European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement

Retinal Microvasculature in Relation to Central Hemodynamics in a Flemish Population

Arterial stiffness and wave reflection predict cardiovascular mortality and morbidity and are associated with renal microvascular disease. We hypothesized that the retinal microvascular traits might be associated with central hemodynamic properties. In 735 randomly recruited Flemish (mean age, 50.3 years; 47.1% women), we derived central pulse pressure and carotid-femoral pulse wave velocity by applanation tonometry and calculated forward (Pf) and backward (Pb) pulse waves, using an automated pressure-based wave separation algorithm. We measured central retinal arteriolar (CRAE) and venular equivalent and their ratio, using IVAN software (Vasculomatic ala Nicola, version 1.1). Mean values for pulse wave velocity (n=554), Pf and Pb were 7.50 m/s, 32.0 mm Hg, and 21.5 mm Hg, respectively. In multivariable-adjusted analyses, CRAE was 4.62 µm and 1.26 µm smaller (P≤0.034) for a 1-SD increment in central mean arterial pressure (+11.3 mm Hg) and central pulse pressure (+15.2 mm Hg); a 1-SD increment in the augmentation ratio (+7.0%), aortic pulse wave velocity (+1.66 m/s), Pf (+10.0 mm Hg), and Pb (+8.5 mm Hg), was associated with smaller CRAE; the association sizes were -1.91 µm, -1.59 µm, -1.45 µm, and -2.38 µm (P≤0.014), respectively. Associations of arteriole-to-venule diameter ratio with the central hemodynamic traits mirrored those of CRAE. None of the multivariable-adjusted associations of central retinal venular diameter with the central hemodynamic traits reached significance with the exception of central diastolic blood pressure (-1.62 µm; P=0.030). In conclusion, in the general population, higher central pulse pressure, pulse wave velocity, Pf, and Pb were associated with smaller CRAE.

Design of a study to investigate the mechanisms of obstructive sleep apnoea by means of drug-induced sleep endoscopy

Background Obstructive sleep apnoea (OSA) is an independent risk factor of hypertension and cardiovascular diseases. Recurrent episodes of upper airways collapse during sleep causing blood oxygen desaturation, hypercapnia, and micro-arousals, are known to activate the sympathetic nervous system (SNS). However, whether changes in the renin-angiotensin-aldosterone system and endothelial activation also occur remains contentious. Methods Based on routine use of drug-induced sleep endoscopy (DISE) for the work-up of OSA patients in our centre, we designed a prospective study to investigate the haemodynamic and humoral changes occurring during the apnoeic episodes reproduced in vivo in the course of DISE. Specifically, plasma aldosterone concentration and renin activity, C-terminal fragment of proendothelin-1, as a marker of endothelial damage, and free plasma catecholamines, will be measured at fixed times during DISE. The activity of catechol-O-methyltransferase (COMT), a key catecholamine-inactivating enzyme that has been scantly investigated thus far owing to the lack of commercially available kits, will be also determined by a newly developed high performance liquid chromatography method, which is herein described. Results and conclusions The aim of this study is to provide novel information on the haemodynamic, hormonal, and SNS changes, and also on COMT activity modification concomitantly occurring during apnoea, thus contributing substantively to the understanding of the pathophysiology of OSA.

Efficacy and toxicity of antihypertensive pharmacotherapy relative to effective dose 50

Antihypertensive drugs have usually been approved at doses near the top of their respective dose-response curves. Efficacy plateaus but adverse drug reactions (ADRs), such as falls, cerebral or renal ischaemia, increase as dose is increased, especially in older patients with comorbidities. ADRs reduce adherence and may be difficult to ascertain reliably. Higher doses have generally not been shown to reduce total mortality, which provides a summary of efficacy and safety. Weight loss and other lifestyle measures are essential and may be sufficient treatment in many young and low risk patients. Most antihypertensive drug lower systolic blood pressure by around 10 mmHg, which reduces stroke and heart failure by about a quarter. Clinical trials have not been designed to demonstrate specific blood pressure treatment thresholds and targets, which are mostly extrapolated from epidemiology. Mean population oral effective dose 50 may be the most appropriate dose at which to commence antihypertensive drugs. The dose can then be titrated up if greater efficacy is demonstrated, or lowered if ADRs develop. Lower dose combination therapy may best balance benefit and harms with fewer ADRs and additive, potentially synergistic, efficacy.

Effect of Intensive and Standard Clinic-Based Hypertension Management on the Concordance Between Clinic and Ambulatory Blood Pressure and Blood Pressure Variability in SPRINT

Background Blood pressure ( BP ) varies over time within individual patients and across different BP measurement techniques. The effect of different BP targets on concordance between BP measurements is unknown. The goals of this analysis are to evaluate concordance between (1) clinic and ambulatory BP , (2) clinic visit-to-visit variability and ambulatory BP variability, and (3) first and second ambulatory BP and to evaluate whether different clinic targets affect these relationships. Methods and Results The SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory BP monitoring ancillary study obtained ambulatory BP readings in 897 participants at the 27-month follow-up visit and obtained a second reading in 203 participants 293±84 days afterward. There was considerable lack of agreement between clinic and daytime ambulatory systolic BP with wide limits of agreement in Bland-Altman plots of -21 to 34 mm Hg in the intensive-treatment group and -26 to 32 mm Hg in the standard-treatment group. Overall, there was poor agreement between clinic visit-to-visit variability and ambulatory BP variability with correlation coefficients for systolic and diastolic BP all <0.16. We observed a high correlation between first and second ambulatory BP ; however, the limits of agreement were wide in both the intensive group (-27 to 21 mm Hg) and the standard group (-23 to 20 mm Hg). Conclusions We found low concordance in BP and BP variability between clinic and ambulatory BP and second ambulatory BP . Results did not differ by treatment arm. These results reinforce the need for multiple BP measurements before clinical decision making.

Current Status and Prospects of Health-Related Sensing Technology in Wearable Devices

The healthcare-related functions of wearable devices are very useful for continuous monitoring of biological information. Wearable devices equipped with communication function can be used for additional healthcare services. Among the wearable devices, the wristband type is most suitable for acquiring biological signals, and the wear preference of the user is high, so it is highly likely to be used more in the future. In this paper, the health-related functions of wristband were investigated and the technical limitations and prospects were also reviewed. Most current wristband-type devices are equipped with the combination of accelerometer, optical sensor, and electrodes for their health functions, and continuously measured data are expanding the possibility of discovering new medical meanings. The blood pressure measurement function without using cuff is the most useful and expected function among the health-related functions expected to be mounted on the wrist wearable device, in spite of its technical limits and difficulties.

An Unobtrusive and Calibration-free Blood Pressure Estimation Method using Photoplethysmography and Biometrics

We introduce a novel paradigm to unobtrusively and optically measure blood pressure (BP) without calibration. The algorithm combines photoplethysmography (PPG) waveform analysis and biometrics to estimate BP, and was evaluated in subjects with various age, height, weight and BP levels (n = 1249). In the young population (<50 years old) with low, medium and high systolic blood pressures (SBP, <120 mmHg; 120-139 mmHg; ≥140 mmHg), the fitting errors are 6.3 ± 7.2, -3.9 ± 7.2 and -20.2 ± 14.2 mmHg for SBP respectively; In the older population (>50 years old) with the same categories, the fitting errors are 12.8 ± 9.0, 0.5 ± 8.2 and -14.6 ± 11.5 mmHg for SBP respectively. A simple personalized calibration reduces fitting errors significantly (n = 147), and good peripheral perfusion helps to improve the fitting accuracy. In conclusion, PPG may be used to calculate BP without calibration in certain populations. When calibrated, it shows great potential to serially monitor BP fluctuation, which can bring tremendous economic and health benefits.

Evaluation of Meditech ABPM-06 ambulatory blood pressure measuring device, according to the European Society of Hypertension, the British Hypertension Society and the International Organization for Standardization Protocol

OBJECTIVE

The devices to be used in clinical practice should be tested for accuracy and should be validated through the validation protocol. The aim of this study was to determine the accuracy of the Meditech-ABPM-06 ambulatory blood pressure monitor.

