Automated compared to manual office blood pressure and to home blood pressure in hypertensive patients

Prevalence of masked hypertension in attended versus unattended office blood pressure measurement

There is a controversial debate regarding whether unattended blood pressure (BP) measurement should be regarded as the new gold standard of office BP measurement. Unattended BP measurement eliminates the white-coat effect and reduces external influences on the patient. On the other hand, it might underestimate real-life BP. The present study compares the prevalence of masked hypertension using attended versus unattended office BP measurements. We performed a cross-sectional study on 213 patients in a general practitioner's outpatient clinic and compared attended and unattended office BP with 24h-ambulatory BP monitoring (24h-ABPM). Masked hypertension was defined as pressure ≥135/85 mmHg in daytime ABPM with office systolic BP < 140/90 mmHg. Median attended and unattended office BPs were 140/86 and 134/80 mmHg with a median 24h-BP of 129/79 mmHg and daytime ABP of 133/82 mmHg. The number of patients with masked hypertension was 45/213 (21.2%) using unattended and 23/213 (10.8%) using attended office BP measurements (p < .0001). Bland-Altman analysis revealed a 7.4 mmHg systolic and 6.2 mmHg diastolic bias between the attended versus unattended office BP, and two systolic and -1.7 mmHg diastolic biases between the unattended office BP and daytime ambulatory BP. In linear regression analysis, an unattended office BP of 134 mmHg corresponded to 140 mmHg in attended BP measurement. Using a cut-off of 135/85 mmHg instead of 140/90 mmHg in unattended office BP measurement, the rate of masked hypertension was 26/213 (12.2%). Thus, unattended office BP measurement results in a substantial increase in the prevalence of masked hypertension using the traditional definition of hypertension. The present findings suggest that it might be reasonable to use a definition of 135/85 mmHg.

[Effet blouse blanche résiduel : un outil pertinent en soins premiers?]

BACKGROUND

White coat effect (WCE) and white coat hypertension (WCH) are hardly both compared in primary care.

OBJECTIVE

To assess the usefulness of repeated measures of systolic blood pressure (SBP) to dissociate various forms of white-coat interactions.

METHODS

An open cross-sectional study on consecutive patients treated or not for high blood pressure was made in family physicians' offices. SBP was measured 5 times by an electronic device. Measurements were performed before (SBP1) and after (SBP5) the office visit by a lay assistant and at the beginning (SBP2), middle (SBP3) and end (SBP4) of visit, by the family physician. Home BP (HBPM) was measured from 3 consecutive days by the patient. WCE and office WCE tail (OWCET) were defined, respectively, as a 10 mmHg SBP increase or decrease between SBP2-SBP1 or SBP4-SBP2. WCH was considered when HBPM was normal (SBP < 135 mmHg) at home and high during the SBP2 office visit.

RESULTS

Two hundred five patients (134 women versus 71 men, ratio 1.9, aged 59.8±15.7 years) were recruited. In categorical terms, there were 51 patients (25%) who presented with WCE, OWCET was seen in 121 patients (62%) and 47 patients (23%) had WCH. Only 36 patients (18%) presented both OWCET and WCE and 32 (16%) had both OWCET and WCH. The receiver operating characteristic curves (ROCs) of OWCET in diagnosing WCE or WCH were respectively 0.67 (p<0.0001) and 0.53 (NS).

CONCLUSION

Thus, OWCET was predictive of WCE and not of WCH and it is worthwhile to be measured in the family physician office.

A comparative trial of blood pressure monitoring in a self-care kiosk, in office, and with ambulatory blood pressure monitoring

BACKGROUND

Automated measurement of blood pressure (BP) in designated BP kiosks have in recent years been introduced in primary care. If kiosk blood pressure (BP) monitoring provides results equivalent to in-office BP or daytime ambulatory BP monitoring (ABPM), follow-up of adult patients could be managed primarily by self-checks. We therefore designed a comparative trial and evaluated the diagnostic performance of kiosk- and office-based BP (nurse- versus physician-measured) compared with daytime ABPM.

METHODS

A trial of automated BP monitoring in three settings: a designated BP kiosk, by nurses and physicians in clinic, and by ABPM. The primary outcome was systolic and diastolic BP, with respective diagnostic thresholds of ≥135 mmHg and/or ≥ 85 mmHg for daytime ABPM and kiosk BP and ≥ 140 mmHg and/or ≥ 90 mmHg for office BP (nurse- and physician-measured).

RESULTS

Compared with daytime ABPM, mean systolic kiosk BP was higher by 6.2 mmHg (95% confidence interval [CI] 3.8-8.6) and diastolic by 7.9 mmHg (95% CI 6.2-9.6; p < 0.001). Mean systolic BP taken by nurses was similar to daytime ABPM values (+ 2.0 mmHg; 95% CI - 0.2-4.2; p = 0.071), but nurse-measured diastolic values were higher, by 7.2 mmHg (95% CI 5.9-9.6; p < 0.001). Mean systolic and diastolic physician-measured BPs were higher compared with daytime ABPM (systolic, by 7.6 mmHg [95% CI 4.5-10.2] and diastolic by 5.8 mmHg [95% CI 4.1-7.6]; p < 0.001). Receiver operating characteristic curves of BP monitoring across pairs of systolic/diastolic cut-off levels among the three settings, with daytime ABPM as reference, demonstrated overall similar diagnostic performance between kiosk and nurse-measured values and over the curve performance for physician-measured BP. Accuracy with nurse-measured BP was 69.2% (95% CI 60.0-77.4%), compared with 65.8% (95% CI 56.5-74.3%) for kiosk BP.

CONCLUSIONS

In this study kiosk BP monitoring was not comparable to daytime ABPM but could be an alternative to in-office BP monitoring by trained nurses. The diagnostic performance of kiosk and nurse-measured BP monitoring was similar and better than that of physician-measured BP.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04488289) 27/07/2020.

Team-Based Approach in Hypertension Management: A Quality Improvement Project

BACKGROUND/LOCAL PROBLEM

Hypertension is a major risk factor for heart diseases and stroke among Americans; only 25% have this under control nationwide.

METHODS

This quality improvement project evaluated the outcomes of team-based care in hypertension control by registered nurses and certified nurse practitioners in a primary care setting. Pre/post-data analysis of blood pressure (BP) control, and BP knowledge, was done.

INTERVENTION

The team provided education and counseling based on knowledge assessment during visits and used unattended automated blood pressure measurement (uAOBPM) techniques to measure BP.

RESULTS

There was a significant reduction in systolic and diastolic BP control ( P < .001). There was a statistically significant increase in disease knowledge score pre- and postintervention ( P < .001).

CONCLUSION

The team-based care approach improved patients' BP control and knowledge of the disease. The uAOBPM technique could be incorporated into clinical settings for accurate BP measurements.

Current practice of blood pressure measurement in Germany: a nationwide questionnaire-based survey in medical practices

PURPOSE

Discrepancies exist between guideline recommendations and real-world practice of blood pressure (BP) measurements. The aim of this study was to assess, with a nationwide, questionnaire-based survey, the current practice of BP measurement and associated BP values in German medical practices.

