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

Measuring blood pressure from Korotkoff sounds as the brachial cuff inflates on average provides higher values than when the cuff deflates

Objectives. In this study, we test the hypothesis that if, as demonstrated in a previous study, brachial arteries exhibit hysteresis as the occluding cuff is deflated and fail to open until cuff pressure (CP) is well below true intra-arterial blood pressure (IAPB), estimating systolic (SBP) and diastolic blood pressure (DBP) from the presence of Korotkoff sounds (KS) as CP increases may eliminate these errors and give more accurate estimates of SBP and DBP relative to IABP readings.Approach. In 62 subjects of varying ages (45.1 ± 19.8, range 20.6-75.8 years), including 44 men (45.3 ± 19.4, range 20.6-75.8 years) and 18 women (44.4 ± 21.4, range 20.9-75.3 years), we sequentially recorded SBP and DBP both during cuff inflation and cuff deflation using KS.Results. There was a significant (p< 0.0001) increase in SBP from 122.8 ± 13.2 to 127.6 ± 13.0 mmHg and a significant (p= 0.0001) increase in DBP from 70.0 ± 9.0 to 77.5 ± 9.7 mmHg. Of the 62 subjects, 51 showed a positive increase in SBP (0-14 mmHg) and 11 subjects showed a reduction (-0.3 to -7 mmHg). The average differences for SBP and DBP estimates derived as the cuff inflates and those derived as the cuff deflates were 4.8 ± 4.6 mmHg and 2.5 ± 4.6 mmHg, not dissimilar to the differences reported between IABP and non-invasive blood pressure measurements. Although we could not develop multiparameter linear or non-linear models to explain this phenomenon we have clearly demonstrated through ANOVA tests that both body mass index (BMI) and pulse wave velocity are implicated, supporting the hypothesis that the phenomenon is associated with age, higher BMI and stiffer arteries.Significance. The implications of this study are that brachial sphygmomanometry carried out during cuff inflation could be more accurate than measurements carried out as the cuff deflates. Further research is required to validate these results with IAPB measurements.

Noninvasive pediatric blood pressure assessment: exploring the clinicians' perspective

BACKGROUND

Obtaining accurate and reliable blood pressure (BP) readings in pediatric patients is challenging, given difficulties in adhering to measurement guidelines, limited device validation and variable patient cooperation. This study aimed to investigate clinicians' perspectives surrounding noninvasive pediatric BP assessment to identify opportunities for improvement in BP technology and clinical practice.

METHOD

Based on an adapted version of the extended Technology Acceptance Model 2, semi-structured interviews were conducted with clinicians involved in noninvasive pediatric BP assessment in a major Australian children's hospital. Transcripts were analyzed thematically and guided by Technology Acceptance Model 2.

RESULTS

Clinician responses ( n  = 20) revealed that poor patient tolerance of BP measurement resulting from excessive cuff inflation is a major hindrance to reliable pediatric BP assessment. Clinicians described low trust in BP readings from automated devices, often relating to poor patient tolerance to cuff inflation, thereby diminishing the clinical utility of these readings in informing treatment decisions. Auscultatory measurement was regarded as more trustworthy and better tolerated, but less convenient to perform as compared with oscillometric measurement.

CONCLUSION

A dissonance exists between (1) low trust and clinical utility of the most common and easy-to-use BP measurement approach (automated devices), versus (2) higher trust and clinical utility, but efficiency and user-related impediments, for the auscultatory method. Based on our results, we have developed the Blood Pressure Acceptance Model, which can be used to explain and predict clinicians' acceptance of BP technology. Further work is needed to improve the tolerability and accuracy of automated BP devices in real-world pediatric settings.

Structural and functional cardiac parameters across occupations: a cross-sectional study in differing work environments

Previous investigations have highlighted notable variations in cardiovascular risk indicators associated with various professional categories. However, only a few studies have examined structural and functional cardiac parameters using echocardiography within distinct occupational groups. Hence, this study endeavored to assess cardiac structural and functional parameters in three additional occupations: firefighters (FFs), police officers (POs), and office workers (OWs). This prospective study encompassed 197 male participants (97 FFs, 54 POs, and 46 OWs) from Germany. All participants underwent 2D and Doppler echocardiography in resting conditions; standard parasternal and apical axis views were employed to evaluate structural (diastolic and systolic) and functional (systolic and diastolic function, and strain) cardiac parameters. All three occupational groups exhibited a tendency towards septal hypertrophy. Notably, OWs exhibited the largest diastolic interventricular septum diameter (IVSd), at 1.33 ± 0.25 cm. IVSd significantly varied between POs and OWs (p = 0.000) and between POs and FFs (p = 0.025). Additionally, during diastole a substantially larger left ventricular posterior wall diameter (LVPWd) was observed in OWs compared to FFs (p = 0.001) and POs (p = 0.013). The left ventricular diastolic cavity diameter (LVIDd) and the left ventricular systolic cavity diameter (LVIDs) were significantly higher in POs than they were in FFs (LVIDd: p = 0.001; LVIDs: p = 0.009), and the LVIDd was notably higher in FFs (p = 0.015) and POs compared to OWs (p = 0.000). FFs exhibited significantly better diastolic function, indicated by higher diastolic peak velocity ratios (MV E/A ratio) and E/E' ratios, compared to POs (E/A ratio: p = 0.025; E/E' ratio: p = 0.014). No significant difference in diastolic performance was found between OWs and FFs. Significantly higher E'(lateral) values were noted in POs compared to FFs (p = 0.003) and OWs (p = 0.004). Ejection fraction did not significantly differ among FFs, POs, and OWs (p > 0.6). The left ventricular mass (LV Mass) was notably higher in POs than it was in FFs (p = 0.039) and OWs (p = 0.033). Strain parameter differences were notably improved in two- (p = 0.006) and four-chamber (p = 0.018) views for FFs compared to POs. Concentric remodeling was the predominant change observed in all three occupational groups. Significant differences in the presence of various forms of hypertrophy were observed in FFs, POs, and OWs (exact Fisher test p-values: FFs vs. OWs = 0.021, POs vs. OWs = 0.002). OWs demonstrated notably higher rates of concentric remodeling than FFs did (71.77% vs. 47.9%). This study underscores disparities in both functional and structural parameters in diverse occupational groups. Larger prospective studies are warranted to investigate and delineate differences in structural and functional cardiac parameters across occupational groups, and to discern their associated effects and risks on the cardiovascular health of these distinct professional cohorts.

Simultaneous 24-h ambulatory blood pressure measurement on both arms: a consideration for improving hypertension management

OBJECTIVE

Arterial hypertension is one of the common treatment goals in today's medicine. 24-h ambulatory blood pressure measurement (ABPM) performed by oscillometric cuff-based devices is considered as the gold standard in hypertension diagnostics. This study aims at examining the measurement accuracy of a widely used, ABPM device.

METHODS

Fifty-two young and healthy participants underwent simultaneous 24-h ABPM on the left and the right upper arm using two Boso/A&D TM-2430 oscillometric cuff-based devices. Pressure curves of the cuffs, as well as hydrostatic pressure difference between the cuffs were recorded.

RESULTS

The mean differences between both simultaneous measurements were 1.16 mmHg with limits of agreement of 36.23 mmHg for SBP and 1.32 mmHg with limits of agreement of 32.65 mmHg for DBP. Excluding measurements where the pressure curves were disturbed and correcting for hydrostatic pressure difference between the cuffs, reduced the measurement error. However, limits of agreement remained around 20 mmHg. There were large differences in hypertension grading and dipping pattern classification between simultaneous measurements on the left and right arm.

CONCLUSION

The cuff-based ABPM device reveals notable measurement uncertainties, influencing hypertension grading, dipping pattern classification and blood pressure variability. These effects are attributed in part to disturbances during cuff deflation and hydrostatic influences. Nonetheless, ABPM has shown its clinical values in several studies, while this study underscores its still unlocked potential to improve hypertension management.

Polygenic risk scores associate with blood pressure traits across the lifespan

AIMS

Hypertension is a major modifiable cause of morbidity and mortality that affects over 1 billion people worldwide. Blood pressure (BP) traits have a strong genetic component that can be quantified with polygenic risk scores (PRSs). To date, the performance of BP PRSs has mainly been assessed in adults, and less is known about polygenic hypertension risk in childhood.

METHODS AND RESULTS

Multiple PRSs for systolic BP (SBP), diastolic BP (DBP), and pulse pressure were developed using either genome-wide significant weights, pruning and thresholding, or Bayesian regression. Among 87 total PRSs, the top performer for each trait was applied in independent cohorts of children and adult to assess genotype-phenotype associations and disease risk across the lifespan. Differences between those with low (1st decile), average (2nd-9th decile), and high (10th decile) PRS emerge in the first years of life and are maintained throughout adulthood. These diverging BP trajectories also seem to affect cardiovascular and renal disease risk, with increased risk observed among those in the top decile and reduced risk among those in the bottom decile of the polygenic risk distribution compared with the rest of the population.