MATERIALS AND METHODS

The test was carried out in accordance with the protocol established by the European Society of Hypertension (ESH-IP), the British Hypertension Society, and the ANSI/AAMI/ISO 81060-2-2013 protocols.

RESULTS

In the European Society of Hypertension validation procedure the subjects with two or three of the absolute differences between observer and device SBP/DBP measurements within 5 mmHg were 31/31. The average device-observer difference was -0.4 ± 3.9 mmHg for SBP and -0.4 ± 2.8 mmHg for DBP. In the British Hypertension Society validation procedure the mean differences of the test device and observer readings were -1.0 ± 4.6 (systolic) and -1.1 ± 4.5 (diastolic). In the ANSI/AAMI/ISO 81060-2-2013 validation procedure (criterion 1) the mean ± SD of the differences between the test device and reference BP was -0.5 ± 4.0/-0.3 ± 4.5 mmHg (systolic/diastolic). The two criteria of the ANSI/AAMI/ISO were fulfilled.

CONCLUSION

The Meditech ABPM-06 blood pressure measure device met the requirements specified by the British Hypertension Society, the European Society of Hypertension International Protocol and the AAMI, and therefore was considered acceptable to clinical use with a Grade of A/A.

Effort-reward imbalance and ambulatory blood pressure among female Las Vegas hotel room cleaners

BACKGROUND

Effort-reward imbalance (ERI) was hypothesized to be associated with ambulatory blood pressure (ABP) and pulse pressure (PP) among female hotel room cleaners.

METHODS

ERI, ABP, and PP were assessed among 419 cleaners from five hotels during 18 waking hours. Adjusted linear regression models were used to assess associations of ERI with ABP and PP during 18-hours, work hours, and after work hours.

RESULTS

There was a pattern of higher ERI being associated with higher 18-hour systolic ABP and 18-hour PP although the results were imprecise. An increase of ERI by half its range was associated with a 1.6 mmHg (95% CI, -1.6-4.7) increase in 18-hour systolic blood pressure (SBP) and a 0.7 mmHg (95% CI, -1.1-2.5) increase in 18-hour PP. An increase in rewards by half its range was associated with a 2 mmHg decrease in after-hours SBP (-2.2, 95% CI, -5.4-1.0) and after-hours PP (-1.9, 95% CI, -3.8-0.0). Among females 45 years or older, ERI was associated with 2.1 and 2.2 mmHg increase in 18-hour and work hours diastolic ABP, respectively, compared to a 0 mmHg change in 18-hour and work hours diastolic ABP in younger women. The number of dependents at home attenuated the association.

CONCLUSIONS

ERI was positively associated with ABP, particularly SBP, and the association was modified by age and the number dependents at home, although the estimates were imprecise. Workplace interventions that integrate stress management and active ABP surveillance appear warranted. However, larger studies with Latina women need to confirm our results.

Limited contribution of insulin resistance and metabolic parameters to obesity-associated increases in ambulatory blood pressure in a black African community

Although accounting for a striking proportion of obesity effects on blood pressure (BP) in other populations, the extent to which obesity-associated increases in BP are explained by insulin resistance and metabolic changes in populations of African ancestry is uncertain. We determined the contribution of insulin resistance and associated metabolic abnormalities to variations in office or ambulatory BP in a black African community with prevalent obesity and hypertension. In 1225 randomly selected participants of black South African ancestry (age>16years, 43.1% obese, 47.4% abdominal obesity), we assessed adiposity indexes, the homeostasis model of insulin resistance (HOMA-IR) and associated metabolic abnormalities and office or ambulatory (n ​= ​798) BP. In separate models, waist circumference (p ​< ​0.0005-<0.0001) and HOMA-IR (p ​< ​0.51–0.005), were independently associated with office, 24 ​h, day or night systolic (SBP) or diastolic (DBP) BP. However, whilst a one standard deviation increase in waist circumference translated into a 1.47–3.08 ​mm Hg increased in office, 24-h SBP or DBP, in mediation analysis HOMA-IR accounted for only 0.12–0.30 ​mm Hg of the impact of a one standard deviation effect of waist circumference on office, and 24-h SBP and 0.003–0.17 ​mm Hg of the impact of a one standard deviation effect of waist circumference on office and 24-h DBP. In conclusion, in a black African community, insulin resistance accounts for a negligible proportion of the impact of obesity on office or ambulatory BP.

The Use of Wireless, Smartphone App-Assisted Home Blood Pressure Monitoring Among Hypertensive Patients in Singapore: Pilot Randomized Controlled Trial

Background

Reliable home blood pressure monitoring (HBPM) is essential to effective hypertension management; however, manual recording is subject to underreporting and inaccuracies. Mobile health technologies hold great potential as HBPM tools, but the fidelity of a smartphone app in HBPM has not been adequately assessed.

Objective

The primary aim of the trial was to compare the fidelity of a smartphone app to that of a handwritten logbook in making HBPM data available to clinicians at follow-up visits. Fidelity was defined as the percentage of scheduled blood pressure (BP) recordings over a 3-week period that were properly recorded and reported to the clinic. The secondary aims were to investigate patient factors associated with HBPM fidelity and to explore the effect of time on the fidelity.

Methods

A 2-arm, parallel, unblinded, randomized controlled pilot trial was conducted in a government polyclinic in Singapore. Hypertensive adults, aged 40 to 70 years, who were on antihypertensive medication and owned a smartphone were recruited and randomized by a computer-generated randomization schedule to 3 weeks of either semiautomated HBPM utilizing a Bluetooth-enabled BP monitor and a smartphone app or a fully manual process utilizing a conventional handwritten logbook. The primary outcome was home BP recording fidelity.

Results

Of the 80 patients randomized, 79 (smartphone app: 38 and logbook: 41) were included in the final analysis. Although fidelity was higher among the app users, it did not differ significantly between study arms (smartphone app: 66.7% and logbook: 52.4%; P=.21). Chinese and Indian ethnicities were associated with higher fidelity (absolute percent and 95% CI) by 35.6% (4.27 to 66.9) and 45.0% (8.69 to 81.3), respectively, in comparison with other ethnicities (P=.03); longer smartphone ownership increased fidelity on an average of 10.5% (0.83 to 20.2) per year (P=.03); the number of apps on the smartphone decreased fidelity at a rate of −0.32% (−0.58 to −0.05) per app (P=.02); years of hypertension morbidity increased fidelity at a rate of 1.56% (0.03 to 3.09) per year (P=.046); and the number of people working in the household decreased fidelity at a rate of −8.18% (−16.3 to −0.08) per additional working person (P=.048). The fidelity of the app was significantly higher in the first week (64.4%) than the second (55.1%, P=.001) and third (58.2%, P=.03) weeks of monitoring.

Conclusions

Amid the increasing integration of health technologies into clinical practice, our study demonstrates the feasibility of smartphone app–assisted HBPM in hypertensive adults of Singapore. Our pilot study found no statistically significant difference in mean BP recording fidelity between a smartphone app and conventional handwritten logbook. However, the small sample size precludes definitive conclusions and highlights the need for a larger, adequately powered trial.

Trial Registration

ClinicalTrials.gov NCT03209024; https://clinicaltrials.gov/ct2/show/NCT03209024 (Archived by WebCite at http://www.webcitation.org/78EVWBg0T)

Frequency and Prognosis of Treated Hypertensive Patients According to Prior and New Blood Pressure Goals

United States and European guidelines have recommended new treatment goals for office blood pressure (BP). We examined 9784 hypertensives of the Spanish Ambulatory BP Monitoring (ABPM) registry with office BP treated to the prior goal (<140/90 mm Hg); and evaluated the frequency and all-cause mortality of 4 BP strata depending on whether or not they attained more conservative or new office BP goal (130-139/80-89 and <130/80 mm Hg, respectively) and whether or not BP was controlled according to ABPM criteria in the European and US guidelines (24-hour ambulatory BP <130/80 and <125/75 mm Hg, respectively). Whether achieving or not the new office BP goal, the total-mortality risk during a 5-year follow-up was only significantly higher than the reference (normal office BP and ABPM) when 24-hour ambulatory BP was above goal (hazard ratio from multivariable Cox models was in the range of 2.4-2.9; P<0.001). The frequency of patients achieving the new office BP goal was 34.4%, and the frequencies of those not achieving the ABPM goal were 31.6% and 53.7% using the 130/80 or the 125/75 ABPM goal, respectively. Mean office systolic BP was 129 mm Hg for patients not achieving the ABPM goal. In hypertensive patients controlled under prior office BP goal, the frequency of those achieving new office BP goal <130/80 was high, suggesting this goal can be attained. In addition, patients had a higher mortality risk only when ABPM was above goal despite having mean office systolic BP under control, a condition that was also common.

