Differences in blood pressure by body position (supine, Fowler's, and sitting) in hypertensive subjects

Comparison of forearm and intra-arterial blood pressure measurements according to body and arm positions in obese patients

RATIONALE

Noninvasive blood pressure (BP) monitoring is very important also difficult for accurate diagnosis and monitor of obese patients.

AIMS

The study aimed to assess the agreement between forearm arm BP and intra-arterial BP values in a different body and arm positions in obese patients.

METHODS

The descriptive study was carried out on 60 intensive care patients with a body mass index above 30 kg/m2 who were monitored with invasive radial BP in the general and surgical intensive care units. BP values obtained from the upper arm and forearm with different arm and body positions were compared with intra-arterial BP results. Bland-Altman analysis and correlation coefficient were used for the accuracy of upper and forearm noninvasive BP reading in different positions.

RESULTS

The best agreement was found between the forearm systolic BP in the supine and half-sitting position with the arm down and intra-arterial BP values. Also, the best agreement in diastolic BP was found between the half-sitting and half-sitting position with the arm down and intra-arterial BP.

CONCLUSIONS

Forearm systolic BP measurement, especially in the supine and half-sitting position with the arm below the heart level position, was best agreement with intra-arterial measurement, regarded as the gold standard. For this reason, it is more appropriate to use forearm BP measurement in obese patients monitored in intensive care to obtain accurate results.

The contribution of cumulative blood pressure load to dementia, cognitive function and mortality in older adults

BACKGROUND

Few studies evaluated the contribution of long-term elevated blood pressure (BP) towards dementia and deaths. We examined the association between cumulative BP (cBP) load and dementia, cognitive decline, all-cause and cardiovascular deaths in older Australians. We also explored whether seated versus standing BP were associated with these outcomes.

METHODS

The Sydney Memory and Aging Study included 1037 community-dwelling individuals aged 70-90 years, recruited from Sydney, Australia. Baseline data was collected in 2005-2007 and the cohort was followed for seven waves until 2021. cSBP load was calculated as the area under the curve (AUC) for SBP ≥140 mmHg divided by the AUC for all SBP values. Cumulative diastolic BP (cDBP) and pulse pressure (cPP) load were calculated using thresholds of 90 mmHg and 60 mmHg. Cox and mixed linear models were used to assess associations.

RESULTS

Of 527 participants with both seated and standing BP data (47.7% men, median age 77), 152 (28.8%) developed dementia over a mean follow-up of 10.5 years. Higher cPP load was associated with a higher risk of all-cause deaths, and cSBP load was associated with a higher risk of cardiovascular deaths in multivariate models (P for trend < 0.05). Associations between cPP load, dementia and cognitive decline lost statistical significance after adjustment for age. Differences between sitting and standing BP load were not associated with the outcomes.

CONCLUSION

Long-term cPP load was associated with a higher risk of all-cause deaths and cSBP load associated with a higher risk of cardiovascular deaths in older Australians.

Disability level's impact on blood pressure-mortality association in older long-term care adults: evidence from a large Chinese cohort study

BACKGROUND

Evidence of the optimal blood pressure (BP) target for older adults with disability in long-term care is limited. We aim to analyze the associations of BP with mortality in older adults in long-term care setting with different levels of disability.

METHODS

This prospective cohort study was based on the government-led long-term care programme in Chengdu, China, including 41,004 consecutive disabled adults aged ≥ 60 years. BP was measured during the baseline survey by trained medical personnel using electronic sphygmomanometers. Disability profile was assessed using the Barthel index. The association between blood pressure and mortality was analyzed with doubly robust estimation, which combined exposure model by inverse probability weighting and outcome model fitted with Cox regression. The non-linearity was examined by restricted cubic spline. The primary endpoint was all-cause mortality, and the secondary endpoints were cardiovascular and non-cardiovascular mortality.

RESULTS

The associations between systolic blood pressure (SBP) and all-cause mortality were close to a U-shaped curve in mild-moderate disability group (Barthel index ≥ 40), and a reversed J-shaped in severe disability group (Barthel index < 40). In mild-moderate disability group, SBP < 135 mmHg was associated with elevated all-cause mortality risks (HR 1.21, 95% CI, 1.10-1.33), compared to SBP between 135 and 150 mmHg. In severe disability group, SBP < 150 mmHg increased all-cause mortality risks (HR 1.21, 95% CI, 1.16-1.27), compared to SBP between 150 and 170 mmHg. The associations were robust in subgroup analyses in terms of age, gender, cardiovascular comorbidity and antihypertensive treatment. Diastolic blood pressure (DBP) < 67 mmHg (HR 1.29, 95% CI, 1.18-1.42) in mild-moderate disability group and < 79 mmHg (HR 1.15, 95% CI, 1.11-1.20) in severe disability group both demonstrated an increased all-cause mortality risk.

CONCLUSION

The optimal SBP range was found to be higher in older individuals in long-term care with severe disability (150-170mmHg) compared to those with mild to moderate disability (135-150mmHg). This study provides new evidence that antihypertensive treatment should be administered cautiously in severe disability group in long-term care setting. Additionally, assessment of disability using the Barthel index can serve as a valuable tool in customizing the optimal BP management strategy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Registration Number: ChiCTR2100049973).

Sitting leg vasculopathy: potential adaptations beyond the endothelium

Increased sitting time, the most common form of sedentary behavior, is an independent risk factor for all-cause and cardiovascular disease mortality; however, the mechanisms linking sitting to cardiovascular risk remain largely elusive. Studies over the last decade have led to the concept that excessive time spent in the sitting position and the ensuing reduction in leg blood flow-induced shear stress cause endothelial dysfunction. This conclusion has been mainly supported by studies using flow-mediated dilation in the lower extremities as the measured outcome. In this review, we summarize evidence from classic studies and more recent ones that collectively support the notion that prolonged sitting-induced leg vascular dysfunction is likely also attributable to changes occurring in vascular smooth muscle cells (VSMCs). Indeed, we provide evidence that prolonged constriction of resistance arteries can lead to modifications in the structural characteristics of the vascular wall, including polymerization of actin filaments in VSMCs and inward remodeling, and that these changes manifest in a time frame that is consistent with the vascular changes observed with prolonged sitting. We expect this review will stimulate future studies with a focus on VSMC cytoskeletal remodeling as a potential target to prevent the detrimental vascular ramifications of too much sitting.

Obesity does not alter vascular function and handgrip exercise hemodynamics in middle-aged patients with hypertension

Lifestyle modification including exercise training is often the first line of defense in the treatment of obesity and hypertension (HTN), however, little is known regarding how these potentially compounding disease states impact vasodilatory and hemodynamic responses at baseline and exercise. Therefore, this study sought to compare the impact of obesity on vascular function and hemodynamics at baseline and during handgrip (HG) exercise among individuals with HTN. Non-obese (13M/7F, 56 ± 16 yr, 25 ± 4 kg/m2) and obese (17M/4F, 50 ± 7 yr, 35 ± 4 kg/m2) middle-aged individuals with HTN forwent antihypertensive medication use for ≥2 wk before assessment of vascular function by brachial artery flow-mediated dilation (FMD) and exercise hemodynamics during progressive HG exercise at 15-30-45% maximal voluntary contraction (MVC). FMD was not different between Non-Obese (4.1 ± 1.7%) and Obese (5.2 ± 1.9%, P = 0.11). Systolic blood pressure (SBP) was elevated by ∼15% during the supine baseline and during HG exercise in the obese group. The blood flow response to HG exercise at 30% and 45% MVC was ∼20% greater (P < 0.05) in the obese group but not different after normalizing for the higher, albeit, nonsignificant differences in workloads (MVC: obese: 24 ± 5 kg, non-obese: 21 ± 5 kg, P = 0.11). Vascular conductance and the brachial artery shear-induced vasodilatory response during HG were not different between groups (P > 0.05). Taken together, despite elevated SBP during HG exercise, obesity does not lead to additional impairments in vascular function and peripheral exercising hemodynamics in patients with HTN. Obesity may not be a contraindication when prescribing exercise for the treatment of HTN among middle-aged adults, however, the elevated SBP should be appropriately monitored.NEW & NOTEWORTHY This study examined vascular function and handgrip exercise hemodynamics in obese and nonobese individuals with hypertension. Obesity, when combined with hypertension, was neither associated with additional vascular function impairments at baseline nor peripheral hemodynamics and vasodilation during exercise compared with nonobese hypertension. Interestingly, systolic blood pressure and pulse pressure were greater in the obese group during supine baseline and exercise. These findings should not be ignored and may be particularly important for rehabilitation strategies.

