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Lurbe E, Mancia G, Calpe J, Drożdż D, Erdine S, Fernandez-Aranda F, Hadjipanayis A, Hoyer PF, Jankauskiene A, Jiménez-Murcia S, Litwin M, Mazur A, Pall D, Seeman T, Sinha MD, Simonetti G, Stabouli S, Wühl E. Joint statement for assessing and managing high blood pressure in children and adolescents: Chapter 1. How to correctly measure blood pressure in children and adolescents. Front Pediatr 2023; 11:1140357. [PMID: 37138561 PMCID: PMC10150446 DOI: 10.3389/fped.2023.1140357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
The joint statement is a synergistic action between HyperChildNET and the European Academy of Pediatrics about the diagnosis and management of hypertension in youth, based on the European Society of Hypertension Guidelines published in 2016 with the aim to improve its implementation. The first and most important requirement for the diagnosis and management of hypertension is an accurate measurement of office blood pressure that is currently recommended for screening, diagnosis, and management of high blood pressure in children and adolescents. Blood pressure levels should be screened in all children starting from the age of 3 years. In those children with risk factors for high blood pressure, it should be measured at each medical visit and may start before the age of 3 years. Twenty-four-hour ambulatory blood pressure monitoring is increasingly recognized as an important source of information as it can detect alterations in circadian and short-term blood pressure variations and identify specific phenotypes such as nocturnal hypertension or non-dipping pattern, morning blood pressure surge, white coat and masked hypertension with prognostic significance. At present, home BP measurements are generally regarded as useful and complementary to office and 24-h ambulatory blood pressure for the evaluation of the effectiveness and safety of antihypertensive treatment and furthermore remains more accessible in primary care than 24-h ambulatory blood pressure. A grading system of the clinical evidence is included.
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Affiliation(s)
- Empar Lurbe
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pediatric, Consorcio Hospital General, University of Valencia, Valencia, Spain
- Correspondence: Empar Lurbe Elke Wühl Adamos Hadjipanayis
| | | | | | - Dorota Drożdż
- Department of Pediatric Nephrology and Hypertension, Pediatric Institute, Jagiellonian University Medical College, Kraków, Poland
| | - Serap Erdine
- Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Fernando Fernandez-Aranda
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | - Adamos Hadjipanayis
- School of Medicine, European University Cyprus, Nicosia, Cyprus
- Department of Paediatrics, Larnaca General Hospital, Larnaca, Cyprus
- Correspondence: Empar Lurbe Elke Wühl Adamos Hadjipanayis
| | - Peter F. Hoyer
- Department of Pediatrics II, University Hospital Essen, Essen, Germany
| | - Augustina Jankauskiene
- Pediatric Center, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Susana Jiménez-Murcia
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- University Hospital of Bellvitge-IDIBELL, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | - Mieczysław Litwin
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Artur Mazur
- Institute of Medical Sciences, Medical College, Rzeszów University, Rzeszow, Poland
| | - Denes Pall
- Department of Medical Clinical Pharmacology, University of Debrecen, Debrecen, Hungary
- Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tomas Seeman
- Division of Pediatric Nephrology, University Children’s Hospital, Charles University, Prague, Czechia
- Department of Pediatrics, University Hospital Ostrava, Ostrava, Czechia
| | - Manish D. Sinha
- Department of Paediatric Nephrology, Evelina London Children's Hospital, Guy's and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Giacomo Simonetti
- Institute of Pediatrics of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University of Thessaloniki, Hippokratio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
- Correspondence: Empar Lurbe Elke Wühl Adamos Hadjipanayis
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Armitage LC, Lawson BK, Roman C, Thompson B, Biggs C, Rutter H, Lewis-Jones M, Ede J, Tarassenko L, Farmer A, Watkinson P. Ambulatory blood pressure monitoring using telemedicine: proof-of-concept cohort and failure modes and effects analyses. Wellcome Open Res 2022; 7:39. [PMID: 36072061 PMCID: PMC9411972 DOI: 10.12688/wellcomeopenres.17537.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 11/20/2022] Open
Abstract