Analysis of Short-term Blood Pressure Variability in Pheochromocytoma/Paraganglioma Patients

Data on short-term blood pressure variability (BPV), which is a well-established cardiovascular prognostic tool, in pheochromocytoma and paraganglioma (PPGL) patients is still lack and conflicting. We retrospectively evaluated 23 PPGL patients referred to our unit from 2010 to 2019 to analyze 24 h ambulatory blood pressure monitoring (24-h ABPM)-derived markers of short-term BPV, before and after surgical treatment. PPGL diagnosis was assessed according to guidelines and confirmed by histologic examination. The 24-h ABPM-derived markers of short-term BPV included: circadian pressure rhythm; standard deviation (SD) and weighted SD (wSD) of 24-h, daytime, and night-time systolic and diastolic blood pressure (BP); average real variability (ARV) of 24-h, daytime, and night-time systolic and diastolic BP. 7 males and 16 females of 53 ± 18 years old were evaluated. After surgical resection of PPGL we found a significant decrease in 24-h systolic BP ARV (8.8 ± 1.6 vs. 7.6 ± 1.3 mmHg, p < 0.001), in 24-h diastolic BP ARV (7.5 ± 1.6 vs. 6.9 ± 1.4 mmHg, p = 0.031), and in wSD of 24-h diastolic BP (9.7 ± 2.0 vs 8.8 ± 2.1 mmHg, p = 0.050) comparing to baseline measurements. Moreover, baseline 24-h urinary metanephrines significantly correlated with wSD of both 24-h systolic and diastolic BP. Our study highlights as PPGL patients, after proper treatment, show a significant decrease in some short-term BPV markers, which might represent a further cardiovascular risk factor.

A randomized cross-over study on the blood pressure lowering effect of the combined passive head-up and -down movement with Device-Guided slow breathing

Purpose: Baroreflex emerges as a therapeutic target of hypertension. We investigated blood pressure (BP) lowering effect of the combined passive head-up and -down movement with device-guided slow breathing in untreated mild hypertension or high-normal BP. Methods: In a randomized, cross-over trial, untreated subjects with an ambulatory systolic/diastolic BP of 125-140/80-90 mmHg and a clinic BP of 130-150/80-90 mmHg were randomized to intervention treatment with head movement and slow breathing or sham control, and then crossed over. Both treatments consisted of 1-week preparation, 2-week treatment, and 1-week recovery. During the 2-week treatment, subjects were treated for a session of 20 min/day. BP, pulse rate and respiration were measured before and after each treatment session. Ambulatory BP monitoring was performed at baseline and the end of the 2-week treatments' period, and home BP monitoring in the morning and evening for the whole 8-week follow-up period. Results: 14 subjects completed the study. The intervention treatment, compared to control, reduced respiration rate by -2.1 breaths/min (95% CI -2.9 to -1.2, p = .0001), but not clinic BP and pulse rate (p ≥ .67). The intervention treatment, compared to control, significantly reduced nighttime systolic/diastolic blood pressure by -5.63/-3.82 mm Hg (p ≤ .01) but not 24-h or daytime ambulatory blood pressure (p ≥ .69). Home BP decreased with the intervention treatment, but the between-treatment difference was not statistically significant (p ≥ .27). Conclusions: The combined head movement with slow breathing did not influence 24-h BP, but reduced nighttime BP in untreated mild hypertension or high-normal BP.

Design of a Care Pathway for Preventive Blood Pressure Monitoring: Qualitative Study

Background

Electronic health (eHealth) services could provide a solution for monitoring the blood pressure of at-risk patients while also decreasing expensive doctor visits. However, a major barrier to their implementation is the lack of integration into organizations.

Objective

Our aim was to design a Care Pathway for monitoring the blood pressure of at-risk patients, in order to increase eHealth implementation in secondary preventive care.

Methods

A qualitative design study was used in this research. Data were collected by conducting visual mapping sessions including semistructured interviews with hypertension patients and doctors. The data were transcribed and coded and thereafter mapped into a Care Pathway.

Results

Four themes emerged from the results: (1) the current approach to blood pressure measuring has disadvantages, (2) risk and lifestyle factors of blood pressure measuring need to be considered, (3) there are certain influences of the at-home context on measuring blood pressure, and (4) new touchpoints between patients and health professionals need to be designed. These in-depth insights combined with the visualization of the current blood pressure process resulted in our Care Pathway design for monitoring the blood pressure of at-risk patients as secondary preventive care.

Conclusions

The Care Pathway guides the implementation of eHealth devices for blood pressure self-measurement. It showcases the pathway of at-risk patients and increases their involvement in managing their blood pressure. It serves as a basis for a new service using eHealth.

Twenty-four hour ambulatory blood pressure reference values in Africans

OBJECTIVE

We aimed to establish reference values for 24 h ambulatory blood pressure (ABP) monitoring in an African community.

PATIENTS AND METHODS

We randomly recruited 1219 participants of African ancestry from Soweto, a township in Johannesburg. Twenty-four hour ABP was measured using ABP monitors (model 90207; Spacelab). Complete 24 h ABP measurements from 530 healthy participants with a mean age of 38 were used to determine thresholds.

RESULTS

Twenty-four hour, daytime and night-time systolic and diastolic BP increased significantly with age. The 95th prediction bands of this relation at age 38 years were ∼135/85 mmHg for 24 h, 140/90 mmHg for daytime and 130/80 mmHg for night-time ABP values, respectively. These thresholds and absolute ABP values are similar to those observed in individuals of other demographics. These thresholds increase with age by an average of 1.5 mmHg with each decade's increase in age.

CONCLUSION

Pending authentication in prospective outcome-based studies, these values might be considered preliminary thresholds to diagnose hypertension in individuals of African descent.

Quality of Blood Pressure Tracking Apps for the iPhone: Content Analysis and Evaluation of Adherence With Home Blood Pressure Measurement Best Practices

Background

Blood pressure (BP) tracking apps may aid in hypertension (HTN) self-management, but app quality may be problematic.

Objective

This study aimed to develop a content-dependent rating system for BP tracking apps and systematically evaluate BP tracking features, content-independent quality, functional characteristics, and educational comprehensiveness of English language iPhone apps developed with the primary purpose of tracking a consumer’s BP measurements.

Methods

We created a 28-item checklist reflecting overall app quality and a simplified 2-item checklist to assess adherence with home BP monitoring best practices. Apps with educational information were evaluated for comprehensiveness on a 7-point scale and for consistency with evidence-based guidelines. Higher scores represent better quality and comprehensiveness. We searched the Canadian App Store on June 28, 2016, using the keywords hypertension and blood pressure. A total of 2 reviewers independently assessed apps according to the standardized template. We determined if paid apps, educational apps, or those rated ≥4 stars were of higher quality.

Results

Of the 948 apps screened, 62 met the inclusion criteria. The mean overall quality score was 12.2 (SD 4.6, out of 28) and 6 apps (10%, 6/62) met the home BP monitoring best practice criteria. In all, 12 apps contained educational content (mean comprehensiveness 2.4, SD 1.6 out of 14), most commonly, background information on HTN. Apps with educational content (mean 15.1, SD 3.8 vs 11.8, SD 4.8; P=.03) or a ≥4 star rating (median 19, interquartile range [IQR] 15-20, vs 12, IQR 9-15; P=.02) had higher overall quality.

