The Effects of Ambulatory Blood Pressure Monitoring on Sleep Quality in Men and Women With Hypertension: Dipper vs. Nondipper and Race Differences

Is the heart rate dipping pattern associated with sleep quality during an ambulatory blood pressure monitoring? A cross-sectional study

OBJECTIVE

The aim of this study was to characterize individuals with nondipping heart rate (HR) and to assess the association between that pattern and sleep quality during the night of an ambulatory blood pressure monitoring (ABPM).

METHODS

Individuals who attended our Unit to perform an ABPM, from February 2022 to May 2024, were asked about clinical and epidemiological antecedents and responded two validated surveys, about sleep quality during the night of the ABPM and in the prior 30 days. Then, they were categorized according to the presence of a dipping in nocturnal HR (defined as a decline in average HR at night equal or higher than 10% compared with daytime values) as HR dippers or HR nondippers (drop in mean nighttime HR lower than 10% of diurnal mean) in order to compare the mentioned variables.

RESULTS

One thousand two hundred and nine individuals were included. They were predominantly female (61.8%), middle-aged (median 50 years, IQR 36-60), overweight (median BMI 29, IQR 25.3-33.5) and had median ABPM estimates within normal ranges. In individuals without beta-blockers ( n  = 1107), HR nondippers had an adverse cardiovascular disease (CVD) risk profile, and no differences were found between HR dippers and HR nondippers concerning perceived good rest during the ABPM night (63.5 vs. 59.7%, P  = 0.211) and usual sleep quality. The sensitivity analysis including beta-blockers' users ( n  = 102) was consistent.

CONCLUSION

A blunted dipping in mean nighttime HR identifies individuals with a high CVD risk profile and is not associated with bad sleep quality during the night of an ABPM.

Minimal changes in sleep parameters during overnight ambulatory blood pressure monitoring do not affect outcomes

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) is considered the gold standard for assessing blood pressure; however, its use may potentially disrupt sleep. Previous studies have produced mixed results on the impact of ABPM on sleep parameters and used actigraphy as the evaluating tool. To date, no studies have investigated the effects of ABPM on sleep parameters evaluated through polysomnography.

PURPOSE

This study aimed to examine the effects of ABPM on objectively assessed sleep parameters.

METHODS

We evaluated five women and five men (age: 38.0 ± 15.0 years; BMI: 27.0 ± 3.5 kg/m²) using full polysomnography over two nights in a sleep laboratory-one night with ABPM and one night without it, with nocturnal assessments every 30 min. The order of the conditions was randomized, with intervals between nights ranging from 3 to 10 days.

RESULTS

N2 sleep was significantly longer during the night with ABPM compared to the night without it (66.4 ± 12.4% vs. 57.7 ± 11.3%, p < 0.003). Conversely, the apnea-hypopnea index was higher on the night without ABPM (13.1 ± 21.2 vs. 10.5 ± 19.8 events/hour, p < 0.005). Participants did not rate the night with ABPM as worse than the night without, and no significant differences were observed in total sleep time, sleep latency, sleep efficiency, number of awakenings, or time awake after sleep onset.

CONCLUSIONS

ABPM does not appear to adversely affect significant objective sleep parameters or subjective evaluations of sleep quality.

Electroencephalogram of Normotensive Individuals During Sitting and Standing Blood Pressure Measurement Positions