MATERIAL AND METHODS

A nationwide survey in German medical practices was performed in the period from 10 May 2021 to 15 August 2021. The questionnaire was divided into five sections. The current office BP (OBP) values as well as the current drug therapy were recorded. In addition, the implementation of office BP (OBP) and home BP monitoring (HBPM) was queried. For analysis, questionnaires were scanned and automatically digitised.

RESULTS

A total of 7049 questionnaires were analysed, the majority of which came from general practitioners (66%) and internal medicine practices (34%). The average OBP (SD) was 140.0 (18)/82.7 (11) mmHg. 40.8% of treated patients had OBP in the controlled range, with monotherapy (34.7%) or dual combination therapy (38.2%) prescribed in most cases. OBP was taken from a single measurement in 66.3% of cases, and in 21.8% from 23 measurements. OBP was mostly measured after a rest period (87.1%) and in a separate room (80.4%). HBPM was performed in 62.3% of patients; however, in 24.9% of the participants HBP measurements were recorded once a week or less.

CONCLUSION

In this nationwide survey in German medical practices, BP control remains at below 50%, while monotherapy is prescribed in around one third of patients. Moreover, office measurements and HBPM are often not performed according to current guideline recommendations.

The debate over the optimal blood pressure treatment target of less than 130/80 mmHg

OBJECTIVES

The objective of this study was to analyze the controversy regarding the optimal blood pressure (BP) target of <130/80 mmHg as proposed by the 2017 American College of Cardiology/American Heart Association (ACC/AHA) across all age groups. Hypertension is a major risk factor for cardiovascular disease (CVD), stroke, and chronic kidney disease (CKD), and its optimal control is associated with lessening or preventing these complications. A recent study has argued that this BP level is universally accepted as an optimal and safe BP level. However, this argument is not accepted by other investigators, arguing that higher BP levels are as effective and safe.

METHODS

In order to investigate the current status of this level of BP control, a Medline search of the English literature was conducted between 2017 and February 2022, and 25 pertinent papers were selected.

RESULTS

The analysis of data from these studies indicates that these BP are effective in lowering the BP and preventing cardiovascular disease, heart failure, and chronic kidney disease, and they are indeed universally accepted.

CONCLUSION

Based on the current evidence, the current proposed by the 2017 ACC/AHA treatment guidelines are effective in lowering the BP and decreasing its cardiovascular complications and should followed, till perhaps, new data come out to the contrary.

Blood pressure response to close or loose contact between physician and patient during attended office blood pressure measurement

PURPOSE

Compared to unattended office blood pressure (uOBP), attended office blood pressure (aOBP) is higher. It is not known, however, to what extent distance between physician and patient influences blood pressure (BP) values.

MATERIALS AND METHODS

Participants were stable hypertensive patients, followed in the university hospital-based out-patient center. During a session, automated office BP was measured three times after a pre-set five-minute pause, using the Omron 907 device; both aOBP and uOBP were done, in a random order. Simultaneously, beat-to-beat BP measurement was performed using the Finapress device. During aOBP, some participants were in close contact with the physician while others were in loose contact where the doctor was sitting in the room about 2.5 m apart. One year later, the second session with the same protocol was organized, but the close and loose contact were interchanged. The data were analyzed using a paired t-test.

RESULTS

Complete data were collected in 32 patients, baseline uOBP was 122.8 ± 14.8/69.5 ± 11.7 mmHg. Systolic and diastolic aOBP with close contact was higher by 4.6 ± 6.9 and 1.9 ± 3.4 mmHg (p < 0.0007 and 0.0039, respectively), while aOBP with loose contact was not different from uOBP. Beat-to-beat BP increased during aOBP by 6.5 ± 8.5/3.3 ± 4.8 mmHg. The increase persisted during all the three aOBP measurements (p < 0.0001 for all systolic and diastolic BP values); the results were similar for close and loose contact. The peak increase during uOBP was of similar magnitude as during aOBP but it lasted shorter: it reached the significance level of p < 0.0001 only during the first uOBP measurement.

CONCLUSIONS

Compared to uOBP, aOBP values were higher with close, but not with loose contact between physician and patient. These differences were, however, not detected by beat-to-beat BP measurement.

Unattended versus Attended Blood Pressure Measurement: Relationship with Retinal Microcirculation

Though the relationship between both “attended” and “unattended” BP and several forms of target organ damage have been evaluated, data on retinal arteriolar alterations are lacking. The aim of our study was to evaluate the relationship between “attended” or “unattended” BP values and retinal arteriolar changes in consecutive individuals undergoing a clinical evaluation and assessment of retinal fundus at an ESH Excellence Centre. An oscillometric device programmed to perform 3 BP measurements, at 1 min intervals and after 5 min of rest was used on all individuals to measure BP with the patient alone in the room (“unattended”) or in the presence of the physician (“attended”) in the same day in a random order. The retinal arteriole’s wall thickness (WT) was measured automatically by a localization algorithm as the difference between external (ED) and internal diameter (ID) by adaptive optics (RTX-1, Imagine Eyes, Orsay, Francia). Media-to-lumen ratio (WLR) of the retinal arterioles and cross-sectional area (WCSA) of the vascular wall were calculated. Results: One-hundred-forty-two patients were examined (mean age 57 ± 12 yrs, 48% female, mean BMI 26 ± 4). Among them, 60% had hypertension (84% treated) and 11% had type 2 diabetes mellitus. Unattended systolic BP (SBP) was lower as compared to attended SBP (129 ± 14.8. vs. 122.1 ± 13.6 mmHg, p < 0.0001). WLR was similarly correlated with unattended and attended SBP (r = 0.281, p < 0.0001 and r = 0.382, p < 0.0001) and with unattended and attended diastolic BP (r = 0.34, p < 0.001 and r = 0.29, p < 0.0001). The differences between correlations were not statistically significant (Steiger’s Z test). Conclusion: The measurement of “unattended” or “attended” BP provides different values, and unattended BP is lower as compared to attended BP. In this study a similar correlation was observed between attended and unattended BP values and structural changes of retinal arterioles.

Clinical implications of central blood pressure measured by radial tonometry and automated office blood pressure measured using automatic devices in cardiovascular diseases

Objective

Central aortic systolic blood pressure (CBP) measured by carotid-femoral pulse wave analysis (cfPWA) is a gold standard method to estimate true arterial pressure. However, the impact of the CBP level measured by radial PWA on cardiovascular (CV) risk assessment is unclear. This study aimed to determine the impact on CV outcome assessment and the association between the optimal levels of non-invasively measured CBP and automated office blood pressure (OBP) in clinical practice.

Materials and methods

A total of 2,115 patients underwent non-invasive semiautomated radial artery applanation tonometry (Omron HEM-9000AI) in the Department of Internal Medicine, St. Vincent’s Hospital, from July 2011 to December 2015. The patients were followed for at least 5 years, and atherosclerotic cardiovascular (ASCVD) outcomes were collected.

Results

Among 2,115 patients (mean age 58 ± 14 years, 50.4% men) who were followed up, the median follow-up period was 52 months (range: 1–104 months). The total number of patients with ASCVD events was 163 (7.70%). In multivariate Cox regression analysis, a CBP of more than 125 mmHg and an automated OBP of more than 131 mmHg were independently associated with a significant increase in ASCVD outcomes. After adjusting for confounding factors, the hazard ratio for ASCVD events increased by 12.5, 11.7, and 12.7%, for every 10 mmHg increase in automated OBP, CBP, and central pulse pressure (PP), respectively.

