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Features from the photoplethysmogram and the electrocardiogram for estimating changes in blood pressure. Sci Rep 2023; 13:986. [PMID: 36653426 PMCID: PMC9849280 DOI: 10.1038/s41598-022-27170-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/27/2022] [Indexed: 01/19/2023] Open
Abstract
There is a growing emphasis being placed on the potential for cuffless blood pressure (BP) estimation through modelling of morphological features from the photoplethysmogram (PPG) and electrocardiogram (ECG). However, the appropriate features and models to use remain unclear. We investigated the best features available from the PPG and ECG for BP estimation using both linear and non-linear machine learning models. We conducted a clinical study in which changes in BP ([Formula: see text]BP) were induced by an infusion of phenylephrine in 30 healthy volunteers (53.8% female, 28.0 (9.0) years old). We extracted a large and diverse set of features from both the PPG and the ECG and assessed their individual importance for estimating [Formula: see text]BP through Shapley additive explanation values and a ranking coefficient. We trained, tuned, and evaluated linear (ordinary least squares, OLS) and non-linear (random forest, RF) machine learning models to estimate [Formula: see text]BP in a nested leave-one-subject-out cross-validation framework. We reported the results as correlation coefficient ([Formula: see text]), root mean squared error (RMSE), and mean absolute error (MAE). The non-linear RF model significantly ([Formula: see text]) outperformed the linear OLS model using both the PPG and the ECG signals across all performance metrics. Estimating [Formula: see text]SBP using the PPG alone ([Formula: see text] = 0.86 (0.23), RMSE = 5.66 (4.76) mmHg, MAE = 4.86 (4.29) mmHg) performed significantly better than using the ECG alone ([Formula: see text] = 0.69 (0.45), RMSE = 6.79 (4.76) mmHg, MAE = 5.28 (4.57) mmHg), all [Formula: see text]. The highest ranking features from the PPG largely modelled increasing reflected wave interference driven by changes in arterial stiffness. This finding was supported by changes observed in the PPG waveform in response to the phenylephrine infusion. However, a large number of features were required for accurate BP estimation, highlighting the high complexity of the problem. We conclude that the PPG alone may be further explored as a potential single source, cuffless, blood pressure estimator. The use of the ECG alone is not justified. Non-linear models may perform better as they are able to incorporate interactions between feature values and demographics. However, demographics may not adequately account for the unique and individualised relationship between the extracted features and BP.
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Fuadah YN, Lim KM. Classification of Blood Pressure Levels Based on Photoplethysmogram and Electrocardiogram Signals with a Concatenated Convolutional Neural Network. Diagnostics (Basel) 2022; 12:diagnostics12112886. [PMID: 36428946 PMCID: PMC9689744 DOI: 10.3390/diagnostics12112886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/04/2022] [Accepted: 11/16/2022] [Indexed: 11/23/2022] Open
Abstract
Hypertension is a severe public health issue worldwide that significantly increases the risk of cardiac vascular disease, stroke, brain hemorrhage, and renal dysfunction. Early screening of blood pressure (BP) levels is essential to prevent the dangerous complication associated with hypertension as the leading cause of death. Recent studies have focused on employing photoplethysmograms (PPG) with machine learning to classify BP levels. However, several studies claimed that electrocardiograms (ECG) also strongly correlate with blood pressure. Therefore, we proposed a concatenated convolutional neural network which integrated the features extracted from PPG and ECG signals. This study used the MIMIC III dataset, which provided PPG, ECG, and arterial blood pressure (ABP) signals. A total of 14,298 signal segments were obtained from 221 patients, which were divided into 9150 signals of train data, 2288 signals of validation data, and 2860 signals of test data. In the training process, five-fold cross-validation was applied to select the best model with the highest classification performance. The proposed concatenated CNN architecture using PPG and ECG obtained the highest test accuracy of 94.56-95.15% with a 95% confidence interval in classifying BP levels into hypotension, normotension, prehypertension, hypertension stage 1, and hypertension stage 2. The result shows that the proposed method is a promising solution to categorize BP levels effectively, assisting medical personnel in making a clinical diagnosis.
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Affiliation(s)
- Yunendah Nur Fuadah
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi 39177, Republic of Korea
- School of Electrical Engineering, Telkom University, Bandung 40257, Indonesia
| | - Ki Moo Lim
- Computational Medicine Lab, Department of IT Convergence Engineering, Kumoh National Institute of Technology, Gumi 39177, Republic of Korea
- Computational Medicine Lab, Department of Medical IT Convergence Engineering, Kumoh National Institute of Technology, Gumi 39177, Republic of Korea
- Correspondence:
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Self-Monitoring Home Blood Pressure in Community-Dwelling Older People: Age Differences in White-Coat and Masked Phenomena and Related Factors—The SONIC Study. Int J Hypertens 2022; 2022:5359428. [PMID: 35535213 PMCID: PMC9078792 DOI: 10.1155/2022/5359428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 02/25/2022] [Accepted: 03/23/2022] [Indexed: 11/21/2022] Open
Abstract
Some studies reported that home blood pressure (HBP) monitoring was conducted by community-dwelling older people themselves, but there have been few studies on HBP including very old populations aged over 90 years old. Thus, the aim of the present study was to clarify the current situation of white-coat and masked phenomena defined by on-site and home BP measurements in community-dwelling old and oldest-old populations. The study subjects were 380 participants from the SONIC study, a cohort study of a community-dwelling old population, who measured their HBP in a series of 3–5 days by themselves and brought their HBP records to the venue on the survey day. Study participants' characteristics were as follows: female, 185 (48.7%); male, 195 (51.3%); 70s, 95 (25.0%); 80s, 245 (64.5%); and 90s, 40 (10.5%). A total of 344 (90.5%) participants had hypertension. A total of 291 (76.6%) hypertensive participants taking antihypertensive medication were analyzed in the present study. Regarding the types of hypertension defined by home and on-site BP, they showed white-coat phenomenon, 183 (48.2%); masked phenomenon, 115 (30.3%); sustained hypertension, 130 (34.2%); and normotension, 82 (21.6%). On comparison of age groups, there was a tendency for the white-coat phenomenon to be common in young-old people in their 70s and the masked phenomenon to be common in very old people in their 90s. Therefore, since the detection of white-coat and masked phenomena is closely associated with appropriate BP management, it is very important for community-dwelling older populations to self-monitor HBP.