Conclusions

The BP tracking apps reviewed had variable quality and few met the home BP monitoring best practice criteria. When deciding to recommend a specific BP tracking app, we suggest clinicians should evaluate whether the app allows input of duplicate BP readings in the morning and evening for at least seven days and presents the mean BP value for user-specified dates. Greater attention to home BP measurement best practices is required during app development.

Automated Office-Based Blood Pressure Measurement: an Overview and Guidance for Implementation in Primary Care

PURPOSE OF REVIEW

The purposes of this study are to review evidence supporting the use of automated office blood pressure (AOBP) measurement and to provide practical guidance for implementing it in clinical settings.

RECENT FINDINGS

Mean AOBP readings correlate with awake ambulatory blood pressure monitor (ABPM) values and predict cardiovascular outcomes better than conventional techniques. However, heterogeneity among readings suggests that AOBP does not replace ABPM. Blood pressure (BP) measurement protocols differ among commonly described AOBP devices, but all produce valid BP estimates. Rest periods should not precede AOBP with BpTRU devices but should occur before use with Omron HEM-907 and Microlife WatchBP Office devices. Attended and unattended AOBP appear to produce similar results. This review also describes a framework to aid AOBP's implementation in clinical practice. Evidence supports AOBP as the preferred method for measuring BP in office settings, but this approach should be a complement to out-of-office measurements, such as self-measured BP monitoring or 24-h ABPM, not a substitute for it.

Central Hemodynamics in Relation to Circulating Desphospho-Uncarboxylated Matrix Gla Protein: A Population Study

Background Stiffening and calcification of the large arteries are forerunners of cardiovascular complications. MGP (Matrix Gla protein), which requires vitamin K-dependent activation, is a potent locally acting inhibitor of arterial calcification. We hypothesized that the central hemodynamic properties might be associated with inactive desphospho-uncarboxylated MGP (dp-uc MGP ). Methods and Results In 835 randomly recruited Flemish individuals (mean age, 49.7 years; 45.6% women), we measured plasma dp-uc MGP , using an ELISA -based assay. We derived central pulse pressure and carotid-femoral pulse wave velocity (PWV) from applanation tonometry and calculated forward and backward pulse waves using an automated, pressure-based wave separation analysis algorithm. Aortic PWV (n=657), central pulse pressure, forward pulse wave, and backward pulse wave mean± SD values were 7.34±1.64 m/s, 45.2±15.3 mm Hg, 33.2±10.2 mm Hg, and 21.8±8.6 mm Hg, respectively. The geometric mean plasma concentration of dp-uc MGP was 4.09 μg/L. All hemodynamic indexes increased across tertiles of dp-uc MGP distribution. In multivariable-adjusted analyses, a doubling of dp-uc MGP was associated with higher PWV (0.15 m/s; 95% CI, 0.01-0.28 m/s), central pulse pressure (1.70 mm Hg; 95% CI, 0.49-2.91 mm Hg), forward pulse wave (0.93 mm Hg; 95% CI, 0.01-1.84 mm Hg), and backward pulse wave (0.71 mm Hg; 95% CI, 0.11-1.30 mm Hg). Categorization of aortic PWV by tertiles of its distribution highlighted a decreasing trend of PWV at low dp-uc MGP (<3.35 μg/L) and an increasing trend at high dp-uc MGP (≥5.31 μg/L). Conclusions In people representative for the general population, higher inactive dp-uc MGP was associated with greater PWV , central pulse pressure, forward pulse wave, and backward pulse wave. These observations highlight new avenues for preserving vascular integrity and preventing cardiovascular complications (eg, by improving a person's vitamin K status).

Acute hyperglycemia increases renal tissue oxygenation as measured by BOLD-MRI in healthy overweight volunteers

AIM

Animal studies have suggested that acute hyperglycemia induces transient renal hypoxia and kidney damage, yet this has not been tested in humans. Therefore, we assessed in human subjects the effect of acute hyperglycemia on renal tissue oxygenation as measured with blood oxygenation level-dependent magnetic resonance imaging (BOLD-MRI).

METHODS

In this single center prospective interventional study, healthy overweight subjects were recruited. BOLD-MRI was performed before and immediately after the intravenous administration of 0.15 g/kg of glucose in a 20% solution under standard hydration and fasting conditions. R2^* maps were analyzed using the twelve layer concentric objects (TLCO) technique, a semi-automatic procedure which divides the kidney parenchyma in 12 equal layers at increasing depth. R2^* is a measure of local desoxyhemoglobin concentrations, with high R2^* values corresponding to low oxygenation.

RESULTS

Nineteen overweight subjects were enrolled (age 37 ± 10 years, BMI 28.9 ± 3 kg/m², HbA1c 5.4 ± 0.3%, 57.9% women): 5 were glucose intolerant, none had diabetes. The mean glycemia rose from 4.5 ± 0.3 mmol/l to 9.0 ± 0.9, 8.9 ± 0.7, 7.7 ± 0.6 and 6.8 ± 0.8 mmol/l at respectively 1, 10, 20 and 30 min after IV glucose. Circulating insulin levels quadrupled. The mean R2^* values decreased significantly in all kidney layers, irrespective of glucose intolerance. The lower BMI, the larger the decrease in R2^*(spearman's r = 0.41, p = 0.035).

CONCLUSION

These data show that acute hyperglycemia decreases the R2^* signal in humans, suggesting an acute increase in renal tissue oxygenation. The precise mechanism of this observation remains unknown, and whether this phenomenon also occurs in patients with diabetes needs additional studies.

Biomarkers of nondipper hypertension in prehypertensive and hypertensive patients

Aim: The aim of this study was to evaluate the relation of gamma glutamyl transferase (GGT), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) with nondipper hypertension. Methods: This study included a total of 409 patients. Patients were grouped into hypertension, prehypertension and normotensive groups, according to their clinical blood pressure. All patients were also followed by ambulatory blood pressure. Results: Mean PLR and NLR were higher in the nondippers compared with dippers among both prehypertensive and hypertensive patients. In addition, PLR (OR: 1.011; 95% CI: 1004-1017; p = 0.001), NLR (OR: 2.296, 95% CI: 1634-3225; p < 0.001), and GGT (OR: 1.067; 95% CI: 1042-1092; p < 0.001) were found to be associated with nondipper pattern among whole study population. Conclusion: The PLR, NLR and GGT values are easily accessible and fairly useful, independently associated with nondipper hypertension for both hypertensive and prehypertensive patients.

The association of calcium channel blockers with β-cell function in type 2 diabetic patients: A cross-sectional study

Type 2 diabetes mellitus (T2DM) patients are often accompanied with hypertension. However, the association of antihypertensive drugs with β-cell function has not been well studied. To investigate this question, the authors performed a cross-sectional study involving 882 hypertensive T2DM patients. To assess β-cell function, patients were given 75g glucose orally and C-peptide levels before and 1, 2, and 3 hours after glucose intake were measured. Homa-β was computed by Homeostasis Model Assessment model to evaluate β-cell function using fasting C-peptide and glucose levels in the plasma. Multivariable-adjusted analysis was performed to evaluate the association of antihypertensive drugs with C-peptide levels, HbA1c, and Homa-β. Among 882 hypertensive patients, 547 (62.0%) received antihypertensive treatment. Multivariate-adjusted analysis demonstrated that use of calcium channel blockers (CCBs) was negatively associated with HbA1c levels (CCBs: 0.95 [95% CI: 0.92-0.98], P = 0.002). Our data further illustrated that the C-peptide levels before and 1, 2, and 3 hours of OGTT were 1.10-, 1.18-, 1.19-, and 1.15-fold increase in T2DM patients taking CCBs (P = 0.084 for fasting C-peptide levels; P ≤ 0.024 for C-peptide levels at 1, 2, and 3 hours after OGTT) in comparison with non-CCB users. Nevertheless, usage of any other antihypertensive drugs did neither associated with HbA1c nor associated with C-peptide levels (P ≥ 0.11). In conclusion, CCB treatment was negatively associated with HbA1c levels but positively associated with β-cell function in hypertensive T2DM patients, implying that CCBs could be considered to treat hypertensive T2DM patients with reduced β-cell function.

