Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: randomised parallel design controlled trial

In-office and out-of-office blood pressure measurement

Accurate blood pressure measurement is the key procedure for the diagnosis and treatment of hypertension. In-office and out-of-office blood pressure measurements both have advantages and weak points, and multifaceted blood pressure information in individuals should be appropriately obtained and assessed. Validation of blood pressure measurement devices has long been an important issue, and several consortiums have emerged to try address it. Clinical guidelines should meet the demands of the region in which they are applied, and out-of-office measurements have been widely stated and recommended in the recently published guidelines worldwide. Appropriate assessment of blood pressure should be performed routinely in order to provide timely and accurate evidence regarding hypertension under any situation, including an unexpected pandemic.

Uncovering clinical rehabilitation technology trends: field observations, mixed methods analysis, and data visualization

Objective

To analyze real-world rehabilitation technology (RT) use, with a view toward enhancing RT development and adoption.

Design

A convergent, mixed-methods study using direct field observations, semi-structured templates, and summative content analysis.

Setting

Ten neurorehabilitation units in a single health system.

Participants

3 research clinicians (1OT, 2PTs) observed ∼60 OTs and 70 PTs in inpatient; ∼18 OTs and 30 PTs in outpatient.

Interventions

Not applicable.

Main Outcome Measures

Characteristics of RT, time spent setting up and using RT, and clinician behaviors.

Results

90 distinct devices across 15 different focus areas were inventoried. 329 RT-uses were documented over 44 hours with 42% of inventoried devices used. RT was used more during interventions (72%) than measurement (28%). Intervention devices used frequently were balance/gait (39%), strength/endurance (30%), and transfer/mobility training (16%). Measurement devices were frequently used to measure vitals (83%), followed by grip strength (7%), and upper extremity function (5%). Device characteristics were predominately AC-powered (56%), actuated (57%), monitor-less (53%), multi-use (68%), and required little familiarization (57%). Set-up times were brief (mean ± SD = 3.8±4.21 and 0.8±1.3 for intervention and measurement, respectively); more time was spent with intervention RT (25.6±15) than measurement RT (7.3±11.2). RT nearly always involved verbal instructions (72%) with clinicians providing more feedback on performance (59.7%) than on results (30%). Therapists' attention was split evenly between direct attention towards the patient during clinician treatment (49.7%) and completing other tasks such as documentation (50%).

Conclusions

Even in a tech-friendly hospital, majority of available RT were observed un-used, but identifying these usage patterns is crucial to predict eventual adoption of new designs from earlier stages of RT development. An interactive data visualization page supplement is provided to facilitate this study.

When blood pressure refuses to budge: exploring the complexity of resistant hypertension

Resistant hypertension, defined as blood pressure that remains above goal despite using three or more antihypertensive medications, including a diuretic, affects a significant proportion of the hypertensive population and is associated with increased cardiovascular morbidity and mortality. Despite the availability of a wide range of pharmacological therapies, achieving optimal blood pressure control in patients with resistant hypertension remains a significant challenge. However, recent advances in the field have identified several promising treatment options, including spironolactone, mineralocorticoid receptor antagonists, and renal denervation. In addition, personalized management approaches based on genetic and other biomarkers may offer new opportunities to tailor therapy and improve outcomes. This review aims to provide an overview of the current state of knowledge regarding managing resistant hypertension, including the epidemiology, pathophysiology, and clinical implications of the condition, as well as the latest developments in therapeutic strategies and future prospects.

The Prognostic Role of Automated Office Blood Pressure Measurement in Hypertensive Patients with Chronic Kidney Disease

BACKGROUND

The aim of this study was to evaluate the prognostic value of automated office blood pressure (AOBP) measurement in patients with hypertension and chronic kidney disease (CKD) stage 3-5 not on dialysis.

METHODS

At baseline, 140 patients were recruited, and blood pressure (BP) measurements with 3 different methods, namely, office blood pressure (OBP), AOBP, and ambulatory blood pressure measurement (ABPM), were recorded. All patients were prospectively followed for a median period of 3.4 years. The primary outcome of this study was a composite outcome of cardiovascular (CV) events (both fatal and nonfatal) or a doubling of serum creatine or progression to end-stage kidney disease (ESKD), whichever occurred first.

RESULTS

At baseline, the median age of patients was 65.2 years; 36.4% had diabetes; 21.4% had a history of CV disease; the mean of estimated glomerular filtration rate (eGFR) was 33 mL/min/1.73 m²; and the means of OBP, AOBP, and daytime ABPM were 151/84 mm Hg, 134/77 mm Hg, and 132/77 mm Hg, respectively. During the follow-up, 18 patients had a CV event, and 37 patients had a renal event. In the univariate cox regression analysis, systolic AOBP was found to be predictive of the primary outcome (HR per 1 mm Hg increase in BP, 1.019, 95% CI 1.003-1.035), and after adjustment for eGFR, smoking status, diabetes, and a history of CV disease and systolic and diastolic AOBP were also found to be predictive of the primary outcome (HR per 1 mm Hg increase in BP, 1.017, 95% CI 1.002-1.032 and 1.033, 95% CI 1.009-1.058, respectively).

CONCLUSIONS

In patients with CKD, AOBP appears to be prognostic of CV risk or risk for kidney disease progression and could, therefore, be considered a reliable means for recording BP in the office setting.

Office blood pressure versus ambulatory blood pressure measurement in childhood obesity

BACKGROUND

The prevalence of obesity-related co-morbidities is rising parallel to the childhood obesity epidemic. High blood pressure (BP), as one of these co-morbidities, is detected nowadays at increasingly younger ages. The diagnosis of elevated BP and hypertension, especially in the childhood population, presents a challenge to clinicians. The added value of ambulatory blood pressure measurement (ABPM) in relation to office blood pressure (OBP) measurements in obese children is unclear. Furthermore, it is unknown how many overweight and obese children have an abnormal ABPM pattern. In this study we evaluated ABPM patterns in a population of overweight and obese children and adolescents, and compared these patterns with regular OBP measurements.

METHODS

In this cross-sectional study in overweight or obese children and adolescents aged 4-17 years who were referred to secondary pediatric obesity care in a large general hospital in The Netherlands, OBP was measured during a regular outpatient clinic visit. Additionally, all participants underwent a 24-hour ABPM on a regular week-day. Outcome measures were OBP, mean ambulatory SBP and DBP, BP load (percentage of readings above the ambulatory 95th blood pressure percentiles), ambulatory BP pattern (normal BP, white-coat hypertension, elevated BP, masked hypertension, ambulatory hypertension), and BP dipping.

