Practical Aspects of Home and Ambulatory Blood Pressure Monitoring

Prognostic value of home blood pressure monitoring in patients under antihypertensive treatment

The prognostic value of home blood pressure monitoring (HBPM) has been investigated in several studies in the general population, demonstrating its independent association with cardiovascular events. However, in the case of treated hypertensive subjects, evidence is controversial. Our purpose was to evaluate the prognostic value of HBPM in this population. Medicated hypertensive patients who performed a 4-day HBPM (Omron® HEM-705CP-II) between 2008 and 2015 were followed up for a median of 5.9 years, registering the occurrence of a composite primary outcome of fatal and non-fatal cardiovascular events. Cox regression models were used to analyze the prognostic value of HBPM, considering 4-day measurements, discarding the first day, and analyzing morning, afternoon and evening periods separately. We included 1582 patients in the analysis (33.4% men, median age 70.8 years, on an average of 2.1 antihypertensive drugs). During follow-up, 273 events occurred. HBPM was significantly associated with cardiovascular events in all five scenarios in the unadjusted models. When adjusting for office BP and other cardiovascular risk factors, the association remained marginally significant for the 4-day period, discarding first-day measurements HBPM (HR 1.04 [95% CI 1-1.1] and 1.04 [95% CI 1-1.1], respectively) and statistically significant for all separate periods of measurement: HR 1.32 (95% CI 1.01-1.72); 1.33 (95% CI 1.02-1.72); and 1.30 (95% CI 1.01-1.67), for morning, afternoon and evening, respectively. When analyzing separately fatal and non-fatal events, statistical significance was held for the former only. In conclusion, HBPM is an independent predictor of cardiovascular events in hypertensives under treatment.

Three Hours Ambulatory Blood Pressure: A Surrogate for Daytime Ambulatory Blood Pressure Assessment in the Pakistani Population

Background Office blood pressure (BP) measurement is affected by the white-coat phenomenon and shows a weaker correlation with the gold standard ambulatory blood pressure monitoring (ABPM). To overcome this limitation, 24-hour ABPM is recommended by the guidelines for the diagnosis of hypertension. However, 24-hour ABPM is expensive and cumbersome, which limits its use in low to middle-income countries like Pakistan. We aimed to assess if an abbreviated ABPM interval can be utilized to diagnose hypertension effectively in our population. Methods A cross-sectional study, involving 150 participants as part of the Post Clinic Ambulatory Blood Pressure (PC-ABP) study, was conducted in the cardiology clinics. Participants ≥18 years of age, who were either hypertensive or referred for assessment of hypertension, were included. Blood pressure (BP) readings were taken with an ambulatory BP monitor over a 24-hour period. After excluding the first hour called the 'white-coat window,' the mean of the first six systolic readings taken every half hour during the daytime was calculated and was called systolic three-hour ABPM. Pearson correlation coefficients were calculated and Bland-Altman plots were constructed to determine the correlation and limits of agreement between mean systolic three-hour ABPM and daytime-ABPM. Receiver operating characteristic (ROC) curve for systolic and diastolic three-hour daytime ABPM and area under the curve (AUC) were analyzed for the level of accuracy in predicting hypertension. Results Of the 150 participants, 49% were male, and 76% of all were hypertensive. The mean age of participants was 60.3 ± 11.9 years. The mean systolic three-hour ABPM was 135.0 ± 16 mmHg. The mean systolic daytime ABPM was 134.7 ± 15 mmHg. Pearson correlation coefficient between mean systolic three-hour ABPM and mean systolic daytime ABPM was 0.85 (p-value <0.001). The limits of agreement were 18 mmHg to -17 mmHg between the two readings on Bland-Altman plots and the area under the curve of the receiver operating characteristic (ROC) was 0.96, suggesting that three-hour systolic ABPM is a good predictor of hypertension. Conclusion Three-hour ABPM correlates well with 24-hour ABPM in the Pakistani population. We recommend considering the use of this abbreviated ABPM to screen hypertension where a full-length ABPM cannot be used. Further studies can be conducted on a larger sample size to determine the prognostic implications of this shortened ABPM.

Ambulatory Blood Pressure Monitoring: Our Experience in Routine Clinical Practice

Objective: To evaluate feasibility and usefulness of ambulatory blood pressure monitoring (ABPM) in outpatient setting.