Background: The COVID-19 pandemic has accelerated adoption of remote consulting in healthcare. Despite opportunities posed by telemedicine, most hypertension services in Europe have suspended ambulatory blood pressure monitoring (ABPM). Methods: We examined the process and performance of remotely delivered ABPM using two methodologies: firstly, a Failure Modes and Effects Analysis (FMEA) and secondly, a quantitative analysis comparing ABPM data from a subgroup of 65 participants of the Screening for Hypertension in the INpatient Environment (SHINE) diagnostic accuracy study. The FMEA was performed over seven sessions from February to March 2021, with a multidisciplinary team comprising a patient representative, a research coordinator with technical expertise and four research clinicians. Results: The FMEA identified a single high-risk step in the remote ABPM process. This was cleaning of monitoring equipment in the context of the COVID-19 pandemic, unrelated to the remote setting. A total of 14 participants were scheduled for face-to-face ABPM appointments, before the UK March 2020 COVID-19 lockdown; 62 were scheduled for remote ABPM appointments since emergence of the COVID-19 pandemic between November 2020 and August 2021. A total of 65 (88%) participants completed ABPMs; all obtained sufficient successful measurements for interpretation. For the 10 participants who completed face-to-face ABPM, there were 402 attempted ABPM measurements and 361 (89%) were successful. For the 55 participants who completed remote ABPM, there were 2516 attempted measurements and 2214 (88%) were successful. There was no significant difference in the mean per-participant error rate between face-to-face (0.100, SD 0.009) and remote (0.143, SD 0.132) cohorts (95% CI for the difference -0.125 to 0.045 and two-tailed P-value 0.353). Conclusions: We have demonstrated that ABPM can be safely and appropriately provided in the community remotely and without face-to-face contact, using video technology for remote fitting appointments, alongside courier services for delivery of equipment to participants.
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Affiliation(s)
- Laura C. Armitage
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Beth K. Lawson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Cristian Roman
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Beth Thompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Christopher Biggs
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Heather Rutter
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | | | - Jody Ede
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Lionel Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Andrew Farmer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Watkinson
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Armitage LC, Lawson BK, Roman C, Thompson B, Biggs C, Rutter H, Lewis-Jones M, Ede J, Tarassenko L, Farmer A, Watkinson P. Ambulatory blood pressure monitoring using telemedicine: proof-of-concept cohort and failure modes and effects analyses. Wellcome Open Res 2022; 7:39. [DOI: 10.12688/wellcomeopenres.17537.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/20/2022] Open
Abstract
Background: The COVID-19 pandemic has accelerated adoption of remote consulting in healthcare. Despite opportunities posed by telemedicine, most hypertension services in Europe have suspended ambulatory blood pressure monitoring (ABPM). Methods: We examined the process and performance of remotely delivered ABPM using two methodologies: firstly, a Failure Modes and Effects Analysis (FMEA) and secondly, a quantitative analysis comparing ABPM data from a subgroup of 65 participants of the Screening for Hypertension in the INpatient Environment (SHINE) diagnostic accuracy study. The FMEA was performed over seven sessions from February to March 2021, with a multidisciplinary team comprising a patient representative, a research coordinator with technical expertise and four research clinicians. Results: The FMEA identified a single high-risk step in the remote ABPM process. This was cleaning of monitoring equipment in the context of the COVID-19 pandemic, unrelated to the remote setting. A total of 14 participants were scheduled for face-to-face ABPM appointments, before the UK March 2020 COVID-19 lockdown; 62 were scheduled for remote ABPM appointments since emergence of the COVID-19 pandemic between November 2020 and August 2021. A total of 65 (88%) participants completed ABPMs; all obtained sufficient successful measurements for interpretation. For the 10 participants who completed face-to-face ABPM, there were 402 attempted ABPM measurements and 361 (89%) were successful. For the 55 participants who completed remote ABPM, there were 2516 attempted measurements and 2214 (88%) were successful. There was no significant difference in the mean per-participant error rate between face-to-face (0.100, SD 0.009) and remote (0.143, SD 0.132) cohorts (95% CI for the difference -0.125 to 0.045 and two-tailed P-value 0.353). Conclusions: We have demonstrated that ABPM can be safely and appropriately provided in the community remotely and without face-to-face contact, using video technology for remote fitting appointments, alongside courier services for delivery of equipment to participants.