Dose–response association of 24-hour urine sodium and sodium to potassium ratio with nighttime blood pressure at older ages

Aims

We investigated the dose–response association of 24-hour urine sodium and potassium with 24-hour ambulatory blood pressure.

Design

Cross-sectional community-based study.

Methods

Among the 1128 participants in the community-based cross-sectional survey, 740 participants (aged 20–70 years) with complete 24-hour urine collection and valid 24-hour ambulatory blood pressure monitoring were included in the study. Participants were grouped into younger (<55 years, n = 523) and older (≥55 years, n = 217).

Results

In the older population, nighttime blood pressure linearly increased with 24-hour urine sodium and the sodium to potassium ratio. For 24-hour urine sodium, adjusted β was 0.171 (95% confidence interval (CI) 0.036–0.305) for nighttime systolic blood pressure and 0.144 (95% CI 0.012–0.276) for nighttime diastolic blood pressure. For the 24-hour urine sodium to potassium ratio, adjusted β was 0.142 (95% CI 0.013–0.270) for nighttime systolic blood pressure and 0.144 (95% CI 0.018–0.270) for nighttime diastolic blood pressure. The 24-hour blood pressure linearly increased with the 24-hour urine sodium to potassium ratio and adjusted β was 0.133 (95% CI 0.003–0.262) for 24-hour systolic blood pressure and 0.123 (95% CI 0.003–0.244) for 24-hour diastolic blood pressure. Daytime blood pressure and 24-hour systolic blood pressure showed a significant but non-linear association with 24-hour urine sodium among the older population. In the younger population, 24-hour urine sodium, potassium and the sodium to potassium ratio were not associated with ambulatory blood pressure.

Conclusion

In the older population, 24-hour urine sodium and the sodium to potassium ratio showed a linear and positive association with nighttime blood pressure, and 24-hour urine sodium was associated with 24-hour systolic blood pressure and daytime blood pressure in a non-linear fashion.

Serum proatrial natriuretic peptide concentrations during oral glucose-induced acute hyperinsulinemia in lean and obese men

Atrial natriuretic peptide (ANP) is primarily seen as a hormone involved in salt and water homeostasis and blood pressure regulation. Evidence supports a link between metabolism and ANP. Circulating ANP concentrations are low in obese individuals with insulin resistance and hyperinsulinemia. The dynamic relationship between insulin and ANP has been sparsely studied. We therefore measured circulating concentrations of midregional proatrial natriuretic peptide (MR-proANP), a stable marker of ANP secretion, and insulin in lean and obese men during an oral glucose challenge. One hundred and three obese men (body mass index (BMI) ≥30.0 kg/m²) were compared with 27 lean men (BMI = 20.0-24.9 kg/m²). During a 75 g oral glucose challenge, circulating concentrations of MR-proANP and insulin were measured at baseline and every half hour for 2 h. Fasting MR-proANP concentrations were lower in the obese men as compared with the lean men (median (interquartile range): 51.2 (38.7-64.7) pmol/L vs. 69.3 (54.3-82.9) pmol/L, P = 0.002). During the oral glucose challenge, serum MR-proANP concentrations fell steadily in the obese men (P < 0.0001), whereas there was no significant fall in the lean men (P = 0.14). However, the time-course curves of MR-proANP did not display a clear reciprocal relation to the time-course curves of insulin. Adjusted for age, the area under curve (AUC) for MR-proANP was inversely correlated with AUC for insulin (r = -0.38, P < 0.0001). In conclusion, during an oral glucose challenge, serum MR-proANP concentrations drop significantly in obese individuals, but the time-course curves of MR-proANP do not display a reciprocal relationship to the time-course curves of insulin.

Biochemical Data and Metabolic Profiles of Male Exclusive Narghile Smokers (ENSs) Compared With Apparently Healthy Nonsmokers (AHNSs)

Studies evaluating the metabolic profiles of ENSs are scarce and presented controversial conclusions. This study aimed to compare the metabolic profiles of ENSs' and AHNSs' groups. Males aged 25-45 years and free from a known history of metabolic and/or cardiovascular diseases were included. According to the smoking status, two groups of ENSs and AHNSs were identified. Body mass index (BMI, kg/m2), waist circumference (WC, cm), systolic and diastolic blood pressures (SBP, DBP, mmHg), fasting blood data in mmol/L (blood glycemia [FBG], triglycerides [TG], total cholesterol [TC], high- and low- density lipoprotein cholesterol [HDL-C, LDL-C]) and obesity status were evaluated. The metabolic syndrome (MetS) was defined according to the 2006 International Diabetes Federation (IDF) recommendations. Data were expressed as mean ± standard deviation ( SD) or percentages. Compared to the AHNSs' group ( n = 29), the ENSs' one ( n = 29) had (a) higher values of BMI (26.5 ± 2.3 vs. 28.2 ± 3.6), WC (95 ± 7 vs. 100 ± 10), and TG (1.22 ± 0.40 vs. 1.87 ± 0.85); and (b) included a lower percentage of males having low HDL-C (82.7% vs. 62.0%), and higher percentages of males having obesity (6.9% vs. 37.9%) or hypertriglyceridemia (10.7% vs. 51.7%). Both the ENSs' and AHNSs' groups: (a) had similar values of FBG (5.38 ± 0.58 vs. 5.60 ± 0.37), TC (4.87 ± 1.16 vs. 4.36 ± 0.74), HDL-C (0.92 ± 0.30 vs. 0.82 ± 0.21), LDL-C (3.09 ± 0.98 vs. 2.92 ± 0.77), SBP (117 ± 9 vs. 115 ± 8), and DBP (76 ± 6 vs. 73 ± 7); and (b) included similar percentages of males having normal weight (17.2% vs. 31.0%); overweight (44.8% vs. 62.1%); android obesity (79.3% vs. 59.6%), hypertension (10.3% vs. 10.3%), hyperglycemia (37.9% vs. 48.2%), and MetS (51.7% vs. 34.5%). There is a need to monitor narghile use among male metabolic patients since it alters some components of the MetS.

Blood pressure differences between home monitoring and daytime ambulatory values and their reproducibility in treated hypertensive stroke and TIA patients

BACKGROUND

Guidelines recommend ambulatory or home blood pressure monitoring to improve hypertension diagnosis and monitoring. Both these methods are ascribed the same threshold values, but whether they produce similar results has not been established in certain patient groups.

METHODS

Adults with mild/moderate stroke or transient ischemic attack (N = 80) completed 2 sets of ambulatory and home blood pressure monitoring. Systolic and diastolic blood pressure values from contemporaneous measurements were compared, and the limits of agreement were assessed. Exploratory analyses for predictive factors of any difference were conducted.

RESULTS

Daytime ambulatory blood pressure values were consistently lower than home values, the mean difference in systolic blood pressure for initial ambulatory versus first home monitoring was -6.6 ± 13.5 mm Hg (P≤.001), and final ambulatory versus second home monitoring was -7.1 ± 11.0mm Hg (P≤.001). Mean diastolic blood pressure differences were -2.1 ± 8.5mm Hg (P=.03) and -2.0 ± 7.2mm Hg (P=.02). Limits of agreement for systolic blood pressure were -33.0 to 19.9mm Hg and -28.7 to 14.5mm Hg for the 2 comparisons and for DBP were -18.8 to 14.5mm Hg and -16.1 to 12.2mm Hg, respectively. The individual mean change in systolic blood pressure difference was 11.0 ± 8.3mm Hg across the 2 comparisons. No predictive factors for these differences were identified.

CONCLUSIONS

Daytime ambulatory systolic and diastolic blood pressure values were significantly lower than home monitored values at both time points. Differences between the 2 methods were not reproducible for individuals. Using the same threshold value for both out-of-office measurement methods may not be appropriate in patients with cerebrovascular disease.