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Finnegan E, Davidson S, Harford M, Jorge J, Watkinson P, Young D, Tarassenko L, Villarroel M. Pulse arrival time as a surrogate of blood pressure. Sci Rep 2021; 11:22767. [PMID: 34815419 PMCID: PMC8611024 DOI: 10.1038/s41598-021-01358-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
Various models have been proposed for the estimation of blood pressure (BP) from pulse transit time (PTT). PTT is defined as the time delay of the pressure wave, produced by left ventricular contraction, measured between a proximal and a distal site along the arterial tree. Most researchers, when they measure the time difference between the peak of the R-wave in the electrocardiogram signal (corresponding to left ventricular depolarisation) and a fiducial point in the photoplethysmogram waveform (as measured by a pulse oximeter attached to the fingertip), describe this erroneously as the PTT. In fact, this is the pulse arrival time (PAT), which includes not only PTT, but also the time delay between the electrical depolarisation of the heart's left ventricle and the opening of the aortic valve, known as pre-ejection period (PEP). PEP has been suggested to present a significant limitation to BP estimation using PAT. This work investigates the impact of PEP on PAT, leading to a discussion on the best models for BP estimation using PAT or PTT. We conducted a clinical study involving 30 healthy volunteers (53.3% female, 30.9 ± 9.35 years old, with a body mass index of 22.7 ± 3.2 kg/m[Formula: see text]). Each session lasted on average 27.9 ± 0.6 min and BP was varied by an infusion of phenylephrine (a medication that causes venous and arterial vasoconstriction). We introduced new processing steps for the analysis of PAT and PEP signals. Various population-based models (Poon, Gesche and Fung) and a posteriori models (inverse linear, inverse squared and logarithm) for estimation of BP from PTT or PAT were evaluated. Across the cohort, PEP was found to increase by 5.5 ms ± 4.5 ms from its baseline value. Variations in PTT were significantly larger in amplitude, - 16.8 ms ± 7.5 ms. We suggest, therefore, that for infusions of phenylephrine, the contribution of PEP on PAT can be neglected. All population-based models produced large BP estimation errors, suggesting that they are insufficient for modelling the complex pathways relating changes in PTT or PAT to changes in BP. Although PAT is inversely correlated with systolic blood pressure (SBP), the gradient of this relationship varies significantly from individual to individual, from - 2946 to - 470.64 mmHg/s in our dataset. For the a posteriori inverse squared model, the root mean squared errors (RMSE) for systolic and diastolic blood pressure (DBP) estimation from PAT were 5.49 mmHg and 3.82 mmHg, respectively. The RMSEs for SBP and DBP estimation by PTT were 4.51 mmHg and 3.53 mmHg, respectively. These models take into account individual calibration curves required for accurate blood pressure estimation. The best performing population-based model (Poon) reported error values around double that of the a posteriori inverse squared model, and so the use of population-based models is not justified.
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Affiliation(s)
- Eoin Finnegan
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK.
| | - Shaun Davidson
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Mirae Harford
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - João Jorge
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Peter Watkinson
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Duncan Young
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Lionel Tarassenko
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Mauricio Villarroel
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK
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Prevalence of masked hypertension evaluated by home blood pressure monitoring in a large sample of patients with office blood pressure <140/90 mmHg. Blood Press Monit 2021; 26:224-229. [PMID: 33577184 DOI: 10.1097/mbp.0000000000000517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM Patients with masked hypertension have a higher incidence of target organ damage, including increased left ventricular mass and carotid atherosclerosis and cardiovascular events when compared with normotensive patients. The adverse cardiovascular risks are even greater in patients already taking antihypertensive medication. OBJECTIVE To identify the prevalence and clinical characteristics of masked hypertension in a large multicenter Brazilian sample that underwent office and home blood pressure monitoring. METHODS This was an observational cross-sectional analytical study based on secondary data from the teleMRPA online platform, which included 32 cities from 15 states in the five regions of Brazil. The database included 3704 outpatient participants with office blood pressure <140/90 mmHg who performed home blood pressure monitoring for diagnostic investigation (diagnosis group; n = 1819) or treatment (treatment group; n = 1885) of hypertension in 2018. RESULTS The prevalence of masked hypertension was 18.0% in the whole studied population and 15.4% and 20.4% in the diagnostic and treatment group, respectively. Masked hypertension was more frequently detected in patients with office blood pressure classified as high normal [systolic blood pressure (SBP) = 130-139 mmHg or diastolic blood pressure (DBP) = 85-89 mmHg], followed by those classified as normal (SBP = 120-129 mmHg or DBP = 80-84 mmHg) and optimal (SBP < 120 mmHg and DBP < 80 mmHg), with respective prevalence of 28.3, 13.4 and 4.4% in the diagnostic group and 30.8, 18.8 and 7.1% in the treatment group. CONCLUSION Masked hypertension has a significant prevalence among individuals with office blood pressure <140/90 mmHg, which is greater with patients with high normal office blood pressure and even higher in patients already using antihypertensive medication.
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Sendzikaite S, Sudikiene R, Tarutis V, Lubaua I, Silis P, Rybak A, Jankauskiene A, Litwin M. Prevalence of arterial hypertension, hemodynamic phenotypes, and left ventricular hypertrophy in children after coarctation repair: a multicenter cross-sectional study. Pediatr Nephrol 2020; 35:2147-2155. [PMID: 32529324 DOI: 10.1007/s00467-020-04645-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study aimed to evaluate hemodynamic phenotypes and prevalence of left ventricular hypertrophy in children after coarctation repair with right arm and leg blood pressure difference < 20 mmHg. Secondary objectives were analysis of effects of age at intervention, residual gradient across the descending aorta, and type of correction. METHODS Blood pressure status and left ventricular hypertrophy were diagnosed according to European Society of Hypertension 2016 guidelines. RESULTS Of 90 patients with a median age 12.5 (8.9-15.8) years, 8.5 (6.0-11.8) years after coarctation repair who were included, 42 (46.7%) were hypertensive. Isolated systolic hypertension dominated among 29 hypertensive patients with uncontrolled or masked hypertension (25 of 29; 86.2%). Of the 48 patients with office normotension, 14.6% (7) had masked hypertension, 8.3% (4) had ambulatory prehypertension, and 54.2% (26) were truly normotensive. Left ventricular hypertrophy was diagnosed in 29 patients (32.2%), including 14 of 42 (33.3%) hypertensive and 15 of 48 (31.3%) normotensive patients. The peak systolic gradient across the descending aorta was greater in hypertensive subjects (33.3 ± 12.7 mmHg) compared with normotensive subjects (25 ± 8.2 mmHg, p = 0.0008). Surgical correction was performed earlier than percutaneous intervention (p < 0.0001) and dominated in 40 of 48 (83.3%) normotensive versus 24 of 42 (57.1%) hypertensive patients (p = 0.006). CONCLUSIONS Arterial hypertension with isolated systolic hypertension as the dominant phenotype and left ventricular hypertrophy are prevalent even after successful coarctation repair. Coarctation correction from the age of 9 years and older was associated with a higher prevalence of hypertension.