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Armitage LC, Lawson BK, Thompson B, Biggs C, Rutter H, Lewis-Jones M, Ede J, Tarassenko L, Farmer A, Watkinson P. Ambulatory blood pressure monitoring using telemedicine: proof-of-concept cohort and failure modes and effects analyses. Wellcome Open Res 2022; 7:39. [DOI: 10.12688/wellcomeopenres.17537.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 11/20/2022] Open
Abstract
Background: The COVID-19 pandemic has accelerated adoption of remote consulting in healthcare. Despite opportunities posed by telemedicine, most hypertension services in Europe have suspended ambulatory blood pressure monitoring (ABPM). Methods: We examined the process and performance of remotely delivered ABPM using two methodologies: firstly, a Failure Modes and Effects Analysis (FMEA) and secondly, a quantitative analysis comparing ABPM data from a subgroup of 65 participants of the Screening for Hypertension in the INpatient Environment (SHINE) diagnostic accuracy study. The FMEA was performed over seven sessions from February to March 2021, with a multidisciplinary team comprising a patient representative, a research coordinator with technical expertise and four research clinicians. Results: The FMEA identified a single high-risk step in the remote ABPM process. This was cleaning of monitoring equipment in the context of the COVID-19 pandemic, unrelated to the remote setting. A total of 14 participants were scheduled for face-to-face ABPM appointments, before the UK March 2020 COVID-19 lockdown; 62 were scheduled for remote ABPM appointments since emergence of the COVID-19 pandemic between November 2020 and August 2021. A total of 65 (88%) participants completed ABPMs; all obtained sufficient successful measurements for interpretation. For the 10 participants who completed face-to-face ABPM, there were 402 attempted ABPM measurements and 361 (89%) were successful. For the 55 participants who completed remote ABPM, there were 2516 attempted measurements and 2114 (88%) were successful. There was no significant difference in the mean per-participant error rate between face-to-face (0.100, SD 0.009) and remote (0.143, SD 0.132) cohorts (95% CI for the difference -0.125 to 0.045 and two-tailed P-value 0.353). Conclusions: We have demonstrated that ABPM can be safely and appropriately provided in the community remotely and without face-to-face contact, using video technology for remote fitting appointments, alongside courier services for delivery of equipment to participants.
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Martinez-Ríos E, Montesinos L, Alfaro-Ponce M, Pecchia L. A review of machine learning in hypertension detection and blood pressure estimation based on clinical and physiological data. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102813] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Lin YT, Lampa E, Fall T, Engström G, Sundström J. Blood pressure phenotypes based on ambulatory monitoring in a general middle-aged population. Blood Press 2021; 30:237-249. [PMID: 33797315 DOI: 10.1080/08037051.2021.1903302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Ambulatory blood pressure monitoring (ABPM) is increasingly recommended for clinical use, but more knowledge about the prevalence and variability in ABPM-derived phenotypes in the general population is needed. We describe these parameters in the community-based Swedish CArdioPulmonary bioImage Study (SCAPIS) cohort. METHODS We examined 5881 men and women aged 50-64 with 24-hour ABPM recordings using validated monitors. ABPM phenotypes were defined according to European guidelines. White coat hypertension was defined as elevated office BP (≥140/90 mmHg) with normal mean ambulatory BP (<135/85 mmHg in day-time, <120/70 mmHg in night-time, <130/80 mmHg over 24-h); and masked hypertension as normal office BP (<140/90 mmHg) with elevated mean ambulatory BP (≥135/85 mmHg in day-time, ≥120/70 mmHg in night-time, ≥130/80 mmHg over 24-h). Blood pressure variability was assessed using the coefficient of variation (CV), standard deviation (SD), and average real variability. RESULTS Based on the ABPM recordings, 36.9% of participants had 24-h hypertension, 40.7% had day-time hypertension, and 37.6% nocturnal hypertension. Among participants treated with anti-hypertensive drugs, one in three had elevated office blood pressures, and more than half had elevated 24-h, day-time or nocturnal blood pressures. Among participants without anti-hypertensive drugs, only one in six had elevated office blood pressures, but one in three had elevated 24-h, day-time or nocturnal blood pressures. Men had higher 24-h blood pressures, more masked hypertension, but less white-coat hypertension than women. The prevalence of white-coat hypertension increased with age, but not the prevalence of masked hypertension. A positive association between blood pressure level and variability was observed, and within-person and between-person SD and CV were of similar magnitude. The variance in ABPM on repeated measurements was substantial. CONCLUSIONS In the middle-aged general population, masked hypertension is an underappreciated problem on the population level.
