Home blood pressure monitoring in the diagnosis and treatment of hypertension: a systematic review

Masked phenomenon: renal and cardiovascular complications; review and updates

BACKGROUND

In the in-clinic blood pressure (BP) recording setting, a sizable number of individuals with normal BP and approximately 30% of patients with chronic renal disease (CKD) exhibit elevated outpatient BP records. These individuals are known as masked hypertension (MHTN), and when they are on antihypertensive medications, but their BP is not controlled, they are called masked uncontrolled hypertension (MUHTN). The masked phenomenon (MP) (MHTN and MUHTN) increases susceptibility to end-organ damage (a two-fold greater risk for cardiovascular events and kidney dysfunction). The potential extension of the observed benefits of MP therapy, including a reduction in end-organ damage, remains questionable.

AIM AND METHODS

This review aims to study the diagnostic methodology, epidemiology, pathophysiology, and significance of MP management in end-organs, especially the kidneys, cardiovascular system, and outcomes. To achieve the purposes of this non-systematic comprehensive review, PubMed, Google, and Google Scholar were searched using keywords, texts, and phrases such as masked phenomenon, CKD and HTN, HTN types, HTN definition, CKD progression, masked HTN, MHTN, masked uncontrolled HTN, CKD onset, and cardiovascular system and MHTN. We restricted the search process to the last ten years to search for the latest updates.

CONCLUSION

MHTN is a variant of HTN that can be missed if medical professionals are unaware of it. Early detection by ambulatory or home BP recording in susceptible individuals reduces end-organ damage and progresses to sustained HTN. Adherence to the available recommendations when dealing with masked phenomena is justifiable; however, further studies and recommendation updates are required.

Low-Dose Triple-Pill vs Standard-Care Protocols for Hypertension Treatment in Nigeria: A Randomized Clinical Trial

Importance

With the high burden of hypertension in sub-Saharan Africa, there is a need for effective, safe and scalable treatment strategies.

Objective

To compare, among Black African adults, the effectiveness and safety of a novel low-dose triple-pill protocol compared with a standard-care protocol for blood pressure lowering.

Design and Setting

Randomized, parallel-group, open-label, multicenter trial conducted in public hospital-based family medicine clinics in Nigeria.

Participants

Black African adults with uncontrolled hypertension (≥140/90 mm Hg) who were untreated or receiving a single blood pressure-lowering drug.

Interventions

Participants were randomly allocated to low-dose triple-pill or standard-care protocols. The triple-pill protocol involved a novel combination of telmisartan, amlodipine, and indapamide in triple one-quarter, one-half, and standard doses (ie, 10/1.25/0.625 mg, 20/2.5/1.25 mg, and 40/5/2.5 mg), with accelerated up-titration. The standard-care protocol was the Nigeria hypertension treatment protocol starting with amlodipine (5 mg).

Main Outcomes and Measures

The primary effectiveness outcome was the reduction in home mean systolic blood pressure, and the primary safety outcome was discontinuation of trial treatment due to adverse events, both from randomization to month 6.

Results

The first participant was randomized on July 19, 2022, and the last follow-up visit was on July 18, 2024. Among 300 randomized participants (54% female; mean age, 52 years; baseline mean home blood pressure, 151/97 mm Hg; and clinic blood pressure, 156/97 mm Hg), 273 (91%) completed the trial. At month 6, mean home systolic blood pressure was on average 31 mm Hg (95% CI, 28 to 33 mm Hg) lower in the triple-pill protocol group and 26 mm Hg (95% CI, 22 to 28 mm Hg) lower in the standard-care protocol group (adjusted difference, -5.8 mm Hg [95% CI, -8.0 to -3.6]; P < .001]). At month 6, clinic blood pressure control (<140/90 mm Hg) was 82% vs 72% (risk difference, 10% [95% CI, -2% to 20%]) and home blood pressure control (<130/80 mm Hg) was 62% vs 28% (risk difference, 33% [95% CI, 22% to 44%]) in the triple-pill compared with the standard-care protocol group; these were 2 of 21 prespecified secondary effectiveness end points. No participants discontinued trial treatment due to adverse events.

Conclusions and Relevance

Among Black African adults with uncontrolled hypertension, a low-dose triple-pill protocol achieved better blood pressure lowering and control with good tolerability compared with the standard-care protocol.

Trial Registration

Pan African Clinical Trials Registry Identifier: PACTR202107579572114.

Effect of health extension workers-led home-based multicomponent intervention on blood pressure reduction among hypertensive patients in rural districts of northwest Ethiopia: a cluster-randomised controlled trial

OBJECTIVES

To evaluate effects of health extension workers-led home-based multicomponent intervention on blood pressure change in hypertensive patients in rural districts of northwest Ethiopia.

DESIGN

Two-arm cluster randomised controlled trial was conducted.

PARTICIPANTS

Hypertensive patients' age ≥25 years were included. 20 clusters or kebeles with 456 participants were randomly assigned to the intervention group (10 clusters with 228 participants) and the control group (10 clusters with 228 participants).

INTERVENTIONS

Participants in the intervention kebeles received health extension workers-led home-based multicomponent interventions every other month for 40-60 min for 9 months.

MAIN OUTCOME MEASURES

The primary outcomes were the differences in mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) changes from baseline between patients in the intervention and control groups. Intention-to-treat analysis was used for the primary analyses. Linear mixed effect model was used to evaluate the intervention's effect on change in mean SBP and DBP. Effect sizes of mean difference and relative benefit increase were used.

RESULTS

At 9 months, the mean SBP decreased by 15.8 mm Hg (95% CI: 13.5, 18.1) in the intervention and 10.8 mm Hg (95% CI: 8.7, 12.9) in the control groups; with a 5.0 mm Hg (95% CI: 1.9, 8.1) greater reduction in the intervention group. The mean DBP decreased by 12.1 mm Hg (95% CI: 10.6, 13.5) in the intervention and 8.4 mm Hg (95% CI: 7.0, 9.8) in the control group. The proportion of optimal blood pressure control was higher in the intervention group (45.8%) than the control group (28.2%) with percentage difference of 17.6% (95% CI: 8.5, 26.7).

CONCLUSIONS

Health extension workers-led home-based multicomponent intervention has resulted significant reduction of blood pressure and achieved a higher proportion of optimal blood pressure control. This strategy is effective, but further research is needed to determine its cost effectiveness for scaling up and integrating in primary care settings.

TRIAL REGISTRATION

The trial is registered with Pan African clinical trial registry (PACTR202102729454417).

How do patients experience and use home blood pressure monitoring? A qualitative analysis with UTAUT 2

Background: Hypertension is an important cardiovascular risk factor with potentially harmful consequences. Home blood pressure monitoring is a promising method for following the effect of hypertension treatment. The use of technology-enabled care and increased patient involvement might contribute to more effective treatment methods. However, more knowledge is needed to explain the motivations and consequences of patients engaging in what has been called 'do-it-yourself healthcare'. Aim: This study aimed to investigate patients' experiences of home blood pressure monitoring through the theoretical frame of the Unified Theory of Acceptance and Use of Technology (UTAUT 2). Methods: The study had a qualitative design, with focus group interviews using the web-based platform Zoom. The data were analysed using qualitative deductive content analysis, inspired by Graneheim and Lundman. Results: The results are presented using the seven theoretical constructs of UTAUT 2: Performance Expectancy, Effort Expectancy, Social Influence, Facilitating Conditions, Hedonistic Motivation, Price Value and Habit. We found one overarching theme ‒ 'It's all about the feeling of security'. The patients were influenced by relatives or healthcare personnel and experienced the home monitoring process as being easy to conduct. The patients emphasised that the quality of the blood pressure monitor was more important than the price. Patients reported home monitoring of blood pressure as a feasible method to follow-up care of their hypertension. Discussion: This study indicates that among motivated patients, home blood pressure measurement entails minimal effort, increases security, and leads to better communication about blood pressure between healthcare personnel and patients.