Meta-Analysis of Pulse Transition Features in Non-Invasive Blood Pressure Estimation Systems: Bridging Physiology and Engineering Perspectives

The pulse transition features (PTFs), including pulse arrival time (PAT) and pulse transition time (PTT), hold significant importance in estimating non-invasive blood pressure (NIBP). However, the literature showcases considerable variations in terms of PTFs' correlation with blood pressure (BP), accuracy in NIBP estimation, and the comprehension of the relationship between PTFs and BP. This inconsistency is exemplified by the wide-ranging correlations reported across studies investigating the same feature. Furthermore, investigations comparing PAT and PTT have yielded conflicting outcomes. Additionally, PTFs have been derived from various bio-signals, capturing distinct characteristic points like the pulse's foot and peak. To address these inconsistencies, this study meticulously reviews a selection of such research endeavors while aligning them with the biological intricacies of blood pressure and the human cardiovascular system (CVS). Each study underwent evaluation, considering the specific signal acquisition locale and the corresponding recording procedure. Moreover, a comprehensive meta-analysis was conducted, yielding multiple conclusions that could significantly enhance the design and accuracy of NIBP systems. Grounded in these dual aspects, the study systematically examines PTFs in correlation with the specific study conditions and the underlying factors influencing the CVS. This approach serves as a valuable resource for researchers aiming to optimize the design of BP recording experiments, bio-signal acquisition systems, and the fine-tuning of feature engineering methodologies, ultimately advancing PTF-based NIBP estimation.

Ambulatory daytime blood pressure versus tonometric blood pressure measurements in the laboratory: effect of posture

OBJECTIVE

To compare blood pressure (BP) in tonometric radial artery recordings during passive head-up tilt with ambulatory recordings and evaluate possible laboratory cutoff values for hypertension.

METHODS

Laboratory BP and ambulatory BP were recorded in normotensive (n = 69), unmedicated hypertensive (n = 190), and medicated hypertensive (n = 151) subjects.

RESULTS

Mean age was 50.2 years, BMI 27.7 kg/m 2 , ambulatory daytime BP 139/87 mmHg, and 276 were male (65%). As supine-to-upright changes in SBP ranged from -52 to +30 mmHg, and in DBP from -21 to +32 mmHg, the mean values of BP supine and upright measurements were compared with ambulatory BP. The mean(supine+upright) systolic laboratory BP was corresponding to ambulatory level (difference +1 mmHg), while mean(supine+upright) DBP was 4 mmHg lower ( P  < 0.05) than ambulatory value. Correlograms indicated that laboratory 136/82 mmHg corresponded to ambulatory 135/85 mmHg. When compared with ambulatory 135/85 mmHg, the sensitivity and specificity of laboratory 136/82 mmHg to define hypertension were 71.5% and 77.3% for SBP, and 71.7% and 72.8%, for DBP, respectively. The laboratory cutoff 136/82 mmHg classified 311/410 subjects similarly to ambulatory BP as normotensive or hypertensive, 68 were hypertensive only in ambulatory, while 31 were hypertensive only in laboratory measurements.

CONCLUSION

BP responses to upright posture were variable. When compared with ambulatory BP, mean(supine+upright) laboratory cutoff 136/82 mmHg classified 76% of subjects similarly as normotensive or hypertensive. In the remaining 24% the discordant results may be attributed to white-coat or masked hypertension, or higher physical activity during out-of-office recordings.

Association of blood pressure measurements in sitting, supine, and standing positions with the 10-year risk of mortality in Korean adults

OBJECTIVES

This prospective cohort study investigated the association between blood pressure (BP) as measured in different body postures and all-cause and cardiovascular (CV) mortality risk.

METHODS

This population-based investigation included 8,901 Korean adults in 2001 and 2002. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured sequentially in the sitting, supine, and standing positions and classified into 4 categories: 1) normal, SBP <120 mmHg and DBP <80 mmHg; 2) high normal/prehypertension, SBP 120-129 mmHg and DBP <80 mmHg/SBP 130-139 mmHg or DBP 80-89 mmHg; 3) grade 1 hypertension (HTN), with SBP 140-159 mmHg or DBP 90-99 mmHg; and 4) grade 2 HTN, SBP ≥160 mmHg or DBP ≥100 mmHg. The date and cause of individual deaths were confirmed in the death record data compiled until 2013. Data were analyzed using Cox proportional hazard regression.

RESULTS

Significant associations were found between the BP categories and all-cause mortality, but only when BPs were measured in the supine position. The multivariate hazard ratios (95% confidence intervals) were 1.36 (1.06-1.75) and 1.59 (1.06-2.39) for grade 1 and grade 2 HTN, respectively, compared with the normal category. The associations between the BP categories and CV mortality were significant regardless of body posture among participants ≥65 years, whereas they were significant for supine BP measurements only in those <65 years.

CONCLUSIONS

BP measured in the supine position predicted all-cause mortality and CV mortality better than BP measured in other postures.

Influence of Internet-Based Health Management on Control of Clinical Parameters in Patients With Hypertension: Four-Year Longitudinal Study

BACKGROUND

In recent years, more and more studies have shown that internet-based health management can help patients with hypertension control their blood pressure. However, there is a lack of similar research in China.

OBJECTIVE

We designed this study to clarify the impact of long-term internet-based health management on the control of clinical parameters in patients with hypertension. These results are also expected to identify the relevant factors affecting the control of clinical parameters in hypertension more accurately toward developing more targeted health management strategies.

METHODS

This was a longitudinal study of internet-based health management in the five provinces of northwest China. The inclusion criteria were aged ≥18 years and no serious cognitive disease or mental disorder. After collecting the physical examination data of 8567 people in the five northwest provinces in 2013, we conducted online health management (including diet, exercise, and behavior) and follow-up. In the physical examination in 2013, 1008 new patients with hypertension were identified, who were divided into a good blood pressure control group and poor blood pressure control group. Physical examination and a questionnaire survey were conducted every 2 years to understand the changes of health management on the subjects' health-related behaviors. We then analyzed the changes of clinical indicators related to hypertension and the influencing factors related to blood pressure control in patients with hypertension. All statistical analyses were performed using R software (version 4.1.2) and a P value <.05 was considered statistically significant.

RESULTS

A total of 8567 people met the inclusion criteria and underwent health management. Self-comparison showed that after 4 years of health management, the smoking cessation rate and amount of exercise significantly increased (both P<.001). The low-density lipoprotein-cholesterol levels also increased (P=.005), whereas the high-density lipoprotein-cholesterol levels decreased (P=.007). The newly discovered patients with hypertension in 2013 were further screened. After 4 years of health management, their smoking cessation rate increased significantly (P=.03) and the amount of exercise increased but not significantly (P=.08). In terms of clinical indicators, the diastolic blood pressure considerably decreased (P<.001) and the systolic blood pressure slightly decreased (P=.13). The correlation analysis of blood pressure control in patients with new-onset hypertension showed that gender (female) and changing relevant factors according to health management behaviors (BMI; cereals and potatoes intake; fish, livestock meat, and eggs intake; fruit intake; and physical activity) were the protective factors of blood pressure control.

CONCLUSIONS

Internet-based health management has a significant and long-term effect on blood pressure control in patients with hypertension.

Compliance to Multidisciplinary Lifestyle Intervention Decreases Blood Pressure in Patients with Resistant Hypertension: A Cross-Sectional Pilot Study

Hypertension is a common chronic medical condition. Treatment is not satisfactory in a significant proportion of patients with primary hypertension, despite the concurrent use of three or more medications with different mechanisms of action. Such treatment-resistant hypertension is a clinical challenge associated with poor prognosis and needs further investigation. The efficacy of lifestyle changes has not been established yet in patients with resistant hypertension, and educational efforts appear clinically irrelevant in patients who must achieve behavioral changes without supervision. A 6-month multidisciplinary pilot intervention enrolled 50 patients with established resistant hypertension. The aims were: (1) to examine whether intensive and supervised lifestyle changes contribute to decreasing blood pressure in this condition, and (2) to identify which components affect compliance and feasibility. The program provided intensive changes in nutrition, physical exercise, and control of sleep disturbances supervised by nutritionists, physiotherapists, and psychologists. Nurses and pharmacists followed up on adherence to the antihypertensive medication. The primary outcome was 24 h blood pressure control. Data in patients with full compliance (n = 30) indicate that lifestyle modifications in resistant hypertension significantly reduced 24 h both systolic and diastolic blood pressure (p < 0.01), body mass index (p < 0.01), medication burden (p = 0.04), improving physical fitness, and cardiovascular risk markers such as heart rate (p = 0.01) and augmentation index (p = 0.02). The adherence to the intervention was moderate, with an attrition rate of 12%. A modified version reducing visits and explorations will likely improve compliance and can be used to assess the long-term maintenance of these benefits in managing resistant hypertension by diverse healthcare providers.