Conclusion

This study demonstrated that the automated OBP measured using the method used in real clinical practice and CBP measured by radial tonometry were associated with an increased risk for adverse ASCVD outcomes.

Sources of automatic office blood pressure measurement error: a systematic review

OBJECTIVE

Accurate and reliable blood pressure (BP) measurement is important for the prevention and treatment of hypertension. The oscillometric-based automatic office blood pressure measurement (AOBPM) is widely used in hospitals and clinics, but measurement errors are common in BP measurements. There is a lack of systematic review of the sources of measurement errors.

APPROACH

A systematic review of all existing research on sources of AOBPM errors. A search strategy was designed in six online databases, and all the literature published before October 2021 was selected. Those studies that used the AOBPM device to measure BP from the upper arm of subjects were included.

MAIN RESULTS

A total of 1365 studies were screened, and 224 studies were included in this final review. They investigated 22 common error sources with clinical AOBPM. Regarding the causes of BP errors, this review divided them into the following categories: the activities before measurement, patient's factors, measurement environment, measurement procedure, and device settings. 13 sources caused increased systolic and diastolic BP (SBP and DBP), 2 sources caused the decrease in SBP and DBP, only 1 source had no significant effect on BPs, and the other errors had a non-uniform effect (either increase or decrease in BPs). The error ranges for SBP and DBP were -14 to 33 mmHg and -6 to 19 mmHg, respectively.

SIGNIFICANCE

The measurement accuracy of AOBPM is susceptible to the influence of measurement factors. Interpreting BP readings need to be treated with caution in clinical measurements. This review made comprehensive evidence for the need for standardized BP measurements and provided guidance for clinical practitioners when measuring BP with AOBPM devices.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adherence Clubs to Improve Hypertension Management in Nigeria: Clubmeds, a Feasibility Study

Background:

Hypertension control remains a significant challenge in reducing the cardiovascular disease burden worldwide. Community peer-support groups have been identified as a promising strategy to improve medication adherence and blood pressure (BP) control.

Objectives:

The study aimed to evaluate the feasibility and impact of adherence clubs to improve BP control in Southeast Nigeria.

Methods:

This was a mixed-methods research involving a formative (pre-implementation) research, pilot study and process evaluation. Hypertensive patients in two communities were recruited into peer-support adherence clubs under the leadership of role-model patients to motivate and facilitate medication adherence, BP monitoring, and monthly medication delivery for six months. The primary outcome was medication adherence measured using visual analogue scale (VAS), with BP level at six months as a key secondary outcome.

Results:

We recruited a total of 104 participants. The mean age was 56.8 (SD–10.7) years, 72 (69.2%) were women, mean BP was 146.7 (SD–20.1)/86.9 (SD–11.2) mmHg, and the mean percentage of medication adherence on the VAS was 41.4% (SD–11.9%). At six months, 67 patients were assessed; self-reported adherence on the VAS increased to 57.3% (SD–25.3%) (mean difference between baseline and follow-up of 15.5%, p < 0.0001), while the mean BP decreased to 132.3 (SD–22.0)/82.9 (SD–12.2) mmHg (mean difference of 13.0 mmHg in systolic BP, p < 0.0001 and of 3.6 mmHg in diastolic BP, p = 0.02). Five in-depth interviews and four focus groups discussions were conducted as part of the qualitative analyses of the study. The participants saw hypertension as a big issue, with many unaware of the diagnosis, and they accepted the CLUBMEDS differential service delivery (DSD) model concept in hypertension.

Conclusions:

The study demonstrates that the implementation of adherence clubs for hypertension control is feasible and led to a statistically significant and clinically meaningful improvement in self-reported medication adherence, resulting in BP reduction. Upscaling the intervention may be needed to confirm these findings.

Comparison of automated office blood pressure measurement with 24-hour ambulatory blood pressure measurement

PURPOSE

Although 24-hour ambulatory blood pressure measurement (24-h ABPM) is the most important method to establish true hypertension, in clinical practice often repeated automated office blood pressure (AOBP) measurements are used because of convenience and lower costs. We aimed to assess the agreement rate between a 30 and 60 min AOBP and 24-h ABPM.

MATERIALS AND METHODS

Patients with known hypertension (cohort 1) and patients visiting the neurology outpatient clinic after minor stroke or transient ischaemic attack (cohort 2) were selected. We performed AOBP for 30-60 min at 5-min intervals followed by 24-h ABPM and calculated average values of both measurements. Agreement between the two methods was studied with McNemar and Bland-Altman plots with a clinically relevant limit of agreement of ≤10 mm Hg difference in systolic BP.

RESULTS

Our final cohort consisted of 135 patients from cohort 1 and 72 patients from cohort 2. We found relatively low agreement based on the clinical relevant cut-off value; 64.7% of the measurements were within the limits of agreement for 24-h systolic and 50.2% for 24-h diastolic. This was 61.4% for daytime systolic and 56.6% for daytime diastolic. In 73.5% of the patients, both methods led to the same diagnosis of either being hypertensive or non-hypertensive. This resulted in a significant difference between the methods to determine the diagnosis of hypertension (p < 0.0001).

CONCLUSION

We conclude that 30-60 min AOBP measurements cannot replace a 24-h ABPM and propose to perform 24-h ABPM at least on a yearly basis to confirm AOBP measurements.

New Aspects in the Management of Hypertension in Patients with Chronic Kidney Disease not on Renal Replacement Therapy

With chronic kidney disease (CKD) being a global arising health problem, strategies for delaying kidney disease progression and reducing the high cardiovascular risk inherent to CKD, are the main objectives of the actual management of patients with kidney diseases. In these patients, the control of arterial hypertension is essential, as high blood pressure (BP) is a strong determinant of worst cardiovascular and renal outcomes. Achieving target blood pressures recommended by international guidelines is mandatory and often demands a multiple levels management, including several pharmacological and lifestyle measures. Even in the presence of adequate BP control, the residual cardiovascular risk remains high. In this respect, the recent demonstration that novel agents such as sodium glucose transporter 2 (SGLT2) inhibitors or the new non-steroidal mineralocorticoid antagonist finerenone can retard the progression of kidney diseases and reduce cardiovascular mortality on top of standard of care treatment with renin-angiotensin system inhibitors represent enormous progresses. These studies also demonstrate that cardiovascular and renal protection can be obtained beyond blood pressure control. Other promising novelties are still to come such as renal denervation and endothelin receptor antagonists in the setting of diabetic and non-diabetic kidney diseases. In the present review, we shall discuss the classic and the new aspects for the management of hypertension in CKD, integrating the new data from recent clinical studies.