Factors influencing the continuation of home blood pressure measurement in community-dwelling older adults: the NOSE study

OBJECTIVE

This study aimed to identify the factors influencing home blood pressure measurement (HBPM) continuation in community-dwelling older adults.

METHODS

A longitudinal analysis used the NOSE study intervention group datasets. The participants were encouraged HBPM with self-monitoring devices provided to them twice in the morning and twice in the evening. Every 7-day interval from the HBPM start date was defined as 1 week, and the number of HBPMs per week was counted. The first week in which the number of HBPMs was zero was defined as the week in which HBPM was discontinued. Participants who did not experienced discontinuation until the end of the observation period were considered complete survivors in the survival time analysis.

RESULTS

Data from 437 participants were included in the analysis. Of these, 120 (27.5%) discontinued HBPM. In univariate analysis, factors significantly associated with HBPM discontinuation included exercise habits [hazard ratio per one unit 0.47; 95% confidence interval (CI) 0.31-0.69], social participation (hazard ratio 0.65; 95% CI 0.42-0.99), MoCA-J score (hazard ratio 0.94; 95% CI 0.90-0.98), and frailty (hazard ratio 5.20; 95% CI 2.87-9.43). In multivariate analysis, factors significantly associated with HBPM discontinuation included sex (hazard ratio 0.55; 95% CI 0.32-0.95; ref. = female individuals), smoking history (hazard ratio 1.69; 95% CI 1.02-2.80), exercise habits (hazard ratio 0.51; 95% CI 0.30-0.85), MoCA-J score (hazard ratio 0.93; 95% CI 0.88-0.98), and frailty (hazard ratio 3.31; 95% CI 1.50-7.29).

CONCLUSION

Among community-dwelling older adults, female sex, smoking history, lack of exercise, cognitive decline, and frailty were identified as factors influencing HBPM discontinuation.

Home Blood Pressure Monitoring and Its Association With Blood Pressure Control Among Hypertensive Patients With High Cardiovascular Risk in China

Objective

Home blood pressure monitoring (HBPM) is viewed as a facilitating factor in the initial diagnosis and long-term management of treated hypertension. However, evidence remains scarce about the effectiveness of HBPM use in the real world. This study aimed to examine the associations of HBPM use with blood pressure (BP) control and medication adherence.

Methods

This prospective cohort study included hypertensive patients with high cardiovascular risk who were aged ≥50 years. At baseline, information about types of BP monitor, frequency of HBPM, perception of anti-hypertensive treatment, and measured office BP were collected. During the 1-year follow-up (visits at 1, 2, 3, 6, and 12 months), information on medication adherence was collected at each visit. The 2 major outcomes were BP control at baseline and medication adherence during the 1-year follow-up. A log-binomial regression model was used to examine the association between frequency of HBPM and outcomes, stratified by the perceptions of anti-hypertensive treatment.

Results

A total of 5,363 hypertensive patients were included in the analysis. The age was (64.6 ± 7.2) years, and 41.2% (2,208) were female. Of the total patients, 85.9% (4,606) had a home BP monitor and 47.8% (2,564) had an incorrect perception of anti-hypertensive treatment. Overall, 24.2% (1,299) of patients monitored their BP daily, 37.6% (2,015) weekly, 17.3% (926) monthly, and 20.9% (1,123) less than monthly. At baseline, the systolic BP and diastolic BP were (146.6 ± 10.8) mmHg and (81.9 ± 10.6) mmHg, respectively, and 28.5% (1,527) of patients had their BP controlled. Regardless of whether the patients had correct or incorrect perceptions of anti-hypertensive treatment, there is no significant association between HBPM frequency and BP control at baseline. During the 1-year follow-up, 23.9% (1,280) of patients had non-adherence to medications at least once. In patients with an incorrect perception of anti-hypertensive treatment, those monitoring BP most frequently (daily) had the highest non-adherence rate (29.9%, 175/585). Compared with those monitoring their BP less than monthly, patients who monitored their BP daily were more likely not to adhere to anti-hypertensive medications (adjusted relative risk = 1.38, 95% confidence interval: 1.11-1.72, P = 0.004).

Conclusions

HBPM performance among hypertensive patients in China is, in general, sub-optimal. No association was observed between using HBPM alone and hypertension control, indicating that the effects of HBPM could be conditional. Patients' misconceptions about anti-hypertensive treatment may impair the role of BP monitoring in achieving medication adherence. Fully incorporating the correct perception of hypertension into the management of hypertensive patients is needed.

The Standardization of Home Blood Pressure Monitoring in Primary Care: A Quality Improvement Project

Current guidelines recommend the use of home blood pressure monitoring (HBPM) to screen for and manage hypertension. In this study, a quality improvement project was designed to standardize the use of HBPM in a primary care setting and demonstrate improved blood pressure outcomes. Initial systolic and diastolic values were compared to averages from patient logs. Patient and provider feedback was collected. Only 40% of patients enrolled presented to follow-up with actionable HBPM data. Patients encountered logistical challenges in obtaining and presenting HBPM data. Interprofessional collaboration and improved information technology systems would improve outcomes. This will require increased policy and insurer support to make this possible in small settings.

Care plan for individuals at risk for preeclampsia: shared approach to education, strategies for prevention, surveillance, and follow-up

Preeclampsia is a multisystemic disorder of pregnancy that affects 250,000 pregnant individuals in the United States and approximately 10 million worldwide per annum. Preeclampsia is associated with substantial immediate morbidity and mortality but also long-term morbidity for both mother and offspring. It is now clearly established that a low dose of aspirin given daily, beginning early in pregnancy modestly reduces the occurrence of preeclampsia. Low-dose aspirin seems safe, but because there is a paucity of information about long-term effects on the infant, it is not recommended for all pregnant individuals. Thus, several expert groups have identified clinical factors that indicate sufficient risk to recommend low-dose aspirin preventive therapy. These risk factors may be complemented by biochemical and/or biophysical tests that either indicate increased probability of preeclampsia in individuals with clinical risk factors, or more importantly, identify increased likelihood in those without other evident risk. In addition, the opportunity exists to provide this population with additional care that may prevent or mitigate the short- and long-term effects of preeclampsia. Patient and provider education, increased surveillance, behavioral modification, and other approaches to improve outcomes in these individuals can improve the chance of a healthy outcome. We assembled a group with diverse, relevant expertise (clinicians, investigators, advocates, and public and private stakeholders) to develop a care plan in which providers and pregnant individuals at risk can work together to reduce the risk of preeclampsia and associated morbidities. The plan is for care of individuals at moderate to high risk for developing preeclampsia, sufficient to receive low-dose aspirin therapy, as identified by clinical and/or laboratory findings. The recommendations are presented using the GRADE methodology with the quality of evidence upon which each is based. In addition, printable appendices with concise summaries of the care plan's recommendations for patients and healthcare providers are provided. We believe that this shared approach to care will facilitate prevention of preeclampsia and its attendant short- and long-term morbidity in patients identified as at risk for development of this disorder.

The neurocognitive disorder cohort RIFADE: Aims, methods, first results showing cognitive improvement in a subgroup

BACKGROUND

The NCD cohort study RIFADE (RIsk FActors of DEmentia) investigates the interaction of risk factors and neurocognitive disorders (NCDs) due to Alzheimer's disease (NCD-AD) and NCD of vascular type (NCD-vascular). Retrospective recruitment referred to a period from 2007 to 2018 in a single centre. In addition to the baseline visit, follow-up visits took place at 3, 6, 12 months followed by yearly visits. Visit times varied in part depending on adherence. The study also comprises an EEG bank and a bank with cerebral MRI (c-MRI).

