Accuracy of automated cuff blood pressure monitors in special populations: International Organization for Standardization (ISO) Task Group report and call for research

OBJECTIVE

Automated cuff blood pressure (BP) devices are widely used for ambulatory, home, and office BP measurement. However, an automated device, which is accurate in the general adult population may be inaccurate in some special populations. A 2018 Collaborative Statement by the US Association for the Advancement of Medical Instrumentation, the European Society of Hypertension, and the International Organization for Standardization (ISO) considered three special populations requiring separate validation (age <3 years, pregnancy, and atrial fibrillation). An ISO Task Group was appointed to identify evidence for additional special populations.

METHOD

Evidence on potential special populations was identified from the STRIDE BP database, which performs systematic PubMed searches for published validation studies of automated cuff BP monitors. Devices that passed in a general population, but failed in potential special populations were identified.

RESULTS

Of 338 publications (549 validations, 348 devices) in the STRIDE BP database, 29 publications (38 validations, 25 devices) involved 4 potential special populations: (i) age 12-18 years: 3 of 7 devices failed but passed in a general population; (ii) age more than 65 years: 1 of 11 devices failed but passed in a general population; (iii) diabetes type-2: 4 devices (all passed); (iv) chronic kidney disease: 2 of 7 devices failed but passed in a general population.

CONCLUSION

Some evidence suggest that the automated cuff BP devices may have different accuracy in adolescents and in patients with chronic kidney disease than in the general population. More research is needed to confirm these findings and investigate other potential special populations.

Validation of the G.LAB MD41A0 upper arm blood pressure monitor in patients with diabetes mellitus according to the AAMI/ESH/ISO 81060-2:2018 Universal Standard

OBJECTIVE

The objective of this study is to determine the accuracy of the G.LAB MD41A0 upper-arm oscillometric blood pressure (BP) monitor for self/home BP measurement in patients with diabetes according to 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).

METHODS

Patients with diabetes were recruited according to AAMI/ESH/ISO Universal Standard using the same arm sequential BP measurement method. The standard cuff of the test device was used for arm circumference 22-44 cm.

RESULTS

A total of 92 patients with diabetes were recruited and 85 were analyzed with an average age of 55.1 ± 17.7 years, 48 men, and arm circumference of 32.0 ± 6.0 cm. For the validation Criterion 1, the mean ± SD of the differences between the test device and reference BP readings was 0.89 ± 6.04/-0.84 ± 5.11 mmHg (systolic/diastolic). For Criterion 2, the SD of the averaged BP differences between the test device and reference BP per subject was 4.23/4.19 mmHg (systolic/diastolic).

CONCLUSION

The G.LAB MD41A0 upper arm BP monitor fulfilled all the requirements of the AAMI/ESH/ISO Universal Standard (ISO 81060-2:2018) in patients with diabetes and can be recommended for self/home use.

Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension

The present paper provides an update of previous recommendations on Home Blood Pressure Monitoring from the European Society of Hypertension (ESH) Working Group on Blood Pressure Monitoring and Cardiovascular Variability sequentially published in years 2000, 2008 and 2010. This update has taken into account new evidence in this field, including a recent statement by the American Heart association, as well as technological developments, which have occurred over the past 20 years. The present document has been developed by the same ESH Working Group with inputs from an international team of experts, and has been endorsed by the ESH.

Robotic Locomotor Training Leads to Cardiovascular Changes in Individuals With Incomplete Spinal Cord Injury Over a 24-Week Rehabilitation Period: A Randomized Controlled Pilot Study

OBJECTIVE

To describe the effect of robotic locomotor training (RLT) and activity-based training (ABT) on cardiovascular indices during various physiological positions in individuals with spinal cord injury.

DESIGN

Randomized controlled pilot study.

SETTING

Private practice: Therapy & Beyond Centre - Walking with Brandon Foundation, Sports Science Institute of South Africa, Cape Town, South Africa.