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Affiliation(s)
- Skaiste Sendzikaite
- Institute of Clinical Medicine, Vilnius University, Faculty of Medicine, Vilnius, Lithuania.
| | - Rita Sudikiene
- Institute of Clinical Medicine, Vilnius University, Faculty of Medicine, Vilnius, Lithuania
| | - Virgilijus Tarutis
- Institute of Clinical Medicine, Vilnius University, Faculty of Medicine, Vilnius, Lithuania
| | - Inguna Lubaua
- Clinic for Paediatric Cardiology and Cardiac Surgery, Children's Clinical University Hospital, Stradins University, Riga, Latvia
| | - Pauls Silis
- Clinic for Paediatric Cardiology and Cardiac Surgery, Children's Clinical University Hospital, Stradins University, Riga, Latvia
| | - Agata Rybak
- Department of Cardiology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Augustina Jankauskiene
- Institute of Clinical Medicine, Vilnius University, Faculty of Medicine, Vilnius, Lithuania
| | - Mieczyslaw Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
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Soh DCK, Ng E, Jahmunah V, Oh SL, Tan RS, Acharya U. Automated diagnostic tool for hypertension using convolutional neural network. Comput Biol Med 2020; 126:103999. [DOI: 10.1016/j.compbiomed.2020.103999] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/29/2020] [Accepted: 08/29/2020] [Indexed: 12/13/2022]
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Padwal R. The Masked Hypertension Conundrum: Risk Is Increased, but What Should Be Done About It? Am J Hypertens 2020; 33:705-707. [PMID: 32179882 DOI: 10.1093/ajh/hpaa045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/13/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Raj Padwal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Prevalence and determinants of masked hypertension among obese individuals at the Yaoundé Central Hospital: a cross-sectional study in sub-Saharan Africa. Blood Press Monit 2020; 25:212-215. [DOI: 10.1097/mbp.0000000000000457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Cesario V, Presta V, Figliuzzi I, Citoni B, Battistoni A, Miceli F, Volpe M, Tocci G. Epidemiological Impact and Clinical Consequences of Masked Hypertension: A Narrative Review. High Blood Press Cardiovasc Prev 2020; 27:195-201. [PMID: 32361899 DOI: 10.1007/s40292-020-00382-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023] Open
Abstract
Masked hypertension (MHT) is a clinical condition characterized by normal blood pressure (BP) levels during clinical consultation and above normal out-of-office BP values. MHT is associated to an increased risk of developing hypertension-mediated organ damage (HMOD) and major cardiovascular (CV) outcomes, such as myocardial infarction, stroke, and hospitalizations due to CV causes, as well as to metabolic abnormalities and diabetes, thus further promoting the development and progression of atherosclerotic disease. Previous studies showed contrasting data on prevalence and clinical impact of MHT, due to not uniform diagnostic criteria (including either home or 24-h ambulatory BP measurements, or both) and background antihypertensive treatment. Whatever the case, over the last few years the widespread diffusion of validated devices for home BP monitoring has promoted a better diagnostic assessment and proper identification of individuals with MHT in a setting of clinical practice, thus resulting in increased prevalence of this clinical condition with potential clinical and socio-economic consequences. Several other items, in fact, remain unclear and debated, particularly regarding the therapeutic approach to MHT. The aim of this narrative review is to illustrate the clinical definition of MHT, to analyze the diagnostic algorithm, and to discuss the potential pharmacological approaches to be adopted in this clinical condition, in the light of the recommendations of the recent European hypertension guidelines.
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Affiliation(s)
- Vincenzo Cesario
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Hypertension Unit, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Vivianne Presta
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Hypertension Unit, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Ilaria Figliuzzi
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Hypertension Unit, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Barbara Citoni
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Hypertension Unit, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Allegra Battistoni
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Hypertension Unit, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Francesca Miceli
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Hypertension Unit, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Massimo Volpe
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Hypertension Unit, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
- IRCCS Neuromed, Pozzilli, Italy
| | - Giuliano Tocci
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Hypertension Unit, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy.
- IRCCS Neuromed, Pozzilli, Italy.
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Kobalava ZD, Konradi AO, Nedogoda SV, Shlyakhto EV, Arutyunov GP, Baranova EI, Barbarash OL, Boitsov SA, Vavilova TV, Villevalde SV, Galyavich AS, Glezer MG, Grineva EN, Grinstein YI, Drapkina OM, Zhernakova YV, Zvartau NE, Kislyak OA, Koziolova NA, Kosmacheva ED, Kotovskaya YV, Libis RA, Lopatin YM, Nebiridze DV, Nedoshivin AO, Ostroumova OD, Oschepkova EV, Ratova LG, Skibitsky VV, Tkacheva ON, Chazova IE, Chesnikova AI, Chumakova GA, Shalnova SA, Shestakova MV, Yakushin SS, Yanishevsky SN. Arterial hypertension in adults. Clinical guidelines 2020. ACTA ACUST UNITED AC 2020. [DOI: 10.15829/1560-4071-2020-3-3786] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Arterial hypertension in adults. Clinical guidelines 2020
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Soh DCK, Ng EYK, Jahmunah V, Oh SL, San TR, Acharya UR. A computational intelligence tool for the detection of hypertension using empirical mode decomposition. Comput Biol Med 2020; 118:103630. [PMID: 32174317 DOI: 10.1016/j.compbiomed.2020.103630] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 12/28/2022]
Abstract
Hypertension (HPT), also known as high blood pressure, is a precursor to heart, brain or kidney diseases. Some symptoms of HPT include headaches, dizziness and fainting. The potential diagnosis of masked hypertension is of specific interest in this study. In masked hypertension (MHPT), the instantaneous blood pressure appears normal, but the 24-h ambulatory blood pressure is abnormal. Hence patients with MHPT are difficult to identify and thus remain untreated or are treated insufficiently. Hence, a computational intelligence tool (CIT) using electrocardiograms (ECG) signals for HPT and possible MHPT detection is proposed in this work. Empirical mode decomposition (EMD) is employed to decompose the pre-processed signals up to five levels. Nonlinear features are extracted from the five intrinsic mode functions (IMFs) thereafter. Student's t-test is subsequently applied to select a set of highly discriminatory features. This feature set is then input to various classifiers, in which, the best accuracy of 97.70% is yielded by the k-nearest neighbor (k-NN) classifier. The developed tool is evaluated by the 10-fold cross validation technique. Our findings suggest that the developed system is useful for diagnostic computational intelligence tool in hospital settings, and that it enables the automatic classification of HPT versus normal ECG signals.
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Affiliation(s)
| | - E Y K Ng
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore.
| | - V Jahmunah
- School of Engineering, Ngee Ann Polytechnic, Singapore
| | - Shu Lih Oh
- School of Engineering, Ngee Ann Polytechnic, Singapore
| | | | - U Rajendra Acharya
- School of Engineering, Ngee Ann Polytechnic, Singapore; Department of Bioinformatics and Medical Engineering, Asia University, Taiwan; International Research Organization for Advanced Science and Technology (IROAST), Kumamoto University, Kumamoto, Japan
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Fujiwara T, Yano Y, Hoshide S, Kanegae H, Kario K. Association of Cardiovascular Outcomes With Masked Hypertension Defined by Home Blood Pressure Monitoring in a Japanese General Practice Population. JAMA Cardiol 2019; 3:583-590. [PMID: 29800067 DOI: 10.1001/jamacardio.2018.1233] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Importance The clinical outcomes associated with masked hypertension defined by home blood pressure monitoring (HBPM) in clinical settings remain uncertain. Objective To assess the association between masked hypertension and cardiovascular disease events in clinical settings. Design, Setting, and Participants This observational cohort study used data from 4261 outpatients treated at 71 primary practices or university hospitals throughout Japan who were enrolled in the Japan Morning Surge-Home Blood Pressure study between January 1, 2005, and December 31, 2012. Participants had a history of or risk factors for cardiovascular disease and were followed up through March 31, 2015. Participants underwent clinic blood pressure (BP) measurements on 2 occasions as well as HBPM measurements in the morning and evening for a 14-day period. Urine albumin to creatinine ratio and circulating brain (or B-type) natriuretic peptide levels were quantified at baseline as a marker of cardiovascular end-organ damage. Data were analyzed from July 1, 2017, to October 31, 2017. Exposures Participants were categorized into 4 BP groups: (1) masked hypertension-hypertensive home BP levels (systolic, ≥135 mm Hg; diastolic, ≥85 mm Hg) and nonhypertensive clinic BP levels (systolic, <140 mm Hg; diastolic, <90 mm Hg); (2) white-coat hypertension-nonhypertensive home BP levels (systolic, <135 mm Hg; diastolic, <85 mm Hg) and hypertensive clinic BP levels (systolic, ≥140 mm Hg; diastolic, ≥90 mm Hg); (3) sustained hypertension-hypertensive home and clinic BP levels; and (4) controlled BP-nonhypertensive home and clinic BP levels. Main Outcomes and Measures Incident stroke and coronary heart disease. Results Of the 4261 participants, 2266 (53.2%) were women, 3374 (79.2%) were taking antihypertensive medication, and the mean (SD) age was 64.9 (10.9) years. During a median (interquartile range) follow-up of 3.9 (2.4-4.6) years, 74 stroke (4.4 per 1000 person-years) and 77 coronary heart disease (4.6 per 1000 person-years) events occurred. The masked hypertension group had a greater risk for stroke compared with the controlled BP group (hazard ratio, 2.77; 95% CI, 1.20-6.37), independent of traditional cardiovascular risk factors, urine albumin to creatinine ratio, and circulating B-type natriuretic peptide levels. Conversely, masked hypertension yielded no association with coronary heart disease risk. Conclusions and Relevance In the Japanese general practice population, masked hypertension defined by HBPM may be associated with an increased risk for stroke events. Use of HBPM may improve the assessment of BP-related risks and identify new therapeutic interventions aimed at preventing cardiovascular disease events.