METHODS

Inclusion criteria were broad in order to cover a wide range of patterns of NCD. At baseline, patients underwent a large panel of assessments, e.g. including clinical history, diagnostic evaluation for NCD according to DSM-IV and NINDS AIREN criteria, a cognitive test battery including the DemTect, the clock drawing test and the Instrumental-Activities-of-Daily-Living-scale of Lawton and Brodie, EEG and c-MRI. At each follow-up visit, cognitive tests were repeated, in most cases also EEGs and in some cases c-MRIs. Numerous risk factors (RF) including vascular RF, atrial fibrillation, heart failure, sleep apnoea and lifestyle factors such as sedentary lifestyle, low cognitive style and smoking were evaluated for presence and for correction status at each visit, and modulation of uncorrected RF was initiated.

RESULTS

Overall, 126 subjects with a clinical diagnosis of NCD were included (52% female, mean age 71 ± 10.6 years (range 35e86)), number of follow-up visits per subject 2.9 ± 2.4, observation time per subject 3.4 ± 2.8 years). Of these, 55/28/17% presented with the clinical stages subjective cognitive decline (SCD)/mild cognitive impairment (MCI)/dementia (major NCD). Clinical diagnoses, retrospectively re-evaluated according to DSM-5, were 5/21/68/6% Alzheimer´s disease (NCD-AD)/vascular NCD (NCD-vascular) / mixed NCD (NCD-AD + NCD-vascular)/unspecified NCD. First longitudinal results revealed a mean DemTect score at baseline 12.6 ± 4.2 vs last visit 12.0 ± 4.8 (p = 0.08) and a clock drawing test score at baseline 1.9 ± 1.3 vs last visit 2.3 ± 1.5 (p < 0.0001). Of all subjects with MCI or major NCD (n = 57), 19 improved in the clinical stage from baseline to last visit (33.3%). Sixteen subjects progressed from SCD or MCI (n = 104) to major NCD (15.4%).

CONCLUSION

The German NCD cohort RIFADE comprises patients with all clinical stages of NCD. A considerable subgroup improved in clinical stage. Further analysis is needed to answer the question of whether modulation of multiple risk factors provides a favourable effect on cognitive outcome in NCD.

Cluster randomised trial to evaluate comprehensive approach to hypertension management in Nepal: a study protocol

INTRODUCTION

Despite having effective approaches for hypertension management including use of antihypertensive medication, monitoring of blood pressure and lifestyle modification many people with hypertension in Nepal remain undetected and untreated. A comprehensive intervention which provides personalised counselling on lifestyle modification, medication adherence together with support for regular monitoring of blood pressure is expected to achieve well controlled blood pressure.

METHODS AND ANALYSIS

This is a community-based, non-blinded, parallel group, two-arm cluster randomised controlled trial, with an allocation ratio of 1:1, conducted in Budhanilkantha municipality, Nepal. Ten health facilities and their catchment area are randomly allocated to either of the two arms. 1250 individuals aged 18 years and older with an established diagnosis of hypertension will be recruited. The intervention arm receives a comprehensive hypertension management package that includes blood pressure audit by health workers, home-based patient support by community health workers to engage patient and family members in providing tailored educational counselling on behavioural and lifestyle changes in addition to routine care. The control arm includes routine hypertension care. Trained enumerators will ensure consent and collect data. Outcome data on blood pressure, weight, waist and hip circumference will be measured and self-reported data on diet, lifestyle, medication adherence and hypertension knowledge will be registered at 11 months' follow-up. The change in outcome measures will be compared by intention to treat, using a generalised linear mixed model. A formative assessment will be conducted using semistructured interviews and focus group discussions to explore factors affecting hypertension management. A mix-method approach will be applied for process evaluation to explore acceptability, adoption, fidelity, feasibility and coverage.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Nepal Health Research Council (682/2021) and Regional Committee for Medical and Health Research Ethics, Norway (399479). The findings will be disseminated in peer-reviewed journal articles and with decision makers in Nepal.

Improving Access to Home Blood Pressure Monitors at a Federally Qualified Health Center

Background: Self-monitoring of blood pressure (BP) clinically decreases BP. However, cost can limit access, especially in underserved populations. Objective: This mixed-methods pilot study aims to determine the impact of providing home BP monitors free of charge to patients at a federally qualified health center (FQHC) by quantifying the effect on BP and surveying patients to measure satisfaction and engagement. Methods: One hundred eighty patients with clinically diagnosed hypertension received BP monitors. Patient charts were reviewed to collect demographics and office BP readings 3 months before and after receiving a monitor. A 13-question phone survey was conducted to a sample of patients addressing satisfaction and engagement. Answers were based on a Likert scale and dichotomous yes/no. Results were analyzed with descriptive statistics and paired t tests. Results: The chart review demonstrated a significant mean decrease in systolic BP by 5.44 mm Hg ( P < 0.001, −8.03 to −2.84) and a mean decrease in diastolic BP by 2.70 mm Hg ( P < 0.001, −4.08 to −1.32) after the intervention. For those included who responded to the survey (13%), there was a significant mean increase in the frequency of checking BP per week by 1.5 Likert points ( P < 0.00001, −1.0 to −1.9), and a majority (57.8%) felt slightly or much more active in their health care in addition to other benefits. Conclusion: Providing BP monitors to FQHC patients free of charge may have contributed to a significantly decreased office BP, improved engagement, and satisfaction. This program removed cost barriers and allowed patients to be more active in their health care.

The 2022 focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension

Hypertension is the leading cause of death in human being, which shows high prevalence and associated complications that increase the mortality and morbidity. Controlling blood pressure (BP) is very important because it is well known that lowering high BP effectively improves patients' prognosis. This review aims to provide a focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension. The importance of ambulatory BP and home BP monitoring was further emphasized not only for the diagnosis but also for treatment target. By adopting corresponding BPs, the updated guideline recommended out-of-office BP targets for both standard and intensive treatment. Based on the consensus on corresponding BPs and Systolic Blood Pressure Intervention Trial (SPRINT) revisit, the updated guidelines recommended target BP in high-risk patients below 130/80 mmHg and it applies to hypertensive patients with three or more additional cardiovascular risk factors, one or more risk factors with diabetes, or hypertensive patients with subclinical organ damages, coronary or vascular diseases, heart failure, chronic kidney disease with proteinuria, and cerebral lacunar infarction. Cerebral infarction and chronic kidney disease are also high-risk factors for cardiovascular disease. However, due to lack of evidence, the target BP was generally determined at < 140/90 mmHg in patients with those conditions as well as in the elderly. Updated contents regarding the management of hypertension in special situations are also discussed.

The reliability of patient blood pressure self-assessments - a cross-sectional study

OBJECTIVE

Home blood pressure monitoring (HBPM) is an increasingly important tool in managing hypertension (HTN); however, its efficacy depends on its accuracy. This study aimed to explore the differences between blood pressure (BP) measurements conducted by patients and medical professionals and the patient demographic factors correlating with inaccurate self-measured BP levels.

METHODS

One hundred hypertensive patients completed a questionnaire inquiring about their health status and HBPM procedures and were filmed while measuring their BP using their own devices. A researcher then measured the patients' BP using a calibrated sphygmomanometer to assess the accuracy of patient-performed readings. This cross-sectional study was conducted in five primary healthcare centers in Kraków, Poland.

RESULTS

The mean differences in systolic and diastolic BP readings by patients and researchers were 8.36 mmHg (SD = 10.90 mmHg) and 2.16 mmHg (SD = 9.12 mmHg), respectively. Inaccuracies in patient BP measurements were associated with a less than high school education level, patients' age, and a family history of HTN.

CONCLUSION

Patient self-measured BP levels were higher than researcher values, likely due to a higher patient error rate. Healthcare providers must increase training regarding correct HBPM techniques offered to patients; such efforts should be directed at all hypertensive patients, emphasizing the most error-prone demographics.