RESULTS

We included 82 children aged 4-17 years. They had a mean BMI Z-score of 3.3 (standard deviation 0.6). Using ABPM, 54.9% of the children were normotensive (95% confidence interval 44.1-65.2), 26.8% had elevated BP, 9.8% ambulatory hypertension, 3.7% masked hypertension, and 4.9% white-coat hypertension. An isolated night-time BP load > 25% was detected in almost a quarter of the children. 40% of the participants lacked physiologic nocturnal systolic BP dipping. In the group of children with normal OBP, 22.2% turned out to have either elevated BP or masked hypertension on ABPM.

CONCLUSIONS

In this study a high prevalence of abnormal ABPM patterns in overweight or obese children and adolescents was detected. Additionally, OBP poorly correlated with the child's actual ABPM pattern. Herewith, we emphasized the usefulness of ABPM as an important diagnostic tool in this population.

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.

Pharmacist interventions to improve blood pressure control in primary care: a cluster randomised trial

BACKGROUND

High blood pressure (BP) is the single largest contributor to mortality world-wide.

AIM

To investigate the effectiveness of a pharmacists-led intervention to improve BP control using automated office blood pressure (AOBP).

METHOD

In this prospective parallel group, unblinded, cluster-randomised trial, 54 pharmacies enrolled pre-treated patients with uncontrolled AOBP above 135/85 mmHg. In the interventional group, pharmacists referred patients to the treating physician for therapy intensification in a structured fashion. In the control group, AOBP was recorded until the end of the trial. The primary endpoint was the proportion of patients achieving BP control at the threshold of 135/85 mmHg after 10 weeks. Key secondary endpoints were systolic AOBP reductions after 10 and 20 weeks.

RESULTS

A total of 497 patients were included between 2017 and 2019. In the interventional and control group, 61.5% and 19.8% of patients underwent a therapy modification within 20 weeks. The primary endpoint was achieved in 38.8% in the interventional group and 31.2% in the control group (mean difference 7.6%, 95% CI -8.1; 23.3, p = 0.336). Mean systolic AOBP reductions were greater in the interventional vs. control group at 10 and 20 weeks (14.3 ± 7.4 vs. 6.9 ± 7.0 mmHg, mean difference 7.3 mmHg, 95% CI 3.2;11.5, p < 0.001, and 15.5 ± 9.0 vs. 9.8 ± 7.5 mmHg, mean difference 5.8 mmHg, 95% CI 0.8;10.7, p = 0.023). Atrial fibrillation was newly detected in 7.8% of patients.

CONCLUSION

Through a pragmatic pharmacist-led disease management program, BP control was improved over time, without significant differences between groups. Greater systolic AOBP reductions were observed in the interventional vs. control group. (Pharmacists Intervention to Improve Hypertension Management in Primary Care:APOTHECARE; ClinicalTrials.gov registration NCT03274531).

Protocol to improve hypertension management in a VA outpatient clinic

This 20-week quality improvement study describes implementation of a hypertension identification and management program with use of a standardized oscillometric blood pressure (BP) measurement protocol, provider education, and audit/feedback of hypertension control in a Veterans Affairs primary care clinic. A total of 692 male Veterans ages 18-85 years with treated hypertension and at least one clinic visit in the previous year were included for analysis. Mean age was 69.7 years (standard deviation 7.6) and race and ethnicity were 42.0% White, 29.1% Black and 3.0% Hispanic. Prior to program implementation, clinic BP was measured using the auscultatory method with a manual syphgmomanometer. Baseline BP measurements demonstrated bias as determined by terminal digit preference for digits 0 and 8 in 29.5% and 25.2% of systolic (SBP) and 31.6% and 21.8% of diastolic BP measurements, respectively (p < 0.001). Post-implementation of the standardized oscillometric BP measurement protocol, digit preference was eliminated. Protocol compliance was 89.1% at 5 weeks and 92.4% at 20 weeks. Overall average SBP was significantly higher in the post-implementation period compared to average SBP in the 12-month pre-implementation period (137.4 [Standard Deviation (SD) 17.4] vs. 126.3 [SD 15.3]; P < 0.001). Uncontrolled hypertension, (BP ≥ 140/90 mmHg), increased from 17.8% at baseline to 41.8% post-implementation while provider therapeutic inertia declined from 84.5% at baseline to 55.8% after 20 weeks. This study shows that terminal digit preference is reduced with implementation of standardized oscillatory BP measurement and a quality improvement program can reduce therapeutic inertia of hypertension treatment.

Clinical benefit of systolic blood pressure within the target range among patients with or without diabetes mellitus: a propensity score-matched analysis of two randomized clinical trials

BACKGROUND

Recent guidelines recommended a systolic blood pressure (SBP) target of < 130 mmHg for patients with or without diabetes but without providing a lower bound. Our study aimed to explore whether additional clinical benefits remain at achieved blood pressure (BP) levels below the recommended target.

METHODS

We performed a secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) among the non-diabetic population and the Action to Control Cardiovascular Risk in Diabetes BP (ACCORD-BP) trial among diabetic subjects. We used the propensity score method to match patients from the intensive BP group to those from the standard group in each trial. Individuals with different achieved BP levels from the intensive BP group were used as "reference." For each stratum, the trial-specific primary outcome (i.e., composite outcome of myocardial infarction (MI), acute coronary syndrome not resulting in MI, stroke, acute decompensated heart failure (HF), or cardiovascular death for SPRINT; non-fatal MI, non-fatal stroke, or cardiovascular death for ACCORD-BP) was compared by Cox regression.

RESULTS

A non-linear association was observed between the mean achieved BP and incidence of composite cardiovascular events, regardless of treatment allocation. The significant treatment benefit for primary outcome remained at SBP 110-120 mmHg (hazard ratio, 0.59 [95% CI, 0.46, 0.76] for SPRINT; 0.67 [0.52, 0.88] for ACCORD-BP) and SBP 120-130 mmHg for SPRINT (0.47 [0.34, 0.63]) but not for ACCORD-BP (0.93 [0.70, 1.23]). The results were similar for the secondary outcomes including all-cause mortality, cardiovascular mortality, MI, stroke, and HF. Intensive BP treatment benefits existed among patients maintaining a diastolic BP of 60-70 mmHg but were less distinct.