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Affiliation(s)
- Yi-Ting Lin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Erik Lampa
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Tove Fall
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Gunnar Engström
- Department of Clinical Sciences, Cardiovascular Epidemiology, Lund University, Malmö, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Gaffey AE, Schwartz JE, Harris KM, Hall MH, Burg MM. Effects of ambulatory blood pressure monitoring on sleep in healthy, normotensive men and women. Blood Press Monit 2021; 26:93-101. [PMID: 33136653 PMCID: PMC7933045 DOI: 10.1097/mbp.0000000000000494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the effect of ambulatory blood pressure monitoring (ABPM) on sleep quality among healthy adults and to explore possible effect modification by demographics. METHODS We examined data from 192 relatively healthy young (median age: 31; 33% men, 18% with clinic BP >130/80 mmHg) participants in an observational study of sleep and arterial stiffness. Demographic/health questionnaires were completed. A wrist-based accelerometer assessed sleep for seven nights, and sleep duration, wakefulness after sleep onset (WASO), fragmentation (physical restlessness), midpoint, and efficiency were estimated. ABPM was conducted for one 36-h period, including one actigraphy night. RESULTS Within-subject comparisons indicated that WASO and fragmentation were higher, midpoint was later, and efficiency was lower on the ABPM night (Ps < 0.001-0.038). Neither age nor sex moderated these associations. Among older adults, a later midpoint and worse fragmentation were observed with ABPM (Ps = 0.002-0.010). There was also a main effect of sex: men demonstrated shorter sleep duration, greater WASO and fragmentation, and less efficiency than women (Ps = 0.002-0.046). With ABPM, women had worse fragmentation and a later midpoint (Ps = 0.002-0.049); for men, WASO and fragmentation were worse (Ps = 0.003-0.023). Importantly, this study does not address whether the effect of wearing ABPM on sleep in turn affects BP during sleep. CONCLUSIONS ABPM appears to modestly disturb actigraphy-assessed sleep among healthy adults. Researchers and clinicians should consider the downstream effects of performing ABPM and whether these effects are more pronounced in those who typically experience sleep disturbance.
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Affiliation(s)
- Allison E. Gaffey
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Joseph E. Schwartz
- Department of Psychiatry and Behavioral Sciences, Stony Brook University, Stony Brook, NY
- Department of Medicine, Columbia University, New York, NY
| | - Kristie M. Harris
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Martica H. Hall
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Matthew M. Burg
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
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Botha D, Breet Y, Schutte AE. Comparing the associations of clinic vs. ambulatory blood pressure with subclinical organ damage in young healthy adults: the African-PREDICT study. Hypertens Res 2021; 44:840-849. [PMID: 33564179 DOI: 10.1038/s41440-021-00627-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/17/2020] [Accepted: 01/05/2021] [Indexed: 01/20/2023]
Abstract
Raised blood pressure (BP) causes pathophysiological cardiovascular changes resulting in target organ damage. Although ambulatory and central BP relate more strongly to outcomes than clinical brachial BP in the elderly population, it is unknown which measure of BP is most strongly associated with markers of organ damage in younger populations. We compared the strength of associations between different BPs and measures of subclinical organ damage and investigated whether ethnic differences exist between these associations. The design was a cross-sectional analysis of the African-PREDICT study, including young black and white men and women (aged 20-30, N = 1202). We obtained clinic, ambulatory, and central BP readings, as well as measures of subclinical organ damage: central retinal arteriolar equivalent (CRAE) from fundus images, echocardiography to determine left ventricular mass index (LVMi), carotid intima media thickness (CIMT), carotid-femoral pulse wave velocity (PWV), and albumin-to-creatinine ratio (ACR) determined from spot urine samples. Overall, weak correlations were evident between CIMT, ACR, and BP, whereas CRAE, LVMi, and PWV correlated strongly with BP. In the total group, clinic brachial BP had stronger associations with CRAE, LVMi, and PWV (all p < 0.001) than ambulatory and central BP. Although the ethnic groups showed similar correlations between CRAE, LVMi, CIMT, and the various BPs, PWV correlated more strongly with ambulatory systolic BP (p < 0.001) in white participants. In young healthy adults, clinic brachial BP correlated more strongly with measures of early target organ damage than central or ambulatory BP. No differences were observed between correlations of BP and measures of target organ damage in the two ethnic groups.