The effect of various breath-hold techniques on the cardiorespiratory response to facial immersion in humans

NEW FINDINGS

What is the central question of this study? What is the effect of three repeated breath-hold techniques routinely used by freedivers, thought to manipulate arterial partial pressures of O2 and CO2 , on the cardiorespiratory and haematological response to breath-holding during facial immersion? What is the main finding and its importance? All three techniques increased breath-hold by a similar duration, probably owing to the similar marked increase in end-tidal O2 and decrease in end-tidal CO2 observed in all three trials before facial immersion. These were the only cardiorespiratory changes that were consistently manipulated before the maximal breath-hold. This would suggest that pronounced bradycardia and vasoconstriction of selective vascular beds are probably not obligatory for prolonging breath-hold duration.

ABSTRACT

Repeated maximal breath-holds have been demonstrated to induce bradycardia, increase haematocrit and haemoglobin and prolong subsequent breath-hold duration by 20%. Freedivers use non-maximal breath-hold techniques (BHTs) to improve breath-hold duration. The aim of this study was to investigate the cardiorespiratory and haematological responses to various BHTs. Ten healthy men (34.5 ± 1.9 years) attended five randomized experimental trials and performed a 40 min period of quiet rest or one of three BHTs followed by a maximal breath-hold challenge during facial immersion in water at 30 or 10°C. Cardiovascular and respiratory parameters were measured continuously using finger plethysmography and breath-by-breath gas analysis, respectively, and venous blood samples were collected throughout. Facial immersion in cold water caused marked bradycardia (74.1 vs. 50.2 beats/min after 40 s) but did not increase breath-hold duration compared with warm water control conditions. Facial immersion breath-hold duration was 30.8-43.3% greater than the control duration when preceded by BHTs that involved repeated breath-holds of constant duration (P = 0.021), increasing duration (P < 0.001) or increasing frequency (P < 0.001), with no difference observed between BHTs. The increased duration of apnoea across all three BHT protocols was associated with a 6.8% increase in end-tidal O2 and a 13.1% decrease in end-tidal CO2 immediately before facial immersion. There were no differences in blood pressure, cardiac output, heart rate, haematocrit or haemoglobin between each BHT and control conditions (P > 0.05). In conclusion, the duration of apnoea can be extended by manipulating blood gases through repeated prior breath-holds, but changes in cardiac output and red blood cell mass do not appear essential.

Exploring the acute cardiovascular effects of Floatation-REST

The central nervous system (CNS) exerts a strong regulatory influence over the cardiovascular system in response to environmental demands. Floatation-REST (Reduced Environmental Stimulation Therapy) is an intervention that minimizes stimulation from the environment, yet little is known about the autonomic consequences of reducing external sensory input to the CNS. We recently found that Floatation-REST induces a strong anxiolytic effect in anxious patients while paradoxically enhancing their interoceptive awareness for cardiorespiratory sensations. To further investigate the physiologic nature of this anxiolytic effect, the present study measured acute cardiovascular changes during Floatation-REST using wireless and waterproof equipment that allowed for concurrent measurement of heart rate, heart rate variability (HRV), breathing rate, and blood pressure. Using a within-subjects crossover design, 37 clinically anxious participants with high levels of anxiety sensitivity and 20 non-anxious comparison participants were randomly assigned to undergo a 90-min session of either Floatation-REST or an exteroceptive comparison condition that entailed watching a relaxing nature film. Measures of state anxiety and serenity were collected before and after each session, while indices of autonomic activity were measured throughout each session. HRV was calculated using both time-series and frequency domain analyses. Linear mixed-effects modeling revealed a significant main effect of condition such that relative to the film condition, Floatation-REST elicited significant decreases (p < 0.001) in diastolic blood pressure, systolic blood pressure, breathing rate, and certain metrics of HRV including the standard deviation of the interbeat interval (SDNN), low-frequency HRV, and very low-frequency HRV. Heart rate showed a non-significant trend (p = 0.073) toward being lower in the float condition, especially toward the beginning of the session. The only metric that showed a significant increase during Floatation-REST was normalized high-frequency HRV (p < 0.001). The observed physiological changes were consistent across both anxious and non-anxious participants, and there were no significant group by condition interactions. Blood pressure was the only cardiac metric significantly associated with float-related reductions in state anxiety and increases in serenity. These findings suggest that Floatation-REST lowers sympathetic arousal and alters the balance of the autonomic nervous system toward a more parasympathetic state.

Clinical trial registration

[https://clinicaltrials.gov/show/NCT03051074], identifier [NCT03051074].

Effect of Lower- versus Higher-Intensity Isometric Handgrip Training in Adults with Hypertension: A Randomized Controlled Trial

This study compared the effects of lower- versus higher-intensity isometric handgrip exercise on resting blood pressure (BP) and associated clinical markers in adults with hypertension. Thirty-nine males were randomly assigned to one of three groups, including isometric handgrip at 60% maximal voluntary contraction (IHG-60), isometric handgrip at 30% IHG-30, or a control group (CON) that had been instructed to continue with their current activities of daily living. The volume was equated between the exercise groups, with IHG-60 performing 8 × 30-s contractions and IHG-30 performing 4 × 2-min contractions. Training was performed three times per week for 8 weeks. Resting BP (median [IQR]), flow-mediated dilation, heart rate variability, and serum markers of inflammation and oxidative stress were measured pre- and post-intervention. Systolic BP was significantly reduced for IHG-60 (−15.5 mmHg [−18.75, −7.25]) and IHG-30 (−5.0 mmHg [−7.5, −3.5]) compared to CON (p < 0.01), but no differences were observed between both the exercise groups. A greater reduction in diastolic BP was observed for IHG-60 (−5.0 mmHg [−6.0, −4.25] compared to IHG-30 (−2.0 mmHg [−2.5, −2.0], p = 0.042), and for both exercise groups compared to CON (p < 0.05). Flow-mediated dilation increased for both exercise groups versus CON (p < 0.001). IHG-30 had greater reductions in interleukin-6 and tumor necrosis factor-α compared to the other groups (p < 0.05) and CON (p = 0.018), respectively. There was a reduction in Endothelin-1 for IHG-60 compared to CON (p = 0.018). Both the lower- and higher-intensity IHG training appear to be associated with reductions in resting BP and improvements in clinical markers of inflammation and oxidative stress.

Sources of automatic office blood pressure measurement error: a systematic review

OBJECTIVE

Accurate and reliable blood pressure (BP) measurement is important for the prevention and treatment of hypertension. The oscillometric-based automatic office blood pressure measurement (AOBPM) is widely used in hospitals and clinics, but measurement errors are common in BP measurements. There is a lack of systematic review of the sources of measurement errors.

APPROACH

A systematic review of all existing research on sources of AOBPM errors. A search strategy was designed in six online databases, and all the literature published before October 2021 was selected. Those studies that used the AOBPM device to measure BP from the upper arm of subjects were included.

MAIN RESULTS

A total of 1365 studies were screened, and 224 studies were included in this final review. They investigated 22 common error sources with clinical AOBPM. Regarding the causes of BP errors, this review divided them into the following categories: the activities before measurement, patient's factors, measurement environment, measurement procedure, and device settings. 13 sources caused increased systolic and diastolic BP (SBP and DBP), 2 sources caused the decrease in SBP and DBP, only 1 source had no significant effect on BPs, and the other errors had a non-uniform effect (either increase or decrease in BPs). The error ranges for SBP and DBP were -14 to 33 mmHg and -6 to 19 mmHg, respectively.

SIGNIFICANCE

The measurement accuracy of AOBPM is susceptible to the influence of measurement factors. Interpreting BP readings need to be treated with caution in clinical measurements. This review made comprehensive evidence for the need for standardized BP measurements and provided guidance for clinical practitioners when measuring BP with AOBPM devices.

Effectiveness of High-Intensity Interval Training and Continuous Moderate-Intensity Training on Blood Pressure in Physically Inactive Pre-Hypertensive Young Adults

The likelihood of pre-hypertensive young adults developing hypertension has been steadily increasing in recent years. Despite the fact that aerobic exercise training (AET) has demonstrated positive results in lowering high blood pressure, the efficacy of different types of AET among pre-hypertensive young adults has not been well-established. The objective of this study was to evaluate the effectiveness of high-intensity interval training (HIIT) and continuous moderate-intensity training (CMT) on the blood pressure (BP) of physically inactive pre-hypertensive young adults. In total, 32 adults (age 20.0 ± 1.1 years and BMI 21.5 ± 1.8) were randomly assigned to three groups: HIIT, CMT and control (CON). The HIIT and CMT groups participated in 5 weeks of AET, while the CON group followed a DASH diet plan only. The HIIT protocol consisted of a 1:4 min work to rest ratio of participants, at an 80−85% heart rate reserve (HR-reserve) and a 40−60% HR-reserve, respectively, for 20 min; the CMT group exercised at 40−60% of their HR-reserve continuously for 20 min. In both the HIIT and CMT groups, systolic blood pressure (SBP) (3.8 ± 2.8 mmHg, p = 0.002 vs. 1.6 ± 1.5 mmHg, p = 0.011) was significantly reduced, while significant reductions in the diastolic blood pressure (DBP) (2.9 ± 2.2 mmHg, p = 0.002) and mean arterial pressure (MAP) (3.1 ± 1.6 mmHg, p < 0.0005) were noted only in the HIIT group. No significant differences in SBP (−0.4 ± 3.7 mmHg, p = 0.718), DBP (0.4 ± 3.4 mmHg, p = 0.714), or MAP (0.1 ± 2.5 mmHg, p = 0.892) were observed in the CON group. Both HIIT and CMT decreased BP in physically inactive pre-hypertensive young adults; however, HIIT yielded more beneficial results in terms of reducing the SPB, DBP and MAP.

