Reporting bias in self-measurement of blood pressure

Medical Telemonitoring for the Management of Hypertension in Older Patients in Japan

Hypertension is the most frequent modifiable risk factor associated with cardiovascular disease (CVD) morbidity and mortality. Even in older people, strict blood pressure (BP) control has been recommended to reduce CVD event risks. However, caution should be exercised since older hypertensive patients have increased physical vulnerability due to frailty and multimorbidity, and older patients eligible for clinical trials may not represent the general population. Medical telemonitoring systems, which enable us to monitor a patient's medical condition remotely through digital communication, have become much more prevalent since the coronavirus pandemic. Among various physiological parameters, BP monitoring is well-suited to the use of such systems, which enable healthcare providers to deliver accurate and safe BP management, even in the presence of frailty and/or living in geographically remote areas. Furthermore, medical telemonitoring systems could help reduce nonadherence to antihypertensive medications and clinical inertia, and also enable multi-professional team-based management of hypertension. However, the implementation of medical telemonitoring systems in clinical practice is not easy, and substantial barriers, including the development of user-friendly devices, integration with existing clinical systems, data security, and cost of implementation and maintenance, need to be overcome. In this review, we focus on the potential of medical telemonitoring for the management of hypertension in older people in Japan.

Using Mobile Video-Teleconferencing to Deliver Secondary Stroke Prevention Interventions: A Pilot Study

OBJECTIVES

Patient self-management support (SMS) interventions help stroke survivors control stroke risk factors and assist with secondary prevention. We examined utility and preliminary effectiveness of mobile video-teleconferencing (VT) to deliver SMS to stroke survivors in rural and low-income urban Texas communities.

METHODS

We applied a within-subjects design to assess improvement in self-management behaviors and stroke risk factors among stroke survivors receiving SMS intervention through mobile VT. Adults with stroke and two or more uncontrolled stroke risk factors were eligible. The SMS program, Video-teleconference-Self-management TO Prevent stroke (V-STOP) was delivered over 6 weeks by trained health coaches through VT. We applied Generalized Estimating Equations with site and time in intervention as covariates to evaluate psychological, social, physiological outcomes, self-management behaviors, and quality of life.

RESULTS

Mean age of 106 participants was 59.3 (±10.9); most were White, Hispanic men, living with someone, with low income. Approximately 69% completed all measures at 6 weeks. Median number of sessions attended was 5 (interquartile range 3) potentially avoiding 210 km of travel per person. Satisfaction with V-STOP and VT delivery was high, at (4.8 [±0.5]) and (4.7 [±0.5]), respectively. Stroke knowledge was improved from 8.8 (±1.0) at baseline to 9.6 (±0.7) at 12 weeks, (p < 0.0001). Improvements were observed in self-efficacy, exercise behaviors, depression and anxiety, disability, and quality of life.

CONCLUSION

Implementation of SMS is feasible and shows good utility and preliminary effectiveness of using mobile VT to provide stroke follow-up care to stroke survivors. Participants improved self-management behaviors and stroke risk factors.

Do patients actually do what we ask: patient fidelity and persistence to the Targets and Self-Management for the Control of Blood Pressure in Stroke and at Risk Groups blood pressure self-management intervention

OBJECTIVE

Self-management of hypertension can reduce and control blood pressure (BP) compared with clinic monitoring. However, self-management relies on patients following an algorithm, which may be variably adhered to. This study reports fidelity of high-risk patients to the self-management algorithm set by the TASMIN-SR trial.

METHODS

Patients with hypertension, above target clinic BP and one or more of stroke, diabetes, coronary heart disease or chronic kidney disease, were invited to self-monitor following an individualized self-titration algorithm. Home BP readings and medication change details were submitted monthly for 12 months. Readings downloaded from patients' electronic monitors were compared with written submissions, and protocol fidelity was assessed.

RESULTS

Two hundred and seventy-six patients were randomized to self-management and 225 (82%) completed the required training sessions. Of these, 166 (74%) completed self-management. A total of 11385 (89.6%) submitted readings were accurate compared with corresponding downloaded monitor readings. Mean error rate was 5.2% per patient, which increased with age but not comorbidities. Patients made 475 of 683 (69.5%) algorithm-recommended medication changes, equating to nearly three medication changes per patient. Mean SBP for patients who completed training and made all recommended changes dropped from 141 mmHg (95% CI 138.26-144.46) to 121 mmHg (95% CI 118.30-124.17 mmHg) compared with 129 mmHg (95% CI 125.27-136.73 mmHg) for patients who made none.

