Ambulatory blood pressure monitoring in clinical practice: a review

Cuff-based blood pressure measurement: challenges and solutions

OBJECTIVE

Accurate measurement of arterial blood pressure (BP) is crucial for the diagnosis, monitoring, and treatment of hypertension. This narrative review highlights the challenges associated with conventional (cuff-based) BP measurement and potential solutions. This work covers each method of cuff-based BP measurement, as well as cuffless alternatives, but is primarily focused on ambulatory BP monitoring.

RESULTS

Manual BP measurement requires stringent training and standardized protocols which are often difficult to ensure in stressful and time-restricted clinical office blood pressure monitoring (OBPM) scenarios. Home Blood pressure monitoring (HBPM) can identify white-coat and masked hypertension but strongly depends on patient adherence to measurement techniques and procedure. The widespread use of nonvalidated automated HBPM devices raises further concerns about measurement accuracy. Ambulatory blood pressure measurement (ABPM) may be used in addition to OBPM. It is recommended to diagnose white-coat and masked hypertension as well as nocturnal BP and dipping, which are the BP values most predictive for major adverse cardiac events. Nonetheless, ABPM is limited by its non-continuous nature and susceptibility to measurement artefacts. This leads to poor overall reproducibility of ABPM results, especially regarding clinical parameters such as BP variability or dipping patterns.

CONCLUSIONS

Cuff-based BP measurement, despite some limitations, is vital for cardiovascular health assessment in clinical practice. Given the wide range of methodological limitations, the paradigm's potential for improvement is not yet fully realized. There are impactful and easily incorporated opportunities for innovation regarding the enhancement of measurement accuracy and reliability as well as the clinical interpretation of the retrieved data. There is a clear need for continued research and technological advancement to improve BP measurement as the premier tool for cardiovascular disease detection and management.

Short-term effects of denervation in the treatment of hypertension: A meta-analysis excluding drug interferences

BACKGROUND

To evaluate the short-term efficacy of denervation in treating hypertension with the exclusion of drug-interfering factors.

METHODS

An electronic search was conducted across 8 databases, including MEDLINE, PubMed, Cochrane Library, and EMBASE, for articles on denervation in the treatment of medication-naïve hypertension published from inception to May 2024. All data were meta-analyzed using RevMan 5.3 software.

RESULTS

Four studies, comprising a total of 752 subjects, were screened according to the inclusion and exclusion criteria. Meta-analysis indicated that, compared to the sham-operated group, the denervation group showed a significant reduction in short-term 24-hour ambulatory systolic blood pressure and office systolic blood pressure (OSBP) as well as office diastolic blood pressure (ODBP). No significant safety events were identified.

CONCLUSION

Denervation has the potential to reduce blood pressure in the short-term for patients with medication-naïve hypertension, demonstrating an acceptable safety profile. This offers hope for patients who are intolerant to drug therapy or unwilling to take lifelong medication. However, its long-term effects require further study. Future research should focus on expanding the sample size and prolonging the follow-up period to further solidify its role in the treatment of hypertension.

Clinical validation of a wearable ultrasound sensor of blood pressure

Options for the continuous and non-invasive monitoring of blood pressure are limited. Cuff-based sphygmomanometers are widely available, yet provide only discrete measurements. The clinical gold-standard approach for the continuous monitoring of blood pressure requires an arterial line, which is too invasive for routine use. Wearable ultrasound for the continuous and non-invasive monitoring of blood pressure promises to elevate the quality of patient care, yet the isolated sonographic windows in the most advanced prototypes can lead to inaccurate or error-prone measurements, and the safety and performance of these devices have not been thoroughly evaluated. Here we describe validation studies, conducted during daily activities at home, in the outpatient clinic, in the cardiac catheterization laboratory and in the intensive care unit, of the safety and performance of a wearable ultrasound sensor for blood pressure monitoring. The sensor has closely connected sonographic windows and a backing layer that improves the sensor's accuracy and reliability to meet the highest requirements of clinical standards. The validation results support the clinical use of the sensor.

The Clinical Implication of Nocturia in Predicting Hypertension Among Working-Aged Koreans

BACKGROUND

Evidence has indicated that nocturia is a clinical manifestation of adverse health conditions, including cardiovascular diseases and metabolic disorders. However, previous studies are less available for the clinical implication of nocturia on the development of hypertension.

METHODS

Study participants were 32,420 working-aged Koreans (21,355 men and 11,065 women) who periodically received health checkups. They were categorized into 4 groups by the frequency of nocturia (never, <1, 1-2, and ≥3/week). We used Cox proportional hazards models to analyze the multivariable-adjusted hazard ratio (HR) and 95% confidence intervals (CIs) for incident hypertension (multivariable-adjusted HR [95% CI]) in relation to the frequency of nocturia. Subgroup analysis was conducted by gender and sleep quality (good and poor sleep quality).

RESULTS

In women, nocturia was associated with an increased risk of hypertension, compared with never nocturia (HR [95% CI]; never: reference, <1/week: 1.33 [1.10-1.60], 1-2/week: 1.26 [1.00-1.58], and ≥3/week: 1.34 [1.05-1.72]). This association was not observed in men (HR [95% CI]; never: reference, <1/week: 1.00 [0.93-1.08], 1-2/week: 1.00 [0.88-1.12], and ≥3/week: 1.06 [0.94-1.23]). In subgroup analysis by sleep quality, only women with good sleep quality showed an association between nocturia and the risk of hypertension. However, women with poor sleep quality and men did not show an association between the frequency of nocturia and the risk of hypertension.

CONCLUSIONS

Nocturia is a potential risk factor for incident hypertension in working-aged women with good sleep quality.

Assessment of appropriate utilization of out-of-office diagnostic tools for the diagnosis of hypertension

Background

Out-of-office blood pressure (BP) measurement devices, such as ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM), enhance the accuracy and reliability of BP readings, detecting white-coat and masked hypertension. The American Heart Association (AHA) advises confirming hypertension diagnoses with ABPM to prevent overdiagnosis, emphasizing the importance of precise out-of-office diagnostic tools. This study aimed to 1) explore the prevalence of ABPM and HBPM use prior to hypertension diagnosis; 2) assess the adherence to AHA recommendations regarding ABPM utilization; and 3) investigate the association between patient characteristics and out-of-office BP monitoring practices.

Methods

A retrospective cross-sectional study analyzed a random sample of adult patients newly diagnosed with essential hypertension at a tertiary hospital primary care center in Riyadh, Saudi Arabia, between 2016 and 2022.

Results

This study evaluated the use of ABPM and HBPM in a sample of 268 newly diagnosed hypertensive patients, with a mean age of 49.17 ± 12.69 years. Although ABPM orders were placed for 57.8% of patients, only 48.5% completed the procedure. Notably, 42.2% of hypertension diagnoses were solely based on ABPM, while 7.1% and 1.1% utilized HBPM alone or in combination with ABPM, respectively. This analysis revealed a lower utilization of ABPM among older adults, individuals with diabetes or chronic kidney disease, and married patients (P < 0.05). However, this association with marital status, diabetes, and chronic kidney disease was no longer statistically significant in a fully adjusted model (P > 0.05).

Conclusion

Out-of-office BP monitoring, particularly ABPM, was underutilized in newly diagnosed hypertensive patients, especially in older age groups and patients with specific comorbidities, who may benefit the most from this method. These results underscore the need for increasing physician knowledge and compliance with the existing guidelines.

Device-estimated sleep metrics do not mediate the relation between race and blood pressure dipping in young black and white women

Short, disturbed, and irregular sleep may contribute to blunted nocturnal blood pressure (BP) dipping, a predictor of cardiovascular disease. Black women (BLW) demonstrate less BP dipping and poorer sleep health than White women (WHW). However, it remains unclear whether device-estimated sleep health metrics mediate the relation between race and BP dipping in young women. We hypothesized that the relation between race and BP dipping would be partly mediated by sleep health metrics of sleep duration, sleep efficiency, and sleep regularity. Participants (20 BLW, 17 WHW) were 18-29 years old, normotensive, nonobese, and without evidence of sleep disorders. Systolic and diastolic BP dipping were derived from 24-h ambulatory BP monitoring. Habitual sleep duration and sleep efficiency were estimated via 14 days of wrist actigraphy. Sleep duration regularity was calculated as the standard deviation (SD) of nightly sleep duration (SDSD). Sleep timing regularity metrics were calculated as the SD of sleep onset and sleep midpoint (SMSD). Mediation analysis tested the mediating effect of each sleep metric on the relation between race and BP dipping. BLW experienced less systolic (P = .02) and diastolic (P = .01) BP dipping. Sleep duration (P = .14) was not different between groups. BLW had lower sleep efficiency (P < .01) and higher SDSD (P = .02), sleep onset SD (P < .01) and SMSD (P = .01). No sleep metrics mediated the relation between race and BP dipping (all indirect effects P > .38). In conclusion, mediation pathways of sleep health metrics do not explain racial differences in nocturnal BP dipping between young BLW and WHW.

