Blood pressure measurements for diagnosing hypertension in primary care: room for improvement

BACKGROUND

In the adult population, about 50% have hypertension, a risk factor for cardiovascular disease and subsequent premature death. Little is known about the quality of the methods used to diagnose hypertension in primary care.

OBJECTIVES

The objective was to assess the frequency of use of recognized methods to establish a diagnosis of hypertension, and specifically for OBPM, whether three distinct measurements were taken, and how correctly the blood pressure levels were interpreted.

METHODS

A retrospective population-based cohort study using electronic medical records of patients aged between 40 and 70 years, who visited their general practitioner (GP) with a new-onset of hypertension in the years 2012, 2016, 2019, and 2020. A visual chart review of the electronic medical records was used to assess the methods employed to diagnose hypertension in a random sample of 500 patients. The blood pressure measurement method was considered complete if three or more valid office blood pressure measurements (OBPM) were performed, or home-based blood pressure measurements (HBPM), the office- based 30-minute method (OBP30), or 24-hour ambulatory blood pressure measurements (24 H-ABPM) were used.

RESULTS

In all study years, OBPM was the most frequently used method to diagnose new-onset hypertension in patients. The OBP-30 method was used in 0.4% (2012), 4.2% (2016), 10.6% (2019), and 9.8% (2020) of patients respectively, 24 H-ABPM in 16.0%, 22.2%, 17.2%, and 19.0% of patients and HBPM measurements in 5.4%, 8.4%, 7.6%, and 7.8% of patients, respectively. A diagnosis of hypertension based on only one or two office measurements occurred in 85.2% (2012), 87.9% (2016), 94.4% (2019), and 96.8% (2020) of all patients with OBPM. In cases of incomplete measurement and incorrect interpretation, medication was still started in 64% of cases in 2012, 56% (2016), 60% (2019), and 73% (2020).

CONCLUSION

OBPM is still the most often used method to diagnose hypertension in primary care. The diagnosis was often incomplete or misinterpreted using incorrect cut-off levels. A small improvement occurred between 2012 and 2016 but no further progress was seen in 2019 or 2020. If hypertension is inappropriately diagnosed, it may result in under treatment or in prolonged, unnecessary treatment of patients. There is room for improvement in the general practice setting.

Home blood pressure self-measurement: “Current situation and new perspectives”

The method typically used to diagnose and monitor hypertensive patients has been to measure blood pressure in the physician's surgery; however, it is a well-known fact that this approach poses certain drawbacks, such as observer bias, failure to detect an alert reaction in the clinic, etc., difficulties that affect its accuracy as a diagnostic method. In recent years, the varying international scientific societies have persistently recommended the use of blood pressure measurements outside the clinic (at home or in the outpatient setting), using validated automatic devices. Data from some studies suggest that if we rely solely on in-office measurements, approximately 15-20% of the time we may be wrong when making decisions, both in terms of diagnosis and patient follow-up. Home blood pressure measurements are a simple and very affordable method that has a similar reproducibility and prognostic value as ambulatory blood pressure monitoring, the availability of which is currently very limited. Moreover, ambulatory self-measurements have the significant benefit of being able to improve control of hypertensive individuals. Healthcare professionals and patients should be aware of the methodology of home blood pressure measurement, its usefulness and limitations.

Can β-blockers influence regular daily physical activity?

BACKGROUND

In hypertension, β-blockers have a high rate of nonadherence to treatment likely because of fatigue.

METHODS

We evaluate daily physical activity and maximal exercise performance in 56 patients with hypertension (grades I-II), with and without β-blockers (bisoprolol 10 mg or atenolol 100 mg) added to standard treatment; 48 patients completed the study. Study tests were performed after 8 weeks of antihypertensive therapy without β blockers and after the following 8 weeks with β-blockers.

RESULTS

No significant differences between β-blockers were observed. At office measurement, β-blockers decreased heart rate (HR) from 78 ± 9 to 62 ± 7 bpm (P < 0.01) and SBP from 133 ± 13 to 125 ± 12 mmHg (P < 0.01). No significant changes were observed for DBP. Conversely, at ambulatory pressure monitoring DBP but not SBP decreased with β-blockers (mean-24-h DBP 77 ± 8 vs. 74 ± 7 mmHg, P < 0.01). An overall reduction of daily activities and of estimated kilocalories consumption was observed as measured by a portable armband device. Of note, time with activity more than 3 METS was reduced by β-blockers from 148.1 (83-201) to 117.9 (82-189) min (P < 0.01). Cardiopulmonary exercise (CPE) showed a preserved exercise performance unaffected by β-blockers.

CONCLUSION

In hypertension, β-blocker treatment is associated to reduction of daily physical activity but not of maximal exercise performance.

Current applications and limitations of European guidelines on blood pressure measurement: implications for clinical practice

Hypertension is the most common cardiovascular (CV) risk factor, strongly and independently associated with an increased risk of major CV outcomes, including myocardial infarction, stroke, congestive heart failure, renal disease and death due to CV causes. Effective control of hypertension is of key importance for reducing the risk of hypertension-related CV complications, as well as for reducing the global burden of CV mortality. However, several studies reported relatively poor rates of control of high blood pressure (BP) in a setting of real-life practice. To improve hypertension management and control, national and international scientific societies proposed several educational and therapeutic interventions, among which the systematic implementation of out-of-office BP measurements represents a key element. Indeed, proper assessment of individual BP profile, including home, clinic and 24-h ambulatory BP levels, may improve awareness of the disease, ensure high level of adherence to prescribed medications in treated hypertensive patients, and thus contribute to ameliorate BP control in treated hypertensive outpatients. In line with these purposes, recent European guidelines have released practical recommendations and clear indications on how, when and how properly measuring BP levels in different clinical settings, with different techniques and different methods. This review aimed at discussing current applications and potential limitations of European guidelines on how to measure BP in office and out-of-office conditions, and their potential implications in the daily clinical management of hypertension.

Home Blood Pressure and Telemedicine: A Modern Approach for Managing Hypertension During and After COVID-19 Pandemic

Hypertension is the most common cardiovascular risk factor for acute cardiovascular outcomes, including acute coronary disease, stroke, chronic kidney disease and congestive heart failure. Despite the fact that it represents the most prevalent risk factor in the general population, mostly in elderly individuals, its awareness is still relatively low, being about one third of patients living with undiagnosed hypertension and high risk of experiencing acute cardiovascular events. In addition, though recent improvement in pharmacological and non-pharmacological therapeutic options, hypertension is largely uncontrolled, with about 35-40% of treated hypertensive patients achieving the recommended therapeutic targets. Among different modern interventions proposed for improving blood pressure control in treated hypertensive patients, a systematic adoption of home BP monitoring has demonstrated to be one of the most effective. Indeed, it improves patients' awareness of the disease and adherence to prescribed medications and allows tailoring and personalizing BP lowering therapies. Home BP monitoring is particularly suitable for telemedicine and mobile-health solutions. Indeed, in specific conditions, when face-to-face interactions between patients and physicians are not allowed or even suspended, as in case of COVID-19 pandemic, telemedicine may ensure effective management of hypertension, as well as other cardiovascular and non-cardiovascular comorbidities. This review will summarize strengths and limitations of telemedicine in the clinical management of hypertension with a particular focus on the lessons learned during the COVID-19 pandemic.