CONCLUSION

Most patients randomized to self-management completed training; however, 36% of these had dropped out by 12 months. Self-monitoring was largely undertaken properly and accurately recorded. Fidelity with self-management was associated with lower achieved SBP. Successful implementation of self-management into daily practice requires careful training and should be accompanied by monitoring of fidelity.

Diagnostic precision of mentally estimated home blood pressure means

CONTEXT

Paper home blood pressure (HBP) charts are commonly brought to physicians at office visits. The precision and accuracy of mental calculations of blood pressure (BP) means are not known.

METHODS

A total of 109 hypertensive patients were instructed to measure and record their HBP for 1 week and to bring their paper charts to their office visit. Study section 1: HBP means were calculated electronically and compared to corresponding in-office BP estimates made by physicians. Study section 2: 100 randomly ordered HBP charts were re-examined repetitively by 11 evaluators. Each evaluator estimated BP means four times in 5, 15, 30, and 60 s (random order) allocated for the task. BP means and diagnostic performance (determination of therapeutic systolic and diastolic BP goals attained or not) were compared between physician estimates and electronically calculated results.

RESULTS

Overall, electronically and mentally calculated BP means were not different. Individual analysis showed that 83% of in-office physician estimates were within a 5-mmHg systolic BP range. There was diagnostic disagreement in 15% of cases. Performance improved consistently when the time allocated for BP estimation was increased from 5 to 15 s and from 15 to 30 s, but not when it exceeded 30 s.

CONCLUSION

Mentally calculating HBP means from paper charts can cause a number of diagnostic errors. Chart evaluation exceeding 30 s does not significantly improve accuracy. BP-measuring devices with modern analytical capacities could be useful to physicians.

The septal bulge--an early echocardiographic sign in hypertensive heart disease

Patients in the early stage of hypertensive heart disease tend to have normal echocardiographic findings. The aim of this study was to investigate whether pathology-specific echocardiographic morphologic and functional parameters can help to detect subclinical hypertensive heart disease. One hundred ten consecutive patients without a history and medication for arterial hypertension (AH) or other cardiac diseases were enrolled. Standard echocardiography and two-dimensional speckle-tracking-imaging analysis were performed. Resting blood pressure (BP) measurement, cycle ergometer test (CET), and 24-hour ambulatory BP monitoring (ABPM) were conducted. Patients were referred to "septal bulge (SB)" group (basal-septal wall thickness ≥ 2 mm thicker than mid-septal wall thickness) or "no-SB" group. Echocardiographic SB was found in 48 (43.6%) of 110 patients. In this SB group, 38 (79.2%) patients showed AH either by CET or ABPM. In contrast, in the no-SB group (n = 62), 59 (95.2%) patients had no positive test for AH by CET or ABPM. When AH was solely defined by resting BP, SB was a reasonable predictive sign for AH (sensitivity 73%, specificity 76%). However, when AH was confirmed by CET or ABPM the echocardiographic SB strongly predicted clinical AH (sensitivity 93%, specificity 86%). In addition, regional myocardial deformation of the basal-septum in SB group was significantly lower than in no-SB group (14 ± 4% vs. 17 ± 4%; P < .001). In conclusion, SB is a morphologic echocardiographic sign for early hypertensive heart disease. Sophisticated BP evaluation including resting BP, ABPM, and CET should be performed in all patients with an accidental finding of a SB in echocardiography.

The impact of dosing frequency on medication adherence in chronic cardiovascular disease: systematic review and meta-analysis

INTRODUCTION AND OBJECTIVE

Non-adherence to drug treatment is a major health problem. In Europe, it has been estimated that 9% of cardiovascular events can be attributed to non-adherence. The complexity of dosing regimens is one of the factors identified as contributing to non-adherence. In this systematic review we aimed to assess the impact of dosing frequency on adherence to drug treatment in patients with chronic cardiovascular disease.

METHODS

MEDLINE and the Cochrane Library (November 2013) were searched for randomized controlled trials (RCTs) comparing different dosing regimens (once-daily administration vs. two or more daily administrations) and assessing adherence to therapy in patients with chronic cardiovascular disease. Only trials with at least five months of follow-up were included. The results of the studies were pooled through a random effects meta-analysis. Relative risk (RR) and 95% confidence interval (CI) were derived. Statistical heterogeneity was calculated using the I(2) test.