CONCLUSIONS

The treatment benefit persists at as low as SBP 110-120 mmHg irrespective of diabetes status. Achieved very low BP levels appeared to increase cardiovascular events and all-cause mortality.

Evaluating novel approaches for estimating awake and sleep blood pressure: design of the Better BP Study - a randomised, crossover trial

INTRODUCTION

For many people, blood pressure (BP) levels differ when measured in a medical office versus outside of the office setting. Out-of-office BP has a stronger association with cardiovascular disease (CVD) events compared with BP measured in the office. Many BP guidelines recommend measuring BP outside of the office to confirm the levels obtained in the office. Ambulatory BP monitoring (ABPM) can assess out-of-office BP but is not available in many US practices and some individuals find it uncomfortable. The aims of the Better BP Study are to (1) test if unattended office BP is closer to awake BP on ABPM compared with attended office BP, (2) assess if sleep BP assessed by home BP monitoring (HBPM) agrees with sleep BP from a full night of ABPM and (3) compare the strengths of associations of unattended versus attended office BP, unattended office BP versus awake BP on ABPM and sleep BP on HBPM versus ABPM with markers of end-organ damage.

METHODS AND ANALYSIS

We are recruiting 630 adults not taking antihypertensive medication in Birmingham, Alabama, and New York, New York. Participants are having their office BP measured with (attended) and without (unattended) a technician present, in random order, using an automated oscillometric office BP device during each of two visits within one week. Following these visits, participants complete 24 hours of ABPM and one night of HBPM, in random order. Psychosocial factors, anthropometrics, left ventricular mass index and albumin-to-creatinine ratio are also being assessed.

ETHICS AND DISSEMINATION

This study was approved by the University of Alabama at Birmingham and the Columbia University Medical Center Institutional Review Boards. The study results will be disseminated at scientific conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04307004.

Update in Hypertension

The treatment of elevated blood pressure (BP) can improve cardiovascular (CV) event rates. Current BP targets depend on expected CV event rates in individuals as assessed by concurrent medical conditions and other risk factors. Importantly, the means by which BP is measured has evolved. This evolution is driven by recognition that techniques different than routine office BP measurements can provide a better assessment of future CV risk.

Association between Variability of Metabolic Risk Factors and Cardiometabolic Outcomes

Despite strenuous efforts to reduce cardiovascular disease (CVD) risk by improving cardiometabolic risk factors, such as glucose and cholesterol levels, and blood pressure, there is still residual risk even in patients reaching treatment targets. Recently, researchers have begun to focus on the variability of metabolic variables to remove residual risks. Several clinical trials and cohort studies have reported a relationship between the variability of metabolic parameters and CVDs. Herein, we review the literature regarding the effect of metabolic factor variability and CVD risk, and describe possible mechanisms and potential treatment perspectives for reducing cardiometabolic risk factor variability.

Impact of a Prescription Produce Program on Diabetes and Cardiovascular Risk Outcomes

OBJECTIVE

To evaluate the impact of a fruit and vegetable prescription program on diabetes and cardiovascular risk outcomes.

DESIGN

Single-arm pre-post study.

SETTING

Primary care clinic in a community-based hospital.

PARTICIPANTS

Adults with type 2 diabetes (n = 97), aged > 18 years, with hemoglobin A1c (HbA1c) ≥ 7.0%, and a body mass index (BMI) of ≥ 25 kg/m².

INTERVENTION

Over 7 months, participants received monthly group-based diabetes self-management education (DSME) and monthly vouchers ($28-$140/month) redeemable for fruits and vegetables at local markets.

ANALYSIS

Biomarker changes (HbA1c, BMI, and blood pressure) were assessed with paired t tests. Voucher distribution and redemption were tracked, and voucher redemption rates were calculated. Linear mixed-effect regression models tested associations between biomarkers, voucher redemption rates, and participant characteristics.

RESULTS

There was a -1.3% (P < 0.001) postprogram change in HbA1c. Reduced HbA1c was associated with higher voucher redemption rates (P = 0.032) and a change in diabetes medications (P = 0.003). There were no associations with BMI, but blood pressure was positively associated with voucher redemption.

CONCLUSIONS AND IMPLICATIONS

Fruit and vegetable prescription programs may improve diabetes outcomes by incentivizing DSME uptake and retention. Future randomized trials are warranted to identify strategies to improve DSME engagement and voucher redemption rates and assess mechanisms through which these programs influence health outcomes.

Unattended automated office blood pressure measurement in children

PURPOSE

We studied the performance of unattended automated office blood pressure (uAOBP) measurement in children, in relation to oscillometric office BP (OBP) and ambulatory blood pressure monitoring (ABPM).

MATERIALS AND METHODS

One hundred and eleven stable treated and untreated outpatients investigated for hypertension underwent uAOBP measurements (seated unattended in a quiet room separate from the renal clinic room, six times after a 5 min rest with the BpTRU device), and immediately before using the oscillometric device. Ambulatory 24 h blood pressure monitoring (ABPM) was performed on the same day in a subgroup of 42 children.

RESULTS

UAOBP measurements were successful in 106 children (95%), 5 pre-school children did not tolerate to be alone in the room. The mean ± SD systolic/diastolic uAOBP, OBP and daytime ABP were 109.1 ± 14.0/70.8 ± 10.7 mmHg, 121.6 ± 16.5/77.6 ± 10.5 mmHg and 123.5 ± 11.3/73.7 ± 6.8 mmHg, respectively. Systolic/diastolic uAOBP was significantly lower than OBP by 13.6/7.6 mmHg (p < 0.0001) and lower than daytime ABP by 14.4 ± 0.5/2.9 ± 0.3 mmHg (p < 0.0001). The heart rate was not significantly different during uAOBP than during OBP measurements. On Bland Altman analysis the uAOBP underestimated OBP by a mean of 15.6 mmHg for systolic BP and by 8.6 mmHg for diastolic BP. In all 9 children with white-coat systolic hypertension uAOBP was within the normal range (<95th pc for OBP), in six of nine children with white-coat diastolic hypertension uAOBP was within the normal range however, in three of them it was elevated despite normal ABP.

CONCLUSION

uAOBP measurement is feasible in school-aged children, its values are considerably lower than OBP as well as daytime ABP and it could help with detection of white-coat systolic hypertension. The clinical applicability of uAOBP in children should be confirmed in further studies.

Feasibility of a randomized hypertension screening initiative in the perioperative setting

Objectives

This study sought to assess feasibility of a randomized trial of blood pressure intervention (home blood pressure monitoring vs. counseling) in the preoperative clinic and the baseline rates of primary care follow-up after such interventions.

