Implementing ABPM into Clinical Practice

[Ambulatory blood pressure monitoring, adult and pediatric population. A narrative review]

Hypertension has become a central risk factor for the development of cardiovascular disease, underscoring the importance of its accurate diagnosis. Numerous studies have established a close relationship between elevated systolic (SBP) and diastolic (DBP) blood pressure and an increased risk of cardiovascular event (CVE). Traditionally, blood pressure (BP) measurements performed in clinical settings have been the main method for diagnosing and assessing hypertension. However, in recent years, it has been recognized that BP measurements obtained outside the clinical setting, using self-monitoring blood pressure (SMBP) and ambulatory blood pressure monitoring (ABPM), offer a more realistic perspective of patients' daily lives and therefore provide more reliable results. Given the evolution of medical devices, diagnostic criteria, and the increasing relevance of certain components of ABPM in the prediction of adverse cardiovascular outcomes, a comprehensive update that is practical for daily clinical practice is required. The main objective of this article is to provide an updated review of ABPM, focusing on its importance in the evaluation of hypertension and its impact on public health in Colombia. In addition, it will discuss the implications of changes in diagnostic thresholds and provide concrete recommendations for the effective implementation of ABPM in clinical practice, allowing health professionals to make informed decisions and improve the care of their patients.

Comparison of ambulatory blood pressure monitoring and office blood pressure in primary health care of populations at a high risk of hypertension

Introduction

Current studies have found that the incidence of masked hypertension is high in Asian countries, but the use of ambulatory blood pressure monitoring (ABPM) in Asian countries is very limited, especially in primary health care. We compared the ABPM and office blood pressure (OBP) in primary health care of a high-risk population of hypertension.

Methods

The study included participants with at least one risk factor for hypertension who received primary health care. Demographic data, present medical history, personal history, and family history were collected by questionnaire.

Results

A total of 823 subjects were included in the study. There were 531 (64.5%) subjects with hypertension by ABPM and 316 patients (38.4%) by OBP. A paired chi-square test showed that the positive rate of ABPM in the diagnosis of hypertension was significantly higher than that of OBP (chi-square value 174.129, P < 0.0001). There were 24 (2.9%) patients with white coat hypertension, 239 (29.0%) with masked hypertension, 504 (52.9%) with a non-dipping pattern, 135 (16.9%) with nocturnal hypertension and 18 (2.2%) with high ambulatory BP variability. Concordance correlation coefficient showed there was a poor correlation between OBP and awake average BP. Scatter plot displayed there was a positive correlation between OBP and awake average BP, but the degree of fitting was not high. The Bland Altman plot showed that OBP and awake average BP were consistent.

Conclusions

Although OBP and ABPM have some consistency, ABPM can screen for masked hypertension and nocturnal hypertension in primary care of populations at high risk of hypertension. Therefore, ABPM is necessary in the primary health care of populations at high risk of hypertension and can be used as a routine screening.

ED BP Management for Subarachnoid Hemorrhage

PURPOSE OF REVIEW

To review most recent literature on management of blood pressure in acute aneurysmal subarachnoid hemorrhage (SAH) and provide practice recommendations for the emergency clinician.

RECENT FINDINGS

There is increased risk of aneurysmal rebleeding with systolic blood pressure (SBP) greater than 160 mmHg in the acute setting. Avoiding large degrees of blood pressure variability improves clinical outcomes in aneurysmal SAH. Acute lowering of SBP to a range of 140-160 mmHg decreases risk of rebleeding while also maintaining cerebral perfusion pressure (CPP) after aneurysmal rupture. Treatment with a short acting antihypertensive agent allows for rapid titration of blood pressure (BP) and reduces BP variability. Elevations in intracranial pressure occur commonly after SAH due to increased intracranial blood volume, cerebral edema, or development of hydrocephalus. Clinicians should be familiar with changes in cerebral autoregulation and effects on CPP when treating elevated BP, in order to mitigate the risk of secondary neurological injury.

Blood Pressure Assessment and Treatment in the Observation Unit

PURPOSE OF REVIEW

To review the pathophysiology, diagnosis, and the management of hypertension. Given the paucity of literature regarding the role of the observation unit in the management of hypertension, we will provide our recommendations based on our experience working in an observation unit.

RECENT FINDINGS

Many patients have limited access to primary care, and hypertension diagnosis often relies on office-based measurements. We will describe situations where that is not necessary to make the diagnosis. We will discuss the current non-pharmacologic treatment guidelines, the education of which should be provided to patients both in the emergency department and observation units. We will provide the current recommendations on what anti-hypertension medications can be initiated in the emergency department and observation units. Hypertension is a leading cause of morbidity and mortality in the USA. The utility of an observation unit in the diagnosis and management of patients with hypertension is beneficial particularly for those with risk factors for atherosclerotic disease. An observation unit stay provides the opportunity to diagnosis hypertension, initiate lifestyle education and pharmacologic treatment if indicated, and help to arrange appropriate follow-up for ongoing management and treatment in individuals with limited access to care.