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Affiliation(s)
- Takeshi Fujiwara
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan.,Higashiagatsuma-machi National Health Insurance Clinic, Gunma, Japan
| | - Yuichiro Yano
- Department of Preventive Medicine, University of Mississippi Medical Center, Jackson
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Hiroshi Kanegae
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan.,Genki Plaza Medical Center for Health Care, Tokyo, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan
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15
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Sanidas E, Tsakalis K, Papadopoulos DP, Zerva K, Velliou M, Perrea D, Mantzourani M, Iliopoulos D, Barbetseas J. The impact of apelin and relaxin plasma levels in masked hypertension and white coat hypertension. J Clin Hypertens (Greenwich) 2018; 21:48-52. [PMID: 30525273 DOI: 10.1111/jch.13449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/19/2018] [Accepted: 09/29/2018] [Indexed: 12/17/2022]
Abstract
Masked hypertension (HTN) and white coat hypertension represent two reverse forms of clinical HTN with questionable prognostic significance. Recent evidence supports that low apelin and relaxin plasma levels contribute to vascular damage accelerating atherogenesis and predisposing to HTN and cardiovascular (CV) events. The aim of this study was to compare apelin and relaxin plasma levels between patients with masked hypertension (MH) and those with white coat HTN (WCH). Overall, 130 patients not receiving antihypertensive therapy were studied. All patients underwent 24-hour ambulatory BP monitoring (ABPM) and office BP measurements. Plasma apelin and relaxin levels were measured by ELISA method. According to BP recordings, 24 subjects had MH (group A) and 32 had WCH (group B). Apelin (200 ± 111 pg/mL vs 305 ± 127 pg/mL, P < 0.01) and relaxin (35.2 ± 6.7 pg/mL vs 46.8 ± 23.6 pg/mL, P < 0.01) plasma levels were significantly lower in patients with MH compared to those with WCH, respectively. In conclusion, our findings showed that patients with MH had significantly lower apelin and relaxin levels compared to those with WCH. This observation implies an additional prognostic role for adipokines supporting the concept that MH is closer to essential HTN whereas WCH is a more benign condition.
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Affiliation(s)
- Elias Sanidas
- Hypertension Excellence Centre - ESH, Department of Cardiology, LAIKO General Hospital, Athens, Greece
| | - Kostas Tsakalis
- Hypertension Excellence Centre - ESH, Department of Cardiology, LAIKO General Hospital, Athens, Greece
| | - Dimitrios P Papadopoulos
- Hypertension Excellence Centre - ESH, Department of Cardiology, LAIKO General Hospital, Athens, Greece
| | - Kanella Zerva
- Hypertension Excellence Centre - ESH, Department of Cardiology, LAIKO General Hospital, Athens, Greece
| | - Maria Velliou
- Hypertension Excellence Centre - ESH, Department of Cardiology, LAIKO General Hospital, Athens, Greece
| | - Despoina Perrea
- Laboratory of Experimental Surgery and Surgical Research "N.S. Christeas", University of Athens, Medical School, Athens, Greece
| | - Marina Mantzourani
- 1st Department of Internal Medicine, LAIKO General Hospital, University of Athens, Medical School, Athens, Greece
| | - Dimitrios Iliopoulos
- Laboratory of Experimental Surgery and Surgical Research "N.S. Christeas", University of Athens, Medical School, Athens, Greece
| | - John Barbetseas
- Hypertension Excellence Centre - ESH, Department of Cardiology, LAIKO General Hospital, Athens, Greece
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2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36:1953-2041. [PMID: 30234752 DOI: 10.1097/hjh.0000000000001940] [Citation(s) in RCA: 1775] [Impact Index Per Article: 295.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.
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Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen SE, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder RE, Shlyakhto E, Tsioufis C, Aboyans V, Desormais I. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:3021-3104. [PMID: 30165516 DOI: 10.1093/eurheartj/ehy339] [Citation(s) in RCA: 5512] [Impact Index Per Article: 918.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Mwasongwe S, Min YI, Booth JN, Katz R, Sims M, Correa A, Young B, Muntner P. Masked hypertension and kidney function decline: the Jackson Heart Study. J Hypertens 2018; 36:1524-1532. [PMID: 29601413 PMCID: PMC5990961 DOI: 10.1097/hjh.0000000000001727] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hypertension diagnosed by blood pressure (BP) measured in the clinic is associated with rapid kidney function decline (RKFD) and incident chronic kidney disease (CKD). The extent to which hypertension defined using out-of-clinic BP measurements is associated with these outcomes is unclear. METHODS We evaluated the association of any masked hypertension (daytime SBP/DBP ≥ 135/85 mmHg, night-time SBP/DBP ≥ 120/70 mmHg or 24-h SBP/DBP ≥ 130/80 mmHg) with RKFD and incident CKD among 676 African-Americans in the Jackson Heart Study with clinic-measured SBP/DBP less than 140/90 mmHg who completed ambulatory BP monitoring in 2000-2004. RKFD was defined as a decline in estimated glomerular filtration rate (eGFR) at least 30% and incident CKD was defined as development of eGFR less than 60 ml/min per 1.73 m with an at least 25% decline in eGFR between 2000-2004 and 2009-2013. RESULTS The mean age of participants was 57.6 years, 28.8% were men and 52.7% had any masked hypertension. After a median follow-up of 8 years, 13.8 and 8.6% of participants had RKFD and incident CKD, respectively. In unadjusted analyses, masked hypertension was associated with an increased odds for incident CKD [odds ratio (OR) 2.20, 95% confidence interval (CI) 1.22, 3.97]. This association remained statistically significant after adjustment for demographic characteristics, baseline eGFR and albumin-to-creatinine ratio (OR 1.95, 95% CI 1.04, 3.67) but was eliminated after propensity score adjustment (OR 1.62, 95% CI 0.87, 3.00). There was no association between masked hypertension and RKFD. CONCLUSION Masked hypertension may be associated with the development of CKD in African-Americans.
