Reference values for ambulatory blood pressure and self-measured blood pressure based on prospective outcome data

Hypoxia inducible factor-1α (HIF-1α) as an early predictor of acute hydrogen cyanamide (Dormex) poisoning

Hydrogen cyanamide (Dormex) is a plant growth regulator that is classified as a highly toxic poison. There are no definite investigations to help in its diagnosis and follow-up. This study aimed to investigate the role of hypoxia-inducible factor-1α (HIF-1α) in the diagnosis, prediction, and follow-up of Dormex-intoxicated patients. Sixty subjects were equally divided into two groups: group A, the control group, and group B, the Dormex group. Clinical and laboratory evaluations, including arterial blood gases (ABG), prothrombin concentration (PC), the international normalized ratio (INR), a complete blood count (CBC), and HIF-1α, were done on admission. CBC and HIF-1α were repeated for group B 24 and 48 h after admission to track abnormalities. Group B also had brain computed tomography (CT). Patients with abnormal CT scans were referred for brain magnetic resonance imaging (MRI). Significant differences in levels of HB, WBCs, and platelets were also detected in group B up to 48 h after admission, as white blood cells (WBCs) rose with time and hemoglobin (HB) and platelets diminished. The results described a highly significant difference in HIF-1α between the groups, and it depended on the clinical condition; therefore, it can be used in the prediction and follow-up of patients up to 24 h after admission.

Association of Workplace Culture of Health and Employee Emotional Wellbeing

The study aimed to examine associations between workplace culture of health and employee work engagement, stress, and depression. Employees (n = 6235) across 16 companies voluntarily completed the Workplace Culture of Health (COH) Scale and provided data including stress, depression, and biometrics through health risk assessments and screening. We used linear regression analysis with COH scores as the independent variable to predict work engagement, stress, and depression. We included age, gender, job class, organization, and biometrics as covariates in the models. The models showed that total COH scores were a significant predictor of employee work engagement (b = 0.75, p < 0.001), stress (b = -0.08, p < 0.001), and depression (b = 0.08, p < 0.001). Job class was also a significant predictor of work engagement (b = 2.18, p < 0.001), stress (b = 0.95, p < 0.001), and depression (b = 1.03, p = 0.02). Gender was a predictor of stress (b = -0.32, p < 0.001). Overall, findings indicate a strong workplace culture of health is associated with higher work engagement and lower employee stress and depression independent of individual health status. Measuring cultural wellbeing supportiveness can help inform implementation plans for companies to improve the emotional wellbeing of their employees.

Normative Data for Blood Pressure in Croatian War Veterans: A Population-Based Study

Purpose: The current study aimed to investigate the normative data for blood pressure. Materials and Methods: From 2017 to 2020, 2032 men and women classified as ‘war veterans’ were recruited (mean age ± standard deviation (SD): 60.97 ± 7.98 years; mean stature: 172.50 ± 9.10 cm; mean body mass: 90.25 ± 36.45 kg; mean body-mass index: 29.66 ± 5.59 kg/m²; 29.9% women). Their systolic and diastolic blood pressures were measured three times. The procedure was carried out according to the American Heart Organization. The sex-specific and age-specific normative data for the 5th, 25th, 50th (median), 75th, and 90th percentiles for systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (measured as SBP-DBP) and mid-BP (the average of SBP and DBP) were presented. Results: The men had higher SBP (p < 0.001), DBP (p < 0.001), pulse pressure (p < 0.001) and mid-BP (p < 0.001) compared to the women. The age-specific differences showed that older individuals had higher values of SBP (p < 0.001), pulse pressure (p < 0.001), and mid-BP (p < 0.001), while no significant differences for DBP (p = 0.496) were observed. Conclusions: This is the first study providing sex-specific and age-specific normative data for blood pressure in war veterans.

Comprehensive laboratory reference intervals for routine biochemical markers and pro-oxidant-antioxidant balance (PAB) in male adults

Background

Reference values of biochemical markers are influenced by various parameters including age, sex, region, and lifestyle. Hence, we aimed to determine age‐ and BMI‐specific reference intervals (RIs) for important clinical biomarkers in a healthy adult male population from northeastern Iran. This is also the first study to investigate reference values for pro‐oxidant‐antioxidant balance (PAB).