Does This Adult Patient Have Hypertension?: The Rational Clinical Examination Systematic Review

IMPORTANCE

Office blood pressure (BP) measurements are not the most accurate method to diagnose hypertension. Home BP monitoring (HBPM) and 24-hour ambulatory BP monitoring (ABPM) are out-of-office alternatives, and ABPM is considered the reference standard for BP assessment.

OBJECTIVE

To systematically review the accuracy of oscillometric office and home BP measurement methods for correctly classifying adults as having hypertension, defined using ABPM.

DATA SOURCES

PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and DARE databases and the American Heart Association website (from inception to April 2021) were searched, along with reference lists from retrieved articles.

DATA EXTRACTION AND SYNTHESIS

Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes as needed.

MAIN OUTCOMES AND MEASURES

Random effects summary sensitivity, specificity, and likelihood ratios (LRs) were calculated for BP measurement methods for the diagnosis of hypertension. ABPM (24-hour mean BP ≥130/80 mm Hg or mean BP while awake ≥135/85 mm Hg) was considered the reference standard.

RESULTS

A total of 12 cross-sectional studies (n = 6877) that compared conventional oscillometric office BP measurements to mean BP during 24-hour ABPM and 6 studies (n = 2049) that compared mean BP on HBPM to mean BP during 24-hour ABPM were included (range, 117-2209 participants per analysis); 2 of these studies (n = 3040) used consecutive samples. The overall prevalence of hypertension identified by 24-hour ABPM was 49% (95% CI, 39%-60%) in the pooled studies that evaluated office measures and 54% (95% CI, 39%-69%) in studies that evaluated HBPM. All included studies assessed sensitivity and specificity at the office BP threshold of 140/90 mm Hg and the home BP threshold of 135/85 mm Hg. Conventional office oscillometric measurement (1-5 measurements in a single visit with BP ≥140/90 mm Hg) had a sensitivity of 51% (95% CI, 36%-67%), specificity of 88% (95% CI, 80%-96%), positive LR of 4.2 (95% CI, 2.5-6.0), and negative LR of 0.56 (95% CI, 0.42-0.69). Mean BP with HBPM (with BP ≥135/85 mm Hg) had a sensitivity of 75% (95% CI, 65%-86%), specificity of 76% (95% CI, 65%-86%), positive LR of 3.1 (95% CI, 2.2-4.0), and negative LR of 0.33 (95% CI, 0.20-0.47). Two studies (1 with a consecutive sample) that compared unattended automated mean office BP (with BP ≥135/85 mm Hg) with 24-hour ABPM had sensitivity ranging from 48% to 51% and specificity ranging from 80% to 91%. One study that compared attended automated mean office BP (with BP ≥140/90 mm Hg) with 24-hour ABPM had a sensitivity of 87.6% (95% CI, 83%-92%) and specificity of 24.1% (95% CI, 16%-32%).

CONCLUSIONS AND RELEVANCE

Office measurements of BP may not be accurate enough to rule in or rule out hypertension; HBPM may be helpful to confirm a diagnosis. When there is uncertainty around threshold values or when office and HBPM are not in agreement, 24-hour ABPM should be considered to establish the diagnosis.

An hybrid ECG-based deep network for the early identification of high-risk to major cardiovascular events for hypertension patients

BACKGROUND AND OBJECTIVE

As the population becomes older and more overweight, the number of potential high-risk subjects with hypertension continues to increase. ICT technologies can provide valuable support for the early assessment of such cases since the practice of conducting medical examinations for the early recognition of high-risk subjects affected by hypertension is quite difficult, time-consuming, and expensive.

METHODS

This paper presents a novel time series-based approach for the early identification of increases in hypertension to discriminate between cardiovascular high-risk and low-risk hypertensive patients through the analyses of electrocardiographic holter signals.

RESULTS

The experimental results show that the proposed model achieves excellent results in terms of classification accuracy compared with the state-of-the-art. In terms of performances, our model reaches an average accuracy at 98%, Sensitivity and Specificity achieve both an average value at 97%.

CONCLUSION

The analysis of the whole time series shows promising results in terms of highlighting the tiny differences between subjects affected by hypertension.

Wearable Devices to Monitor and Reduce the Risk of Cardiovascular Disease: Evidence and Opportunities

There is a growing interest in using wearable devices to improve cardiovascular risk factors and care. This review evaluates how wearable devices are used for cardiovascular disease monitoring and risk reduction. Wearables have been evaluated for detecting arrhythmias (e.g., atrial fibrillation) as well as monitoring physical activity, sleep, and blood pressure. Thus far, most interventions for risk reduction have focused on increasing physical activity. Interventions have been more successful if the use of wearable devices is combined with an engagement strategy such as incorporating principles from behavioral economics to integrate social or financial incentives. As the technology continues to evolve, wearable devices could be an important part of remote-monitoring interventions but are more likely to be effective at improving cardiovascular care if integrated into programs that use an effective behavior change strategy.