Material and methods: In this prospective study, data of 58 patients who were evaluated with ABPM for diagnosis or therapeutic efficacy purpose were collected from their records. Demographic details of these were recorded. Patients were categorized into different categories based on 24 hours BP pattern. Dipping pattern was compared based on the gender, age, and presence of diabetes or hypertension. Number of patients diagnosed as hypertensive with ABPM reports was compared with office and home BP measurement.

Results: Fifty-eight patients (mean age 57.8 years; 70.69% males) were included of whom 22 (37.93%) underwent ABPM for diagnostic purposes. There was gender-wise significant difference in terms of purpose of performing ABPM (p=0.040). Diabetes was present in 22 (37.93%) patients. Out of 36 known hypertensive patients, 17 (47.22%) patients were receiving dual therapy. Out of 45 patients whose records for active BP variability were available, 26 (57.78%) had high variability. The number and percentage of dippers, extreme dippers and reverse dippers as 23 (42.79%), three (5.56%), and six (11.11%), respectively. Depending on the age, there was significant difference in the dipping pattern (p=0.013). On office blood pressure measurement, 35 (64.81%) patients were found to have hypertension. ABPM revealed hypertension in 32 (59.26%). Masked hypertension and white-coat hypertension was observed in nine (16.17%) and 12 (22.22%) patients, respectively.

Conclusion: ABPM is feasible and useful in routine outpatient clinical practice for diagnosis of essential hypertension, pattern of dipping, masked hypertension, and white-coat hypertension and also for the therapeutic evaluation of patients in clinical practice.

Validation of a wearable cuff-less wristwatch-type blood pressure monitoring device

Ambulatory blood pressure (BP) monitoring is recommended to improve the management of hypertension. Here, we investigated the accuracy of BP estimated using a wearable cuff-less device, InBodyWATCH, compared with BP measured using a manual sphygmomanometer. Thirty-five adults were enrolled (age 57.1 ± 17.9 years). The BP was estimated using InBodyWATCH with an individualized estimation based on a neural network model. Three paired sets of BPs from the two devices were compared using correlation analysis and Bland–Altman plots (n = 105 paired BP readings). The correlations for both systolic and diastolic BP (SBP and DBP) between the two devices were high (r = 0.964 and 0.939, both P < 0.001). The mean difference was 2.2 ± 6.1 mmHg for SBP and −0.2 ± 4.2 mmHg for DBP; these were not significant (P = 0.472 for SBP and P = 0.880 for DBP). The proportions of estimated SBP/DBP obtained from the InBodyWATCH within ± 5 mmHg of manual SBP/DBP were 71.4%/83.8%; within ± 10 mmHg they were 86.7%/98.1%; and within ± 15 mmHg they were 97.1%/99.0%. The estimated BP from this wearable cuff-less device correlated highly with the manual BP and showed good accuracy, suggesting its potential to be used in ambulatory BP monitoring.

Beyond Fish Oil Supplementation: The Effects of Alternative Plant Sources of Omega-3 Polyunsaturated Fatty Acids upon Lipid Indexes and Cardiometabolic Biomarkers-An Overview

Cardiovascular diseases remain a global challenge, and lipid-associated biomarkers can predict cardiovascular events. Extensive research on cardiovascular benefits of omega-3 polyunsaturated fatty acids (n3-PUFAs) is geared towards fish oil supplementation and fish-rich diets. Nevertheless, vegetarianism and veganism are becoming more popular across all segments of society, due to reasons as varied as personal, ethical and religious values, individual preferences and environment-related principles, amongst others. Due to the essentiality of PUFAs, plant sources of n3-PUFAs warrant further consideration. In this review, we have critically appraised the efficacy of plant-derived n3-PUFAs from foodstuffs and supplements upon lipid profile and selected cardiometabolic markers. Walnuts and flaxseed are the most common plant sources of n3-PUFAs, mainly alpha-linolenic acid (ALA), and feature the strongest scientific rationale for applicability into clinical practice. Furthermore, walnuts and flaxseed are sources of fibre, potassium, magnesium, and non-essential substances, including polyphenols and sterols, which in conjunction are known to ameliorate cardiovascular metabolism. ALA levels in rapeseed and soybean oils are only slight when compared to flaxseed oil. Spirulina and Chlorella, biomasses of cyanobacteria and green algae, are important sources of n3-PUFAs; however, their benefits upon cardiometabolic markers are plausibly driven by their antioxidant potential combined with their n3-PUFA content. In humans, ALA is not sufficiently bioconverted into eicosapentaenoic and docosahexaenoic acids. However, evidence suggests that plant sources of ALA are associated with favourable cardiometabolic status. ALA supplementation, or increased consumption of ALA-rich foodstuffs, combined with reduced omega-6 (n6) PUFAs intake, could improve the n3/n6 ratio and improve cardiometabolic and lipid profile.