A randomized multicenter study on ambulatory blood pressure and arterial stiffness in patients treated with valsartan/amlodipine or nifedipine GITS

In a pre-specified subgroup analysis of a 12-week randomized multicenter study, we investigated effects of valsartan/amlodipine 80/5 mg single-pill combination (n = 75) and nifedipine GITS 30 mg (n = 75) on ambulatory blood pressure (BP) and arterial stiffness assessed by brachial-ankle pulse wave velocity (PWV) in patients with uncontrolled hypertension. At week 12, the between-treatment mean differences in systolic/diastolic BP were smaller for 24-hour and daytime (-2.1/-1.7 and -2.0/-1.5 mm Hg, respectively, P ≥ 0.22) but greater (P < 0.01) for nighttime (-4.0/-2.8 mm Hg, P ≤ 0.09), especially in sustained uncontrolled hypertension (-5.0/-4.1 mm Hg, P ≤ 0.04) and non-dippers (-6.5/-3.7 mm Hg, P ≤ 0.07), in favor of valsartan/amlodipine. At week 12, PWV was significantly reduced from baseline by valsartan/amlodipine (n = 59, P < 0.0001) but not nifedipine (n = 59, P = 0.06). The changes in PWV were significantly associated with that in ambulatory systolic BP and pulse pressure in the nifedipine (P ≤ 0.0008) but not valsartan/amlodipine group (P ≥ 0.57), with a significant interaction (P ≤ 0.045). The valsartan/amlodipine combination was more efficacious than nifedipine GITS in lowering nighttime BP in sustained uncontrolled hypertension and non-dippers, and in lowering arterial stiffness independent of BP lowering.

The Effect of Kyolic Aged Garlic Extract on Gut Microbiota, Inflammation, and Cardiovascular Markers in Hypertensives: The GarGIC Trial

Background: Previous research suggests Kyolic-aged-garlic-extract to be effective in reducing blood pressure in a large proportion of hypertensive patients similar to first-line standard antihypertensive medication. High blood pressure has been linked to gut dysbiosis, with a significant decrease in microbial richness and diversity in hypertensives compared to normotensives. Furthermore, gut dysbiosis has been associated with increased inflammatory status and risk of cardiovascular events. Objective: To assess the effect of Kyolic aged GARlic extract on Gut microbiota, Inflammation, and Cardiovascular markers, including blood pressure, pulse wave velocity and arterial stiffness. Methods: A total of 49 participants with uncontrolled hypertension completed a double-blind randomized placebo-controlled trial of 12-weeks, investigating the effect of daily intake of aged-garlic-extract (1.2 g containing 1.2 mg S-allylcysteine) or placebo on blood pressure, pulse wave velocity and arterial stiffness, inflammatory markers, and gut microbiota. Results: Mean blood pressure was significantly reduced by 10 ± 3.6 mmHg systolic and 5.4 ± 2.3 mmHg diastolic compared to placebo. Vitamin B12 status played a role in responsiveness to garlic on blood pressure in 17% of patients. Garlic significantly lowered central blood pressure, pulse pressure and arterial stiffness (p < 0.05). Trends observed in inflammatory markers TNF-α and IL-6 need to be confirmed in larger trials. Furthermore, aged-garlic-extract improved gut microbiota, evident by higher microbial richness and diversity with a marked increase in Lactobacillus and Clostridia species after 3 months of supplementation. Conclusions: Kyolic-aged-garlic-extract is effective in reducing blood pressure in patients with uncontrolled hypertension, and has the potential to improve arterial stiffness, inflammation, and gut microbial profile. Aged-garlic-extract is highly tolerable with a high safety profile as a stand-alone or adjunctive antihypertensive treatment, with multiple benefits for cardiovascular health. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12616000185460 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370096).

An analysis of ambulatory blood pressure monitoring using multi-label classification

Ambulatory blood pressure monitoring (ABPM) involves measuring blood pressure by means of a tensiometer carried by the patient for a duration of 24 h, it currently occupies a central place in the diagnosis and follow-up of hypertensive patients, it provides crucial information which allows to make a specific diagnosis and adapt therapeutic attitude accordingly. The traditional analysis process suffers from different problems: it requires a lot of time and expertise, and several calculations should be performed manually by the expert, who is generally very busy. In this work, we attempt to improve the analysis of ABPM data using multi-label classification methods, where a record is associated with more than one label (class) at the same time. Seven algorithms are experimentally compared on a new multi-label ABPM-dataset. Experiments are conducted on 270 hypertensive patient records characterized by 40 attributes and associated with six labels. Results show that the multi-label modeling of ABPM data helps to investigate label dependencies and provide interesting insights, which can be integrated into the ABPM devices to dispense automatically detailed reports with possible future complications.

Long-term renal follow-up of children treated with cisplatin, carboplatin, or ifosfamide: a pilot study

BACKGROUND

Childhood cancer survivors treated with cisplatin, ifosfamide, or carboplatin are at risk for late kidney and blood pressure (BP) abnormalities. Few studies have comprehensively evaluated kidney outcomes and 24-h ambulatory BP monitoring (ABPM) in this population. We aimed to describe chemotherapy-associated acute kidney injury (AKI) and late kidney outcomes using standardized definitions.

METHODS

This was a single-center longitudinal pilot study of 23 children who participated in a previous study during cisplatin, carboplatin, or ifosfamide treatment. Medical charts were reviewed retrospectively. Available patients were approached for a study visit for blood and urine collection, BP measurement, and ABPM. AKI is defined by serum creatinine (SCr) rise (Kidney Disease: Improving Global Outcomes definition [SCr-AKI]). Electrolyte-AKI is defined by hypokalemia, hypophosphatemia, or hypomagnesemia. Chronic kidney disease (CKD) is defined by estimated glomerular filtration rate < 90 mL/min/1.73 m², albuminuria, or proteinuria. Electrolyte-CKD is defined by low serum electrolyte concentration or electrolyte supplementation.

RESULTS

Median age at chemotherapy start was 8.3 years; 9/23 (39%) were boys. Fourteen out of 23 (61%) patients had SCr-AKI during therapy; all developed electrolyte-AKI. Median 5.7 years post-chemotherapy, 7/22 (32%) had CKD, 11/23 (48%) had electrolyte-CKD, and 2/20 (10%) had hypertension. Fifteen out of 23 patients (65%) had either CKD, electrolyte-CKD, or hypertension. In ten patients available for a study visit (median 4.9 years post-chemotherapy), 1/10 (10%) had hypertension by ABPM; none had masked or white coat hypertension. All ten had at least one kidney abnormality (CKD, electrolyte-CKD, office pre-hypertension, or abnormal ABPM).

CONCLUSIONS

Using standardized outcome definitions, children treated with cisplatin, carboplatin, or ifosfamide have a high prevalence of late kidney abnormalities. Research must elucidate best practice for post-cancer treatment follow-up and kidney complication treatment.

Long-term blood pressure monitoring by office and 24-h ambulatory blood pressure in renal transplant patients: a longitudinal study

Background

Renal transplant patients have a high prevalence of nocturnal hypertension, and hypertension misclassification by office blood pressure (BP) is quite common in these patients. The potential impact of hypertension misclassification by office BP on hypertension management in this population has never been analysed.

Methods

We performed a longitudinal study in a cohort of 260 clinically stable renal transplant patients. In all, 785 paired office and 24-h ambulatory blood pressure monitoring (24-hABPM) measurements over a median follow-up of 3.9 years were available in the whole cohort.

Results

A total of 74% of patients had nocturnal hypertension (&gt;120/70 mmHg). Average office BP and 24-hABPM remained quite stable over follow-up, as did the prevalence of nocturnal hypertension, which was 77% at the last observation. However, the global agreement between office BP and average 24 h, daytime and night-time BP was unsatisfactory (k-statistics 0.10–0.26). In 193 visits (25% of all visits) where office BP indicated the need of antihypertensive therapy institution or modification (BP &gt;140/90 mmHg), 24-hABPM was actually normal (&lt;130/80 mmHg), while in 94 visits (12%), 24-hABPM was in the hypertensive range while office BP was normal. Overall, in 37% of visits, office BP provided misleading therapeutic indications.