Unattended automated office blood pressure measurement in children

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The diastolic blood pressure J-curve revisited: An update

Hypertension remains a leading cause of morbidity and mortality. Recent treatment guidelines stress more strict systolic blood pressure (SBP) targets without regard for abnormally low achieved diastolic blood pressures (DBP). However, as DBP falls below a critical level, adverse events increase, the so-called J-shaped curve. Proponents argue that the low DBP is causative due to reduced coronary perfusion during diastole with obstructive coronary artery disease (CAD), whereas others postulate the J-curve represents reverse causality from underlying comorbidity. Most data are observational, derived from population-based cohorts or post-hoc analyses of randomized controlled trials (RCT) conducted for other reasons. The purpose of this review is to analyze the observational studies performed over the last decade addressing the J-curve, with consideration of earlier data. Overall, a J-curve exists, but it remains uncertain whether low DBP is causative or instead reflects reverse causation from either diseased vasculature (widened pulse pressure) or severe underlying comorbidity. The most convincing data for causation come from studies restricted to patients with documented CAD, with evidence suggesting revascularization may mitigate risk. RCTs are needed to determine if a low DBP should preclude intensification of therapy, especially with documented CAD. Firm recommendations cannot be made with contemporary data.

Automated office blood pressure measurement by elderly patients in the waiting room

OBJECTIVE

Unattended automated office blood pressure (AOBP) may be a better estimate of true blood pressure (BP) than conventional office BP by physicians or nurses. However, measurement of AOBP is cumbersome in general clinical practice. We compared unattended AOBP by the patients themselves using the rigid cuff in the waiting room with attended AOBP and home BP (HBP) (N = 72).

METHODS

Unattended AOBP by patients was measured in the waiting room using a rigid cuff with the fully automated device (Omron, HEM-907, triple BP readings taken at 1-min intervals after 5 min of rest). Attended AOBP was measured using a soft cuff by a physician in an examination room without specific resting time. HBP was measured for 5 consecutive days.

RESULTS

The mean age was 76.5 ± 8.6 years. The mean systolic unattended AOBP by patients, attended AOBP and HBP were 139.3 ± 16.6, 144.8 ± 17.1 and 139.1 ± 14.4 mmHg, respectively. Unattended AOBP by patients was significantly related to attended AOBP (r = 0.798; P < 0.01) and to HBP (r = 0.404; P < 0.001). It was significantly lower than attended AOBP (difference 5.5 ± 10.7 mmHg; P < 0.001) and comparable with HBP (difference 0.26 ± 17.0 mmHg; P = 0.90) in Bland-Altman plots. However, 22% of patients had a difference of over 20 mmHg between unattended AOBP by patients and HBP. Multivariate regression demonstrated older age (B = -0.73; P = 0.002) to be related to the difference between unattended AOBP by patients and HBP.

CONCLUSION

The mean unattended AOBP by patients was lower than attended AOBP and comparable with HBP, but older age affected the difference between unattended AOBP by patients and HBP.

Survey on arterial hypertension management: a report from the ESC Council for Cardiology Practice and the ESC Council on Hypertension

Aims

To explore the management of hypertensive patients by general cardiologists a few months after the European Society of Cardiology (ESC)-European Society of Hypertension (ESH) Guidelines publication.

Methods and results

A survey based on a 26-point questionnaire was sent to ∼69 000 worldwide ESC members, a few months after the ESC-ESH Guidelines publication. A total of 1458 responses were collected via a web-based form. Among them, 68% were men, 48% were below 45 years old, and 60% were from Europe. Current guidelines have been read, at least partially, by 92.8%. Measurement of blood pressure (BP) is mostly done using the auscultatory method (58.8%) while unattended BP is rarely performed. Different bladder cuffs are not available for different arm circumferences for 27% of responders. Routine workup in hypertensive patients includes more often 12 leads ECG (97.7%) and echocardiography (79.6%). Only 30.9% of responders systematically assess the cardiovascular risk by the SCORE system and orthostatic hypotension is systematically researched by only 39.1%. Respondents consider that BP target of 140/90 mmHg is achievable in 60-80% of patients and 130/80 mmHg in 40-60%. Guidelines are considered too tight to be achievable by 15.6%, while 77.4% consider they are exactly right. Low patient's compliance, awareness of hypertension (HT) risk, and, at a lower degree, physician inertia, represent the main treatment challenges in reaching BP goals to most respondents, while treatment effectiveness is not in question. The present survey demonstrates specific gaps in HT management that need attention in clinical practice.

Relationship between arterial stiffness and unattended or attended blood pressure values

BACKGROUND AND METHOD

Measurement of 'unattended' blood pressure (BP) may reduce or eliminate the 'white-coat effect'. Despite the possible advantages of this approach for BP measurement, only few studies analysed the relationship between unattended BP and cardiovascular events or with hypertension-mediated organ damage (HMOD). The aim of our study was to evaluate the relationship between 'attended' or 'unattended' BP values and carotid-femoral pulse wave velocity (PWV) in 285 individuals undergoing a visit and assessment of arterial stiffness at an ESH Excellence Centre. Unattended BP (measured with the patient alone in the room, with an oscillometric device programmed to perform three BP measurements, at 1-min intervals, after 5 min) and attended BP were measured with the same device, on the same day of the measurement of PWV, in a random order.

RESULTS

Mean age was 63 ± 13 years, mean BMI 26 ± 4, 47% were women, 76% had hypertension (55% treated). Systolic unattended BP was lower than attended SBP (124.4 ± 14.3 vs. 130.9 ± 16.1 mmHg). PWV was similarly correlated with attended and unattended SBP values (r = 0.428 and r = 0.404, P < 0.0001, respectively). No difference for the prediction of increased arterial stiffness was observed at receiver operator curves (ROCs) analysis [attended SBP area under the curve (AUC) 0.665, 95% confidence interval (95% CI) 0.607-0.720 vs. unattended SBP: AUC 0.651, 95% CI 0.593-0.706, P for the comparison = ns].

CONCLUSION

Attended and unattended BP values are similarly correlated with PWV, the gold standard measure of arterial stiffness. These findings may provide further information on the clinical value of unattended BP.

Reducing overuse by recognising the unintended harms of good intentions

Overdiagnosis and overtreatment-overuse-is gaining wide acceptance as a leading nosocomial intervention in medicine. Not only does overuse create anxiety and diminish patients' quality of life, in some cases it causes harm to both patients and others not directly involved in clinical care. Reducing overuse begins with the recognition and acceptance of the potential for unintended harm of our best intentions. In this paper, we introduce five cases to illustrate where harm can occur as the result of well-intended healthcare interventions. With this insight, clinicians can learn to appreciate the critical role of probability-based, evidence-informed decision-making in medicine and the need to consider the outcomes for all who may be affected by their actions. Likewise, educators need to evolve medical education and medical decision-making so that it focuses on the hierarchy of evidence and that what 'ought to work', based on traditional pathophysiological, disease-focused reasoning, should be subordinate to what 'does work'.

Office Blood Pressure Range and Cardiovascular Events in Patients With Hypertension: A Nationwide Cohort Study in South Korea

Background

It is unclear what office blood pressure (BP) is the optimal treatment target range in patients with hypertension.

