Blood pressure measurement in research and in clinical practice: recent evidence

Strong and Bitter Vegetables from Traditional Cultivars and Cropping Methods Improve the Health Status of Type 2 Diabetics: A Randomized Control Trial

Vegetables rich in bitter-tasting phytochemicals may exert enhanced beneficial effects against key factors associated with type two diabetes (T2D). This study investigates whether selected cultivars of bitter and strong-tasting (BST) Brassica and root vegetables exert greater health benefits on T2D patients compared to equivalent modern mild and sweet tasting (MST) vegetables. A 12-week randomized, controlled, parallel intervention study involved 92 T2D patients, who were allocated three different diets: (1) 500 g daily of bitter and strong-tasting (BST) vegetables; (2) 500 g daily of mild and sweet-tasting (MST) vegetables; (3) 120 g daily MST normal diet (control). Both vegetable diets contained root vegetables and cabbages selected based on sensory differences and content of phytochemicals. Prior to and after the study, all participants underwent an oral glucose tolerance test (OGTT), 24 h blood pressure measurements, DEXA scans, and fasted blood samples. Both diets high in vegetables significantly reduced the participants' BMI, total body fat mass, and HbA1c levels compared to control, but in the BST group, significant differences were also found regarding incremental area under the curve glucose 240 min (OGTT) and fasting glucose levels. A high daily intake of root vegetables and cabbages showed significant health improvements in both vegetable groups. BST vegetables had the greatest impact on insulin sensitivity, body fat mass, and blood pressure compared to control; moreover, they further improved glycemic control compared to MST vegetables.

Right ventricular remodelling in mild hypertensive patients: role of left ventricular morpho-functional parameters

Previous studies suggested that hypertensive patients with left ventricular (LV) hypertrophy display right ventricular (RV) remodelling. Few data are available about RV remodelling in naive hypertensives without severe cardiac organ damage. Our aim was to evaluate the relationship between RV and LV morpho-functional parameters in never-treated patients with grade 1 hypertension and whether central blood pressure (CBP), inflammatory and metabolic parameters are potentially associated with RV remodelling. 150 never-treated subjects without evidence of diabetes or other cardiovascular diseases were enrolled in our study. We recruited 100 patients with mild hypertension (twenty-four hours blood pressure (24 h BP) ≥ 130/80 mmHg) and 50 normotensive subjects matched for gender, age and body mass index. To estimate the LV/RV parameters, we performed echography as well as arterial tonometry to assess pulse wave analysis/velocity (PWA/PWV). We found 24 h BP, CBP and PWV were higher in hypertensive patients than in normotensives. In addition, LV mass index was higher in hypertensives, and greater RV free wall thickness was observed (5.3 ± 1.4 vs 4.6 ± 1.2 mm, P = 0.02). RV thickness correlated with interventricular septum (IVS), systolic CBP and RV E' (r = 0.50, P = 0.0001, r = 0.30, P = 0.003, r = -0.24, P = 0.015); linear regression analysis showed a correlation with only IVS (β = 0.39, P = 0.001). RV E' was correlated with IVS, LV E' and systolic CBP (r = -0.35, P = 0.0001, r = 0.25, P = 0.012, r = -0.24, P = 0.019); the correlation with IVS and LV E' (β = -0.310, P = 0.001; β = 0.27, P = 0.004) was confirmed by linear regression analysis. Our study shows RV remodelling is mostly correlated with IVS thickness, supporting the ventricular interdependence hypothesis.

Accuracy of non-invasive blood pressure measurements in obese patients

This article describes an evidence-based literature review, comparing upper arm and forearm blood pressure measurements using non-invasive devices on obese patients. The focus on blood pressure monitoring was in response to regularly witnessing inappropriately applied blood pressure cuffs on obese patient's upper arms in practice. An inaccurately obtained blood pressure measurement can result in the misdiagnosis and treatment of hypertension. As the prevalence of obesity grows worldwide, healthcare settings need to ensure they have the necessary equipment and trained staff to accurately measure obese patients' blood pressure. The aim of this review was to identify whether a forearm measurement provided a suitable alternative to upper arm measurements. The article discusses the development and execution of a search strategy, as well as the critical appraisal of a selected article. The results of the review demonstrated that forearm blood pressure measurements in obese patients do not replace upper arm blood pressure measurements taken with an appropriate cuff. It is recommended that further research is undertaken in order to identify suitable alternatives for obtaining an accurate non-invasive blood pressure measurement in obese patients.

Blood Pressure Measurement Training Program and Adherence of Public Health Nurses to BP Measurement Guidelines

Objective

To compare the level of adherence of public health nurses to BP measurement guidelines based on their knowledge if the guidelines and skills in BP measurement before and after Blood Pressure Measurement Training Program (BPMTP).

Methods

An experimental pre- and post-test design using two-staged cluster randomization was conducted. 118 PHNs (mean age ± 38.45 years, mean years of experience ± 13.45 years; 84.1% women) from six districts in Manila were equally assigned to either the BPMTP group or control group. Structured instruments were used.

Results

Demographic characteristics, current BP measurement practices, and level of adherence to BP measurement guidelines based on knowledge of the guidelines and skills in BP measurement were equivalent in both groups at baseline. Nurses in the BPMTP group showed improved adherence (p=<0.05) compared to nurses in the control group. Both groups did not show significant change in their skill on recording, interpretation, and referral (p=1.000).