Hypertension in Dialysis Patients: Diagnostic Approaches and Evaluation of Epidemiology

Whereas hypertension is an established cardiovascular risk factor in the general population, the contribution of increased blood pressure (BP) to the huge burden of cardiovascular morbidity and mortality in patients receiving dialysis continues to be debated. In a large part, this controversy is attributable to particular difficulties in the accurate diagnosis of hypertension. The reverse epidemiology of hypertension in dialysis patients is based on evidence from large cohort studies showing that routine predialysis or postdialysis BP measurements exhibit a U-shaped or J-shaped association with cardiovascular or all-cause mortality. However, substantial evidence supports the notion that home or ambulatory BP measurements are superior to dialysis-unit BP recordings in diagnosing hypertension, in detecting evidence of target-organ damage and in prognosticating the all-cause death risk. In the first part of this article, we explore the accuracy of different methods of BP measurement in diagnosing hypertension among patients on dialysis. In the second part, we describe how the epidemiology of hypertension is modified when the assessment of BP is based on dialysis-unit versus home or ambulatory recordings.

Optimization of blood pressure measurement practices for pharmacodynamic analyses of tyrosine-kinase inhibitors

Blood pressure measurements form a critical component of adverse event monitoring for tyrosine kinase inhibitors, but might also serve as a biomarker for dose titrations. This study explored the impact of various sources of within-individual variation on blood pressure readings to improve measurement practices and evaluated the utility for individual- and population-level dose selection. A pharmacokinetic-pharmacodynamic modeling framework was created to describe circadian blood pressure changes, inter- and intra-day variability, changes from dipper to non-dipper profiles, and the relationship between drug exposure and blood pressure changes over time. The framework was used to quantitatively evaluate the influence of physiological and pharmacological aspects on blood pressure measurements, as well as to compare measurement techniques, including office-based, home-based, and ambulatory 24-h blood pressure readings. Circadian changes, as well as random intra-day and inter-day variability, were found to be the largest sources of within-individual variation in blood pressure. Office-based and ambulatory 24-h measurements gave rise to potential bias (>5 mmHg), which was mitigated by model-based estimations. Our findings suggest that 5-8 consecutive, home-based, measurements taken at a consistent time around noon, or alternatively within a limited time frame (e.g., 8.00 a.m. to 12.00 p.m. or 12.00 p.m. to 5.00 p.m.), will give rise to the most consistent blood pressure estimates. Blood pressure measurements likely do not represent a sufficiently accurate method for individual-level dose selection, but may be valuable for population-level dose identification. A user-friendly tool has been made available to allow for interactive blood pressure simulations and estimations for the investigated scenarios.

Agreement between attended home and ambulatory blood pressure measurements in adolescents with chronic kidney disease

BACKGROUND

This study aimed to compare attended home blood pressure (BP) measurements (HBPM) with ambulatory BP monitor (ABPM) readings and examine if level of agreement between measurement modalities differs overall and by subgroup.

METHODS

This was a secondary analysis of data from a 2-year, multicenter observational study of children 11-19 years (mean 15, SD = 2.7) with chronic kidney disease. Participants had 3 standardized resting oscillometric home BPs taken by staff followed by 24-h ABPM within 2 weeks of home BP. BP indices (measured BP/95%ile BP) were calculated for mean triplicate attended HBPM and mean ABPM measurements. Paired HBPM and ABPM measurements taken during any of 5 study visits were compared using linear regression with robust standard errors. Generalized estimating equation-based logistic regression determined sensitivity, specificity, negative, and positive predictive values with ABPM as the gold standard. Analyses were conducted for the group overall and by subgroup.

RESULTS

A total of 103 participants contributed 251 paired measurements. Indexed systolic BP did not differ between HBPM and daytime APBM (mean difference - 0.002; 95% CI: - 0.006, 0.003); the difference in indexed diastolic BP was minimal (mean difference - 0.033; 95% CI: - 0.040, - 0.025). Overall agreement between HBPM and 24-h ABPM in identifying abnormal BP was high (81.8%). HBPM had higher sensitivity (87.5%) than specificity (77.4%) and greater negative (89.8%) than positive (73.3%) predictive value, and findings were consistent in subgroups.

CONCLUSIONS

Attended HBPM may be reasonable for monitoring BP when ABPM is unavailable. The greater accessibility and feasibility of attended HBPM may potentially help improve BP control among at-risk youth. A higher resolution version of the Graphical abstract is available as Supplementary information.

Towards Developing a Voice-activated Self-monitoring Application (VoiS) for Adults with Diabetes and Hypertension

The integration of motivational strategies and self-management theory with mHealth tools is a promising approach to changing the behavior of patients with chronic disease. In this manuscript, we describe the development and current architecture of a prototype voice-activated self-monitoring application (VoiS) which is based on these theories. Unlike prior mHealth applications which require textual input, VoiS app relies on the more convenient and adaptable approach of asking users to verbally input markers of diabetes and hypertension control through a smart speaker. The VoiS app can provide real-time feedback based on these markers; thus, it has the potential to serve as a remote, regular, source of feedback to support behavior change. To enhance the usability and acceptability of the VoiS application, we will ask a diverse group of patients to use it in real-world settings and provide feedback on their experience. We will use this feedback to optimize tool performance, so that it can provide patients with an improved understanding of their chronic conditions. The VoiS app can also facilitate remote sharing of chronic disease control with healthcare providers, which can improve clinical efficacy and reduce the urgency and frequency of clinical care encounters. Because the VoiS app will be configured for use with multiple platforms, it will be more robust than existing systems with respect to user accessibility and acceptability.

Self-monitoring of blood pressure among women with hypertensive disorders of pregnancy: a systematic review

BACKGROUND

The World Health Organization (WHO) recommends self-monitoring of blood pressure (SMBP) for hypertension management. In addition, during the COVID-19 response, WHO guidance also recommends SMBP supported by health workers although more evidence is needed on whether SMBP of pregnant individuals with hypertension (gestational hypertension, chronic hypertension, or pre-eclampsia) may assist in early detection of pre-eclampsia, increase end-user autonomy and empowerment, and reduce health system burden. To expand the evidence base for WHO guideline on self-care interventions, we conducted a systematic review of SMBP during pregnancy on maternal and neonatal outcomes.

METHODS

We searched for publications that compared SMBP with clinic-based monitoring during antenatal care. We included studies measuring any of the following outcomes: maternal mortality, pre-eclampsia, long-term risk and complications, autonomy, HELLP syndrome, C-section, antenatal hospital admission, adverse pregnancy outcomes, device-related issues, follow-up care with appropriate management, mental health and well-being, social harms, stillbirth or perinatal death, birthweight/size for gestational age, and Apgar score. After abstract screening and full-text review, we extracted data using standardized forms and summarized findings. We also reviewed studies assessing values and preferences as well as costs of SMBP.

RESULTS

We identified 6 studies meeting inclusion criteria for the effectiveness of SMBP, 6 studies on values and preferences, and 1 study on costs. All were from high-income countries. Overall, when comparing SMBP with clinic-monitoring, there was no difference in the risks for most of the outcomes for which data were available, though there was some evidence of increased risk of C-section among pregnant women with chronic hypertension. Most end-users and providers supported SMBP, motivated by ease of use, convenience, self-empowerment and reduced anxiety. One study found SMBP would lower health sector costs.

CONCLUSION

Limited evidence suggests that SMBP during pregnancy is feasible and acceptable, and generally associated with maternal and neonatal health outcomes similar to clinic-based monitoring. However, more research is needed in resource-limited settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021233839 .

Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke

Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant. Important questions in a secondary prevention setting include should everyone be treated regardless of their poststroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored. We review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.