Blood Pressure Variability and Cognitive Function: a Scoping Review

PURPOSE OF REVIEW

To conduct a scoping review of articles which have evaluated BPV and cognitive function. Articles with keywords, titles or abstracts containing the terms 'cognitive' OR 'cognition' OR 'dementia' AND 'blood pressure variability' were identified from CINAHL, Medline, PMC and Web of Science.

RECENT FINDINGS

Methods of acquisition and analysis of BPV and cognitive measurements and their relationship were extracted from selected articles. Of 656 studies identified, 53 articles were selected. Twenty-five evaluated long-term (LTBPV), nine mid-term (MTBPV), 12 short-term (STBPV) and nine very short-term BPV (VSTBPV) with conflicting findings on the relationship between BPV and cognition. Variations existed in devices, period and procedure for acquisition. The studies also utilized a wide range of methods of BPV calculation. Thirteen cognitive assessment tools were used to measure global cognition or domain functions which were influenced by the population of interest. The interpretation of available studies was hence limited by heterogeneity. There is an urgent need for standardization of BPV assessments to streamline research on BPV and cognition. Future studies should also establish whether BPV could be a potential modifiable risk factor for cognitive decline, as well as a marker for treatment response.

Effect of positioning on blood pressure measurement in pregnancy

Blood pressure is the key vital sign to detecting hypertensive disorders in pregnancy. The importance of taking blood pressure properly was recently underscored by the publication of updated ACC/AHA guidelines for measuring blood pressure in patients. However, the recommended position of seating with arms and back supported is not always feasible to achieve clinically, especially for inpatient women who are pregnant. Therefore, it is clinically important to understand the effects of alternative patient positioning on blood pressure measurements. We conducted a review of studies which considered patient position on the effect of blood pressure in pregnancy. This review demonstrates that clinically significant differences may occur based on patient positioning. Despite the small number of primary studies that include pregnant women, notable reductions in blood pressure measurements have been observed in the left lateral recumbent position, a common position during labor or during monitoring, in comparison to measurements taken in the supported seated position. Ultimately, these differences could affect the clinical management of patients and care should be taken to document and consider the position in which the reading was taken.

Improved cardiovascular profile in Danish centenarians? A comparative study of two birth cohorts born 20 years apart

PURPOSE

Cardiovascular health among middle-aged and older people has improved in high-income countries. It is unknown whether this also applies for the oldest-old and if so, is it driven by better treatment or by a health improvement? Therefore, we compared two Danish centenarian birth cohorts born in 1895 and 1915, respectively, to investigate if the cardiovascular profile had improved in the most recent born cohort.

METHODS

All individuals turning 100 years old in 1995 and 2015, respectively, were included with participation rates of 74% (n = 106) and 79% (n = 238), respectively. Data were collected through structured in-home interviews. Cardiovascular profile was obtained by measured blood pressure, electrocardiogram (ECG), and information on medication. Hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg.

RESULTS

Mean SBP and DBP were almost identical in the two cohorts. Yet, the prevalence of measured hypertension was non-significantly higher in the 1895 cohort [73%, 95% CI (61;82)] compared to the 1915 cohort [63%, 95% CI (55;70)]. The proportion receiving at least one type of cardiovascular drug was significantly higher in the 1915 cohort [80%, 95% CI (74;86)] compared to 1895 cohort [66%, 95% CI 55;76)]. ECG findings were similar in the two cohorts, e.g., atrial fibrillation was present in 17% of the 1895 cohort and 20% of the 1915 cohort.

CONCLUSION

This comparison study found a non-significant improvement in measured hypertension irrespective of medical treatment in the recent born cohort. Also, the recent born cohort was treated more intensively with cardiovascular drugs than earlier. However, the prevalence of pathological ECG-findings was unchanged.

Normal ranges of non-invasive left ventricular myocardial work indices in healthy young people

OBJECTIVES

Echocardiographic global myocardial work (GMW) indices recently emerged to non-invasively evaluate left ventricular (LV) myocardial performance with less load-dependence than LV ejection fraction (LVEF) or global longitudinal strain (GLS). Yet, few data exist on the descriptions of LV GMW indices in young people. We therefore aimed to provide normal reference values of LV GMW in a healthy young cohort, and simultaneously to investigate factors associated with non-invasive GMW indices.

MATERIALS AND METHODS

A total of 155 healthy young people (age 10-24 years, 59% male) underwent transthoracic echocardiography were recruited and further stratified for age groups and divided by gender. Two-dimensional speckle-tracking echocardiography (2D-STE) were performed to determine LV GLS, peak strain dispersion (PSD) and GMW indices, which include global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). LV peak systolic pressure was assumed to be equal to the systolic brachial artery cuff blood pressure.

RESULTS

Age and gender specific normal ranges for LV GMW indices were presented. On multivariable analysis, GWI and GCW correlated more closely with systolic blood pressure (SBP) than LV GLS, while both GWW and GWE independently correlated with PSD (P < 0.05 for all). There were no associations between any of the GMW indices with age, sex, body mass index, heart rate, left ventricular mass index as well as LV sizes or LVEF. Of noted, LV GMW indices had good intra-observer and inter-observer reproducibility.

CONCLUSION

We reported echocardiographic reference ranges for non-invasive LV GMW indices in a large group of healthy young subjects, which are reproducible and reliable, and thus can be further used when assessing subclinical dysfunction in young people with myocardial diseases.

Effect of Beach-Chair Position on Cerebral Blood Flow in Patients Undergoing Shoulder Surgery—A Preliminary Observational Study

Background Hypotension and cerebral hypoperfusion, commonly encountered in beach-chair position under general anesthesia, carry the risk of neurologic complications. There is a paucity of data on monitoring cerebral perfusion. Our objective was to compare the mean arterial pressure (MAP) and middle cerebral artery velocity (Vmca) in the supine and beach-chair position and estimate its correlation during hypotension.

Materials and Methods Twenty ASA class I and II patients undergoing elective shoulder surgery in beach-chair position were included in the study. MAP was measured invasively with the pressure transducer leveled to the phlebostatic axis. Vmca was measured with a 2 MHz transcranial Doppler (TCD) probe through the temporal window. Both MAP and Vmca were measured at baseline after anesthetic induction in the supine position (BL), on assuming the beach-chair position (AP), at steady-state hemodynamics in beach-chair position (P1), whenever there was a drop in MAP > 20% (P2), and on the restoration of MAP (P3).

Results A mean decrease in MAP and Vmca by 24.76% and 27.96%, respectively, from supine to beach-chair position with a significant linear correlation between MAP and Vmca along with a Pearsons’ coefficient of 0.77 was seen. A change in MAP of 1 mm of Hg resulted in a change in Vmca by 0.53 cm/sec (p < 0.05).

Conclusion A significant decrease in MAP and Vmca was observed in the beach-chair position. TCD could be used as a point-of-care noninvasive technique to reliably assess cerebral perfusion.

Gain in net survival from hypertension control over the last half-century

AIMS

This study determined whether the improvements in hypertension management over the last five decades have influenced subjects' prognosis.

METHODS AND RESULTS 

The study considered 5693 eligible subjects seen January 1969 to February 1991 (follow-up until December 2003) or January 1995 to October 2014 (follow-up until July 2016) in an all-grade hypertension reference centre. Missing data or incomplete follow-ups led to exclude 1036 subjects (18%). The outcome was all-cause death. An adjusted modelling of the excess mortality rate assessed subjects' net survival over five inclusion periods to allow for the increase in life expectancy of the general population during the same periods. The analysis of 4657 records (mean age: 47 years; 43.2% women) showed that the proportion of subjects with grade 3 hypertension decreased significantly from 43.3% (1142) to only 6.3% (22) over the five periods and that the net survival improved in men and women regardless of the hypertension grade; i.e. the gain in net survival at 15 years was estimated at 12.3% (95% confidence interval: 8.1-22.3). The 15-year restricted mean survival was estimated at 13 years over the first period and 14.8 years over the last period, which is nearly a 2-year gain in life expectancy at 15 years.

CONCLUSION 

Since the 70s and the advent of modern management, the excess mortality of hypertensive subjects (vs. the general population) was markedly reduced. Within a context of trivialization of blood pressure measurement and reluctance to long-term treatments, physicians should consider this advantage and use it to promote blood pressure control.