Conclusion

This study showed that Blood Pressure Measurement Training Package is feasible in improving adherence of nurses based on their increased knowledge of the BP measurement guidelines and skills in BP measurement. A larger-scale study is warranted to show that BPMTP can potentially improve clinical management of hypertension in public health clinics globally.

Principles of Blood Pressure Measurement - Current Techniques, Office vs Ambulatory Blood Pressure Measurement

Blood pressure measurement has a long history and a crucial role in clinical medicine. Manual measurement using a mercury sphygmomanometer and a stethoscope remains the Gold Standard. However, this technique is technically demanding and commonly leads to faulty values. Automatic devices have helped to improve and simplify the technical aspects, but a standardised procedure of obtaining comparable measurements remains problematic and may therefore limit their validity in clinical practice. This underlines the importance of less error-prone measurement methods such as ambulatory or home blood pressure measurements and automated office blood pressure measurements. These techniques may help to uncover patients with otherwise unrecognised or overestimated arterial hypertension. Additionally these techniques may yield a better prognostic value.

Clinical characteristics and prevalence of complications of chronic kidney disease in children: the Taiwan Pediatric Renal Collaborative study

BACKGROUND

Little information is available regarding the clinical characteristics and prevalence of complications in children with chronic kidney disease (CKD), especially in early disease stages. The objective of this study was to determine the clinical characteristics and prevalence of complications in children with predialytic CKD.

METHODS

This multicenter, cross-sectional study enrolled children at all stages of predialytic CKD. Children who were between the ages of 1 year and 18 years and who fulfilled the clinical criteria of CKD were included in the study. Baseline demographic data, previous history, clinical characteristics, and laboratory data were collected.

RESULTS

A total of 757 children were included in the study. The median age at the time of enrollment was 10.6 years; 397 patients (52.4 %) were males. A total of 39.0 % of the patients were in CKD stage 1, 37.6 % were in stage 2, 14.8 % were in stage 3, 3.0 % were in stage 4, and 5.5 % were in stage 5. Nonglomerular renal diseases were the primary cause of CKD, comprising 51.9 % of the patients with CKD. The age at disease onset, gender, CKD stage distribution, and proportion of co-morbidities varied between the glomerular and nonglomerular CKD cases. Anemia, hyperlipidemia, hypocalcemia, and hyperphosphatemia were more prevalent in patients with glomerular CKD. The overall prevalence of complications was as follows: uncontrolled blood pressure, 44.1 %; anemia, 34.2 %; hyperlipidemia, 44.9 %; short stature, 10.3 %; and failure to thrive, 8.2 %. Uncontrolled blood pressure (BP), anemia, and hyperlipidemia were common, even in the early CKD stages. The prevalence of CKD complications generally increased with the worsening stage of CKD.

CONCLUSIONS

This study reveals differences in CKD etiology and prevalence of specific complications according to the stage of CKD. Early recognition and awareness of complications are mandatory for clinicians during the follow-up visits of children with CKD.

European Society of Hypertension position paper on ambulatory blood pressure monitoring

Ambulatory blood pressure monitoring (ABPM) is being used increasingly in both clinical practice and hypertension research. Although there are many guidelines that emphasize the indications for ABPM, there is no comprehensive guideline dealing with all aspects of the technique. It was agreed at a consensus meeting on ABPM in Milan in 2011 that the 34 attendees should prepare a comprehensive position paper on the scientific evidence for ABPM.This position paper considers the historical background, the advantages and limitations of ABPM, the threshold levels for practice, and the cost-effectiveness of the technique. It examines the need for selecting an appropriate device, the accuracy of devices, the additional information and indices that ABPM devices may provide, and the software requirements.At a practical level, the paper details the requirements for using ABPM in clinical practice, editing considerations, the number of measurements required, and the circumstances, such as obesity and arrhythmias, when particular care needs to be taken when using ABPM.The clinical indications for ABPM, among which white-coat phenomena, masked hypertension, and nocturnal hypertension appear to be prominent, are outlined in detail along with special considerations that apply in certain clinical circumstances, such as childhood, the elderly and pregnancy, and in cardiovascular illness, examples being stroke and chronic renal disease, and the place of home measurement of blood pressure in relation to ABPM is appraised.The role of ABPM in research circumstances, such as pharmacological trials and in the prediction of outcome in epidemiological studies is examined and finally the implementation of ABPM in practice is considered in relation to the issue of reimbursement in different countries, the provision of the technique by primary care practices, hospital clinics and pharmacies, and the growing role of registries of ABPM in many countries.

Comparison between an automated device and a manual mercury sphygmomanometer in an epidemiological survey of hypertension prevalence

BACKGROUND

Automated devices (AD) for measuring blood pressure (BP) are gradually replacing mercury sphygmomanometers (MM) in clinical settings. However, the use of ADs in epidemiological surveys has not been established. We investigated the factors associated with measurement differences when using an MM and an AD.

METHODS

Two trained observers took three BP measurements in 454 subjects as part of an epidemiological survey, alternately using an MM and an AD. BP measurement difference was defined as BPMM - BPAD. Alarm reactions (ARs) were calculated by subtracting the third systolic BP (SBP) measurement from the first SBP.