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Affiliation(s)
- Dimoné Botha
- Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa
| | - Yolandi Breet
- Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa.,MRC Research Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
| | - Aletta E Schutte
- Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa. .,MRC Research Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa. .,School of Population Health, University of New South Wales; The George Institute for Global Health, Sydney, NSW, Australia.
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Dahle N, Skau E, Leppert J, Ärnlöv J, Hedberg P. Poorly controlled ambulatory blood pressure in outpatients with peripheral arterial disease. Ups J Med Sci 2021; 126:7609. [PMID: 33995892 PMCID: PMC8098705 DOI: 10.48101/ujms.v126.7609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients with peripheral arterial disease (PAD) are generally less intensively managed than patients with coronary heart disease (CHD), despite that their risk of complications is believed to be equivalent. Identification of PAD patients at risk of poorly controlled blood pressure (BP) could lead to improved treatment, thus lowering the risk of cardiovascular (CV) complications. We aimed to describe the prevalence of poorly controlled cardiovascular (CV) risk factors, focusing on BP, in outpatients with PAD diagnosed in a vascular ultrasound laboratory. METHODS Consecutive outpatients with carotid and/or lower extremity PAD were included (n = 402) and examined with blood sampling, clinical BP, and 24-h ambulatory BP measurements. A poorly controlled clinical BP was defined as ≥140/90 mmHg, ambulatory BP ≥130/80 mmHg, low-density lipoprotein (LDL)-cholesterol level ≥2.5 mmol/L, and glycated hemoglobin (HbA1c) level >53 mmol/mol in those with diabetes. RESULTS Most of the patients had poorly controlled clinical (76.6%) and ambulatory BP (51.7%) profiles. Antihypertensive medications were prescribed in 84% of the patients. However, >40% of them used only 0-1 medication, and <25% of them used three or more agents. Clinical BP, a low number of medications, body mass index, and the presence of diabetes independently predicted a poorly controlled ambulatory BP. Nearly one-third of the patients were smokers, and most of the cohort had an LDL-cholesterol level of ≥2.5 mmol/L. An HbA1c level of >53 mmol/mol was present in 55% of diabetic patients. CONCLUSION Poorly controlled clinical and ambulatory systolic BP profiles were common. In addition, suboptimal control of other important CV risk factors was detected. The findings of this study highlight the need for better preventive efforts against CV risk factors in outpatients with PAD.