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Affiliation(s)
| | - Yuan-I Min
- University of Mississippi Medical Center, Jackson Heart Study, Jackson, Mississippi
| | - John N. Booth
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ronit Katz
- Division of Nephrology, Kidney Research Institute, University of Washington
| | - Mario Sims
- University of Mississippi Medical Center, Jackson Heart Study, Jackson, Mississippi
| | - Adolfo Correa
- University of Mississippi Medical Center, Jackson Heart Study, Jackson, Mississippi
| | - Bessie Young
- Division of Nephrology, Kidney Research Institute, University of Washington
- Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
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Abstract
Background Masked hypertension (MHT), defined as normal office blood pressure (BP) but high ambulatory BP, has been associated with increased cardiovascular risk. Although MHT has been associated with obesity, there is limited knowledge on the prevalence and covariates of MHT in obese cohorts. Methods Office and ambulatory BP recordings and other cardiovascular risk factors were assessed in 323 obese participants included in the fat-associated cardiovascular dysfunction study (mean age 48.9±9.0 years, 55% women, mean BMI 32.3±4.4 kg/m2). Office BP 130–139/85–89 mmHg was considered high-normal. Subclinical arterial damage was identified as carotid–femoral pulse wave velocity more than 10 m/s by applanation tonometry or carotid plaque by ultrasound (maximal intima–media thickness ≥1.5 mm). Results MHT was present in 17.1% of the population. Patients with MHT had a higher prevalence of metabolic syndrome, high-normal office BP, and were more often male compared with the normotensive (NT) individuals (all P<0.05), but were younger and had lower prevalence of diabetes and subclinical arterial damage than the sustained hypertensive group (all P<0.05). In multinomial logistic regression analysis, MHT was associated with the presence of metabolic syndrome and high-normal office BP compared with NT individuals, and lower pulse wave velocity and fewer carotid plaques than sustained hypertension (all P<0.05). Conclusion In obese patients, MHT was associated with the presence of metabolic syndrome and high-normal office BP compared with NT individuals, but less subclinical arterial damage than sustained hypertensive patients.
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Hypertension types defined by clinic and ambulatory blood pressure in 14 143 patients referred to hypertension clinics worldwide. Data from the ARTEMIS study. J Hypertens 2016; 34:2187-98. [DOI: 10.1097/hjh.0000000000001074] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Masked Hypertension: How to Identify and When to Treat? High Blood Press Cardiovasc Prev 2016; 23:181-6. [PMID: 27041372 DOI: 10.1007/s40292-016-0140-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 03/14/2016] [Indexed: 10/22/2022] Open
Abstract
Approximately one out of 7-8 individuals with normal blood pressure (BP) in the clinic or doctor's office and one third of patients with chronic kidney disease with normal clinic BP have elevated ambulatory BP (masked hypertension). Patients with masked hypertension have an increased risk for target organ damage and a two-fold increased risk for cardiovascular events compared to patients with normal clinic and ambulatory BP. Despite this elevated risk for adverse outcomes, patients with masked hypertension have been excluded from hypertension trials because of their normal clinic BP. It is still unknown whether the reduction in target organ damage and adverse cardiovascular outcomes associated with treatment of hypertension extends to patients with masked hypertension. Ongoing and planned interventional studies will provide an answer to this crucial question in a few years. At present, it seems reasonable to follow the suggestion of current European guidelines, that lifestyle measures and drug treatment should be considered in the presence of masked hypertension.
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Unsal S, Ozkara A, Albayrak T, Ozturk Y, Beysel S, Kucukler FK. Evaluation of prehypertension and masked hypertension rate among clinically normotensive patients. Clin Exp Hypertens 2016; 38:218-24. [PMID: 26818410 DOI: 10.3109/10641963.2015.1047951] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The present cross-sectional study was aimed to identify pre-hypertension and masked hypertension rate in clinically normotensive adults in relation to socio-demographic, clinical and laboratory parameters. METHODS A total of 161 clinically normotensive adults with office blood pressure (OBP) <140/90 mmHg without medication were included in this single-center cross-sectional study. OBP, home BP (HBP) recordings and ambulatory BP monitoring (ABPM) were used to identify rates of true normotensives, true pre-hypertensives and masked hypertensives. Data on sociodemographic and clinical characteristics were collected in each subject and evaluated with respect to true normotensive vs. pre-hypertensive patients with masked hypertension or true pre-hypertensive. Target organ damage (TOD) was evaluated in masked hypertensives based on laboratory investigation. RESULTS Masked hypertension was identified in 8.7% of clinically normotensives. Alcohol consumption was significantly more common in masked hypertension than in true pre-hypertension (28.6 vs. 0.0%, p = 0.020) with risk ratio of 2.7 (95% CI 1.7-4.4). Patients with true pre-hypertension and masked hypertension had significantly higher values for body mass index, waist circumference, systolic and diastolic OBP and HBP (p < 0.05 for each) compared to true normotensive subjects. ABPM revealed significantly higher values for day-time and night-time systolic and diastolic BP (p = 0.002 for night-time diastolic BP, p < 0.001 for others) in masked hypertension than true pre-hypertension. CONCLUSIONS Given that the associations of pre-hypertension with TOD might be attributable to the high prevalence of insidious presentation of masked hypertension among pre-hypertensive individuals, ABPM seems helpful in early identification and management of masked hypertension in the pre-hypertensive population.
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Affiliation(s)
- S Unsal
- a Department of Family Medicine , Cankiri Public Hospital , Cankiri , Turkey
| | - A Ozkara
- b Department of Family Medicine , Hitit University , Corum , Turkey .,c Department of Family Medicine , Ankara Numune Training and Research Hospital , Ankara , Turkey
| | - T Albayrak
- c Department of Family Medicine , Ankara Numune Training and Research Hospital , Ankara , Turkey
| | - Y Ozturk
- d Department of Biochemistry , Gazi University Medical Faculty Hospital , Ankara , Turkey
| | - S Beysel
- e Department of Endocrinology and Metabolism , Diskapi Yildirim Beyazit Training and Research Hospital , Ankara , Turkey , and
| | - F K Kucukler
- f Department of Endocrinology and Metabolism , Hitit University , Corum , Turkey
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Claisse G, Maldonado P, Kpogbemabou N, Boudghène-Stambouli F, Delsart P, Devos P, Mounier-Vehier C. [Systematic screening of masked hypertension in patients with peripheral arterial disease: a pilot study]. JOURNAL DES MALADIES VASCULAIRES 2015; 40:10-17. [PMID: 25631643 DOI: 10.1016/j.jmv.2014.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 12/04/2014] [Indexed: 06/04/2023]
Abstract
AIM Masked hypertension (MH) is defined by a normal office blood pressure (BP) and a high ambulatory BP. MH is characterized by high prevalence and poor cardiovascular prognosis. The aim of this study was to evaluate the usefulness of routine MH screening, using 24-h blood pressure monitoring (BPM), among patients with peripheral arterial disease (PAD). METHODS Between 2011 and 2013, 54 patients with PAD were included in the Hypertension and Vascular Medicine Unit of the Lille Hospital. They had normal office BP (< 140/90mmHg). A 24 h-BPM device was set on each patient. MH diagnosis was established if the BP average over 24 hours was ≥ 130/80 mmHg and/or the daytime average ≥ 135/85 mmHg and/or the nighttime average ≥ 120/70 mmHg. RESULTS MH prevalence was about 42.6% (23 patients). It was significantly more frequent in diabetic patients (odds ratio: 3.8 [1.1-12.8]), in patients with known hypertension (odds ratio: 5 [1.5-16.9]) or with high normal office BP (<140/90 mmHg but ≥ 130/85 mmHg) (odds ratio: 5.6 [1.7-18.2]). By multivariate analysis, only known hypertension and high normal office BP were associated with masked hypertension. CONCLUSION The high prevalence of MH in patients with PAD shows us the importance of a careful screening of MH in this population, especially in diabetic patients, in patients with known hypertension or with a high normal office BP.