RESULTS

The mean age of subjects was 50.7±15.4 years (n = 454). The mean BPs using the MM and the AD were 119.8±13.9 vs. 119.5±13.6mm Hg in males and 115.0±16.8 vs. 111.6±15.7mm Hg in females for SBP and 77.7±10.4 vs. 74.7±10.4mm Hg in males and 73.2±9.3 vs. 69.9±10.3mm Hg in females for diastolic BP (DBP). Age, gender, arm circumference, and AR were the factors related to the difference. The concordance correlation coefficients for SBP and DBP were 0.8914 (95% confidence interval [CI], 0.8727-0.9102) and 0.8207 (95% CI, 0.7920-0.8494). The kappa values for the diagnosis of hypertension and Joint National Committee 7 BP classification were 0.6538 (0.5436-0.7641) and 0.5703 (0.5055-0.6351), respectively. The diagnostic sensitivity for hypertension was 59.0%.

CONCLUSIONS

Age, gender, arm circumference, and AR were the factors related to the differences. Despite small differences in the mean values, the agreement and reliability were not good enough to recommend the A&D UA-767PC for adoption in epidemiological surveys of hypertension prevalence.

Blood pressure assessment in severe obesity: validation of a forearm approach

OBJECTIVE

Obesity is frequently associated with systemic hypertension. Blood pressure measure is inaccurate in severely obese patients because of poor cuff size fitting. The aim of the study is to assess the degree of agreement between the intra-arterial method as the gold standard vs. noninvasive methods, i.e., forearm blood pressure and upper-arm blood pressure measures.

DESIGN AND METHODS

A total of 1285 measures of intra-arterial and forearm blood pressure were taken in 51 severely obese patients in a supine position in the operating and the recovery room. A subset of 352 upper-arm measures were taken in the recovery room and compared to the intra-arterial and the forearm methods.

RESULTS

Correlation between the intra-arterial and the forearm measures was 0.90 (P < 0.001) for the 2570 data (systolic and diastolic). Compared to intra-arterial, the forearm method overestimated systolic (6 ± 16 mm Hg, P < 0.001) and underestimated diastolic blood pressure (2 ± 11 mm Hg, P = 0.03). Compared to intra-arterial, upper-arm underestimated systolic (8 ± 16 mm Hg, P < 0.01) and overestimated diastolic blood pressure (9 ± 7 mm Hg, P < 0.001).

CONCLUSION

The magnitude of differences between the intra-arterial and forearm method was less than differences between the intra-arterial and upper-arm method. Our results suggest that forearm method may be a more accurate alternative to upper-arm measurement to assess blood pressure in severely obese patients.

Influence of age and sex on the pressor response following a spontaneous burst of muscle sympathetic nerve activity

The sympathetic nervous system is critical for the beat-to-beat regulation of arterial blood pressure (BP). Although studies have examined age- and sex-related effects on BP control, findings are inconsistent and limited data are available in postmenopausal women. In addition, the majority of studies have focused on time-averaged responses without consideration for potential beat-to-beat alterations. Thus we examined whether the ability of muscle sympathetic nerve activity (MSNA) to modulate BP on a beat-to-beat basis is affected by age or sex. BP and MSNA were measured during supine rest in 40 young (20 men) and 40 older (20 men) healthy subjects. Beat-to-beat fluctuations in mean arterial pressure (MAP) were characterized for 15 cardiac cycles after each MSNA burst using signal averaging. The rise in MAP following an MSNA burst was similar between young men and women (+2.64 ± 0.3 vs. +2.57 ± 0.3 mmHg, respectively). However, the magnitude of the increase in MAP after an MSNA burst was reduced in older compared with young subjects (P < 0.05). Moreover, the attenuation of the pressor response was greater in older women (+1.20 ± 0.1 mmHg) compared with older men (+1.72 ± 0.2 mmHg; P < 0.05). Interestingly, in all groups, MAP consistently decreased after cardiac cycles without MSNA bursts (nonbursts) with the magnitude of fall greatest in older men. In summary, healthy aging is associated with an attenuated beat-to-beat increase in BP after a spontaneous MSNA burst, and this attenuation is more pronounced in postmenopausal women. Furthermore, our nonburst findings highlight the importance of sympathetic vasoconstrictor activity to maintain beat-to-beat BP, particularly in older men.

Home blood pressure monitoring: how good a predictor of long-term risk?

Most management decisions for the diagnosis and treatment of hypertension are made using blood pressure (BP) measurements made in the clinic. However, home BP recordings may be of superior prognostic value. In this review, we show that home BP recordings are generally superior to clinic BP measurements in predicting long-term prognosis. Home BP has been shown to significantly predict important end points including all-cause mortality, progression of chronic kidney disease, and functional decline in the elderly. In addition, home BP recordings significantly and strongly predict cardiovascular events. These findings are robust, as they concur despite having been studied in disparate populations, using heterogeneous methods of clinic and home BP measurement, and with varied methods of statistical analysis. The advantages of home BP recordings are not due solely to a larger number of measurements, and they extend to the elderly, patients with chronic kidney disease, and those on hemodialysis. Because home BP recordings combine improved accuracy with the advantages of low cost and easy implementation, most patients with known or suspected hypertension should have their BP assessed and managed by means of home BP recordings.