Methods

A prospective randomized feasibility study was performed at Yale New Haven Hospital Preadmission Testing Clinic. A sample of 100 adults, with elevated blood pressure, were recruited during their preadmission visit, and randomized 1:1 to receive brief BP counseling and an educational brochure versus additionally receiving a home BP monitor (HBPM) with a mailed report of their home readings. At 60-day post-surgery telephone follow-up, investigators asked whether participants had primary-care follow-up; had new/adjusted hypertension treatment; and felt satisfied with the study.

Results

There were 51 patients in the counseling group and 49 in the HBPM group. Of 46 patients in the HBPM group who returned their monitors, 36 (78%) were hypertensive at home. At 60 days post-surgery, 31 (61%) patients in the counseling group and 30 (61%) in the HBPM group were reached by telephone with the remaining followed by EHR. Thirty-six (71%) patients in the counseling group and 36 (73%) in the HBPM group had seen their primary care provider. Seventeen of 36 (47%) in the counseling group and 18 of 31 (58%) in the HBPM group received new or adjusted hypertension medications. Sixty-one participants answered questions regarding their satisfaction with the study with 52 (85%) reporting that they felt moderately to very satisfied.

Conclusions

This feasibility study suggests that interventional blood pressure trials in the preoperative clinic are feasible, but telephone follow-up leads to significant gaps in outcome ascertainment.

Trial registration

Clinicaltrials.gov, NCT03634813. Registered 16 of August 2018.

Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

BACKGROUND

Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories.

METHODS

We used data from 1990 to 2019 on people aged 30-79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age.

FINDINGS

The number of people aged 30-79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306-359) million women and 317 (292-344) million men in 1990 to 626 (584-668) million women and 652 (604-698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55-62) of women and 49% (46-52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43-51) of women and 38% (35-41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20-27) for women and 18% (16-21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran.

INTERPRETATION

Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings.

FUNDING

WHO.

Blood pressure measurement: Should technique define targets?

Accurate assessment of blood pressure (BP) is the cornerstone of hypertension management. The objectives of this study were to quantify the effect of medical personnel presence during BP measurement by automated oscillometric BP (AOBP) and to compare resting office BP by AOBP to daytime average BP by 24‐h ambulatory BP monitoring (ABPM). This study is a prospective randomized cross‐over trial, conducted in a referral population. Patients underwent measurements of casual and resting office BP by AOBP. Resting BP was measured as either unattended (patient alone in the room during resting and measurements) or as partially attended (nurse present in the room during measurements) immediately prior to and after 24‐h ABPM. The primary outcome was the effect of unattended 5‐min rest preceding AOBP assessment as the difference between casual and resting BP measured by the Omron HEM 907XL. Ninety patients consented and 78 completed the study. The mean difference between the casual and Omron unattended systolic BP was 7.0 mm Hg (95% confidence interval [CI] 4.5, 9.5). There was no significant difference between partially attended and unattended resting office systolic BP. Resting office BP (attended and partially attended) underestimated daytime systolic BP load from 24‐h ABPM. The presence or absence of medical personnel does not impact casual office BP which is higher than resting office AOBP. The requirement for unattended rest may be dropped if logistically challenging. Casual and resting office BP readings by AOBP do not capture the complexity of information provided by the 24‐h ABPM.

Performance of an automated blood pressure measurement device in a stroke rehabilitation unit

CONTEXT

Valid blood pressure (BP) measurements are needed in post-stroke rehabilitation hospital units for the management of hypertension. Automated devices could be used to improve on usual care BP measurement. However, more information is needed about the performance of these devices in such a context.

METHODS

This prospective nonrandomized study was performed in stroke patients with hypertension hospitalized in a stroke rehabilitation unit. Two in-hospital BP assessment strategies were compared: usual care BP and in-hospital automated office BP (AOBP) standardized measurements. In-office AOBP and ambulatory BP monitoring (ABPM) were also performed on these patients. The main outcome was SBP. Study follow-up was until discharge, up to a maximum of 4 weeks.

RESULTS

Sixty-two patients with stroke hospitalized in a rehabilitation unit were included. Usual care BP was 130 ± 12/79 ± 9 mmHg and differed from an in-hospital AOBP of 117 ± 14/75 ± 12 mmHg (P < 0.001/P < 0.001). In-hospital and in-office AOBP measurements did not differ. Twenty percent of patients reached SBP therapeutic goals according to in-hospital AOBP but not according to usual care BP measurements.

CONCLUSION

This study shows that in a post-stroke rehabilitation unit, standardized in-hospital AOBP estimates are on average much lower than the usual care BP correlates and similar to the in-office AOBP estimates. In-hospital AOBP devices in a stroke rehabilitation unit could add important information for the management of hypertension.

Validity and inter-observers reliability of blood pressure measurements using mercury sphygmomanometer in the PERSIAN Guilan cohort study

OBJECTIVE

Accurate measuring of blood pressure is a vital step in both clinical and para-clinical settings. The aims of the present study were to evaluate the validity and inter-observer reliability of measured blood pressures by two trained observers and one expert supervisor in the PERSIAN Guilan cohort study (PGCS).

PARTICIPANTS AND METHODS

In a quasi-experimental study, two trained observers and one expert supervisor measured systolic and diastolic blood pressures (SBP and DBP) in 85 included participants. All measurements were done using Riester mercury sphygmomanometer as duplicate for each people.

RESULTS

Lack of validity in the total SBP (P = 0.017), DBP in age <50 years (P = 0.039), and DBP in BMI >25 (P=0.019) of first observer and total SBP (P = 0.045), SBP of male (P = 0.019), both SBP and DBP in age >50 years (P = 0.034, P = 0.012) and DBP in BMI <25 (P = 0.001) of second observer were seen. In addition, total inter-rater reliability was found as 12.2% and 27.2% in SBP and DBP, respectively. Age, sex and BMI categorized inter-observer reliability were not more than 15% in SBP of BMI <25 kg/m and 31.6% in DBP of female. The final inter-observer agreement after educational course was higher than 0.7 totally and in all categorical evaluations.

CONCLUSION

Based on lack of validity in some conditions and low level of reliability, education of all observers to measure both SBP and DBP accurately is needed. This is more necessary to done before performing the high population surveys.