Background Investigating changes in brain electroencephalogram activity during blood pressure measurement in sitting and standing positions is clinically significant for understanding the neural correlates of postural changes, which may affect cerebral perfusion and autonomic regulation. Shifts in blood pressure can influence visual cortical activity, potentially altering cognitive and sensory processing. This research holds clinical relevance in evaluating disorders like orthostatic hypotension and syncope, where postural changes compromise cerebral blood flow. Furthermore, it can help refine diagnostic protocols and management strategies for neurovascular and autonomic dysfunction. The study also highlighted the possibility of using polygraphs to identify and manage discrepancies in blood pressure measurement caused by posture-induced changes in brain activities for accurate diagnosis. Methodology The electroencephalogram of healthy normotensive female individuals undergoing blood pressure measurements at sitting and standing positions was investigated. Ten healthy young adult females who satisfy the inclusion criteria were selected. Electroencephalographic (EEG) waves were recorded with the aid of Powerlab 26T (ADInstruments Pty Ltd., Bella Vista, Australia). Blood pressure and pulse rate measurements were conducted using a sphygmomanometer and stopwatch. Results During sitting and standing blood pressure positions, diastolic blood pressure and pulse rate were higher when compared to baseline values but the standing blood pressure position showed a higher pulse rate than the sitting blood pressure position. Although alpha wave frequency was higher during both sitting and standing blood pressure measurement positions, the standing blood pressure position caused lower alpha wave frequency when compared with the sitting blood pressure measurement position. While a strong negative correlation was found between alpha wave frequency and pulse rate, beta wave frequency positively correlated with pulse rate during sitting blood pressure measurement position. Furthermore, during standing blood pressure measurement position, the alpha wave did not correlate with pulse rate nor was there a correlation between beta wave frequency and pulse rate. In conclusion, the present study indicated that both sitting and standing blood pressure measurement positions caused a decrease in alpha wave frequency when compared with baseline, but the standing blood pressure measurement position elicited a lower alpha wave frequency when compared with the sitting blood pressure measurement position.

Cognitive behavior therapy for insomnia for untreated hypertension with comorbid insomnia disorder: The SLEEPRIGHT clinical trial

Insomnia and poor sleep are associated with an increased risk of developing cardiovascular disease (CVD) and its precursors, including hypertension. In 2022, the American Heart Association (AHA) added inadequate sleep to its list of health behaviors that increase the risk for CVD. It remains unknown, however, whether the successful treatment of insomnia and inadequate sleep can reduce heightened CVD risk. SLEEPRIGHT is a single-site, prospective clinical trial designed to evaluate whether the successful treatment of insomnia results in improved markers of CVD risk in patients with untreated hypertension and comorbid insomnia disorder. Participants (N = 150) will undergo baseline assessments, followed by a 6-week run-in period after which they will receive cognitive behavior therapy for insomnia (CBT-I), comprised of 6 hourly sessions with an experienced CBT-I therapist over a 6-week period. In addition to measures of insomnia severity, as well as both subjective and objective measures of sleep, the primary outcome measures are nighttime blood pressure (BP) and BP dipping assessed by 24-h ambulatory BP monitoring (ABPM). Secondary outcomes include several CVD risk biomarkers, including clinic BP, lipid profile, vascular endothelial function, arterial stiffness, and sympathetic nervous system (SNS) activity. Data analysis will evaluate the association between improvements in insomnia and sleep with primary and secondary CVD risk biomarker outcomes. The SLEEPRIGHT trial (ClinicalTrials.Gov NCT04009447) will utilize CBT-I, the current gold standard treatment for insomnia disorder, to evaluate whether reducing insomnia severity and improving sleep are accompanied by improved biomarkers of CVD risk in patients with untreated hypertension.

Feasibility and Effectiveness of a Ring-Type Blood Pressure Measurement Device Compared With 24-Hour Ambulatory Blood Pressure Monitoring Device

BACKGROUNDS AND OBJECTIVES

This study aimed to evaluate the applicability and precision of a ring-type cuffless blood pressure (BP) measurement device, CART-I Plus, compared to conventional 24-hour ambulatory BP monitoring (ABPM).

METHODS

Forty patients were recruited, and 33 participants were included in the final analysis. Each participant wore both CART-I Plus and ABPM devices on the same arm for approximately 24 hours. BP estimation from CART-I Plus, derived from photoplethysmography (PPG) signals, were compared with the corresponding ABPM measurements.

RESULTS

The CART-I Plus recorded systolic blood pressure (SBP)/diastolic blood pressure (DBP) values of 131.4±14.1/81.1±12.0, 132.7±13.9/81.9±11.9, and 128.7±14.6/79.3±12.2 mmHg for 24-hour, daytime, and nighttime periods respectively, compared to ABPM values of 129.7±11.7/84.4±11.2, 131.9±11.6/86.3±11.1, and 124.5±13.6/80.0±12.2 mmHg. Mean differences in SBP/DBP between the two devices were 1.74±6.69/-3.24±6.51 mmHg, 0.75±7.44/-4.41±7.42 mmHg, and 4.15±6.15/-0.67±5.23 mmHg for 24-hour, daytime, and nighttime periods respectively. Strong correlations were also observed between the devices, with r=0.725 and r=0.750 for transitions in SBP and DBP from daytime to nighttime, respectively (both p<0.001).