Magnitude of the white-coat effect in the community pharmacy setting: the MEPAFAR study

BACKGROUND

There is little information regarding the community pharmacy blood pressure (CPBP) measurement method and their differences with home (HBP) or ambulatory BP (ABP). The aim of this study was to measure such differences and their variation over successive visits.

METHOD

Cross-sectional study carried out in eight pharmacies in Gran Canaria (Spain). The study included 169 treated hypertensive patients. BP was measured at the pharmacy (four visits), at HBP (4 days) and 24-h ABP monitoring. We defined pharmacy white-coat effect (PWCE) as differences between CPBP and HBP (home PWCE) or daytime ABP (ambulatory PWCE).

RESULTS

The overall (pooled values for all visits) ambulatory PWCE was not significantly different from zero for systolic BP (SBP) (-0.4 mm Hg (95% confidence interval (CI): -1.8 to 1.1)), but greater than zero for diastolic BP (DBP) (3.4 mm Hg (95% CI: 2.3 to 4.6)). The overall home PWCE was not significantly different from zero, both for SBP (1.2 mm Hg (95% CI: -0.1 to 2.6)) and DBP (0.1 mm Hg (95% CI: -0.7 to 1.0)). The ambulatory and home PWCE on the first visit were greater than zero (P < 0.001) (SBP/DBP): 3.5/4.8 and 1.9/1.5 mm Hg, respectively; but showed important reductions at the second visit and became not significantly different from zero, except the ambulatory PWCE in DBP, which persisted until the last visit.

CONCLUSION

The trend in the PWCE decreased over the successive visits to the pharmacy. Only the ambulatory PWCE in DBP proved to be statistically greater than zero after the second visit. Repeated CPBP measurements could be a useful alternative to assess the response to antihypertensive treatment.

[Ambulatory blood pressure monitoring]

During the last decades non-invasive 24-hour ambulatory blood pressure monitoring has evolved from a research tool of limited clinical use into an important method for stratifying cardiovascular risk and guiding therapeutic decisions. Until recently, clinical use of ambulatory blood pressure monitoring focused on identifying patients with white-coat hypertension, but accumulated evidence now points to its greater prognostic significance in determining risk for target-organ damage compared with that of office blood pressure measurements. Ambulatory measurement of blood pressure using automated devices has also demonstrated benefit in other indications, such as treatment resistance and borderline hypertension, or in hypertension during pregnancy. Future directions for hypertension research and treatment will need to consider the circadian cycle of blood pressure, the effect of treatment on blood pressure variability, and the magnitude of blood pressure changes in daily life.

Right ventricular dysfunction in early systemic hypertension: a tissue Doppler imaging study in patients with high-normal and mildly increased arterial blood pressure

PURPOSE

To analyze the relationship between increasing systemic blood pressure (BP) and right ventricular (RV) function.

SUBJECTS AND METHODS

Ninety-eight never-treated, nonobese patients with BP values varying from the optimal to the mild hypertensive range. Peak early diastolic (Em) and systolic (Sm) velocities were recorded at the tricuspid and mitral annuli by tissue Doppler imaging (TDI); global RV and left ventricular (LV) structure and function by conventional echo-Doppler sonography; insulin sensitivity by homeostasis model assessment (HOMA) index. Data were analyzed by 24-h systolic BP (cut-offs 117 and 130 mmHg), thus partitioning an optimal BP from an intermediate high-normal and an upper mildly increased BP stratum.

RESULTS

Em decreased in the mid-third and decelerated further in association with reduced Sm in the upper BP tertile; both correlated negatively to septal thickness and positively to homologous TDI-derived LV indices. RV and LV indices of global ventricular function, estimated pulmonary pressure, HOMA did not differ by systemic BP.

CONCLUSION

RV diastolic and systolic function deteriorates in response to slightly increased systemic BP. The process paralleled homologous changes at the LV side and was driven by interventricular septum remodeling, perhaps as a reflection of its role in RV function and biventricular interdependence. Insulin sensitivity seemed to play no relevant role.

Determining the accuracy of blood pressure measurement by the Omron HEM-907 before and after hemodialysis

BACKGROUND

The accuracy of oscillometric blood pressure (BP) measuring devices determined in resting conditions may be distorted in those under hemodialysis (HD).

METHODS

The evaluation of accuracy of the Omron HEM-907 was performed in accordance with the International Protocol for validation of BP measuring devices (IP). Out of a group of 49 patients with end-stage renal disease (ESRD) (56.7 +/- 15.6 years), four groups of 33 patients each were selected to ascertain their BP before and after HD.

RESULTS

The Omron HEM-907 fulfilled the IP accuracy requirements for systolic BP measurements before and after HD. In the case of diastolic BP before HD, the Omron HEM-907 did not fulfill both requirements for phase 2.2 IP. In only 21 out of 33 patients, the difference between the mean of two observers and the Omron HEM-907 device (Diff) was not more than 5 mmHg, while the requirement was 22 patients. In seven patients, all three Diff were over 5 mmHg, while the accepted limit is three. After HD, the Omron HEM-907 did not fulfill one out of two criteria of phase 2.2 IP - in five people, all three Diff were over 5 mmHg.