CONCLUSION

Genetic risk factors are associated with BP traits across the lifespan, beginning in the first years of life. Given the importance of exposure time in disease pathogenesis and the early rise in BP levels among those genetically susceptible, PRSs may help identify high-risk individuals prior to hypertension onset, facilitate primordial prevention, and reduce the burden of this public health challenge.

Impact of sleep quality and physical activity on blood pressure variability

Increased blood pressure variability (BPV) is linked to cardiovascular disease and mortality, yet few modifiable BPV risk factors are known. We aimed to assess the relationship between sleep quality and activity level on longitudinal BPV in a cohort of community-dwelling adults (age ≥18) from 17 countries. Using Withings home measurement devices, we examined sleep quality and physical activity over one year, operationalized as mean daily step count and number of sleep interruptions, both transformed into tertiles. The primary study outcome was high BPV, defined as the top tertile of systolic blood pressure standard deviation. Our cohort comprised 29,375 individuals (mean age = 58.6 years) with 127.8±90.1 mean days of measurements. After adjusting for age, gender, country, body mass index, measurement days, mean blood pressure, and total time in bed, the odds ratio of having high BPV for those in the top tertile of sleep interruptions (poor sleep) was 1.37 (95% CI, 1.28-1.47) and 1.44 (95% CI, 1.35-1.54) for those in the lowest tertile of step count (physically inactive). Combining these exposures revealed a significant excess relative risk of 0.20 (95% CI, 0.04-0.35, p = 0.012), confirming their super-additive effect. Comparing individuals with the worst exposure status (lowest step count and highest sleep interruptions, n = 2,690) to those with the most optimal status (highest step count and lowest sleep interruptions, n = 3,531) yielded an odds ratio of 2.01 (95% CI, 1.80-2.25) for high BPV. Our findings demonstrate that poor sleep quality and physical inactivity are associated with increased BPV both independently and super-additively.

Implementation of Video Blood Pressure Visits in the Veterans Health Administration

Introduction: Almost half of veterans (44.6%) seen in the U.S. Department of Veterans Affairs outpatient setting are diagnosed with hypertension (HTN). Because of the widespread nature of HTN, use of virtual visits has the potential to improve blood pressure (BP) management. This evaluation assessed the effectiveness of video blood pressure visits (VBPVs) in the management of HTN in veterans enrolled in Veterans Health Administration primary care. Methods: The program was implemented within the existing veteran-centered medical home. VBPVs are scheduled where the nurse observes veterans taking their BP and provides teaching or counseling. A national training curriculum was delivered to local nurse champions through Microsoft Teams. We analyzed improvement in BP over a 2-year period. We also captured actions taken by nurses during the VBPV by searching the electronic notes. Ratings of training and comments were summarized using feedback forms completed after training. Results: In total, 81,476 veterans participated in VBPVs over 2 years. Of those, 44,682 veterans had an existing ICD-10 code related to HTN. Of the 18,078 veterans who had a pre- and post-VBPV BP, the average change to systolic measurement was -10.6 mm Hg (range -82 to 78). Average change to diastolic measurement was -4.61 mm Hg (range -59 to 55). Most interventions addressed medication management (77%). Nurses' evaluations of the program were positive. Conclusions: Video visits provide reliable and convenient veteran-centered care. Such visits enable care when unanticipated interruptions occur such as the coronavirus disease 2019 pandemic. In addition to medication management, nurse-led interventions such as counseling on lifestyle changes can be effective in HTN management.

Calibration-free blood pressure estimation based on a convolutional neural network

In this study, we conducted research on a deep learning-based blood pressure (BP) estimation model suitable for wearable environments. To measure BP while wearing a wearable watch, it needs to be considered that computing power for signal processing is limited and the input signals are subject to noise interference. Therefore, we employed a convolutional neural network (CNN) as the BP estimation model and utilized time-series electrocardiogram (ECG) and photoplethysmogram (PPG) signals, which are quantifiable in a wearable context. We generated periodic input signals and used differential and thresholding methods to decrease noise in the preprocessing step. We then applied a max-pooling technique with filter sizes of 2 × 1 and 5 × 1 within a 3-layer convolutional neural network to estimate BP. Our method was trained, validated, and tested using 2.4 million data samples from 49 patients in the intensive care unit. These samples, totaling 3.1 GB were obtained from the publicly accessible MIMIC database. As a result of a test with 480,000 data samples, the average root mean square error in BP estimation was 3.41, 5.80, and 2.78 mm Hg in the prediction of pulse pressure, systolic BP (SBP), and diastolic BP (DBP), respectively. The cumulative error percentage less than 5 mm Hg was 68% and 93% for SBP and DBP, respectively. In addition, the cumulative error percentage less than 15 mm Hg was 98% and 99% for SBP and DBP. Subsequently, we evaluated the impact of changes in input signal length (1 cycle vs. 30 s) and the introduction of noise on BP estimation results. The experimental results revealed that the length of the input signal did not significantly affect the performance of CNN-based analysis. When estimating BP using noise-added ECG signals, the mean absolute error (MAE) for SBP and DBP was 9.72 and 6.67 mm Hg, respectively. Meanwhile, when using noise-added PPG signals, the MAE for SBP and DBP was 26.85 and 14.00 mm Hg, respectively. Therefore, this study confirmed that using ECG signals rather than PPG signals is advantageous for noise reduction in a wearable environment. Besides, short sampling frames without calibration can be effective as input signals. Furthermore, it demonstrated that using a model suitable for information extraction rather than a specialized deep learning model for sequential data can yield satisfactory results in BP estimation.

Mechanistic Assessment of Cardiovascular State Informed by Vibroacoustic Sensors

Monitoring blood pressure, a parameter closely related to cardiovascular activity, can help predict imminent cardiovascular events. In this paper, a novel method is proposed to customize an existing mechanistic model of the cardiovascular system through feature extraction from cardiopulmonary acoustic signals to estimate blood pressure using artificial intelligence. As various factors, such as drug consumption, can alter the biomechanical properties of the cardiovascular system, the proposed method seeks to personalize the mechanistic model using information extracted from vibroacoustic sensors. Simulation results for the proposed approach are evaluated by calculating the error in blood pressure estimates compared to ground truth arterial line measurements, with the results showing promise for this method.

Prevalence of postprandial hypotension in older adults: a systematic review and meta-analysis

BACKGROUND

Older adults with postprandial hypotension (PPH) increase susceptibility to falls, syncope, stroke, acute cardiovascular diseases and even death. However, the prevalence of this condition varies significantly across studies. We aimed to determine the prevalence of PPH in older adults.

METHODS

Web of Science, PubMed, Cochrane Library, Embase and CINAHL were searched from their inception until February 2023. Search terms included 'postprandial period', 'hypotension' and 'postprandial hypotension'. Eligible studies were assessed using the Joanna Briggs Institute tool. Meta-analyses were performed among similar selected studies.

RESULTS

Thirteen eligible studies were included, and data from 3,021 participants were pooled. The meta-analysis revealed a PPH prevalence of 40.5% [95% confidence interval (CI): 0.290-0.519] in older adults, and this was prevalent in the community (32.8%, 95% CI: 0.078-0.647, n = 1,594), long-term healthcare facility (39.4%, 95% CI: 0.254-0.610, n = 1,062) and geriatrics department of hospitals (49.3%, 95% CI: 0.357-0.630, n = 365). The pooled results showed significant heterogeneity (I2 > 90%), partially related to the different ages, sex, pre-prandial systolic blood pressure levels of participants, or the different criteria and methodology used to diagnose PPH.

CONCLUSIONS

PPH is a prevalent condition in older adults. Further research is needed to confirm this result, and priority should be given to establishing international consensus on PPH diagnostic criteria and designing its diagnostic procedure.

Comparison of blood pressure measurements on the bare and sleeved arms - what does it uncover?

Accurate office blood pressure (BP) measurement remains crucial in diagnosing and managing hypertension. In this study, we aimed to compare BP measurements done over a bare arm versus a sleeved arm, while controlling all other possible sources of variance. We collected BP measurements of 100 hypertensive patients visiting a nephrology and hypertension clinic between January 2019 and December 2023. Measurements were taken by a single operator and according to the updated guidelines. BP measurements were performed first with one arm bare, and the other arm sleeved, with measurements taken simultaneously. Then, measurements were again taken simultaneously after exposing the arm which was first sleeved, and dressing the arm which was bare at first. A nonparametric Wilcoxon test was performed to compare each patient's measurements on each arm. No statistically significant differences were found between the sleeved and the bare arm measurements, with one exception of SBP measured on the left arm (slightly lower SBP on the bare arm). While looking at the absolute value of differences, the median difference was impressive with a 7-8 mmHg systolic difference and 5.5 mmHg diastolic difference. Our study revealed a robust and unpredicted effect of clothing on BP; in some patients, BP was increased while in others decreased. Therefore, we believe there is importance in measuring BP on bare skin, regardless of clothing or sleeve type.