CONCLUSIONS

The CART-I Plus device, with its unique ring-type design, shows promising accuracy in BP estimation and offers a potential avenue for continuous BP monitoring in clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06084065.

Clinical and life style factors related to the nighttime blood pressure, nighttime dipping and their phenotypes in Korean hypertensive patients

BACKGROUND

Non-dipping or reverse dipping patterns are known to be associated with adverse cardiovascular prognosis among the general population and clinical cohort. Few large sized studies have explored factors including sleep duration and sleep quality related to nighttime blood pressure (BP) and nocturnal dipping patterns.

METHODS

Among 5,360 patients enrolled  in Korean multicenter nationwide prospective Registry of ambulatory BP monitoring (KORABP), 981 subjects with complete data on sleep duration, sleep quality assessed using a 4-point Likert scale, and clinical variables were included in the analysis. Phenotypes of nighttime BP pattern were categorized as extreme dipper, dipper, non-dipper, and reverse dipper. Hypertension was defined as a 24-h ambulatory BPs were 130/80 mmHg or higher.

RESULTS

Among 981 subjects, 221 were normotensive, 359 were untreated hypertensive, and 401 were treated hypertensive. Age of the participants were 53.87 ± 14.02 years and 47.1% were female. In overall patients, sleep duration was 431.99 ± 107.61 min, and one to four points of sleep quality were observed in 15.5%, 30.0%, 30.4%, and 24.2%, respectively. Of the 760 hypertensive patients, extreme dipper, dipper, non-dipper, and reverse dipper were observed in 58 (7.63%), 277 (36.45%), 325 (42.76%), and 100 (13.16%), respectively. In multiple linear regression analysis, sleep duration (β = 0.0105, p < 0.001) and sleep quality (β = -0.8093, p < 0.001) were associated with nighttime systolic BP and sleep quality was associated with extent of nighttime systolic BP dipping (β = 0.7622, p < 0.001) in hypertensive patients. In addition, sleep quality showed positive association with dipper pattern (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.03-1.30) and showed negative association with reverse dipper pattern (OR = 0.73, 95% CI = 0.62-0.86) in multiple logistic regression analyses.

CONCLUSION

When adjusted covariates, less sleep duration and poor sleep quality were positively associated with nighttime systolic BP. Additionally, sleep quality was the independent associated factor for dipper and reverse dipper phenotypes. The study also found that male sex, low estimated glomerular filtration rate, high ambulatory BP, low office BP, and poor sleep quality were associated with blunted nighttime SBP dipping.

Classification of blood pressure during sleep impacts designation of nocturnal nondipping

The identification of nocturnal nondipping blood pressure (< 10% drop in mean systolic blood pressure from awake to sleep periods), as captured by ambulatory blood pressure monitoring, is a valuable element of risk prediction for cardiovascular disease, independent of daytime or clinic blood pressure measurements. However, capturing measurements, including determination of wake/sleep periods, is challenging. Accordingly, we sought to evaluate the impact of different definitions and algorithms for defining sleep onset on the classification of nocturnal nondipping. Using approaches based upon participant self-reports, applied definition of a common sleep period (12 am -6 am), manual actigraphy, and automated actigraphy we identified changes to the classification of nocturnal nondipping, and conducted a secondary analysis on the potential impact of an ambulatory blood pressure monitor on sleep. Among 61 participants in the Eastern Caribbean Health Outcomes Research Network hypertension study with complete ambulatory blood pressure monitor and sleep data, the concordance for nocturnal nondipping across methods was 0.54 by Fleiss' Kappa (depending on the method, 36 to 51 participants classified as having nocturnal nondipping). Sleep quality for participants with dipping versus nondipping was significantly different for total sleep length when wearing the ambulatory blood pressure monitor (shorter sleep duration) versus not (longer sleep duration), although there were no differences in sleep efficiency or disturbances. These findings indicate that consideration of sleep time measurements is critical for interpreting ambulatory blood pressure. As technology advances to detect blood pressure and sleep patterns, further investigation is needed to determine which method should be used for diagnosis, treatment, and future cardiovascular risk.