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Affiliation(s)
- G Claisse
- Service de médecine vasculaire et hypertension artérielle, hôpital cardiologique, CHRU de Lille, 59037 Lille, France
| | - P Maldonado
- Service de médecine vasculaire et hypertension artérielle, hôpital cardiologique, CHRU de Lille, 59037 Lille, France
| | - N Kpogbemabou
- Service de cardiologie et médecine polyvalente, centre hospitalier de Wattrelos, 59150 Wattrelos, France
| | - F Boudghène-Stambouli
- Service de médecine vasculaire et hypertension artérielle, hôpital cardiologique, CHRU de Lille, 59037 Lille, France
| | - P Delsart
- Service de médecine vasculaire et hypertension artérielle, hôpital cardiologique, CHRU de Lille, 59037 Lille, France
| | - P Devos
- Département de biostatistiques, CHRU de Lille, 59037 Lille, France
| | - C Mounier-Vehier
- Service de médecine vasculaire et hypertension artérielle, hôpital cardiologique, CHRU de Lille, 59037 Lille, France.
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2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2014; 31:1281-357. [PMID: 23817082 DOI: 10.1097/01.hjh.0000431740.32696.cc] [Citation(s) in RCA: 3272] [Impact Index Per Article: 327.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Alessi A, Brandão AA, de Paiva AMG, Nogueira ADR, Feitosa A, Gonzaga CDC, Amodeo C, Mion D, de Souza DDSM, Barbosa E, Lima Junior E, Nobre F, Fuchs FD, Chaves Junior H, Schneider JC, Gemelli J, Villela-Martin JF, Scala LCN, Gomes MAM, Malachias MVB, de Morais NS, Moreira Filho O, Passarelli Junior O, Jardim PCBV, Miranda RD, Póvoa R, Fuchs SC, Baiocchi S, Jardim TV, Barroso WKS. I Brazilian position paper on prehypertension, white coat hypertension and masked hypertension: diagnosis and management. Arq Bras Cardiol 2014; 102:110-8. [PMID: 24676366 PMCID: PMC3987343 DOI: 10.5935/abc.20140011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 12/03/2013] [Accepted: 12/03/2013] [Indexed: 01/22/2023] Open
Affiliation(s)
- Alexandre Alessi
- Brazilian Society of Cardiology Arterial Hypertension Department
| | | | | | | | - Audes Feitosa
- Brazilian Society of Cardiology Arterial Hypertension Department
| | | | - Celso Amodeo
- Brazilian Society of Cardiology Arterial Hypertension Department
| | - Decio Mion
- Brazilian Society of Cardiology Arterial Hypertension Department
| | | | - Eduardo Barbosa
- Brazilian Society of Cardiology Arterial Hypertension Department
| | | | - Fernando Nobre
- Brazilian Society of Cardiology Arterial Hypertension Department
| | | | | | | | - João Gemelli
- Brazilian Society of Cardiology Arterial Hypertension Department
| | | | | | | | | | | | | | | | | | | | - Rui Póvoa
- Brazilian Society of Cardiology Arterial Hypertension Department
| | | | - Sergio Baiocchi
- Brazilian Society of Cardiology Arterial Hypertension Department
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Gaciong Z, Siński M, Lewandowski J. Blood pressure control and primary prevention of stroke: summary of the recent clinical trial data and meta-analyses. Curr Hypertens Rep 2013; 15:559-74. [PMID: 24158454 PMCID: PMC3838588 DOI: 10.1007/s11906-013-0401-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Stroke is the second most common cause of death worldwide and of adult disability, but in the near future the global burden of cerebrovascular diseases will rise due to ageing and adverse lifestyle changes in populations worldwide. The risk of stroke increases at blood pressure levels above 115/75 mm Hg and high blood pressure (BP) is the most important modifiable risk factor for stroke, associated with 54 % episodes of stroke worldwide. There is strong evidence from clinical trials that antihypertensive therapy reduces substantially the risk of any type of stroke, as well as stroke-related death and disability. The risk attributed to BP is associated not only with absolute values but also with certain parameters describing BP diurnal pattern as well as short-term and long-term variability. Many studies reported that certain features of BP like nocturnal hypertension, morning surge or increased variability predict an increased stroke risk. However, there is no accepted effective modality for correction of these disturbances (chronotherapy, certain classes of antihypertensive drugs). In the elderly, who are mostly affected by stroke, the primary prevention guidelines recommend treatment with diuretics and calcium channel blockers to lower blood pressure to the standard level.