The biopsychosociotechnical model: a systems-based framework for human-centered health improvement

The biopsychosocial model is among the most influential frameworks for human-centered health improvement but has faced significant criticism- both conceptual and pragmatic. This paper extends and fundamentally re-structures the biopsychosocial model by combining it with sociotechnical systems theory. The resulting biopsychosociotechnical model addresses key critiques of the biopsychosocial model, providing a more "practical theory" for human-centered health improvement. It depicts the determinants of health as complex adaptive system of systems; includes the the artificial world (technology); and provides a roadmap for systems improvement by: differentiating between "health status" and "health and needs assessment", [promoting problem framing]; explaining health as an emergent property of the biopsychosociotechnical context [imposing a systems orientation]; focusing on "interventions" vs. "treatments" to modify the biopsychosociotechnical determinants of health, [expanding the solution space]; calling for a participatory design process [supporting systems awareness and goal-orientation]; and including intervention management to support the full lifecycle of health improvement.

Interventions for Adherence Improvement in the Primary Prevention of Cardiovascular Diseases: Expert Consensus Statement

Over the last 2 decades, the management of chronic disease in Korea has been improved, but it has gradually stagnated. In order to improve care and reduce cardiovascular morbidity and mortality, it is crucial to improve primary prevention of cardiovascular diseases. In recent international guidelines for hypertension, diabetes, hyperlipidemia, obesity, and other conditions, adherence issues have become more frequently addressed. However, in terms of implementation in practice, separate approaches by dozens of related academic specialties need to be integrated into a systematic approach including clinician’s perspectives such as the science behind adherence, clinical skills, and interaction within team approach.

In primary prevention for cardiovascular diseases, there are significant barriers to adherence including freedom from symptoms, long latency for therapeutic benefits, life-long duration of treatment, and need for combined lifestyle changes. However, to implement more systematic approaches, the focus on adherence improvement needs to be shifted away from patient factors to the effects of the treatment team and healthcare system. In addition to conventional educational approaches, more patient-oriented approaches such as patient-centered clinical communication skills, counseling using motivational strategies, decision-making by patient empowerment, and a multi-disciplinary team approach should be developed and implemented. Patients should be involved in a program of self-monitoring, self-management, and active counseling. Because most effective interventions on adherence improvement demand greater resources, the health care system and educational or training system of physicians and healthcare staff need to be supported for systematic improvement.

Home blood pressure monitors owned by participants in a large decentralised clinical trial in hypertension: the Treatment In Morning versus Evening (TIME) study

Various home blood pressure monitors (HBPMs) are available to the public for purchase but only some are validated against standardised protocols. This study aimed to assess whether HBPMs owned by participants taking part in a clinical trial were validated models. The TIME study is a decentralised randomised trial investigating the effect of antihypertensive medication dosing time on cardiovascular outcomes in adults with hypertension. No HBPMs were provided to participants in this trial but patients were asked to report if they already owned one. We identified the model of HBPM reported by participants, then cross-referenced this against lists of validated HBPMs produced by dabl Educational Trust and the British and Irish Hypertension Society (BIHS). Of 21,104 participants, 10,464 (49.6%) reported their model of HBPM. 7464 (71.3%) of these participants owned a monitor that could be identified from the participants' entry. Of these, 6066 (81.3%) participants owned a monitor listed as validated by either dabl (n = 5903) or BIHS (n = 5491). Some were listed as validated by both. 1398 (18.7%) participants owned an identifiable HBPM that lacked clear evidence of validation. 6963 (93.3%) participants owned an upper arm HBPM and 501 (6.7%) owned a wrist HBPM. Validated HBPMs had a higher median online retail price of £45.00 compared to £20.00 for HBPMs lacking clear evidence of validation. A significant number of participants own HBPMs lacking evidence of validation.

Factors influencing home blood pressure monitor ownership in a large clinical trial

Home blood pressure monitor (HBPM) ownership prevalence and the factors that influence it are unclear. This study aimed to investigate factors associated with HBPM ownership among participants in the Treatment in Morning versus Evening (TIME) hypertension study. This study is a sub-analysis of the TIME study, a randomised trial investigating the effect of day-time versus night-time dosing of antihypertensive medication on cardiovascular outcomes in adults with hypertension. As part of the TIME study online registration process, participants were asked to indicate whether they owned an HBPM. A multivariable logistic regression model was constructed to determine factors associated with HBPM ownership. Of 21,104 randomised participants, 11,434 (54.2%) reported owning an HBPM. The mean age of all participants at enrolment was 67.7 ± 9.3 years, 12,134 (57.5%) were male, and 8892 (42.1%) reported a current or previous history of smoking. Factors associated with an increased likelihood of reporting HBPM owned include being male (OR:1.47; 95% CI 1.39–1.56) or residing in a less deprived socioeconomic region (IMD Decile 6–10) (OR:1.31; 95% CI 1.23–1.40). Participants with a history of diabetes mellitus (OR:0.74; 95% CI:0.64–0.86) or current smokers, compared to non-smokers, (OR:0.71; 95% CI:0.62–0.82) were less likely to report owning an HBPM. This study has identified important patient factors influencing HBPM ownership. Further qualitative research would be valuable to identify and explore potential patient-level barriers to engagement with self-monitoring of blood pressure.

The effects of foot reflexology on blood pressure and heart rate: A randomized clinical trial in stage-2 hypertensive patients

Hypertension (HT) is a prominent cardiovascular risk factor. Although there are various pharmacological treatment choices for this condition, many patients fail to adhere to them, making non-pharmacological options attractive alternatives. Foot reflexology has been proven to decrease blood pressure (BP), but data are limited in patients with stage-2 HT. We conducted a randomized clinical trial to examine the effectiveness of foot reflexology in reducing BP and heart rate (HR). Stage-2 HT patients were enrolled and randomized into the intervention and the control groups (n = 47, each), the former of which underwent foot reflexology during a follow-up visit. Office BP and HR were measured before and at 15 and 30 min after the procedure in the intervention group and after resting in the control group. In the intervention group, systolic BP (SBP), diastolic BP (DBP), and HR at 15 min were significantly lower than at baseline: -3.29 mm Hg (95%CI; -5.64 to -0.93), -1.71 mm Hg (95%CI; -3.11 to -0.32), and -1.71 beats per min (bpm; 95%CI; -2.88 to -0.54), respectively. Similar trends were also observed at 30 min. However, when compared with the control group, only the reduction in HR was significant (-4.96 bpm; 95%CI, -9.63 to -0.28). We conclude that foot reflexology was effective in reducing HR in stage-2 HT patients and partially effective in reducing BP.

Adding Home and/or Ambulatory Blood Pressure to Office Blood Pressure for Cardiovascular Risk Prediction

Home and 24-hour blood pressure (BP_Home and BP_24h) are believed to improve the prognostic value of office BP (BP_Office) alone, but the evidence has limitations such as that (1) these 3 BPs are characterized by multicollinearity and (2) the procedures adopted do not allow quantification of the prognostic advantage. One thousand eight hundred thirty-three individuals belonging to the PAMELA (Pressioni Arteriose Monitorate e Loro Associazioni) were followed for 16 years. Prediction of cardiovascular and all-cause mortality was determined via the goodness of fit of individual data (Cox model), the area underlying the receiving operator curves and the net reclassification improvement of cardiovascular and all-cause mortality risk. Calculations were made for BP_Office alone and after addition of BP_Home, BP_24h, or both, limited to their residual portion which was found to be unexplained by, and thus independent on, BP_Office. With all methods addition of residual out-of-office systolic or diastolic BP to BP_Office significantly improved cardiovascular and all-cause mortality prediction. The improvement was more consistent when BP_Home rather than BP_24h was added to BP_Office and, compared with BP_Office plus BP_Home, no better prediction was found when addition was extended to BP_24h. With all additions, however, the improvement was quantitatively modest, which was the case also when data were separately analyzed in younger and older individuals or in dippers and nondippers. Thus, addition of out-of-office to BP_Office improves prediction of cardiovascular risk, even when data analysis avoids previous limitations. The improvement appears to be limited, however, which raises the question of the advantage to recommend their extended use in clinical practice.