Management of Hypertension in the Digital Era: Small Wearable Monitoring Devices for Remote Blood Pressure Monitoring

Out-of-office blood pressure measurement is an essential part of diagnosing and managing hypertension. In the era of advanced digital health information technology, the approach to achieving this is shifting from traditional methods (ambulatory and home blood pressure monitoring) to wearable devices and technology. Wearable blood pressure monitors allow frequent blood pressure measurements (ideally continuous beat-by-beat monitoring of blood pressure) with minimal stress on the patient. It is expected that wearable devices will dramatically change the quality of detection and management of hypertension by increasing the number of measurements in different situations, allowing accurate detection of phenotypes that have a negative impact on cardiovascular prognosis, such as masked hypertension and abnormal blood pressure variability. Frequent blood pressure measurements and the addition of new features such as monitoring of environmental conditions allows interpretation of blood pressure data in the context of daily stressors and different situations. This new digital approach to hypertension contributes to anticipation medicine, which refers to strategies designed to identify increasing risk and predict the onset of cardiovascular events based on a series of data collected over time, allowing proactive interventions to reduce risk. To achieve this, further research and validation is required to develop wearable blood pressure monitoring devices that provide the same accuracy as current approaches and can effectively contribute to personalized medicine.

New Approaches in Hypertension Management: a Review of Current and Developing Technologies and Their Potential Impact on Hypertension Care

Abstract

Hypertension is a key risk factor for cardiovascular disease. Currently, around a third of people with hypertension are undiagnosed, and of those diagnosed, around half are not taking antihypertensive medications. The World Health Organisation (WHO) estimates that high blood pressure directly or indirectly causes deaths of at least nine million people globally every year.

Purpose of Review

In this review, we examine how emerging technologies might support improved detection and management of hypertension not only in the wider population but also within special population groups such as the elderly, pregnant women, and those with atrial fibrillation.

Recent Findings

There is an emerging trend to empower patients to support hypertension screening and diagnosis, and several studies have shown the benefit of tele-monitoring, particularly when coupled with co-intervention, in improving the management of hypertension.

Summary

Novel technology including smartphones and Bluetooth®-enabled tele-monitoring are evolving as key players in hypertension management and offer particular promise within pregnancy and developing countries. The most pressing need is for these new technologies to be properly assessed and clinically validated prior to widespread implementation in the general population.

Relationship Between Outpatient Clinic and Ambulatory Blood Pressure Measurements and Mortality

PURPOSE OF REVIEW

This review aims to summarize and discuss the relationship between outpatient clinic and ambulatory blood pressure (BP) measurements and cardiovascular morbidity and mortality.

RECENT FINDINGS

Contemporary clinical practice guidelines worldwide recommend ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. Recent epidemiological studies and systematic reviews showed ABPM predicts cardiovascular events and mortality independent of clinic BP. Ambulatory BP appears to be prognostically superior to clinic BP. ABPM characterizes BP phenotypes that would not have otherwise identified with clinic BP measurement only. Identification of white coat hypertension, which carries a prognosis almost similar to normotension, and masked hypertension, which carries a prognosis almost similar to sustained hypertension, can be accomplished only by ABPM. Randomize controlled trials to assess the cardiovascular effects of hypertensive patients managed with ABPM vs. clinic BP measurement and cost-effective studies of ABPM are warranted.

Druggable targets in the Rho pathway and their promise for therapeutic control of blood pressure

The prevalence of high blood pressure (also known as hypertension) has steadily increased over the last few decades. Known as a silent killer, hypertension increases the risk for cardiovascular disease and can lead to stroke, heart attack, kidney failure and associated sequela. While numerous hypertensive therapies are currently available, it is estimated that only half of medicated patients exhibit blood pressure control. This signifies the need for a better understanding of the underlying cause of disease and for more effective therapies. While blood pressure homeostasis is very complex and involves the integrated control of multiple body systems, smooth muscle contractility and arterial resistance are important contributors. Strong evidence from pre-clinical animal models and genome-wide association studies indicate that smooth muscle contraction and BP homeostasis are governed by the small GTPase RhoA and its downstream target, Rho kinase. In this review, we summarize the signaling pathways and regulators that impart tight spatial-temporal control of RhoA activity in smooth muscle cells and discuss current therapeutic strategies to target these RhoA pathway components. We also discuss known allelic variations in the RhoA pathway and consider how these polymorphisms may affect genetic risk for hypertension and its clinical manifestations.