Methods and Results

Using the Korean National Health Insurance Service database, we extracted the data on 479 359 patients with hypertension with available BP measurements and no history of cardiovascular events from 2002 to 2011. The study end point was major cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, or stroke. This cohort study evaluated the association of BP levels (<120/<70, 120–129/70–79, 130–139/80–89, 140–149/90–99, and ≥150/≥100 mm Hg) with MACE. During a median follow‐up of 9 years, 55 401 MACE were documented in our cohort. The risk of MACE was the lowest (adjusted hazard ratio [HR], 0.79; 95% CI, 0.76–0.84) at BP level of <120/<70 mm Hg, and was the highest (HR, 1.32; 95% CI, 1.29–1.36) at ≥150/≥100 mm Hg in comparison with 130 to 139/80 to 89 mm Hg. These results were consistent in all age groups and both sexes. Among patients treated with antihypertensive medication (n=237 592, 49.5%), in comparison with a BP level of 130 to 139/80 to 89 mm Hg, the risk of MACE was significantly higher in patients with elevated BP (≥140/≥90 mm Hg), but not significantly lower in patients with BP of <130/<80 mm Hg. Low BP <120/70 mm Hg was associated with increased risk of all‐cause or cardiovascular death in all age groups.

Conclusions

BP level is significantly correlated with the risk of MACE in all Korean patients with hypertension. However, there were no additional benefits for MACE amongst those treated for hypertension with BP <120/70 mm Hg.

Short-term reproducibility of ambulatory blood pressure measurements: a systematic review and meta-analysis of 35 observational studies

OBJECTIVE

A systematic review on the reproducibility of ambulatory blood pressure measurements (ABPM) has not yet been conducted. This meta-analysis compared 24-h/daytime/night-time SBP and DBP mean values and SBP/DBP nocturnal dipping status from ABPMs in participants with or without hypertension.

METHODS

Ovid MEDLINE, EMBASE, and CINAHL Complete databases were searched for articles published before 3 May 2019. Eligible studies reporting a 24-h ABPM repeated at least once within 1 month were included. The mean daytime/night-time/24-h BP values, percentage of nocturnal dipping, and proportion of nondippers were compared between the first and second day of measurements, and the proportion of participants with inconsistent dipping status were estimated using a random effect model.

RESULTS

Population-based analysis found a 0-1.1 mmHg difference between the first and second ABPM for 24-h/daytime/night-time SBP and DBP and 0-0.5% for percentage of SBP/DBP nocturnal dipping. The proportion of non-dippers was not different between the first and second ABPM. Intra-individual analysis found that the 95% limit of agreements (LOA) for SBP/DBP were wide and the 95% LOA for daytime SBP, common reference to diagnose hypertension, ranged -16.7 to 18.4 mmHg. Similarly, 32% of participants had inconsistent nocturnal dipping status.

CONCLUSION

ABPM had excellent reproducibility at the population level, favouring its application for research purposes; but reproducibility of intra-individual BP values and dipping status from a 24-h ABPM was limited. The available evidence was limited by the lack of high-quality studies and lack of studies in non-Western populations.

Validation of Omron HBP-1100-E Professional Blood Pressure Measuring Device According to the American Association for the Advancement of Medical Instrumentation Protocol: The PERSIAN Guilan Cohort Study (PGCS)

BACKGROUND

Blood pressure (BP) measurement accuracy is critical to the diagnosis and management of hypertension. The aim of the present study was to validate the Omron HBP-1100-E professional blood pressure measuring device in accordance with the American Association for the Advancement of Medical Instrumentation in Iranian adults.

MATERIALS AND METHODS

Simultaneous blood pressure auscultator measurements were obtained by two observers using mercury sphygmomanometers as a reference, sequentially with a measurement by using the Omron HBP-1100-E device. Absolute device-reference blood pressure differences were categorized into three error categories (within 5, 10, and 15 mmHg), and mean device-reference blood pressure difference (standard deviation) was calculated and evaluated using the American Association for the Advancement of Medical Instrumentation criteria.

RESULTS

A total of 85 participants (250 paired readings) were enrolled to the study. 26.8%, 55.6%, and 79.6% of the device-reference blood pressure differences agreed to within 5, 10 and 15 mmHg, respectively, for systolic blood pressure, and 39.6%, 69.2%, and 81.6% of measurements for diastolic blood pressure, respectively, and failed to pass the protocol criteria. The mean device-reference blood pressure difference was 8.0 ± 13.1 mmHg for systolic BP and 2.2 ± 11.3 mmHg for diastolic BP, and was >5.0 ± 8.0 mmHg (required criteria).

CONCLUSION

Omron HBP-1100-E professional blood pressure monitor is not desirable for measuring the BP for Iranian adults as it overestimates blood pressure in this population.

Are Unattended Blood Pressure Measurements Necessary in All Patients Visiting an Outpatient Cardiology Clinic?

INTRODUCTION

Unattended automatic office blood pressure (BP) measurement has given new evidence regarding treatment goals.

AIM

We aimed to explore any differences between unattended and conventional office BP measurements in different groups of patients visiting a European Society of Hypertension (ESH)  Excellence Centre.

METHODS

We performed two unattended (Microlife Watch BP Home) followed by a single attended (mercury sphygmomanometer) BP measurement in 310 patients (mean age 62 ± 15 years, 151 males, 64% hypertensives and 36% normotensive individuals) visiting our ESH Centre for a scheduled follow-up. Office BP < 140 mmHg (systolic) and < 90 mmHg (diastolic) were characterized as controlled or normal in hypertensives and normotensive individuals, respectively.

RESULTS

Attended BP (systolic/diastolic) was higher than unattended BP in total population (p < 0.001 and p = 0.02) and hypertensives (p < 0.001). In hypertensives, attended BP was higher than unattended BP regardless of age, smoking habit, obesity or controlled BP status but it was similar to unattended in diabetic patients. In normotensive individuals, attended BP was higher than unattended BP in older (p = 0.04), non-smoker (p = 0.002) and non-diabetic (p = 0.02) subjects. Finally, unattended BP was important for treatment decisions only in a small group of non-diabetic hypertensive patients (7%) whose unattended BP was controlled while attended BP was uncontrolled.

CONCLUSIONS

Unattended BP was lower than attended BP in the majority of hypertensive patients. However, it was useful only in a small percentage of non diabetic hypertensive patients in order to take appropriate treatment plan decisions.

Evaluation of blood pressure through home monitoring in brazilian primary care: a feasibility study

Blood pressure measurements taken in a clinical setting are subject to errors, therefore there are advantages to monitoring blood pressure at home, especially in in patients diagnosed with hypertension. The study describes the feasibility of home monitoring to assess blood pressure in primary care and compares blood pressure measured at home and during a medical consultation. This cross-sectional study was carried out with patients whose used home blood pressure in the morning and evening, thrice for seven consecutive day sat home. Participants included patients older than 18 years with suspected whitecoat hypertension, taking antihypertensives, or those intolerant of ambulatory blood pressure monitoring, and excluded patients who did not follow the protocol, suffered from an irregular heart rate, and pregnant women. Of the 134 patients who participated in the study, 63.3% had altered blood pressure when measured at health facilities and 48% had higher blood pressure at home. The mean difference between the methods was 10.1 mmHg for systolic and 4.3 mmHg for diastolic. The prevalence of whitecoat hypertension was 19.4%. Blood pressure monitoring at home is a practicable strategy in the Brazilian healthcare system.

Blood pressure targets in chronic kidney disease: an update on the evidence

PURPOSE OF REVIEW

Hypertension is the leading modifiable cause of cardiovascular events and of mortality and is generally considered as a direct cause of chronic kidney disease. Defining optimal blood pressure targets in patients with chronic kidney disease is therefore of critical importance.