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Affiliation(s)
- Nina Dahle
- Centre for Clinical Research, Uppsala University, Falun, Sweden
- Primary Health Care Center Britsarvet-Grycksbo, County of Dalarna, Falun, Sweden
| | - Emma Skau
- Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
- Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Jerzy Leppert
- Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
| | - Johan Ärnlöv
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- School of Health and Social Studies, Dalarna University, Falun, Sweden
| | - Pär Hedberg
- Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
- Department of Clinical Physiology, Västmanland County Hospital, Västerås, Sweden
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Desai R, Dietrich EA, Park H, Smith SM. Out-of-Pocket Payment for Ambulatory Blood Pressure Monitoring Among Commercially Insured in the United States. Am J Hypertens 2020; 33:999-1002. [PMID: 32930343 DOI: 10.1093/ajh/hpaa120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/07/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Clinical guidelines increasingly recommended ambulatory blood pressure monitoring (ABPM) for hypertension diagnosis and management. Yet, ABPM is used infrequently in the United States, possibly because of low insurance coverage and high patient costs. We sought to analyze out-of-pocket payments (OPPs) for ABPM among privately insured patients. METHODS We conducted a retrospective analysis using IBM® MarketScan® commercial claims of beneficiaries aged ≥18 years receiving ABPM from January 2012 to December 2018. The date of first ABPM claim (Healthcare Common Procedure Coding System codes 93784, 93786, 93788, or 93790) was considered the index date. Patients with 12 months of continuous enrollment preindex and 30-day postindex were included. Per beneficiary OPP was calculated by aggregating all ABPM-related OPPs within the 30-day postindex window (ABPM episode). RESULTS Of 22,317 beneficiaries receiving ABPM, 62% had $0 OPP and 38% had OPP >$0. Among the latter, median OPP per beneficiary for an ABPM episode was $23 (interquartile range [IQR], $14, $32), driven primarily by full ABPM claims (median, $22; IQR, $14, $24). Among individual components, scan analysis and report claims (median, $25; IQR, $13, $49) had the greatest OPP. The median OPP per ABPM episode did not change substantively from 2012 through 2018. CONCLUSIONS Among commercially insured in the United States, nearly 4-in-10 have an OPP for ABPM. Though most OPPs are relatively modest, some patients incur substantial OPP. Our findings highlight the need for policymakers to ensure adequate ABPM coverage in the commercial insurance marketplace.
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Affiliation(s)
- Raj Desai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Eric A Dietrich
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Division of General Internal Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Steven M Smith
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Nocturnal hypertension: a common phenotype in a tertiary clinical setting associated with increased arterial stiffness and central blood pressure. J Hypertens 2020; 39:250-258. [PMID: 33031168 DOI: 10.1097/hjh.0000000000002620] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although the detrimental effect of increased mean blood pressure (BP) is well established, the role of the dynamic and circadian features of BP is less well defined but may be similarly important. In this prospective analysis of hypertensive patients from a tertiary hospital hypertension clinic, we investigated whether the presence of night-time systolic hypertension is associated with more pronounced end-organ damage as assessed by measures of pulse wave analysis (PWA) and pulse wave velocity (PWV). METHODS A cohort of 222 consecutive hypertensive patients underwent ambulatory blood pressure measurements, PWA, PWV testing and collection of routine clinical data. Group differences and group-effects of daytime and night-time hypertension on target organ damage and cardiovascular risk parameters were analysed. RESULTS Nocturnal hypertension was evident in more than half of the study population. PWV, central systolic, mean arterial and pulse pressure were higher in patients with nocturnal hypertension. Stratification into four groups according to daytime and night-time hypertension status revealed group differences in all outcome parameters. Posthoc testing for individual group differences demonstrated significant differences between fully controlled individuals and the group with high daytime and night-time BP. In a regression analysis for independent effects of categorical night-time and daytime hypertension, nocturnal hypertension was a significant predictor for all PWA and PWV outcomes. CONCLUSION Nocturnal hypertension was a highly prevalent phenotype in this population and associated with increased central BP and more pronounced target organ damage as indicated by elevated PWV. Regression analysis confirmed the role of night-time hypertension as an independent explanatory variable for elevated PWV.
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Pandit JA, Lores E, Batlle D. Cuffless Blood Pressure Monitoring: Promises and Challenges. Clin J Am Soc Nephrol 2020; 15:1531-1538. [PMID: 32680913 PMCID: PMC7536750 DOI: 10.2215/cjn.03680320] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Current BP measurements are on the basis of traditional BP cuff approaches. Ambulatory BP monitoring, at 15- to 30-minute intervals usually over 24 hours, provides sufficiently continuous readings that are superior to the office-based snapshot, but this system is not suitable for frequent repeated use. A true continuous BP measurement that could collect BP passively and frequently would require a cuffless method that could be worn by the patient, with the data stored electronically much the same way that heart rate and heart rhythm are already done routinely. Ideally, BP should be measured continuously and frequently during diverse activities during both daytime and nighttime in the same subject by means of novel devices. There is increasing excitement for newer methods to measure BP on the basis of sensors and algorithm development. As new devices are refined and their accuracy is improved, it will be possible to better assess masked hypertension, nocturnal hypertension, and the severity and variability of BP. In this review, we discuss the progression in the field, particularly in the last 5 years, ending with sensor-based approaches that incorporate machine learning algorithms to personalized medicine.