Measurement of SBP at home by parents using hand-held Doppler device and aneroid sphygmomanometer: a single-centre experience

OBJECTIVE

We taught parents to use at home a hand-held Doppler device and aneroid sphygmomanometer for SBPmeasurement (HDBPM).

METHODS

Retrospective study including all children referred to evaluate hypertension over a 6-year period. Each child underwent HDBPM measurements performed by parents while awake over 2 weeks with three measurements performed twice daily.

RESULTS

Of n = 155 children, 145 (93.5%) were successful and aged median (interquartile range) 2.48 (1.01, 5.12) years, including 85 boys. Overall, there were 25, 19, 30 and 26% aged less than 1, 1 to less than 2, 2 to less than 5 and at least 5 years old, respectively. Seventy-eight (54%) had been referred for confirming diagnosis and 67 (46%) for ongoing monitoring of treated hypertension. Following HDBPM, 70 of 78 (90%) patients in the 'Diagnosis subgroup' were observed to have normal blood pressure (BP). In the monitoring subgroup, treated hypertension that required no medication changes was recorded in 35 of 67 (52%) and medication changed in 32 of 67 (48%), [increased, decreased or changed] in 22, 6 and 5%, respectively. In 10 of 67 (15%) medication was weaned and stopped completely following HDBPM. None of the children required admission to hospital to evaluate their BP level or manage hypertension.

CONCLUSION

Out-of-office BP monitoring using HDBPM is acceptable to children and families of young children when parents are taught to measure BP and supported by health professionals. We report evidence of the feasibility and clinical utility of HDBPM in a challenging population of children who are either too young or unable to tolerate 24-h ambulatory BP monitoring for both the diagnosis and ongoing management of clinically relevant hypertension.

The Night Side of Blood Pressure: Nocturnal Blood Pressure Dipping and Emotional (dys)Regulation

Introduction: The dipping phenomenon is a physiological drop in blood pressure (around 10-20%) during sleep and represents an event related to the circadian blood pressure trend. This phenomenon, in some cases, is characterized by some alterations that can be expressed by an increase (extreme dipping), a decrease (non-dipping), or a reverse (i.e., higher blood pressure during sleep compared to awake state; reverse-dipping) physiological decline of blood pressure. Few studies focused on the association between the circadian variation of blood pressure and psychological variables, although this information could help understanding how psychological characteristics (e.g., emotional regulation or dysregulation) interact with individuals' physiological processes. Given the association between emotional dysregulation and essential hypertension, this study aimed to investigate the relationship between alexithymia and dipping status in a sample of healthy and hypertensive adults in the absence of other medical conditions. Methods: Two hundred and ten adults took part in the study and were classified, according to ambulatorial blood pressure measure (ABPM), into three groups: dippers (n = 70), non-dippers (n = 70), and extreme dippers (n = 70). The participants completed a socio-demographic and anamnestic interview and the Toronto Alexithymia Scale-20 (TAS-20). Results: The ANOVAs on the TAS-20 subscales showed that the groups differed in the difficulty identifying feelings and difficulty describing feelings. In both the subscales, dippers showed lower scores than non-dippers and extreme dippers. The ANOVA on the global score of TAS-20 confirmed that dippers were less alexithymic than both extreme dippers and non-dippers. Conclusions: This study confirms that some psychological factors, like alexithymia, could represent a characteristic of patients who fail to exhibit an adaptive dipping phenomenon. Moreover, an association between an excessive reduction of BP (extreme dipping) or a lack of the decrease of BP during sleep (non-dipping) and a worse emotional regulation, considering alexithymia construct, was highlighted for the first time, confirming the relevant role of the emotional process in the modulation of an essential psychophysiological process such as the circadian variation of BP.

Overview of blood pressure measurement by Brazilian health professionals

Although automated monitors for blood pressure (BP) measurement are used increasingly worldwide, understanding of how such devices are used in Brazil is low. This study analyzed the status of BP measurement by Brazilian health professionals. A questionnaire regarding experience with BP measurement was sent electronically to Brazilian nurses, nursing assistants, and doctors. It had 2004 responses. Previous experience with use of automated monitors was most frequent in men (71.2%), nursing technicians (65.5%), specialists (61.1%), secondary care (71.9%), emergency care (70.6%), or the private sector (66.3%). The least complied aspects of the standardized measurement protocol were availability of various cuff sizes (53.9% and 72.9% for auscultatory and oscillometric methods, respectively) and proper calibration checks (21.5% and 46.8% for auscultatory and oscillometric methods, respectively). Brazilian health professionals report not adequately performing all the necessary aspects to measure BP in accordance with the standardized protocol in both methods, but mainly regarding the oscillometric.

Optimizing observer performance of clinic blood pressure measurement: a position statement from the Lancet Commission on Hypertension Group

High blood pressure (BP) is a highly prevalent modifiable cause of cardiovascular disease, stroke, and death. Accurate BP measurement is critical, given that a 5-mmHg measurement error may lead to incorrect hypertension status classification in 84 million individuals worldwide. This position statement summarizes procedures for optimizing observer performance in clinic BP measurement, with special attention given to low-to-middle-income settings, where resource limitations, heavy workloads, time constraints, and lack of electrical power make measurement more challenging. Many measurement errors can be minimized by appropriate patient preparation and standardized techniques. Validated semi-automated/automated upper arm cuff devices should be used instead of auscultation to simplify measurement and prevent observer error. Task sharing, creating a dedicated measurement workstation, and using semi-automated or solar-charged devices may help. Ensuring observer training, and periodic re-training, is critical. Low-cost, easily accessible certification programs should be considered to facilitate best BP measurement practice.

The Night Effect of Anger: Relationship with Nocturnal Blood Pressure Dipping

INTRODUCTION

The circadian pattern of blood pressure is characterized by a physiological drop occurring after sleep onset. The alteration of this phenomenon (non-dipping, extreme dipping, or reverse dipping) is associated with an increased cardiovascular risk. Besides altered autonomic and endocrine circadian rhythms, psychological aspects seem to play a role in this modification. However, the few studies that have analyzed the influence of psychological dimensions on the dipping phenomenon have reported inconsistent results. This study aimed to examine the relationship between anger expression and blood pressure (BP) dipping.

METHODS

We obtained 24 h ambulatory BP measurements from 151 participants and used them to define three groups according to their dipping status: Dippers (N = 65), Non-Dippers (N = 42), and Extreme Dippers (N = 44). Sociodemographic and anamnestic information was collected, and the State-Trait Anger Expression Inventory was used to assess anger.

RESULTS

Analysis of variance evidenced significant higher scores for Trait Anger Temperament and Anger Expression in Extreme Dippers than in both Dippers and Non-Dippers. However, after controlling for confounding variables, there was no significant relationship with trait anger, and only the result concerning the suppression of anger was confirmed.

CONCLUSIONS

These findings suggest that the analysis of some psychological factors, such as anger, could be necessary to better understand differences in nocturnal BP alterations. Trait anger and suppression of anger may contribute to the description and classification of patients who exhibit a maladaptive dipping phenomenon. However, modifiable (i.e., cigarette consumption) and unmodifiable (i.e., age) risk factors appear to mediate this relationship. Although further studies are necessary to explore this association, these results highlight that some aspects of anger can represent risk factors or markers of maladaptive modulation of the dipping phenomenon.

Blood pressure after PREeclampsia/HELLP by SELF monitoring (BP-PRESELF): rationale and design of a multicenter randomized controlled trial

Background

Hypertensive disorders of pregnancy (HDP), such as preeclampsia (PE) or the Hemolysis Elevated Liver enzymes and Low Platelets (HELLP) syndrome are associated with elevated cardiovascular disease (CVD) risks, but standardized prevention guidelines after such pregnancies are lacking. Hypertension is the first emerging risk factor after PE/HELLP pregnancies and is a major risk factor for CVD. Hypertension before the age of 55 years may lead to various manifestations of end-organ damage at relatively young age. Therefore, timely treatment of elevated blood pressure is mandatory, but many of these high-risk women have long-term undetected and untreated hypertension before adequate treatment is initiated.

