that could be used to compare the probability of correctly classifying participants' office BP status using differing numbers and types of office BP readings.

RESULTS

Averaging 2 systolic BP readings across 2 visits correctly classified participants as having BP below or above the 140 mm Hg threshold at least 95% of the time if the averaged reading was <134 or >149 mm Hg, respectively. Our model demonstrated that more confidence was gained by increasing the number of visits with readings than by increasing the number of readings within a visit. No clinically significant confidence was gained by dropping the first reading vs. averaging all readings, nor by measuring with a manual mercury device vs. with an automated oscillometric device.

CONCLUSIONS

Averaging 2 BP readings across 2 office visits appeared to best balance increased confidence in office BP status with efficiency of BP measurement, though the preferred measurement strategy may vary with the clinical context.

Evaluating different criteria for defining a complete ambulatory blood pressure monitoring recording: data from the Jackson Heart Study

OBJECTIVE

We determined differences in the prevalence of blood pressure (BP) phenotypes and the association of these phenotypes with left ventricular hypertrophy (LVH) for individuals who fulfilled and did not fulfill various criteria used for defining a complete ambulatory blood pressure monitoring (ABPM) recording.

METHODS

We analyzed data for 1141 participants from the Jackson Heart Study. Criteria evaluated included having greater than or equal to 80% of planned readings with more than or equal to one reading per hour (Spanish ABPM Registry criteria), more than or equal to 70% of planned readings with a minimum of 20 daytime and seven nighttime readings (2013 European Society of Hypertension criteria), greater than or equal to 14 daytime and greater than or equal to seven nighttime readings (2003 European Society of Hypertension criteria), more than or equal to 10 daytime and more than or equal to 5 nighttime readings (International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcome criteria), and greater than or equal to 14 daytime readings (UK National Institute of Health and Clinical Excellence criteria).

RESULTS

Between 45.0% (Spanish ABPM Registry) and 91.8% (UK National Institute of Health and Clinical Excellence) of the participants fulfilled the different criteria for a complete ABPM recording. Across the various criteria evaluated, 55.5-57.8% of participants had nocturnal hypertension and 62.8-66.8% had nondipping systolic BP. Among participants with clinic-measured systolic/diastolic BP of more than or equal to 140/90 mmHg, 22.9-26.5% had white-coat hypertension. The prevalence of daytime, 24-h, sustained, and masked hypertension differed by up to 2% for participants fulfilling each criterion. The association of BP phenotypes with LVH was similar for participants who fulfilled versus those who did not fulfill different criteria (each P>0.05).

CONCLUSION

Irrespective of the criteria used for defining a complete ABPM recording, the prevalence of BP phenotypes and their association with LVH were similar.

Implementing ABPM into Clinical Practice

PURPOSE OF REVIEW

To review the data supporting the use of ambulatory blood pressure monitoring (ABPM), and to provide practical guidance for practitioners who are establishing an ambulatory monitoring service.

RECENT FINDINGS

ABPM results more accurately reflect the risk of cardiovascular events than do office measurements of blood pressure. Moreover, many patients with high blood pressure in the office have normal blood pressure on ABPM-a pattern known as white coat hypertension-and have a prognosis similar to individuals who are normotensive in both settings. For these reasons, ABPM is recommended by the US Preventive Services Task Force to confirm the diagnosis of hypertension in patients with high office blood pressure before medical therapy is initiated. Similarly, the 2017 ACC/AHA High Blood Pressure Clinical Practice Guideline advocates the use of out-of-office blood pressure measurements to confirm hypertension and evaluate the efficacy of blood pressure-lowering medications. In addition to white coat hypertension, blood pressure phenotypes that are associated with increased cardiovascular risk and that can be recognized by ABPM include masked hypertension-characterized by normal office blood pressure but high values on ABPM-and high nocturnal blood pressure. In this review, best practices for starting a clinical ABPM service, performing an ABPM monitoring session, and interpreting and reporting ABPM data are described. ABPM is a valuable adjunct to careful office blood pressure measurement in diagnosing hypertension and in guiding antihypertensive therapy. Following recommended best practices can facilitate implementation of ABPM into clinical practice.