RESULTS

Four RCTs (a total of 2557 patients) were included. Dosing regimens with once-daily administration were associated with a significant 56% reduction in risk of non-adherence to drug therapy (RR: 0.44; 95% CI: 0.35-0.54, I(2)=25%).

CONCLUSIONS

Few clinical trials have assessed the long-term impact of dosing frequency on medication adherence in chronic cardiovascular disease. The best available evidence suggests that taking medication once daily decreases the risk of non-adherence to treatment by approximately 50%. The impact on clinical outcomes remains to be established.

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.

Blood pressure measurement: clinic, home, ambulatory, and beyond

Blood pressure traditionally has been measured in the clinic setting using the auscultatory method and a mercury sphygmomanometer. Technologic advances have led to improvements in measuring clinic blood pressure and allowed for measuring blood pressures outside the clinic. This review outlines various methods for evaluating blood pressure and the clinical utility of each type of measurement. Home blood pressures and 24-hour ambulatory blood pressures have improved our ability to evaluate the risk of target-organ damage and hypertension-related morbidity and mortality. Measuring home blood pressures may lead to more active participation in health care by patients and has the potential to improve blood pressure control. Ambulatory blood pressure monitoring enables measuring nighttime blood pressures and diurnal changes, which may be the most accurate predictors of risk associated with elevated blood pressure. Additionally, reducing nighttime blood pressure is feasible and may be an important component of effective antihypertensive therapy. Finally, estimating central aortic pressures and pulse wave velocity are 2 of the newer methods for assessing blood pressure and hypertension-related target-organ damage.

Home blood pressure monitoring in the diagnosis and treatment of hypertension: a systematic review

BACKGROUND

It is recognized that for the reliable assessment of blood pressure (BP) and the accurate diagnosis of hypertension, out-of-office BP measurement with ambulatory (ABPM) or home BP monitoring (HBPM) is often required. The clinical usefulness of ABPM is well established. However, despite the wide use of HBPM, only in the last decade convincing evidence on its usefulness has accumulated.

METHODS

Systematic review of the evidence on applying HBPM in the diagnosis and treatment of hypertension (PubMed, Cochrane Library, 1970-2010).

RESULTS

Sixteen studies in untreated and treated subjects assessed the diagnostic ability of HBPM by taking ABPM as reference. Seven randomized studies compared HBPM vs. office measurements or ABPM for treatment adjustment, whereas many studies compared HBPM with office measurements in assessing the antihypertensive drug effects. Several studies with different design investigated the role of HBPM vs. office measurements in improving patients' compliance with treatment and hypertension control rates. The evidence on the cost-effectiveness of HBPM is limited. The studies reviewed consistently showed moderate diagnostic agreement between HBPM and ABPM, and superiority of HBPM compared to office measurements in diagnosing uncontrolled hypertension, assessing antihypertensive drug effects and improving patients' compliance and hypertension control. Preliminary evidence suggests that HBPM has the potential for cost savings.

CONCLUSIONS

There is conclusive evidence that HBPM is useful for the initial diagnosis and the long-term follow-up of treated hypertension. These data are useful for the optimal application of HBPM, which is widely used in clinical practice. More studies on the cost-effectiveness of HBPM are needed.

European Society of Hypertension practice guidelines for home blood pressure monitoring

Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners.

Home blood pressure monitoring in clinical practice: a review

Home blood pressure monitoring is a convenient and inexpensive technique to monitor blood pressure in hypertensive patients. There are convincing data that home blood pressure monitoring is a good predictor of future cardiovascular risk, perhaps better than office blood pressure. Home blood pressure measurement can be standardized using validated instruments and systematic protocols; normative criteria have established home blood pressure >135/85 mm Hg as hypertensive. Home blood pressure monitoring has been shown to improve compliance and blood pressure control, and to reduce health care costs. Ongoing studies are evaluating management of hypertension based on home blood pressure readings compared with traditional office-based readings. Home blood pressure monitoring is particularly useful for evaluation of white coat hypertension and masked hypertension. In this article, we discuss the methodology for measuring blood pressure at home, its comparison to the other measurement techniques, the advantages and disadvantages, cost benefit analyses, and ongoing clinical trials to help define the role of home blood pressure monitoring in the clinical management of hypertension.