Methods

Seven hundred and twenty (720) healthy men, aged 20‐60 years, were recruited from Sarakhs in the northeast region of Iran. Reference values for lipid profiles (total cholesterol, triglyceride, HDL‐C and LDL‐C), fasting blood glucose, inflammatory factors (hs‐CRP and PAB), minerals (zinc and copper), uric acid, and blood pressure were measured and statistically analyzed to establish accurate age‐ and BMI‐specific RIs in alignment with CLSI Ep28‐A3 guidelines.

Results

RIs for lipid profiles, inflammatory factors, minerals, and uric acid required no age partitioning with the exception of fasting blood glucose and blood pressure, which demonstrated significantly higher values in subjects aged 50 years and older. Among these biomarkers, only uric acid, blood pressure, and triglycerides demonstrated statistically significant increases in reference value concentrations with increasing BMI.

Conclusion

In this study, age‐ and BMI‐specific RIs for several biochemical markers were determined in healthy adult Iranian men. Partitioning by age and BMI was only required for a few analytes with most demonstrating no statistically significant changes with these covariates. These data can be useful to monitor various diseases in male adults with varying BMI in this region and others.

Blood pressure profile is associated with microalbuminuria and retinopathy in hypertensive nondiabetic patients

BACKGROUND

Target organ damage is important for global cardiovascular risk assessment. The aim of this study was to explore the association between the blood pressure profile and end-organ damage in a hypertensive non-diabetic cohort.

METHODS

A total of 560 consecutive hypertensive nondiabetic patients (mean age: 58.2 ± 13.3 years, 221 men) were included in the study. All patients underwent thorough physical examination including fundoscopic examination. First morning urine samples were obtained from each patient and measurement of the albumin-to-creatinine ratio in first morning urine collection samples was used for diagnosis of microalbuminuria. All patients underwent a 24-h ambulatory blood pressure monitoring and were grouped as dippers and non-dippers according to the presence or absence of >10% decrease in blood pressure during the night, respectively.

RESULTS

The non-dipper group consisted of 247 patients with a non-dipper blood pressure profile, 31 patients with reverse dipping and 4 patients with extreme dipping. Non-dipper patients were significantly older. Coronary artery disease, cerebrovascular disease, hypertensive retinopathy and microalbuminuria were significantly more prevalent in the non-dipper patients. Non-dipping hypertension increased the risk of hypertensive retinopathy by 1.89 times (95% confidence interval, CI:1.35-2.65, p < 0.001) and the risk of microalbuminuria by 2.23 times (95% CI:1.49-3.33, p < 0.001). Non-dipping hypertension was still significantly associated with hypertensive retinopathy and microalbuminuria when adjusted by age and sex.

CONCLUSION

Non-dipping hypertension was associated with increased risk of hypertensive retinopathy and microalbuminuria. Blood pressure profiles should also be considered in assessing the risk for hypertensive patients.

The use of ambulatory blood pressure measurement

Measurement of ambulatory blood pressure is recommended by the National Institute for Health and Care Excellence guidelines to confirm the diagnosis of hypertension in the UK. This article describes the use of ambulatory devices, and discusses the benefits and disadvantages of their use in clinical practice.

What is the evidence base for diagnosing hypertension and for subsequent blood pressure treatment targets in the prevention of cardiovascular disease?

Diagnosing and treating hypertension plays an important role in minimising the risk of cardiovascular disease and stroke. Early and accurate diagnosis of hypertension, as well as regular monitoring, is essential to meet treatment targets. In this article, current recommendations for the screening and diagnosis of hypertension are reviewed. The evidence for treatment targets specified in contemporary guidelines is evaluated and recommendations from the USA, Canada, Europe and the UK are compared. Finally, consideration is given as to how diagnosis and management of hypertension might develop in the future.

Ethnicity and differences between clinic and ambulatory blood pressure measurements

BACKGROUND

This study investigated the relationship of ethnicity to the differences between blood pressure (BP) measured in a clinic setting and by ambulatory blood pressure monitoring (ABPM) in individuals with a previous diagnosis of hypertension (HT) and without a previous diagnosis of hypertension (NHT).