Canadian Society of Transplantation and Canadian Society of Nephrology Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

Purpose of review:

To review an international guideline on the evaluation and care of living kidney donors and provide a commentary on the applicability of the recommendations to the Canadian donor population.

Sources of information:

We reviewed the 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors and compared this guideline to the Canadian 2014 Kidney Paired Donation (KPD) Protocol for Participating Donors.

Methods:

A working group was formed consisting of members from the Canadian Society of Transplantation and the Canadian Society of Nephrology. Members were selected to have representation from across Canada and in various subspecialties related to living kidney donation, including nephrology, surgery, transplantation, pediatrics, and ethics.

Key findings:

Many of the KDIGO Guideline recommendations align with the KPD Protocol recommendations. Canadian researchers have contributed to much of the evidence on donor evaluation and outcomes used to support the KDIGO Guideline recommendations.

Limitations:

Certain outcomes and risk assessment tools have yet to be validated in the Canadian donor population.

Implications:

Living kidney donors should be counseled on the risks of postdonation outcomes given recent evidence, understanding the limitations of the literature with respect to its generalizability to the Canadian donor population.

Are Automated Office Blood Pressure Readings More Variable Than Home Readings?

A recent report from the American Heart Association stated that automated office blood pressure (AOBP) is preferred for evaluating office blood pressure (BP) because it is more accurate and devoid of white coat effect, which is mostly caused by higher systolic BP readings. However, AOBP has been criticized for being too variable to be used for identifying patients with possible hypertension. We, therefore, compared AOBP with home BP monitoring (HBPM) with respect to variability as determined by their relationship with the gold standard for determining BP status, awake ambulatory BP (ABP). The main focus was on systolic BP. Data on AOBP, HBPM, and awake ABP were collected on 300 patients referred from the community for 24-hour ambulatory BP monitoring. The SD of the difference between mean systolic awake ABP (136.4±11.5) and AOBP (131.2±15.7) was 13.6 mm Hg compared with 13.1 for the SD of the difference ( P =0.52) between the systolic awake ABP and the HBPM (136.7±16.1). Coefficients of correlation were slightly lower for systolic awake ABP versus AOBP ( r =0.54) compared with HBPM ( r =0.60). Coefficients of variation for AOBP (12.0%) and HBPM (11.8%) and variances between AOBP and HBPM were similar. Of the 139 patients with hypertension as defined by a manual office systolic BP ≥140 mm Hg, variability in BP readings as determined by the SDs of the mean difference versus awake ABP were similar ( P =0.56) for AOBP (14.6) and HBPM (13.9). Overall, both systolic AOBP and HBPM exhibited a similar degree of variability as assessed by the various methods.

Associations between novel jump test measures, grip strength, and physical performance: the Osteoporotic Fractures in Men (MrOS) Study

BACKGROUND/AIMS

Weight-bearing jump tests measure lower extremity muscle power, velocity, and force, and may be more strongly related to physical performance than grip strength. However, these relationships are not well described in older adults.

METHODS

Participants were 1242 older men (mean age 84 ± 4 years) in the Osteoporotic Fractures in Men (MrOS) Study. Jump peak power (Watts/kg body weight), force (Newton/kg body weight) at peak power, and velocity (m/s) at peak power were measured by jump tests on a force plate. Grip strength (kg/kg body weight) was assessed by hand-held dynamometry. Physical performance included 400 m walk time (s), 6 m usual gait speed (m/s), and 5-repeated chair stands speed (#/s).

RESULTS

In adjusted Pearson correlations, power/kg and velocity moderately correlated with all performance measures (range r = 0.41-0.51; all p < 0.001), while correlations for force/kg and grip strength/kg were weaker (range r = 0.20-0.33; all p < 0.001). Grip strength/kg moderately correlated with power/kg (r = 0.44; p < 0.001) but not velocity or force/kg. In adjusted linear regression with standardized βs, 1 SD lower power/kg was associated with worse: 400 m walk time (β = 0.47), gait speed (β = 0.42), and chair stands speed (β = 0.43) (all p < 0.05). Associations with velocity were similar (400 m walk time: β = 0.42; gait speed: β = 0.38; chair stands speed: β = 0.37; all p < 0.05). Force/kg and grip strength/kg were more weakly associated with performance (range β = 0.18-0.28; all p < 0.05).

CONCLUSIONS/DISCUSSION

Jump power and velocity had stronger associations with physical performance than jump force or grip strength. This suggests lower extremity power and velocity may be more strongly related to physical performance than lower extremity force or upper extremity strength in older men.

Association of 24-Hour Ambulatory Blood Pressure Patterns with Cognitive Function and Physical Functioning in CKD

BACKGROUND AND OBJECTIVES

Hypertension is highly prevalent in patients with CKD as is cognitive impairment and frailty, but the link between them is understudied. Our objective was to determine the association between ambulatory BP patterns, cognitive function, physical function, and frailty among patients with nondialysis-dependent CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Ambulatory BP readings were obtained on 1502 participants of the Chronic Renal Insufficiency Cohort. We evaluated the following exposures: (1) BP patterns (white coat, masked, sustained versus controlled hypertension) and (2) dipping patterns (reverse, extreme, nondippers versus normal dippers). Outcomes included the following: (1) cognitive impairment scores from the Modified Mini Mental Status Examination of <85, <80, and <75 for participants <65, 65-79, and ≥80 years, respectively; (2) physical function, measured by the short physical performance battery (SPPB), with higher scores (0-12) indicating better functioning; and (3) frailty, measured by meeting three or more of the following criteria: slow gait speed, muscle weakness, low physical activity, exhaustion, and unintentional weight loss. Cognitive function and frailty were assessed at the time of ambulatory BP (baseline) and annually thereafter. SPPB was assessed at baseline logistic and linear regression and Cox discrete models assessed the cross-sectional and longitudinal relationship between dipping and BP patterns and outcomes.

RESULTS

Mean age of participants was 63±10 years, 56% were male, and 39% were black. At baseline, 129 participants had cognitive impairment, and 275 were frail. Median SPPB score was 9 (interquartile range, 7-10). At baseline, participants with masked hypertension had 0.41 (95% CI, -0.78 to -0.05) lower SPPB scores compared with those with controlled hypertension in the fully adjusted model. Over 4 years of follow-up, 529 participants had incident frailty, and 207 had incident cognitive impairment. After multivariable adjustment, there was no association between BP or dipping patterns and incident frailty or cognitive impairment.

CONCLUSIONS

In patients with CKD, dipping and BP patterns are not associated with incident or prevalent cognitive impairment or prevalent frailty.