Insights in Public Health: Ambulatory Blood Pressure Monitoring: Underuse in Clinical Practice in Hawai'i

Hypertension is one of the leading causes of death and disability worldwide. Blood pressure reduction and control are associated with reduced risk of stroke and cardiovascular disease. To achieve optimal reduction and control, reliable and valid methods for blood pressure measurement are needed. Office based measurements can result in 'white coat' hypertension, which is when a patient's blood pressure in a clinical setting is higher than in other settings, or 'masked' hypertension, which occurs when a patient's blood pressure is normal in a clinical setting, but elevated outside the clinical setting. In 2015, the US Preventative Services Task Force recommended Ambulatory Blood Pressure Monitoring (ABPM) as the "best method" for measuring blood pressure, endorsing its use both for confirming the diagnosis of hypertension and for excluding 'white coat' hypertension. ABPM is a safe, painless and non-invasive test wherein patients wear a small digital blood pressure machine attached to a belt around their body and connected to a cuff around their upper arm that enables multiple automated blood pressure measurements at designated intervals (typically every 15 to 30 minutes) throughout the day and night for a specified period (eg, 24 hours). Patients can go about their typical daily activities wearing the device as much as possible, except when they are bathing, showering, or engaging in heavy exercise. Given the importance of blood pressure monitoring and control to population public health, this article provides details on the relevance and challenges of blood pressure measurement broadly then describes ABPM generally and specifically in the Hawai'i context.

An Update on Masked Hypertension

Masked hypertension refers to the phenomenon of having a non-elevated clinic blood pressure (BP) despite having an elevated out-of-clinic BP. Masked hypertension is a common phenotype with a cardiovascular risk profile similar to that of sustained hypertension, defined as elevated clinic and out-of-clinic BP. Current guidelines offer little guidance on the best practices for detecting and treating masked hypertension. This is in part due to insufficient evidence upon which to base recommendations as many questions remain regarding the optimal clinical management of masked hypertension. In this review, we will discuss the recent literature on masked hypertension related to disease prevalence, diagnosis, screening strategies, adverse outcomes, and treatment, and will highlight critical areas for future research.

Integrating Out-of-Office Blood Pressure in the Diagnosis and Management of Hypertension

Guidelines for the diagnosis and monitoring of hypertension were historically based on in-office blood pressure measurements. However, the US Preventive Services Task Force recently expanded their recommendations on screening for hypertension to include out-of-office blood pressure measurements to confirm the diagnosis of hypertension. Out-of-office blood pressure monitoring modalities, including ambulatory blood pressure monitoring and home blood pressure monitoring, are important tools in distinguishing between normotension, masked hypertension, white-coat hypertension, and sustained (including uncontrolled or drug-resistant) hypertension. Compared to in-office readings, out-of-office blood pressures are a greater predictor of renal and cardiac morbidity and mortality. There are multiple barriers to the implementation of out-of-office blood pressure monitoring which need to be overcome in order to promote more widespread use of these modalities.

Modulating Oxidative Stress and Inflammation in Elders: The MOXIE Study

Cardiovascular disease (CVD) is the leading cause of death among women in the United States. Endothelial dysfunction and arterial stiffness increase with advancing age and are early predictors of future CVD outcomes. We designed the Modulating Oxidative Stress and Inflammation in Elders (MOXIE) study to examine the effects of 100% watermelon juice as a "food-first" intervention to reduce CVD risk among African American (AA) and European American (EA) women aged 55-69 years. Vascular dysfunction is more pronounced in AA compared to EA women due in part to lower nitric oxide bioavailability caused by higher oxidative stress. However, bioactive compounds in watermelon may improve vascular function by increasing nitric oxide bioavailability and antioxidant capacity. This trial will use a randomized, placebo-controlled, crossover design to investigate the potential of 100% watermelon juice to positively impact various robust measures of vascular function as well as serum biomarkers of oxidative stress and antioxidant capacity. This nutrition intervention and its unique methodology to examine both clinical and mechanistic outcomes are described in this article.