Prevalence and clinical characteristics of isolated systolic hypertension in young: analysis of 24 h ambulatory blood pressure monitoring database

Isolated systolic hypertension (ISHT) is common in elderly patients, whilst its prevalence and clinical impact in young adults are still debated. We aimed to estimate prevalence and clinical characteristics of ISHT and to evaluate out-of-office BP levels and their correlations with office BP in young adults. A single-center, cross-sectional study was conducted at our Hypertension Unit, by including treated and untreated individuals aged 18-50 years, who consecutively underwent home, clinic and 24 h ambulatory BP assessment. All BP measurements were performed and BP thresholds were set according to European guidelines: normotension (NT), clinic BP <140/<90 mmHg; ISHT, BP ≥140/<90 mmHg; isolated diastolic hypertension (IDHT), BP <140/≥90 mmHg; systolic-diastolic hypertension (SDHT), BP ≥140/≥90 mmHg. European SCORE, vascular and cardiac HMOD were also assessed. From an overall sample of 13,053 records, we selected 2127 young outpatients (44.2% female, age 40.5 ± 7.4 years, BMI 26.7 ± 5.0 kg/m², clinic BP 141.1 ± 16.1/94.1 ± 11.8 mmHg, 24 h BP 129.0 ± 12.8/82.4 ± 9.8 mmHg), among whom 587 (27.6%) had NT, 391 (18.4%) IDHT, 144 (6.8%) ISHT, and 1005 (47.2%) SDHT. Patients with ISHT were predominantly male (61.1%), younger and with higher BMI compared to other groups. They also showed higher home and 24 h ambulatory SBP levels than those with NT or IDHT (P < 0.001), though similar to those with SDHT. ISHT patients showed significantly higher pulse pressure (PP) levels than other groups, at all BP measurements (P < 0.001 for all comparisons), and significantly higher proportion (65.3%) of patients with ISHT had PP >60 mmHg. European SCORE resulted significantly higher in patients with ISHT (1.6 ± 2.9%) and SDHT (1.5 ± 2.7%) compared to those with IDHT (0.9 ± 1.5%) or NT (0.8 ± 1.9%) (P = 0.017). Though relatively rare, ISHT should be not viewed as a benign condition, being associated with sustained SBP elevation, high European SCORE risk, and vascular HMOD.

Sub-maximal aerobic exercise training reduces haematocrit and ameliorates symptoms in Andean highlanders with chronic mountain sickness

New Findings

What is the central question of this study?

What is the effect of sub‐maximal aerobic exercise training on signs and symptoms of chronic mountain sickness (CMS) in Andean highlanders?

What is the main finding and its importance?

Aerobic exercise training (ET) effectively reduces haematocrit, ameliorates symptoms and improves aerobic capacity in CMS patients, suggesting that a regular aerobic ET programme might be used as a low‐cost non‐invasive/non‐pharmacological management strategy of this syndrome.

Abstract

Excessive erythrocytosis is the hallmark sign of chronic mountain sickness (CMS), a debilitating syndrome associated with neurological symptoms and increased cardiovascular risk. We have shown that unlike sedentary residents at the same altitude, trained individuals maintain haematocrit within sea‐level range, and thus we hypothesise that aerobic exercise training (ET) might reduce excessive haematocrit and ameliorate CMS signs and symptoms. Eight highlander men (38 ± 12 years) with CMS (haematocrit: 70.6 ± 1.9%, CMS score: 8.8 ± 1.4) from Cerro de Pasco, Peru (4340 m) participated in the study. Baseline assessment included haematocrit, CMS score, pulse oximetry, maximal cardiopulmonary exercise testing and in‐office plus 24 h ambulatory blood pressure (BP) monitoring. Blood samples were collected to assess cardiometabolic, erythropoietic, and haemolysis markers. ET consisted of pedalling exercise in a cycloergometer at 60% of V˙O2peak for 1 h/day, 4 days/week for 8 weeks, and participants were assessed at weeks 4 and 8. Haematocrit and CMS score decreased significantly by week 8 (to 65.6 ± 6.6%, and 3.5 ± 0.8, respectively, P < 0.05), while V˙O2peak and maximum workload increased with ET (33.8 ± 2.4 vs. 37.2 ± 2.0 ml/min/kg, P < 0.05; and 172.5 ± 9.4 vs. 210.0 ± 27.8 W, P < 0.01; respectively). Except for an increase in high‐density lipoprotein cholesterol, other blood markers and BP showed no differences. Our results suggest that reduction of haematocrit and CMS symptoms results mainly from haemodilution due to plasma volume expansion rather than to haemolysis. In conclusion, we show that ET can effectively reduce haematocrit, ameliorate symptoms and improve aerobic capacity in CMS patients, suggesting that regular aerobic exercise might be used as a low‐cost non‐invasive and non‐pharmacological management strategy.

Accuracy of non-invasive blood pressure measurement in patients with atrial fibrillation

Although the accuracy of oscillometric blood pressure (BP) measurement is not so satisfied, the BP reading is still associated with cardiovascular events and death in patients with atrial fibrillation (AF). Because the currently used auscultatory or oscillometric methods were developed on sinus rhythm (SR), these BP measurement methods were not reasonable for AF patients. It is suggested that the average of three BP readings in the AF patients is accepted in clinical, even so, high systolic BP (SBP) variability and inaccurate diastolic BP (DBP) value have been reported in AF patients. In sinus rhythm, oscillometric pressure pulses (OPPs) are spindle-like, regardless of the heart rate. However, the shape of OPP is obviously associated with frequency of ventricular rate (VR) in AF patients. When the VR is rapid, the OPP is far from a spindle-like shape. With intro-aortic BP as reference, a study demonstrated that the oscillometric SBP level significantly underestimated the intro-aortic SBP level in the AF patients with increasing VR. In clinical practice, the physician should use the average of three BP readings in the AF patients. When the mean pulse rates (PR) reported by the oscillometric BP devise is less than 90 bpm and the variation of three pulse rate <10 bpm, the oscillometric SBP readings may be clinically accepted in AF patients. It is necessary to develop a new BP measurement method for AF as the current methods in AF are not so accurate as in SR.

Feasibility of 24-h blood pressure telemonitoring in community pharmacies: the TEMPLAR project

OBJECTIVES

Low-quality ambulatory blood pressure monitoring (ABPM) due to recurring artifacts may limit its clinical value. We evaluated the features and impact on BP control and patient management of ABPMs performed in Italian community pharmacies, according to their quality.

METHODS

Twenty-four-hour ABPMs were obtained by a clinically validated, automated upper arm device and uploaded on a certified web-based telemedicine platform (www.tholomeus.net). The system automatically evaluated the quality of the recording according to current guidelines. In case of poor ABPM quality, the pharmacist was prompted to repeat the test. All the ABPMs were labeled as valid or invalid. Demographic and clinical characteristics of the patients and BP control were compared between the two groups.

RESULTS

A total of 45 232 ABPMs were obtained in as many patients through 812 pharmacies (87.7% recordings were valid). Factors significantly associated with a better ABPM quality were younger age, use of antihypertensive medications, presence of at least one cardiovascular risk factor, concomitant disease or treatment, a test performed in the coldest months, and residence in the cooler northern regions of the country. The 24-h and daytime ambulatory BP level and the prevalence of ambulatory hypertension and white-coat hypertension were higher, and the prevalence of masked hypertension lower in patients with valid recordings. High odds of obtaining a valid recording were observed in patients repeating the ABPM.

CONCLUSION

Ambulatory BP telemonitoring is feasible in community pharmacies as long as potential predictors of unsuccessful outcomes are taken into account and adequately managed.

Effectiveness of a family nurse-led programme on accuracy of blood pressure self-measurement: A randomised controlled trial

AIMS AND OBJECTIVES

To evaluate the effectiveness of a Family Nurse Practitioner (FNP)-led programme on the degree of adherence of current recommendations on home blood pressure self-measurement (HBPM) as compared to routine care and management.

BACKGROUND

HBPM plays an important role for monitoring hypertensive patients; however, patients' adherence to current guidelines is unsatisfactory. A nurse-led training programme in the community setting could be an effective strategy to achieve high level of patients' adherence to recommendations.

DESIGN

A multicentre randomised controlled trial was carried out from September 2016 to September 2017.

METHODS

In total, 170 patients were randomly allocated into the intervention group (n = 83) and the usual care (n = 87). All participants received usual care (written and verbal information on HBPM recommendations); subjects in the intervention group also received 1-hour training session on how to correctly self-measure BP. Clinical trial registration was done (ClinicalTrials.gov.: NCT04681703). The CONSORT checklist for randomised controlled trials was used in this study.

RESULTS

At baseline, the level of adherence to the recommendation was similar in the two groups (p < .05). After 1 month, the adherence significantly increased in the intervention group, where patients were more likely to measure BP at the same hour and from the same arm, in a quiet environment, with the back and uncovered arm supported and the legs uncrossed; recording BP more than once in each measurement session; keeping a diary of blood pressure measurements; use of the appropriate cuff and proper placement of the cuff; and resting for >5 min before performing the measurement (all p < .05).

CONCLUSIONS

The FNP-led programme is effective in improving patients' adherence to guidelines on the correct technique to self-measure BP at home.