Quality in screening and measuring blood pressure in China's primary health care: a national cross-sectional study using unannounced standardized patients

Background

This study aims to evaluate primary care providers' adherence to the standard of measuring blood pressure for people aged 35 or above during their initial visit, as per Chinese guidelines, and to identify factors affecting their practices.

Methods

We developed 11 standardized patients (SP) cases as tracer conditions to evaluate primary care, and deployed trained SPs for unannounced visits to randomly selected providers in seven provinces of China. The SPs used a checklist based on guidelines to record whether and how blood pressure was measured. Data were analyzed descriptively and regression analysis was performed to examine the association between outcomes and factors such as provider, patient, facility, and clinical case characteristics.

Findings

The SPs conducted 1201 visits and found that less than one-third of USPs ≥35 had their blood pressure measured. Only 26.9% of migraine and 15.4% of diabetes cases received blood pressure measurements. Additionally, these measurements did not follow the proper guidelines and recommended steps. On average, 55.6% of the steps were followed with few providers considering influencing factors before measurement and only 6.0% of patients received both-arm measurements. The use of wrist sphygmomanometers was associated with poor blood pressure measurement.

Interpretation

In China, primary care hypertension screening practices fall short of guidelines, with infrequent initiation of blood pressure measurements and inadequate adherence to proper measurement steps. To address this, priority should be placed on adopting, implementing, and upholding guidelines for hypertension screening and measurement.

Funding

National Natural Science Foundation of China, Swiss Agency for Development and Cooperation, Doctoral Fund Project of Inner Mongolia Medical University, China Postdoctoral Science Foundation.

Blood pressure variability supersedes heart rate variability as a real-world measure of dementia risk

Blood pressure variability (BPV) and heart rate variability (HRV) have been associated with Alzheimer's Disease and Related Dementias (ADRD) in rigorously controlled studies. However, the extent to which BPV and HRV may offer predictive information in real-world, routine clinical care is unclear. In a retrospective cohort study of 48,204 adults (age 54.9 ± 17.5 years, 60% female) receiving continuous care at a single center, we derived BPV and HRV from routinely collected clinical data. We use multivariable Cox models to evaluate the association of BPV and HRV, separately and in combination, with incident ADRD. Over a median 3 [2.4, 3.0] years, there were 443 cases of new-onset ADRD. We found that clinically derived measures of BPV, but not HRV, were consistently associated with incident ADRD. In combined analyses, only patients in both the highest quartile of BPV and lowest quartile of HRV had increased ADRD risk (HR 2.34, 95% CI 1.44-3.81). These results indicate that clinically derived BPV, rather than HRV, offers a consistent and readily available metric for ADRD risk assessment in a real-world patient care setting. Thus, implementation of BPV as a widely accessible tool could allow clinical providers to efficiently identify patients most likely to benefit from comprehensive ADRD screening.

Screening for hypertension in adults: protocol for evidence reviews to inform a Canadian Task Force on Preventive Health Care guideline update

PURPOSE

To inform updated recommendations by the Canadian Task Force on Preventive Health Care on screening in a primary care setting for hypertension in adults aged 18 years and older. This protocol outlines the scope and methods for a series of systematic reviews and one overview of reviews.

METHODS

To evaluate the benefits and harms of screening for hypertension, the Task Force will rely on the relevant key questions from the 2021 United States Preventive Services Task Force systematic review. In addition, a series of reviews will be conducted to identify, appraise, and synthesize the evidence on (1) the association of blood pressure measurement methods and future cardiovascular (CVD)-related outcomes, (2) thresholds for discussions of treatment initiation, and (3) patient acceptability of hypertension screening methods. For the review of blood pressure measurement methods and future CVD-related outcomes, we will perform a de novo review and search MEDLINE, Embase, CENTRAL, and APA PsycInfo for randomized controlled trials, prospective or retrospective cohort studies, nested case-control studies, and within-arm analyses of intervention studies. For the thresholds for discussions of treatment initiation review, we will perform an overview of reviews and update results from a relevant 2019 UK NICE review. We will search MEDLINE, Embase, APA PsycInfo, and Epistemonikos for systematic reviews. For the acceptability review, we will perform a de novo systematic review and search MEDLINE, Embase, and APA PsycInfo for randomized controlled trials, controlled clinical trials, and observational studies with comparison groups. Websites of relevant organizations, gray literature sources, and the reference lists of included studies and reviews will be hand-searched. Title and abstract screening will be completed by two independent reviewers. Full-text screening, data extraction, risk-of-bias assessment, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) will be completed independently by two reviewers. Results from included studies will be synthesized narratively and pooled via meta-analysis when appropriate. The GRADE approach will be used to assess the certainty of evidence for outcomes.

DISCUSSION

The results of the evidence reviews will be used to inform Canadian recommendations on screening for hypertension in adults aged 18 years and older.

SYSTEMATIC REVIEW REGISTRATION

This protocol is registered on PROSPERO and is available on the Open Science Framework (osf.io/8w4tz).

The Role of a Smart Health Ecosystem in Transforming the Management of Chronic Health Conditions

The effective management of chronic conditions requires an approach that promotes a shift in care from the clinic to the home, improves the efficiency of health care systems, and benefits all users irrespective of their needs and preferences. Digital health can provide a solution to this challenge, and in this paper, we provide our vision for a smart health ecosystem. A smart health ecosystem leverages the interoperability of digital health technologies and advancements in big data and artificial intelligence for data collection and analysis and the provision of support. We envisage that this approach will allow a comprehensive picture of health, personalization, and tailoring of behavioral and clinical support; drive theoretical advancements; and empower people to manage their own health with support from health care professionals. We illustrate the concept with 2 use cases and discuss topics for further consideration and research, concluding with a message to encourage people with chronic conditions, their caregivers, health care professionals, policy and decision makers, and technology experts to join their efforts and work toward adopting a smart health ecosystem.

Is the Blood Pressure-Enabled Smartwatch Ready to Drive Precision Medicine? Supporting Findings From a Validation Study

Background

The popular wrist-worn wearables recording a variety of health metrics such as blood pressure (BP) in real time could play a potential role to advance precision medicine, but these devices are often insufficiently validated for their performance to enhance confidence in its use across diverse populations. The accuracy of BP-enabled smartwatch is assessed among the multi-ethnic Malaysians, and findings is discussed in comparison with conventional automated upper-arm BP device.

Methods

Validation procedures followed the guidelines by the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Universal Standard (ISO 81060-2:2018). Quota sampling was employed to obtain eligible patients with normal and abnormal BP as per guideline. The measurements of BP were taken at wrist using HUAWEI WATCH D (test BP); and the readings were assessed against reference BP by the mercury sphygmomanometer. Agreement statistics and linear regression analyses were performed.

Results

BP measurements (234 data pairs) from 78 patients that fulfilled AAMI/ESH/ISO protocol were analyzed. The BP readings taken by the HUAWEI WATCH D were comparable to reference BP by sphygmomanometer based on 1) Criterion 1: systolic blood pressure (SBP) = -0.034 (SD 5.24) and diastolic blood pressure (DBP) = -0.65 (SD 4.66) mm Hg; and 2) Criterion 2: SBPs = -0.034 (SD 4.18) and DBPs = -0.65 (SD 3.94) mm Hg. Factors of sociodemographic characteristics, anthropometric measurements, cardiovascular comorbidities, and wrist hair density were not significantly associated with the mean BP differences.

Conclusions

HUAWEI WATCH D fulfilled criteria 1 and 2 of the AAMI/ESH/ISO Universal Standard (ISO 81060-2:2018) guidelines. It can be recommended for clinical use across a wider population. The rich data from real-time BP measurements in concurrent with other health-related parameters recorded by the smartwatch wearable offer opportunities to drive precision medicine in tackling therapeutic inertia by personalizing BP control regimen.