Blood Pressure Measurement: A KDOQI Perspective

The majority of patients with chronic kidney disease (CKD) have elevated blood pressure (BP). In patients with CKD, hypertension is associated with increased risk for cardiovascular disease, progression of CKD, and all-cause mortality. New guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommend new thresholds and targets for the diagnosis and treatment of hypertension in patients with and without CKD. A new aspect of the guidelines is the recommendation for measurement of out-of-office BP to confirm the diagnosis of hypertension and guide therapy. In this KDOQI (Kidney Disease Outcomes Quality Initiative) perspective, we review the recommendations for accurate BP measurement in the office, at home, and with ambulatory BP monitoring. Regardless of location, validated devices and appropriate cuff sizes should be used. In the clinic and at home, proper patient preparation and positioning are critical. Patients should receive information about the importance of BP measurement techniques and be encouraged to advocate for adherence to guideline recommendations. Implementing appropriate BP measurement in routine practice is feasible and should be incorporated in system-wide efforts to improve the care of patients with hypertension. Hypertension is the number 1 chronic disease risk factor in the world; BP measurements in the office, at home, and with ambulatory BP monitoring should adhere to recommendations from the AHA.

A comparative study of automated blood pressure device and mercury-free LED blood pressure device using Lin's concordance correlation coefficient and other validity measures in Indian population

INTRODUCTION

Automated blood pressure (BP) monitor is widely used to assess the blood pressure (BP) of the study subjects in community-based researches. This study aims at the detection of hypertension by automated BP device and examines the concordance and validity between automated and mercury-free LED BP devices.

MATERIALS AND METHODS

This cross-sectional study was conducted in the tribal state of Jharkhand in India from January 2017 to June 2017. A total of 300 study participants aged more than 18 years were enrolled in this study. BP of the patients in the sitting position was measured three times each by automated device and mercury-free LED BP device. The different sets of readings were assessed by concordance correlation coefficient (CCC) and other validity measures.

RESULTS

The CCC for systolic and diastolic BP measured by automated and mercury-free LED BP is 0.88 and 0.85, respectively. The mean difference between systolic and diastolic BP by both the instruments is statistically insignificant (P > 0.05). The sensitivity, specificity, PPV, NPV, and accuracy of automated BP devices to predict hypertension is 96.61%, 92.21%, 75%, 99%, and 93%. The area under ROC for systolic and diastolic BP is 0.984 and 0.97, respectively with P values < 0.0001 in both the cases.

CONCLUSIONS

This study concluded that the overall automated BP machine has fair degree of agreement (CCC) with a manual BP device. The validity of this monitor to screen hypertension may also be considered in field settings.

The influence of blood pressure patterns on renal outcomes in patients with chronic kidney disease: The long-term follow up result of the APrODiTe-2 study

Blood pressure (BP) control is the most established practice for preventing the progression and complications of chronic kidney disease (CKD). We examined the influence of BP patterns on target organ damage in hypertensive patients with CKD by using long-term follow-up data of the APrODiTe-2 study.We collected 5 years of data of APrODiTe-2 study (1 year longitudinal study) participants after the enrollment on the progression of estimated glomerular filtration (eGFR), renal outcomes (doubling of serum creatinine, 50% decrease of eGFR, maintenance dialysis, and kidney transplantation), cerebro-cardiovascular (CCV) accidents, and all-cause mortality (n=378) to evaluate the long-term influence of BP patterns on target organ damages.Initially, more than 2/3 of patients showed masked (50.0%) and sustained uncontrolled (30.6%) BP control states as well as non- (31.3%) and reverse-dipping (35.0%) states. Only 18.8% and 20.8% of participants showed a better change in BP control patterns and a dipping pattern change to dippers over 1 year, respectively. Composite of new CCV accidents occurred in 43 patients (11.4%), and no BP patterns were associated with the occurrence of new CCV accidents. A worse change in BP control categories over 1 year was associated with increased occurrence of composites of renal outcomes after adjustment for age, sex, and the cause of CKD (HR 5.997 [1.454-24.742], P = .013 and HR 4.331 [1.347-13.927], P = .014, respectively). Patients with a worse initial BP control category, a worse change in BP control categories over 1 year, and higher clinic systolic BP and pulse pressure (PP) (> median level) were more likely to have faster eGFR progression (absolute eGFR and eGFR ratio).Higher BP burden (a worse change in BP control categories, higher initial clinic systolic BP and PP) was associated with faster eGFR progression and increased occurrence of renal outcomes.

Resistant hypertension-defining the scope of the problem

The updated scientific statement by the American Heart Association has defined resistant hypertension (HTN;RH) as uncontrolled blood pressure (BP) ≥ 130/80 mmHg, despite concurrent use of 3 anti-HTN drug classes comprising a calcium channel blocker, a blocker of renin-angiotensin system, and a thiazide diuretic, preferably chlorthalidone. Using the updated BP criteria, the prevalence of RH in the United States is found to be modestly increased by approximately 3-4% among treated population. Meta-analysis of observational studies have demonstrated that pseudo-RH from white coat HTN or medication nonadherence is as much common as the truly RH. Thus, screening for pseudo-resistance in the evaluation of all apparent RH is of utmost importance as diagnosis of white-coat HTN requires no treatment, while medication nonadherence would benefit from identifying and targeting barriers to adherence.

[Expert consensus statement on blood pressure measurement from the French Society of Hypertension, an affiliate of the French Society of Cardiology]

Since 2016, the French Society of Hypertension has warned about the decline in the management of high blood pressure in France: stagnation, or even decreased number of people who know their blood pressure level, take a treatment and are controlled. These results are lower than those observed in many other countries. Blood pressure is measured with an old method in the doctor's office. Accepted, simple and cost-effective, this method is currently unavoidable for reasons of feasibility and social habit. It has been used in observational and intervention studies that are the basis of the medical reasoning for screening, treatment and drug control of hypertension. In practice, it is too often poorly applied and unpredictable. It is now necessary to measure blood pressure in mmHg using a validated oscillometric automatic device coupled to a specific upper arm cuff adapted to the arm circumferences for the diagnosis and monitoring of high blood pressure in the doctor's office and at home. The auscultatoric measurement is only recommended if any doubt about the reliability of the electronic measurement. Blood pressure measurement is basically performed on both arms to detect asymmetry and then on the arm with the highest blood pressure. It is performed in sitting or lying position after a few minutes of rest without speaking and without having smoked and then in standing position to diagnose orthostatic hypotension, especially in elderly, diabetic and multi-medicated subjects. The blood pressure measurement during the consultation must be repeated and include at least 3 consecutive measurements at one minute intervals. The average of the last 2 measurements determines the blood pressure level. It is recommended to perform BP measurements outside the medical environment for the diagnosis and monitoring of hypertension; Home BP measurement is preferred to ambulatory blood pressure measurement for practical reasons unless otherwise specified. The home blood pressure measurement should include three measurements in the morning at breakfast and three measurements in the evening before bedtime at one minute intervals for at least three days. Prior training must be provided. In treated hypertensive patients, a masked hypertension should be considered as an uncontrolled hypertension and antihypertensive therapy adapted accordingly. The measurement of central BP pressure (aorta) should be limited to clinical research.