Measuring arterial blood pressure in humans: Auscultatory and automatic measurement techniques for human biological field studies

Human biologists have been examining arterial blood pressure since they began studying the effects of the environment and culture on the health of diverse populations. The Korotkoff auscultatory technique with a trained observer and aneroid sphygmomanometer is the method of choice for blood pressure measurement in many bioanthropological field contexts. Korotkoff sounds (the first and fifth phases) are the preferred determinants of systolic and diastolic pressure, even in infants, children, pregnant women, and the elderly. Training of observers, positioning of individuals, and selection of cuff size are all essential for obtaining standardized measurements. Automatic electronic devices are increasingly being used for blood pressure measurement in human biological studies. The automatic monitors often use the oscillometric method for measuring pressure, but must be validated before use. The emergence of automatic ambulatory blood pressure monitors has opened another avenue of research on blood pressure in human biology, where allostasis and circadian responses to environmental change and real life behavioral challenges can be defined and evaluated, largely because there is now the ability to make multiple measurements over time and in varying contexts. Stand-alone automatic monitors can also be substituted for manual auscultated readings in field contexts, although in studies where participants measure their own pressure, education about how the devices work and protocol specifics are necessary. Finally, computer-driven plethysmographic devices that measure pressure in the finger are available to evaluate short-term reactivity to specific challenges.

Ambulatory monitoring demonstrates an acute association between cookstove-related carbon monoxide and blood pressure in a Ghanaian cohort

BACKGROUND

Repeated exposure to household air pollution may intermittently raise blood pressure (BP) and affect cardiovascular outcomes. We investigated whether hourly carbon monoxide (CO) exposures were associated with acute increases in ambulatory blood pressure (ABP); and secondarily, if switching to an improved cookstove was associated with BP changes. We also evaluated the feasibility of using 24-h ambulatory blood pressure monitoring (ABPM) in a cohort of pregnant women in Ghana.

METHODS

Participants were 44 women enrolled in the Ghana Randomized Air Pollution and Health Study (GRAPHS). For 27 of the women, BP was measured using 24-h ABPM; home blood pressure monitoring (HBPM) was used to measure BP in the remaining 17 women. Personal CO exposure monitoring was conducted alongside the BP monitoring.

RESULTS

ABPM revealed that peak CO exposure (defined as ≥4.1 ppm) in the 2 hours prior to BP measurement was associated with elevations in hourly systolic BP (4.3 mmHg [95% CI: 1.1, 7.4]) and diastolic BP (4.5 mmHg [95% CI: 1.9, 7.2]), as compared to BP following lower CO exposures. Women receiving improved cookstoves had lower post-intervention SBP (within-subject change in SBP of -2.1 mmHg [95% CI: -6.6, 2.4] as compared to control), though this result did not reach statistical significance. 98.1% of expected 24-h ABPM sessions were successfully completed, with 92.5% of them valid according to internationally defined criteria.

CONCLUSIONS

We demonstrate an association between acute exposure to carbon monoxide and transient increases in BP in a West African setting. ABPM shows promise as an outcome measure for assessing cardiovascular health benefits of cookstove interventions.

TRIAL REGISTRATION

The GRAPHS trial was registered with clinicaltrials.gov on 13 April 2011 with the identifier NCT01335490 .

Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States

In 2015, the US Preventive Services Task Force updated their hypertension recommendations to advise that adults with elevated office blood pressure (BP) undergo out-of-office BP measurement to exclude white coat hypertension before diagnosis. Our goal was to determine the most important barriers to primary care providers' ordering ambulatory and home BP monitoring in the United States. We enrolled 63 primary care providers into nominal group panels in which participants iteratively listed and ranked barriers to ambulatory and home BP monitoring. Top-ranked barriers to ambulatory BP monitoring were challenges in accessing testing, costs of testing, concerns about the willingness or ability of patients to successfully complete tests, and concerns about the accuracy and benefits of testing. Top-ranked barriers to home BP monitoring were concerns about compliance with the correct test protocol, accuracy of tests results, out-of-pocket costs of home BP devices, and time needed to instruct patients on home BP monitoring protocol. Efforts to increase the use of ambulatory and home BP monitoring by primary care providers in the United States should prioritize increasing the financial and personnel resources available for testing and addressing provider concerns about patients' ability to conduct high-quality tests.

Predicted Atherosclerotic Cardiovascular Disease Risk and Masked Hypertension Among Blacks in the Jackson Heart Study

BACKGROUND

Among individuals without hypertension based on clinic blood pressure (BP), it is unclear who should be screened for masked hypertension, defined as having hypertension based on out-of-clinic BP. We hypothesized that individuals with a higher 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk, calculated using the pooled cohort risk equations, have a higher prevalence of masked hypertension.

METHODS AND RESULTS

We analyzed data from the Jackson Heart Study-a population-based cohort of blacks-to determine the association of predicted ASCVD risk with masked hypertension. The sample included 644 participants, 40 to 79 years of age, with clinic systolic/diastolic BP <140/90 mm Hg, who completed ambulatory BP monitoring, were free of cardiovascular disease, and had data on factors needed to calculate ASCVD risk. Ten-year predicted ASCVD risk was calculated using the pooled cohort risk equations. Any masked hypertension was defined as masked daytime hypertension (mean daytime systolic/diastolic BP ≥135/85 mm Hg), masked nighttime hypertension (mean nighttime systolic/diastolic BP ≥120/70 mm Hg), or masked 24-hour hypertension (mean 24-hour systolic/diastolic BP ≥130/80 mm Hg). The prevalence of any masked hypertension was 54.0%. Compared with participants in the lowest (<5%) predicted ASCVD risk category, multivariable-adjusted prevalence ratios (95% confidence interval) for any masked hypertension were 1.36 (1.03-1.79), 1.62 (1.22-2.16), and 1.91 (1.47-2.48) for those with ASCVD risk of 5% to <7.5%, 7.5% to <10%, and ≥10%, respectively. The C statistic for discriminating between participants with versus without any masked hypertension was 0.681 (95% confidence interval, 0.640-0.723) for ASCVD risk and 0.703 (95% confidence interval, 0.663-0.744) for clinic systolic BP and diastolic BP.

CONCLUSIONS

Higher ASCVD risk was associated with an increased prevalence of masked hypertension. Although the discrimination of ASCVD risk for masked hypertension was not superior to clinic BP, risk prediction equations may be useful for identifying the subgroup of individuals with both masked hypertension and high predicted ASCVD risk.

Thresholds for Ambulatory Blood Pressure Among African Americans in the Jackson Heart Study

BACKGROUND

Ambulatory blood pressure (BP) monitoring is the reference standard for out-of-clinic BP measurement. Thresholds for identifying ambulatory hypertension (daytime systolic BP [SBP]/diastolic BP [DBP] ≥135/85 mm Hg, 24-hour SBP/DBP ≥130/80 mm Hg, and nighttime SBP/DBP ≥120/70 mm Hg) have been derived from European, Asian, and South American populations. We determined BP thresholds for ambulatory hypertension in a US population-based sample of African American adults.

METHODS

We analyzed data from the Jackson Heart Study, a population-based cohort study comprised exclusively of African American adults (n=5306). Analyses were restricted to 1016 participants who completed ambulatory BP monitoring at baseline in 2000 to 2004. Mean SBP and DBP levels were calculated for daytime (10:00 am-8:00 pm), 24-hour (all available readings), and nighttime (midnight-6:00 am) periods, separately. Daytime, 24-hour, and nighttime BP thresholds for ambulatory hypertension were identified using regression- and outcome-derived approaches. The composite of a cardiovascular disease or an all-cause mortality event was used in the outcome-derived approach. For this latter approach, BP thresholds were identified only for SBP because clinic DBP was not associated with the outcome. Analyses were stratified by antihypertensive medication use.