RELEVANCE TO CLINICAL PRACTICE

This programme may be added to the existing interventions in the community setting or considered into specifically nurse-led hypertension management models.

Microvascular Structural Alterations in Cancer Patients Treated With Antiangiogenic Drugs

Objective: Antiangiogenic therapies (tyrosine kinase inhibitors-TKI and direct anti-VEGF monoclonal antibodies) are being increasingly used in the treatment of solid tumors; hypertension represents a common side effect of these agents. Several mechanisms are involved in the development of hypertension, including microvascular rarefaction and other microvascular alterations. Therefore, the aim of our study was to evaluate whether TKI and direct anti-VEGF agents may affect the structure of retinal arterioles or capillary density.

Design and Methods: We investigated 20 patients with a diagnosis of cancer who underwent a treatment with either a TKI or an anti-VEGF antibody. Patients were submitted to ambulatory monitoring blood pressure for blood pressure evaluation. Basal and total capillary density were assessed by capillaroscopy whereas, retinal arteriole morphology was measured by Adaptive Optics. Patients were evaluated before starting the antiangiogenic therapy (T0) and re-evaluated after 3 (T3) and 6 (T6) months after treatment. Fourteen patients completed the study.

Results: Systolic and diastolic blood pressure values were similar in all patients at T3 and T6 compared to T0. However, during the study antihypertensive treatment was optimized (increased dose and/or addition of drugs) in 57% of patients (n = 8). No differences were observed in retinal arteriole structural parameters and in large artery stiffness. Basal capillary density was reduced by antiangiogenic drugs after 3 or 6 months.

Conclusions: Our data suggest that an increase of antihypertensive treatment is necessary in patients treated with a TKI or a direct VEGF inhibitor, confirming pro-hypertensive effects of these drugs. However, under adequate blood pressure control, microvascular structure seem to be partially preserved, since a worsening of basal capillary density but no changes in retinal arteriole morphology were observed.

The UrgeRe (Urgenze Ipertensive: Un Progetto Educazionale Fondato Sulla Vita Reale, Hypertensive Urgencies: A Project in the Real World) Project

The approach to hypertensive emergiencies (HE) and urgencies (HU) may be different according to local clinical practice, despite recent guidelines and position papers recommendations. The Italian Society of Hypertension (Società Italiana della Ipertensione Arteriosa, SIIA) developed an online survey, in order to explore the awareness, management and treatment of HU in Italy, sending by e mail a 12 items questionnaire to the members of the SIIA. The results show that the definition of HU was correctly identified by 62% of the responders. Most physicians identified the role of pharmacological therapy or legal/illegal substances abuse as possible cause of BP elevation; the use of a benzodiazepine drugs was considered worthwhile by 65% of responders. The prescription of diagnostic test and drug administration significantly differed from guidelines recommendations and only 57% of the physicians reported to treat HU with oral drug administration. Sub-lingual nifedipine was prescribed by 13% or responders. This survey shows the need to further spread the updated scientific information on the management and treatment of HE and HU, along with the improvement of the interrelationship with the general practitioner health system in Italy.

Does the mean 24-h pulse rate from ambulatory blood pressure monitoring reflect the mean 24-h ventricular rate from Holter electrocardiogram in atrial fibrillation patients?

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) on the oscillometric method is applicable in patients with atrial fibrillation, but the mean pulse rate is or not similar to the ventricular rate from the Holter in atrial fibrillation patients remains unknown.

METHODS

This study included 228 persistent atrial fibrillation patients who received simultaneous 24-h ABPM and 24-h Holter. The mean 24-h pulse rate and the mean 24-h ventricular rate were calculated, and mVR-mPR was used to reflect the difference between them. The SD of 24-h pulse rate values was calculated as SD-pulse rate. Furthermore, according to the SD-pulse rate, the patients were divided into ≤5, 6-10, 11-15 and >15 bpm subgroups.

RESULTS

For the total population, the mean 24-h pulse rate is positively correlated with the mean 24-h ventricular rate, and the Bland-Altman plot showed quite wide 95% limits. As the SD-pulse rate increased, the 24-h mVR-mPR also increased. The mean 24-h mVR-mPR was 0.5 bpm when SD-pulse rate ≤5, 3.5 bpm when SD-pulse rate of 6-10, 7.6 bpm when SD-pulse rate of 11-15, and 12.5 bpm when SD-pulse rate >15 bpm, respectively. Meanwhile, in the SD-pulse rate 0-10 subgroup, the 95% limits were only from -13.8 to 19.7 bpm, while in the >10 subgroup, these values were from -19.5 to 36.5 bpm.

CONCLUSION

The mean 24-h pulse rate should not be used to represent the true ventricular rate for all atrial fibrillation patients. However, when lower the SD-pulse rate, the mVR-mPR becomes smaller.

Blood pressure measurement in atrial fibrillation: review and meta-analysis of evidence on accuracy and clinical relevance

: Atrial fibrillation (AF) often coexists with hypertension in the elderly and multiplies the risk of stroke and death. Blood pressure (BP) measurement in patients with AF is difficult and uncertain and has been a classic exclusion criterion in hypertension clinical trials leading to limited research data. This article reviews the evidence on the accuracy of BP measurement in AF performed using different methods (office, ambulatory, home) and devices (auscultatory, oscillometric) and its clinical relevance in predicting cardiovascular damage. The current evidence suggests the following: (i) Interobserver and intra-observer variation in auscultatory BP measurement is increased in AF because of increased beat-to-beat BP variability and triplicate measurement is required; (ii) Data from validation studies of automated electronic BP monitors in AF are limited and methodologically heterogeneous and suggest reasonable accuracy in measuring SBP and a small yet consistent overestimation of DBP; (iii) 24-h ambulatory BP monitoring is feasible in AF, with similar proportion of errors as in individuals without AF; (iv) both auscultatory and automated oscillometric BP measurements appear to be clinically relevant in AF, providing similar associations with intra-arterial BP measurements and with indices of preclinical cardiac damage as in patients without AF, and predict cardiovascular events and death; (v) Screening for AF in the elderly using an AF-specific algorithm during routine automated office, home or ambulatory BP measurement has high diagnostic accuracy. In conclusion, in AF patients, BP measurement is important, reliable, and clinically relevant and should not be neglected in clinical research and in practice.

Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association

The diagnosis and management of hypertension, a common cardiovascular risk factor among the general population, have been based primarily on the measurement of blood pressure (BP) in the office. BP may differ considerably when measured in the office and when measured outside of the office setting, and higher out-of-office BP is associated with increased cardiovascular risk independent of office BP. Self-measured BP monitoring, the measurement of BP by an individual outside of the office at home, is a validated approach for out-of-office BP measurement. Several national and international hypertension guidelines endorse self-measured BP monitoring. Indications include the diagnosis of white-coat hypertension and masked hypertension and the identification of white-coat effect and masked uncontrolled hypertension. Other indications include confirming the diagnosis of resistant hypertension and detecting morning hypertension. Validated self-measured BP monitoring devices that use the oscillometric method are preferred, and a standardized BP measurement and monitoring protocol should be followed. Evidence from meta-analyses of randomized trials indicates that self-measured BP monitoring is associated with a reduction in BP and improved BP control, and the benefits of self-measured BP monitoring are greatest when done along with cointerventions. The addition of self-measured BP monitoring to office BP monitoring is cost-effective compared with office BP monitoring alone or usual care among individuals with high office BP. The use of self-measured BP monitoring is commonly reported by both individuals and providers. Therefore, self-measured BP monitoring has high potential for improving the diagnosis and management of hypertension in the United States. Randomized controlled trials examining the impact of self-measured BP monitoring on cardiovascular outcomes are needed. To adequately address barriers to the implementation of self-measured BP monitoring, financial investment is needed in the following areas: improving education and training of individuals and providers, building health information technology capacity, incorporating self-measured BP readings into clinical performance measures, supporting cointerventions, and enhancing reimbursement.

E-Health in Hypertension Management: an Insight into the Current and Future Role of Blood Pressure Telemonitoring

PURPOSE OF REVIEW

Out-of-office blood pressure (BP) monitoring techniques, including home and ambulatory BP monitoring, are currently recommended by hypertension guidelines worldwide to confirm the diagnosis of hypertension and to monitor the appropriateness of treatment. However, such techniques are not always effectively implemented or timely available in the routine clinical practice. In recent years, the widespread availability of e-health solutions has stimulated the development of blood pressure telemonitoring (BPT) systems, which allow remote BP tracking and tighter and more efficient monitoring of patients' health status.