Genome mining yields putative disease-associated ROMK variants with distinct defects

Bartter syndrome is a group of rare genetic disorders that compromise kidney function by impairing electrolyte reabsorption. Left untreated, the resulting hyponatremia, hypokalemia, and dehydration can be fatal, and there is currently no cure. Bartter syndrome type II specifically arises from mutations in KCNJ1, which encodes the renal outer medullary potassium channel, ROMK. Over 40 Bartter syndrome-associated mutations in KCNJ1 have been identified, yet their molecular defects are mostly uncharacterized. Nevertheless, a subset of disease-linked mutations compromise ROMK folding in the endoplasmic reticulum (ER), which in turn results in premature degradation via the ER associated degradation (ERAD) pathway. To identify uncharacterized human variants that might similarly lead to premature degradation and thus disease, we mined three genomic databases. First, phenotypic data in the UK Biobank were analyzed using a recently developed computational platform to identify individuals carrying KCNJ1 variants with clinical features consistent with Bartter syndrome type II. In parallel, we examined genomic data in both the NIH TOPMed and ClinVar databases with the aid of Rhapsody, a verified computational algorithm that predicts mutation pathogenicity and disease severity. Subsequent phenotypic studies using a yeast screen to assess ROMK function-and analyses of ROMK biogenesis in yeast and human cells-identified four previously uncharacterized mutations. Among these, one mutation uncovered from the two parallel approaches (G228E) destabilized ROMK and targeted it for ERAD, resulting in reduced cell surface expression. Another mutation (T300R) was ERAD-resistant, but defects in channel activity were apparent based on two-electrode voltage clamp measurements in X. laevis oocytes. Together, our results outline a new computational and experimental pipeline that can be applied to identify disease-associated alleles linked to a range of other potassium channels, and further our understanding of the ROMK structure-function relationship that may aid future therapeutic strategies to advance precision medicine.

Blood pressure targets in chronic kidney disease: still no consensus

PURPOSE OF REVIEW

Despite a strong consensus that treatment of hypertension is fundamental to strategies seeking to slow chronic kidney disease (CKD) progression and reduce the associated risk of cardiovascular events (CVE), controversy persists regarding optimal blood pressure (BP) targets. This article reviews the evidence for different targets, discusses associated controversies and suggests approaches to improve BP control.

RECENT FINDINGS

Landmark clinical trials established the principle that lower BP targets are associated with slower progression of CKD in people with a greater magnitude of proteinuria and previous guidelines recommended a target BP of <130/80 mmHg for those with proteinuria. However, the Systolic Blood Pressure Intervention Trial provided new evidence that a systolic BP target of <120 mmHg was associated with a reduced risk of CVE, though there was no impact on CKD progression and there was concern about an increase in renal adverse events. Nevertheless, 2021 Kidney Disease Improving Global Outcomes guidelines recommended systolic BP <120 mmHg, though other updated guidelines did not follow this trend. All guidelines emphasise the importance of standardised BP measurement and a personalised approach.

SUMMARY

An individualised and shared decision-making approach to BP target setting and management is recommended, guided by standardised BP measurement.

Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial

Importance

Clinical practice guidelines recommend selecting an appropriately sized cuff based on mid-arm circumference prior to measuring blood pressure (BP). To our knowledge, the effect of miscuffing on BP measurement when using an automated BP device has not been quantified.

Objective

To determine the effect of using a regular BP cuff vs an appropriately sized BP cuff on automated BP readings.

Design, Setting, and Participants

This randomized crossover trial of community-dwelling adults with a wide range of mid-arm circumferences took place between March 16 and October 25, 2021, in Baltimore, Maryland. Participants were recruited via BP screening events at a public food market and a senior housing facility, targeted mailings to prior research participants, placement of study brochures in hypertension clinics at Johns Hopkins University, and referrals from physicians providing hypertension care to adults.

Interventions

Participants underwent 4 sets of triplicate BP measurements, with the initial 3 sets using an appropriate, too-small, or too-large BP cuff in random order; the fourth set of triplicate measurements was always completed with an appropriate BP cuff.

Main Outcomes and Measures

The primary outcome was the difference in mean BP when measured with a regular BP cuff compared with an appropriate BP cuff. The secondary outcome was the difference in BP when using too-small or too-large BP cuffs vs an appropriate BP cuff across all cuff sizes. Results were also stratified by systolic BP (≥130 mm Hg vs <130 mm Hg) and body mass index (calculated as weight in kilograms divided by height in meters squared; ≥30 vs <30).

Results

A total of 195 adults (mean [SD] age, 54 [16] years; 67 [34%] male; 132 [68%] Black; 100 [51%] with hypertension) were randomized for inclusion. Among individuals requiring a small BP cuff, use of a regular BP cuff resulted in a statistically significant lower BP reading (mean systolic BP difference, -3.6 [95% CI, -5.6 to -1.7] mm Hg). In contrast, among individuals requiring a large or extra-large BP cuff, use of a regular BP cuff resulted in a statistically significant higher BP reading (mean systolic BP difference, 4.8 [95% CI, 3.0-6.6] mm Hg and 19.5 [95% CI, 16.1-22.9] mm Hg, respectively). For the secondary outcome, BP differences with overcuffing and undercuffing by 1 and 2 cuff sizes were greater among those requiring larger BP cuffs. The results were consistent in stratified analyses by systolic BP and body mass index.

Conclusions and Relevance

In this randomized crossover trial, miscuffing resulted in strikingly inaccurate BP measurements. This is particularly concerning for settings where 1 regular BP cuff size is routinely used in all individuals, regardless of arm size. A renewed emphasis on individualized BP cuff selection is warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT04610775.

Comparison of outcomes for routine versus American Heart Association-recommended technique for blood pressure measurement (CORRECT BP): a randomised cohort study

Background

Optimal clinical care, diagnosis and treatment requires accurate blood pressure (BP) values. The primary objective was to compare BP readings taken while adhering to American Heart Association (AHA) guidelines to those typical of routine clinical care. Specifically studied: the combined effect of feet flat on the floor, back supported, and arm supported with cuff at heart level, while adhering to other guideline recommendations.

Methods

In this prospective, randomised, three-group cohort study, a modified cross-over design was applied in a primary care outpatient office setting in Columbus (OH, USA). Eligible participants were adults (aged ≥18 years) with an arm circumference of ≥18 cm and ≤42 cm who did not have a renal dialysis shunt or a previous or current diagnosis of atrial fibrillation. 150 recruited volunteers meeting the inclusion criteria were randomly randomised into the three groups. Group methodologies were BP readings taken on a fixed-height exam table followed by readings taken in an exam chair with adjustable positioning options (Group A), readings taken in the reverse order, chair then table (Group B), and both sets of readings in the exam chair (Group C). A rest period occurred before each set of readings. Group C was included for the purpose of obtaining an independent estimate of the order effect. The order in which the two types of readings (table vs chair) were taken was randomised. The primary outcome was the difference between the mean of three BP readings taken on the table and the mean of three readings taken in the chair.

Findings

Between September and October, 2022, 150 participants were enrolled in the study; all 150 of whom completed testing: 48 in Group A, 49 in Group B, 53 in Group C. The mean systolic/diastolic BP (SBP/DBP) of readings taken on the table (Group A first readings, Group B second readings) were 7.0/4.5 mmHg higher than those taken in the chair (Group A second readings, Group B first readings); both statistically significant, p < 0.0001. These findings show that AHA-recommended positioning-feet flat on the floor, back supported, arm supported with the BP cuff at heart level-results in substantially lower BP values than improper positioning. The mean SBP/DBP of the first set of readings taken on the chair were 1.6/0.6 mmHg higher than for the second set of readings (Group C, included to estimate order effect).

Interpretation

The observed benefit of proper positioning is sufficient to change the BP classification of several million patients from having hypertension to not having hypertension and therefore avoiding medication and/or intense follow-up.

Funding

Midmark Corporation, Versailles, Ohio, USA.

A randomized n-of-1 study comparing blood pressure measured on a clothed arm and on an arm with a rolled-up sleeve

BACKGROUND

Blood pressure [BP] should be measured using a bare upper arm with an appropriately sized cuff. In practice, it is more convenient to measure BP on a bare arm below a rolled-up sleeve or on a sleeved arm.

AIM

A n-of-1 randomized controlled trial was performed to assess the difference between BP measurements over a sleeve or below a rolled-up sleeve.

METHODS

The study subject was male, white, 72 years old, BMI 26 kg/m2, arm circumference 29 cm, and under stable antihypertensive treatment. The mean of three BP measurements over a thin sleeve was compared with measurements below a rolled-up sleeve. Additional measurements on a completely bare arm, with thicker sleeves and up to three layers were performed. The order of measurements was determined by chance and two oscillometric devices were used. Descriptive statistics, Bland-Altman test and 2-side T test were used for comparisons.

RESULTS

504 measurements were performed: 50 % over the sleeve and 50 % below the rolled-up sleeve. The mean systolic blood pressure (SBP) was respectively 116.9 ± 9. 2 [95% CI 115.7-118.0, range 96-135] and 122.8 ± 9.2 [95% CI 121.7-124.0, range 103-139, p = 0.001] mm Hg. The mean diastolic blood pressure [DBP] was respectively 67.6 ± 6.8 [95% CI 66.8-68.4, range 52-84] and 71.8 ± 6.8 [95% CI 71.0-72.7, range 55-85, p = 0.001] mm Hg. There was no significant difference between the measurements over the sleeve and on the completely bare arm [n = 94, p = 0.97]. Sleeve thickness with 2 layers up to 3 mm thick did not affect the results.