CONCLUSION

The Omron HEM-907 oscillometric method of BP measurement should not be used to measure BP before and after HD in ESRD patients. In ESRD patients, an alternative method of BP measurement, in the event of a lack of a mercury sphygmomanometer, could be a classical auscultatory method together with the Omron HEM-907, which allows for this type of BP measurement.

Clinical applications of pulse transit time in paediatric critical care

A simple and non-invasive technique, termed pulse transit time (PTT), has shown its potential in long-term investigations such as respiratory sleep studies and cardiovascular studies. Based on these findings, the PTT technique shows relevance for continuous haemodynamic monitoring in critical care. The objective of this review is to understand the potential, applications and limitations of PTT in this clinical setting. Present non-invasive haemodynamic monitoring methods such as automated oscillometric blood pressure (BP) and auscultatory techniques have their known limitations. They tend to underestimate systolic BP while overestimating diastolic BP. Due to the periodic increase in cuff pressure cycles during data acquisition, these techniques may cause much discomfort in elderly geriatric patients, or lessen the cooperation of younger paediatric patients. Thus, there can be adverse effects on therapeutic decisions and possibly clinical outcomes. Documented evidences have indicated that changes observed in PTT are inversely correlated to the corresponding BP changes. In critical care, a simple and accommodating technique like PTT may be useful in providing better comfort for patients during extended monitoring. Being a semi-quantitative measure, blanket recommendations for its utility can then become possible. The basic instrumentations needed are often part of standard critical care monitoring system. Furthermore, PTT also has the potential to monitor the often tachypnoeic respiratory dependent BP changes seen in small infants during critical care.

Blood pressure in children with chronic kidney disease: a report from the Chronic Kidney Disease in Children study

To characterize the distribution of blood pressure (BP), prevalence, and risk factors for hypertension in pediatric chronic kidney disease, we conducted a cross-sectional analysis of baseline BPs in 432 children (mean age 11 years; 60% male; mean glomerular filtration rate 44 mL/min per 1.73 m(2)) enrolled in the Chronic Kidney Disease in Children cohort study. BPs were obtained using an aneroid sphygmomanometer. Glomerular filtration rate was measured by iohexol disappearance. Elevated BP was defined as BP >or=90th percentile for age, gender, and height. Hypertension was defined as BP >or=95th percentile or as self-reported hypertension plus current treatment with antihypertensive medications. For systolic BP, 14% were hypertensive and 11% were prehypertensive (BP 90th to 95th percentile); 68% of subjects with elevated systolic BP were taking antihypertensive medications. For diastolic BP, 14% were hypertensive and 9% were prehypertensive; 53% of subjects with elevated diastolic BP were taking antihypertensive medications. Fifty-four percent of subjects had either systolic or diastolic BP >or=95th percentile or a history of hypertension plus current antihypertensive use. Characteristics associated with elevated BP included black race, shorter duration of chronic kidney disease, absence of antihypertensive medication use, and elevated serum potassium. Among subjects receiving antihypertensive treatment, uncontrolled BP was associated with male sex, shorter chronic kidney disease duration, and absence of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use. Thirty-seven percent of children with chronic kidney disease had either elevated systolic or diastolic BP, and 39% of these were not receiving antihypertensives, indicating that hypertension in pediatric chronic kidney disease may be frequently under- or even untreated. Treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may improve BP control in these patients.

The role of functional foods in the psychobiology of health and disease

The effect of psychological stress on health is becoming a serious concern, with figures from the World Health Organization showing that stress-related disorders affect nearly 450 million individuals worldwide. Heightened physiological stress responses and psychosocial factors have been linked to disease pathways such as hypertension and CVD. This has prompted significant interest within the scientific community, public health bodies and industry to employ interventions to control and reduce the impact of stress on health. There is now strong potential for functional foods to offer stress management benefits. Various physiological pathways have been targeted by specific dietary supplements for stress reduction, including the hypothalamic–pituitary–adrenal axis and sympathetic nervous system. Presently there are a number of ingredients, which include vitamin C, milk proteins, a number of herbal extracts (ginkgo biloba, ginseng, kava, valerian and lemon balm), andn-3 fatty acids, that have demonstrated potential stress reactivity-lowering and mood-enhancing effects, although further work is required to substantiate the efficacy in human subjects. Dietary supplements that can alleviate excessive stress responses may play an increasingly important role for the maintenance of health in a stressful environment. However, future research should employ a greater range of measures that will provide stronger evidence to substantiate functional food claims for stress relief.

Validation of the Omron M6 (HEM-7001-E) upper-arm blood pressure measuring device according to the International Protocol in adults and obese adults

BACKGROUND

Electronic blood pressure (BP) measurement devices are the preferred choice of patients owing to their user-friendly nature; however, there is a requirement to investigate the accuracy and reliability of these devices. The objective of this study is to evaluate the accuracy of the Omron M6 upper-arm BP device against the mercury sphygmomanometer in adults and obese adults according to the International Protocol criteria.

METHODS

One hundred and twenty-one patients, older than 30 years of age, were studied and classified on the basis of the range of the International Protocol. BP measurements at the upper arm with the Omron M6 were compared with the results obtained by two trained observers using a mercury sphygmomanometer. Nine sequential BP measurements were taken. A total of 33 participants were selected for each validation study. During the validation study, 99 measurements were performed on 33 participants for comparison. The first phase was performed on 15 participants, and if the device passed this phase, 18 more participants were selected. Having a two-fold purpose, this study was conducted on both adult and obese adult patients.