Aim

The aim of our study is to assess whether home blood pressure monitoring (HBPM) in women with a previous PE/HELLP pregnancy is a valuable tool for the early detection of hypertension.

Methods

Women with a history of both early and late PE/HELLP syndrome aged 40–60 years are invited to participate. Patients with a history of CVD, known hypertension and/or use of antihypertensive medication are excluded. Women are randomized between HPBM or ‘usual care’. The primary outcome is feasibility and usability of HBPM after 1 year of follow-up.

Secondary outcomes will be the effectiveness of HPBM to detect hypertension, the efficacy of BP treatment, quality of life, health-related symptoms, work ability, and life-style behaviour.

The results of this study will provide better strategies for timely detection and prevention of hypertension in women after PE/HELLP.

Trial registration

ClinicalTrials.gov, NCT03228082. Registered June 15, 2017.

Comparison of monocyte with high density lipoprotein cholesterol ratio in dipper and nondipper hypertensive patients

Aim: We aimed to compare the monocyte to HDL-cholesterol ratio (MHR) of nondipper hypertension (NDHT) and dipper hypertension patients. Patients & methods: A total of 162 patients were included in the study. Patients were grouped as dipper and nondipper according to 24-h ambulatory blood pressure recordings. Results: The MHR was significantly higher in nondipper hypertension group compared with control (p < 0.001) and dipper hypertension groups (p = 0.03). MHR, hs-CRP and red-cell distribution width (RDW) were independent predictors of nondipper hypertension. Area under the curve was 0.62 (p = 0.034) for MHR and 0.61 (p = 0.012) for hs-CRP in the ROC analysis. Conclusion: MHR has elevated levels in NDHT patients. Increased levels of MHR may evaluate as increased risk of cardiovascular events in NDHT patients.

Changes in community pharmacists' knowledge, attitudes, and practice regarding the management of hypertension before and after educational interventions

Objective: To clarify changes in community pharmacists' knowledge, attitudes, and practice regarding the management of hypertension before and after attending educational interventions based on their self-report on a questionnaire survey.Method: We conducted questionnaire surveys regarding the management of hypertension with a sample of community pharmacists before and after educational interventions.Results: The proportions of pharmacists who knew the 2014 Japanese Society of Hypertension Guidelines, guidelines for home blood pressure measurement, reference values for hypertension based on clinic-measured blood pressure, and reference values for hypertension based on home-measured blood pressure after the educational interventions (59.3%, 41.4%, 75.1%, and 70.8% respectively) were significantly higher relative to those recorded before interventions (31.6%, 13.7%, 47.7%, and 25.4% respectively).Conclusions: These findings suggest that in-house training might increase the knowledge of community pharmacists regarding hypertension management.

Validity of self blood pressure measurement in the control of the hypertensive patient: factors involved

Background

Improving clinical practice aimed at controlling hypertension is a pending issue in health systems. One of the methods currently used for this purpose is self blood pressure measurement (SBPM) whose use increases every day. The aims of this study are to establish the optimal cut-off point for the 3-day SMBP protocol and to identify factors that could affect the precision of the 3-day SMBP protocol using 24-h ambulatory blood pressure monitoring (ABPM) as a reference.

Method

This is a cross-sectional descriptive study to validate a diagnostic test performed by a primary care team in Murcia, Spain. A total of 153 hypertensive patients under 80 years of age who met the inclusion criteria were evaluated. ABPM was performed for 24 h. The SBPM protocol consisted of recording 2 measurements in the morning and 2 at night for 3 days.

Results

The cut-off point for SBP was set at 135 mmHg (sensitivity: 80.39%, specificity: 74.19%), and for DBP, it was set at 83 mmHg (sensitivity: 76.48%, specificity: 84.89%), which yielded the highest combined sensitivity and specificity. After carrying out the validation study with the new figures, we proceeded to establish which socio-demographic factors prevented a correct classification of patients. These errors were more common in male patients for the assessments of both DBP (OR = 2.4) and SBP (OR = 2.5); hypertensive patients with age < 67,5 years (OR = 1,5); having no work activity (OR = 3,6) and with concomitant chronic kidney disease (CKD) (OR = 5.0).

Conclusion

Being male, older than 67.5 years, with CKD or with no work activity increases the probability of being misclassified for hypertension during follow-up as assessed by SBPM over 3 days.

Trial registration

This study was approved by the research ethics committee of the University of Murcia under registration number 1018/2015.

Connected Health in Hypertension Management

e-health is defined as the use of communication and information technologies (ICT) to manage patients and their health in a more efficient way, with the aim of improving the overall quality of care. Healthcare services relying on telehealth (or telemedicine) and mobile health (m-health) are the most popular e-health tools used by healthcare professionals and consumers. These applications allow the exchange of medical data between patients and their doctors or among healthcare professionals, mainly through the Internet, and are used to provide healthcare services remotely (so-called "connected health"). The most popular telemedicine application in the field of hypertension is blood pressure telemonitoring (BPT), which enables transmission of BP and various clinical information from patients' homes or from the community to the doctor's surgery or the hospital. Numerous randomized controlled trials have documented a significant BP reduction combined with an intensification and optimization of the use of antihypertensive medications in patients making use of BPT plus remote counseling by a case manager, with the supervision of a doctor or a community pharmacist (telepharmacy). The major benefits of BPT are usually observed in high-risk patients. BPT can also be based on m-health wireless solutions, provided with educational support, medication trackers and reminders, and teleconsultation. In this context, BPT may favor patient's self-management, as an adjunct to the doctor's intervention, and foster patient's participation in medical decision making, with consequent improvement in BP control and increase in medication adherence. In conclusion, e-health solutions, and in particular telemedicine, are increasingly attaining a key position in the management of the hypertensive patient, with an enormous potential in terms of improvement of the quality of the delivered care, increase in the chance of a successful BP control and effective prevention of cardiovascular diseases.

The optimal night-time home blood pressure monitoring schedule: agreement with ambulatory blood pressure and association with organ damage

OBJECTIVE

Night-time home blood pressure (HBP) monitoring has emerged as a feasible, reliable and low-cost alternative to ambulatory blood pressure (ABP) monitoring. This study evaluated the optimal schedule of night-time HBP monitoring in terms of agreement with night-time ABP and association with preclinical target-organ damage.

METHODS

Untreated hypertensive adults were evaluated with ABP (24-h) and HBP monitoring (daytime: six days, duplicate morning and evening measurements; night-time: three nights, three-hourly automated measurements/night), and determination of left ventricular mass index, common carotid intima-media thickness and urinary albumin excretion.

RESULTS

A total of 94 patients with all nine night-time HBP measurements were analysed [mean age 51.8 ± 11.1 (SD) years, men 57%). By averaging an increasing number of night-time systolic HBP readings, there was a consistent trend towards stronger association of night-time HBP with night-time ABP (correlation coefficients r increased from 0.69 to 0.81), and with target-organ damage indices (for left ventricular mass index r increased from 0.13 to 0.22, carotid intima-media thickness 0.12-0.25, urinary albumin excretion 0.33-0.41). However, no further improvement in the association was observed by averaging more than four to six night-time readings. The diagnostic agreement between HBP and ABP in detecting nondippers was improved by averaging more readings, with a plateau at four readings (single reading: agreement 81%, kappa 0.37; four readings: 88%, 0.49; nine readings: 84%, 0.40).

CONCLUSION

A two-night HBP schedule (six readings) appears to be the minimum requirement for a reliable assessment of night-time HBP, which gives reasonable agreement with ABP and association with preclinical organ damage.

Automated Office-Based Blood Pressure Measurement: an Overview and Guidance for Implementation in Primary Care

PURPOSE OF REVIEW

The purposes of this study are to review evidence supporting the use of automated office blood pressure (AOBP) measurement and to provide practical guidance for implementing it in clinical settings.