Aortic Stiffness Is Associated With Higher Nighttime Ambulatory Blood Pressure in Middle-Aged and Older Adults

PURPOSE

The objective of this study was to determine the relationship between aortic stiffening and brachial and central ambulatory blood pressure (AMBP) in a nonclinical sample of middle-aged and older adults (MA/O). We hypothesized aortic stiffness would be positively associated with 24-hr, daytime, and nighttime brachial and central AMBP.

METHODS

Fifty-one participants aged ≥50 yr (21 males and 30 females, mean age 63.4 ± 9.0 yr) with a body mass index <35 kg/m 2 who also had a resting brachial blood pressure (BP) <160/100 mmHg with or without BP medications were recruited for this cross-sectional analysis. All participants underwent measures of aortic stiffness (carotid-femoral pulse wave velocity [cfPWV]) and 24-hr AMBP monitoring. Bivariate correlations assessed the relationship between cfPWV, brachial, and central AMBP. Partial correlations were used to independently adjust for traditional cardiovascular disease (CVD) risk factors including age, sex, waist circumference, glucose, and augmentation index normalized to heart rate 75 bpm, a surrogate measure of arterial stiffness, and in a multivariable combined model.

RESULTS

Nighttime brachial systolic BP ( r = 0.31) and central systolic BP ( r = 0.30) were correlated with cfPWV in the multivariable combined model ( P ≤ .05). Nighttime brachial pulse pressure and central pulse pressure were correlated with cfPWV after independently adjusting for all CVD risk factors ( P ≤ .05, all) but not when combined in the multivariable model ( P > .05).

CONCLUSIONS

Higher nighttime brachial and central AMBP with older age are related, in part, to greater aortic stiffening. Therefore, interventions to lower or prevent aortic stiffening may also lower nighttime BP in MA/O adults to lower CVD risk.

Association of Remote Patient Monitoring with Mortality and Healthcare Utilization in Hypertensive Patients: a Medicare Claims-Based Study

BACKGROUND

Hypertension management is complex in older adults. Recent advances in remote patient monitoring (RPM) have warranted evaluation of RPM use and patient outcomes.

OBJECTIVE

To study associations of RPM use with mortality and healthcare utilization measures of hospitalizations, emergency department (ED) utilization, and outpatient visits.

DESIGN

A retrospective cohort study.

PATIENTS

Medicare beneficiaries aged ≥65 years with an outpatient hypertension diagnosis between July 2018 and September 2020. The first date of RPM use with a corresponding hypertension diagnosis was recorded (index date). RPM non-users were documented from those with an outpatient hypertension diagnosis; a random visit was selected as the index date. Six months prior continuous enrollment was required.

MAIN MEASURES

Outcomes studied within 180 days of index date included (i) all-cause mortality, (ii) any hospitalization, (iii) cardiovascular-related hospitalization, (iv) non-cardiovascular-related hospitalization, (v) any ED, (vi) cardiovascular-related ED, (vii) non-cardiovascular-related ED, (viii) any outpatient, (ix) cardiovascular-related outpatient, and (x) non-cardiovascular-related outpatient. Patient demographics and clinical variables were collected from baseline and index date. Propensity score matching (1:4) and Cox regression were performed. Hazard ratios (HR) and 95% confidence intervals (CI) are reported.

KEY RESULTS

The matched sample had 16,339 and 63,333 users and non-users, respectively. Cumulative incidences of mortality outcome were 2.9% (RPM) and 4.3% (non-RPM), with a HR (95% CI) of 0.66 (0.60-0.74). RPM users had lower hazards of any [0.78 (0.75-0.82)], cardiovascular-related [0.79 (0.73-0.87)], and non-cardiovascular-related [0.79 (0.75-0.83)] hospitalizations. No significant association was observed between RPM use and the three ED measures. RPM users had higher hazards of any [1.10 (1.08-1.11)] and cardiovascular-related outpatient visits [2.17 (2.13-2.19)], while a slightly lower hazard of non-cardiovascular-related outpatient visits [0.94 (0.93-0.96)].

CONCLUSIONS

RPM use was associated with substantial reductions in hazards of mortality and hospitalization outcomes with an increase in cardiovascular-related outpatient visits.

A Multifaceted Implementation Strategy to Increase Out-of-Office Blood Pressure Monitoring: The EMBRACE Cluster Randomized Clinical Trial

Importance

Few primary care patients complete guideline-recommended out-of-office blood pressure (BP) monitoring prior to having hypertension diagnosed.

Objective

To evaluate the effectiveness of a behavioral theory-informed, multifaceted implementation strategy on out-of-office BP monitoring (ambulatory BP monitoring [ABPM] or home BP monitoring [HBPM]) among patients with new hypertension.

Design, Setting, and Participants

This 2-group, pre-post cluster randomized trial was conducted within a primary care network of 8 practices (4 intervention practices with 99 clinicians; 4 control practices with 55 clinicians) and 1186 patients (857 intervention; 329 control) with at least 1 visit with elevated office BP and no prior hypertension diagnosis between October 2016 and September 2017 (preimplementation period) or between April 2018 and March 2019 (postimplementation period). Data were analyzed from February to July 2023.

Interventions

Usual care (control group) or a multifaceted implementation strategy consisting of an accessible ABPM service; electronic health record (EHR) tools to facilitate test ordering; clinician education, reminders, and feedback relevant to out-of-office BP monitoring; nurse training on HBPM; and patient information handouts.

Main Outcomes and Measures

The primary outcome was patient completion of out-of-office BP monitoring within 6 months of an eligible visit. Secondary outcomes included clinician ordering of out-of-office BP monitoring. Blinded assessors extracted outcomes from the EHR.

Results

A total of 1186 patients (857 intervention; 329 control) were included, with a mean (SD) age of 54 (16) years; 808 (68%) were female, and 549 (48%) were Spanish speaking; among those with race and ethnicity documented, 123 (10%) were Black or African American, and 368 (31%) were Hispanic. Among intervention practices, the percentage of visits resulting in completed out-of-office BP monitoring increased from 0.6% (0% ABPM; 0.6% HBPM) to 5.7% (3.7% ABPM; 2.0% HBPM) between the preimplementation and postimplementation periods (P = .009). Among control practices, the percentage of visits resulting in completed out-of-office BP monitoring changed from 5.4% (0% ABPM; 5.4% HBPM) to 4.3% (0% ABPM; 4.3% HBPM) during the corresponding period (P = .94). The ratio of relative risks (RRs) of out-of-office BP monitoring in the postimplementation vs preimplementation periods for intervention vs control practices was 10.5 (95% CI, 1.9-58.0; P = .01). The ratio of RRs of out-of-office BP monitoring being ordered was 2.2 (95% CI, 0.8-6.3; P = .12).

Conclusions and Relevance

This study found that a theory-informed implementation strategy that included access to ABPM modestly increased out-of-office BP monitoring among patients with elevated office BP but no hypertension diagnosis.

Trial Registration

ClinicalTrials.gov Identifier: NCT03480217.

Effects of Nondipping Blood Pressure Changes: A Nephrologist Prospect

Blood pressure (BP) variations depend on various internal, environmental, and behavioral factors. BP fluctuations occur both in normotensive and hypertensive people. Although it fluctuates over the 24-hr day and night, the morning BP increases after waking up and declines throughout sleep. It is typical for BP to decrease by 10% to 20%, while sleeping, known as dipping BP. However, if there is no decrease in nighttime mean systolic BP or a drop of less than 10 mmHg, it is called nondipping BP. Conversely, reverse dipping BP means an increase in mean systolic BP instead of a drop during the night. Reverse dipping is observed in hypertension (HTN), diabetes mellitus (DM), chronic kidney disease (CKD), and obstructive sleep apnea (OSA) syndrome. The introduction of ambulatory BP monitoring (ABPM) led to the emergence of identifying normal and elevated BP patterns. Non-dipping BP increases the risk of cardiovascular system (CVS) complications such as left ventricular hypertrophy, proteinuria, glomerular filtration rate (GFR) reduction, and CKD progression. A loss or blunting of the normal BP profile is recognized as a deleterious variant, and restoring abnormal BP patterns has been reported to significantly impact end-organ damage, morbidity, and mortality. In this non-systematic clinically-oriented, comprehensive review, we aim to update the BP variables and the pathophysiology of nondipping BP and point out the areas which need more investigation from a nephrology perspective because the nondipping BP increases the risk of proteinuria, GFR reduction, and CKD progression. A literature search of PubMed, Google, EMBASE, and Google Scholar was conducted. Checks of selected papers and relevant reviews complemented the electronic search. With improved BP measurement methods, the physiology of BP profile variations is readily detectable during the day and night. A nondipping BP profile is a distinct BP pattern that may have significant end-organ damage effects and therapeutic importance for nephrologists. The pathophysiology of the nondipping BP variant must be clarified to prevent complications, and further investigations are required. Furthermore, there is debate about the best BP index to utilize: systolic BP, diastolic BP, mean arterial pressure, or a mixture of all. All these areas are important and need new research projects.