RESULTS

Mean discrepancies and standard deviations of the monitor-mercury sphygmomanometer were 1.1+/-4.0 mmHg for systolic BP (SBP) and -0.5+/-3.5 mmHg for diastolic BP (DBP) in the adult group. The device passed phase 1 in 15 participants. In phase 2.1, out of a total of 99 comparisons, 88, 96, and 97 for SBP, and 88, 98, and 99 for DBP were <5, <10, and <15 mmHg, respectively. Mean discrepancies and standard deviations of the monitor-mercury sphygmomanometer were 1.7+/-4.8 mmHg for SBP and -0.8+/-4.3 mmHg for DBP in the obese adult group. The device passed phase 1 in 15 participants. In phase 2.1, out of a total of 99 comparisons, 82, 90, and 97 for SBP, and 80, 97, and 99 for DBP were <5, <10, and <15 mmHg, respectively. It was found that the Omron M6 automatic monitor, which measures BP at the upper arm, produced results in accordance with the criteria of phases 2.1 and 2.2 in both SBP and DBP, when applied to adults and to obese adults.

CONCLUSION

It was concluded that the Omron M6 device, which measures BP at the upper arm, was deemed to be in accordance with the International Protocol criteria and can be recommended for use by adults and obese adults.

Do we need out-of-office blood pressure in every patient?

PURPOSE OF REVIEW

The limitations affecting office blood pressure readings have spurred the development of techniques for measuring blood pressure out of a clinical environment. The increasing use of home and ambulatory blood pressure monitoring has allowed the identification of specific blood pressure patterns related either to a discrepancy between office and out-of-office blood pressure or to alterations in the 24-h blood pressure profiles. This review offers an update on the most recent data published on the above issues.

RECENT FINDINGS

A critical overview is provided on recent data published on blood pressure patterns suggested to have clinical relevance. These include white coat hypertension, the so-called masked hypertension, enhanced overall blood pressure variability over 24 h, a steeper morning blood pressure surge and a blunted or an excessive blood pressure fall at night.

SUMMARY

All of these different conditions have been variably reported to carry prognostic implications, and may represent specific targets for antihypertensive treatment. Their identification and management require information on out-of-office blood pressure, which suggests that self blood pressure monitoring at home or 24-h ambulatory blood pressure monitoring should be used more frequently in clinical practice, following the indications issued in recent guidelines.

A724A polymorphism of sarco(endo)plasmic reticulum Ca2+-ATPase 2 (SERCA2) in hypertensive patients

BACKGROUND

Impaired function of calcium ion transporter sarco(endo)plasmic reticulum Ca2+-ATPase2 (SERCA2), encoded by ATP2A2 gene, was observed in hypertension. The aim of this study was to screen for mutations in the ATP2A2 gene, in hypertensive patients compared to healthy controls.

METHODS

The frequency of a novel mutation in exon 15 of ATP2A2, coding SERCA2, was studied in 107 hypertensive patients and a control group of 50 healthy volunteers. 24-h ambulatory blood-pressure monitoring (ABPM) was carried out. ATP2A2 genotyping was performed by denaturing HPLC and sequencing.

RESULTS

In exon 15 of the ATP2A2 gene, a novel c.2171G>A polymorphism was identified that does not change the amino acid sequence. The frequency of the A allele was significantly higher in normotensive controls than in hypertensive patients (p=0.017). GA genotype carriers demonstrated a tendency towards lower blood pressure values in the doctor's office (p=0.367 systolic, p=0.439 diastolic blood pressure) and measured by ABPM.

CONCLUSIONS

Our results suggest a protective role of the A724A (c.2171G>A) polymorphism of ATP2A2 in subjects without hypertension.

A comparative study of an ambulatory blood pressure measuring device and a wrist blood pressure monitor with a position sensor versus a mercury sphygmomanometer

BACKGROUND

Self-measurements of blood pressure (BP) and 24-hour BP measurements are better predictors of cardiovascular mortality and morbidity than office BP measurements. The objective of this study was to compare the accuracy and precision of a wrist BP monitor with a position sensor (Omron 637IT) and of an ambulatory BP measuring monitor (ABPM; Nissei DS-250) with a mercury sphygmomanometer.

METHODS

A total of 139 patients (69 women and 70 men) were included in the study. The BP of each subject was first measured with a mercury device using the same (left) arm. After this, the wrist monitor was used for BP measurement. Upon completion of the BP readings, 24-hour BP monitoring was performed using Nissei DS-250 monitors. Mean and standard deviations were calculated for all devices. In order to assess the agreement between the measurement methods, the Bland-Altman method and graphics were utilized.

RESULTS

The mean systolic BP measured by the mercury device was 133.2+/-18.4 mmHg and the diastolic BP was 85.4+/-12.5 mmHg, whereas the digital device measured systolic BP as 135.7+/-17.2 mmHg and diastolic BP as 87.0+/-12.5 mmHg. The 24-hour BP measurement was 134.6+/-16.6 mmHg for systolic BP and 85.6+/-11.1 mmHg for diastolic BP. The difference with regard to systolic BP between the mercury and the Omron devices was -2.5+/-5.3 mmHg, which is within the AAMI standard. However, while the mean values of the differences between the mercury and ABPM devices remained under 5 mmHg, their standard deviation was above +/- 8 mmHg. For diastolic BP, the difference between all of the devices was below 5+/-8 mmHg.