Screening for hypertension: an elevated office blood pressure measurement is valuable, adding an automated one is even better

BACKGROUND

Previous studies have examined the relevance of hypertension (HTN) screening in walk-in clinics. So far, no valid algorithm has been proposed on how to integrate HTN screening in this context. The aim of our study was to assess, in a walk-in clinic setting, the HTN screening strategy for performing an automated office blood pressure (AOBP) measurement following an initially high office blood pressure (OBP) measurement.

PATIENTS AND METHODS

Included participants were adults with nonemergent medical conditions and an initial walk-in clinic OBP between systolic 140 and/or diastolic 90 mmHg and systolic 180 and/or diastolic 110 mmHg. AOBP was performed with patients unattended. The 24-h ambulatory blood pressure measurement (ABPM) was used as the diagnostic threshold.

RESULTS

Fifty participants were included in the study. The overall HTN prevalence as confirmed by the 24-h ABPM was 46% [95% confidence interval (CI): 32.19-59.81]. After an elevated OBP, AOBP over diagnostic thresholds occurred in 32 patients and were confirmed by ABPM in 20 participants, leading to a 62.5% positive predictive value (95% CI: 51.5-72.3%). Measurements under the AOBP diagnostic threshold occurred in 18 patients and were confirmed by ABPM in 15 participants, leading to a negative predictive value of 83.3% (95% CI: 62.3-93.8%).

CONCLUSION

In a walk-in clinic, an elevated OBP is a useful screening tool due its ability to recognize nearly one in two patients as actually hypertensive. Adding an AOBP makes it possible to specify what course of action to take. This ultimately results in better targeting of patients for an ABPM referral.

The Impact of Measurement Methods on Office Blood Pressure and Management of Hypertension in General Practice

INTRODUCTION

The use of unattended automated office blood pressure (uAutoOBP) versus attended automated (aAutoOBP) and manual auscultatory office blood pressure (AuscOBP) measurements is a topic of current controversy.

AIM

To evaluate the differences between OBP measurements methods in the general practice (GP) setting.

METHODS

We first compared aAutoOBP and uAutoOBP in 42 consecutive patients with hypertension (group 1). Secondly, we compared AuscOBP to uAutoOBP measurements in 133 consecutive patients with hypertension (group 2). In addition, we analyzed the achieved OBP targets as recommended in the 2018 European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) guidelines in group 2.

RESULTS

The mean age of patients in group 1 was 71 years (range 34-89 years, 54.8% females). The aAutoOBP and uAutoOBP systolic (131.7 and 131.6 mmHg) and diastolic (83.4 and 82.4 mmHg) mean values were not significantly different. The patient characteristics in group 2 were similar to group 1. We observed a significant difference between AuscOBP and uAutoOBP measurement for both systolic (149.4 versus 129.5 mm Hg) and diastolic (85.4 versus 81.6 mm Hg, p < 0.0001, respectively). Accordingly, 20.3% and 45.9% of patients reached the overall 2018 ESC/ESH systolic and diastolic OBP targets of < 140/80 mmHg according to AuscOBP and uAutoOBP (p < 0.0001).

CONCLUSION

The attended versus unattended status of automated OBP measurements had no impact on OBP values in GP. However, significantly higher OBP values and lower rates of achieved target OBP were observed by using AuscOBP measurements by physicians in comparison to automated OBP recordings.

Barriers to Accurate Blood Pressure Measurement in the Medical Office

Background: Despite the high prevalence of blood pressure (BP) measurement errors in the outpatient setting, little is known about why primary care clinics struggle to achieve consistently accurate BP measurements in routine practice. We investigated barriers affecting measurement of BP for adult patients in primary care. Methods: We conducted a qualitative evaluation in 6 adult primary care clinics. BP measurement was observed during 54 routine patient encounters. Six managers completed semistructured interviews and 18 clinical staff members participated in focus group discussions. We used an inductive, data-driven approach to identify and organize findings into cohesive, overarching themes describing factors affecting BP measurement. Results: Observed errors in BP measurement spanned the entire spectrum of steps required to obtain BP properly. Barriers to proper BP measurement were related to staff knowledge and behavior (inadequate knowledge, training, and feedback); workflow constraints (need to multitask, inadequate time); and equipment issues (BP monitors, seating). Patient characteristics and behavior also affected BP measurement. Conclusions: Correct measurement of BP is affected by a wide range of factors and is challenging to accomplish consistently in primary care. These findings may inform the design of performance improvement programs to maximize the quality of BP measurement in the outpatient setting.

Can an automatic oscillometric device replace a mercury sphygmomanometer on blood pressure measurement? a systematic review and meta-analysis

OBJECTIVE

A mercury sphygmomanometer has been considered a gold standard for measuring blood pressure. However, by the Minamata Convention on Mercury, the traditional mercury sphygmomanometer is being replaced by an automated oscillometric device. This study aimed to provide scientific evidence to determine whether an automated oscillometric device can replace a mercury sphygmomanometer and if it is applicable in routine practice.

METHODS

MEDLINE, EMBASE, the Cochrane Library, and CINAHL were searched on 4 May 2018. Studies comparing blood pressure measurements between automated oscillometric devices and mercury sphygmomanometers were included. Study characteristics were abstracted using the evidence table, and random-effects meta-analyses were conducted.

RESULTS

Data were compiled from 24 studies comprising 47 759 subjects. The results of meta-analysis showed that automated oscillometric devices measured lower than mercury sphygmomanometers for both systolic blood pressure (mean differences -1.75 mmHg, 95% confidence intervals: -3.05 to -0.45, I = 91.0%) and diastolic blood pressure (mean differences -1.20 mmHg, 95% confidence intervals: -2.16 to -0.24, I = 95.0%). In sub-group analyses by manufacturer, BpTRU measured lower than the mercury sphygmomanometer and OMRON showed no difference compared to the mercury sphygmomanometer for both systolic and diastolic blood pressure, but the results differed depending on the devices.