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Key Words
- stroke
- risk, risk factors
- blood, blood pressure
- ambulatory, ambulatory blood pressure measurement
- circadian, circadian rhythm
- non, non-dipping
- morning, morning surge
- blood, blood pressure variability
- antihypertensive, antihypertensive treatment
- randomized, randomized clinical trial
- meta, meta-analysis
- hypertension
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Affiliation(s)
- Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, The Medical University of Warsaw, 1a Banacha Street, 02 097, Warsaw, Poland,
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Lehmann M, Zeymer U, Dechend R, Kaiser E, Hagedorn I, Deeg E, Senges J, Schmieder R. Ambulatory blood pressure monitoring: Is it mandatory for blood pressure control in treated hypertensive patients? Int J Cardiol 2013; 168:2255-63. [DOI: 10.1016/j.ijcard.2013.01.209] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 01/18/2013] [Indexed: 12/31/2022]
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Franklin SS, Thijs L, Li Y, Hansen TW, Boggia J, Liu Y, Asayama K, Björklund-Bodegård K, Ohkubo T, Jeppesen J, Torp-Pedersen C, Dolan E, Kuznetsova T, Stolarz-Skrzypek K, Tikhonoff V, Malyutina S, Casiglia E, Nikitin Y, Lind L, Sandoya E, Kawecka-Jaszcz K, Filipovský J, Imai Y, Wang J, Ibsen H, O’Brien E, Staessen JA. Response to Masked Hypertension in Untreated and Treated Patients With Diabetes Mellitus: Attractive But Questionable Interpretations and Response to Is Masked Hypertension Related to Diabetes Mellitus? Hypertension 2013; 62:e23-5. [DOI: 10.1161/hypertensionaha.113.01700] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stanley S. Franklin
- Heart Disease Prevention Program, Division of Cardiology, School of Medicine, University of California, Irvine
| | - Lutgarde Thijs
- The Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Yan Li
- Center for Epidemiological Studies and Clinical Trials and Center for Vascular Evaluation, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tine W. Hansen
- Research Center for Prevention and Health and Steno Diabetes Center, Gentofte, Denmark
| | - José Boggia
- The Centro de Nefrología and Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la RepúblicaMontevideo, Uruguay
| | - Yanping Liu
- The Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Kei Asayama
- The Tohoku University Graduate School of Pharmaceutical Science and Medicine, Sendai, Japan
| | - Kristina Björklund-Bodegård
- The Section of Geriatrics, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Takayoshi Ohkubo
- The Tohoku University Graduate School of Pharmaceutical Science and Medicine, Sendai, Japan
| | | | | | - Eamon Dolan
- Cambridge University Hospitals, Addenbrook’s Hospital, Cambridge, United Kingdom
| | - Tatiana Kuznetsova
- The Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Katarzyna Stolarz-Skrzypek
- First Department of Cardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
| | - Valérie Tikhonoff
- Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy
| | - Sofia Malyutina
- Institute of Internal Medicine, Siberian Branch of the Russian Academy of Medical Sciences, Novosibirsk, Russian Federation
| | - Edoardo Casiglia
- Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy
| | - Yuri Nikitin
- Institute of Internal Medicine, Siberian Branch of the Russian Academy of Medical Sciences, Novosibirsk, Russian Federation
| | - Lars Lind
- The Section of Geriatrics, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Edgardo Sandoya
- The Asociación Española Primera de Socorros Mutuos, Montevideo, Uruguay
| | - Kalina Kawecka-Jaszcz
- First Department of Cardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
| | - Jan Filipovský
- Faculty of Medicine, Charles University, Pilsen, Czech Republic
| | - Yutaka Imai
- The Tohoku University Graduate School of Pharmaceutical Science and Medicine, Sendai, Japan
| | - Jiguang Wang
- Center for Epidemiological Studies and Clinical Trials, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hans Ibsen
- The Aarhus University and Division of Cardiology, Holbak Hospital, Holbak, Denmark
| | - Eoin O’Brien
- The Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
| | - Jan A. Staessen
- The Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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Barochiner J, Cuffaro PE, Aparicio LS, Alfie J, Rada MA, Morales MS, Galarza CR, Waisman GD. Predictors of masked hypertension among treated hypertensive patients: an interesting association with orthostatic hypertension. Am J Hypertens 2013; 26:872-8. [PMID: 23482377 DOI: 10.1093/ajh/hpt036] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Masked hypertension (MH) entails an increased cardiovascular risk. Therefore, it is important to identify those individuals who would benefit the most from out-of-office blood pressure (BP) measurement. We sought to determine the prevalence and identify predictors of MH among adult hypertensive patients under treatment. METHODS Treated hypertensive patients aged ≥ 18 years underwent office (duplicate sitting and standing BP in 1 visit) and home BP measurements (duplicate measurements for 4 days in the morning, afternoon, and evening; at least 16 measurements) and completed a questionnaire regarding risk factors and history of cardiovascular disease. MH was defined as normal office BP (<140/90mm Hg) with elevated home BP (≥135/85mm Hg, average of all readings discarding first day measurements). Patients with a systolic BP rise upon standing ≥5mm Hg were considered to have orthostatic hypertension (OHT). Variables indentified as relevant predictors of MH were entered into a multivariable logistic regression analysis model. RESULTS Three hundred and four patients were included (mean age = 66.7 ±13.8; 67.4% women). The prevalence of MH in the whole population was 12.4% and was 20.9% among patients with office-controlled hypertension. Factors independently associated with MH were age (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.03-1.14), high-normal office systolic BP (OR = 5.61, 95% CI = 1.39-22.57), history of peripheral artery disease (PAD) (OR = 8.83, 95% CI = 1.5-51.84), moderate alcohol consumption (OR = 0.08, 95% CI = 0.01-0.73), and OHT (OR = 3.65, 95% CI = 1.27 to 10.51). CONCLUSIONS Easily measurable parameters such as age, office systolic BP, history of PAD, and OHT may help to detect a population at risk of MH that would benefit from home BP monitoring.
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Affiliation(s)
- Jessica Barochiner
- Hypertension Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
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Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, Christiaens T, Cifkova R, De Backer G, Dominiczak A, Galderisi M, Grobbee DE, Jaarsma T, Kirchhof P, Kjeldsen SE, Laurent S, Manolis AJ, Nilsson PM, Ruilope LM, Schmieder RE, Sirnes PA, Sleight P, Viigimaa M, Waeber B, Zannad F, Redon J, Dominiczak A, Narkiewicz K, Nilsson PM, Burnier M, Viigimaa M, Ambrosioni E, Caufield M, Coca A, Olsen MH, Schmieder RE, Tsioufis C, van de Borne P, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Clement DL, Coca A, Gillebert TC, Tendera M, Rosei EA, Ambrosioni E, Anker SD, Bauersachs J, Hitij JB, Caulfield M, De Buyzere M, De Geest S, Derumeaux GA, Erdine S, Farsang C, Funck-Brentano C, Gerc V, Germano G, Gielen S, Haller H, Hoes AW, Jordan J, Kahan T, Komajda M, Lovic D, Mahrholdt H, Olsen MH, Ostergren J, Parati G, Perk J, Polonia J, Popescu BA, Reiner Z, Rydén L, Sirenko Y, Stanton A, Struijker-Boudier H, Tsioufis C, van de Borne P, Vlachopoulos C, Volpe M, Wood DA. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34:2159-219. [PMID: 23771844 DOI: 10.1093/eurheartj/eht151] [Citation(s) in RCA: 3162] [Impact Index Per Article: 287.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Giuseppe Mancia
- Centro di Fisiologia Clinica e Ipertensione, Università Milano-Bicocca, Milano, Italy.