METHODS

A cross-sectional comparison of BP measurement was performed in 770 participants (white British (WB, 39%), South Asian (SA, 31%), and African Caribbean (AC, 30%)) in 28 primary care clinics in West Midlands, United Kingdom. Mean differences between daytime ABPM, standardized clinic (mean of 3 occasions), casual clinic (first reading on first occasion), and last routine BP taken at the general practitioner practice were compared in HT and NHT individuals.

RESULTS

Daytime systolic and diastolic ABPM readings were similar to standardized clinic BP (systolic: 128 (SE 0.9) vs. 125 (SE 0.9) mm Hg (NHT) and 132 (SE 0.7) vs. 131 (SE 0.7) mm Hg (HT)) and were not associated with ethnicity to a clinically important extent. When BP was taken less carefully, differences emerged: casual clinic readings were higher than ABPM, particularly in the HT group where the systolic differences approached clinical relevance (131 (SE 1.2) vs. 129 (SE 1.0) mm Hg (NHT) and 139 (SE 0.9) vs. 133 (SE 0.7) mm Hg (HT)) and were larger in SA and AC hypertensive individuals (136 (SE 1.5) vs. 133 (SE 1.2) mm Hg (WB), 141 (SE 1.7) vs. 133 (SE 1.4) mm Hg (SA), and 142 (SE 1.6) vs. 134 (SE 1.3) mm Hg (AC); mean differences: 3 (0-7), P = 0.03 and 4 (1-7), P = 0.01, respectively). Differences were also observed for the last practice reading in SA and ACs.

CONCLUSIONS

BP differences between ethnic groups where BP is carefully measured on multiple occasions are small and unlikely to alter clinical management. When BP is measured casually on a single occasion or in routine care, differences appear that could approach clinical relevance.

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.

Inter-arm blood pressure differences compared with ambulatory monitoring: a manifestation of the 'white-coat' effect?

BACKGROUND

Inter-arm difference in blood pressure of >10 mmHg is associated with peripheral vascular disease, but it is unclear how much of the difference in sequential right and left arm blood pressure measurements might be due to a 'white-coat' effect.

AIM

To use ambulatory blood pressure monitoring (ABPM) to better understand the clinical significance of inter-arm differences in blood pressure.

DESIGN AND SETTING

Retrospective study in a teaching hospital in Birmingham.

METHOD

Anonymised clinical data collected from 784 patients attending a single hospital-based hypertension clinic were retrospectively analysed. Each participant had blood pressure measured sequentially in both arms, followed by ABPM over the subsequent 24 hours.

RESULT

Data were available for 710 (91%) patients, of whom 39.3% (279) had a blood pressure difference of 10 mmHg or more between each arm. Compared to daytime systolic ABPM, the difference was 25.1 mmHg using the arm with the highest reading, but only 15.5 mmHg if the lower reading was taken (mean difference 9.6 mmHg (95% confidence interval [CI] = 9.0 mmHg to 10.3 mmHg)). However, differences between mean right (20.7 mmHg) or left (19.9 mmHg) arm blood pressure and daytime systolic ABPM were very similar.

CONCLUSION

Compared with ABPM, use of the higher of the left and right arm readings measured sequentially appears to overestimate true mean blood pressure. As there is no significant difference in the extent of disparity with ABPM by left or right arm, this is unlikely to be due to arm dominance and may be due to the 'white-coat' effect reducing blood pressure on repeated measurement. Where a large inter-arm blood pressure difference is detected with sequential measurement, healthcare professionals should re-measure the blood pressure in the original arm.

The natural history of, and risk factors for, progressive chronic kidney disease (CKD): the Renal Impairment in Secondary care (RIISC) study; rationale and protocol

BACKGROUND

Chronic kidney disease (CKD) affects up to 16% of the adult population and is associated with significant morbidity and mortality. People at highest risk from progressive CKD are defined by a sustained decline in estimated glomerular filtration rate (eGFR) and/or the presence of significant albuminuria/proteinuria and/or more advanced CKD. Accurate mapping of the bio-clinical determinants of this group will enable improved risk stratification and direct the development of better targeted management for people with CKD.

