Performance of a new blood pressure monitor in children and young adults: the difficulties in clinical validation

Ambulatory and home blood pressure monitoring in children and adolescents: diagnosis of hypertension and assessment of target-organ damage

The prevalence of elevated blood pressure in children and adolescents is more common than previously believed and often represents the early onset of essential hypertension, particularly in adolescents. The definition of hypertension in children is based on distribution criteria and normalcy tables that provide blood pressure percentiles for each measurement method (office, ambulatory and home) according to the individual's age, gender and body size. Owing to the white coat and masked hypertension phenomena, ambulatory blood pressure monitoring is indispensable for the diagnosis of hypertension in children. Home blood pressure monitoring in children has been less well studied, and at present, treatment decisions should not be based solely on such measurements. Hypertension-induced preclinical target-organ damage (mainly echocardiographic left ventricular hypertrophy) is not uncommon in children and should be evaluated in all hypertensive children. Other indices of target-organ damage, such as carotid intima-media thickness, pulse wave velocity and microalbuminuria, remain under investigation in pediatric hypertension.

Office, ambulatory and home blood pressure measurement in children and adolescents

There is an increasing interest in pediatric hypertension, the prevalence of which is rising in parallel with the obesity epidemic. Traditionally the assessment of hypertension in children has relied on office blood pressure (BP) measurements by the physician. However, as in adults, office BP might be misleading in children mainly due to the white coat and masked hypertension phenomena. Thus, out-of-office BP assessment, using ambulatory or home monitoring, has gained ground for the accurate diagnosis of hypertension and decision-making. Ambulatory monitoring is regarded as indispensable for the evaluation of pediatric hypertension. Preliminary data support the usefulness of home monitoring, yet more evidence is needed. Office, ambulatory and home BP normalcy tables providing thresholds for diagnosis have been published and should be used for the assessment of elevated BP in children.

Ambulatory blood pressure monitoring: a versatile tool for evaluating and managing hypertension in children

In recent years, pediatric practitioners have increasingly used ambulatory blood pressure (ABP) monitoring for evaluating blood pressure (BP) abnormalities in children. ABP monitoring in adults is superior to casual BP measurements for predicting cardiovascular morbidity and mortality, and whereas the association with target-organ damage in children is not as definitive, early evidence does seem to parallel the adult data. In addition to confirming hypertension at diagnosis, ABP monitoring may be useful for identifying isolated nocturnal hypertension, characterizing BP patterns, and assessing response to therapeutic interventions. This article reviews current evidence supporting the use of ABP monitoring in children and discusses limitations in our understanding of this technology, specifically focusing on indications for its use and interpretation of the large quantity of data obtained by ABP monitoring.

Dynamic blood pressure changes and recovery under different work shifts in young women

BACKGROUND

Some studies have reported that shift work can affect blood pressure (BP), but few have studied recovery from BP changes occurring during different shifts.

METHODS

We recruited 16 young female nurses working rotating shifts and six working the regular day shift. All received repeated ambulatory BP monitoring (ABPM) during their workdays and following day off.

RESULTS

Our linear mixed-effect model showed that both systolic and diastolic BPs were significantly decreased during sleeping period and significantly increased while on working period, on a work day, but increased during sleeping period after a night shift or evening shift. BP measurements that changed after evening shift usually returned to baseline on consecutive off-duty day after day shift, but they did not completely return to baseline after a night shift (P < 0.05). We also found 69% of those working rotating shifts had at least changed once in dipper/nondipper status. The rates of change in dipper/nondipper status between work day and off-duty day were 33, 44, 50, and 38% for nurses worked in outpatient clinic, night shift, evening shift, and day shift, respectively.

CONCLUSION

Shift work is significantly associated with BP and possibly dipper/nondipper status in young female nurses. Except for those working night shifts, BP levels returned to baseline the off-duty day after day shift. We recommend that potential influence of shift work be considered when evaluating a person's BP.

Ambulatory blood pressure monitoring and target organ damage in pediatrics

The prevalence of hypertension in children and adolescents is rising in association with the increasing rate of childhood obesity, and it is associated with early target organ damage. Published guidelines on high blood pressure in children and adolescents, focused on the early and accurate diagnosis of hypertension, resulted in improved ability to identify children with hypertension. Although auscultation using a mercury sphygmomanometer remains the method of choice for evaluation of hypertension in children, accumulating evidence suggests that ambulatory blood pressure monitoring is a more accurate method for diagnosis, and it is more closely associated with target organ damage. In addition, ambulatory blood pressure monitoring is a valuable tool in the assessment of white-coat hypertension, and masked hypertension in children and adolescents. Masked hypertension in children and adolescents is associated with a similar risk of target organ damage as in established hypertension.

Ambulatory blood pressure monitoring: what a pediatrician should know

PURPOSE OF REVIEW

Ambulatory blood pressure monitoring is a useful tool for the evaluation and management of hypertension in children and adolescents. This review provides a basic overview of ambulatory blood pressure monitoring and summarizes the most recent available knowledge regarding its use in the pediatric population.