PARTICIPANTS

Participants with chronic traumatic motor incomplete tetraplegia (N=16) who resided in the Western Cape, South Africa.

INTERVENTION

Robotic locomotor training (Ekso GT) and activity-based training over a 24-week intervention.

MAIN OUTCOME MEASURES

Brachial and ankle blood pressure, heart rate, heart rate variability, and cardiovascular efficiency during 4 physiological positions.

RESULTS

No differences between groups or over time were evident in resting systolic and diastolic blood pressure, ankle systolic pressure, ankle brachial pressure index, and heart rate variability. Standing heart rate at 24 weeks was significantly higher in the ABT group (95.58±12.61 beats/min) compared with the RLT group (75.14±14.96 beats/min) (P=.05). In the RLT group, no significant changes in heart rate variability (standard deviation R-R interval and root mean square of successive differences) was found between the standing and 6-minute walk test physiological positions throughout the intervention. Cardiovascular efficiency in the RLT group during the 6-minute walk test improved from 11.1±2.6 at baseline to 7.5±2.8 beats per meter walked at 6 weeks and was maintained from 6 to 24 weeks.

CONCLUSIONS

Large effect sizes and significant differences between groups found in this pilot study support the clinical effectiveness of RLT and ABT for changing cardiovascular indices as early as 6 weeks and up to 24 weeks of rehabilitation. RLT may be more effective than ABT in improving cardiac responses to orthostatic stress. Based on heart rate variability metrics, the stimulus of standing has comparable effects to RLT on the parasympathetic nervous system. Cardiovascular efficiency of exoskeleton walking improved, particularly over the first 6 weeks. Both the RLT and ABT interventions were limited in their effect on brachial and ankle blood pressure. A randomized controlled trial with a larger sample size is warranted to further examine these findings.

Acute effect of bodyweight-based strength training on blood pressure of hypertensive older adults: A randomized crossover clinical trial

Background: Strength Training (ST) reduces the cardiovascular risk of hypertensive elderly people; however, there is a need for efficient and low-cost ST programs that aim to reduce blood pressure (BP) in elderly people with adherence and affectivity in this population. Objective: Evaluate the acute effect on BP and satisfaction with the practice of bodyweight-based strength training (BWST) in hypertensive older adults. Methods: Participants performed a BWST session and a control session (CS). The BWST consisted of six exercises, with three sets of 30 seconds. In the CS, no activity was performed. BP was measured before and at 0, 10, 20, and 30 minutes post-session. Participants' satisfaction was assessed. Results: Eleven older adults (65.8 ± 4.6 years; 7 men) participated in the study. There was an increase (p = .028) in systolic BP immediately after BWST, returning to baseline values in the intervals 10, 20, and 30 post-section. In the CS there was an increase (p = .009) 30 minutes post-session compared to 20 minutes. Between sessions, a lower systolic BP was found in BWST (-6.54 ± 3.31; p = .048) 30 minutes post-sessions. For satisfaction, 82% of participants were "totally satisfied" with BWST. Conclusion: The SBP is lower 30 minutes after BWST session than control session, and BWST promoted a pleasant affective response in hypertensive older adults.

An Automated Blood Pressure Display for Self-Measurement in Patients With Chronic Kidney Disease (iHealth Track): Device Validation Study

BACKGROUND

Hypertension is a global public health issue and is closely related to chronic kidney disorder (CKD). In people with CKD, strict monitoring of blood pressure is an important part of therapy.

OBJECTIVE

The aim of this research was to validate the iHealth Track blood pressure monitoring device for patients with CKD according to the European Society of Hypertension International Protocol 2010 (ESH-IP2).

METHODS

In total, 33 patients who received hemodialysis in Plasencia participated in the study. There were 9 successive measurements made, which conformed to the ESH-IP2. We calculated the differences between the standard reference device (Omron M3 Intellisense) and the test device (iHealth Track) for blood pressure and heart rate values. For 99 total comparisons of paired measurements, we classified differences into various categories (≤5 mmHg, ≤10 mmHg, and ≤15 mmHg for blood pressure; ≤3, ≤5, and ≤8 beats per minute for heart rate).