CONCLUSIONS

Blood pressure measurements over a thin sleeve were significantly lower than measurements below a rolled-up sleeve and match measurements on a completely bare arm.

Cuff Size Variation Across Manufacturers of Home Blood Pressure Devices: A Current Patient Dilemma

BACKGROUND

The American Heart Association (AHA) recommends cuff sizes of blood pressure (BP) monitoring devices based on patient arm circumference, which is critical for accurate BP measurement. This study aimed to assess cuff size variation across validated BP devices and to examine the degree of alignment with the AHA recommendations.

METHODS

Data on home BP devices were obtained from the US BP Validated Device Listing website and listed cuff sizes were compared against AHA recommendations: small adult (22-26 cm), adult (27-34 cm), large (35-44 cm), and extra-large (XL) (45-52 cm).

RESULTS

There were 42 home validated BP devices from 13 manufacturers, and none offered cuffs that were aligned with the AHA recommendations. Over half of the devices (22, 52.4%) were compatible with only a broad-range cuff, generally excluding arm sizes larger than 44 cm. Only 5 devices from 4 manufacturers offered a cuff labeled "XL," and of these, only 3 devices had sizes that covered the AHA XL range. Terminology lacked consistency with manufacturers using: different labels to describe the same-sized cuffs (e.g., 22-42 cm was labeled "integrated," "standard," "adult," "large," and "wide range"); the same labels to describe differently sized cuffs (e.g., cuffs labeled "large" were sized 22-42 cm, 32-38 cm, 32-42 cm, 36-45 cm).

CONCLUSIONS

Manufacturers of US home BP devices employ inconsistent terminologies and thresholds for cuff sizes, and sizes were not aligned with AHA recommendations. This lack of standardization could pose challenges for clinicians and patients attempting to select a properly sized cuff to support hypertension diagnosis and management.

Self-Measured Blood Pressure Telemonitoring Programs: A Pragmatic How-to Guide

Self-measured blood pressure (SMBP) telemonitoring is the process of securely storing and tele-transmitting reliably measured, patient self-performed blood pressure (BP) measurements to healthcare teams, while ensuring that these data are viewable and clinically actionable for the purposes of improving hypertension diagnosis and management. SMBP telemonitoring is a vital component of an overall hypertension control strategy. Herein, we present a pragmatic guide for implementing SMBP in clinical practice and provide a comprehensive list of resources to assist with implementation. Initial steps include defining program goals and scope, selecting the target population, staffing, choosing appropriate (clinically validated) BP devices with proper cuff sizes, and selecting a telemonitoring platform. Adherence to recommended data transmission, security, and data privacy requirements is essential. Clinical workflow implementation involves patient enrollment and training, review of telemonitored data, and initiating or titrating medications in a protocolized fashion based upon this information. Utilizing a team-based care structure is preferred and calculation of average BP for hypertension diagnosis and management is important to align with clinical best practice recommendations. Many stakeholders in the United States are engaged in overcoming challenges to SMBP program adoption. Major barriers include affordability, clinician and program reimbursement, availability of technological elements, challenges with interoperability, and time/workload constraints. Nevertheless, it is anticipated that uptake of SMBP telemonitoring, still at a nascent stage in many parts of the world, will continue to grow, propagated by increased clinician familiarity, broader platform availability, improvements in interoperability, and reductions in costs that occur with scale, competition, and technological innovation.

Blood pressure measurement modalities and indexed left ventricular mass in men with low-risk hypertension confirmed by ambulatory monitoring

BACKGROUND

Blood pressure (BP) measurement modalities such as ambulatory monitoring (ABPM) and noninvasive central aortic systolic pressure (CASP), have been reported to improve prediction of hypertension-mediated organ damage (HMOD) compared with conventional clinic BP. However, clinic BP is often confounded by poor measurement technique and 'white-coat hypertension' (WCH). We compared prediction of cardiac MRI (cMRI)-derived left ventricular mass index (LVMI) by differing BP measurement modalities in young men with elevated BP, confirmed by ABPM.

METHODS

One hundred and forty-three treatment-naive men (<55 years) with hypertension confirmed by ABPM and no clinical evidence of HMOD or cardiovascular disease (37% with masked hypertension) were enrolled. Relationships between BP modalities and cMRI-LVMI were evaluated.

RESULTS

Men with higher LVMI (upper quintile) had higher clinic, central and ambulatory SBP compared with men with lower LVMI. Regression coefficients for SBP with LVMI did not differ across BP modalities ( r  = 0.32; 0.3; 0.31, for clinic SBP, CASP and 24-h ABPM, respectively, P  < 0.01 all). Prediction for high LVMI using receiver-operated curve analyses was similar between measurement modalities. No relationship between DBP and LVMI was seen across measurement modalities.

CONCLUSION

In younger men with hypertension confirmed by ABPM and low cardiovascular risk, clinic SBP and CASP, measured under research conditions, that is, with strict adherence to guideline recommendations, performs as well as ABPM in predicting LVMI. Prior reports of inferiority for clinic BP in predicting HMOD and potentially, clinical outcomes, may be due to poor measurement technique and/or failure to exclude WCH.

The sine transform is the sine qua non of the pulmonary and systemic pressure relationship

Assessment of therapeutic interventions in patients with pulmonary arterial hypertension (PAH) suffers from several commonly encountered limitations: (1) patient studies are often too small and short-term to provide definitive conclusions, (2) there is a lack of a universal set of metrics to adequately assess therapy and (3) while clinical treatments focus on management of symptoms, there remain many cases of early loss of life in a seemingly arbitrary distribution. Here we provide a unified approach to assess right and left pressure relationships in PAH and pulmonary hypertension (PH) patients by developing linear models informed by the observation of Suga and Sugawa that pressure generation in the ventricle (right or left) approximately follows a single lobe of a sinusoid. We sought to identify a set of cardiovascular variables that either linearly or via a sine transformation related to systolic pulmonary arterial pressure (PAPs) and systemic systolic blood pressure (SBP). Importantly, both right and left cardiovascular variables are included in each linear model. Using non-invasively obtained cardiovascular magnetic resonance (CMR) image metrics the approach was successfully applied to model PAPs in PAH patients with an r2 of 0.89 (p < 0.05) and SBP with an r2 of 0.74 (p < 0.05). Further, the approach clarified the relationships that exist between PAPs and SBP separately for PAH and PH patients, and these relationships were used to distinguish PAH vs. PH patients with good accuracy (68%, p < 0.05). An important feature of the linear models is that they demonstrate that right and left ventricular conditions interact to generate PAPs and SBP in PAH patients, even in the absence of left-sided disease. The models predicted a theoretical right ventricular pulsatile reserve that in PAH patients was shown to be predictive of the 6 min walk distance (r2 = 0.45, p < 0.05). The linear models indicate a physically plausible mode of interaction between right and left ventricles and provides a means of assessing right and left cardiac status as they relate to PAPs and SBP. The linear models have potential to allow assessment of the detailed physiologic effects of therapy in PAH and PH patients and may thus permit cross-over of knowledge between PH and PAH clinical trials.

Genome mining yields new disease-associated ROMK variants with distinct defects

Bartter syndrome is a group of rare genetic disorders that compromise kidney function by impairing electrolyte reabsorption. Left untreated, the resulting hyponatremia, hypokalemia, and dehydration can be fatal. Although there is no cure for this disease, specific genes that lead to different Bartter syndrome subtypes have been identified. Bartter syndrome type II specifically arises from mutations in the KCNJ1 gene, which encodes the renal outer medullary potassium channel, ROMK. To date, over 40 Bartter syndrome-associated mutations in KCNJ1 have been identified. Yet, their molecular defects are mostly uncharacterized. Nevertheless, a subset of disease-linked mutations compromise ROMK folding in the endoplasmic reticulum (ER), which in turn results in premature degradation via the ER associated degradation (ERAD) pathway. To identify uncharacterized human variants that might similarly lead to premature degradation and thus disease, we mined three genomic databases. First, phenotypic data in the UK Biobank were analyzed using a recently developed computational platform to identify individuals carrying KCNJ1 variants with clinical features consistent with Bartter syndrome type II. In parallel, we examined ROMK genomic data in both the NIH TOPMed and ClinVar databases with the aid of a computational algorithm that predicts protein misfolding and disease severity. Subsequent phenotypic studies using a high throughput yeast screen to assess ROMK function-and analyses of ROMK biogenesis in yeast and human cells-identified four previously uncharacterized mutations. Among these, one mutation uncovered from the two parallel approaches (G228E) destabilized ROMK and targeted it for ERAD, resulting in reduced protein expression at the cell surface. Another ERAD-targeted ROMK mutant (L320P) was found in only one of the screens. In contrast, another mutation (T300R) was ERAD-resistant, but defects in ROMK activity were apparent after expression and two-electrode voltage clamp measurements in Xenopus oocytes. Together, our results outline a new computational and experimental pipeline that can be applied to identify disease-associated alleles linked to a range of other potassium channels, and further our understanding of the ROMK structure-function relationship that may aid future therapeutic strategies.