Diurnal changes in blood pressure and heart rate in children with narcolepsy with cataplexy

The hypocretin neurons in the lateral hypothalamus are connected not only to brain alertness systems but also to brainstem nuclei that regulate blood pressure and heart rate. The premise is that regulation of blood pressure and heart rate is altered and affected by methylphenidate, a stimulant drug in children with narcolepsy with cataplexy. The changes in 24-hr ambulatory systolic and diastolic blood pressure and heart rate were compared among pre-treated narcolepsy with cataplexy patients (40 males, 10 females), with mean age 10.4 ± 3.5 years (M ± SD, range 5-17 years) with values from 100 archival age-sex-body mass index matched controls. Patients had a lower diurnal systolic blood pressure (-6.5 mmHg; p = 0.000) but higher heart rate (+11.0 bpm; p = 0.000), particularly evident in the waketime, while diastolic blood pressure was comparable. With methylphenidate (18 mg sustained release at 08:00 hours), patients with narcolepsy with cataplexy had higher systolic blood pressure (+4.6 mmHg, p = 0.015), diastolic blood pressure (+3.3 mmHg, p = 0.005) and heart rate (+7.1 bpm, p = 0.028) during wake time, but nighttime cardiovascular values were unchanged from pre-treated values; amplitude variation in cardiovascular values was unchanged over 24 hr. In conclusion, children with narcolepsy with cataplexy had downregulation blood pressure profile but a higher heart rate, and lesser non-dipping profiles. Daytime methylphenidate treatment increases only waketime blood pressure and further elevated heart rate values.

Social Support: The Effect on Nocturnal Blood Pressure Dipping

Social support has long been associated with cardiovascular disease risk assessed with blood pressure (BP). BP exhibits a circadian rhythm in which BP should dip between 10 and 15% overnight. Blunted nocturnal dipping (non-dipping) is a predictor of cardiovascular morbidity and mortality independent of clinical BP and is a better predictor of cardiovascular disease risk than either daytime or nighttime BP. However, it is often examined in hypertensive individuals and less often in normotensive individuals. Those under age 50 are at increased risk for having lower social support. This study examined social support and nocturnal dipping in normotensive individuals under age 50 using ambulatory blood pressure monitoring (ABP). ABP was collected in 179 participants throughout a 24-h period. Participants completed the Interpersonal Support Evaluation List, which assesses perceived levels of social support in one's network. Participants with low levels of social support demonstrated blunted dipping. This effect was moderated by sex, with women showing greater benefit from their social support. These findings demonstrate the impact social support can have on cardiovascular health, exhibited through blunted dipping, and are particularly important as the study was conducted in normotensive individuals who are less likely to have high levels of social support.

Relationships between Easily Available Biomarkers and Non-Dipper Blood Pressure Pattern in Patients with Stable Coronary Artery Disease

Introduction. Chronic inflammation plays an essential role in the pathophysiology of both arterial hypertension (HTN) and coronary artery disease (CAD), and is more pronounced in individuals with a non-dipper circadian blood pressure (BP) pattern. A non-dipping BP pattern is in turn is associated with increased cardiovascular morbi-mortality, and a higher risk of atherosclerotic events. Neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR) and platelet to lymphocyte ratio (PLR) are readily available predictors of systemic inflammation and cardiovascular risk. The purpose of our study is to evaluate whether NLR, MLR and PLR can be used as cost-effective predictors of a non-dipping blood pressure pattern in hypertensive patients with stable CAD. Materials and Methods: We performed a cross-sectional retrospective analysis that included 80 patients with hypertension and stable CAD (mean age 55.51 ± 11.83 years, 71.3% male) referred to a cardiovascular rehabilitation center. All patients underwent clinical examination, 24 h ambulatory blood pressure monitoring (ABPM) and standard blood analysis. Results: Baseline demographic characteristics were similar in both groups. Patients with non-dipper pattern had significantly higher NLR (median = 2, IR (2–3), p < 0.001), MLR (median = 0.31, IR (0.23–0.39), p < 0.001) and PLR (median = 175, IR (144–215), p < 0.001) compared to dippers. Conclusion: Our results suggest that MLR and PLR are inexpensive and easily accessible biomarkers that predict a non-dipping pattern in hypertensive patients with stable CAD.

Infection in Hospitalized Patients With Systemic Lupus Erythematosus: Proposal of an Algorithm for Diagnosis

BACKGROUND

Identification of infection in patients with systemic lupus erythematosus (SLE) is a major challenge in clinical practice.

OBJECTIVE

This medical records review study evaluated clinical markers, including the performance of C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) in the diagnosis of infection in SLE patients.

METHODS

One hundred four SLE patients hospitalized between 2014 and 2018 were allocated into 3 groups, namely, infection, infection and disease activity, and isolated disease activity. Groups were compared in relation to clinical and laboratory variables. Accuracy measures were calculated for CRP, NLR, and PLR.

RESULTS

C-reactive protein, NLR, and PLR differed between the groups with higher values observed in the infected group, intermediate values in the mixed group, and lower values in the group with isolated activity-CRP (56 vs 26 vs 15 mg/dL, p = 0.002), NLR (7.9 vs 4.0 vs 3.1, p = 0.005), and PLR (270 vs 227 vs 134, p = 0.025). Fever, tachypnea, and PLR were independently associated with infection. The cutoff points of the CRP of 20 mg/L, NLR of 3.5, and PLR of 151.4 presented values of sensitivity and specificity for the prediction of infection equal to 67% and 67%, 65% and 58%, and 71% and 53%, respectively. The developed algorithm showed a sensitivity of 86.6% and specificity of 81% for the diagnosis of infection.

CONCLUSIONS

The combined use of clinical and laboratory markers presented superior accuracy than their isolated use, suggesting a great potential for the application of the algorithm in clinical practice.

Perceived social support and ambulatory blood pressure during daily life: a meta-analysis

Perceived social support has been linked to lower rates of morbidity and mortality. However, more information is needed on the biological mechanisms potentially responsible for such links. The main aim of this paper was to conduct a meta-analytic review of the association between perceived social support and awake ambulatory blood pressure (ABP) which is linked to cardiovascular morbidity and mortality. The review identified 12 studies with a total of 3254 participants. The omnibus meta-analysis showed that higher perceived social support was not significantly related to lower ABP (Zr = -0.052, [ -0.11, 0.01]). In addition, there was evidence of significant bias across several indicators. Future research will be needed to explore the boundary conditions linking social support to ABP and its implications for theoretical models and intervention development.

Factors affecting systolic blood pressure trajectory in low and high activity conditions

Background: Typically, blood pressure dips during sleep and increases during daytime. The blood pressure trend is affected by the autonomic nervous system. The activity of this system is observable in the low and high activity conditions. The aim of this study was to assess the effect of individual characteristics on systolic blood pressure (SBP) across day-night under low and high activity conditions.

Methods: The samples were 34 outpatients who were candidates for evaluation of 24 hours of blood pressure with an ambulatory. They were admitted to the heart clinic of Farshchian hospital, located in Hamadan province in the west of Iran. The hourly SBP during 24 hours was considered as a response variable. To determine the factors effecting SBP in each condition, the hidden semi-Markov model (HSMM), with 2 hidden states of low and high activity, was fitted to the data.

Results: Males had lower SBP than females in both states. The effect of age was positive in the low activity state (β=0.30; p<0.001) and negative in high activity state (β= -0.21; p=0.001). The positive effect of cigarette smoking on SBP was seen in low activity state (β=5.02; p=0.029). The overweight and obese patients had higher SBP compared to others in high activity state (β=11.60; p<0.001 and β=5.87; p=0.032, respectively).

Conclusion: The SBP variability can be displayed by hidden states of low and high activity. Moreover, the effects of studied variables on SBP were different in low and high activity states.

The Effects of Acute Exposure to Prolonged Sitting, with and Without Interruption, on Peripheral Blood Pressure Among Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Previous reviews have shown that exposure to acute prolonged sitting can have detrimental effects on several cardiovascular and cardiometabolic health markers. However, to date, there has been no synthesis of peripheral blood pressure data (including systolic blood pressure, diastolic blood pressure and mean arterial pressure), an important and translatable marker of cardiovascular health. Similarly, no previous study has consolidated the effects of sitting interruptions on peripheral blood pressure.

OBJECTIVES

We aimed to (1) assess the effect of exposure to acute prolonged sitting on peripheral blood pressure and (2) determine the efficacy of sitting interruption strategies as a means of offsetting any negative effects. Subgroup analyses by age and interruption modality were performed to explore heterogeneity.

DATA SOURCES

Electronic databases (PubMed, Web of Science and, SPORTDiscus) were searched from inception to March 2021. Reference lists of eligible studies and relevant reviews were also screened.