RESULTS

Among participants not taking antihypertensive medication, the regression-derived thresholds for daytime, 24-hour, and nighttime SBP/DBP corresponding to clinic SBP/DBP of 140/90 mm Hg were 134/85 mm Hg, 130/81 mm Hg, and 123/73 mm Hg, respectively. The outcome-derived thresholds for daytime, 24-hour, and nighttime SBP corresponding to a clinic SBP ≥140 mm Hg were 138 mm Hg, 134 mm Hg, and 129 mm Hg, respectively. Among participants taking antihypertensive medication, the regression-derived thresholds for daytime, 24-hour, and nighttime SBP/DBP corresponding to clinic SBP/DBP of 140/90 mm Hg were 135/85 mm Hg, 133/82 mm Hg, and 128/76 mm Hg, respectively. The corresponding outcome-derived thresholds for daytime, 24-hour, and nighttime SBP were 140 mm Hg, 137 mm Hg, and 133 mm Hg, respectively, among those taking antihypertensive medication.

CONCLUSIONS

On the basis of the outcome-derived approach for SBP and regression-derived approach for DBP, the following definitions for daytime, 24-hour, and nighttime hypertension corresponding to clinic SBP/DBP ≥140/90 mm Hg are proposed for African American adults: daytime SBP/DBP ≥140/85 mm Hg, 24-hour SBP/DBP ≥135/80 mm Hg, and nighttime SBP/DBP ≥130/75 mm Hg, respectively.

Race and sex differences in ambulatory blood pressure measures among HIV+ adults

Ambulatory blood pressure monitoring (ABPM) can identify phenotypes that cannot be measured in the clinic. Determining race and sex disparities in ABPM measures among HIV+ individuals may improve strategies to diagnose and treat hypertension in this high-risk population. We compared ABPM measures between 24 African-American and 25 white HIV+ adults (36 men and 13 women). Awake systolic blood pressure (SBP) and diastolic blood pressure (DBP) were similar in African-Americans and whites. After multivariable adjustment, sleep SBP and DBP were 9.7 mm Hg (95% confidence interval [95% CI]: 4.7, 14.8) and 8.4 mm Hg (95% CI: 4.3, 12.5) higher, respectively, among African-Americans compared with whites. After multivariable adjustment, SBP and DBP dipping ratios were 5.2% (95% CI: 1.7%, 8.7%) and 6.1% (95% CI 2.0%, 10.3%) smaller among African-Americans compared with whites. After multivariable adjustment, awake and sleep SBP and DBP were higher in men compared to women. There was no difference in SBP or DBP dipping ratios comparing men and women. The prevalence of awake masked hypertension was 42% in men versus 17% in women, and the prevalence of sleep masked hypertension was 57% among African-Americans versus 18% among whites. These data suggest that ABPM measures differ by race and sex in HIV+ adults.

Associations of Blood Pressure Dipping Patterns With Left Ventricular Mass and Left Ventricular Hypertrophy in Blacks: The Jackson Heart Study

Background

Abnormal diurnal blood pressure (BP), including nondipping patterns, assessed using ambulatory BP monitoring, have been associated with increased cardiovascular risk among white and Asian adults. We examined the associations of BP dipping patterns (dipping, nondipping, and reverse dipping) with cardiovascular target organ damage (left ventricular mass index and left ventricular hypertrophy), among participants from the Jackson Heart Study, an exclusively black population–based cohort.