CONCLUSIONS

The wrist BP monitor produced results consistent with those of the mercury sphygmomanometer when both were compared with the results of the ABPM. As BP measurement with these devices is a practical and repeatable method, they can be used instead of ABPM in the diagnosis and monitoring of hypertension. However, there is a need for further comparative studies.

Validation of the Braun BP 3550 wrist blood pressure measuring device with a position sensor and an EasyClick cuff according to the International Protocol in adults

OBJECTIVE

Among the electronic blood pressure measuring devices used for self-measurement of blood pressure by patients, models that measure at the wrist are becoming increasingly popular. Validation studies done with these equipments, however, are quite few. The objective of this study was to evaluate the accuracy of the Braun BP 3550 wrist blood pressure device against the mercury sphygmomanometer in adults according to the International Protocol criteria.

METHODS

Fifty-four patients over 30 years of age were studied and classified on the basis of the range of the International Protocol. Blood pressure measurements at the wrist with the Braun BP 3550 were compared with the results obtained by two trained observers using a mercury sphygmomanometer. Nine sequential blood pressure measurements were taken. A total of 33 individuals with randomly distributed arm circumferences were selected for the validation study. During the validation study, 99 measurements were obtained for comparison from 33 individuals. The first phase was performed on 15 individuals and if the device passed this phase, 18 more individuals were selected.

RESULTS

Mean discrepancies and standard deviations of the device sphygmomanometer were 0.4+/-8.1 mmHg for systolic blood pressure and 2.1+/-5.8 mmHg for diastolic blood pressure in the study group. The device passed phase 1 in 15 individuals. In phase 2.1, from the total 99 comparisons, 65, 84 and 91 for systolic blood pressure and 62, 91 and 98 for diastolic blood pressure were <5, <10 and <15 mmHg, respectively. In phase 2.2, 23 individuals had at least two of the differences within 5 mmHg, and two had no differences within 5 mmHg for systolic blood pressure. In terms of diastolic blood pressure, 23 individuals had at least two of the differences within 5 mmHg and three had no differences within 5 mmHg. Braun BP 3550 passed phases 2.1 and 2.2 in the adult participants.

CONCLUSION

The Braun BP 3550 wrist blood pressure device passed according to the International Protocol criteria and can be recommended for use in adults. Deviation from the average value, however, was greater in patients with high systolic blood pressure as compared with those with lower blood pressure.

Arterial blood pressure monitoring in overweight critically ill patients: invasive or noninvasive?

Introduction

Blood pressure measurements frequently guide management in critical care. Direct readings, commonly from a major artery, are considered to be the gold standard. Because arterial cannulation is associated with risks, alternative noninvasive blood pressure (NIBP) measurements are routinely used. However, the accuracy of NIBP determinations in overweight patients in the outpatient setting is variable, and little is known about critically ill patients. This prospective, observational study was performed to compare direct intra-arterial blood pressure (IABP) with NIBP measurements obtained using auscultatory and oscillometric methods in overweight patients admitted to our medical intensive care unit.

Method

Adult critically ill patients with a body mass index (BMI) of 25 kg/m² or greater and a functional arterial line (assessed using the rapid flush test) were enrolled in the study. IABP measurements were compared with those obtained noninvasively. A calibrated aneroid manometer (auscultatory technique) with arm cuffs compatible with arm sizes and a NIBP monitor (oscillometric technique) were used for NIBP measurements. Agreement between methods was assessed using Bland-Altman analysis.

Results

Fifty-four patients (23 males) with a mean (± standard error) age of 57 ± 3 years were studied. The mean BMI was 34.0 ± 1.4 kg/m². Mean arm circumference was 32 ± 0.6 cm. IABP readings were obtained from the radial artery in all patients. Only eight patients were receiving vasoactive medications. Mean overall biases for the auscultatory and oscillometric techniques were 4.1 ± 1.9 and -8.0 ± 1.7 mmHg, respectively (P < 0.0001), with wide limits of agreement. The overestimation of blood pressure using the auscultatory technique was more important in patients with a BMI of 30 kg/m² or greater. In hypertensive patients both NIBP methods underestimated blood pressure as determined using direct IABP measurement.

Conclusion

Oscillometric blood pressure measurements underestimated IABP readings regardless of patient BMI. Auscultatory measurements were also inaccurate, tending to underestimate systolic blood pressure and overestimate mean arterial and diastolic blood pressure. NIBP can be inaccurate among overweight critically ill patients and lead to erroneous interpretations of blood pressure.