RECENT FINDINGS

There is currently strong evidence that BPT may be of benefit for hypertension screening and diagnosis and for improving hypertension management. The advantage is more significant when BPT is coupled with multimodal interventions involving a physician, a nurse or pharmacist, and including education on lifestyle and risk factors and drug management. Several randomized controlled studies documented enhanced hypertension management and improved BP control of hypertensive patients through BPT. Potential additional effects of BPT are represented by improved compliance to treatment, intensification, and optimization of drug use, improved quality of life, reduction in risk of developing cardiovascular complications, and cost-saving. Applications based on m-health and making use of wearables or smartwatches integrated with machine learning models are particularly promising for the future development of efficient BPT solutions, and they will provide remarkable support decision tools for doctors. BPT and telehealth will soon disrupt hypertension management. However, which approach will be the most effective and whether it will be sustainable in the long-term still need to be elucidated.

Epidemiological Impact and Clinical Consequences of Masked Hypertension: A Narrative Review

Masked hypertension (MHT) is a clinical condition characterized by normal blood pressure (BP) levels during clinical consultation and above normal out-of-office BP values. MHT is associated to an increased risk of developing hypertension-mediated organ damage (HMOD) and major cardiovascular (CV) outcomes, such as myocardial infarction, stroke, and hospitalizations due to CV causes, as well as to metabolic abnormalities and diabetes, thus further promoting the development and progression of atherosclerotic disease. Previous studies showed contrasting data on prevalence and clinical impact of MHT, due to not uniform diagnostic criteria (including either home or 24-h ambulatory BP measurements, or both) and background antihypertensive treatment. Whatever the case, over the last few years the widespread diffusion of validated devices for home BP monitoring has promoted a better diagnostic assessment and proper identification of individuals with MHT in a setting of clinical practice, thus resulting in increased prevalence of this clinical condition with potential clinical and socio-economic consequences. Several other items, in fact, remain unclear and debated, particularly regarding the therapeutic approach to MHT. The aim of this narrative review is to illustrate the clinical definition of MHT, to analyze the diagnostic algorithm, and to discuss the potential pharmacological approaches to be adopted in this clinical condition, in the light of the recommendations of the recent European hypertension guidelines.

A comparison of first trimester blood pressures obtained at the time of first trimester pre-eclampsia screening and those obtained during prenatal care visits

OBJECTIVE

To determine if enrollment blood pressures in a study on first trimester preeclampsia prediction significantly differed from those obtained during routine prenatal care visits in the first trimester.

STUDY DESIGN

Women carrying a singleton gestation were prospectively enrolled in a first trimester study on preeclampsia prediction, and had systolic and diastolic blood pressure (SBP, DBP) measured at the time of enrollment. Blood pressure was also measured with the same technique by clinic nurses during the routine prenatal visits throughout the first trimester of pregnancy (9-14 weeks). The enrollment-BP (E-BP) and average first trimester-BP (aFT-BP) were compared using a paired samples t-test or Wilcoxon test, as appropriate. Smokers and patients on antihypertensive medications were excluded from the analysis. test.

RESULTS

644 women had prenatal care in the primary study center and met study criteria. The mean gestational age at study enrollment was 12.5 weeks. No significant difference was found between E-SBP and aFT-SBP (p = 0.10). Enrollment DBP and mean arterial pressure (MAP) were significantly lower than the aFT- DBP and -MAP (median DPB 67 vs 70 mm Hg and median MAP 83.7 vs 85 mmHg, respectively, p < 0.001). However, the difference was not clinically relevant (3 mmHg for DBP, and 1.3 mmHg for MAP).

CONCLUSIONS

Blood pressures obtained in a setting of preeclampsia screening are not higher than those obtained during regular prenatal care in the first trimester. This suggests that the setting in which pre-eclampsia screening is performed is unlikely to be a confounder for blood pressure measurements and the risk assessment.

The usefulness of 24-hour blood pressure monitoring for the patients with atrial fibrillation: based on the variability of blood pressure parameters

OBJECTIVE

The aim of this study was to test whether ambulatory blood pressure monitoring (ABPM) in patients with atrial fibrillation is reliable as in patients with sinus rhythm.

METHOD

This study included 92 persistent atrial fibrillation patients (50% females; mean age 70.49 ± 11.56 years) and 92 matched sinus rhythm patients (46% females; mean age 69.23 ± 12.63 years). The participants were examined simultaneously with 24-hour ABPM and 24-hour Holter electrocardiography. The mean 24-hour (24-hour-), daytime (day-) and nighttime (night-) BP, types of BP curve, morning systolic BP (SBP) surge (MBPS), the SD of BP readings and the coefficient of variability (the SD/mean BP × 100%) were compared between atrial fibrillation and sinus rhythm patients.

RESULTS

No differences of 24-hour-, day- and night-SBP levels were observed between two groups. Meanwhile, the 24-hour-SD, day-SD and night-SD, as well as the coefficient of variability for SBP were also similar between two groups. There was no significant difference in the number of MBPS between the two groups. On diastolic BP (DBP), the similar 24 hour and day levels, the 24-hour-SD, day-SD and night-SD as well as the coefficient of variability were also similar between two groups. But the nighttime DBP levels and the night-SD were higher in atrial fibrillation than in sinus rhythm.

CONCLUSION

ABPM provides data with similar SBP variability in patients with atrial fibrillation as in subject with normal cardiac rhythm. The ABPM on oscillometric method may be suitable for the atrial fibrillation patients, especially for the SBP evaluation.

The association of smoothness index of central blood pressure with ambulatory carotid femoral pulse wave velocity after 20-week treatment with losartan in combination with amlodipine versus hydrochlorothiazide

Supplemental Digital Content is available in the text

The aim of this study was to identify associations between the smoothness index of central SBP (CSBP) and changes of ambulatory carotid femoral pulse wave velocity in response to 20-week treatments with losartan and amlodipine vs. losartan and hydrochlorthiazide combinations.

Effect of Education for Hypertensive Patients with Correctly Performed Self-Blood Pressure Monitoring (SBPM)

INTRODUCTION

The study objective was to assess the impact of pharmacist-led education on the patient's knowledge and skills on SBPM (self-blood pressure monitoring).

METHODS

Patient knowledge was assessed using tests and patients' skills were based on a checklist (20 parameters) completed by the researcher based on the SBPM video records. Patients taking pressure measurements were filmed for 20 days and after 6 months. After the first 10 days, patients were educated about the correct SBPM procedure. Knowledge tests were repeated three times (before/after/6 months after education).

RESULTS

All patients' knowledge and skills in the field of SBPM were improved after education. After the education, patients scored an average of 9 out of 10 points in the knowledge test (increasing an average of five points after education), six months later-an average increase of 7.36 points. Patient skills after training were rated at 17.4 out of 20 points on average (increase by an average of 5.14 points after education), six months later, there was an average of 16.23 points.

CONCLUSIONS

The study showed an increase in patients' knowledge and skills in the field of SBPM after training.

Telemonitoring of 24-Hour Blood Pressure in Local Pharmacies and Blood Pressure Control in the Community: The Templar Project

BACKGROUND

The analysis of ambulatory blood pressure monitorings (ABPMs) performed in 639 Italian pharmacies in the context of a telehealth-based service allowed to evaluate the level of blood pressure (BP) control in the community.

METHODS

Twenty-four-hour ABPMs were performed by a clinically validated, automated, upper-arm BP monitor. Recordings were uploaded on a certified web-based telemedicine platform (www.tholomeus.net) and remote medical reporting provided. In each subject, an automatic BP measurement was obtained in the pharmacy and clinical information collected before starting the ABPM.

RESULTS

A total of 20,773 subjects (mean age 57 ± 15 years; 54% females; 28% receiving antihypertensive medications, 31% with any cardiovascular [CV] risk factor) provided valid ABPMs. BP control was poor, but better in ambulatory conditions (24-hour BP <130/80 mm Hg 54% vs. pharmacy BP < 140/90 mm Hg 43%; P < 0.0001) and in drug-treated subjects. Sustained normotension was reported in only 28% subjects. Isolated nocturnal hypertension (16%; nighttime BP ≥120/70 mm Hg with normal daytime BP) was more common (P < 0.0001) than isolated daytime hypertension (9%; daytime BP ≥ 135/85 mm Hg with normal nighttime BP). Sustained hypertension (43%) was more common in younger males at the lowest CV risk, with daytime hypertension. White-coat hypertension (14%) was more common in females. Masked hypertension was not uncommon (15%) and more often observed in older males with an elevated nocturnal BP.