RESULTS

In 90 of 99 systolic blood pressure and 89 of 99 diastolic blood pressure comparisons between the devices, measurement differences were within 5 mmHg. In 81 of 99 heart rate comparisons between the devices, measurement differences were within 3 beats per minute. The mean differences between the test and reference standard measurements were 3.27 (SD 2.99) mmHg for systolic blood pressure, 3.59 (SD 4.55) mmHg for diastolic blood pressure, and 2.18 (SD 2.75) beats per minute for heart rate. We also observed that for both systolic and diastolic blood pressure, 31 of 33 participants had at least two of three comparisons between the devices with measurement differences less than 5 mmHg. For heart rate, 28 of 33 patients had at least two of three comparisons between the devices with measurement differences less than 3 beats per minute.

CONCLUSIONS

To our knowledge, this is the first study to show that iHealth Track meets the requirements of the ESH-IP2 in patients with CKD. Therefore, the iHealth Track is suitable for use in renal patients.

Seasonal variation in home blood pressure and its relationship with room temperature in patients with type 2 diabetes

Our aim was to examine the seasonal variations in home blood pressure measurements and the relationship of ambient temperature or room temperature with the seasonal variations in home blood pressure measurements using a home blood pressure telemonitoring system in patients with type 2 diabetes. The home blood pressure measurements of 41 patients with type 2 diabetes were self-measured. Patients performed triplicate morning and evening blood pressure measurements at least 5 days per month for 12 consecutive months. The lowest values of both systolic blood pressure and diastolic blood pressure were observed in August (126.3 and 70.4 mmHg, respectively), and the highest systolic and diastolic blood pressure values were observed in January (140.3 and 76.9 mmHg, respectively). The root mean squared error between the mean systolic blood pressure and room temperature was 6.50 mmHg and between mean systolic blood pressure and ambient temperature was 6.55 mmHg. Using a home blood pressure telemonitoring system, this study revealed for the first time that home blood pressure varied seasonally, with the highest values observed in January and the lowest values observed in August, and that the seasonal variations in home blood pressure were related to room temperature as well as ambient temperature.

QardioArm Upper Arm Blood Pressure Monitor Against Omron M3 Upper Arm Blood Pressure Monitor in Patients With Chronic Kidney Disease: A Validation Study According to the European Society of Hypertension International Protocol Revision 2010

Background

Hypertension is considered as a main risk factor for chronic kidney disease development and progression. Thus, the control and evaluation of this disease with new software and devices are especially important in patients who suffer from chronic kidney disease.

Objective

This study aimed to validate the QardioArm mobile device, which is used for blood pressure (BP) self-measurement in patients who suffer from chronic kidney disease, by following the European Society of Hypertension International Protocol 2 (ESH-IP2) guidelines.

Methods

A validation study was carried out by following the ESH-IP2 guidelines. A sample of 33 patients with chronic kidney disease self-measured their BP by using the QardioArm and Omron M3 Intellisense devices. Heart rate (HR), diastolic BP, and systolic BP were measured.

Results

The QardioArm fulfilled the ESH-IP2 validation criteria in patients who suffered from chronic kidney disease.

Conclusions

Thus, this study is considered as the first validation using a wireless upper arm oscillometric device connected to an app to measure BP and HR meeting the ESH-IP2 requirements in patients who suffer from chronic kidney disease. New validation studies following the ESH-IP2 guidelines should be carried out using different BP devices in patients with specific diseases.

Validation in the General Population of the iHealth Track Blood Pressure Monitor for Self-Measurement According to the European Society of Hypertension International Protocol Revision 2010: Descriptive Investigation

Background

High blood pressure is one of the most common reasons why patients seek assistance in daily clinical practice. Screening for hypertension is fundamental and, because hypertension is identified only when blood pressure is measured, accurate measurements are key to the diagnosis and management of this disease. The European Society of Hypertension International Protocol revision 2010 (ESH-IP2) was developed to assess the validity of automatic blood pressure measuring devices that are increasingly being used to replace mercury sphygmomanometers.