Poor adherence to home blood pressure measurement schedule

BACKGROUND

Consensus dictates that devices used for home blood pressure (BP) measurement should be equipped with a memory to store readings, rather than trusting patients' logbooks. However, data entered in the memory rely on patients' adherence to measurement schedules. We investigated the number and relevance of deviations from the requested measurement schedule.

METHODS

We instructed 106 patients to perform 28 BP readings in a 2-week period with a memory-equipped electronic device. Patients were requested to note their scheduled BP values in their logbook and were not informed of the presence of a memory function.

RESULTS

The concordance between all BP recordings in both memory and logbook was 90.1% of possible total scheduled readings. The difference in mean BP of all readings from memory compared with all readings from the logbook was -0.06 mmHg (95% confidence interval -0.79 to 0.68) systolic and -0.28 mmHg (95% confidence interval -0.97 to 0.40) diastolic. Unscheduled measurements were performed by 57.5% of patients. Missing scheduled readings in both logbook and memory were found in 34.0% of patients. Fictional data were present for 16.0% of patients. When comparing all individual BP readings from the memory and the logbook, 10.4% of patients were classified in another hypertension stratum according to the European Society of Hypertension criteria. In 23.6% of patients, we did not find any bias.

CONCLUSION

In spite of the use of memory-equipped devices, to ensure patients' adherence to measurement schedules, patients still need proper instruction and a close watch.

Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association

Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (Class IIa; Level of Evidence A). This call-to-action article makes the following recommendations: (1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; (3) Two to 3 readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of >/=12 readings are recommended for making clinical decisions; (4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; (5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; (6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; (7) The target HBPM goal for treatment is <135/85 mm Hg or <130/80 mm Hg in high-risk patients; (8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; (9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; (10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and (11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed.

Can validated wrist devices with position sensors replace arm devices for self-home blood pressure monitoring? A randomized crossover trial using ambulatory monitoring as reference

BACKGROUND

Electronic devices that measure blood pressure (BP) at the arm level are regarded as more accurate than wrist devices and are preferred for home BP (HBP) monitoring. Recently, wrist devices with position sensors have been successfully validated using established protocols. This study assessed whether HBP values measured with validated wrist devices are sufficiently reliable to be used for making patient-related decisions in clinical practice.

METHODS

This randomized crossover study compared HBP measurements taken using validated wrist devices (wrist-HBP, Omron R7 with position sensor) with those taken using arm devices (arm-HBP, Omron 705IT), and also with measurements of awake ambulatory BP (ABP, SpaceLabs), in 79 subjects (36 men and 43 women) with hypertension. The mean age of the study population was 56.7 +/- 11.8 years, and 33 of the subjects were not under treatment for hypertension.

RESULTS

The average arm-HBP was higher than the average wrist-HBP (mean difference, systolic 5.2 +/- 9.1 mm Hg, P < 0.001, and diastolic 2.2 +/- 6.7, P < 0.01). Twenty-seven subjects (34%) had a > or =10 mm Hg difference between systolic wrist-HBP and arm-HBP and twelve subjects (15%) showed similar levels of disparity in diastolic HBP readings. Strong correlations were found between arm-HBP and wrist-HBP (r 0.74/0.74, systolic/diastolic, P < 0.0001). However, ABP was more strongly correlated with arm-HBP (r 0.73/0.76) than with wrist-HBP (0.55/0.69). The wrist-arm HBP difference was associated with systolic ABP (r 0.34) and pulse pressure (r 0.29), but not with diastolic ABP, sex, age, arm circumference, and wrist circumference.

CONCLUSIONS

There might be important differences in HBP measured using validated wrist devices with position sensor vs. arm devices, and these could impact decisions relating to the patient in clinical practice. Measurements taken using arm devices are more closely related to ABP values than those recorded by wrist devices. More research is needed before recommending the widespread use of wrist monitors in clinical practice. American Journal of Hypertension doi:10.1038/ajh.2008.176American Journal of Hypertension (2008); 21, 7, 753-758. doi:10.1038/ajh.2008.176.

Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association

Home blood pressure monitoring (HBPM) overcomes many of the limitations of traditional office blood pressure (BP) measurement and is both cheaper and easier to perform than ambulatory BP monitoring. Monitors that use the oscillometric method are currently available that are accurate, reliable, easy to use, and relatively inexpensive. An increasing number of patients are using them regularly to check their BP at home, but although this has been endorsed by national and international guidelines, detailed recommendations for their use have been lacking. There is a rapidly growing literature showing that measurements taken by patients at home are often lower than readings taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors, which is the BP that best predicts cardiovascular risk. Because of the larger numbers of readings that can be taken by HBPM than in the office and the elimination of the white-coat effect (the increase of BP during an office visit), home readings are more reproducible than office readings and show better correlations with measures of target organ damage. In addition, prospective studies that have used multiple home readings to express the true BP have found that home BP predicts risk better than office BP (Class IIa; Level of Evidence A). This call-to-action article makes the following recommendations: (1) It is recommended that HBPM should become a routine component of BP measurement in the majority of patients with known or suspected hypertension; (2) Patients should be advised to purchase oscillometric monitors that measure BP on the upper arm with an appropriate cuff size and that have been shown to be accurate according to standard international protocols. They should be shown how to use them by their healthcare providers; (3) Two to 3 readings should be taken while the subject is resting in the seated position, both in the morning and at night, over a period of 1 week. A total of >or=12 readings are recommended for making clinical decisions; (4) HBPM is indicated in patients with newly diagnosed or suspected hypertension, in whom it may distinguish between white-coat and sustained hypertension. If the results are equivocal, ambulatory BP monitoring may help to establish the diagnosis; (5) In patients with prehypertension, HBPM may be useful for detecting masked hypertension; (6) HBPM is recommended for evaluating the response to any type of antihypertensive treatment and may improve adherence; (7) The target HBPM goal for treatment is <135/85 mm Hg or <130/80 mm Hg in high-risk patients; (8) HBPM is useful in the elderly, in whom both BP variability and the white-coat effect are increased; (9) HBPM is of value in patients with diabetes, in whom tight BP control is of paramount importance; (10) Other populations in whom HBPM may be beneficial include pregnant women, children, and patients with kidney disease; and (11) HBPM has the potential to improve the quality of care while reducing costs and should be reimbursed.

Home blood pressure monitoring in children: how many measurements are needed?

OBJECTIVE

To investigate the minimum schedule of blood pressure (BP) measurements necessary to provide a reliable assessment of home BP (HBP) in children and adolescents.

METHODS

Subjects aged 6-18 years referred for elevated BP were assessed with HBP monitoring (6 workdays, duplicate morning and evening measurements) and 24-h ambulatory BP monitoring (ABP). Criteria for HBP reliability were its reproducibility (test-retest correlations and SD of differences (SDDs) between repeated measurements), its stability (average home BP of an increasing number of readings and its SD), and its relationship with ABP.

RESULTS

Data from 100 subjects were analyzed (mean age 13 +/- 2.8 (SD) years, 61 boys). The reproducibility of 3-day HBP (r 0.88/0.79, SDDs 5.1/4.9, systolic/diastolic) was superior to that of a single (r 0.79/0.65, SDDs 7.6/7.1) or 2-day HBP (r 0.85/0.72, SDDs 6.1/5.4). By averaging up to 12 readings (3 days), there was a progressive decline in average HBP, with no further decline thereafter. The SD of average HBP was also progressively reduced, with little change after day 3. The association of HBP with ABP was improved by averaging more readings up to 12, with no further improvement when more readings were averaged. The exclusion of first-day measurements slightly increased the SD of average HBP and weakened the correlation with ABP, probably due to reduced number of readings.

CONCLUSIONS

In children and adolescents, 3-day monitoring with duplicate morning and evening measurements appears to be the minimum schedule for the reliable assessment of HBP.

Changing relationship between home and office blood pressure with increasing age in children: the Arsakeion School study

BACKGROUND

Home blood pressure (HBP) monitoring is being used in children. However, there is no information on the relationship between HBP and office measurements (Office BP (OBP)) in this population.

METHODS

This school-based study investigated the effect of age on the difference between HBP and OBP in 765 healthy subjects aged 6-18 years (mean age 12 +/- 3 (SD years)). HBP (3 days, 12 readings) and OBP (2 visits, 6 readings) were measured using electronic devices validated in children (Omron 705IT).