Author Summary

Bartter syndrome is a rare genetic disorder characterized by defective renal electrolyte handing, leading to debilitating symptoms and, in some patients, death in infancy. Currently, there is no cure for this disease. Bartter syndrome is divided into five types based on the causative gene. Bartter syndrome type II results from genetic variants in the gene encoding the ROMK protein, which is expressed in the kidney and assists in regulating sodium, potassium, and water homeostasis. Prior work established that some disease-associated ROMK mutants misfold and are destroyed soon after their synthesis in the endoplasmic reticulum (ER). Because a growing number of drugs have been identified that correct defective protein folding, we wished to identify an expanded cohort of similarly misshapen and unstable disease-associated ROMK variants. To this end, we developed a pipeline that employs computational analyses of human genome databases with genetic and biochemical assays. Next, we both confirmed the identity of known variants and uncovered previously uncharacterized ROMK variants associated with Bartter syndrome type II. Further analyses indicated that select mutants are targeted for ER-associated degradation, while another mutant compromises ROMK function. This work sets-the-stage for continued mining for ROMK loss of function alleles as well as other potassium channels, and positions select Bartter syndrome mutations for correction using emerging pharmaceuticals.

Quantifying Blood Pressure Visit-to-Visit Variability in the Real-World Setting: A Retrospective Cohort Study

BACKGROUND

Visit-to-visit variability (VVV) in blood pressure values has been reported in clinical studies. However, little is known about VVV in clinical practice and whether it is associated with patient characteristics in real-world setting.

METHODS

We conducted a retrospective cohort study to quantify VVV in systolic blood pressure (SBP) values in a real-world setting. We included adults (age ≥18 years) with at least 2 outpatient visits between January 1, 2014 and October 31, 2018 from Yale New Haven Health System. Patient-level measures of VVV included SD and coefficient of variation of a given patient's SBP across visits. We calculated patient-level VVV overall and by patient subgroups. We further developed a multilevel regression model to assess the extent to which VVV in SBP was explained by patient characteristics.

RESULTS

The study population included 537 218 adults, with a total of 7 721 864 SBP measurements. The mean age was 53.4 (SD 19.0) years, 60.4% were women, 69.4% were non-Hispanic White, and 18.1% were on antihypertensive medications. Patients had a mean body mass index of 28.4 (5.9) kg/m2 and 22.6%, 8.0%, 9.7%, and 5.6% had a history of hypertension, diabetes, hyperlipidemia, and coronary artery disease, respectively. The mean number of visits per patient was 13.3, over an average period of 2.4 years. The mean (SD) intraindividual SD and coefficient of variation of SBP across visits were 10.6 (5.1) mm Hg and 0.08 (0.04). These measures of blood pressure variation were consistent across patient subgroups defined by demographic characteristics and medical history. In the multivariable linear regression model, only 4% of the variance in absolute standardized difference was attributable to patient characteristics.

CONCLUSIONS

The VVV in real-world practice poses challenges for management of patients with hypertension based on blood pressure readings in outpatient settings and suggest the need to go beyond episodic clinic evaluation.

The Association between the Atherogenic Index of Plasma and Cardiometabolic Risk Factors: A Review

Background: Metabolic syndrome (MetS) is a condition caused by a combination of cardiometabolic risk factors (CMR). MetS leads to type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD), both of which place a burden on not only the patients but also the healthcare system. Diagnostic criteria for MetS vary, and there is no universal tool to detect it. Recently, many studies have found positive associations between the atherogenic index of plasma (AIP) and some CMR factors. Therefore, a comprehensive review was needed to recapitulate these studies and qualitatively estimate the likelihood of AIP being associated with CMR. We aimed to review and summarise observational data on AIP and CMR factors and verify their association. Materials and Methods: A review of observational studies was conducted by searching “atherogenic index of plasma” in PubMed, One Search, and the Cochrane library. A total of 2068 articles were screened, and 32 were included after excluding paediatric, non-human and interventional studies, and those carried out on cohorts with conditions unrelated to MetS or on lipid-lowering medication. The Newcastle-Ottawa scale was used to assess their quality. Results: Most studies that reported high waist circumference (WC), triglycerides (TG), insulin resistance (IR) and low high-density lipoprotein cholesterol (HDL-C) concentration, also reported high AIP. Few studies investigated blood pressure (BP) and some discrepancies existed between their results. Conclusion: AIP may be associated with WC, TG, IR, and HDL-C. It is unclear if AIP is associated with BP. The current study’s results should be used to inform futureward a meta-analysis to be seen quantitatively. It is also recommended that more cohort studies stratified by gender and ethnicity be performed to ascertain if AIP can predict MetS before it manifests.

Perceptions of pharmacists on the quality of automated blood pressure devices: a national survey

A recent study found that only 23.8% of blood pressure (BP) devices available for purchase from Australian pharmacies were validated for accuracy. The extent to which pharmacists are aware of this, and other issues related to the accuracy of BP devices, is not known and gathering this information was the aim of this study. An online survey of Australian pharmacists was distributed via the Pharmaceutical Society of Australia between 1 October and 25 November 2020. Questions were focused on the views of pharmacists related to the accuracy of BP devices. Two hundred and ten pharmacists completed the survey. The accuracy of BP devices sold by pharmacists was considered 'quite' or 'extremely important' to most respondents (94%). However, most respondents (90%) were unaware that less than one-quarter of BP devices sold by Australian pharmacies were validated, and this was 'quite' or 'extremely surprising' to many (69%). Many respondents (64%) associated a particular brand of BP device with greater accuracy. There was low awareness on proper ways to identify accurate BP devices, such as checking reputable online databases (43%). BP devices were stocked in respondents' pharmacies based on perceived quality (50%), accuracy (40%), or as determined by the pharmacy chain (36%). In conclusion, providing accurate BP devices to consumers is important to pharmacists, but they were generally unaware that most devices available from pharmacies were not validated for accuracy. Pharmacist education, alongside advocacy for policies including regulations and strategic action, is required to ensure only validated BP devices are sold in Australia.

The 2022 focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension

Hypertension is the leading cause of death in human being, which shows high prevalence and associated complications that increase the mortality and morbidity. Controlling blood pressure (BP) is very important because it is well known that lowering high BP effectively improves patients' prognosis. This review aims to provide a focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension. The importance of ambulatory BP and home BP monitoring was further emphasized not only for the diagnosis but also for treatment target. By adopting corresponding BPs, the updated guideline recommended out-of-office BP targets for both standard and intensive treatment. Based on the consensus on corresponding BPs and Systolic Blood Pressure Intervention Trial (SPRINT) revisit, the updated guidelines recommended target BP in high-risk patients below 130/80 mmHg and it applies to hypertensive patients with three or more additional cardiovascular risk factors, one or more risk factors with diabetes, or hypertensive patients with subclinical organ damages, coronary or vascular diseases, heart failure, chronic kidney disease with proteinuria, and cerebral lacunar infarction. Cerebral infarction and chronic kidney disease are also high-risk factors for cardiovascular disease. However, due to lack of evidence, the target BP was generally determined at < 140/90 mmHg in patients with those conditions as well as in the elderly. Updated contents regarding the management of hypertension in special situations are also discussed.

Association of blood pressure variability during acute care hospitalization and incident dementia

Background and objectives

Recognized as a potential risk factor for Alzheimer's disease and related dementias (ADRD), blood pressure variability (BPV) could be leveraged to facilitate identification of at-risk individuals at a population level. Granular BPV data are available during acute care hospitalization periods for potentially high-risk patients, but the incident ADRD risk association with BPV measured in this setting is unknown. Our objective was to evaluate the relation of BPV, measured during acute care hospitalization, and incidence of ADRD.

Methods

We retrospectively studied adults, without a prior ADRD diagnosis, who were admitted to a large quaternary care medical center in Southern California between January 1, 2013 and December 31, 2019. For all patients, determined BPV, calculated as variability independent of the mean (VIM), using blood pressure readings obtained as part of routine clinical care. We used multivariable Cox proportional hazards regression to examine the association between BP VIM during hospitalization and the development of incident dementia, determined by new ICD-9/10 coding or the new prescription of dementia medication, occurring at least 2 years after the index hospitalization.