RECENT FINDINGS

Over the recent years, results and post-hoc analyses of several important trials comparing blood pressure targets which included patients with chronic kidney disease have been published. Although these results provide important means to understand the consequences of high blood pressure and to improve the management of hypertension in chronic kidney disease, they led to remarkably different interpretations and recommendations in the current guidelines.

SUMMARY

The present review summarizes the current evidence and areas of controversy for the definition of blood pressure targets in patients with chronic kidney disease.

Large discrepancy between unobserved automated office blood pressure and ambulatory blood pressure in a high cardiovascular risk cohort

OBJECTIVES

Automated office blood pressure (AOBP) measurement has been shown to eliminate the white-coat effect and to be more concordant with ambulatory blood pressure monitoring (ABPM) and home blood pressure (BP) measurements. This study aimed to compare AOBP with ABPM in patients with a high cardiovascular risk.

METHODS AND RESULTS

Participants were recruited from a prospective cohort study (Cardiovascular and Metabolic Disease Etiology Research Center-High Risk Cohort, clinicaltrials.gov: NCT02003781). A total of 1208 persons who had undergone both AOBP and ABPM within 7 days of each other were analyzed. The 95% limits of agreement between systolic AOBP and daytime ABPM SBP were -34.8 and 20.2 mmHg (mean difference = -7.3 ± 14.0). The mean differences in blood pressure across quintiles of AOBP distributions increased with decreasing systolic AOBP [-17.8 ± 11.2 (Q1, systolic AOBP <113 mmHg), -10.9 ± 11.1 (Q2, systolic AOBP 113-121 mmHg), -8.5 ± 10.7 (Q3, systolic AOBP 121-128 mmHg), -4.2 ± 11.8 (Q4, systolic AOBP 128-137 mmHg), 4.9 ± 14.2 (Q5, systolic AOBP >137 mmHg), P < 0.001]. The prevalence of masked hypertension phenomena was 310 (25.7%) and that of white-coat hypertension phenomena was 102 (8.4%). Large discrepancies were significantly associated with lower systolic AOBP, higher atherosclerotic cardiovascular disease risk score, and history of asymptomatic cardiovascular disease.

CONCLUSION

The lower range of systolic AOBP exhibited a large discrepancy with daytime ABPM SBP. Moreover, higher cardiovascular risk was independently associated with larger discrepancy between AOBP and ABPM. The status of blood pressure control should be confirmed using out-of-office blood pressure measurements, even when using AOBP as a clinical BP reference in high-risk patients.

Potential impact of the 2017 ACC/AHA guideline on high blood pressure in normotensive patients with stable coronary artery disease: insights from the CLARIFY registry

Aims

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline on high blood pressure (BP) lowered the threshold defining hypertension and BP target in high-risk patients to 130/80 mmHg. Patients with coronary artery disease and systolic BP 130–139 mmHg or diastolic BP 80–89 mmHg should now receive medication to achieve this target. We aimed to investigate the relationship between BP and cardiovascular events in ‘real-life’ patients with coronary artery disease considered as having normal BP until the recent guideline.

Methods and results

Data from 5956 patients with stable coronary artery disease, no history of hypertension or heart failure, and average BP <140/90 mmHg, enrolled in the CLARIFY registry (November 2009 to June 2010), were analysed. In a multivariable-adjusted Cox proportional hazards model, after a median follow-up of 5.0 years, diastolic BP 80–89 mmHg, but not systolic BP 130–139 mmHg, was associated with increased risk of the primary endpoint, a composite of cardiovascular death, myocardial infarction, or stroke (hazard ratio 2.15, 95% confidence interval 1.22–3.81 vs. 70–79 mmHg and 1.12, 0.64–1.97 vs. 120–129 mmHg). No significant increase in risk for the primary endpoint was observed for systolic BP <120 mmHg or diastolic BP <70 mmHg.

Conclusion

In patients with stable coronary artery disease defined as having normal BP according to the 140/90 mmHg threshold, diastolic BP 80–89 mmHg was associated with increased cardiovascular risk, whereas systolic BP 130–139 mmHg was not, supporting the lower diastolic but not the lower systolic BP hypertension-defining threshold and treatment target in coronary artery disease.

ClinicalTrials identifier

ISRCTN43070564.

Österreichischer Blutdruckkonsens 2019

Erhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.

New American and European Hypertension Guidelines, Reconciling the Differences

In November 2017, the American College of Cardiology and the American Heart Association released hypertension guidelines for the first time, replacing the Joint National Committee periodical reports, appearing from 1977 to 2003. In parallel, the European Society of Cardiology and the European Society of Hypertension updated their own recommendations with a new document released in August 2018. While both documents contain similar recommendations concerning several aspects of detection, prevention, and management of hypertension, they differ in some sensitive characteristics, which specifically affect diagnostic and therapeutic aspects. While the European guidelines do not substantially modify previous recommendations, the American proposals are clearly disruptive. Main examples include a new definition for hypertension, with a blood pressure threshold of 130/80 mmHg. Not only does it modify its prevalence, but also carries important changes in therapeutic aspects, including treatment initiation and blood pressure goals for treated patients. In this review, the main differences between American and European recommendations are highlighted, along with the arguments exposed by both groups of experts and their possible impact affecting clinical practice in hypertension management.

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

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Commercial Devices-Based System Designed to Improve the Treatment Adherence of Hypertensive Patients

This paper presents an intelligent system designed to increase the treatment adherence of hypertensive patients. The architecture was developed to allow communication among patients, physicians, and families to determine each patient's rate assertion of medication intake time and their self-monitoring of blood pressure. Concerning the medication schedule, the system is designed to follow a predefined prescription, adapting itself to undesired events, such as mistakenly taking medication or forgetting to take medication on time. When covering the blood pressure measurement, it incorporates best medical practices, registering the actual values in recommended frequency and form, trying to avoid the known "white-coat effect." We assume that taking medicine precisely and measuring blood pressure correctly may lead to good adherence to the treatment. The system uses commercial consumer electronic devices and can be replicated in any home equipped with a standard personal computer and Internet access. The resulting architecture has four layers. The first is responsible for adding electronic devices that typically exist in today's homes to the system. The second is a preprocessing layer that filters the data generated from the patient's behavior. The third is a reasoning layer that decides how to act based on the patient's activities observed. Finally, the fourth layer creates messages that should drive the reactions of all involved actors. The reasoning layer takes into consideration the patient's schedule and medication-taking activity data and uses implicit algorithms based on the J48, RepTree, and RandomTree decision tree models to infer the adherence. The algorithms were first adjusted using one academic machine learning and data mining tool. The system communicates with users through smartphones (anytime and anywhere) and smart TVs (in the patient's home) by using the 3G/4G and WiFi infrastructure. It interacts automatically through social networks with doctors and relatives when changes or mistakes in medication intake and blood pressure mean values are detected. By associating the blood pressure data with the history of medication intake, our system can indicate the treatment adherence and help patients to achieve better treatment results. Comparisons with similar research were made, highlighting our findings.

Diagnostic Accuracy of Unattended Automated Office Blood Pressure Measurement in Screening for Hypertension in Kenya

Supplemental Digital Content is available in the text.