STUDY SELECTION

Inclusion criteria for objective (1) were: (i) peripheral blood pressure was assessed non-invasively in the upper limb pre-sitting and post-sitting; (ii) studies were either randomised controlled, randomised crossover or quasi-experimental pre-test vs post-test trials; (iii) the sitting period was ≥ 1 h; (iv) pre-sitting and post-sitting measures were performed in the same posture; and (v) participants were adults (aged ≥ 18 years), free of autonomic or neuromuscular dysfunction. Additional criteria for objective (2) were: (i) the interruption strategy was during the sitting period; (ii) there was an uninterrupted sitting control condition; and (iii) the interruption strategy must have involved participants actively moving their upper or lower limbs.

APPRAISAL AND SYNTHESIS METHODS

In total, 9763 articles were identified, of which 33 met inclusion criteria for objective (1). Of those articles, 22 met inclusion criteria for objective (2). Weighted mean difference (WMD), 95% confidence intervals (95% CI), and standardised mean difference (SMD) were calculated for all trials using inverse variance heterogeneity meta-analysis modelling. Standardised mean difference was used to determine the magnitude of effect, where < 0.2, 0.2, 0.5 and 0.8 were defined as trivial, small, moderate and large, respectively.

RESULTS

(1) Prolonged uninterrupted sitting resulted in trivial and small significant increases in systolic blood pressure (WMD = 3.2 mmHg, 95% CI 0.6 to 5.8, SMD = 0.14) and mean arterial pressure (WMD = 3.3 mmHg, 95% CI 2.2 to 4.4, SMD = 0.37), respectively, and a non-significant trivial increase in diastolic blood pressure. Subgroup analyses indicated that the increases in systolic blood pressure and mean arterial pressure were more pronounced in younger age groups. (2) Interrupting bouts of prolonged sitting resulted in significantly lower systolic blood pressure (WMD =  - 4.4 mmHg, 95% CI - 7.4 to - 1.5, SMD = 0.26) and diastolic blood pressure (WMD =  - 2.4 mmHg, 95% CI - 4.5 to - 0.3, SMD = 0.19) compared with control conditions, particularly when using aerobic interruption strategies.

CONCLUSIONS

Exposure to acute prolonged uninterrupted sitting results in significant increases in systolic blood pressure and mean arterial pressure, particularly in younger age groups. Regularly interrupting bouts of prolonged sitting, particularly with aerobic interruption strategies may reduce negative effects.

An Alignment-Free Sensing Module for Noninvasive Radial Artery Blood Pressure Measurement

Sensor–artery alignment has always been a significant problem in arterial tonometry devices and prevents their application to wearable continuous blood pressure (BP) monitoring. Traditional solutions are to use a complex servo system to search for the best measurement position or to use an inefficient pressure sensor array. In this study, a novel solid–liquid mixture pressure sensing module is proposed. A flexible film with unique liquid-filled structures greatly reduces the pulse measurement error caused by sensor misplacement. The ideal measuring location was defined as −2.5 to 2.5 mm from the center of the module and the pressure variation was within 5.4%, which is available in the real application. Even at a distance of ±4 mm from the module center, the pressure decays by 23.7%, and its dynamic waveform is maintained. In addition, the sensing module is also endowed with the capability of measuring the pulse wave transmit time as a complementary method for BP measuring. The capability of the developed alignment-free sensing module in BP measurement was been validated. Twenty subjects were selected for the BP measurement experiment, which followed IEEE standards. The experimental results showed that the mean error of SBP is −4.26 mmHg with a standard deviation of 7.0 mmHg, and the mean error of DBP is 2.98 mmHg with a standard deviation of 5.07 mmHg. The device is expected to provide a new solution for wearable continuous BP monitoring.

The relationship between mean platelet volume and reverse dipping blood pressure pattern in patients with essential hypertension

OBJECTIVE

An association between increased mean platelet volume (MPV) and cardiovascular events is well established. Recent studies suggest that a nondipper blood pressure pattern is closely related to increased MPV. Because little information has been revealed about the relationship between reverse dipper hypertension (RDHT) and MPV, we aimed to investigate this relation.

METHODS

A total of 317 patients were retrospectively evaluated by analyzing the records of ambulatory blood pressure monitoring (ABPM). Patients were categorized into three groups according to their ABPM values as RDHT (n = 63), non-dipper hypertension (NDHT) (n = 95), and dipper hypertension (DHT) groups (n = 159). MPV and biochemical analyses were recorded from the hospital database.

RESULTS

The largest MPV was found in patients with RDHT, followed by patients with NDHT and DHT group (9.1 ± 0.4 fl, 8.8 ± 0.6 fl, and 8.6 ± 0.5 fl, respectively, for all p < .05). MPV was positively correlated with mean 24-hour systolic blood pressure (SBP), mean 24-hour diastolic blood pressure (DBP), mean daytime SBP, mean nighttime SBP and mean nighttime DBP. In multivariate logistic regression analysis, MPV (OR 1.761, 95% CI 1.329 to 2.334, p = .001) and age (OR 1.065, 95% CI 1.019 to 1.113, p = .001) were found to be associated with RDHT. ROC curve analysis of MPV for prediction of RDHT showed that at the cutoff value of >9,1 fl with a sensitivity of 60% and specificity of 69%, respectively (AUC = 0.696 ± 0.035, 95% CI: 0.627-0.764). Our data show that the RDHT pattern is associated with increased MPV values in patients with essential hypertension.

Ambulatory Blood Pressure Monitoring: Our Experience in Routine Clinical Practice

Objective: To evaluate feasibility and usefulness of ambulatory blood pressure monitoring (ABPM) in outpatient setting.

Material and methods: In this prospective study, data of 58 patients who were evaluated with ABPM for diagnosis or therapeutic efficacy purpose were collected from their records. Demographic details of these were recorded. Patients were categorized into different categories based on 24 hours BP pattern. Dipping pattern was compared based on the gender, age, and presence of diabetes or hypertension. Number of patients diagnosed as hypertensive with ABPM reports was compared with office and home BP measurement.

Results: Fifty-eight patients (mean age 57.8 years; 70.69% males) were included of whom 22 (37.93%) underwent ABPM for diagnostic purposes. There was gender-wise significant difference in terms of purpose of performing ABPM (p=0.040). Diabetes was present in 22 (37.93%) patients. Out of 36 known hypertensive patients, 17 (47.22%) patients were receiving dual therapy. Out of 45 patients whose records for active BP variability were available, 26 (57.78%) had high variability. The number and percentage of dippers, extreme dippers and reverse dippers as 23 (42.79%), three (5.56%), and six (11.11%), respectively. Depending on the age, there was significant difference in the dipping pattern (p=0.013). On office blood pressure measurement, 35 (64.81%) patients were found to have hypertension. ABPM revealed hypertension in 32 (59.26%). Masked hypertension and white-coat hypertension was observed in nine (16.17%) and 12 (22.22%) patients, respectively.

Conclusion: ABPM is feasible and useful in routine outpatient clinical practice for diagnosis of essential hypertension, pattern of dipping, masked hypertension, and white-coat hypertension and also for the therapeutic evaluation of patients in clinical practice.

Utility of 24-hour ambulatory blood pressure monitoring in potential living kidney donors

Introduction

Hypertension (HTN) is a risk factor for cardiovascular disease; therefore, it is imperative to risk stratify potential kidney donors during evaluation. Clinic blood pressure (CBP) measurement is inaccurate in assessing presence or absence of HTN. There is paucity of data about utility of 24-h ambulatory blood pressure monitoring (ABPM) during kidney donor evaluation.

Methods

24-h ABPM is performed on all kidney donors at Mayo Clinic Florida. We conducted retrospective review of 264 consecutive potential kidney donors from 1/1/2012 to 12/31/2017. Demographic, comorbid conditions, laboratory results and 24-h ABPM data were collected. Subjects were divided into two groups: Group1: Subjects with no prior history of HTN and new diagnosis of HTN using 24-h ABPM; Group 2: Subjects with no prior history of hypertension and normal BP on 24-h ABPM.

Results

Baseline demographic included mean age 46.40 years, 39% males, 78.4% Caucasians, and mean BMI was 26.94. Twenty one subjects (8.0%) had prior diagnosis of HTN. Among 243 subjects without prior HTN, 62 (25.5%) were newly diagnosed with HTN using 24-h ABPM. CBP was high only in 27 out of 62 (43.6%) of newly diagnosed HTN subjects. Thirty-five subjects (14.4%) had masked HTN and 14 subjects (5.8%) had white-coat HTN. Newly diagnosed hypertensive subjects were more likely to be males as compared to Group 2 (53.2% vs 34.3% P = 0.008). There was a trend of more non-Caucasians subjects (30.6% vs 19.9% P = 0.08) and more active smokers (17.7% vs 11.6%, P = 0.054) in Group1 as compared to Group 2. Only 17 (27.4%) out of 62 newly diagnosed hypertensive subjects were deemed suitable for kidney donation as compared to 105 (58.0%) out of 181 normotensive subjects (P < 0.001).