CONCLUSIONS

A telemedicine-based service provided to community pharmacies may facilitate access to ABPM, thus favoring a more accurate hypertension screening and detection. It may also help describe the occurrence of different 24-hour BP phenotypes and personalize the physician's intervention.

Fixed-dose combination of zofenopril plus hydrochlorothiazide vs. irbesartan plus hydrochlorothiazide in hypertensive patients with established metabolic syndrome uncontrolled by previous monotherapy. The ZAMES study (Zofenopril in Advanced MEtabolic Syndrome)

OBJECTIVE

Whether all antihypertensive drugs are equally effective in patients with metabolic syndrome is still unclear. The goal of the Zofenopril in Advanced MEtabolic Syndrome (ZAMES) study was to investigate whether treatment with the fixed-dose combination of sulphydril-containing angiotensin-converting enzyme inhibitor zofenopril plus hydrochlorothiazide is at least as effective as that with the angiotensin receptor blocker irbesartan plus hydrochlorothiazide in patients with metabolic syndrome and essential hypertension, uncontrolled by a previous monotherapy.

METHODS

We enrolled 721 patients in a multicenter, international (Italy and Romania), randomized, double-blind, parallel group, phase III study. Following a 1-week screening withdrawal period, 482 patients (mean age 59 ± 10 years, 53% men) bearing a SBP at least 140 mmHg and/or DBP at least 90 mmHg plus metabolic syndrome (ATP-III criteria) were randomly allocated to a fixed-dose combination of zofenopril 30 mg plus hydrochlorothiazide 12.5 mg or irbesartan 150 mg plus hydrochlorothiazide 12.5 mg once daily for a cumulative period of 24 weeks. After 8 and 16 weeks, zofenopril and irbesartan doses were doubled in nonnormalized study participants. The study endpoint was the office DBP reduction at study end. In 20% of patients, an ambulatory blood pressure monitoring was performed.

RESULTS

The prevalence of diabetes at baseline was significantly (P < 0.05) greater in the zofenopril plus hydrochlorothiazide group (82%) than in the irbesartan plus hydrochlorothiazide (73%) group. Baseline-adjusted DBP reductions were superimposable (P = 0.370) with zofenopril plus hydrochlorothiazide [n = 231; 9.8 (95% confidence interval: 11.1, 8.4) mmHg] and irbesartan plus hydrochlorothiazide [n = 235; 10.4 (11.8, 9.0) mmHg]. The same was for SBP [17.0 (19.2, 14.8) mmHg zofenopril plus hydrochlorothiazide vs. 18.8 (21.0, 16.6) mmHg irbesartan plus hydrochlorothiazide, P = 0.113]. Rate of normalized and responder patients (SBP/DBP < 140/90 mmHg or SBP reduction more than 20 mmHg or DBP reduction more than 10 mmHg) did not differ at study end (65.8% and 77.5% zofenopril plus hydrochlorothiazide vs. 67.7% and 81.5% irbesartan plus hydrochlorothiazide; P = 0.695, P = 0.301). These results were confirmed in the 69 study participants undergoing ambulatory blood pressure monitoring (35 zofenopril plus hydrochlorothiazide; 34 irbesartan plus hydrochlorothiazide), with a comparable 24-h average BP reduction [BP difference between-treatment: SBP: 0.1 (-5.7, 5.9) mmHg, P = 0.975; DBP: -0.9 (-3.8, 2.0) mmHg, P = 0.541]. Both drugs attained similar BP reductions also in the last 6 h of the dosing interval [between-treatment difference SBP: 0.1 (-7.4, 7.5) mmHg P = 0.990; DBP: -0.9 (-4.4, 2.6) mmHg, P = 0.602]. Metabolic and renal indexes were not altered. Few patients were withdrawn for moderate adverse events (5% zofenopril plus hydrochlorothiazide; 5% irbesartan plus hydrochlorothiazide).

CONCLUSION

This is the first study supporting the comparable antihypertensive and metabolic response to fixed-dose combinations of sulphydril-containing angiotensin-converting enzyme inhibitors (zofenopril) or angiotensin receptor blockers (Irbesartan) with a diuretic in patients with advanced metabolic syndrome and nonresponders to monotherapy. The results of this study can further improve the clinical management of high cardiovascular risk patients with hypertension and metabolic syndrome, because these two drug combinations increase the number of available combinations, which may significantly improve patients' adherence in this special clinical condition that is frequently found in everyday practice.

Zofenopril or irbesartan plus hydrochlorothiazide in elderly patients with isolated systolic hypertension untreated or uncontrolled by previous treatment: a double-blind, randomized study

OBJECTIVE

To compare zofenopril + hydrochlorothiazide (Z + H) vs. irbesartan + hydrochlorothiazide (I + H) efficacy on daytime SBP in elderly (>65 years) patients with isolated systolic hypertension (ISH), untreated or uncontrolled by a previous monotherapy.

METHODS

After a 1-week run-in, 230 ISH patients (office SBP ≥ 140  mmHg and DBP < 90  mmHg + daytime SBP ≥ 135  mmHg and daytime DBP < 85  mmHg) were randomized double-blind to 18-week treatment with Z + H (30 + 12.5  mg) or I + H (150 + 12.5  mg) once daily, in an international, multicenter study. Z and I doses could be doubled after 6 and 12 weeks, and nitrendipine 20  mg added at 12 weeks in nonnormalized patients.

RESULTS

In the full analysis set (n = 216) baseline-adjusted average (95% confidence interval) daytime SBP reductions after 6 weeks (primary study end point) were similar (P = 0.888) with Z + H [7.7 (10.7, 4.6)  mmHg, n = 107] and I + H [7.9 (10.7, 5.0)  mmHg, n = 109]. Daytime SBP reductions were sustained during the study, and larger (P = 0.028) with low-dose Z + H at study end [16.2 (20.0, 12.5)  mmHg vs. 11.2 (14.4, 7.9)  mmHg I + H]. Daytime SBP normalization (<135 mmHg) rate was similar under Z + H and I + H at 6 and 12 weeks, but more common under Z + H at 18 weeks (68.2 vs. 56.0%, P = 0.031). Both drugs equally reduced SBP in the last 6 h of the dosing interval and homogeneously reduced SBP throughout the 24 h. The proportion of patients reporting drug-related adverse events was low (Z + H: 4.4% vs. I + H: 6.0%; P = 0.574).

CONCLUSION

Elderly patients with ISH respond well to both low and high-dose Z or I combined with H.

Vascular Health Assessment of The Hypertensive Patients (VASOTENS) Registry: Study Protocol of an International, Web-Based Telemonitoring Registry for Ambulatory Blood Pressure and Arterial Stiffness

Background

Hypertension guidelines recommend ambulatory blood pressure (ABP), central aortic pressure (CAP), and pulse wave velocity (PWV) as parameters for estimating blood pressure (BP) control and vascular impairment. Recent advances in technology have enabled devices to combine non-invasive estimation of these parameters over the 24-hour ABP monitoring. However, currently there is limited evidence on the usefulness of such an approach for routine hypertension management.

Objective

We recently launched an investigator-initiated, international, multicenter, observational, prospective study, the Vascular health Assessment Of The Hypertensive patients (VASOTENS) Registry, aimed at (1) evaluating non-invasive 24-hour ABP and arterial stiffness estimates (through 24-hour pulse wave analysis, PWA) in hypertensive subjects undergoing ambulatory blood pressure monitoring (ABPM) for clinical reasons; (2) assessing the changes in estimates following treatment; (3) weighing the impact of 24-hour PWA on target organ damage and cardiovascular prognosis; (4) assessing the relationship between arterial stiffness, BP absolute mean level and variability, and prognosis; and (5) validating the use of a 24-hour PWA electronic health (e-health) solution for hypertension screening.