Despite increasing adoption of unattended automated office blood pressure (uAOBP) measurement for determining clinic blood pressure (BP), its diagnostic performance in screening for hypertension in low-income settings has not been determined. We determined the validity of uAOBP in screening for hypertension, using 24-hour ambulatory BP monitoring as the reference standard. We studied a random population sample of 982 Kenyan adults; mean age, 42 years; 60% women; 2% with diabetes mellitus; none taking antihypertensive medications. We calculated sensitivity using 3 different screen positivity cutoffs (≥130/80, ≥135/85, and ≥140/90 mm Hg) and other measures of validity/agreement. Mean 24-hour ambulatory BP monitoring systolic BP was similar to mean uAOBP systolic BP (mean difference, 0.6 mm Hg; 95% CI, −0.6 to 1.9), but the 95% limits of agreement were wide (−39 to 40 mm Hg). Overall discriminatory accuracy of uAOBP was the same (area under receiver operating characteristic curves, 0.66–0.68; 95% CI range, 0.64–0.71) irrespective of uAOBP cutoffs used. Sensitivity of uAOBP displayed an inverse association (P<0.001) with the cutoff selected, progressively decreasing from 67% (95% CI, 62–72) when using a cutoff of ≥130/80 mm Hg to 55% (95% CI, 49–60) at ≥135/85 mm Hg to 44% (95% CI, 39–49) at ≥140/90 mm Hg. Diagnostic performance was significantly better (P<0.001) in overweight and obese individuals (body mass index, >25 kg/m²). No differences in results were present in other subanalyses. uAOBP misclassifies significant proportions of individuals undergoing screening for hypertension in Kenya. Additional studies on how to improve screening strategies in this setting are needed.

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

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

Impact of the SPRINT Trial on Hypertension Management

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

Low on-treatment diastolic blood pressure and cardiovascular outcome: A post-hoc analysis using NHLBI SPRINT Research Materials

Recent studies including the SPRINT trial have shown beneficial effects of intensive systolic blood pressure reduction over the standard approach. The awareness of the J-curve for diastolic blood pressure (DBP) causes some uncertainty regarding the net clinical effects of blood pressure reduction. The current analysis was performed to investigate effects of low on-treatment DBP on cardiovascular risk in the SPRINT population. The primary composite outcome was the occurrence of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure or death from cardiovascular causes. The prevalence of primary outcomes was significantly higher in subjects within low DBP in both standard (44-67 mmHg [10.8%] vs 67-73 mmHg [6.7%] vs 73-78 mmHg [5.1%] vs 78-83 mmHg [4.4%] vs 83-113 mmHg [4.3%], p < 0.001) and intensive treatment (38-61 mmHg [6.7%] vs 61-66 mmHg [4.1%] vs 66-70 mmHg [4.5%] vs 70-74 mmHg [2.7%] vs 74-113 mmHg [3.4%], p < 0.001) arms. After adjusting for covariates, low DBP showed no significant effects on cardiovascular risk. Therefore, while reaching blood pressure targets, low DBP should not be a matter of concern.

The role of wrist monitors to measure blood pressure in older adults

BACKGROUND

Arterial hypertension is a common condition in older adults with increasing data about blood pressure (BP) targets and antihypertensive treatment in this population. Recent studies have opened new discussions about the different usual and unusual methods of blood pressure monitoring. However, there are no evidence-based recommendations whether BP should be measured at upper arms or at wrist, which seems to be more comfortable in older and frail people.

AIMS

The purpose of this study was to test the quality of wrist BP monitors as diagnostic method in older adults.

METHODS

BP measurements at both upper arms and at both wrists were compared under standardized conditions in 605 patients ≥ 75 years. Differences in wrist and upper arm BP were, furthermore, correlated with various diagnoses and parameters including ankle-brachial-index (ABI).

RESULTS

In patients of 75-80 years, there were no differences in BP measurements at upper arms compared to wrists whereas in patients > 80 years, BP measurements at wrists were significantly lower than at upper arms. In both age groups BP measured at wrist was significantly lower in patients with ABI < 0.9.

CONCLUSIONS

BP wrist monitors could be considered as a serious alternative in adults of 75-80 years or in older persons with normal ABI values.

Unattended Automated Office Blood Pressure Measurement and Cardiac Target Organ Damage, A Pilot Study

INTRODUCTION

The ESC-2018 guidelines suggest the use of Unattended automated office blood pressure (UAOBP) to avoid or at least reduce the white coat effect, even if do not support its use as preferred method.

AIM

To assess the pressure difference between UAOBP and Attended office blood pressure (AOBP) and to evaluate their correlations with target organ damage in hypertensive patients.

METHODS

UAOBP and AOBP were taken in a cohort of 48 outpatients. The pressure difference between the 2 methods and their correlation with anthropometric and cardiac parameters were analyzed.

RESULTS

Unattended systolic and diastolic BP were lower than Attended systolic and diastolic BP (135 ± 17 mmHg vs 139 ± 21 mmHg and 79 ± 10 mmHg vs 82 ± 10 mmg). ΔDBP was significantly directly correlated with female sex (r = 0.347, p = 0.016) and it was lower in men compared to women (0.11 ± 8.9 mmHg vs 6.07 ± 7.42 mmHg, p = 0.016). Correlation coefficients for LVMi and RWT for attended and unattended BP were not statistically different (for LVMi r = 0.286 vs r = 0.381, p = 0.61, for RWT r = 0.413 vs r = 0.363, p = 0.78). The relationship between attended and unattended BP was described by the following equation: y = - 4.68 + 1.06*x; where Y is the attended systolic BP and X is the unattended systolic BP; in accordance with this equation, an unattended systolic BP of 140 mmHg corresponds to an attended systolic BP of 143.7 mmHg.

CONCLUSIONS

UAOBP provides significantly lower values than AOBP. The difference in BP values between the two methods is much lower than the one obtained in most clinical studies.

Association of Optimal Blood Pressure With Critical Cardiorenal Events and Mortality in High-Risk and Low-Risk Patients Treated With Antihypertension Medications

IMPORTANCE

There are few studies comparing the optimal level of treated blood pressure (BP) between high- and low-risk patients.

OBJECTIVE

To examine whether optimally treated BP is different according to risk status.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cohort study using data from the National Health Information Database in Korea from 2002 to 2015 and 2006 to 2017. A total of 1 402 975 adults aged 40 to 79 years who had no known cardiorenal disease were included.

EXPOSURES

Systolic BP treated with antihypertensive medication.

MAIN OUTCOMES AND MEASURES

The yearly rates of critical cardiorenal events and all-cause death were estimated according to the levels of treated systolic BP and the presence of 5 risk factors (hypertension, diabetes, hyperlipidemia, proteinuria, and smoking).