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Interpreting treatment-induced blood pressure reductions measured by ambulatory blood pressure monitoring. J Hum Hypertens 2013; 27:715-20. [DOI: 10.1038/jhh.2013.39] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/19/2013] [Accepted: 03/26/2013] [Indexed: 11/08/2022]
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Franklin SS, Thijs L, Li Y, Hansen TW, Boggia J, Liu Y, Asayama K, Björklund-Bodegård K, Ohkubo T, Jeppesen J, Torp-Pedersen C, Dolan E, Kuznetsova T, Stolarz-Skrzypek K, Tikhonoff V, Malyutina S, Casiglia E, Nikitin Y, Lind L, Sandoya E, Kawecka-Jaszcz K, Filipovsky J, Imai Y, Wang J, Ibsen H, O'Brien E, Staessen JA. Masked hypertension in diabetes mellitus: treatment implications for clinical practice. Hypertension 2013; 61:964-71. [PMID: 23478096 DOI: 10.1161/hypertensionaha.111.00289] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although distinguishing features of masked hypertension in diabetics are well known, the significance of antihypertensive treatment on clinical practice decisions has not been fully explored. We analyzed 9691 subjects from the population-based 11-country International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes. Prevalence of masked hypertension in untreated normotensive participants was higher (P<0.0001) among 229 diabetics (29.3%, n=67) than among 5486 nondiabetics (18.8%, n=1031). Over a median of 11.0 years of follow-up, the adjusted risk for a composite cardiovascular end point in untreated diabetic-masked hypertensives tended to be higher than in normotensives (hazard rate [HR], 1.96; 95% confidence interval [CI], 0.97-3.97; P=0.059), similar to untreated stage 1 hypertensives (HR, 1.07; CI, 0.58-1.98; P=0.82), but less than stage 2 hypertensives (HR, 0.53; CI, 0.29-0.99; P=0.048). In contrast, cardiovascular risk was not significantly different in antihypertensive-treated diabetic-masked hypertensives, as compared with the normotensive comparator group (HR, 1.13; CI, 0.54-2.35; P=0.75), stage 1 hypertensives (HR, 0.91; CI, 0.49-1.69; P=0.76), and stage 2 hypertensives (HR, 0.65; CI, 0.35-1.20; P=0.17). In the untreated diabetic-masked hypertensive population, mean conventional systolic/diastolic blood pressure was 129.2 ± 8.0/76.0 ± 7.3 mm Hg, and mean daytime systolic/diastolic blood pressure 141.5 ± 9.1/83.7 ± 6.5 mm Hg. In conclusion, masked hypertension occurred in 29% of untreated diabetics, had comparable cardiovascular risk as stage 1 hypertension, and would require considerable reduction in conventional blood pressure to reach daytime ambulatory treatment goal. Importantly, many hypertensive diabetics when receiving antihypertensive therapy can present with normalized conventional and elevated ambulatory blood pressure that mimics masked hypertension.
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Affiliation(s)
- Stanley S Franklin
- Heart Disease Prevention Program, Division of Cardiology, School of Medicine, University of California, Irvine, California, USA
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Schmieder RE, Lehmann MV, Schmidt S. Optimizing blood pressure control in hypertension: the need to use ABPM. Blood Press 2012; 22:65-72. [PMID: 23035939 DOI: 10.3109/08037051.2012.727253] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hypertension is the most prevalent, treatable cause of cardiovascular (CV) disease. Patients with hypertension and one or more comorbidities increasingly form a significant part of the primary care practitioner's caseload. The emphasis on intensive blood pressure (BP) lowering has softened, encouraging any degree of BP lowering, since any fall in BP is beneficial for reducing CV risk. Consistency of BP control during long-term therapy (i.e. low visit-to-visit variability) and decreasing BP variability over 24-h may be as, if not more, important than degree of BP lowering per se. Fluctuations in BP between visits as well as within a 24-h period have been associated with increased CV risk. Ambulatory BP monitoring (ABPM) is a crucial element of the clinician's armamentarium not only for assessing the "true" BP load and fluctuations under real-life conditions but for identification of various abnormal BP patterns that may require attention, including white- coat hypertension, masked hypertension, non-dipping and the morning BP surge. ABPM provides accurate assessment of treatment effectiveness over 24-h and may lead to better tailoring of therapy. This article reviews the benefits of ABPM and discusses the importance of selecting long-acting antihypertensive agents for optimizing BP control.
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Affiliation(s)
- Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany.
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Ginter E, Simko V. Dramatic decline of ischaemic heart disease mortality in post communist central Europe: recovery from totality. Cent Eur J Public Health 2012; 20:101-3. [PMID: 22966731 DOI: 10.21101/cejph.a3658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
After 1970 the preexisting gap in population health between democratic Europe and communist countries became even more prominent. While in the democratic Europe there was a progressive rise in life expectancy associated with the decline in ischaemic heart disease (IHD), the trend on the other side of the iron curtain was exactly reverse. After the fall of communism in 1989 population health in the post-communist central Europe (CE) rapidly signalled a favourable recovery. This biphasic trend in post-communist countries is very remarkable. Most remarkably the decline in IHD mortality started soon after the demise of totality, even before the modernization of health care (new more effective medications and diagnostic technology), public campaign against smoking and improved supply of protective nutrients got chance to attain an important role. The decades-long psychosocial depression of communism was rapidly replaced with a promise of a better future. It is generally accepted that psychosocial factors are powerfool tools in the pathogenesis of IHD.
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Affiliation(s)
- Emil Ginter
- Institute of Preventive and Clinical Medicine, Emeritus, Bratislava, Slovakia.
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Dégi A, Kerti A, Kis E, Cseprekál O, Tory K, Szabó AJ, Reusz GS. Cardiovascular risk assessment in children following kidney transplantation. Pediatr Transplant 2012; 16:564-76. [PMID: 22694162 DOI: 10.1111/j.1399-3046.2012.01730.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CV diseases are the leading cause of death among patients with ESRD. RTX decreases the CV risk; however, it still remains definitely higher than that of the general population. Large multicenter and longitudinal studies are difficult to perform and hard end-points of CV events are usually missing among pediatric population. Thus, appropriate estimation of CV risk is of crucial importance to define the potential hazards and to evaluate the effect of treatments aimed to reduce the risk. A number of validated non-invasive methods are available to assess the extent of CV damage in adults, such as calcification scores, cIMT, aPWV, 24-h ABPM, AASI, and HRV; however, they need adaptation, standardization, and validation in pediatric studies. cIMT and PWV are the most promising methods, as pediatric normative values are already present. The up-to-date treatment of ESRD aims not only to save life, but to offer the patient a life expectancy approaching that of the healthy population and to ensure a reasonable quality of life.
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Affiliation(s)
- Arianna Dégi
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
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Lyamina NP, Smith ML, Lyamina SV, Manukhina EB, Senchikhin VN, Pacchia CF, Downey HF. Pressor response to 30-s breathhold: A predictor of masked hypertension. Blood Press 2012; 21:372-6. [DOI: 10.3109/08037051.2012.694213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Adderley R, Smith LL, Bond JW, Smith M. Physiological Measurement of Crime Scene Investigator Stress. ACTA ACUST UNITED AC 2012. [DOI: 10.1350/ijps.2012.14.2.274] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study aims to identify quantitatively the level of increased stress in civilian crime scene investigators (CSIs) whilst they were performing a variety of tasks as part of their normal duties. Mean above-average resting heart rate was used as the quantitative measure of physiological changes, recorded once a second for 12 CSIs during a working shift of 8 hours over a period of 7 days. Each CSI maintained an activity log of their work which enabled the physiological readings to be aligned to tasks undertaken. As well as physical stress, results show that CSIs undergo psychosocial stress during the examination of routine crime scenes such as domestic burglary and vehicle examination. Increased levels of stress diminished between scene visits. Reasons for increased stress reactivity at routine crime scenes are considered and opportunities for further work discussed. This study demonstrates quantitatively the stress undergone by civilian CSIs and questions the effect this might have on the effective recovery of forensic material from the crime scene as well as the welfare of the CSI.
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Affiliation(s)
- Rick Adderley
- AE Solutions (BI) Ltd, 9 Stone Pippin Orchard, Badsey WR11 7AA, UK
| | - Lisa L. Smith
- Department of Criminology, University of Leicester, The Friars, 154 Upper New Walk, Leicester LE1 7QA, UK
| | | | - Michelle Smith
- AE Solutions (BI) Ltd, 9 Stone Pippin Orchard, Badsey WR11 7AA, UK
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