Conclusion

In our cohort, use of ABPM resulted in new diagnosis of HTN in 1 out of 4 potential kidney donors. Newly diagnosed HTN was more common in men, those with non-Caucasian race, and in active smokers. There was a significantly reduced acceptance rate for kidney donation among newly diagnosed HTN subjects. Further studies are needed to determine the value of 24-h ABPM among these high risk groups.

Correlation Between Ambulatory Blood Pressure Monitoring and Office Blood Pressure Measurement in Patients with Hypertension: A Community Study

Background The current gold standard for blood pressure (BP) measurements is based on office BP measurements (OBPMs) by a sphygmomanometer or a digital device. Ambulatory BP measurement (ABPM) is a noninvasive method for continuous monitoring of BP over a period during routine activities of the patient. Thus, ABPM offers multiple BP readings during the patients' daily routine as compared to the single reading by OBPM at rest. A good correlation exists between mean 24-hour BP readings and the prediction of cardiovascular events. The present multicenter observational study was aimed to assess the correlation between ABPM and OBPM in patients with newly diagnosed, controlled, or uncontrolled hypertension in the community setting. Our hypothesis was to test if ABPM provides any further value in those hypertensive patients in whom the office blood pressure levels are controlled. A supplementary hypothesis was whether obtaining ABPM in patients with newly diagnosed or uncontrolled hypertension yields any value over and beyond OBPM. Another objective was to find out the applicability of ABPM in the community setting where the medical care is provided by primary care family physicians and not by specialists. Materials and Methods A total of 1000 patients were analysed for this study. Those with controlled hypertension were assigned to Group A, and those with newly diagnosed/untreated hypertension comprised Group B. Group A was followed up during Visit 2 and Group B was followed up during Visit 2 and either Visit 3 or Visit 4 to assess the BP measurements by ABPM and OBPM. Results The correlation between ABPM and OBPM showed minimal variation in the BP readings of Group A subjects at Visit 2. A variation in BP readings was observed in Group B at Visit 2. Furthermore, the correlation was established between ABPM and OBPM noted for Group B subjects during Visit 3, and minimal variation was noted during Visit 4. Conclusions A good correlation was observed between ABPM and OBPM during both visits in patients in Groups A and B. However, a notable variation was noted in the diastolic BP readings. Thus, large-scale clinical studies are required to detect the prevalence of hypertension, masked hypertension, and dipping patterns associated with hypertension and other related medical co-morbidities.

The Impact of Various Blood Pressure Measurements on Cardiovascular Outcomes

Hypertension is a potent risk factor for cardiovascular morbidity and mortality. High blood pressure (BP) correlates closely with all-cause and cardiovascular mortality. Although the gold standard remains office BP (auscultatory or automated), other methods (central or out-of-office) are gaining popularity as better predictors of CV events. In this review, we investigated the prognostic value of each method of BP measurement and explored their advantages and pitfalls. Unattended automated office BP is a novel technique of BP measurement with promising data. Ambulatory BP monitoring, and to a lesser extent, home BP measurements, seem to predict cardiovascular events and mortality outcomes better, while at the same time, they can help distinguish hypertensive phenotypes. Data on the association of central BP levels with cardiovascular and mortality outcomes, are conflicting. Future extensive cross-sectional and longitudinal studies are needed to evaluate head-to-head the corresponding levels and results of each method of BP measurement, as well as to highlight disparities in their prognostic utility.

Monitoring Symptoms of Infectious Diseases: Perspectives for Printed Wearable Sensors

Infectious diseases possess a serious threat to the world's population, economies, and healthcare systems. In this review, we cover the infectious diseases that are most likely to cause a pandemic according to the WHO (World Health Organization). The list includes COVID-19, Crimean-Congo Hemorrhagic Fever (CCHF), Ebola Virus Disease (EBOV), Marburg Virus Disease (MARV), Lassa Hemorrhagic Fever (LHF), Middle East Respiratory Syndrome (MERS), Severe Acute Respiratory Syndrome (SARS), Nipah Virus diseases (NiV), and Rift Valley fever (RVF). This review also investigates research trends in infectious diseases by analyzing published research history on each disease from 2000-2020 in PubMed. A comprehensive review of sensor printing methods including flexographic printing, gravure printing, inkjet printing, and screen printing is conducted to provide guidelines for the best method depending on the printing scale, resolution, design modification ability, and other requirements. Printed sensors for respiratory rate, heart rate, oxygen saturation, body temperature, and blood pressure are reviewed for the possibility of being used for disease symptom monitoring. Printed wearable sensors are of great potential for continuous monitoring of vital signs in patients and the quarantined as tools for epidemiological screening.

High prevalence of non-dipping patterns among Black Africans with uncontrolled hypertension: a secondary analysis of the CREOLE trial

BACKGROUND

Dipping of blood pressure (BP) at night is a normal physiological phenomenon. However, a non-dipping pattern is associated with hypertension mediated organ damage, secondary forms of hypertension and poorer long-term outcome. Identifying a non-dipping pattern may be useful in assessing risk, aiding the decision to investigate for secondary causes, initiating treatment, assisting decisions on choice and timing of antihypertensive therapy, and intensifying salt restriction.

OBJECTIVES

To estimate the prevalence and factors associated with non-dipping pattern and determine the effect of 6 months of three antihypertensive regimens on the dipping pattern among Black African hypertensive patients.

METHODS

This was a secondary analysis of the CREOLE Study which was a randomized, single blind, three-group trial conducted in 10 sites in 6 Sub-Saharan African countries. The participants were 721 Black African patients, aged between 30 and 79 years, with uncontrolled hypertension and a baseline 24-h ambulatory blood pressure monitoring (ABPM). Dipping was calculated from the average day and average night systolic blood pressure measures.

RESULTS

The prevalence of non-dipping pattern was 78% (564 of 721). Factors that were independently associated with non-dipping were: serum sodium > 140 mmol/l (OR = 1.72, 95% CI 1.17-2.51, p-value 0.005), a higher office systolic BP (OR = 1.03, 95% CI 1.01-1.05, p-value 0.003) and a lower office diastolic BP (OR = 0.97, 95% CI 0.95-0.99, p-value 0.03). Treatment allocation did not change dipping status at 6 months (McNemar's Chi2 0.71, p-value 0.40).

CONCLUSION

There was a high prevalence of non-dipping among Black Africans with uncontrolled hypertension. ABPM should be considered more routinely in Black Africans with uncontrolled hypertension, if resources permit, to help personalise therapy. Further research is needed to understand the mechanisms and causes of non-dipping pattern and if targeting night-time BP improves clinical outcomes. Trial registration ClinicalTrials.gov (NCT02742467).

Textile-integrated polymer optical fibers for healthcare and medical applications

With ever growing interest in far-reaching solutions for pervasive healthcare and medicine, polymer optical fibers have been rendered into textile forms. Having both fiber-optic functionalities and traditional fabric-like comfort, textile-integrated polymer optical fibers have been advocated to remove the technical barriers for long-term uninterrupted health monitoring and treatment. In this context, this paper spotlights and reviews the recently developed textile-integrated polymer optical fibers in conjunction with fabrication techniques, applications in long-term continuous health monitoring and treatment, and future perspectives in the vision of mobile health (mHealth), as well as the introductory basics of polymer optical fibers. It is designed to serve as a topical guidepost for scientists and engineers on this highly interdisciplinary and rapidly growing topic.

Isoflavone Supplementation Does Not Potentiate the Effect of Combined Exercise Training on Resting and Ambulatory Blood Pressure in Non-Obese Postmenopausal Women: A Randomized Double-Blind Controlled Trial-A Pilot Study

Physical exercise and isoflavone supplementation are potential strategies to prevent and treat cardiovascular diseases in postmenopausal women. The aim of this study was to investigate whether there are additive effects of isoflavone supplementation when associated with combined aerobic and resistance exercise on resting and ambulatory blood pressure monitoring (ABPM) and in blood pressure variability (BPV). Thirty-one non-obese postmenopausal women were randomly allocated into two groups: placebo and exercise (Placebo n = 19); and isoflavone supplementation (100 mg/day) and exercise (isoflavone n = 19). ABPM and BPV were evaluated before and after 10 weeks of moderate combined (aerobic and resistance) exercise training. Generalized Estimating Equation (GEE) with Bonferroni correction and intention-to-treat analysis was used to compare the effects of interventions on resting BP, ABPM and BPV. Combined exercise training decreased resting systolic (SBP) and diastolic blood pressure (DBP) and reduced 24 h and awake ambulatory SBP, DBP and mean blood pressure over time, with no additional effects of isoflavone supplementation. No changes were observed in sleep period, or in BPV indexes (Standard Deviation of 24 h (SD), daytime and nighttime interval (SDdn) and average real variability (ARV) in both groups. We conclude that isoflavone supplementation does not potentiate the effects of combined training on resting and ambulatorial systolic and diastolic blood pressure in non-obese postmenopausal women.