Results

Of 81,892 adults hospitalized without a prior ADRD diagnosis, 2,442 (2.98%) went on to develop ADRD (2.6 to 5.2 years after hospitalization). In multivariable-adjusted Cox models, both systolic (HR 1.05, 95% CI 1.00-1.09) and diastolic (1.06, 1.02-1.10) VIM were associated with incident ADRD. In pre-specified stratified analyses, the VIM associations with incident ADRD were most pronounced in individuals over age 60 years and among those with renal disease or hypertension. Results were similar when repeated to include incident ADRD diagnoses made at least 1 or 3 years after index hospitalization.

Discussion

We found that measurements of BPV from acute care hospitalizations can be used to identify individuals at risk for developing a diagnosis of ADRD within approximately 5 years. Use of the readily accessible BPV measure may allow healthcare systems to risk stratify patients during periods of intense patient-provider interaction and, in turn, facilitate engagement in ADRD screening programs.

Validation testing of five home blood pressure monitoring devices for the upper arm according to the ISO 81060-2:2018/AMD 1:2020 protocol

The accuracy of Omron 10 Series BP7450 (HEM-7342T-Z), Omron Platinum BP5450 (HEM-7343T-Z), Walmart Equate Premium 8000 Series UA-8000WM, Walgreens Premium 15+ WGNBPA-960BT, and CVS Series 800 BP3MW1-4YCVS were assessed in an adult general population compared to a mercury sphygmomanometer standard according to the ISO 81060-2:2018/AMD 1:2020 validation procedure. Omron selected the monitors and included three non-Omron monitors because they were from large retail vendors in the United States and these monitors did not have accessible results from validation testing. The BP7450, N = 85, passed both criteria for the standard. Mean (SD) differences in paired SBP and DBP determinations between the test device and reference were 0.5 (7.7) and 2.5 (6.8) mm Hg. The BP5450, N = 86, passed both criteria. Mean (SD) differences in paired SBP and DBP determinations were 1.9 (7.0) and 3.6 (6.4) mm Hg. The UA-8000WM, N = 85, did not meet the first criterion for the standard. Mean (SD) differences in paired SBP and DBP determinations were 2.5 (8.0) and 5.1 (6.4) mm Hg. The WGNBPA-240BT, N = 85, did not meet the first criterion for the standard. Mean (SD) differences in paired SBP and DBP determinations were 7.9 (8.5) and 5.5 (6.7) mm Hg. The BP3MW1-4YCVS, N = 85, did not meet the first criterion for the standard. Mean (SD) differences in paired SBP and DBP determinations were 5.8 (8.7) and 3.1 (5.6) mm Hg. These findings emphasize the importance of verifying the validation status of home blood pressure monitors before use by consumers.

Automated 'oscillometric' blood pressure measuring devices: how they work and what they measure

Automated 'oscillometric' blood pressure (BP) measuring devices (BPMDs) were developed in the 1970s to replace manual auscultatory BP measurement by mercury sphygmomanometer. Automated BPMDs that have passed accuracy testing versus a reference auscultatory sphygmomanometer using a scientifically accepted validation protocol are recommended for clinical use globally. Currently, there are many thousands of unique automated BPMDs manufactured by hundreds of companies, with each device using proprietary algorithms to estimate BP and using a method of operation that is largely unchanged since inception. Validated automated BPMDs provide similar BP values to those recorded using manual auscultation albeit with potential sources of error mostly associated with using empirical algorithms to derive BP from waveform pulsations. Much of the work to derive contemporary BP thresholds and treatment targets used to manage cardiovascular disease risk was obtained using automated BPMDs. While there is room for future refinement to improve accuracy for better individual risk stratification, validated BPMDs remain the recommended standard for office and out-of-office BP measurement to be used in hypertension diagnosis and management worldwide.

Conventional office blood pressure measurements and unattended automated office blood pressure compared with home self-measurement and 24-h ambulatory blood pressure monitoring

OBJECTIVE

To assess whether automated office blood pressure (BP) (AOBP) measurement is a better method for measuring BP in the office than conventional techniques and an alternative to out-of-office BP measurements: home-self BP (HSBP) or ambulatory BP monitoring (ABPM).

METHODS

We conducted a cross-sectional study of 74 patients and compared AOBP with the conventional technique using a mercury sphygmomanometer and with both out-to-office BP measurements: HSBP of 7 days (three measurements in the morning, afternoon, and night) and daytime ABPM. In addition, we compared BP values obtained using HSBP and ABPM to determine their level of agreement. We used ANOVA to compare means, Bland-Altman, and intraclass correlation coefficients (ICC) for concordance.

RESULTS

BP values obtained by the two office methods were similar: conventional 147.2/85.0 mmHg and AOBP 146.0/85.5 mmHg ( P > 0.05) with good agreement (ICC 0.85). The mean SBP differences between AOBP and HSBP ( P < 0.001) and between AOBP and ABPM ( P < 0.001) were 8.6/13.0 mmHg with limits of agreement of -21.2 to 38.5 and -18.4 to 44.3 mmHg, respectively. The average SBP values obtained by HSBP were 4.3 mmHg higher than those obtained by ABPM ( P < 0.01).

CONCLUSION

Our study showed good agreement and concordance between the two office methods as well between the two out-to-office methods, although there was a significant difference in the mean SBP between the HSBP and ABPM. Moreover, AOBP was not comparable to either HSBP or ABPM; therefore, the estimation of out-to-office BP using AOBP is not supported.

How to find and use validated blood pressure measuring devices

Clinically validated, automated arm-cuff blood pressure measuring devices (BPMDs) are recommended for BP measurement. However, most BPMDs available for purchase by consumers globally are not properly validated. This is a problem because non-validated BPMDs are less accurate and precise than validated ones, and therefore if used clinically could lead to misdiagnosis and mismanagement of BP. In response to this problem, several validated device lists have been developed, which can be used by clinicians and consumers to identify devices that have passed clinical validation testing. The purpose of this review is to describe the resources that are available for finding validated BPMDs in different world regions, to identify the differences between validated device lists, and describe current gaps and challenges. How to use validated BPMDs properly is also summarised.

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.

International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework

SYNOPSIS: This position statement, stemming from the International IFOMPT (International Federation of Orthopaedic Manipulative Physical Therapists) Cervical Framework, was developed based upon the best contemporary evidence and expert opinion to assist clinicians during their clinical reasoning process when considering presentations involving the head and neck. Developed through rigorous consensus methods, the International IFOMPT Cervical Framework guides assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned interventions. Within the cervical spine, events and presentations of vascular pathologies of the neck are rare but are an important consideration as part of patient examination. Vascular pathologies may be recognizable if the appropriate questions are asked during the patient history-taking process, if interpretation of elicited data enables recognition of this potential, and if the physical examination can be adapted to explore any potential vasculogenic hypothesis. J Orthop Sports Phys Ther 2023;53(1):7-22. Epub: 14 September 2022. doi:10.2519/jospt.2022.11147.

Detecting Preeclampsia Severity Using Maternal-Obstetrical Characteristics and Complete Blood Cell Counts

Purpose

This study aimed to use the combination of maternal-obstetrical characteristics (MOCs) and complete blood cell counts (CBCs) with different red blood cell (RBC) indices as an alternative tool to detect preeclampsia (PE) severity immediately before delivery.

Patients and Methods

This retrospective study included all singleton pregnancies delivered after 24 weeks of gestation from April 2016 to April 2020. Patients were divided into four different groups: non-hypertensive (NH), gestational hypertension (GH), PE, and severe PE (SPE). Univariate and forward stepwise multivariate logistic regression analysis was conducted using MOCs, CBCs, and RBC indices. The calculation was performed between SPE and other non-hypertensive and hypertensive (GH, PE) groups. Moreover, the area under the curve (AUC) for the receiver operating characteristic curve, sensitivity, and specificity were estimated.

Results

The combined variables for differentiating SPE from NH were maternal age >29.5 years, weight >27.24, gestational age <272 days at the time of blood withdrawal, platelet count <217.5×103/μL, Srivastava indices <6.35, and Siradah indices <43.02 (AUC, 0.834; 95% confidence interval [CI], 0.773-0.895). The combined variables for differentiating SPE from GH were maternal age >29.5 years, body mass index >25.28, gestational age <268.5 days at the time of blood withdrawal, mean corpuscular volume <78.85 fL, and platelet count <234.5×103/μL (AUC, 0777; 95% CI, 0.703-0.852). The combined variables for differentiating SPE from PE were maternal age >32.5 years, mean corpuscular hemoglobin concentration >34.55 g/dL, and Siradah indices <40.05 (AUC, 0.745; 95% CI, 0.656-0.833).

Conclusion

The combination of selected variables from MOCs and CBCs with RBC indices before delivery showed satisfactory results for detecting PE severity.