Objective

We sought to determine whether the iHealth Track blood pressure monitor meets ESH-IP2 requirements for self-measurement of blood pressure and heart rate at the brachial level and is appropriate for use in the general population.

Methods

This study was a descriptive investigation. ESH-IP2 requires a total number of 33 participants. For each measure, the difference between observer and device blood pressure and heart rate values is calculated. In all, 99 pairs of blood pressure differences are classified into 3 categories (≤5, ≤10, and ≤15 mm Hg), and 99 pairs of heart rate differences are classified into 3 categories (≤3, ≤5, and ≤8 beats/min). We followed these protocol procedures in a convenience sample of 33 participants.

Results

iHealth Track fulfilled ESH-IP2 requirements and passed the validation process successfully. We observed an absolute difference within 5 mm Hg in 75 of 99 comparisons for systolic blood pressure, 78 of 99 comparisons for diastolic blood pressure, and 89 of 99 comparisons for heart rate. The mean differences between the test and standard readings were 4.19 (SD 4.48) mm Hg for systolic blood pressure, 3.74 (SD 4.55) mm Hg for diastolic blood pressure, and 1.95 (SD 3.27) beats/min for heart rate. With regard to part 2 of ESH-IP2, we observed a minimum of 2 of 3 measurements within a 5-mm Hg difference in 29 of 33 participants for systolic blood pressure and 26 of 33 for diastolic blood pressure, and a minimum of 2 of 3 measurements within a 3-beat/min difference in 30 of 33 participants for heart rate.

Conclusions

iHealth Track readings differed from the standard by less than 5, 10, and 15 mm Hg, fulfilling ESH-IP2 requirements. Consequently, this device is suitable for use in the general population.

Functional health literacy in hypertensive elders at primary health care

ABSTRACT Objective: to assess the relationship between inadequate functional health literacy and inadequate blood pressure control in older people with hypertension in Primary Health Care. Method: a cross-sectional study with sample calculated at 392. SAHLPA-18 tool was used for functional health literacy; blood pressure was measured; sociodemographic and clinical data were collected. Hierarchical logistic regression was used. Results: (high) inadequate blood pressure and (low) functional inadequate health literacy were present in 41.6% and 54.6% of the people, respectively. Factors associated with inadequate blood pressure were: inadequate functional health literacy, black-brown skin color, overweight-obesity, hypertension diagnosis time, non-adherence to exercise/diet, drug treatment. Schooling had no association with inadequate blood pressure Conclusion: hypertensive elderly people with inadequate health literacy were more likely to have inadequate blood pressure. Thus, health professionals need to value functional health literacy as a possible component to control blood pressure.

The QardioArm Blood Pressure App for Self-Measurement in an Obese Population: Validation Study Using the European Society of Hypertension International Protocol Revision 2010

Background

Obesity and high blood pressure (HBP) pose high cardiovascular risks, and they are frequent causes of cardiovascular disease.

Objective

The aim of this study was to validate the mobile app QardioArm for high blood pressure monitoring in obese subjects (body mass index ≥30 kg/m²) according to guidelines in the European Society of Hypertension-International Protocol 2 (ESH-IP2).

Methods

We recruited 33 obese subjects and measured their blood pressure using QardioArm (test device) and Omron M3 Intellisense (Omron Healthcare, Kyoto, Japan; standard device). We compared systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) according to the ESH-IP2.