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Affiliation(s)
- Jay A Pandit
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Enrique Lores
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel Batlle
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kidambi S, Wang T, Chelius T, Nunuk I, Agarwal P, Laud P, Mattson D, Cowley AW, Liang M, Kotchen T. Twenty-four-hour versus clinic blood pressure levels as predictors of long-term cardiovascular and renal disease outcomes among African Americans. Sci Rep 2020; 10:11685. [PMID: 32669581 PMCID: PMC7363933 DOI: 10.1038/s41598-020-68466-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 06/25/2020] [Indexed: 01/10/2023] Open
Abstract
In Caucasian and Asian populations, evidence suggests that 24-h blood pressures (BP) are more predictive of long-term cardiovascular events than clinic BP. However, few long-term studies have evaluated the predictive value of 24-h BP phenotypes (24-h, daytime, nighttime) among African Americans (AA). The purpose of this study is to evaluate the added value of 24-h BP phenotypes compared to clinic BP in predicting the subsequent fatal and non-fatal cardiovascular/renal disease events in AA subjects. AA subjects (n = 270) were initially studied between 1994 and 2006 and standardized clinic BP measurements were obtained during screening procedures for a 3-day inpatient clinical study during which 24-h BP measurements were obtained. To assess the subsequent incidence of cardiovascular and renal disease events, follow-up information was obtained and confirmed by review of paper and electronic medical records between 2015 and 2017. During a mean follow-up of 14 ± 4 years, 50 subjects had one or more fatal or non-fatal cardiovascular/renal disease events. After adjustment for covariates, clinic systolic and diastolic BP were strongly associated with cardiovascular/renal disease events and all-cause mortality (p < 0.0001). Twenty-four-hour BP phenotypes conferred a small incremental advantage over clinic BP in predicting cardiovascular/renal events, which was limited to making a difference of one predicted event in 250-1,000 predictions depending on the 24-h BP phenotype. Nocturnal BP was no more predictive than the other 24-h BP phenotypes. In AA, 24-h BP monitoring provides limited added value as a predictor of cardiovascular/renal disease events. Larger studies are needed in AA to confirm these findings.
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Affiliation(s)
- Srividya Kidambi
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Tao Wang
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Thomas Chelius
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Irene Nunuk
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Priyanka Agarwal
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Purushottam Laud
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - David Mattson
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Allen W Cowley
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Mingyu Liang
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Theodore Kotchen
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
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Shahab H, Khan HS, Almas A, Tufail M, Kazmi KA, Khan AH. The Post Clinic Ambulatory Blood Pressure (PC-ABP) study correlates Post Clinic Blood Pressure (PCBP) with the gold standard Ambulatory Blood Pressure. BMC Res Notes 2018; 11:460. [PMID: 29996947 PMCID: PMC6042456 DOI: 10.1186/s13104-018-3509-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/18/2018] [Indexed: 11/10/2022] Open
Abstract
Objective Our previous study showed that post-clinic blood pressure (BP) taken 15 min after a physician–patient encounter was the lowest reading in a routine clinic. We aimed to validate this reading with 24 h Ambulatory Blood Pressure Monitoring (ABPM) readings. A cross-sectional study was conducted in the cardiology clinics at the Aga Khan University, Pakistan. Hypertensive patients aged ≥ 18 years, or those referred for the diagnosis of hypertension were included. Results Of 150 participants, 49% were males. 76% of all participants were hypertensive. Pre-clinic BP reading was measured by a nurse, in-clinic by a physician and 15 min post-clinic by a research assistant using a validated, automated BP device (Omron-HEM7221-E). All patients were referred for 24 h ABPM. Among the three readings taken during a clinic visit, mean (± SD) systolic BP (SBP) pre-clinic, in-clinic, and 15 min post-clinic were 153.2 ± 23, 152.3 ± 21, and 140.0 ± 18 mmHg, respectively. Mean (± SD) diastolic BP (DBP) taken pre-clinic, in-clinic and 15 min post-clinic were 83.5 ± 12, 90.9 ± 12, and 86.4 ± 11 mmHg respectively. Mean (± SD) daytime ambulatory SBP, DBP and pulse readings were 134.7 ± 15, 78.7 ± 15 mmHg, and 72.6 ± 12/min, respectively. Pearson correlation coefficients of pre-clinic, in-clinic and post-clinic SBP with daytime ambulatory-SBP were 0.4 (p value: < 0.001), 0.5 (p value: < 0.001) and 0.6 (p value: < 0.001), respectively. Post-clinic BP has a good correlation with ambulatory BP and may be considered a more reliable reading in the clinic setting.