RECENT FINDINGS

Mean AOBP readings correlate with awake ambulatory blood pressure monitor (ABPM) values and predict cardiovascular outcomes better than conventional techniques. However, heterogeneity among readings suggests that AOBP does not replace ABPM. Blood pressure (BP) measurement protocols differ among commonly described AOBP devices, but all produce valid BP estimates. Rest periods should not precede AOBP with BpTRU devices but should occur before use with Omron HEM-907 and Microlife WatchBP Office devices. Attended and unattended AOBP appear to produce similar results. This review also describes a framework to aid AOBP's implementation in clinical practice. Evidence supports AOBP as the preferred method for measuring BP in office settings, but this approach should be a complement to out-of-office measurements, such as self-measured BP monitoring or 24-h ABPM, not a substitute for it.

Biomarkers of nondipper hypertension in prehypertensive and hypertensive patients

Aim: The aim of this study was to evaluate the relation of gamma glutamyl transferase (GGT), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) with nondipper hypertension. Methods: This study included a total of 409 patients. Patients were grouped into hypertension, prehypertension and normotensive groups, according to their clinical blood pressure. All patients were also followed by ambulatory blood pressure. Results: Mean PLR and NLR were higher in the nondippers compared with dippers among both prehypertensive and hypertensive patients. In addition, PLR (OR: 1.011; 95% CI: 1004-1017; p = 0.001), NLR (OR: 2.296, 95% CI: 1634-3225; p < 0.001), and GGT (OR: 1.067; 95% CI: 1042-1092; p < 0.001) were found to be associated with nondipper pattern among whole study population. Conclusion: The PLR, NLR and GGT values are easily accessible and fairly useful, independently associated with nondipper hypertension for both hypertensive and prehypertensive patients.

Accuracy of oscillometric blood pressure algorithms in healthy adults and in adults with cardiovascular risk factors

BACKGROUND

Fixed-ratio and slope-based algorithms are used to derive oscillometric blood pressure (BP). However, a paucity of published data exists assessing the accuracy of these methods. Our objective was to determine the accuracy of fixed-ratio and slope-based algorithms in healthy adults and in adults with cardiovascular risk factors.

PATIENTS AND METHODS

Overall, 85 healthy adults (age≥18 years) and 85 adults with cardiovascular risk factors were studied. Three oscillometric and four two-observer mercury-based auscultation measurements were performed in each, according to International Standards Organization 2013 methodology. Two fixed-ratio algorithms and one slope-based algorithm were applied to process oscillometric waveform envelopes and derive oscillometric BP. Paired and unpaired t-tests were used to compare mean oscillometric BP within and between each group, respectively.

RESULTS

For healthy adults, mean age was 50.3±17.8 years, mean arm circumference was 30.4±3.8 cm, and 62% were female. In the cardiovascular risk group, mean age was 63.8±12.4 years, mean arm circumference was 31.9±4.2 cm, and 62% were female. For systolic BP, the fixed-ratio algorithms produced the lowest mean error and narrowest SD. For diastolic BP, mean errors were similar for all three algorithms, but the fixed-ratio algorithms had higher precision. The comparison of healthy adults and those with cardiovascular risk factor showed high variability for systolic and diastolic BP (SD: 8.113.9 mmHg).

CONCLUSION

In both healthy adults and in those with cardiovascular risk factors, the fixed-ratio technique performed better than the slope-based algorithm. High between-group variability indicates that subject-specific algorithms may be needed.

Implementing Home Blood Pressure Monitoring into Clinical Practice

PURPOSE OF REVIEW

To review data supporting the use of home blood pressure monitoring (HBPM) and provide practical guidance to clinicians wishing to incorporate HBPM into their practice.

RECENT FINDINGS

HBPM more accurately reflects the risk of cardiovascular events than office blood pressure measurement. In addition, there is high-quality evidence that HBPM combined with clinical support improves blood pressure control. Therefore, HBPM is increasingly recommended by guidelines to confirm the diagnosis of hypertension and evaluate the efficacy of blood pressure-lowering medications. Nevertheless, HBPM use remains low due to barriers from the patient, clinician, and healthcare system level. Understanding these barriers is crucial for developing strategies to effectively implement HBPM into routine clinical practice. HBPM is a valuable adjunct to office blood pressure measurement for diagnosing hypertension and guiding antihypertensive therapy. Following recommended best practices can facilitate the successful implementation of HBPM and impact how hypertension is managed in the primary care setting.

Development and Preliminary Feasibility of an Automated Hypertension Self-Management System

BACKGROUND

Uncontrolled hypertension constitutes a significant challenge throughout the world. Blood pressure measurement by patients is informative for both patients and providers but is rarely performed systematically, thereby reducing its utility. Mobile phones can be used to efficiently prompt individuals to measure blood pressure and automate data management while avoiding technology barriers to widespread adoption. Presented is the design and pilot test results of MyBP, an automated texting intervention to support blood pressure self-monitoring and patient self-management.

METHODS

Three sequential phases are described: (1) stakeholders' needs assessment, (2) preliminary design pilot (n = 10), and (3) a 6-week pilot of the redesigned comprehensive program with hypertensive patients (n = 43) recruited from 3 clinical sites (Emergency Department, Primary Care, Hypertension Center). Outcomes of interest included participant adherence, perceived importance of blood pressure monitoring, and healthy behavior change.

RESULTS

Median adherence to MyBP prompts over 6 weeks was 79% (72% emergency department, 84% primary care, and 96% hypertension center, H[2] = 5.56, P = .06). Adherence did not vary by age, sex, education, or baseline use of texting but was lowest among patients recruited from the emergency department (χ[2]2 = 6.66, P = .04). In the exit survey, MyBP was associated with increased importance of blood pressure self-monitoring and particularly motivated primary care and emergency department groups to improve dietary habits, increase daily physical activity, and focus on stress reduction. The majority of participants (88%) indicated interest in using the program for 6 months.

CONCLUSIONS

Automated mobile-phone-based blood pressure self-monitoring using MyBP is feasible, acceptable, and scalable, and may improve self-management and support clinical care.

Links between blood pressure and medication intake, well-being, stress, physical activity and symptoms reported via a mobile phone-based self-management support system: a cohort study in primary care

OBJECTIVES

To explore relationships between patients' self-monitoring of blood pressure (BP) and their concurrent self-reports of medication intake, well-being, stress, physical activity and symptoms.

DESIGN

This study is a secondary analysis of a prospective study exploring the 8-week effectiveness of a mobile phone-based self-management support system for patients with hypertension.

SETTING

Four primary healthcare centres situated in urban and suburban communities in Sweden.

PARTICIPANTS

50 patients undergoing treatment for hypertension.

PRIMARY AND SECONDARY OUTCOME MEASURES

Associations between systolic (SBP) and diastolic blood pressure (DBP) and 10 self-report lifestyle-related variables were analysed using linear mixed effects modelling.

RESULTS

Medication intake, better well-being, less stress and greater physical activity were associated variously with lower same-day SBP and DBP. The single strongest association was found between medication intake and SBP, where failure to take medications was associated with an estimated 7.44 mm Hg higher SBP. To a lesser degree, medication intake was also associated with DBP, where DBP was 4.70 mm Hg higher in cases where medications were not taken. Well-being and stress were consistently associated with SBP and DBP, whereas physical activity was associated with only SBP. None of the symptoms-dizziness, headache, restlessness, fatigue or palpitations-were significantly associated with BP.

CONCLUSIONS

Our findings that BP was associated with patients' BP management behaviours and experiences of well-being and stress, but not symptoms suggest that enabling persons with hypertension to monitor and track their BP in relation to medication intake, physical activity, well-being, stress and symptoms may be a fruitful way to help them gain first-hand understanding of the importance of adherence and persistence to treatment recommendations.

TRIAL REGISTRATION NUMBER

NCT01510301; Pre-results.