Conclusions

Hypertension misclassification by office BP is a common phenomenon in stable renal transplant patients on long-term follow-up. Office BP may lead to inappropriate therapeutic decisions in over one-third of follow-up visits in these patients.

Cardiovascular Diseases and Long-term Self-reported Exposure to Pollution: RESULTS OF A NATIONAL EPIDEMIOLOGICAL STUDY IN LEBANON

BACKGROUND

Cardiovascular diseases (CVDs) are linked to high mortality and morbidity, particularly in developing countries. Some studies have linked indoor and outdoor pollution to CVD, but results are inconsistent. Our objective was to assess this association in Lebanon, a Middle Eastern country.

METHODS

A national cross-sectional study was conducted across Lebanon. CVD prevalence, which included prevalent ischemic heart and cerebrovascular diseases, was assessed. Moreover, in addition to self-reported items of pollution exposure, we assessed potential predictors of CVD, including sociodemographic characteristics, self-reported health information, and biological measurements.

RESULTS

We assessed the dose-effect relationship of pollution items in relation with CVD. Self-reported indoor and outdoor pollution exposures were associated with CVD, with or without taking biological values into account. Moreover, we found a dose-effect relationship of exposure with risk of disease (44% increase in risk of CVD for every additional pollution exposure item), after adjustment for sociodemographic and biological characteristics.

CONCLUSION

Although additional studies would be necessary to confirm these findings, interventions should start to sensitize the population about the effect of pollution on chronic diseases and the work of reducing pollution and improving air quality should be implemented to decrease the disease burden on the population and health system.

Comparing Office, Central, Home and Ambulatory Blood Pressure in Predicting Left Ventricular Mass

The blood pressure measurement method that more accurately predicts a left ventricular mass is controversial, and the evidence suggesting superiority of central over brachial measurements is contradictory. The aim of this study was to compare the relationship between the different clinic and out-of-clinic blood pressure measurements methods with left ventricular mass in patients who attended a specialised hypertension centre for a central blood pressure measurement. An analysis was performed on the correlations between left ventricular mass and central and brachial blood pressure measurements made in the clinic, and home, as well as 24-h systolic blood pressure measurements. A linear regression analysis was then performed to assess the independent relationship of each blood pressure measurement with left ventricular mass. The results on 824 treated and 123 untreated patients showed no significant differences between correlations, although home readings tended to have the best correlations. In regression adjusted models, for each 10 mmHg increase in systolic home blood pressure the left ventricular mass increased 10 g/m² (95% CI; 3.7-27, p=.01, _adjR² 0.38), and for 24-h ambulatory systolic blood pressure it increased 2.3 g/m² (95% CI 0.76-3.9, p<.01, _adjR² 0.15) in treated and untreated patients, respectively. The association of systolic blood pressure with left ventricular mass was better explained by home and 24-h ambulatory monitoring than to clinic-based measurements in treated and untreated patients, respectively. In the clinic, however, the central measurement was not superior to brachial blood pressure.

Psychosocial Stressors at Work and Ambulatory Blood Pressure

PURPOSE OF REVIEW

Psychosocial stressors at work from the demand-latitude and effort-reward imbalance models are adverse exposures affecting about 20-25% of workers in industrialized countries. This review aims to summarize evidence on the effect of these stressors on blood pressure (BP).

RECENT FINDINGS

Three systematic reviews have recently documented the effect of these psychosocial stressors at work on BP. Among exposed workers, statistically significant BP increases ranging from 1.5 to 11 mmHg have been observed in prospective studies using ambulatory BP (ABP). Recent studies using ABP have shown a deleterious effect of these psychosocial stressors at work on masked hypertension as well as on blood pressure control in pharmacologically treated patients. Evidence on the effect of these psychosocial stressors on BP supports the relevance to tackle these upstream factors for primary prevention and to reduce the burden of poor BP control. There is a need for increased public health and clinical awareness of the occupational etiology of high BP, hypertension, and poor BP control.

Masked hypertension incidence and risk factors in a prospective cohort study

Aims

Masked hypertension may affect up to 30% of the general population and is associated with a high cardiovascular disease risk. No previous study has examined the incidence of masked hypertension and its risk factors. The study aim was to determine the incidence of masked hypertension and to examine its related risk factors.

Methods

This is a cohort study including 1836 initially normotensive participants followed up on average for 2.9 years. Blood pressure was measured using Spacelabs 90207. Manual blood pressure was defined as the mean of the first three readings taken at rest. Ambulatory blood pressure was defined as the mean of the next readings recorded every 15 minutes during daytime working hours. Masked hypertension incidence at follow-up was defined as manual blood pressure less than 140 and less than 90 mmHg and ambulatory blood pressure at least 135 or at least 85 mmHg. Generalised estimating equations were used.

Results

The cumulative incidence of masked hypertension was 10.3% and was associated with male gender (relative risk (RR) 1.51, 95% confidence interval (CI) 1.18–1.94), older age (RR40–49 years 1.56, 95% CI 1.16–2.11, RR≥50 years 1.50, 95% CI 1.06–2.10), higher education (RRcollege 1.31, 95% CI 1.03–1.65), body mass index (RR≥27 1.43, 95% CI 1.11–1.85), smoking (RR 1.51, 95% CI 1.09–2.010) and alcohol intake (RR≥6/week 1.65, 95% CI 1.13–2.03).

Conclusion

The present study is the first to identify risk factors for the incidence of masked hypertension. Current guidelines for hypertension detection recommend ambulatory blood pressure in patients with an elevated blood pressure reading at the clinic. As it is impractical to measure ambulatory blood pressure in all normotensive patients, factors identified in the present study should be considered for the screening of at-risk individuals and for primary prevention of masked hypertension.

Automated blood pressure self-measurement station compared to office blood pressure measurement for first trimester screening of pre-eclampsia

Background:

Preeclampsia is a serious medical disorder affecting pregnancy. Screening in early pregnancy can identify women at risk and enable effective prophylactic treatment. Accurate blood pressure (BP) measurement is an important element of the screening algorithm. Automated self-screening, while attending the first trimester ultra sound scan, using a BP self-measurement (BPSM) station, could be a low-cost alternative to office BP measurements (OBPM) on both arms performed by clinical staff, if the measurement quality can be ensured.

Objectives:

The aim of this study was to compare automated BPSM using a self-measurement station on one arm, with OBPM performed by clinical staff on both arms. Primary outcome was the difference in mean arterial pressure (MAP) between the two methods and secondary outcomes were safety and practicality issues.

Methods:

Pregnant women attending ultrasound-examination at 12 weeks gestational age were recruited and randomized to start with having two OBPMs taken on both arms by staff, using two standard validated automatic upper arm BP devices, or self-measuring using an automated BPSM station following a crossover study design. The BPSM station consists of a validated blood pressure device, and an add-on sensor system capable of registering blood pressure values, rest-time, back-supported, legs-crossed, and ambient noise-levels respectively, and providing interactive guidance during the measurement process, for supporting the self-measurement process.

Results:

A total of 80 complete BP measurement sets were obtained, for a total of 240 BPSM measurements and 320 OBPM measurements. We found no significant difference between the OBPM and BPSM methods (p=0.86) for mean arterial pressure (MAP). However, erroneous measurements were observed frequently during the experiment, mainly during the first of the 3 BPSM measurements (6%), secondary during the second BPSM measurement (3%). Only one data set (1%) was excluded due to OBPM errors.

Conclusion:

No significant difference in MAP between the two methods was found. Means for detecting and repeating erroneous BP measurements should be implemented. Measurement errors was found in 9 % of the measurement sets which is not acceptable for clinical use. Thus, several measures have been identified in order to properly identify and recover from such measurement errors in the future.