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Affiliation(s)
- Hunaina Shahab
- Cardiology, Aga Khan University Hospital, Second Floor, Faculty Offices Building, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Hamza Sohail Khan
- Cardiology, Aga Khan University Hospital, Second Floor, Faculty Offices Building, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Aysha Almas
- Internal Medicine, Aga Khan University Hospital, Second Floor, Faculty Offices Building, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Mayera Tufail
- Cardiology, Aga Khan University Hospital, Second Floor, Faculty Offices Building, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Khawar Abbas Kazmi
- Cardiology, Aga Khan University Hospital, Second Floor, Faculty Offices Building, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Aamir Hameed Khan
- Cardiology, Aga Khan University Hospital, Second Floor, Faculty Offices Building, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan.
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Ringrose J, Padwal R. The ongoing saga of poor blood pressure measurement: Past, present, and future perspectives. J Clin Hypertens (Greenwich) 2017; 19:611-613. [DOI: 10.1111/jch.13016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
| | - Raj Padwal
- Department of Medicine; University of Alberta; Edmonton AB Canada
- Alberta Diabetes Institute; Edmonton AB Canada
- Mazankowski Alberta Heart Institute; Edmonton AB Canada
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The importance and prognostic value of nocturnal blood pressure assessments using inexpensive domestic devices. J Hypertens 2017; 35:463-465. [DOI: 10.1097/hjh.0000000000001244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Solak Y, Kario K, Covic A, Bertelsen N, Afsar B, Ozkok A, Wiecek A, Kanbay M. Clinical value of ambulatory blood pressure: Is it time to recommend for all patients with hypertension? Clin Exp Nephrol 2015; 20:14-22. [PMID: 26493178 DOI: 10.1007/s10157-015-1184-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/11/2015] [Indexed: 01/21/2023]
Abstract
Hypertension is a very common disease, and office measurements of blood pressure are frequently inaccurate. Ambulatory Blood Pressure Monitoring (ABPM) offers a more accurate diagnosis, more detailed readings of average blood pressures, better blood pressure measurement during sleep, fewer false positives by detecting more white-coat hypertension, and fewer false negatives by detecting more masked hypertension. ABPM offers better management of clinical outcomes. For example, based on more accurate measurements of blood pressure variability, ABPM demonstrates that taking antihypertensive medication at night leads to better controlled nocturnal blood pressure, which translates into less end organ damage and fewer clinical complications of hypertension. For these reasons, albeit some shortcomings which were discussed, ABPM should be considered as a first-line tool for diagnosing and managing hypertension.
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Affiliation(s)
- Yalcin Solak
- Division of Nephrology, Department of Internal Medicine, Sakarya University Training and Research Hospital, Sakarya, Turkey
| | - Kazuomi Kario
- Department of Cardiovascular Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Nathan Bertelsen
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Sariyer, Istanbul, Turkey
| | - Baris Afsar
- Division of Nephrology, Department of Medicine, Konya Numune State Hospital, Konya, Turkey
| | - Abdullah Ozkok
- Division of Nephrology, Department of Medicine, Istanbul Medeniyet University School of Medicine, Istanbul, Turkey
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Sariyer, Istanbul, Turkey.
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Head GA. The Prognostic Value of Self-Assessed Nocturnal Blood Pressure. J Clin Hypertens (Greenwich) 2015; 17:349-51. [DOI: 10.1111/jch.12502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Geoffrey A. Head
- Baker IDI Heart and Diabetes Institute; Melbourne Vic. Australia
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