Ambulatory blood pressure in patients with systemic lupus erythematosus: Association with markers of immune activation

Objectives: Ambulatory blood pressure monitoring measures 24-hour blood pressure, night-time blood pressure, and impaired dipping of nocturnal blood pressure, parameters that better predict cardiovascular risk than standard office blood pressure measurements. Systemic lupus erythematosus is characterized by immune system hyperactivity, elevated cardiovascular risk and high prevalence of hypertension; however, little is known about ambulatory blood pressure in lupus patients and its relationship to immune activation. Methods: We studied 26 patients with lupus and 26 control subjects. We obtained ambulatory 24-hour blood pressure measurements and report plasma concentrations of 77 markers of immune activation using a multiplex immunoassay and assessed their association with blood pressure measurements. Results: Despite similar office blood pressure measurements in patients with lupus and controls, lupus patients had higher 24-hour systolic [median (interquartile range) 129 (113 - 140) vs. 116 (111 - 121) mmHg, p = 0.03] and diastolic blood pressure [80 (69 - 86) vs. 72 (64 - 75) mmHg, p = 0.006] as well as less nocturnal dipping [7.8% (5.1 - 14.2%) vs. 12.0% (8.1 20.0%)] p = 0.03], compared to controls. In patients with lupus, markers of the innate (monocyte chemotactic protein-3) and adaptive immune systems [CUB domain-containing protein-1 and Interleukin-15 receptor subunit-α,] were associated with nocturnal blood pressure measurements and attenuated nocturnal dipping. In conclusion, 24-hour systolic and diastolic blood pressure was higher and nocturnal blood pressure dipping was attenuated in patients with lupus compared to control subjects. Conclusion: In patients with SLE, nocturnal blood pressure and attenuated nocturnal blood pressure dipping were significantly associated with several innate and adaptive immune system biomarkers.

Design and study protocol for a cluster randomized trial of a multi-faceted implementation strategy to increase the uptake of the USPSTF hypertension screening recommendations: the EMBRACE study

Background

The US Preventive Services Task Force (USPSTF) recommends out-of-office blood pressure (BP) testing to exclude white coat hypertension prior to hypertension diagnosis. Despite improved availability and coverage of home and 24-h ambulatory BP monitoring (HBPM, ABPM), both are infrequently used to confirm diagnoses. We used the Behavior Change Wheel (BCW) framework, a multi-step process for mapping barriers to theory-informed behavior change techniques, to develop a multi-component implementation strategy for increasing out-of-office BP testing for hypertension diagnosis. Informed by geographically diverse provider focus groups (n = 63) exploring barriers to out-of-office testing and key informant interviews (n = 12), a multi-disciplinary team (medicine, psychology, nursing) used rigorous mixed methods to develop, refine, locally adapt, and finalize intervention components.

The purpose of this report is to describe the protocol of the Effects of a Multi-faceted intervention on Blood pRessure Actions in the primary Care Environment (EMBRACE) trial, a cluster randomized control trial evaluating whether a theory-informed multi-component strategy increased out-of-office testing for hypertension diagnosis.

Methods/design

The EMBRACE Trial patient sample will include all adults ≥ 18 years of age with a newly elevated office BP (≥ 140/90 mmHg) at a scheduled visit with a primary care provider from a study clinic. All providers with scheduled visits with adult primary care patients at enrolled ACN primary care clinics were included. We determined that the most feasible, effective implementation strategy would include delivering education about out-of-office testing, demonstration/instruction on how to perform out-of-office HBPM and ABPM testing, feedback on completion rates of out-of-office testing, environmental prompts/cues via computerized clinical decision support (CDS) tool, and a culturally tailored, locally accessible ABPM testing service. We are currently comparing the effect of this locally adapted multi-component strategy with usual care on the change in the proportion of eligible patients who complete out-of-office BP testing in a 1:1 cluster randomized trial across 8 socioeconomically diverse clinics.

Conclusions

The EMBRACE trial is the first trial to test an implementation strategy for improving out-of-office testing for hypertension diagnosis. It will elucidate the degree to which targeting provider behavior via education, reminders, and decision support in addition to providing an ABPM testing service will improve referral to and completion of ABPM and HBPMs.

Trial registration

Clinicaltrials.gov, NCT03480217, Registered on 29 March 2018

A survey on personnel awareness of the factors affecting accurate blood pressure measurement in the medical centres of Jahrom County

Aims and objectives

The main purpose of this study was to determine the clinical skill of the medical personnel on level of awareness of standard methods used during blood pressure measurement.

Background

Blood pressure measurement is one of the vital clinical proficiencies the hospital personnel must be equipped with. Results from different surveys highlight the importance of awareness amongst medical personnel in controlling blood pressure.

Design

Descriptive cross-sectional study.

Methods

Using standardized questionnaires devised by the researcher, data were collected from 302 participants working in healthcare centres in Jahrom. The extracted data were analysed using SPSS.

Results

Observations showed that 10-20% of the participants had wide knowledge of influential factors affecting blood pressure measurement. Moreover, there was a meaningful relation between holding higher degrees and accurate blood pressure measurement (p < .05). Nevertheless, besides the personnel holding lower degrees, those holding higher educational degrees also had dearth of knowledge of factors affecting blood pressure measurement.

Conclusions

The overall findings of this study indicate that the knowledge among the hospital personnel in determining factors affecting blood pressure measurement was inadequate.

[Antihypertensives always evenings-absolutely not or sensible?]

The Spanish Hygia study has led to considerable irritation due to the general recommendation to prescribe antihypertensives preferably to be taken in the evening, especially since the lay press as well as medical media made enthusiastic comments. The discussion about the optimal time to take antihypertensive drugs shows once again how dangerous the uncritical handling of study data can be. No possible risks were pointed out. The Hygia study compared 19,084 patients with morning and evening intake of antihypertensive drugs under the control of a 48‑h blood pressure measurement (!). There was a significantly better reduction in blood pressure and the rate of cardiovascular and cerebrovascular events with evening intake. The data are scientifically valuable; however, the conclusions are incomprehensible based on the data, contradict many other studies and are dangerous for certain patient groups. There are also methodological shortcomings. Therefore, a general evening intake is not justified and nonsensical due to the diverse, individually very different pathophysiological findings of the nocturnal blood pressure behavior. Basically, the outpatient 24‑h blood pressure measurement (ABPM) enables a better assessment of the individual cardiovascular and cerebrovascular risks and prevents an incorrect assessment of the blood pressure and thus unnecessary or sufficient treatment. Instead of a general recommendation, the ABPM offers the option of an individually tailored treatment. Taking antihypertensive drugs in the evening should always be preceded by an ABDM in the case of prognostically unfavorable nocturnal hypertension in order to avoid the risk of nocturnal ischemic risks due to excessive drops in blood pressure.

Beat-to-beat blood pressure measurement using a cuffless device does not accurately reflect invasive blood pressure

BACKGROUND

The availability of an accurate continuous cuffless blood pressure (BP) monitor would provide an alternative to both invasive continuous BP and 24-h intermittent cuff-based BP monitors. We investigated the accuracy of a cuffless beat to beat (BtB) device compared to both invasive BP (iBP) and brachial cuff BP (cBP) measurements.

METHODS

Patients undergoing clinically indicated coronary angiography (CA) and/or percutaneous coronary intervention (PCI) were recruited. After calibration to an initial cBP reading, BP was measured simultaneously using a BtB device (SOMNOtouch NIBP), brachial artery iBP, and cBP at two time points.

RESULTS

The study was terminated early due to a significant bias. Recordings from 14 participants (11 males, mean age 68.4 years) were analysed. Readings from BtB BP were higher than iBP. The bias between BtB BP and iBP was 34.3 mmHg (95%CI: 27.0, 41.5) and 23.6 mmHg (95%CI: 16.8, 30.4) for SBP and DBP respectively. A similar bias was seen between BtB BP and cBP, but cBP and iBP were largely in agreement.

CONCLUSIONS

In patients undergoing CA/PCI, significant differences were detected between BtB BP and both invasively measured and cuff BP. The non-invasive BtB BP measurement device tested is not suitable for clinical or research use.

Self-Rated Health and Age-Related Differences in Ambulatory Blood Pressure: The Mediating Role of Behavioral and Affective Factors

OBJECTIVE

Despite the well-established association between self-rated health (SRH) and health, little is known about the potential psychobiological mechanisms responsible for such links and if these associations differ by age. The main goals of this study were to investigate the links between SRH and ambulatory blood pressure (ABP), if age moderated the risk, and the health behavior/affective mechanisms responsible for such links.

METHODS

A total of 188 men and women (94 married couples; ages, 18-63 years) completed a standard measure of SRH and a 1-day ABP assessment. Multilevel models were run to examine whether SRH was associated with daily ABP and whether these links were moderated by age. The Monte Carlo method was used to construct confidence intervals for mediation analyses.