Utility of ambulatory blood pressure monitoring in children and adolescents

Diagnosis of hypertension is critically dependent on accurate blood pressure measurement. "Accurate" refers to carefully following the guidelines for blood pressure measurement laid out for children and adults to minimize observer and subject errors that commonly occur in clinical blood pressure measurement. Accurate blood pressure measurement is more important in children and adolescents as the misdiagnosis of hypertension may have a life-long adverse impact on insurability and employment. Automated blood pressure measurement offers multiple advantages in achieving high-quality blood pressure determinations by reducing observer errors. The most commonly used form of automated blood pressure measurement is 24-h ambulatory blood pressure measurement (ABPM). Information on ABPM in children has grown exponentially over the last decade. Normative data exists for diagnosis of hypertension in children using ABPM including a novel method for determining normal values with the LMS method. There is further information about the utility of different determinants of 24-h blood pressure such as dipping status, morning surge and blood pressure load. ABPM has been able to detect significant differences in blood pressure in many disease states in children including chronic renal failure, polycystic kidney disease, solitary functioning kidney, and after renal transplantation. Increasingly nonambulatory automated blood pressure determinations have been used in management of hypertension in children. Although nonambulatory automated readings lack information about nocturnal blood pressure or blood pressure during daily activity, studies have suggested that home automated blood pressure measurements are a helpful adjunct to the usual office blood pressure reading.

Validation of the Omron 637IT wrist blood pressure measuring device with a position sensor according to the International Protocol in adults and obese adults

OBJECTIVE

Wrist blood pressure devices are becoming popular for the self-measurement of blood pressure. Despite widespread use of these devices, there is limited published evidence for their accuracy and reliability. In this study, we assessed the accuracy of the Omron 637IT wrist blood pressure device against the mercury sphygmomanometer in adults and obese adults according to the International Protocol criteria.

METHODS

A hundred and thirty-one participants were studied and classified on the basis of the International Protocol range. Blood pressure measurements at the wrist using the Omron 637IT were compared with the results obtained by two trained observers using a mercury sphygmomanometer. Nine sequential blood pressure measurements were taken. Initially, 33 participants with random arm circumferences were selected for the first validation study. Then, the device was evaluated in adults with arm circumferences equal to or higher than 34 cm. During each validation study, 99 measurements were obtained for comparison from the 33 participants. The first phase was performed on 15 participants, and, if the device passed this phase, 18 more participants were selected.

RESULTS

Mean discrepancies and standard deviations of the sphygmomanometer device were 0.5+/-6.2 mmHg for systolic blood pressure and 0.1+/-3.7 mmHg for diastolic blood pressure in the adult group. The device passed phases 1 and 2 in 33 participants. Mean discrepancies and standard deviations of the sphygmomanometer device were 1.8+/-6.6 mmHg for systolic blood pressure and 1.6+/-4.7 mmHg for diastolic blood pressure in the obese adult group. The device passed phases 1 and 2 in 33 participants in this group.

CONCLUSION

The Omron 637IT passed according to the International Protocol criteria and can be recommended for use in adults and obese adults.

Validity of measures is no simple matter

PURPOSE AND METHOD

This article aims to promote a better understanding of the nature of measurement, the special problems posed by measurement in the social sciences, and the inevitable limitations on inferences in science (so that results are not overinterpreted), by using the measurement of blood pressure as an example. As it is necessary to raise questions about the meaning and extent of the validity of something as common as measured blood pressure, even more serious questions are unavoidable in relation to other commonly used measures in social science. The central issue is the validity of the inferences about the construct rather than the validity of the measure per se.

CONCLUSION

It is important to consider the definition and validity of the construct at issue as well as the adequacy of its representation in the measurement instrument. By considering a particular construct within the context of a conceptual model, researchers and clinicians will improve their understanding of the construct's validity as measured.

Self-measurement of blood pressure at home in the management of hypertension

To be suitable for the management of hypertension, self-measurement of blood pressure (BP) at home should follow international recommendations. The use of accurate and validated measuring devices is an important prerequisite. Upper arm BP monitors are the first choice, while wrist and finger devices cannot be recommended. Measurements should, preferentially, be downloaded from the memory of a device or printed. Reference values have been proposed, but were mostly based on cross-sectional observations and have not yet been widely validated by prospective outcome studies. Currently, levels of home BP of <135 mm Hg systolic and 85 mm Hg diastolic are usually considered normal. Home BP measurement is sometimes recommended as an alternative to ambulatory BP monitoring to diagnose white-coat hypertension.However, home BP measurement cannot replace ambulatory BP monitoring in the diagnosis of hypertension (white-coat), but both techniques have complementary roles. The appropriateness of home BP measurement to guide antihypertensive treatment has only been tested in one large-scale randomized trial: the THOP (Treatment of Hypertension Based on Home or Office Blood Pressure) trial. The THOP trial showed that antihypertensive treatment based on home instead of office BP led to less intensive drug treatment, but also to less BP control with no differences in general wellbeing and left ventricular mass. Home BP monitoring also contributed to the identification of patients with white-coat hypertension. On balance, most evidence supports the view that office BP measurement remains the key in the diagnosis and treatment of hypertension. Treatment can be started without confirmation of elevated office BP in patients with high office BP and target organ damage, or a high cardiovascular risk profile. In patients with raised office BP but without target organ damage (white-coat hypertension), or with normal office BP but unexplained target organ damage (masked hypertension), ambulatory or home BP monitoring or both must be used to confirm the diagnosis. Few longitudinal studies have addressed the long-term prognostic meaning of home BP measurement. Until more prospective data become available, management of hypertension exclusively based on self-measurement of BP at home cannot be recommended.