Supine Hypertension Is Associated With an Impaired Cerebral Oxygenation Response to Orthostasis: Finding From The Irish Longitudinal Study on Ageing

[Figure: see text].

Effectiveness of a family nurse-led programme on accuracy of blood pressure self-measurement: A randomised controlled trial

AIMS AND OBJECTIVES

To evaluate the effectiveness of a Family Nurse Practitioner (FNP)-led programme on the degree of adherence of current recommendations on home blood pressure self-measurement (HBPM) as compared to routine care and management.

BACKGROUND

HBPM plays an important role for monitoring hypertensive patients; however, patients' adherence to current guidelines is unsatisfactory. A nurse-led training programme in the community setting could be an effective strategy to achieve high level of patients' adherence to recommendations.

DESIGN

A multicentre randomised controlled trial was carried out from September 2016 to September 2017.

METHODS

In total, 170 patients were randomly allocated into the intervention group (n = 83) and the usual care (n = 87). All participants received usual care (written and verbal information on HBPM recommendations); subjects in the intervention group also received 1-hour training session on how to correctly self-measure BP. Clinical trial registration was done (ClinicalTrials.gov.: NCT04681703). The CONSORT checklist for randomised controlled trials was used in this study.

RESULTS

At baseline, the level of adherence to the recommendation was similar in the two groups (p < .05). After 1 month, the adherence significantly increased in the intervention group, where patients were more likely to measure BP at the same hour and from the same arm, in a quiet environment, with the back and uncovered arm supported and the legs uncrossed; recording BP more than once in each measurement session; keeping a diary of blood pressure measurements; use of the appropriate cuff and proper placement of the cuff; and resting for >5 min before performing the measurement (all p < .05).

CONCLUSIONS

The FNP-led programme is effective in improving patients' adherence to guidelines on the correct technique to self-measure BP at home.

RELEVANCE TO CLINICAL PRACTICE

This programme may be added to the existing interventions in the community setting or considered into specifically nurse-led hypertension management models.

Non-invasive continuous blood pressure monitoring (ClearSight™ system) during shoulder surgery in the beach chair position: a prospective self-controlled study

Background

The beach chair position that is commonly used in shoulder surgery is associated with relative hypovolemia, which leads to a reduction in arterial blood pressure. The effects of patient positioning on the accuracy of non-invasive continuous blood pressure monitoring with the ClearSight™ system (CS-BP; Edwards Lifesciences, Irvine CA, USA) have not been studied extensively. Our research aim was to assess agreement levels between CS-BP measurements with traditional blood pressure monitoring techniques.

Methods

For this prospective self-controlled study, we included 20 consecutively treated adult patients undergoing elective shoulder surgery in the beach chair position. We performed Bland-Altman analyses to determine agreement levels between blood pressure values from CS-BP and standard non-invasive (NIBP) methods. Perioperative measurements were done in both the supine (as reference) and beach chair surgical positions. Additionally, we compared invasive blood pressure (IBP) measurements with both the non-invasive methods (CS-BP and NIBP) in a sub-group of patients (n = 10) who required arterial blood pressure monitoring.

Results

We analyzed 229 data points (116 supine, 113 beach chair) from the entire cohort; per patient measurements were based on surgical length (range 3–9 supine, 2–10 beach chair). The mean difference (±SD; 95% limits of agreement) in the mean arterial pressure (MAP) between CS-BP and NIBP was − 0.9 (±11.0; − 24.0–22.2) in the beach chair position and − 4.9 mmHg (±11.8; − 28.0–18.2) when supine. In the sub-group, the difference between CS-BP and IBP in the beach chair position was − 1.6 mmHg (±16.0; − 32.9–29.7) and − 2.8 mmHg (±15.3; − 32.8–27.1) in the supine position. Between NIBP and IBP, we detected a difference of 3.0 mmHg (±9.1; − 20.8–14.7) in the beach chair position, and 4.6 mmHg (±13.3; − 21.4–30.6) in the supine position.

Conclusions

We found clinically acceptable mean differences in MAP measurements between the ClearSight™ and non-invasive oscillometric blood pressure systems when patients were in either the supine or beach chair position. For all comparisons of the monitoring systems and surgical positions, the standard deviations and limits of agreement were wide.

Trial registration

This study was prospectively registered at the German Clinical Trial Register (www.DRKS.de; DRKS00013773). Registered 26/01/2018.

The Effects of Gradual Change in Head Positioning on the Relationship between Systemic and Cerebral Haemodynamic Parameters in Healthy Controls and Acute Ischaemic Stroke Patients

(1) Background: Larger blood pressure variability (BPv) in the first 3 h post-stroke onset increases pathophysiological effects such as infarct size, and leads to greater risk of disability, comorbidities and mortality at 90 days. However, there is limited information on the relationship between systemic and cerebral haemodynamic and variability parameters. (2) Objectives: This study determined the effect of a gradual change in head position (GHP) on cerebral blood flow velocity variability (CBFVv) and mean arterial blood pressure variability (MABPv), in healthy controls and acute ischaemic stroke (AIS) patients. Methods: CBFVv and MABPv were expressed as standard deviation (SD) and coefficient of variation. A total of 16 healthy controls (mean age 57 ± 16 years) were assessed over two visits, 12 ± 8 days apart, and 15 AIS patients (mean age 69 ± 8.5 years) were assessed over three visits (V1: 13.3 ± 6.9 h, V2: 4.9 ± 3.2 days and V3: 93.9 ± 11.5 days post-stroke). (3) Results: In response to GHP, MABPv does not initially increase, but over time MABPv showed a significant increase in response to GHP in AIS (visits 2 and 3) and controls (visit 2). Additionally, in response to GHP in AIS, CBFVv increased in the affected hemisphere. Lastly, in AIS, a significant correlation between CBFVv and MABPv, assessed by SD, was seen in the unaffected hemisphere, whereas this relationship was not demonstrated in the affected hemisphere. (4) Conclusions: To our knowledge, this is the first study to analyse the relationship between CBFVv and MABPv. Shedding light on the effect of head position on the relationship between cerebral blood flow and blood pressure is important to improve our understanding of the underlying effects of cerebral autoregulation impairment. This early mechanistic study provides evidence supporting supine head positioning in healthy controls and stroke patients, through demonstration of a reduction of MABPv and increase in CBFVv.

A Proxy for Detecting IUGR Based on Gestational Age Estimation in a Guatemalan Rural Population

In-utero progress of fetal development is normally assessed through manual measurements taken from ultrasound images, requiring relatively expensive equipment and well-trained personnel. Such monitoring is therefore unavailable in low- and middle-income countries (LMICs), where most of the perinatal mortality and morbidity exists. The work presented here attempts to identify a proxy for IUGR, which is a significant contributor to perinatal death in LMICs, by determining gestational age (GA) from data derived from simple-to-use, low-cost one-dimensional Doppler ultrasound (1D-DUS) and blood pressure devices. A total of 114 paired 1D-DUS recordings and maternal blood pressure recordings were selected, based on previously described signal quality measures. The average length of 1D-DUS recording was 10.43 ± 1.41 min. The min/median/max systolic and diastolic maternal blood pressures were 79/102/121 and 50.5/63.5/78.5 mmHg, respectively. GA was estimated using features derived from the 1D-DUS and maternal blood pressure using a support vector regression (SVR) approach and GA based on the last menstrual period as a reference target. A total of 50 trials of 5-fold cross-validation were performed for feature selection. The final SVR model was retrained on the training data and then tested on a held-out set comprising 28 normal weight and 25 low birth weight (LBW) newborns. The mean absolute GA error with respect to the last menstrual period was found to be 0.72 and 1.01 months for the normal and LBW newborns, respectively. The mean error in the GA estimate was shown to be negatively correlated with the birth weight. Thus, if the estimated GA is lower than the (remembered) GA calculated from last menstruation, then this could be interpreted as a potential sign of IUGR associated with LBW, and referral and intervention may be necessary. The assessment system may, therefore, have an immediate impact if coupled with suitable intervention, such as nutritional supplementation. However, a prospective clinical trial is required to show the efficacy of such a metric in the detection of IUGR and the impact of the intervention.

Simultaneous influence of sex and age on blood pressure difference between supine and sitting body positions

OBJECTIVES

Doctors' offices and outpatient departments typically measure blood pressure (BP) with the patient in a sitting position, whereas inpatient departments also use the supine position. As sex and age influence the autonomic function associated with BP regulation our study compared BP measurements in supine and sitting positions for men and women of different ages.

METHODS

We included 91 men and 118 women (≥18 years) without severe diseases. Hypertension was not an exclusion criterion because it is common in older persons. Mean left brachial BP and heart rate were determined by a digital sphygmomanometer in supine position as well as in sitting position before and after hand force measurement.