Methods and Results

Analyses included 1015 participants who completed ambulatory BP monitoring and had echocardiography data from the baseline visit. Participants were categorized based on the nighttime to daytime systolic BP ratio into 3 patterns: dipping pattern (≤0.90), nondipping pattern (>0.90 to ≤1.00), and reverse dipping pattern (>1.00). The prevalence of dipping, nondipping, and reverse dipping patterns was 33.6%, 48.2%, and 18.2%, respectively. In a fully adjusted model, which included antihypertensive medication use and clinic and daytime systolic BP, the mean differences in left ventricular mass index between reverse dipping pattern versus dipping pattern was 8.3±2.1 g/m² (P<0.001) and between nondipping pattern versus dipping pattern was −1.0±1.6 g/m² (P=0.536). Compared with participants with a dipping pattern, the prevalence ratio for having left ventricular hypertrophy was 1.65 (95% CI, 1.05–2.58) and 0.96 (95% CI, 0.63–1.97) for those with a reverse dipping pattern and nondipping pattern, respectively.

Conclusions

In this population‐based study of blacks, a reverse dipping pattern was associated with increased left ventricular mass index and a higher prevalence of left ventricular hypertrophy. Identification of a reverse dipping pattern on ambulatory BP monitoring may help identify black at increased risk for cardiovascular target organ damage.

Ambulatory Blood Pressure Monitoring: A Complementary Strategy for Hypertension Diagnosis and Management in Low-Income and Middle-Income Countries

Ambulatory blood pressure monitoring (ABPM) can assess out-of-clinic blood pressure. ABPM is an underutilized resource in low-income and middle-income countries but should be considered a complementary strategy to clinic blood pressure measurement for the diagnosis and management of hypertension. Potential uses for ABPM in low-income and middle-income countries include screening of high-risk individuals who have concurrent communicable diseases, such as HIV, and in task-shifting health care strategies.

Association of Morning Hypertension Subtype With Vascular Target Organ Damage and Central Hemodynamics

BACKGROUND

A recent study reported that morning hypertension is associated with poor cardiovascular outcomes in hypertensive patients. However, it is unclear whether morning hypertension associated with sustained nocturnal hypertension and that associated with morning blood pressure (BP) surge differ in terms of their effects on cardiovascular target organ damage and clinical outcomes. The present study aimed to determine the association of morning hypertension with/without nocturnal hypertension with vascular target organ damage and central hemodynamics in patients at high risk for cardiovascular disease.

METHODS AND RESULTS

Ambulatory BP monitoring was performed and central BP was measured in 1070 consecutive patients with high cardiovascular risk. We grouped morning hypertension into the following 3 subtypes: (I) morning normotension; (II) morning hypertension without nocturnal hypertension; and (III) morning hypertension with nocturnal hypertension. Morning hypertension was noted in 469 (43.8%) patients and morning hypertension with nocturnal hypertension was noted in 374 (34.9%) patients. The central systolic/diastolic BP and carotid to femoral pulse wave velocity were significantly higher in the subtype III group than in the subtype I and II groups (all P<0.001). Subtype III (versus subtype I) was an independent predictor of central hypertension and high-risk arterial stiffness (P<0.001 and P=0.018, respectively) but not vascular damage in a fully adjusted model (model Y).

CONCLUSIONS

Morning hypertension, especially that associated with nocturnal hypertension, is related to high central BP and increased arterial stiffness. Further studies on whether morning hypertension with or without nocturnal hypertension is related to clinical outcomes should be performed.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02003781.

Perfect 24-h management of hypertension: clinical relevance and perspectives

Out-of-office blood pressure (BP) measured by home BP monitoring, or ambulatory BP monitoring, was demonstrated to be superior to office BP for the prediction of cardiovascular events. The J-HOP study of a nationwide Japanese cohort demonstrated that morning home BP is the best stroke predictor. In the prospective HONEST study of >21 000 hypertensives, on-treatment morning home BP was shown to be a strong predictor both of future coronary artery disease and stroke events. In subjects whose office BP was maintained at ⩾150 mm Hg, there was no increase in cardiovascular events when their morning systolic BP was well-controlled at <125 mm Hg. Since Asians show greater morning BP surges, it is particularly important for Asians to achieve 'perfect 24-hr BP control,' that is, the 24-h BP level, nocturnal BP dipping and BP variability including morning surge. The morning BP surge and the extremes of disrupted circadian rhythm (riser and extreme dipper patterns) are independent risks for stroke in hypertensives. A morning BP-guided approach is thus the first step toward perfect 24-h BP control, followed by the control of nocturnal hypertension. In the resonance hypothesis, the synergistic resonance of BP variability phenotypes would produce an extraordinary large 'dynamic BP surge' that can trigger a cardiovascular event, especially in high-risk patients with systemic hemodynamic atherothrombotic syndrome, a vicious cycle of exaggerated BP variability and vascular disease. In the future, information and communications technology and artificial intelligence technology with the innovation of wearable continuous surge BP monitoring will contribute to 'anticipation medicine' with the goal of zero cardiovascular events.