METHODS/DESIGN

The Renal Impairment In Secondary Care study is a prospective, observational cohort study, patients with CKD 4 and 5 or CKD 3 and either accelerated progression and/or proteinuria who are managed in secondary care are eligible to participate. Participants undergo a detailed bio-clinical assessment that includes measures of vascular health, periodontal health, quality of life and socio-economic status, clinical assessment and collection of samples for biomarker analysis. The assessments take place at baseline, and at six, 18, 36, 60 and 120 months; the outcomes of interest include cardiovascular events, progression to end stage kidney disease and death.

DISCUSSION

The determinants of progression of chronic kidney disease are not fully understood though there are a number of proposed risk factors for progression (both traditional and novel). This study will provide a detailed bio-clinical phenotype of patients with high-risk chronic kidney disease (high risk of both progression and cardiovascular events) and will repeatedly assess them over a prolonged follow up period. Recruitment commenced in Autumn 2010 and will provide many outputs that will add to the evidence base for progressive chronic kidney disease.

Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study

BACKGROUND

The diagnosis of hypertension has traditionally been based on blood-pressure measurements in the clinic, but home and ambulatory measurements better correlate with cardiovascular outcome, and ambulatory monitoring is more accurate than both clinic and home monitoring in diagnosing hypertension. We aimed to compare the cost-effectiveness of different diagnostic strategies for hypertension.

METHODS

We did a Markov model-based probabilistic cost-effectiveness analysis. We used a hypothetical primary-care population aged 40 years or older with a screening blood-pressure measurement greater than 140/90 mm Hg and risk-factor prevalence equivalent to the general population. We compared three diagnostic strategies-further blood pressure measurement in the clinic, at home, and with an ambulatory monitor-in terms of lifetime costs, quality-adjusted life years, and cost-effectiveness.

FINDINGS

Ambulatory monitoring was the most cost-effective strategy for the diagnosis of hypertension for men and women of all ages. It was cost-saving for all groups (from -£56 [95% CI -105 to -10] in men aged 75 years to -£323 [-389 to -222] in women aged 40 years) and resulted in more quality-adjusted life years for men and women older than 50 years (from 0·006 [0·000 to 0·015] for women aged 60 years to 0·022 [0·012 to 0·035] for men aged 70 years). This finding was robust when assessed with a wide range of deterministic sensitivity analyses around the base case, but was sensitive if home monitoring was judged to have equal test performance to ambulatory monitoring or if treatment was judged effective irrespective of whether an individual was hypertensive.

INTERPRETATION

Ambulatory monitoring as a diagnostic strategy for hypertension after an initial raised reading in the clinic would reduce misdiagnosis and save costs. Additional costs from ambulatory monitoring are counterbalanced by cost savings from better targeted treatment. Ambulatory monitoring is recommended for most patients before the start of antihypertensive drugs.

FUNDING

National Institute for Health Research and the National Institute for Health and Clinical Excellence.

Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review

OBJECTIVE

To determine the relative accuracy of clinic measurements and home blood pressure monitoring compared with ambulatory blood pressure monitoring as a reference standard for the diagnosis of hypertension.

DESIGN

Systematic review with meta-analysis with hierarchical summary receiver operating characteristic models. Methodological quality was appraised, including evidence of validation of blood pressure measurement equipment.

DATA SOURCES

Medline (from 1966), Embase (from 1980), Cochrane Database of Systematic Reviews, DARE, Medion, ARIF, and TRIP up to May 2010. Eligibility criteria for selecting studies Eligible studies examined diagnosis of hypertension in adults of all ages using home and/or clinic blood pressure measurement compared with those made using ambulatory monitoring that clearly defined thresholds to diagnose hypertension.

RESULTS

The 20 eligible studies used various thresholds for the diagnosis of hypertension, and only seven studies (clinic) and three studies (home) could be directly compared with ambulatory monitoring. Compared with ambulatory monitoring thresholds of 135/85 mm Hg, clinic measurements over 140/90 mm Hg had mean sensitivity and specificity of 74.6% (95% confidence interval 60.7% to 84.8%) and 74.6% (47.9% to 90.4%), respectively, whereas home measurements over 135/85 mm Hg had mean sensitivity and specificity of 85.7% (78.0% to 91.0%) and 62.4% (48.0% to 75.0%).