CONCLUSION

As a result of this review, the difference in blood pressure between the mercury sphygmomanometer and the automated oscillometric device was within 5 mmHg, but the heterogeneity between the studies was very high. The automated oscillometric devices showed differences in blood pressure results according to the manufacturer and product type.

Development of equations for converting random-zero to automated oscillometric blood pressure values

Background: This study aimed to collect data to compare blood pressure values between random-zero sphygmomanometers and automated oscillometric devices and generate equations to convert blood pressure values from one device to the other. Methods: Omron HEM-907, a widely used automated oscillometric device in many epidemiologic surveys and cohort studies, was compared here with random-zero sphygmomanometers. In total, 201 participants aged 40-79 years (37% men) were enrolled and randomly assigned to one of two groups, with blood pressure measurement first taken by automated oscillometric devices or by random-zero sphygmomanometers. The study design enabled comparisons of blood pressure values between random-zero sphygmomanometers and two modes of this automated oscillometric device (automated and manual), and assessment of effects of measurement order on blood pressure values. Results: Among all participants, mean blood pressure levels were the lowest when measured with random-zero sphygmomanometers compared with both modes of automated oscillometric devices. Several variables, including age and gender, were found to contribute to the blood pressure differences between random-zero sphygmomanometers and automated oscillometric devices. Equations were developed using multiple linear regression after taking those variables into account to convert blood pressure values by random-zero sphygmomanometers to automated oscillometric devices. Conclusions: Equations developed in this study could be used to compare blood pressure values between epidemiologic and clinical studies or identify shift of blood pressure distribution over time using different devices for blood pressure measurements.

Rehabilitation of patients after transient ischaemic attack or minor stroke: pilot feasibility randomised trial of a home-based prevention programme

BACKGROUND

Although the importance of secondary prevention after transient ischaemic attack (TIA) or minor stroke is recognised, research is sparse regarding novel, effective ways in which to intervene in a primary care context.

AIM

To pilot a randomised controlled trial (RCT) of a novel home-based prevention programme (The Healthy Brain Rehabilitation Manual) for patients with TIA or 'minor' stroke.

DESIGN AND SETTING

Pilot RCT, home-based, undertaken in Northern Ireland between May 2017 and March 2018.

METHOD

Patients within 4 weeks of a first TIA or 'minor' stroke received study information from clinicians in four hospitals. Participants were randomly allocated to one of three groups: standard care (control group) (n = 12); standard care with manual and GP follow-up (n = 14); or standard care with manual and stroke nurse follow-up (n = 14). Patients in all groups received telephone follow-up at 1, 4, and 9 weeks. Eligibility, recruitment, and retention were assessed; stroke/cardiovascular risk factors measured at baseline and 12 weeks; and participants' views were elicited about the study via focus groups.

RESULTS

Over a 32-week period, 28.2% of clinic attendees (125/443) were eligible; 35.2% of whom (44/125) consented to research contact; 90.9% of these patients (40/44) participated, of whom 97.5% (39/40) completed the study. After 12 weeks, stroke risk factors [cardiovascular risk factors, including blood pressure and measures of physical activity] improved in both intervention groups. The research methods and the programme were acceptable to patients and health professionals, who commented that the programme 'filled a gap' in current post-TIA management.

CONCLUSION

Findings indicate that implementation of this novel cardiac rehabilitation programme, and of a trial to evaluate its effectiveness, is feasible, with potential for clinically important benefits and improved secondary prevention after TIA or 'minor' stroke.

Effect of self-initiated and fully-automated self-measurement on blood pressure

Self-measurement of blood pressure (BP) is regularly used to diagnose hypertension and to monitor BP at home. We recently showed that self-measurement of BP may elicit a pressor or 'auto-cuff' response. In this study we examined whether the pressor response is different between self-initiated and fully-automated BP measurement. We performed two randomized crossover studies in outpatients visiting a hypertension clinic. The first cohort of 52 participants performed six unattended self-initiated and six fully-automated BP measurements, while continuously monitoring BP and central haemodynamics using finger photoplethysmography. The second cohort consisted of 120 patients who performed three self-initiated and three fully-automated BP measurements. In the first cohort (mean age 61.2 ± 10.4 years, mean office BP 142.0 ± 19.9/82.5 ± 12.2 mmHg, 36.7% female) average systolic and diastolic BP increased by 7.3 ± 8.5/3.3 ± 4.0 mmHg in the group with self-initiated BP measurements, while BP increased by 3.3 ± 6.3/1.4 ± 3.0 mmHg during fully-automated measurements (p = 0.002/p = 0.002 for difference between groups). The higher BP increase during self-initiated BP measurements resulted from an increase in heart rate and cardiac output. In the second cohort (mean age 58.0 ± 14.1 years, mean office BP 153.6 ± 23.8/86.3 ± 14.0 mmHg, 44.1% female) self-initiated BP measurement resulted in a 2.1 ± 6.8/0.9 ± 4.0 mmHg higher systolic and diastolic BP compared with fully-automated self-measurement (p = 0.001/0.018). In conclusion, our findings suggest that self-initiated BP measurement using a fully-automated method results in a more reliable BP compared with a self-initiated semi-automated method by attenuating the auto-cuff response. These findings may have implications for the self-measurement of BP.

Impact of the SPRINT Trial on Hypertension Management

The Systolic Blood Pressure Intervention Trial is the first large prospective randomized controlled trial to demonstrate the benefit of an intensive systolic blood pressure (SBP) treatment target (<120 mm Hg) compared to a standard target (<140 mm Hg) in reducing cardiovascular morbidity and mortality and all-cause mortality in high-risk hypertensive patients. The impact of SPRINT on hypertension treatment has been large, but major questions remain about the feasibility of achieving the SPRINT intensive SBP target in routine practice, the generalizability of the SPRINT findings to hypertensive populations that were excluded from the trial, and the cost effectiveness of adopting the SPRINT intensive treatment goal. In this review, we discuss the generalizability of SPRINT data to the general population of adults with hypertension and with various comorbidities, the cost effectiveness of intensive SBP-lowering therapy, and the implications of SPRINT for future hypertension guideline development and clinical practice.