Validation of the Grandway MD2301 digital automatic blood pressure monitor according to the European Society of Hypertension International Protocol

OBJECTIVE

The aim of the present study was to validate the Grandway MD2301 digital automatic blood pressure monitor according to the European Society of Hypertension International Protocol (ESH-IP) revision 2010.

METHODS

The ESH-IP revision 2010 for the validation of blood pressure-measuring devices in adults was followed precisely. Systolic and diastolic blood pressure (SBP and DBP, respectively) were measured sequentially in 33 adult patients and compared with a standard mercury sphygmomanometer (two observers). A total of 99 comparison pairs were obtained.

RESULTS

The device produced 78, 95 and 99 measurements within 5, 10, and 15 mmHg for SBP and 83, 96, and 99 for DBP, respectively. The average device-observer difference was -1.81±4.22 mmHg for SBP and -0.15±3.93 mmHg for DBP. All of the data were within the standards requirements to pass the testing.

CONCLUSION

The Grandway MD2301 digital automatic blood pressure monitor meets the standards of the ESH-IP revision 2010 and can be recommended for self/home measurement in the general population.

Ambulatory Blood Pressure Monitoring in Individuals with HIV: A Systematic Review and Meta-Analysis

INTRODUCTION

Abnormal diurnal blood pressure (BP) rhythms may contribute to the high cardiovascular disease risk in HIV-positive (HIV+) individuals. To synthesize the current literature on ambulatory BP monitoring (ABPM) in HIV+ individuals, a systematic literature review and meta-analysis were performed.

METHODS

Medical databases were searched through November 11, 2015 for studies that reported ABPM results in HIV+ individuals. Data were extracted by 2 reviewers and pooled differences between HIV+ and HIV-negative (HIV-) individuals in clinic BP and ABPM measures were calculated using random-effects inverse variance weighted models.

RESULTS

Of 597 abstracts reviewed, 8 studies with HIV+ cohorts met the inclusion criteria. The 420 HIV+ and 714 HIV- individuals in 7 studies with HIV- comparison groups were pooled for analyses. The pooled absolute nocturnal systolic and diastolic BP declines were 3.16% (95% confidence interval [CI]: 1.13%, 5.20%) and 2.92% (95% CI: 1.64%, 4.19%) less, respectively, in HIV+ versus HIV- individuals. The pooled odds ratio for non-dipping systolic BP (nocturnal systolic BP decline <10%) in HIV+ versus HIV- individuals was 2.72 (95% CI: 1.92, 3.85). Differences in mean clinic, 24-hour, daytime, or nighttime BP were not statistically significant. I2 and heterogeneity chi-squared statistics indicated the presence of high heterogeneity for all outcomes except percent DBP dipping and non-dipping SBP pattern.

CONCLUSIONS

An abnormal diurnal BP pattern may be more common among HIV+ versus HIV- individuals. However, results were heterogeneous for most BP measures, suggesting more research in this area is needed.

The use of ambulatory blood pressure measurement

Measurement of ambulatory blood pressure is recommended by the National Institute for Health and Care Excellence guidelines to confirm the diagnosis of hypertension in the UK. This article describes the use of ambulatory devices, and discusses the benefits and disadvantages of their use in clinical practice.