RECENT FINDINGS

Evaluation and validation of ambulatory blood pressure monitoring equipment in children remains limited, although advances in the interpretation of results for this age group have been reported specifically in the area of circadian (24 h) and ultradian (<24 h) variability. Blood pressure is a dynamic phenomenon that varies not only with time but also with changing patient and environmental circumstances. Growing evidence regarding conditions identified when this variability is considered, specifically white coat and masked hypertension, suggests that office blood pressure measurement may not be a sufficient screening test for hypertension-related target-organ damage.

SUMMARY

Information regarding ambulatory blood pressure monitoring use in children is increasing, although due to its limitations and expense, it remains a tool primarily utilized by the pediatric sub-specialist.

Ambulatory blood pressure monitoring in children and adolescents

With recent technological advances, 24-hour ambulatory blood pressure (BP) monitoring (ABPM) has become a useful tool for the evaluation, diagnosis, and management of hypertensive children. It provides a more accurate representation of an individual's BP rather than intermittent casual or office BP measurements. Hence, ABPM is being used more often to assess the BP of children. In this comprehensive review, we provide the reader with the available literature on ABPM, discuss the advantages and limitations of ABPM, and the interpretation of ABPM data. The role of ABPM in various clinical conditions and hypertension research in children is presented.

Impact of ambulatory blood pressure monitoring on daily activity

We evaluated the impact of wearing an ambulatory blood pressure (ABP) monitor on the usual daily activity of 16 healthy men and women. Daily ABP and heart rate (HR) were recorded on 2 days using the DynaPulse 5000 A system. Daily HR and activity were recorded on two further days using a dedicated HR monitoring system. All four sets of measurements were made for 8 h during which time the volunteers kept a simultaneous diary record of their physical activity. There was no detectable difference in physical activity records on any day. Mean daily HR was lower during ABP monitoring than during the dedicated HR monitoring carried out on different occasions (73+/-7 versus 81+/-7 beats min(-1), P<0.001). The lower mean HR observed during ABP monitoring compared with dedicated HR monitoring may reflect subtle differences in the physical behaviour of subjects being monitored, which could not be detected from the diary records.

Oscillometric blood pressure measurement: progress and problems

Oscillometric blood pressure measurement has become very popular, but although a number of devices have now passed both the Association for the Advancement of Medical Instrumentation and British Hypertension Society criteria, complacency with the state of the technique is as yet premature. In individual subjects, a substantial number of readings may deviate more than a clinically relevant 5 mmHg in devices that have earned a British Hypertension Society grade A rating. The marketing of pressure-wave-simulating devices is a welcome development as monitors can now be tested for reproducibility; an intra-device standard deviation of less than 2 mmHg has been proposed as the limit. Authors suggest that these simulators are currently better suited to intra- than between-device testing since they are not yet fully confident that the simulated waveforms are indistinguishable from the man-made pressure waves. Simulators should, however, be incorporated into our standard validation protocols in order eventually to obviate the human, fallible, factor in the validation protocols. The currently employed maximal amplitude algorithm has many drawbacks as the parameter identification points for systolic and diastolic pressure depend on many factors, for example pulse pressure, heart rate and arterial stiffness. These errors have now been demonstrated in clinical studies. Modern pattern recognition algorithms are being constructed but have not yet produced convincing results. As repeatedly stated, the development of a more robust and more widely applicable algorithm than the maximal amplitude approach should be allocated a high priority.

Blood pressure responses to high-calcium skim milk and potassium-enriched high-calcium skim milk

OBJECTIVE

This study was designed to evaluate the effect of high-calcium skim milk or potassium-enriched high-calcium skim milk on blood pressure compared with nonenriched skim milk.

DESIGN

This was a randomized double-blind controlled trial. Each milk intervention lasted for 4 weeks, with a minimum of 4 weeks of wash-out between interventions.

METHODS

We recruited 38 healthy people, aged over 40 years, to take part in a double-blind, randomized, controlled cross-over study. We asked them to replace their usual liquid milk with two servings per day of skim milk (control), high-calcium skim milk or potassium-enriched high-calcium skim milk. We measured office blood pressures (seated and standing) at the start and after 2 and 4 weeks of milk intervention and we measured daytime ambulatory blood pressures at the start and after 4 weeks of milk intervention. Each milk intervention was interspaced by a 4-week interval.

RESULTS

Office systolic blood pressure (standing) decreased from 127 +/- 16 to 124 +/- 16 mmHg (P<0.05) after 4 weeks of skim milk and from 130 +/- 18 to 126 +/- 17 mmHg (P<0.05) after 4 weeks of high calcium skim milk. After 4 weeks of consuming the potassium-enriched high-calcium milk, systolic blood pressure decreased from 125 +/- 18 to 117 +/- 16 mmHg (P<0.001) seated, and from 130 +/- 16 to 122 +/- 15 mmHg (P<0.001) standing. There were no significant changes in office diastolic blood pressure after any milk. There was no change in ambulatory blood pressure after either skim milk or high-calcium skim milk. After 4 weeks of potassium-enriched high-calcium milk, ambulatory daytime systolic blood pressure decreased from 138 +/- 13 to 135 +/- 11 mm Hg (P<0.05) and daytime diastolic blood pressure decreased from 80 +/- 8 to 78 +/- 9 mmHg (P<0.05).

CONCLUSIONS

High-calcium milk enriched with potassium has a small hypotensive effect in healthy people aged over 40 years.