RESULTS

Results indicated that poor SRH was associated with higher ambulatory systolic blood pressure (SBP; b = 3.14, SE = 0.68, p < .001) and diastolic blood pressure (DBP; b = 1.34, SE = 0.43, p = .002) levels. Age also moderated the links between SRH and ambulatory SBP (b = 0.19, SE = 0.08, p = .011) and DBP (b = 0.14, SE = 0.05, p = .004), with links being stronger in relatively older individuals. However, only daily life negative affect significantly mediated the age by SRH interaction for both ambulatory SBP and DBP.

CONCLUSIONS

These results highlight the potential psychobiological mechanisms linking SRH to longer-term health outcomes. Such work can inform basic theory in the area as well as intervention approaches that target such pathways.

Wearable skin-like optoelectronic systems with suppression of motion artifacts for cuff-less continuous blood pressure monitor

According to the statistics of the World Health Organization, an estimated 17.9 million people die from cardiovascular diseases each year, representing 31% of all global deaths. Continuous non-invasive arterial pressure (CNAP) is essential for the management of cardiovascular diseases. However, it is difficult to achieve long-term CNAP monitoring with the daily use of current devices due to irritation of the skin as well as the lack of motion artifacts suppression. Here, we report a high-performance skin-like optoelectronic system integrated with ultra-thin flexible circuits to monitor CNAP. We introduce a theoretical model via the virtual work principle for predicting the precise blood pressure and suppressing motion artifacts, and propose optical difference in the frequency domain for stable optical measurements in terms of skin-like devices. We compare the results with the blood pressure acquired by invasive (intra-arterial) blood pressure monitoring for >1500 min in total on 44 subjects in an intensive care unit. The maximum absolute errors of diastolic and systolic blood pressure were ±7/±10 mm Hg, respectively, in immobilized, and ±10/±14 mm Hg, respectively, in walking scenarios. These strategies provide advanced blood pressure monitoring techniques, which would directly address an unmet clinical need or daily use for a highly vulnerable population.

The Relationship Between Homocysteine, Blood Pressure Variability, and Left Ventricular Hypertrophy in Patients with Essential Hypertension: An Observational Study

INTRODUCTION

This study aimed to investigate the relationship between homocysteine (Hcy) and blood pressure variability (BPV) and the relationship between Hcy and left ventricular hypertrophy (LVH) in 102 patients with essential hypertension.

METHODS

The 102 patients were divided into the Hcy < 10 μmol/L group (n = 47) and the Hcy ≥ 10 μmol/L group (n = 55) according to Hcy concentration. The differences between Hcy and BPV and Hcy and LVH were compared between the two groups. Finally, the correlations between Hcy and BPV and between Hcy and LVH were analyzed.

RESULTS

The results showed that there were significant differences between Hcy and BPV and between Hcy and LVH in the two groups. Hcy correlated positively with the coefficient of variation in nighttime diastolic blood pressure and night systolic blood pressure standard deviation (nDBPSD), with correlation coefficients of 0.331 and 0.303 (P < 0.001). At the same time, Hcy correlated positively with interventricular septal thickness and left ventricular posterior wall thickness, which were indicators of LVH, with correlation coefficients of 0.350 and 0.352 (P < 0.001).

CONCLUSIONS

There was a correlation between Hcy and BPV and between Hcy and LVH. Attention should also be paid to blood Hcy and BPV for patients with essential hypertension.

Association of the mean platelet volume and red cell distribution width with dipper and non-dipper blood pressure in prehypertensive non-smokers

OBJECTIVE

Absence of nocturnal blood pressure (BP) dipping is associated with poor health outcomes, including increased mortality. Non-dipper BP seems to be a predictor of cardiovascular damage in hypertensive patients. The aim of this study was to investigate the association of the mean platelet volume (MPV) and red cell distribution width (RDW) with nocturnal dipping/non dipping status in newly diagnosed and untreated prehypertensive non-smokers, using ambulatory BP monitoring.

RESULTS

Twenty-eight patients (15 males) in the dipper group and 24 patients (11 males) in the non-dipper group were evaluated in this study. The age of patients was 41.64 ± 15.01 and 37.96 ± 15.08 years in the dipper and non-dipper groups, respectively. The rate of nocturnal systolic BP drop in the dipper and non-dipper groups was 13.79 ± 3.35% (10.20-22.10) and 5.96 ± 2.87% (1.10-9.30) (P < 0.001), respectively. Also, the mean rate of nocturnal diastolic BP drop in the dipper and non-dipper groups was 17.02 ± 5.09% (10.30-26.90) and 6.19 ± 2.75% (1.20-9.70) (P < 0.001), respectively. RDW and MPV were significantly higher in non-dipper patients than dipper patients (P = 0.001 and P = 0.012, respectively). Bivariate analysis revealed that MPV was inversely correlated with the nocturnal systolic BP drop (P = 0.005, r = - 0.385). Furthermore, RDW was inversely correlated with systolic BP drop (P = 0.019, r = - 0.324).

Ethnic Differences in Nighttime Melatonin and Nighttime Blood Pressure: A Study in European Americans and African Americans

BACKGROUND

Ethnic differences in nighttime blood pressure (BP) have long been documented with African Americans (AAs) having higher BP than European Americans (EAs). At present, lower nighttime melatonin, a key regulator of circadian rhythms, has been associated with higher nighttime BP levels in EAs. This study sought to test the hypothesis that AAs have lower nighttime melatonin secretion compared with EAs. We also determined if this ethnic difference in melatonin could partially explain the ethnic difference in nighttime BP.

METHODS

A total of 150 young adults (71 AA; 46% females; mean age: 27.7 years) enrolled in the Georgia Stress and Heart study provided an overnight urine sample for the measurement of 6-sulfatoxymelatonin, a major metabolite of melatonin. Urine melatonin excretion (UME) was calculated as the ratio between 6-sulfatoxymelatonin concentration and creatinine concentration. Twenty-four-hour ambulatory BP was assessed and nighttime systolic BP (SBP) was used as a major index of BP regulation.

RESULTS

After adjustment of age, sex, body mass index, and smoking, AAs had significantly lower UME (P = 0.002) and higher nighttime SBP than EAs (P = 0.036). Lower UME was significantly associated with higher nighttime SBP and this relationship did not depend on ethnicity. The ethnicity difference in nighttime SBP was significantly attenuated after adding UME into the model (P = 0.163).

CONCLUSION

This study is the first to document the ethnic difference in nighttime melatonin excretion, demonstrating that AAs have lower melatonin secretion compared with EAs. Furthermore, the ethnic difference in nighttime melatonin can partially account for the established ethnic difference in nighttime SBP.

Comparisons between different blood pressure measurement techniques in patients with chronic kidney disease

BACKGROUND

Automated office blood pressure (AOBP) machines measure blood pressure (BP) multiple times over a brief period. We aimed to compare the results of manual office blood pressure (MOBP) and AOBP methods with ambulatory BP monitoring (ABPM) in patients with chronic kidney disease (CKD).

METHODS

This study was performed on 64 patients with CKD (stages 3-4). A nurse manually measured the BP on both arms using a mercury sphygmomanometer, followed by AOBP of the arm with the higher BP and then ABPM. Mean BP readings were compared by paired t test and Bland-Altman graphs.

RESULTS

The mean ± standard deviation (SD) age of participants was 59.3 ± 13.6. The mean ± SD awake systolic BP obtained by ABPM was 140.2 ± 19.0 mmHg, which was lower than the MOBP and AOBP methods (156.6 ± 17.8 and 148.8 ± 18.6 mmHg, respectively; P < 0.001). The mean ± SD awake diastolic BP was 78.6 ± 13.2 mmHg by ABPM which was lower than the MOBP and AOBP methods (88.9 ± 13.2 and 84.1 ± 14.0 mmHg, respectively; P < 0.001). Using Bland-Altman graphs, MOBP systolic BP readings showed a bias of 16.4 mmHg, while AOBP measurements indicated a bias of 8.6 mmHg compared with ABPM.

CONCLUSION

AOBP methods may be more reliable than MOBP methods for determining BP in patients with CKD. However, the significantly higher mean BPs recorded by AOBP method suggested that AOBPs may not be as accurate as ABPM in patients with CKD.

Comorbid hypertension in patients with major depressive disorder - Results from a European multicenter study

The objective of the present multicenter study was to elucidate relevant associations between major depressive disorder (MDD) and comorbid hypertension that are known for their frequent co-occurrence and interaction with regard to functional disability. Demographic and clinical information of altogether 1410 patients were retrieved cross-sectionally. Consecutively, a comparison of patient characteristics between MDD subjects with and without comorbid hypertension were conducted by descriptive statistics, analyses of covariance (ANCOVA) and binary logistic regression analyses. The point prevalence rate for comorbid hypertension was 18.9%. Patients with MDD+comorbid hypertension were significantly older, heavier, more likely to be in a relationship, inpatient and diagnosed with further comorbid chronic somatic diseases including heart disease, diabetes and thyroid dysfunction. In addition, individuals with MDD and comorbid hypertension exhibited a higher score at the Montgomery and Åsberg Depression Rating Scale (MADRS) at onset of the current depressive episode. Melancholic features of depression showed a higher probability. The first line antidepressant treatment did not differ significantly between MDD subjects with versus without comorbid hypertension. Augmentation with pregabalin and combination with one additional antidepressant, however, were more common in the MDD+hypertension group. In conclusion, high blood pressure may influence illness severity and is associated with a distinct psychopathology in MDD patients. Patients with MDD and comorbid hypertension, that seems to be underdiagnosed in MDD patients compared to the general population, are subject to additional somatic diseases in almost 100 percent of the cases and hence, need to be screened and treated accordingly.