Visit-to-visit blood pressure variability is a risk factor for all-cause mortality and cardiovascular disease: a systematic review and meta-analysis

OBJECTIVE

Clinical cohort studies have reported that visit-to-visit variability (VVV) of blood pressure (BP) is associated with cardiovascular disease (CVD) or mortality. However, the results were not consistent in all studies. The current study is, therefore, aimed to conduct a systematic review and meta-analysis to determine the association between VVV of BP and CVD and all-cause mortality.

METHOD

PubMed and EMBASE were searched through 18 May 2014, using the following terms: VVV, BP, CVD, coronary heart disease (CHD), myocardial ischemia, stroke, and mortality. Overall, 84 records were identified, and 23 publications were enrolled into the current study. Data were extracted from selected publications, and meta-analysis was performed using a random effect model.

RESULT

VVV of SBP was significantly associated with outcomes of all-cause mortality with the relative risk (RR) and 95% confidence interval (CI) 1.14 (1.09, 1.18), CVD incidence (RR = 1.12, 95% CI: 1.05, 1.09), CVD mortality (RR = 1.18, 95% CI: 1.09, 1.28), CHD incidence (RR = 1.12, 95% CI: 1.06, 1.19), and stroke incidence (RR = 1.34, 95% CI: 1.11, 1.61).

CONCLUSION

In summary, among the wide heterogenetic population, modest associations between VVV of SBP and all-cause mortality, CVD incidence, CVD mortality, CHD incidence, and stroke incidence were found. Findings of the current study suggested that standardized approaches of monitoring VVV in the high-risk population, including patients with cardiac infarction, diabetes, stroke, and patients with chronic kidney disease or in dialysis, are necessary in designing a prospective clinical study on the association of VVV and patients' prognosis.

Personalized Hypertension Management Using Patient-Generated Health Data Integrated With Electronic Health Records (EMPOWER-H): Six-Month Pre-Post Study

BACKGROUND

EMPOWER-H (Engaging and Motivating Patients Online With Enhanced Resources-Hypertension) is a personalized-care model facilitating engagement in hypertension self-management utilizing an interactive Web-based disease management system integrated with the electronic health record. The model is designed to support timely patient-provider interaction by incorporating decision support technology to individualize care and provide personalized feedback for patients with chronic disease. Central to this process were patient-generated health data, including blood pressure (BP), weight, and lifestyle behaviors, which were uploaded using a smartphone.

OBJECTIVE

The aim of this study was to evaluate the program among patients within primary care already under management for hypertension and with uncontrolled BP.

METHODS

Using a 6-month pre-post design, outcome measures included office-measured and home-monitored BP, office-measured weight, intervention contacts, diet, physical activity, smoking, knowledge, and health-related quality of life.

RESULTS

At 6 months, 55.9% of participants (N=149) achieved office BP goals (<140/90 mm Hg; P<.001) and 86.0% achieved clinically meaningful reduction in office BP (reduction in systolic BP [SBP] ≥5 mm Hg or diastolic BP [DBP] ≥3 mm Hg). At baseline, 25.2% of participants met home BP goals (<135/85 mm Hg), and this percentage significantly increased to 71.4% (P<.001) at 6 months. EMPOWER-H also significantly reduced both office and home SBP and DBP, decreased office-measured weight and consumption of high-salt and high-fat foods (all P<.005), and increased intake of fruit and vegetables, minutes of aerobic exercise, and hypertension knowledge (all P<.05). Patients with higher home BP upload frequencies had significantly higher odds of achieving home BP goals. Patients receiving more total intervention, behavioral, pharmaceutical contacts had significantly lower odds of achieving home BP goals but higher improvements in office BP (all P<.05).

CONCLUSIONS

EMPOWER-H significantly improved participants' office-measured and home-monitored BP, weight, and lifestyle behaviors, suggesting that technologically enabled BP home-monitoring, with structured use of patient-generated health data and a personalized care-plan facilitating patient engagement, can support effective clinical management. The experience gained in this study provides support for the feasibility and value of using carefully managed patient-generated health data in the day-to-day clinical management of patients with chronic conditions. A large-scale, real-world study to evaluate sustained effectiveness, cost-effectiveness, and scalability is warranted.