RESULTS

In a supine position women had slightly lower diastolic BP values than men. After sitting up, the diastolic BP increased in nearly all subjects. This increase was greater in women older than 50 years than for aged-matched men. In contrast to diastolic BP the systolic BP increased after sitting up in only two thirds of the subjects. Especially in women younger than 50 years the systolic BP often did not increase but decreased in response to postural change. The pulse pressure was mostly reduced after sitting up. This reduction was more pronounced in women than men independent of age and physical effort (i.e. hand force measurement). The sitting position also caused an increased heart rate, which was independent of sex and age.

CONCLUSION

Postural changes in the systolic and diastolic BP simultaneously depend on sex and age that needs to be considered for BP measurements in supine and sitting body positions.

Normal variations in brain oxygen extraction fraction are partly attributed to differences in end-tidal CO2

Cerebral oxygen extraction fraction is an important physiological index of the brain's oxygen consumption and supply and has been suggested to be a potential biomarker for a number of diseases such as stroke, Alzheimer's disease, multiple sclerosis, sickle cell disease, and metabolic disorders. However, in order for oxygen extraction fraction to be a sensitive biomarker for personalized disease diagnosis, inter-subject variations in normal subjects must be minimized or accounted for, which will otherwise obscure its interpretation. Therefore, it is essential to investigate the physiological underpinnings of normal differences in oxygen extraction fraction. This work used two studies, one discovery study and one verification study, to examine the extent to which an individual's end-tidal CO₂ can explain variations in oxygen extraction fraction. It was found that, across normal subjects, oxygen extraction fraction is inversely correlated with end-tidal CO₂. Approximately 50% of the inter-subject variations in oxygen extraction fraction can be attributed to end-tidal CO₂ differences. In addition, oxygen extraction fraction was found to be positively associated with age and systolic blood pressure. By accounting for end-tidal CO₂, age, and systolic blood pressure of the subjects, normal variations in oxygen extraction fraction can be reduced by 73%, which is expected to substantially enhance the utility of oxygen extraction fraction as a disease biomarker.

The effects of different degrees of head-of-bed elevation on the respiratory pattern and drainage following thyroidectomy: a randomized controlled trial

Background

The patient's position is important for ensuring patient comfort and preventing complications after thyroidectomy.

Objectives

This study was carried out to determine the effects of different degrees of head-of-bed elevation (HOBE) on the respiratory pattern and drainage following thyroidectomy and to provide suggestions for evidence-based clinical practice.

Methods

The sample of this prospective, parallel arm, randomized controlled trial included 114 patients undergoing thyroidectomy in a university hospital in Turkey. The patients were randomly assigned (1:1:1) to supine 0° (baseline), 30° and 45° HOBE groups. Respiratory pattern including respiratory rate (RR), peripheral oxygen saturation (SpO₂) and dyspnea, and drainage including amount of drainage and hematoma formation were evaluated at the 1^rd, 2^rd, 3^rd and 4^th hours following thyroidectomy.

Results

The majority of the patients (83.3%) were female and 84.2% had undergone total thyroidectomy. The mean RR (18.47, 95% CI=17.85–19.09) of the patients in the supine 30° HOBE group at the 1^rd hour was significantly higher than that of the patients in the supine 0° group (17.32, 95% CI=16.88–17.76; p<0.05). There was no significant difference between the SpO₂ values of the patients in the groups (p>0.05). The amount of drainage was significantly higher in the supine 0° group at the 2nd hour than that of the patients in the supine 45° HOBE group (5.92±5.18; 3.34±5.56 respectively; p<0.05). None of the patients in the groups had hematoma formation. While no patient in the supine 30° HOBE group had dyspnea, dyspnea occurred in 9 patients in the supine 0° group and in 3 patients in the supine 45° HOBE group.

Conclusion

This study showed that different HOBE positions resulted in clinically insignificant changes on the RR and amount of drainage during the first 4 hours following thyroidectomy but did not affect SpO₂ value.

Blood Pressure Measurements with Different Currently Available Methods in Elderly Hypertensive Hospitalized Patients: A Real World Cross-Sectional Study

BACKGROUND

The reliability of blood pressure (BP) measurement in hospitalized patients is a topic of debate and the therapeutic implication of the routinely collected BP profiles is probably overestimated. When measurements are performed in elderly patients, further potential sources of misinterpretation occur.

METHODS

We conducted a subanalysis of a previous study including 79 over 80-year-old hypertensive patients, hospitalized in an internal medicine ward. Five modalities of BP evaluations (measurement by physicians and nurses, self-measurement by patients, Finometer® beat-to-beat finger monitoring, and 24h monitoring) were analyzed, considering agreement and accuracy.

RESULTS

The mean (SD) age of the patients was 86.9±4.9 years (50% women). Patients' self-measurements of both systolic and diastolic BP (SBP and DBP) did not differ significantly from daytime 24-hour monitoring (D24hBPM) (mean difference -1.52, SE 1.71; p: ns and -0.58, SE 1.19 mmHg; p: ns). Conversely, SBP and DBP registered by nurses did significantly differ (mean difference -7.34, SE 1.42; p=0.007 and -4.7, SE 1.05 mmHg; p=0.003). SBP and DBP measured by patients also showed the better concordance, with lowest biases, and narrowest limits of agreements (LoA) and for SBP higher Kappa statistic values (bias 1.5, LoA -28.9 to 31.9; κ 0.563 and bias 0.6, LoA -20.4 to 21.5 mmHg; κ 0.412). The patients' sensitivity and specificity in predicting hypertensive systolic D24hBPM were 84.8% and 69.7%, respectively.

CONCLUSIONS

In elderly hospitalized patients an alternative to 24hBPM, self-measurements by patients offer the better agreement and reliability in detecting hypertensive values.

The Impact of Head-of-Bed Positioning and Transducer Location on Cerebral Perfusion Pressure Measurement

INTRODUCTION

Head-of-bed (HOB) elevation is the standard of care for patients with intracranial pressure monitoring at risk for intracranial hypertension. Measurement of cerebral perfusion pressure (CPP) based on HOB elevation and arterial transducer position has not been adequately studied.

METHODS

This is a planned secondary analysis of prospectively collected data in which paired, serial arterial blood pressure (ABP), intracranial pressure, and CPP measures were obtained once per day for 3 days, with measures leveled at the tragus (Tg) and the phlebostatic axis (PA). The HOB position was recorded for all paired readings.

RESULTS

From 136 subjects, ABP and CPP values were lower when the transducer was leveled at the Tg, compared with the PA (P < .001); these differences persisted regardless of HOB position.

CONCLUSION

The difference in CPP when ABP is referenced at the Tg versus PA is not consistently attributed to HOB elevation.

Acute Cardiovascular Responses to the Application of Manual Lymphatic Drainage in Different Body Regions

Background: The purpose of this study was to investigate acute cardiovascular responses to manual lymphatic drainage (MLD) on different parts of the body. Materials and Methods: Thirty healthy individuals (10 women and 20 men) participated in the study voluntarily. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), respiration frequency, and oxygen saturation were measured before and after MLD was applied to different regions of the body (neck, abdomen, anastomosis, arm, and leg). HR, SBP, and DBP were measured with a sphygmomanometer (OMRON, USA) and oxygen saturation was measured with a pulse oximeter. Results: Increase in DBP was seen after abdominal drainage (p = 0.038); reduction in SBP (p = 0.002) and DBP (p = 0.004) after neck drainage; reduction in SBP (p < 0.001) and HR (p = 0.004) after arm drainage; and reduction in SBP and DBP after leg drainage. There was no change in the oxygen saturation levels of participants after MLD (p > 0.05). Conclusions: In healthy subjects, the effects of MLD were found to vary according to the region of application. This study signals that the cardiovascular effects of MLD treatment vary in different regions of the body.

Oscillometric central blood pressure and central systolic loading in stroke patients: Short-term reproducibility and effects of posture and fasting state

BACKGROUND

This study examined the short-term reproducibility of non-invasive estimates of central and peripheral blood pressure and markers of central systolic loading (augmentation index [AIx; a measure of central systolic loading] and AIx75 [AIx standardised to 75 b·min-1 heart rate]) and the effect of posture and fasting state on these variables in patients with acute stroke.

METHODS

Twenty-two acute stroke patients (72 ± 10y) had blood pressure measured using the SphygmoCor XCEL in supine and seated postures and whilst fasted and non-fasted.

RESULTS

Acceptable short-term reproducibility (ICC >0.75) was reported for all peripheral and central variables in all conditions (ICC = 0.77-0.90) and for AIx and AIx75 in both fasted postures (ICC = 0.78-0.81). Food consumption significantly lowered all blood pressures (p <0.05; η2p = 0.20-0.55). The seated posture resulted in a significantly greater AIx than supine (p <0.05; η2p = 0.22). Fasting state had significant main effects on AIx and AIx75 (p <0.05; η2p = 0.14-0.22).