RESULTS

During the study periods, 225 103 of 487 412 participants (54.0% male; median [interquartile range] age, 50 [44-59] years) in the primary cohort and 360 503 of 915 563 participants (50.1% male; median [interquartile range] age, 52 [46-60] years) in the secondary cohort received antihypertensive treatment. In total, 28 411 of 51 292 cardiorenal incidents and 33 102 of 72 500 deaths were noted in ever-treated participants. The absolute increase in cardiorenal and mortality risk associated with inadequately treated BP was greater in participants with multiple risk factors than in those with 1 or 0 risk factors. The hazard ratios for critical cardiorenal events increased as the treated systolic BP increased to more than 130 to 140 mm Hg. The hazard ratio for all-cause mortality for patients with 3 or more risk factors and treated systolic BP within the range of 110 to 119 mm Hg was 1.21 (95% CI, 1.07-1.37); 130 to 139 mm Hg, 1.04 (95% CI, 0.98-1.11); 140 to 149 mm Hg, 1.12 (95% CI, 1.05-1.20); 150 to 159 mm Hg, 1.21 (95% CI, 1.11-1.32); and 160 mm Hg or greater, 1.46 (95% CI, 1.32-1.62) compared with high-risk patients with BP of 120 to 129 mm Hg. For participants with 1 or 0 risk factors and treated systolic BP within the range of 110 to 119 mm Hg, the hazard ratio was 1.14 (95% CI, 1.07-1.22); 130 to 139 mm Hg, 0.97 (95% CI, 0.93-1.02); 140 to 149 mm Hg, 1.00 (95% CI, 0.91-1.09); 150 to 159 mm Hg, 1.06 (95% CI, 0.99-1.14); and 160 mm Hg or greater, 1.26 (95% CI, 1.15-1.37). However, when categorized using cardiovascular risk calculators, there was no consistent trend in mortality thresholds of BP across the risk score categories.

CONCLUSIONS AND RELEVANCE

These results suggest that intensive BP control is appropriate for reducing all-cause mortality in addition to cardiorenal risk in higher- rather than lower-risk patients. However, caution may be required when determining BP targets using current risk calculators.

2018 Korean Society of Hypertension Guidelines for the management of hypertension: part II-diagnosis and treatment of hypertension

The standardized techniques of blood pressure (BP) measurement in the clinic are emphasized and it is recommended to replace the mercury sphygmomanometer by a non-mercury sphygmomanometer. Out-of-office BP measurement using home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) and even automated office BP (AOBP) are recommended to correctly measure the patient’s genuine BP. Hypertension (HTN) treatment should be individualized based on cardiovascular (CV) risk and the level of BP. Based on the recent clinical study data proving benefits of intensive BP lowering in the high risk patients, the revised guideline recommends the more intensive BP lowering in high risk patients including the elderly population. Lifestyle modifications, mostly low salt diet and weight reduction, are strongly recommended in the population with elevated BP and prehypertension and all hypertensive patients. In patients with BP higher than 160/100 mmHg or more than 20/10 mmHg above the target BP, two drugs can be prescribed in combination to maximize the antihypertensive effect and to achieve rapid BP control. Especially, single pill combination drugs have multiple benefits, including maximizing reduction of BP, minimizing adverse effects, increasing adherence, and preventing cardiovascular disease (CVD) and target organ damage.

Treatment of hypertension in the elderly in 2017/2018 - what's new?

Introduction: Hypertension is highly prevalent in the elderly and represents a major risk factor for cardiovascular complications such as coronary heart disease, stroke, and cognitive dysfunction. Areas covered: The recently published AHA/ACC and ESC/ESH guidelines for the management of hypertension in adult populations modified their approach towards hypertension in the elderly, particularly in those older than 85 years. The new concepts presented in these guidelines are discussed. They recommend a less conservative threshold and lower blood pressures targets; an emphasis on considering the biological rather than chronological age for patients >85 years, and the use of single-pill combinations to simplify treatment algorithms and increase long-term drug adherence. Expert opinion: Considering the high prevalence of hypertension in the elderly and the negative impact of untreated hypertension, early detection of hypertension in patients over 60 years old is crucial. The screening of hypertension should be reinforced in patient populations using out-of-office BP measurements. The author supports the latest ESC/ESH guidelines, which define a threshold at >140 mmHg for patients aged 65 to 79 years and >160 mmHg for those >85 years and propose a target BP of 130-140 mmHg, while considering patient frailty and the tolerability of the treatment.

Determination of optimal on-treatment diastolic blood pressure range using automated measurements in subjects with cardiovascular disease-Analysis of a SPRINT trial subpopulation

Automated office blood pressure measurement (AOBPM) is recommended for diagnosing hypertension; however, optimal treatment targets using this method are not established. Discrepancies between automated and office measurements of blood pressure have been described, producing uncertainty regarding the use of AOBPM in clinical practice. The Systolic Blood Pressure Intervention Trial (SPRINT) results improved our understanding of target AOBPM systolic blood pressure (SBP) levels; however, diastolic blood pressure (DBP) targets remain unknown. Therefore, we sought to determine the optimal on-treatment DBP range. The analysis was performed on the participants of the SPRINT trial who had hypertension and prior cardiovascular disease. We analyzed the data of 1470 participants (mean age 70.3 ± 9.3 years, 24.1% female) selected from the SPRINT trial database of National Heart, Lung and Blood Institute. The mean achieved SBP and DBP were 127.9 ± 10.7 and 68.3 ± 9.4 mm Hg, respectively. Most of the participants (57.4%) had a DBP lower than 70 mm Hg, while only 11.7% had DPB ≥80 mm Hg. Clinical composite endpoint was defined as myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure or death from cardiovascular causes. There were 159 (10.8%) clinical endpoint events. The participants with on-treatment AOBPM DBP range of 68.6-78.6 mm Hg showed the lowest hazard risk of a clinical composite endpoint. These results correspond to the office DBP range of 70-80 mm Hg recommended in ESC guidelines. This is the first attempt to determine the range of optimal DBP values using population-based AOBPM in patients with prior cardiovascular disease.

Comparison of blood pressure values-self-measured at home, measured at an unattended office, and measured at a conventional attended office

Self-measured blood pressure (BP) at home (HBP) has been commonly used in clinical practice. Although the unattended office BP (UBP), in which a patient is left alone before and during the measurement, has been investigated, the advantages of UBP over HBP or conventionally measured attended office BP obtained using automated devices (CBP) remain unclear. We performed a multicenter clinical study in Japan to compare the UBP, CBP, and HBP among 308 patients with hypertension at 3 clinics (women, 57.8%; mean age 71.8 years; under antihypertensive drug therapy, 96.4%). The patients measured HBP twice in the morning and twice in the evening for 5 days according to the Japanese Society of Hypertension guidelines. Using the Omron HEM-907 cuff-oscillometric device, the UBP and CBP were measured in line with the protocol in the Systolic blood PRessure INtervention Trial (SPRINT) and in accordance with the guidelines, respectively. Correlation coefficients were ≤0.16 for the comparison of UBP versus morning and evening HBP for the systolic measurement, whereas they were approximately 0.5 (P < 0.001) for the diastolic measurement. The difference between UBP minus HBP was small on average but varied among individuals (mean ± SD for UBP minus morning HBP: 0.9 ± 17.8/-4.5 ± 10.5 mmHg; UBP minus evening HBP: 5.7 ± 17.8/-0.1 ± 11.3 mmHg). In contrast, the measurement values of CBP and UBP were highly correlated (r ≥ 0.72), but the difference between CBP minus UBP was 10.4 ± 12.0/4.2 ± 6.5 mmHg. Based on the low correlations and wide range of differences, UBP cannot be used as an alternative to HBP.