Effects of an educational program using a virtual social network on nurses' knowledge and performance of blood pressure measurement: a randomized controlled trial

BACKGROUND

Hypertension diagnosis, treatment, and follow-up depend on accurate blood pressure measurement; however, inaccurate measurement techniques are common among healthcare providers. To improve professional performance, continuous education is necessary. Distance education through virtual social network can be used as it is easy to use and accessible.

METHODS

This study adopted a randomized controlled trial design and was conducted at two hospitals in Mansoura, Egypt. The subjects were selected from two hospitals using Stratified random sampling method in proportion to the total number of nurses. Seventy nurses were included in this study and were randomly divided into the intervention (n = 35) and control (n = 35) groups using block randomization. Data were gathered before and after intervention using a blood pressure measurement knowledge questionnaire and a blood pressure measurement observation checklist. The blood pressure measurement error (the difference between the BP determined by each observer and the reference BP) was calculated for the randomly selected recordings in both groups. The intervention group received 24 blood pressure measurement education sessions using WhatsApp, while the control group received only routine education using traditional lecture.

RESULTS

No statistically significant differences in pretest knowledge scores, performance scores, and range of error were found between both groups, whereas, after intervention, knowledge scores were higher in the intervention group than those in the control group (p < 0.001). The range of error of systolic and diastolic blood pressure values significantly reduced after the intervention in the intervention group, and the posttest performance scores were higher than the pretest performance scores; however, the difference was not statistically significant.

CONCLUSIONS

The blood pressure measurement education program via WhatsApp was effective in increasing nurses' knowledge and reducing the range of error; however, a multimodal approach may be required to improve performance scores.

TRIAL REGISTRATION

Prospectively registered with ClinicalTrials.gov on 09/03/2021; registration number NCT04789642.

Effect of personalized perioperative blood pressure management on postoperative complications and mortality in high-risk patients having major abdominal surgery: protocol for a multicenter randomized trial (IMPROVE-multi)

BACKGROUND

Intraoperative hypotension is common in patients having non-cardiac surgery and is associated with serious complications and death. However, optimal intraoperative blood pressures for individual patients remain unknown. We therefore aim to test the hypothesis that personalized perioperative blood pressure management-based on preoperative automated blood pressure monitoring-reduces the incidence of a composite outcome of acute kidney injury, acute myocardial injury, non-fatal cardiac arrest, and death within 7 days after surgery compared to routine blood pressure management in high-risk patients having major abdominal surgery.

METHODS

IMPROVE-multi is a multicenter randomized trial in 1272 high-risk patients having elective major abdominal surgery that we plan to conduct at 16 German university medical centers. Preoperative automated blood pressure monitoring using upper arm cuff oscillometry will be performed in all patients for one night to obtain the mean of the nighttime mean arterial pressures. Patients will then be randomized either to personalized blood pressure management or to routine blood pressure management. In patients assigned to personalized management, intraoperative mean arterial pressure will be maintained at least at the mean of the nighttime mean arterial pressures. In patients assigned to routine management, intraoperative blood pressure will be managed per routine. The primary outcome will be a composite of acute kidney injury, acute myocardial injury, non-fatal cardiac arrest, and death within 7 days after surgery.

DISCUSSION

Our trial will determine whether personalized perioperative blood pressure management reduces the incidence of major postoperative complications and death within 7 days after surgery compared to routine blood pressure management in high-risk patients having major abdominal surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05416944. Registered on June 14, 2022.

Relations between white coat effect of blood pressure and arterial stiffness

The aim of this study was to analyze the relationship between brachial-ankle pulse wave velocity (b-a PWV) and white coat effect (WCE), that is the difference between the elevated office blood pressure (BP) and the lower mean daytime pressure of ambulatory BP, in a mixed population of normotention, untreated sustained hypertension, sustained controlled hypertension, sustained uncontrolled hypertension, white coat hypertension, white coat uncontrolled hypertension. A total of 444 patients with WCE for systolic BP (54.1% female, age 61.86 ± 13.3 years) were enrolled in the study. Patients were separated into low WCE (<9.5 mm Hg) and high WCE (≥9.5 mm Hg) according to the median of WCE. The subjects with a high WCE showed a greater degree of arterial stiffness than those with a low WCE for systolic BP values (P < .05). The b-a PWV were 17.2 ± 3.3 m/s and 18.4 ± 3.4 m/s in low WCE and high WCE, respectively. The b-a PWV increased with the increase of WCE, showing a positive correlation between them (P > .05 for non-linearity). The significant association between the high WCE and the b-a PWV was confirmed by the results of multiple regression analysis after adjusting for confounding factors (β = .78, 95% Cl .25-1.31, P = . 004). Similar results were observed in subgroups. In conclusion, WCE is significantly associated with arterial stiffness. More research is needed to determine the WCE and target organ damage.

Clinic, Home, and Kiosk Blood Pressure Measurements for Diagnosing Hypertension: a Randomized Diagnostic Study

BACKGROUND

The US Preventive Services Task Force recommends blood pressure (BP) measurements using 24-h ambulatory monitoring (ABPM) or home BP monitoring before making a new hypertension diagnosis.

OBJECTIVE

Compare clinic-, home-, and kiosk-based BP measurement to ABPM for diagnosing hypertension.

DESIGN, SETTING, AND PARTICIPANTS

Diagnostic study in 12 Washington State primary care centers, with participants aged 18-85 years without diagnosed hypertension or prescribed antihypertensive medications, with elevated BP in clinic.

INTERVENTIONS

Randomization into one of three diagnostic regimens: (1) clinic (usual care follow-up BPs); (2) home (duplicate BPs twice daily for 5 days); or (3) kiosk (triplicate BPs on 3 days). All participants completed ABPM at 3 weeks.

MAIN MEASURES

Primary outcome was difference between ABPM daytime and clinic, home, and kiosk mean systolic BP. Differences in diastolic BP, sensitivity, and specificity were secondary outcomes.

KEY RESULTS

Five hundred ten participants (mean age 58.7 years, 80.2% white) with 434 (85.1%) included in primary analyses. Compared to daytime ABPM, adjusted mean differences in systolic BP were clinic (-4.7mmHg [95% confidence interval -7.3, -2.2]; P<.001); home (-0.1mmHg [-1.6, 1.5];P=.92); and kiosk (9.5mmHg [7.5, 11.6];P<.001). Differences for diastolic BP were clinic (-7.2mmHg [-8.8, -5.5]; P<.001); home (-0.4mmHg [-1.4, 0.7];P=.52); and kiosk (5.0mmHg [3.8, 6.2]; P<.001). Sensitivities for clinic, home, and kiosk compared to ABPM were 31.1% (95% confidence interval, 22.9, 40.6), 82.2% (73.8, 88.4), and 96.0% (90.0, 98.5), and specificities 79.5% (64.0, 89.4), 53.3% (38.9, 67.2), and 28.2% (16.4, 44.1), respectively.

LIMITATIONS

Single health care organization and limited race/ethnicity representation.

CONCLUSIONS

Compared to ABPM, mean BP was significantly lower for clinic, significantly higher for kiosk, and without significant differences for home. Clinic BP measurements had low sensitivity for detecting hypertension. Findings support utility of home BP monitoring for making a new diagnosis of hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03130257 https://clinicaltrials.gov/ct2/show/NCT03130257.

Standardized home blood pressure monitoring: Rationale behind the 722 protocol

Home blood pressure (HBP) has been recognized as a prognostic predictor for cardiovascular events, and integrated into the diagnosis and management of hypertension. With increasing accessibility of oscillometric blood pressure devices, HBP monitoring is easy to perform, more likely to obtain reliable estimation of blood pressures, and feasible to document long-term blood pressure variations, compared to office and ambulatory blood pressures. To obtain reliable HBP estimates, a standardized HBP monitoring protocol is essential. A consensus regarding the optimal duration and frequency of HBP monitoring is yet to be established. Based on the current evidence, the "722" protocol, which stands for two measurements on one occasion, two occasions a day (morning and evening), and over a consecutive of 7 days, is most commonly used in clinical studies and recommended in relevant guidelines and consensus documents. HBP monitoring based on the "722" protocol fulfills the minimal requirement of blood pressure measurements to achieve agreement of blood pressure classifications defined by office blood pressures and to predict cardiovascular risks. In the Taiwan HBP consensus, the frequency of repeating the "722" protocol of HBP monitoring according to different scenarios of hypertension management, from every 2 weeks to 3 months, is recommended. It is reasonable to conclude that the "722" protocol for HBP monitoring is clinically justified and can serve as a basis for standardized HBP monitoring.

Update on Hypertension Research in 2021

In 2021, 217 excellent manuscripts were published in Hypertension Research. Editorial teams greatly appreciate the authors' contribution to hypertension research progress. Here, our editorial members have summarized twelve topics from published work and discussed current topics in depth. We hope you enjoy our special feature, "Update on Hypertension Research in 2021".