CONSLUSIONS

Oscillometric estimates of central blood pressure have high short-term reproducibility in different postures and fasting states but markers of systolic load should be assessed whilst fasted. Fasting state has a large effect on central and peripheral blood pressures and on measures of systolic loading. It is important for clinicians to be aware of optimal assessment conditions without this impacting on patient wellbeing.

TRIAL REGISTRATION

Clinical trial registry name: NCT02537652.

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

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

Consensus statement on the definition of neurogenic supine hypertension in cardiovascular autonomic failure by the American Autonomic Society (AAS) and the European Federation of Autonomic Societies (EFAS) : Endorsed by the European Academy of Neurology (EAN) and the European Society of Hypertension (ESH)

PURPOSE

Patients suffering from cardiovascular autonomic failure often develop neurogenic supine hypertension (nSH), i.e., high blood pressure (BP) in the supine position, which falls in the upright position owing to impaired autonomic regulation. A committee was formed to reach consensus among experts on the definition and diagnosis of nSH in the context of cardiovascular autonomic failure.

METHODS

As a first and preparatory step, a systematic search of PubMed-indexed literature on nSH up to January 2017 was performed. Available evidence derived from this search was discussed in a consensus expert round table meeting in Innsbruck on February 16, 2017. Statements originating from this meeting were further discussed by representatives of the American Autonomic Society and the European Federation of Autonomic Societies and are summarized in the document presented here. The final version received the endorsement of the European Academy of Neurology and the European Society of Hypertension.

RESULTS

In patients with neurogenic orthostatic hypotension, nSH is defined as systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, measured after at least 5 min of rest in the supine position. Three severity degrees are recommended: mild, moderate and severe. nSH may also be present during nocturnal sleep, with reduced-dipping, non-dipping or rising nocturnal BP profiles with respect to mean daytime BP values. Home BP monitoring and 24-h-ambulatory BP monitoring provide relevant information for a customized clinical management.

CONCLUSIONS

The establishment of expert-based criteria to define nSH should standardize diagnosis and allow a better understanding of its epidemiology, prognosis and, ultimately, treatment.

Reliability of oscillometric central blood pressure and central systolic loading in individuals over 50 years: Effects of posture and fasting

BACKGROUND AND AIMS

The between-day reliability of oscillometric pulse wave analysis has been demonstrated in a young, healthy population but not in an older sample. This study examined the between-day reliability of the SphygmoCor XCEL in individuals over 50 years. As blood pressure is measured in a range of postures and fasting states (supine/seated, fasted/non-fasted), this study also investigated the effect of these variables on central blood pressure and central systolic loading.

METHODS

Fifty-one adults (m = 21; age 57 ± 6.4 y) were tested on three mornings in supine and seated conditions and in fasted and non-fasted states. Data was analysed as a whole and for normotensive (n = 25) and hypertensive participants (n = 26).

RESULTS

SphygmoCor XCEL demonstrated strong reliability in the whole sample for central systolic and diastolic blood pressures, augmentation index (AIx) and AIx75 (ICC = 0.77-0.95). Significant interaction effects were observed in central diastolic blood pressure, central pulse pressure, augmentation index (AIx) and AIx75 (p < 0.05; η_p² = 0.10-0.23). Fasting state had a greater influence on central pressures in a seated than supine posture, but a greater effect on central systolic loading measures in a supine posture.

CONCLUSIONS

The SphygmoCor XCEL is a reliable tool to assess central haemodynamic variables in an older population. It would be pertinent for clinicians and researchers to record central measures in a supine posture to minimise the effects of food consumption. Conversely, the assessment of central systolic loading should occur in a seated condition to minimise the influence of varying fasting states.

Hemodynamic Perturbations in Deep Brain Stimulation Surgery: First Detailed Description

Background: Hemodynamic perturbations can be anticipated in deep brain stimulation (DBS) surgery and may be attributed to multiple factors. Acute changes in hemodynamics may produce rare but severe complications such as intracranial bleeding, transient ischemic stroke and myocardium infarction. Therefore, this retrospective study attempts to determine the incidence of hemodynamic perturbances (rate) and related risk factors in patients undergoing DBS surgery.

Materials and Methods: After institutional approval, all patients undergoing DBS surgery for the past 10 years were recruited for this study. Demographic characteristics, procedural characteristics and intraoperative hemodynamic changes were noted. Event rate was calculated and the effect of all the variables on hemodynamic perturbations was analyzed by regression model.

Results: Total hemodynamic adverse events during DBS surgery was 10.8 (0–42) and treated in 57% of cases.

Conclusion: Among all the perioperative variables, the baseline blood pressure including systolic, diastolic, and mean arterial pressure was found to have highly significant effect on these intraoperative hemodynamic perturbations.

Assessment of effects of differences in trunk posture during Fowler's position on hemodynamics and cardiovascular regulation in older and younger subjects

Background

Downward shifts in blood volume with changing position generally cause tachycardic responses. Age-related decreases in vagal nerve activity could contribute to orthostatic hypotension in older individuals. Fowler’s position is a reclined position with the back between 30° and 60°, used to facilitate breathing, eating, and other routine daily activities in frail and elderly patients.

Objective

This study examined whether stroke volume (SV) was higher and heart rate (HR) lower in Fowler’s position with an upright upper trunk than in Fowler’s position with the whole trunk upright in both older and younger subjects, based on the assumption that lower HR would result from reduced sympathetic activation in older individuals.

Methods

We assessed hemodynamics and HR variability from electrocardiography, noninvasive arterial pressure and impedance cardiography in 11 younger male subjects (age range, 20–22 years) and 11 older male subjects (age range, 64–79 years), using three positions: supine, or Fowler’s positions with either 30° of lower trunk inclination and 60° of upper trunk inclination (UT60) or 60° of whole trunk inclination (WT60). Comparisons were then made between age groups and between positions.

Results

Reductions in SV and tachycardic response were smaller with UT60 than with WT60, in both younger and older subjects. In addition, reduced tachycardic response with upright upper trunk appeared attributable to decreased vagal withdrawal in younger subjects and to reduced sympathetic activation in older subjects.

Conclusion

Our findings indicate that an upright upper trunk during Fowler’s position allowed maintenance of SV and inhibited tachycardic response compared to an upright whole trunk regardless of age, although the autonomic mechanisms underlying tachycardic responses differed between younger and older adults. An upright upper trunk in Fowler’s position might help to reduce orthostatic stress and facilitate routine activities and conversation in frail patients.

Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review

BACKGROUND

To interpret blood pressure (BP) data appropriately, healthcare providers need to be knowledgeable of the factors that can potentially impact the accuracy of BP measurement and contribute to variability between measurements.

METHODS

A systematic review of studies quantifying BP measurement inaccuracy. Medline and CINAHL databases were searched for empirical articles and systematic reviews published up to June 2015. Empirical articles were included if they reported a study that was relevant to the measurement of adult patients' resting BP at the upper arm in a clinical setting (e.g. ward or office); identified a specific source of inaccuracy; and quantified its effect. Reference lists and reviews were searched for additional articles.

RESULTS

A total of 328 empirical studies were included. They investigated 29 potential sources of inaccuracy, categorized as relating to the patient, device, procedure or observer. Significant directional effects were found for 27; however, for some, the effects were inconsistent in direction. Compared with true resting BP, significant effects of individual sources ranged from -23.6 to +33 mmHg SBP and -14 to +23 mmHg DBP.

CONCLUSION

A single BP value outside the expected range should be interpreted with caution and not taken as a definitive indicator of clinical deterioration. Where a measurement is abnormally high or low, further measurements should be taken and averaged. Wherever possible, BP values should be recorded graphically within ranges. This may reduce the impact of sources of inaccuracy and reduce the scope for misinterpretations based on small, likely erroneous or misleading, changes.

Association of blood pressure in the supine position with target organ damage in subjects over 60 years old

Objective Toexplore the correlation between blood pressure in the supine position and target organ damage in subjects over 60 years of age. Methods In 2444 individuals, we investigated the association of systolic blood pressure (SBP) in the supine position with the target organ damage indices microalbuminuria (ALBU), brachial-ankle pulse wave velocity (baPWV), and carotid intima-media thickness (IMT). Supine hypertension (SH) is defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Subjects were assigned to either the SH group (1275 cases) or the non-SH group (1169 cases). Results The levels of ALBU, baPWV, and IMT, as well as the percentage of participants with ALBU > 30 mg/L, baPWV ≥ 1400 cm/s, and IMT ≥ 1 mm, were significantly higher in the SH group than in the non-SH group. Multivariate logistic regression analysis showed that SH was an independent risk factor for baPWV and IMT, but the relationship with ALBU was not statistically significant after correction for confounding factors. Conclusions SH is a risk factor for target organ damage, as expressed by the indices baPWV and IMT. The association of SH with kidney damage requires further study.