RESULTS

Average OBP was slightly lower than HBP by 0.6+/- 7.0 mm Hg (95% confidence intervals (CI) 0.1, 1.1, P=0.01) systolic and 1+/- 6 mm Hg (95% CI 0.7, 1.6, P<0.0001) diastolic, whereas pulse rate was higher in the office by 7+/- 10 beats/min (95% CI 6.2, 7.6, P<0.0001). Age was significantly correlated with the OBP-HBP difference (r = 0.13/0.24 for systolic/diastolic, P< 0.001). In the younger children (6-12 years), both diastolic and systolic HBP were higher than OBP, whereas pulse rate was higher in the office. In older children and adolescents, the BP difference was eliminated whereas the pulse rate difference was reduced but remained significant. These changes with age were similar in boys and girls.

CONCLUSIONS

In the pediatric population OBP appears to be higher than HBP. This difference is reduced with advancing age and eliminated after the age of 12 years. These data should be taken into account in the assessment of HBP in children and adolescents.

Home blood pressure normalcy in children and adolescents: the Arsakeion School study

OBJECTIVE

There is evidence that home blood pressure (BP) is being used in clinical practice for the assessment of out-of-office blood pressure in children. However, there is no information on the normal range of home BP in this population. This prospective school-based study was designed to investigate the normal range of home BP in children and adolescents.

SUBJECTS AND METHODS

A total of 778 healthy subjects (358 boys) with mean age 12.3 +/- 3.3 (SD) years (range 6-18 years), height 157 +/- 18 cm (113-198 cm) and weight 50 +/- 18 kg (16-135 kg) were included. Home BP was monitored for 3 days using validated electronic devices (Omron 705IT).

RESULTS

Reliable home BP readings provided by 767 subjects (98%) were analysed. Strong correlations were found between systolic home BP and body height (r = 0.49) and age (r = 0.41), whereas for diastolic BP these correlations were poor (r = 0.11 and 0.08, respectively). The 50th (midpoint of distribution) and the 95th percentile (suggested upper normal limit) for systolic and diastolic home BP in children are provided by body height. There was a marked increase in the estimated 95th percentile for systolic home BP with increasing height in boys (from 119 to 134 mmHg) and less so in girls (from 119 to 128 cm). Regarding diastolic home BP, there was little change with increasing height (from 75 to 80 cm) and no difference between boys and girls.

CONCLUSIONS

These data suggest that home BP monitoring in children and adolescents is feasible. Reference values for home BP in the paediatric population are provided.

A tool for reliable self-home blood pressure monitoring designed according to the European Society of Hypertension recommendations: the Microlife WatchBP Home monitor

BACKGROUND

Self-blood pressure monitoring by patients at home (HBPM) is being increasingly used in clinical practice and has been endorsed by hypertension societies as an important adjunct to the conventional office blood pressure measurements. Several problems, however, exist regarding the application of HBPM in practice, such as device inaccuracy, observer bias and misreporting, variable monitoring schedule and variable method for summarizing measurements. The European Society of Hypertension Working Group (ESH-WG) on Blood Pressure Monitoring has published detailed recommendations on how to apply HBPM in clinical practice.

OBJECTIVE

The Microlife WatchBP Home monitor is designed to provide reliable and unbiased self-blood pressure monitoring by patients at home, strictly according to the ESH-WG recommendations.

DESIGN

Dual-function automated oscillometric monitor for HBPM in the arm, with memory, PC link capacity and embedded monitoring schedule. The device has a Usual mode for casual HBPM and a Diag (diagnostic) mode for HBPM strictly according to the ESH-WG proposed schedule (duplicate morning and evening measurements for 7 days). Readings are averaged by the device after exclusion of the initial day according to ESH-WG recommendations and can be transferred to PC for storing or printing. A pilot study in hypertensive patients with previous experience in HBPM suggested that the device is user-friendly and well accepted.

CONCLUSION

The Microlife WatchBP Home monitor is a novel device that provides a reliable and unbiased assessment of home blood pressure strictly according to the ESH recommendations.

The value of home blood pressure monitoring

Home blood pressure (BP) monitoring has become popular and acceptable. The value of home BP monitoring has been recognized, because it has some potential advantages over office BP. Home BP monitoring is more accurate and reproducible, has a better prognostic value, and increases patients' compliance with treatment. Home BP monitoring should be performed with an adequate device, following a standardized procedure. The automated arm-cuff-oscillometric devices are recommended currently, and home BP should be measured at least twice daily, in the morning and in the evening. Home BP monitoring has revealed the phenomena of "white-coat hypertension," "masked hypertension," and "morning hypertension," and it is useful for their management. In the future, home BP monitoring will be an essential aspect of clinical practice.