CONCLUSIONS

Neither clinic nor home measurement had sufficient sensitivity or specificity to be recommended as a single diagnostic test. If ambulatory monitoring is taken as the reference standard, then treatment decisions based on clinic or home blood pressure alone might result in substantial overdiagnosis. Ambulatory monitoring before the start of lifelong drug treatment might lead to more appropriate targeting of treatment, particularly around the diagnostic threshold.

The benefit of strength training on arterial blood pressure in patients with type 2 diabetes mellitus measured with ambulatory 24-hour blood pressure systems

BACKGROUND

An ambulatory 24-hour BP-monitoring (ABPM) is of paramount importance, while patients are engaged in their usual activities, for a better representation of blood pressure (BP). ABPM provides not only automated measurements of brachial-artery pressure over a 24-hour period but also a highly reproducible circadian profile. The purpose of this investigation was to evaluate the effect of strength training (ST) on BP in patients with type 2 diabetes mellitus (T2D) and to obtain new and important information on BP profiles over 24-hour by using an ABPM.

MATERIAL AND METHODS

We recruited ten patients (mean age: 59.7 +/- 7.3) from our Diabetes Department who participated in a 4-month systematic ST program on three non-consecutive days of the week. The ST program consisted of exercises for all major muscle groups. The numbers of sets for each muscle group were systematically increased from 3 at the beginning of the program to 4, 5 and finally 6 sets per week at the end of the program. The ABPM equipment (oscillometric Model Mobil-O-Graph CE 0434) was applied before and after 4-month training period. Routine HbA1C levels were measured using standard techniques. All subjects took a cycling test to measure maximum oxygen uptake (VO2peak) and maximum workload (Wmax) before and after the training period. Maximal strength was determined by one repetition maximum (1RM) in kp for the bench press, bench pull and leg press exercises, using the Concept 2 Dyno.

RESULTS

Analysis of the pooled daytime and night-time data showed a significant reduction of mean arterial BP (from 93.8 +/- 19.2 to 90.6 +/- 14.3 mmHg; p > 0.01) after a 4-month ST (-3.4% mmHg). VO2peak (p < 0.05), Wmax (p < 0.05), 1RM for all muscle groups (p < 0.01), lean body mass (p < 0.05) and percent body fat (p < 0.05) improved significantly after a 4-month of ST. HbA1C showed a significant reduction by 14.5% (from 8.3 +/- 1.7 to 7.1 +/- 0.9%; p < 0.01).

CONCLUSION

We found a significant reduction of mean arterial BP after a 4-month ST, measured by the ABPM system. These results demonstrate that ST may not only increase muscle strength but also decrease BP and perhaps the risk of future CVD development.

The BpTRU automatic blood pressure monitor compared to 24 hour ambulatory blood pressure monitoring in the assessment of blood pressure in patients with hypertension

BACKGROUND

Increasing evidence suggests that ABPM more closely predicts target organ damage than does clinic measurement. Future guidelines may suggest ABPM as routine in the diagnosis and monitoring of hypertension. This would create difficulties as this test is expensive and often difficult to obtain. The purpose of this study is to determine the degree to which the BpTRU automatic blood pressure monitor predicts results on 24 hour ambulatory blood pressure monitoring (ABPM).

METHODS

A quantitative analysis comparing blood pressure measured by the BpTRU device with the mean daytime blood pressure on 24 hour ABPM. The study was conducted by the Centre for Studies in Primary Care, Queen's University, Kingston, Ontario, Canada on adult primary care patients who are enrolled in two randomized controlled trials on hypertension. The main outcomes were the mean of the blood pressures measured at the three most recent office visits, the initial measurement on the BpTRU-100, the mean of the five measurements on the BpTRU monitor, and the daytime average on 24 hour ABPM.