Uneven Accuracy of Home Blood Pressure Measurement: A Multicentric Survey

Home blood pressure monitoring (HBPM) is increasingly commonly performed, but the concordance between patient HBPM measurement technique and prevailing recommendations has not been well-assessed according to the literature. The authors performed a multicentric survey to evaluate the degree of patients' adherence to current recommendations on HBPM, and investigate potential predictors of a higher-quality self-measurement. A structured questionnaire was administered to 725 Italian outpatient hypertensive patients (mean age, 52.2±14.4 years). Overall, ≥10 recommended procedures were followed by 52.8% of the participants; only 1.0% followed all recommendations. A total of 49.7% of participants rested for ≥5 minutes before the measurement, 36.8% recorded BP more than once in each measurement session, and 34.3% used a chair or bed saddle to support their back. Less than 40% of the patients received some form of training by health professionals. After multivariate analysis, patients receiving/reading instructions showed higher-quality HBPM (P<.01). The accuracy of HBPM needs to be improved, and more efforts should be devoted to provide patient training on HBPM, especially on the less-frequently followed recommendations.

Effects of trunk posture in Fowler's position on hemodynamics

We speculated that stroke volume would be higher and heart rate would be lower when the head and upper trunk were mainly upright in the Fowler's position. We therefore analyzed the effects of three trunk postures in Fowler's position on heart rate, blood pressure and circulatory volume. Heart rate (HR), blood pressure (BP), stroke volume (SV), cardiac output (Q), systemic vascular resistance (SVR), ejection time (ET) and pre-ejection period (PEP) were measured in 10 healthy male volunteers (mean age ± SEM, 20.7 ± 0.5 y; range, 19-23 y) while in three trunk postures in Fowler's position. Stroke volume and Q were measured using impedance cardiography. The three trunk postures were 30° of lower and upper trunk inclination (WT30°), 30° and 60° of lower and upper trunk inclination (UT 60°), respectively and 60° of upper and lower trunk inclination (WT60°). Both SV and ET were significantly higher and HR and PEP were lower at UT60° than at WT60° (p < 0.01) whereas these values did not significantly differ between WT30° and UT60° (p > 0.05). None of Q, SVR and BP significantly differed among the three conditions (p > 0.05). These findings suggested that SV and preload are higher when the upper trunk is upright (UT60°) than when the entire trunk is upright (WT60°) while in Fowler's position. In addition, Q might be maintained without increasing HR through vagal withdrawal when only the upper trunk is upright in healthy young males in Fowler's position.

Care manager to control cardiovascular risk factors in primary care: the Raffaello cluster randomized trial

BACKGROUND AND AIM

This cluster randomized trial evaluated the efficacy of a disease and care management (D&CM) model in cardiovascular (CVD) prevention in primary care.

METHODS AND RESULTS

Eligible subjects had ≥ 1 among: blood pressure ≥ 140/90 mmHg; glycated hemoglobin ≥ 7%; LDL-cholesterol ≥ 160 or ≥ 100 mg/dL (primary or secondary prevention, respectively); BMI ≥ 30; current smoking. The D&CM intervention included a teamwork including nurses as care managers for the implementation of tailored care plans. Control group was allocated to usual-care. The main outcome was the proportion of subjects achieving recommended clinical targets for ≥ 1 of uncontrolled CVD risk factors at 12-month. During 2008-2009 we enrolled 920 subjects in the Abruzzo/Marche regions, Italy. Following the exclusion of L'Aquila due to 2009 earthquake, final analyses included 762 subjects. The primary outcome was achieved by 39.1% (95%CI: 34.2-44.2) and 25.2% (95%CI: 20.9-29.9) of subjects in the intervention and usual-care group, respectively (p < 0.001). The D&CM intervention significantly increased the proportion of subjects who achieved clinical targets for both diabetes and hypertension, with no differences in hypercholesterolemia, smoking status and obesity.

CONCLUSIONS

The D&CM intervention was effective in controlling cardiovascular risk factors, in particular hypertension and diabetes. Numbers needed to treat were small. Such intervention may deserve further consideration in clinical practice.

REGISTRATION NUMBER

ACTRN12611000813987.

Efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: a randomized controlled trial

BACKGROUND

Many strategies have been evaluated to improve the prevention and control of cardiovascular (CVD) risk factors. Nursing telephonic and tele-counseling individualized lifestyle educational programs have been found to improve blood pressure control and adherence to lifestyle recommendation. This study tested the efficacy of a nurse-led reminder program through email (NRP-e) to improve CVD risk factors among hypertensive adults.

METHODS

All participants received usual CVD prevention and a guideline-based educational program. Subjects in the NRP-e group also received weekly email alerts and phone calls from a nurse care manager for 6 months. Emails contained a reminder program on the need for adherence with a healthy lifestyle based upon current guidelines. Follow-up visits were scheduled at 1, 3 and 6 months after enrollment; randomization was made centrally and blood samples were evaluated into a single laboratory.

RESULTS

The final sample consisted of 98 (control) and 100 (NRP-e) subjects (mean age 59.0 ± 14.5 years; 51.0% males). After 6 months, the following CVD risk factors significantly improved in both groups: body mass index, alcohol and fruit consumption, cigarette smoking, adherence to therapy hours, systolic and diastolic blood pressure, fasting blood glucose, low-density lipoproteins (LDL) and total cholesterol, triglycerides, and physical activity. In the NRP-e group, however, the prevalence of several behaviors or conditions at risk decreased significantly more than in the control group: obesity (-16%), low fruit consumption (-24%), uncontrolled hypertension (-61%), LDL (-56%), and total cholesterol (-40%).

CONCLUSIONS

The NRP-e improved a range of CVD risk factors. The program had low costs, required only an average of <20 min per day in addition to normal practice, and may deserve further evaluation for the inclusion among existing care management approaches.

Effect of upper torso inclination in Fowler's position on autonomic cardiovascular regulation

The present study investigates autonomic cardiovascular regulation during postural changes while in Fowler's position. Respiratory sinus arrhythmia (RSA) and sequence baroreflex sensitivity (sBRS) were measured in 12 healthy individuals in three positions (Experiment 1). We also measured RSA, sBRS, tidal volume (TV), lung volume spectrum (LV spectrum), and transfer gain and phase between lung volume and RR interval (RSA-TF, RSATF-phase) in 11 healthy individuals in two positions (Experiment 2). All participants maintained respiratory frequency at 15 breaths/min. The three positions in Experiment 1 were 30°, 45°, and 60° of upper torso inclination with a lower torso inclination of 30° throughout all evaluations. The two positions in Experiment 2 were 30° and 60° of upper torso backrest inclination with a lower torso inclination of 30° throughout all evaluations. The results of Experiment 1 showed significantly higher RSA and sBRS at 60° and 45° than at 30°, whereas RR interval (RRI), systolic blood pressure (SBP), and diastolic blood pressure (DBP) did not differ significantly under any condition. The results of Experiment 2 showed that RSA, RSA-TF, sBRS, TV, and LV spectrum were significantly higher at 60° than at 30°, and that RRI, SBP, DBP, and the RSATF phase did not significantly differ under any condition. These findings suggested that slight flexion of the upper torso in Fowler's position activates respiratory function and increases the contribution of vagal nerve activity to the cardiovascular system in young participants under conditions of a fixed respiratory rate.

Association between sodium intake and change in uric acid, urine albumin excretion, and the risk of developing hypertension

BACKGROUND

A high-sodium diet has little short-term effect on blood pressure in nonhypertensive individuals but, for unclear reasons, is associated with hypertension if consumed long term. We hypothesized that a chronically high sodium intake would be associated with increases in biomarkers of endothelial dysfunction, specifically serum uric acid (SUA) and urine albumin excretion (UAE), and that high sodium intake would be associated with incident hypertension among those with higher SUA and UAE.

METHODS AND RESULTS

We prospectively analyzed the associations between sodium intake and the change in SUA (n=4062) and UAE (n=4146) among participants of the Prevention of Renal and Vascular End Stage Disease (PREVEND) study who were not taking antihypertensive medications. We also examined the association of sodium intake with the incidence of hypertension (n=5556) among nonhypertensive participants. After adjustment for confounders, each 1-g-higher sodium intake was associated with a 1.2-μmol/L increase in SUA (P=0.01) and a 4.6-mg/d increase in UAE (P<0.001). The relation between sodium intake and incident hypertension varied according to SUA and UAE. For each 1-g-higher sodium intake, the adjusted hazard ratio for developing hypertension was 0.98 (95% confidence interval, 0.89-1.08) among those in the lowest tertile of SUA and 1.09 (1.02-1.16) among those in the highest tertile. Corresponding hazard ratios were 0.99 (confidence interval, 0.93-1.06) among participants whose UAE was <10 mg/d and 1.18 (confidence interval, 1.07-1.29) among those whose UAE was >15 mg/d.

CONCLUSIONS

Over time, higher sodium intake is associated with increases in SUA and UAE. Among individuals with higher SUA and urine UAE, a higher sodium intake is an independent risk factor for developing hypertension.