Effectiveness of a new one-hour blood pressure monitoring method to diagnose hypertension: a diagnostic accuracy clinical trial protocol

INTRODUCTION

24-hour ambulatory blood pressure monitoring (ABPM) is the gold standard diagnostic method for hypertension, but has some shortcomings in clinical practice while clinical settings often lack sufficient devices to accommodate all patients with suspected hypertension. Home blood pressure monitoring (HBPM) and office blood pressure monitoring (OBPM) also have shortcomings, such as the white coat effect or a lack of accuracy. This study aims to study the validity of a new method of diagnosing hypertension consisting of monitoring blood pressure (BP) for 1 hour and comparing it with OBPM and HBPM and examining the sensitivity and specificity of this method compared with 24-hour ABPM. The patient experience will be examined in each method.

METHODS AND ANALYSIS

A minimum sample of 214 patients requiring a diagnostic test for hypertension from three urban primary healthcare centres will be included. Participants will undergo 24-hour ABPM, 1-hour BP measurement (1-BPM), OBPM for three consecutive weeks and HBPM. Patients will follow a random sequence to first receive 24-hour ABPM or 1-hour ABPM. Daytime 24-hour ABPM records will be compared with the other monitoring methods using the correlation coefficient and Bland Altman plots. The kappa concordance index and the sensitivity and specificity of the methods will be calculated. The patient's experience will be studied, with selected indicators of efficiency and satisfaction calculated using parametric tests.

ETHICS AND DISSEMINATION

The protocol has been authorised by the research ethics committee of the Hospital Clinic of Barcelona (Ref. HCB/2014/0615): protocol details and amendments will be recorded and reported to ClinicalTrials.com. The results will be disseminated in peer-reviewed literature, and to policy makers and healthcare partners.

TRIAL REGISTRATION

NCT03147573; Pre-results.

Assessment of Blood Pressure: Techniques and Implications From Clinical Trials

Hypertension is a global health problem and without adequate diagnosis and treatment is a risk factor for morbidity and mortality. Proper assessment of blood pressure is key to diagnosis and management of hypertension. Different methods of measurement are available for use and varying techniques are applied to patient care. Understanding the proper methods of blood pressure measurement both in and out of the physician's office is crucial for providing appropriate care to an individual patient. In addition, understanding the techniques used in research, on which current guidelines are based, is critical for proper application to daily practice. In this article, we review the types of blood pressure measurement techniques, discuss the benefits and limitations to each, explore future technological advances in measurement devices, and provide insight into research techniques, which ultimately guide our practice.

Pure Autonomic Failure with Asymptomatic Hypertensive Urgency: A Case Report and Literature Review

We report the case study of a 70-year-old gentleman who presented with isolated, slowly progressive dizziness after prolonged standing and was eventually diagnosed with pure autonomic failure. Initially, his symptoms improved with the use of midodrine and fludrocortisone, but gradually became refractory and disabling. Despite multiple therapeutic interventions, his symptoms persisted along with worsening supine hypertension. We discuss the challenges faced in the treatment of an uncommon condition and discuss the clinical utility of performing serial 24-h ambulatory monitoring to detect subclinical blood pressure fluctuations.

Ambulatory blood pressure monitoring in clinical practice

Being one of the most widely prevalent diseases throughout the world, hypertension has emerged as one of the leading causes of global premature morbidity and mortality. Hence, blood pressure (BP) measurements are essential for physicians in the diagnosis and management of hypertension. Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend initiating antihypertensive medications on the basis of office BP readings. However, office BP readings provide a snapshot evaluation of the patient's BP, which might not reflect patient's true BP, with the possibility of being falsely elevated or falsely low. Recently, there is ample evidence to show that ambulatory blood pressure monitoring (ABPM) is a better predictor of major cardiovascular events than BP measurements at clinic settings. ABPM helps in reducing the number of possible false readings, along with the added benefit of understanding the dynamic variability of BP. This article will focus on the significance of ambulatory BP, its advantages and limitations compared with the standard office BP measurement and a brief outlook on its use and interpretation to diagnose and treat hypertension.

The Emerging Role of Mobile-Health Applications in the Management of Hypertension

PURPOSE OF REVIEW

Mobile-health technology, frequently referred to as m-health, encompasses smartphone, tablet, or personal computer use in the management of chronic disease. There has been a rise in the number of commercially available smartphone applications and website-based platforms which claim to help patients manage hypertension. Very little research has been performed confirming whether or not use of these applications results in improved blood pressure (BP) outcomes. In this paper, we review existing literature on m-health systems and how m-health can affect hypertension management.

RECENT FINDINGS

M-health systems help patients manage hypertension in the following ways: (1) setting alarms and reminders for patients to take their medications, (2) linking patients' BP reports to their electronic medical record for their physicians to review, (3) providing feedback to patients about their BP trends, and (4) functioning as point-of-care BP sensors. M-health applications with alarms and reminders can increase medication compliance while applications that share ambulatory BP data with patients' physicians can foster improved patient-physician dialog. However, the most influential tool for achieving positive BP outcomes appears to be patient-directed feedback about BP trends. A large number of commercially available m-health applications may facilitate self-management of hypertension by enhancing medication adherence, maintaining a log of blood pressure measurements, and facilitating physician-patient communication. A small number of applications function as BP sensors, thereby transforming the smartphone into a medical device. Such BP sensors often generate unreliable recordings. Patients must be cautioned regarding the use of smartphones for BP measurement at least until these applications have been more extensively validated.

Wearable Health Devices-Vital Sign Monitoring, Systems and Technologies

Wearable Health Devices (WHDs) are increasingly helping people to better monitor their health status both at an activity/fitness level for self-health tracking and at a medical level providing more data to clinicians with a potential for earlier diagnostic and guidance of treatment. The technology revolution in the miniaturization of electronic devices is enabling to design more reliable and adaptable wearables, contributing for a world-wide change in the health monitoring approach. In this paper we review important aspects in the WHDs area, listing the state-of-the-art of wearable vital signs sensing technologies plus their system architectures and specifications. A focus on vital signs acquired by WHDs is made: first a discussion about the most important vital signs for health assessment using WHDs is presented and then for each vital sign a description is made concerning its origin and effect on heath, monitoring needs, acquisition methods and WHDs and recent scientific developments on the area (electrocardiogram, heart rate, blood pressure, respiration rate, blood oxygen saturation, blood glucose, skin perspiration, capnography, body temperature, motion evaluation, cardiac implantable devices and ambient parameters). A general WHDs system architecture is presented based on the state-of-the-art. After a global review of WHDs, we zoom in into cardiovascular WHDs, analysing commercial devices and their applicability versus quality, extending this subject to smart t-shirts for medical purposes. Furthermore we present a resumed evolution of these devices based on the prototypes developed along the years. Finally we discuss likely market trends and future challenges for the emerging WHDs area.

Nitrate, the oral microbiome, and cardiovascular health: a systematic literature review of human and animal studies

Background

Dietary nitrate is an important source of nitric oxide (NO), a molecule critical for cardiovascular health. Nitrate is sequentially reduced to NO through an enterosalivary nitrate-nitrite-NO pathway that involves the oral microbiome. This pathway is considered an important adjunct pathway to the classical l-arginine-NO synthase pathway.

Objective

The objective of this study was to systematically assess the evidence for dietary nitrate intake and improved cardiovascular health from both human and animal studies.

Design

A systematic literature search was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by using key search terms in Medline and EMBASE databases and defined inclusion and exclusion criteria.

Results

Thirty-seven articles on humans and 14 articles on animals were included from 12,541 screened references. Data on the effects of dietary nitrate on blood pressure, endothelial function, ischemic reperfusion injury, arterial stiffness, platelet function, and cerebral blood flow in both human and animal models were identified. Beneficial effects of nitrate on vascular health have predominantly been observed in healthy human populations, whereas effects in populations at risk of cardiovascular disease are less clear. Few studies have investigated the long-term effects of dietary nitrate on cardiovascular disease clinical endpoints. In animal studies, there is evidence that nitrate improves blood pressure and endothelial function, particularly in animal models with reduced NO bioavailability. Nitrate dose seems to be a critical factor because there is evidence of cross-talk between the 2 pathways of NO production.

Conclusions

Evidence for a beneficial effect in humans at risk of cardiovascular disease is limited. Furthermore, there is a need to investigate the long-term effects of dietary nitrate on cardiovascular disease clinical endpoints. Further animal studies are required to elucidate the mechanisms behind the observed effects.