RESULTS

The group mean of the three charted clinic measured blood pressures (150.8 (SD10.26) / 82.9 (SD 8.44)) was not statistically different from the group mean of the initial reading on BpTRU (150.0 (SD21.33) / 83.3 (SD12.00)). The group mean of the average of five BpTRU readings (140.0 (SD17.71) / 79.8 (SD 10.46)) was not statistically different from the 24 hour daytime mean on ABPM (141.5 (SD 13.25) / 79.7 (SD 7.79)). Within patients, BpTRU average correlated significantly better with daytime ambulatory pressure than did clinic averages (BpTRU r = 0.571, clinic r = 0.145). Based on assessment of sensitivity and specificity at different cut-points, it is suggested that the initial treatment target using the BpTRU be set at <135/85 mmHG, but achievement of target should be confirmed using 24 hour ABPM.

CONCLUSION

The BpTRU average better predicts ABPM than does the average of the blood pressures recorded on the patient chart from the three most recent visits. The BpTRU automatic clinic blood pressure monitor should be used as an adjunct to ABPM to effectively diagnose and monitor hypertension.

Home, clinic, and ambulatory blood pressure monitoring in children with chronic renal failure

Ambulatory blood pressure monitoring (ABPM) provides superior information for diagnosis and treatment of pediatric hypertension, but for reasons of practicality, clinic blood pressure measurements (CBP) are still the primary diagnostic tool. Regular home blood pressure measurements (HBP) may be an alternative to ABPM, but this technique awaits validation in practice. We analyzed the concordance of ABPM, CBP and HBP in 118 pediatric patients (3-19 y) with chronic renal failure. HBP readings (10.5 +/- 5.4 per patient) were averaged for one week around the day of ABPM and CBP. Mean arterial pressure (MAP) measured by HBP (84.0 +/- 10 mm Hg) was significantly lower than both CBP (86.1 +/- 14.1 mm Hg, P< 0.05) and daytime ABPM (90.3 +/- 10.4 mm Hg, P< 0.05). HBP detected hypertensive patients with greater specificity (82 versus 70%), but lower sensitivity (52 versus 70%) than CBP. The fraction of patients rated erroneously hypertensive was 23% with CBP, but only 14% with HBP. The 95% limits of agreement with ABPM were narrower for HBP (-23 to10 mm Hg) than for CBP (-30 to 21 mm Hg). CBP, but not HBP measurements, were less precise in the upper BP range. The accuracy of HBP measurements did not change with use over a six months time period. In conclusion, HBP was superior to CBP in predicting ABPM, but neither CBP nor HBP detected hypertension with enough sensitivity or specificity to replace ABPM. The greater specificity of HBP compared with CBP makes it a more suitable tool for diagnosis, rather than screening, of hypertension in children.

How well are we managing and monitoring high blood pressure?

PURPOSE OF REVIEW

We will summarize the latest available data on hypertension control levels in different populations throughout the world, and review the factors that appear to contribute to the widespread lack of blood pressure control in identified hypertensive patients.

RECENT FINDINGS

Population surveys throughout the world indicate that the proportion of hypertensive patients with blood pressure controlled to below 140/90 mmHg ranges from 5% in Taiwan to 25% in the United States. Studies in the US have shown that the majority of hypertensive patients classified as uncontrolled have diastolic pressure below 90 mmHg with mild systolic elevation in the 140-160 mmHg range, and that these blood pressure levels rarely elicit a treatment intensification action by the physician. The results of the Antihypertensive and Lipid Lowering to Prevent Heart Attack Trial indicate that it is feasible to maintain average blood pressures on treatment to levels well below 140/90 mmHg in elderly hypertensive patients in primary care settings. Although the literature on automated blood pressure measurement and comparisons between office blood pressure and home blood pressure continues to grow, there has been little attention paid to practicing physicians' attitudes and beliefs about different blood pressure measurement methods, or to the feasibility of standardizing blood pressure measurement in typical practice settings.

SUMMARY

The experience in the US indicates that widely publicized treatment guidelines recommending blood pressure control targets and choice of first-line agents may have little influence on practicing physicians, even when based on solid evidence from clinical trials. Controversies in the literature regarding treatment targets, appropriate drug choices, and blood pressure monitoring methods are likely to delay improvements in overall population control.