Methods

Approximately 2000 subjects, referred to 20 hypertension clinics for routine diagnostic evaluation and follow-up of hypertension of any severity or stage, will be recruited. Data collection will include ABPM, performed with a device allowing simultaneous non-invasive assessment of 24-hour CAP and arterial stiffness (BPLab), and clinical data (including cardiovascular outcomes). As recommended by current guidelines, each patient will be followed-up with visits occurring at regular intervals (ideally every 6 months, and not less than once a year depending on disease severity). A Web-based telemedicine platform (THOLOMEUS) will be used for data collection. The use of the telemedicine system will allow standardized and centralized data collection, data validation by experts and counseling to remote centers, setup and maintenance of the Registry, and prompt data analysis.

Results

First follow-up results are expected to be available in the next 2 years.

Conclusions

The results of the VASOTENS Registry will help define the normalcy thresholds for current and future indices derived from 24-hour PWA, according to outcome data, and will also provide supporting evidence for the inclusion of this type of evaluation in hypertension management.

Trial registration

Clinicaltrials.gov NCT02577835; https://clinicaltrials.gov/ct2/show/NCT02577835 (Archived by WebCite at http://www.Webcitation.org/6hzZBKY2Q)

Trends in Prevalence, Awareness, Treatment, and Control of Blood Pressure Recorded From 2004 to 2014 During World Hypertension Day in Italy

Estimates of blood pressure (BP) control in real life are not systematically collected in Italy. We evaluated trends in systolic/diastolic BP levels, as well as prevalence, awareness, treatment, and control rates of hypertension among adult individuals visiting open checkpoints during the 2004 to 2014 annual editions of World Hypertension Day. Hypertension was defined as BP level ≥140/90 mm Hg or use of antihypertensive medication, whereas BP control was defined as BP level <140/90 mm Hg. We included 10,051 individuals (53.2% female, age 56.2±16.8 years, body mass index 25.7±7.6 kg/m(2) , systolic/diastolic BP 131.9±18.6/79.1±10.5 mm Hg). Hypertension prevalence and treatment were substantially unchanged, whereas awareness appears to increase over time. Controlled hypertension in diagnosed treated patients increased from 50.0% in 2004-2010 to 55.5% in 2011-2012 towards 57.6% in 2013-2014. This analysis provides real-life snapshots of hypertension over the years in the occasion of World Hypertension Day, showing increased awareness and improved control rates among treated hypertensive patients attending open checkpoints during 2004 to 2014 in Italy.

Evaluation of Criteria to Detect Masked Hypertension

The prevalence of masked hypertension (out-of-clinic daytime systolic/diastolic blood pressure (SBP/DBP) ≥135/85 mm Hg on ambulatory blood pressure monitoring [ABPM] among adults with clinic SBP/DBP <140/90 mm Hg) is high. It is unclear who should be screened for masked hypertension. The authors derived a clinic blood pressure (CBP) index to identify populations for masked hypertension screening. Index cut points corresponding to 75% to 99% sensitivity and prehypertension were evaluated as ABPM testing criterion. In a derivation cohort (n=695), the index was clinic SBP+1.3*clinic DBP. In an external validation cohort (n=675), the sensitivity for masked hypertension using an index ≥190 mm Hg and ≥217 mm Hg and prehypertension status was 98.5%, 71.5%, and 82.5%, respectively. Using National Health and Nutrition Examination Survey data (n=11,778), the authors estimated that these thresholds would refer 118.6, 44.4, and 59.3 million US adults, respectively, to ABPM screening for masked hypertension. In conclusion, the CBP index provides a useful approach to identify candidates for masked hypertension screening using ABPM.

Understanding and treating hypertension in diabetic populations

Hypertension and diabetes frequently occurs in the same individuals in clinical practice. Moreover, the presence of hypertension does increase the risk of new-onset diabetes, as well as diabetes does promote development of hypertension. Whatever the case, the concomitant presence of these conditions confers a high risk of major cardiovascular complications and promotes the use integrated pharmacological interventions, aimed at achieving the recommended therapeutic targets. While the benefits of lowering abnormal fasting glucose levels in patients with hypertension and diabetes have been consistently demonstrated, the blood pressure (BP) targets to be achieved to get a benefit in patients with diabetes have been recently reconsidered. In the past, randomized clinical trials have, indeed, demonstrated that lowering BP levels to less than 140/90 mmHg was associated to a substantial reduction of the risk of developing macrovascular and microvascular complications in hypertensive patients with diabetes. In addition, epidemiological and clinical reports suggested that "the lower, the better" for BP in diabetes, so that levels of BP even lower than 130/80 mmHg have been recommended. Recent randomized clinical trials, however, designed to evaluate the potential benefits obtained with an intensive antihypertensive therapy, aimed at achieving a target systolic BP level below 120 mmHg as compared to those obtained with less stringent therapy, have challenged the previous recommendations from international guidelines. In fact, detailed analyses of these trials showed a paradoxically increased risk of coronary events, mostly myocardial infarction, in those patients who achieved the lowest BP levels, particularly in the high-risk subsets of hypertensive populations with diabetes. In the light of these considerations, the present article will briefly review the common pathophysiological mechanisms, the potential sites of therapeutic interactions and the currently recommended BP targets to be achieved under pharmacological treatment in hypertension and diabetes.

Blood Pressure Response to Zofenopril or Irbesartan Each Combined with Hydrochlorothiazide in High-Risk Hypertensives Uncontrolled by Monotherapy: A Randomized, Double-Blind, Controlled, Parallel Group, Noninferiority Trial

In this randomized, double-blind, controlled, parallel group study (ZENITH), 434 essential hypertensives with additional cardiovascular risk factors, uncontrolled by a previous monotherapy, were treated for 18 weeks with zofenopril 30 or 60 mg plus hydrochlorothiazide (HCTZ) 12.5 mg or irbesartan 150 or 300 mg plus HCTZ. Rate of office blood pressure (BP) response (zofenopril: 68% versus irbesartan: 70%; p = 0.778) and 24-hour BP response (zofenopril: 85% versus irbesartan: 84%; p = 0.781) was similar between the two treatment groups. Cardiac and renal damage was equally reduced by both treatments, whereas the rate of carotid plaque regression was significantly larger with zofenopril. In conclusion, uncontrolled monotherapy treated hypertensives effectively respond to a combination of zofenopril or irbesartan plus a thiazide diuretic, in terms of either BP response or target organ damage progression.

Evaluation of 24-Hour Arterial Stiffness Indices and Central Hemodynamics in Healthy Normotensive Subjects versus Treated or Untreated Hypertensive Patients: A Feasibility Study

Objective. Central blood pressure (BP) and vascular indices estimated noninvasively over the 24 hours were compared between normotensive volunteers and hypertensive patients by a pulse wave analysis of ambulatory blood pressure recordings. Methods. Digitalized waveforms obtained during each brachial oscillometric BP measurement were stored in the device memory and analyzed by the validated Vasotens technology. Averages for the 24 hours and for the awake and asleep subperiods were computed. Results. 142 normotensives and 661 hypertensives were evaluated. 24-hour central BP, pulse wave velocity (PWV), and augmentation index (AI) were significantly higher in the hypertensive group than in the normotensive group (119.3 versus 105.6 mmHg for systolic BP, 75.6 versus 72.3 mmHg for diastolic BP, 10.3 versus 10.0 m/sec for aortic PWV, −9.7 versus −40.7% for peripheral AI, and 24.7 versus 11.0% for aortic AI), whereas reflected wave transit time (RWTT) was significantly lower in hypertensive patients (126.6 versus 139.0 ms). After adjusting for confounding factors a statistically significant between-group difference was still observed for central BP, RWTT, and peripheral AI. All estimates displayed a typical circadian rhythm. Conclusions. Noninvasive assessment of 24-hour arterial stiffness and central hemodynamics in daily life dynamic conditions may help in assessing the arterial function impairment in hypertensive patients.