Validation of the Omron 705 IT oscillometric device for home blood pressure measurement in children and adolescents: The Arsakion School Study

BACKGROUND

Limited evidence exists on the accuracy of oscillometric devices for blood pressure measurement in children. This study validated the Omron 705 IT monitor (Omron Healthcare Europe BV, Hoofddorp, The Netherlands) in normotensive children and adolescents.

METHODS

Simultaneous blood pressure measurements were taken by two observers (connected mercury sphygmomanometers) four times, sequentially with three measurements by using the tested device. Absolute device-observer blood pressure differences were classified into three zones (within 5, 10 and 15 mmHg) and assessed using the European Society of Hypertension International Protocol criteria. The number of readings with a difference within 5 mmHg was calculated for each individual. The American Association for the Advancement of Medical Instrumentation criterion (mean difference+ or -SD <5+ or -8 mmHg) was also applied.

RESULTS

A total of 197 study participants (591 readings) were included (99 boys, mean age+ or -SD 10.6+ or -2.4 years (range 6-16 years). The device produced 378 (64%), 532 (90%) and 579 (98%) measurements within 5, 10 and 15 mmHg, respectively, for systolic blood pressure, and 415 (70%), 525 (89%) and 577 (98%) measurements, respectively, for diastolic blood pressure. In all, 136 study participants (69%) had at least two systolic blood pressure differences within 5 mmHg and 16 (8%) had no differences within 5 mmHg (for diastolic blood pressure 147 (75%) and nine (5%) participants, respectively). Mean systolic blood pressure difference was 4.0+ or -4.8 mmHg and diastolic blood pressure -2.1+ or -5.9 mmHg and was <5+ or -8 mmHg in quartiles of participants divided by age, height, body mass index, arm circumference, blood pressure or pulse rate.

CONCLUSIONS

The Omron 705 IT appears to be an accurate device for blood pressure measurement in normotensive children and adolescents.

White-coat hypertension and masked hypertension in children

The use of ambulatory blood pressure monitoring in addition to the conventional office measurements makes possible the detection of individuals with white-coat hypertension and masked hypertension. In children referred for elevated blood pressure, both these phenomena appear to be common (10-15% for each). In a population of healthy children, white-coat hypertension appears to be as common as hypertension, whereas masked hypertension appears to be more common than white-coat hypertension or hypertension. In children with persistent white-coat or masked hypertension, assessment of target organ damage by echocardiography is required. Preliminary evidence suggests that, in contrast to white-coat hypertension, which is not associated with target organ damage, masked hypertension in children is associated with increased left ventricular mass. Children with masked hypertension should be followed up and possibly treated for hypertension if the phenomenon persists or there is evidence of target organ damage.

Use of home blood-pressure monitoring in the detection, treatment and surveillance of hypertension

PURPOSE OF REVIEW

Use of home blood-pressure monitoring is increasing but the technique and the equipment have limitations. We provide an overview of recent evidence in this rapidly evolving field.

RECENT FINDINGS

Home blood-pressure monitoring is an acceptable method for screening patients for hypertension. There is increasing evidence supporting the predictive power of home blood pressure for stroke risk even in the general population. The identification of white-coat and masked hypertension remains an important role for home blood-pressure monitoring. Unvalidated equipment and poor patient technique are major concerns. The purchase of devices needs to be linked to a simple patient-education programme, which is perhaps an opportunity for collaboration between healthcare providers and commercial companies. Devices that store the blood-pressure measurements in the memory are preferred to ensure accuracy of reporting. Data-transmission systems providing automatic storage, transmission and reporting of blood pressure, direct involvement of the patient and potentially a reduced number of hospital/general practitioner visits, offer significant advantages. To reduce patient anxiety, overuse of home blood-pressure monitoring should be avoided but there is the potential for self-modification of treatment, subject to certain safeguards.

SUMMARY

Self-monitoring of blood pressure is developing rapidly, linked to increasing awareness of the impact of reducing high blood pressure on public health and the marketing/advertising strategies used to sell automatic devices. Home blood-pressure monitoring has a role in the detection and management of blood pressure, but not at the expense of careful blood-pressure measurement in the office and adherence to national guidelines.

Can NPs rely on self-blood pressure measurements?

The development of relatively inexpensive and automated devices has stimulated the use of self or home blood pressure (BP) monitors. This article provides a guide for NPs to understand when self-BP measurement (SBPM) is a reliable alternative to traditional in-office measurements.