Results

A total of 95 of 99 differences for SBP and 91 of 99 for DBP displayed absolute differences within 10 mm Hg. A total of 98 of 99 differences for SBP and 98 of 99 for DBP exhibited absolute differences within 15 mm Hg. This result satisfied requirements for part 1 of the ESH-IP2. A total of 27 out of 33 individuals for SBP and 30 out of 33 individuals for DBP had a minimum of 2 of 3 comparisons within 5 mm Hg difference. None of the subjects had 3 differences outside 5 mm Hg for SBP and DBP, satisfying part 2 of the ESH-IP2. For HR measurements, a total of 90 of 99 differences had absolute differences within 3 beats per minute (bpm), and a total of 94 or 99 differences had absolute differences within 5 bpm. A total of 98 of 99 differences had absolute differences within 8 bpm. Therefore, the test device satisfied part 1 of ESH-IP2 criteria for HR. For part 2 of ESH-IP2, 31 of 33 individuals had a minimum of 2 of 3 comparisons within 3 bpm difference for HR. Only 1 of 33 subjects had 3 differences outside 3 bpm.

Conclusions

To the best of our knowledge, this was the first study to show that an app that measures blood pressure and HR meets the requirements of the ESH-IP2 in an obese population. We believe the ESH-IP2 should publish explicit criteria for validation of blood pressure devices in specific populations.

A strategy utilizing ambulatory monitoring and home and clinic blood pressure measurements to optimize the safety evaluation of noncardiovascular drugs with potential for hemodynamic effects: a report from the SYNERGY trial

Supplemental Digital Content is available in the text.

Objective

The aim of this study was to perform a blood pressure (BP) safety evaluation in patients with an overactive bladder receiving solifenacin (an antimuscarinic agent), mirabegron (a β₃-adrenoceptor agonist), or both compared with placebo in the SYNERGY trial.

Patients and methods

Patients were randomized to receive solifenacin 5 mg+mirabegron 50 mg (combination 5+50 mg); solifenacin 5 mg+mirabegron 25 mg (combination 5+25 mg); solifenacin 5 mg; mirabegron 50 mg; mirabegron 25 mg; or placebo for a double-blind 12-week treatment period. Systolic BP, diastolic BP, and heart rate were measured by ambulatory BP monitoring, and in the clinic or home.

Results

A total of 715 patients were analyzed in an ambulatory BP monitoring substudy. At the end of treatment, ambulatory BP monitoring measurements showed no consistent increases from baseline in the mean 24-h systolic BP or diastolic BP for combination versus monotherapy groups or for monotherapy groups versus placebo. Analysis of 1-h BP averages during the 6 h range that included the T_max values of both study drugs showed no significant BP effects. Shift analysis (switch between different normotension/hypertension stages) did not show differences among the active and placebo groups, nor did outlier analysis of major BP changes differ between placebo and active treatment. Similarly, there were no significant signals in the 24-h heart rate. Office and home measurements were consistent with ambulatory BP monitoring findings.

Conclusions

A paradigm of ambulatory BP monitoring analysis designed to test BP safety of noncardiovascular drugs showed that solifenacin plus mirabegron combination therapy during 12 weeks produced no meaningful changes in BP or heart rate.

Olmesartan with azelnidipine versus with trichlormethiazide on home blood pressure variability in patients with type II diabetes mellitus

The aim of the present study was to compare the effects of olmesartan combined with azelnidipine versus olmesartan combined with trichlormethiazide, on home blood pressure (BP) and pressure variability in type II diabetes mellitus patients using home BP telemonitoring system. We performed an open-label cross-over pilot study of 28 patients with type II diabetes mellitus. Patients received combination treatment with either olmesartan 20 mg plus azelnidipine 16 mg or olmesartan 20 mg plus trichlormethiazide 1 mg for more than 6 weeks each in a cross-over method. The coefficient of morning systolic BP variability in the olmesartan plus azelnidipine group was significantly lower than that in the olmesartan plus trichlormethiazide group (6.4 ± 1.9 vs. 7.5 ± 2.6, P = .004). There were no significant differences in mean morning systolic BP between the two groups. Using home BP telemonitoring for hypertensive patients with type II diabetes, this study revealed for the first time that the olmesartan with azelnidipine combination is superior to the olmesartan with trichlormethiazide combination in reducing home BP variability.