European Society of Hypertension position paper on ambulatory blood pressure monitoring

Ambulatory blood pressure monitoring (ABPM) is being used increasingly in both clinical practice and hypertension research. Although there are many guidelines that emphasize the indications for ABPM, there is no comprehensive guideline dealing with all aspects of the technique. It was agreed at a consensus meeting on ABPM in Milan in 2011 that the 34 attendees should prepare a comprehensive position paper on the scientific evidence for ABPM.This position paper considers the historical background, the advantages and limitations of ABPM, the threshold levels for practice, and the cost-effectiveness of the technique. It examines the need for selecting an appropriate device, the accuracy of devices, the additional information and indices that ABPM devices may provide, and the software requirements.At a practical level, the paper details the requirements for using ABPM in clinical practice, editing considerations, the number of measurements required, and the circumstances, such as obesity and arrhythmias, when particular care needs to be taken when using ABPM.The clinical indications for ABPM, among which white-coat phenomena, masked hypertension, and nocturnal hypertension appear to be prominent, are outlined in detail along with special considerations that apply in certain clinical circumstances, such as childhood, the elderly and pregnancy, and in cardiovascular illness, examples being stroke and chronic renal disease, and the place of home measurement of blood pressure in relation to ABPM is appraised.The role of ABPM in research circumstances, such as pharmacological trials and in the prediction of outcome in epidemiological studies is examined and finally the implementation of ABPM in practice is considered in relation to the issue of reimbursement in different countries, the provision of the technique by primary care practices, hospital clinics and pharmacies, and the growing role of registries of ABPM in many countries.

Zofenopril plus hydrochlorothiazide and irbesartan plus hydrochlorothiazide in previously treated and uncontrolled diabetic and non-diabetic essential hypertensive patients

Introduction

In most treated patients with hypertension, a two or more drug combination is required to achieve adequate blood pressure (BP) control. In our study we assessed whether the combination of zofenopril + hydrochlorothiazide (HCTZ) was at least as effective as irbesartan + HCTZ in essential hypertensives with at least one additional cardiovascular risk factor, uncontrolled by a previous monotherapy.

Methods

After a 2-week placebo washout, 361 treated hypertensive patients [office sitting diastolic BP (DBP), ≥90 mmHg], aged 18–75 years, were randomized double blind to 18-week treatment with zofenopril 30 mg plus HCTZ 12.5 mg or irbesartan 150 mg plus HCTZ 12.5 mg once daily, in an international, multicenter study. After the first 6 and 12 weeks, zofenopril and irbesartan doses could be doubled in non-normalized subjects. The primary study end point was the office sitting DBP reduction after 18 weeks of treatment. Secondary end points included office systolic BP (SBP), ambulatory BP and high sensitivity C-reactive protein (hs-CRP).

Results

The between-treatment difference for office DBP averaged to +1.0 (95% CI −0.4, +0.8) mmHg (P = 0.150), the upper limit of the 95% confidence interval being inferior to the protocol-defined non-inferiority limit (3 mmHg). In the subset of patients with valid ambulatory BP, no difference in 24-h average DBP [n = 181; 6.7 (8.7, 4.6) zofenopril + HCTZ vs. 6.3 (8.8, 3.7) mmHg irbesartan + HCTZ, P = 0.810] and SBP reductions [11.7 (15.4, 8.0) vs. 12.6 (17.2, 8.0) mmHg, P = 0.758] were observed between the two treatment groups. hs-CRP was reduced by zofenopril + HCTZ [−0.52 (−1.05, 0.01) mg/L], while it was increased by irbesartan plus HCTZ [0.97 (0.29, 1.65) mg/L, P = 0.001 between treatments].

Conclusion

In previously monotherapy-treated, uncontrolled patients with hypertension, zofenopril 30–60 mg + HCTZ 12.5 mg is as effective as irbesartan 150–300 mg plus HCTZ 12.5 mg, with the added value of a potential protective effect against vascular inflammation.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-013-0090-8) contains supplementary material, which is available to authorized users.

Efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: a randomized controlled trial

BACKGROUND

Many strategies have been evaluated to improve the prevention and control of cardiovascular (CVD) risk factors. Nursing telephonic and tele-counseling individualized lifestyle educational programs have been found to improve blood pressure control and adherence to lifestyle recommendation. This study tested the efficacy of a nurse-led reminder program through email (NRP-e) to improve CVD risk factors among hypertensive adults.

METHODS

All participants received usual CVD prevention and a guideline-based educational program. Subjects in the NRP-e group also received weekly email alerts and phone calls from a nurse care manager for 6 months. Emails contained a reminder program on the need for adherence with a healthy lifestyle based upon current guidelines. Follow-up visits were scheduled at 1, 3 and 6 months after enrollment; randomization was made centrally and blood samples were evaluated into a single laboratory.

RESULTS

The final sample consisted of 98 (control) and 100 (NRP-e) subjects (mean age 59.0 ± 14.5 years; 51.0% males). After 6 months, the following CVD risk factors significantly improved in both groups: body mass index, alcohol and fruit consumption, cigarette smoking, adherence to therapy hours, systolic and diastolic blood pressure, fasting blood glucose, low-density lipoproteins (LDL) and total cholesterol, triglycerides, and physical activity. In the NRP-e group, however, the prevalence of several behaviors or conditions at risk decreased significantly more than in the control group: obesity (-16%), low fruit consumption (-24%), uncontrolled hypertension (-61%), LDL (-56%), and total cholesterol (-40%).

CONCLUSIONS

The NRP-e improved a range of CVD risk factors. The program had low costs, required only an average of <20 min per day in addition to normal practice, and may deserve further evaluation for the inclusion among existing care management approaches.

Ambulatory blood pressure monitoring in elderly patients with chronic atrial fibrillation: is it absolutely contraindicated or a useful tool in clinical practice and research?

The aim of this study was to test whether ambulatory blood pressure monitoring (ABPM) in elderly patients with atrial fibrillation (AF) is as feasible and reliable as ABPM is in patients with normal sinus rhythm (SR). Studies of ABPM in the elderly remain limited, and the use of this method in patients with AF remains controversial. The Italian SIIA 2008 guidelines consider ABPM 'absolutely contraindicated' for AF patients. This study was conducted on 200 hospitalized patients aged ≥ 65 years (68% females; mean age 82.4 ± 6.3 years): 100 patients with SR and 100 patients with permanent AF. Each patient completed serial blood pressure (BP) measurements with a clinical sphygmomanometer (Sphyg) and ABPM. Differences in mean heart rate (HR) between patient groups were not statistically significant. A total of 99.5% of patients were hypertensive. There were no significant differences between SR and AF patients in mean systolic BP (SBP) and diastolic BP (DBP) values, as measured with the Sphyg or by ABPM. Compared with the Sphyg, errors associated with BP measurements obtained by ABPM did not significantly differ between the two groups. ABPM proved to be as feasible as Sphyg measurements in both AF patients (intraclass correlation coefficients=0.73, 0.67 and 0.74 for SBP, DBP and HR, respectively) and SR patients (intraclass correlation coefficients=0.74, 0.58 and 0.67 for SBP, DBP and HR, respectively). A Bland-Altman plot analysis confirmed that there was good agreement between the two methods. Stable AF (HR 60-100 b.p.m.) should not be considered as an absolute contraindication for the use of ABPM, even in the elderly; it could be a 'relative' contraindication for very unstable AF patients.

Awareness, treatment, and control of major cardiovascular risk factors in a small-scale Italian community: results of a screening campaign

INTRODUCTION

Hypertension, hypercholesterolemia, and diabetes are the main causes of cardiovascular diseases in developed countries. However, these conditions are still poorly recognized and treated.

OBJECTIVE

This study aimed at estimating the prevalence, awareness, treatment, and control rates of major cardiovascular risk factors in an unselected sample of individuals of a small community located in northern Italy.

METHODS

We screened 344 sequential subjects in this study. Data collection included family and clinical history, anthropometric data, blood pressure, blood glucose, and serum cholesterol values. Individual cardiovascular risk profiles were assessed by risk charts of the Progetto Cuore.

RESULTS

Based on personal history and/or measured values, 78.2% of subjects had hypercholesterolemia (total cholesterol levels > 190 mg/dL), 61.0% had central obesity (waist circumference ≥ 94 cm for men and ≥80 cm for women), 51.2% had arterial hypertension (blood pressure ≥ 140/90 mmHg), 8.1% had diabetes (blood glucose ≥ 126 mg/dL), 22.7% had impaired fasting glucose (blood glucose 100-125 mg/dL), and 35.5% were overweight (body mass index 25-29 kg/m(2)). Alcohol drinkers and smokers accounted for 46.2% and 22.4% of subjects, respectively. Awareness of hypertension, hypercholesterolemia, and diabetes was poor, and control of these risk factors, except for diabetes, was even worse. Prevalence of high blood pressure, high serum cholesterol, overweight, and obesity significantly increased with aging. Hypercholesterolemia and obesity were significantly more common in women, while overweight and diabetes in men. In 15.4% of participants, the risk of a major cardiovascular event in the next 10 years was either high or very high.