Epidemiological and clinical implications of blood pressure measured in seated versus supine position

The evidence concerning how posture influences blood pressure is not consistent. The aim of this cross-sectional study was to consider the clinical and epidemiological implications of blood pressure measured in seated versus supine position, and to investigate the impact of age, sex, body mass index (BMI), and diabetes on these differences.This study included 1298 individuals (mean age 58.6 ± 11.8 years) from the Vara-Skövde cohort at the 10 years' follow-up visit in 2014. Physical examination included blood pressure measurements in seated and supine position. Self-reported information on diabetes status, hypertension, ongoing medication, leisure time physical activity, and smoking habits were obtained. Linear regression models accounted for differences in age, sex, BMI, and known diabetes.Both systolic and diastolic blood pressure were significantly higher in the seated position [1.2 mm Hg, P < .001, 95% confidence interval (95% CI) 0.79-1.54 and 4.2 mm Hg, P < .001, 95% CI 4.08-4.71, respectively]. The prevalence of high blood pressure in seated position was higher (19.9%) than in supine position (13.5%). Linear regression analysis showed that age (β = -0.215, P < .001) and diabetes (β = -0.072, P = .012) were associated with smaller differences in postural diastolic blood pressure and BMI (β = 0.124, P < .001) with greater difference.This study showed substantial postural differences in blood pressures measured in office. Measuring blood pressure in the supine position shows lower blood pressure readings when compared with the seated position. Clinicians should be aware of how age, BMI, and diabetes influence these differences.

Validity of ambulatory blood pressure monitoring in daily primary healthcare practice in France

OBJECTIVE

The objective of the study was to assess 24-h ambulatory blood pressure monitoring (ABPM) validity in daily primary healthcare practice in France.

PATIENTS AND METHODS

An observational, longitudinal, prospective, multicenter study was performed in the Burgundy region, France. Participants were patients who had been prescribed ABPM by their general practitioner (GP), whatever its indication. ABPM was performed by employees of the healthcare providers group, which is publicly funded. The validity of ABPM was established according to the European Society of Cardiology (ESC) criteria. GPs interpretation of the ABPM results was collected and compared with the ESC recommendations. Determinants of ABPM validity were identified using logistic regression models.

RESULTS

Among the 531 patients included, 357 (67.23%) had a valid ABPM measurement. Multivariate analyses showed that ABPM validity was associated with nonmanual worker status [odds ratio (OR)=1.14; 95% confidence interval (CI)=1.04-1.23], participant's age of at least 65 years (OR=0.88; 95% CI=0.81-0.95) and participant's BMI above 30 kg/m (OR=0.90; 95% CI=0.81-0.99). GPs' interpretation of ABPM results was consistent with the ESC recommendation in 508 (95.67%) cases.

CONCLUSION

ABPM is feasible in daily primary healthcare practice in the studied condition, that is to say relying on trained employees. GPs should be careful when prescribing ABPM to patients aged 65 years and older, to those with BMI over 30 or to manual workers.

Methods of Blood Pressure Assessment Used in Milestone Hypertension Trials

In the present review, we summarized the blood pressure (BP) measurement protocols of contemporary outcome trials in hypertension. In all these trials, clinic BP was used for the diagnosis and therapeutic monitoring of hypertension. In most trials, BP was measured in the sitting position with mercury sphygmomanometers or automated electronic BP monitors by trained observers. BP readings were taken on each occasion at least twice with a 30-to-60-s interval after 5 min of rest. Details regarding the arm side, cuff size, and the timing of BP measurement were infrequently reported. If clinic BP continues being used in future hypertension trials, the measurement should strictly follow current guidelines. The observers must be trained and experienced, and the device should be validated by automated electronic BP monitors. On each occasion, BP readings should be taken 2-3 times. The time interval between successive measurements has to be 30-60 s, and the resting period before the measurement should be at least 5 min in the supine or seated position and 1-3 min standing. BP should usually be measured in the seated position. The higher arm side and an appropriate size cuff should be chosen and noted. BP should be measured at defined trough hours. Automated office BP measurement has recently been used and seems to have less white-coat effect. The out-of-office BP measurement, either ambulatory or home BP monitoring, was only used in a subset of study participants of few hypertension trials. Future trials should consider these novel office or out-of-office BP measurements in guiding the therapy and preventing cardiovascular events.

The Post Clinic Ambulatory Blood Pressure (PC-ABP) study correlates Post Clinic Blood Pressure (PCBP) with the gold standard Ambulatory Blood Pressure

Objective

Our previous study showed that post-clinic blood pressure (BP) taken 15 min after a physician–patient encounter was the lowest reading in a routine clinic. We aimed to validate this reading with 24 h Ambulatory Blood Pressure Monitoring (ABPM) readings. A cross-sectional study was conducted in the cardiology clinics at the Aga Khan University, Pakistan. Hypertensive patients aged ≥ 18 years, or those referred for the diagnosis of hypertension were included.

Results

Of 150 participants, 49% were males. 76% of all participants were hypertensive. Pre-clinic BP reading was measured by a nurse, in-clinic by a physician and 15 min post-clinic by a research assistant using a validated, automated BP device (Omron-HEM7221-E). All patients were referred for 24 h ABPM. Among the three readings taken during a clinic visit, mean (± SD) systolic BP (SBP) pre-clinic, in-clinic, and 15 min post-clinic were 153.2 ± 23, 152.3 ± 21, and 140.0 ± 18 mmHg, respectively. Mean (± SD) diastolic BP (DBP) taken pre-clinic, in-clinic and 15 min post-clinic were 83.5 ± 12, 90.9 ± 12, and 86.4 ± 11 mmHg respectively. Mean (± SD) daytime ambulatory SBP, DBP and pulse readings were 134.7 ± 15, 78.7 ± 15 mmHg, and 72.6 ± 12/min, respectively. Pearson correlation coefficients of pre-clinic, in-clinic and post-clinic SBP with daytime ambulatory-SBP were 0.4 (p value: < 0.001), 0.5 (p value: < 0.001) and 0.6 (p value: < 0.001), respectively. Post-clinic BP has a good correlation with ambulatory BP and may be considered a more reliable reading in the clinic setting.

Effect of Respiration on the Characteristic Ratios of Oscillometric Pulse Amplitude Envelope in Blood Pressure Measurement

Systolic and diastolic blood pressures (BPs) are important physiological parameters for disease diagnosis. Systolic and diastolic characteristic ratios derived from oscillometric pulse waveform have been widely used to estimate automated non-invasive BPs in oscillometric BP measurement devices. The oscillometric pulse waveform is easily influenced by respiration, which may cause variability to the characteristic ratios and subsequently BP measurement. This study quantitatively investigated how respiration patterns (i.e., normal breathing and deep breathing) affect the systolic and diastolic characteristic ratios. The study was performed with clinical data collected from 39 healthy subjects, and each subject conducted BP measurements during normal and deep breathings. Analytical results showed that the systolic characteristic ratio increased significantly from 0.52 ± 0.13 under normal breathing to 0.58 ± 0.14under deep breathing (p < 0.05), and the diastolic characteristic ratio was not significantly affected from 0.75 ± 0.12 under normal breathing to 0.76 ± 0.13 under deep breathing (p = 0.48). In conclusion, deep breathing significantly affected the systolic characteristic ratio, suggesting that automated oscillometric BP device which is validated under resting condition should be strictly used for measurements under resting condition.

Short-Term Test-Retest Reliability of Respiratory Sinus Arrhythmia (RSA) in Young Adults

Abstract. Despite the burgeoning use of respiratory sinus arrhythmia (RSA), heart period (HP), and blood pressure (BP) to study individual differences in autonomic regulatory processes in young adults, few studies have examined the short-term reliability of such autonomic measures in emerging adulthood. If resting autonomic measures indeed reflect “trait-like” individual differences, they should have acceptable levels of test-retest reliability. We examined the 1-month test-retest reliability of resting measures of RSA as well as HP, systolic (SBP) and diastolic blood pressure (DBP) in a sample of 41 healthy young adults. Test-retest reliability of all four measures was good-to-excellent across the 1-month period. However, uncontrolled mean RSA declined from Time 1 to Time 2, suggesting that while individual differences in RSA were stable, mean RSA appeared to be sensitive to condition effects. Even with random variation, all of these measures were stable across one month, demonstrating acceptable short-term test-retest reliability in emerging adulthood.