Assessing the accuracy of the OMRON HEM-907XL oscillometric blood pressure measurement device in patients with nondialytic chronic kidney disease

The OMRON HEM-907XL is a commercial oscillometric blood pressure (BP) monitor that was used in the Systolic Blood Pressure Intervention Trial (SPRINT), in which 28% of participants had chronic kidney disease (CKD). This study examined the accuracy of the monitor in nondialytic patients with CKD. Eighty-seven patients met inclusion criteria. The authors used a modified Association for the Advancement of Medical Instrumentation (AAMI) protocol, with one observer recording measurements from the monitor and two blinded physicians obtaining simultaneous aneroid values by auscultation. Using AAMI method 1, there was a 2.5±9.5 mm Hg difference in OMRON and aneroid systolic BP, and a -1.6±6.5 mm Hg difference in diastolic BP. Using AAMI method 2, there was a 5.1±7.4 mm Hg difference in systolic BP and a -0.2±5.4 mm Hg difference in diastolic BP. In patients with CKD, the OMRON HEM-907XL appears to be accurate for measuring diastolic BP, but did not perform as well for systolic BP.

The effects of passive leg raising and ultrafiltration stopping on blood pressure in hemodialysis patients

PURPOSE

Hemodialysis-associated hypotension, one of the more serious issues in hemodialysis patients, can be treated by passive leg raising (PLR) and ultrafiltration (UF) stopping. We investigated the effects of PLR and UF stopping on blood pressure in hemodialysis patients.

METHODS

The study was conducted in 76 end-stage renal disease patients. After the second hour of dialysis, systolic and diastolic blood pressure (SBP and DBP) of the patients who did not develop intradialytic hypotension (IDH) were measured in the supine position. Thereafter, PLR was performed by raising the legs 20°; and after 3 min, SBP and DBP were measured again. UF was then stopped in the PLR position; SBP and DBP were repeated 3 min later. The same procedure was performed during IDH in the patients that developed IDH.

RESULTS

A mean 5-mmHg (p < 0.05) increase in SBP and a mean 2-mmHg increase in DBP (p < 0.05) were observed by PLR in the supine position. UF stopping during PLR increased SBP by a mean of 1 mmHg (p < 0.05) while no change was observed in DBP (p = ns). IDH occurred in 19 (25 %) patients. PLR positioning increases SBP and DBP by a mean of 8 mmHg (p < 0.05) and 3 mmHg (p < 0.05), respectively, in the supine position during IDH. During IDH, UF stopping in the PLR position did not significantly increase SBP and DBP in patients as compared to the PLR position.

CONCLUSIONS

SBP and DBP increase during PLR. UF stopping during PLR does not lead to a higher increase in blood pressure as compared to PLR positioning.

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

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

Arm circumference: its importance for dialysis patients in the obesity era

PURPOSE

The purposes of this study were to investigate the association between arm circumference and body mass index (BMI) and to discuss problems, mainly arm circumference and cuff size mismatch, that could affect the reliability of home blood pressure monitoring (HBPM) among peritoneal dialysis (PD) and hemodialysis (HD) patients.

METHODS

525 PD and 502 HD patients from 16 centers were included in the study. A two-part questionnaire was used to gather information from the participants. Arm circumferences were categorized into four groups according to the British Hypertension Society cuff size recommendations.

RESULTS

Mean BMI and arm circumference of all participants were 25.0 kg/m(2) and 27.6 cm, respectively. There was a significant correlation between BMI and arm circumference. The mean BMI and arm circumference values were higher in PD patients than in HD patients. Requirement of a large-sized adult cuff was more common among PD patients compared to HD patients (14 % vs 8 %, p = 0.002).

CONCLUSIONS

Since HBPM is a useful tool for clinicians to improve BP control, nephrologists should be aware of the problems related to HBPM in dialysis patients and take an active role to increase the reliability of HBPM.