CONCLUSION

In a small community in a wealthy region of Italy, the prevalence of major cardiovascular risk factors is high, while awareness, treatment, and control are poor. Such a result highlights the importance of screening campaigns as a strategy to improve early diagnosis and access to treatment, and thus effective prevention of cardiovascular diseases in the general population.

Nutraceuticals for blood pressure control in patients with high-normal or grade 1 hypertension

BACKGROUND

Current hypertension management guidelines do not recommend drug treatment in subjects with blood pressure (BP) in the high-normal range due to the risk of side effects of the currently available antihypertensive agents that overcomes the possible benefit. Nutraceuticals are free from relevant side effects and could be a valuable strategy for the treatment of these patients.

AIM

The objective of this study was to compare the efficacy of two nutraceutical compositions given by the combination of policosanol, red yeast rice extract, berberine, folic acid and coenzyme Q(10) with or without Orthosiphon stamineus in lowering the BP and lipid profile.

METHODS

Thirty patients with grade 1 essential hypertension and low cardiovascular risk were analysed. At the end of a run-in period, patients were divided into two study arms and assigned to receive the nutraceutical combination with and without Orthosiphon stamineus. All participants underwent 24-hour ambulatory BP monitoring at the end of the run-in period and of the 4-week treatment with each of the two different nutraceutical combinations.

RESULTS

In patients treated with Orthosiphon stamineus a significant reduction of mean 24-hour systolic and diastolic BP levels compared with baseline values was registered and the smoothness index calculated for systolic and diastolic BP showed a more reliable and homogeneous effect on BP over 24 hours. In contrast, nutraceutical treatment without Orthosiphon stamineus was not associated with a significant reduction of BP.

CONCLUSIONS

Our results show that the addition of Orthosiphon stamineus to the combination of nutraceuticals confers an antihypertensive effect that allows a surprisingly effective 24-hour BP control in hypertensive patients.

Nutraceuticals for blood pressure control in patients with high-normal or grade 1 hypertension

BACKGROUND

Current hypertension management guidelines do not recommend drug treatment in subjects with blood pressure (BP) in the high-normal range due to the risk of side effects of the currently available antihypertensive agents that overcomes the possible benefit. Nutraceuticals are free from relevant side effects and could be a valuable strategy for the treatment of these patients.

AIM

The objective of this study was to compare the efficacy of two nutraceutical compositions given by the combination of policosanol, red yeast rice extract, berberine, folic acid and coenzyme Q(10) with or without Orthosiphon stamineus in lowering the BP and lipid profile.

METHODS

Thirty patients with grade 1 essential hypertension and low cardiovascular risk were analysed. At the end of a run-in period, patients were divided into two study arms and assigned to receive the nutraceutical combination with and without Orthosiphon stamineus. All participants underwent 24-hour ambulatory BP monitoring at the end of the run-in period and of the 4-week treatment with each of the two different nutraceutical combinations.

RESULTS

In patients treated with Orthosiphon stamineus a significant reduction of mean 24-hour systolic and diastolic BP levels compared with baseline values was registered and the smoothness index calculated for systolic and diastolic BP showed a more reliable and homogeneous effect on BP over 24 hours. In contrast, nutraceutical treatment without Orthosiphon stamineus was not associated with a significant reduction of BP.

CONCLUSIONS

Our results show that the addition of Orthosiphon stamineus to the combination of nutraceuticals confers an antihypertensive effect that allows a surprisingly effective 24-hour BP control in hypertensive patients.

Blood pressure control and treatment adherence in hypertensive patients with metabolic syndrome: protocol of a randomized controlled study based on home blood pressure telemonitoring vs. conventional management and assessment of psychological determinants of adherence (TELEBPMET Study)

BACKGROUND

Inadequate blood pressure control and poor adherence to treatment remain among the major limitations in the management of hypertensive patients, particularly of those at high risk of cardiovascular events. Preliminary evidence suggests that home blood pressure telemonitoring (HBPT) might help increasing the chance of achieving blood pressure targets and improve patient's therapeutic adherence. However, all these potential advantages of HBPT have not yet been fully investigated.

METHODS/DESIGN

The purpose of this open label, parallel group, randomized, controlled study is to assess whether, in patients with high cardiovascular risk (treated or untreated essential arterial hypertension--both in the office and in ambulatory conditions over 24 h--and metabolic syndrome), long-term (48 weeks) blood pressure control is more effective when based on HBPT and on the feedback to patients by their doctor between visits, or when based exclusively on blood pressure determination during quarterly office visits (conventional management (CM)). A total of 252 patients will be enrolled and randomized to usual care (n = 84) or HBPT (n = 168). The primary study endpoint will be the rate of subjects achieving normal daytime ambulatory blood pressure targets (< 135/85 mmHg) 24 weeks and 48 weeks after randomization. In addition, the study will assess the psychological determinants of adherence and persistence to drug therapy, through specific psychological tests administered during the course of the study. Other secondary study endpoints will be related to the impact of HBPT on additional clinical and economic outcomes (number of additional medical visits, direct costs of patient management, number of antihypertensive drugs prescribed, level of cardiovascular risk, degree of target organ damage and rate of cardiovascular events, regression of the metabolic syndrome).

DISCUSSION

The TELEBPMET Study will show whether HBPT is effective in improving blood pressure control and related medical and economic outcomes in hypertensive patients with metabolic syndrome. It will also provide a comprehensive understanding of the psychological determinants of medication adherence and blood pressure control of these patients.

TRIAL REGISTRATION

Clinical Trials.gov: NCT01541566.

An observational, prospective, open-label, multicentre evaluation of aliskiren in treated, uncontrolled patients: a real-life, long-term, follow-up, clinical practice in Italy

INTRODUCTION

The addition of the direct renin inhibitor aliskiren is demonstrated to improve blood pressure (BP) control rate and reduce progression of organ damage in treated hypertensive patients in clinical trials with a relatively short follow-up period.

AIM

The objective of this study was to assess the effectiveness, safety and tolerability of aliskiren as an add-on antihypertensive therapy in high-risk, treated, hypertensive patients, who were not controlled with concomitant treatment with at least two antihypertensive drugs under 'real-life' conditions, during a planned observation and treatment period of at least 12 months in Italy.

METHODS

Clinical data were derived from medical databases of treated, uncontrolled, hypertensive patients followed by specialized physicians operating in different clinical settings (hospital divisions or outpatient clinics) in Italy. Aliskiren was added to stable antihypertensive treatment, including at least two drug classes (independently of class or dosage) and unable to achieve BP control. Follow-up visits for measuring clinic BP levels and collecting data on drug safety and tolerability were planned at time intervals of 1, 6 and 12 months. At each predefined follow-up visit, aliskiren could be up-titrated from 150 to 300 mg daily if BP control was not achieved.

RESULTS

From May 2009 to June 2011, a total of 1186 treated, uncontrolled, hypertensive patients (46.3% female, aged 65.2 ± 11.7 years, mean duration of hypertension 13.2 ± 9.3 years, mean clinic BP levels 156.5 ± 15.9/90.3 ± 9.5 mmHg) were enrolled. Systolic and diastolic BP levels were 141.1/82.4, 134.9/79.8 and 133.6/78.9 mmHg at 1-, 6- and 12-month follow-up visits, respectively (p < 0.0001 vs baseline for all comparisons). These effects were consistent in all predefined subgroups, including those with left ventricular hypertrophy, renal disease, diabetes mellitus, coronary artery disease or cerebrovascular disease. Reduced levels of microalbuminuria were also reported, without affecting other renal and electrolyte parameters. Overall, compliance to study medication was high (93.0%), with a very low proportion of patients experiencing adverse events leading to drug discontinuation (3.6%).

CONCLUSIONS

In this observational, prospective, open-label, multicentre study, we reported the 12-month clinical effectiveness, safety and tolerability of adding aliskiren to treated, uncontrolled, hypertensive patients in a 'real-life' setting in Italy. This strategy leads to a significantly improved BP control rate and low incidence of drug-related side effects or discontinuations.