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.

Sleep characteristics associated with nocturnal blood pressure nondipping in healthy individuals: a systematic review

OBJECTIVE

The current literature investigating nocturnal blood pressure (BP) nondipping has largely focused on clinical populations, however, conditions such as hypertension, obstructive sleep apnoea and insomnia are recognized confounding factors for BP dipping. The exact mechanisms responsible for BP nondipping remain unclear, therefore, there is a need to investigate BP nondipping in healthy individuals to better understand the underlying mechanisms. This review identifies sleep characteristics that may contribute to BP nondipping in healthy individuals. It is anticipated that an understanding of the sleep characteristics that contribute to BP nondipping may inform future sleep-related behavioral interventions to ultimately reducing the burden of cardiovascular disease.

METHODS

The PubMed, Scopus and Web of Science databases were searched for relevant, English language, peer-reviewed publications (from inception to March 2022). The search identified 550 studies. After duplicates were removed, the titles and abstracts of the remaining 306 studies were screened. Of these, 250 studies were excluded leaving 56 studies to test for eligibility. Thirty-nine studies were excluded such that 17 studies fully met the inclusion criteria for the review.

RESULTS

Findings from this review indicate that short sleep duration, more sleep fragmentation, less sleep depth and increased variability in sleep timing may be associated with BP nondipping in healthy individuals.

CONCLUSION

While there is no evidence-based approach for the treatment of nocturnal BP nondipping, it seems promising that addressing one's sleep health may be an important starting point to reduce the prevalence of BP nondipping and perhaps the progression to cardiovascular disease.

The circadian rhythm of blood pressure in patients with panic disorder and generalized anxiety disorder

BACKGROUND

Anxiety disorders affect blood pressure both during the day and at night. Little is known about the effect of individual anxiety disorders on the circadian rhythm of blood pressure.

OBJECTIVES

The purpose of this study is to compare the nocturnal drop in blood pressure in patients with panic disorder (PD), generalized anxiety disorder (GAD), and healthy individuals.

METHODS

The study was conducted on fifty consecutive outpatients with anxiety disorders and personality disorders who participated in intensive group psychotherapy. Diagnoses were made according to DSM-IV-TR criteria using the PSE-10 questionnaire. Out of 50 patients under study, 17 were diagnosed with PD and 21 with GAD. The control group consisted of 40 healthy people recruited in the course of other studies. The resulting three groups were compared in terms of circadian blood pressure using the ABPM method.

RESULTS

Mean nocturnal falls in systolic and diastolic blood pressure were the following: 2% and 3% (PD), 11% and 12% (GAD), 27% and 23% (control). Four people out of PD group had higher systolic and diastolic blood pressure at night than during the day. The ratios between non-dippers/dippers were: 0/15 (PD), 8/21 (38% - GAD) and 40/40 (100% - control).

CONCLUSIONS

The patients with PD were characterized by an almost flat course of circadian blood pressure. The patients with GAD had a lower mean nocturnal fall in blood pressure than the control group, but significantly higher than the patients with PD. The differences in the circadian course of blood pressure between PD and GAD are so large that the impact of these disorders should be investigated separately.

Blood Pressure Cuff Inflation Briefly Increases Female Adolescents' Restlessness During Sleep on the First But Not Second Night of Ambulatory Blood Pressure Monitoring

OBJECTIVE

Ambulatory blood pressure monitoring (ABPM) increases restlessness during adults' sleep in laboratory settings, but there is little evidence of an association among adolescents or in naturalistic environments. This study examined activity levels before and after blood pressure cuff inflation during sleep to determine whether and for how long ABPM increased restlessness during sleep in healthy adolescents.

METHODS

Two hundred thirty-four healthy adolescents (mean age = 15.72 [1.30] years; 54% female; 57% Black) completed two consecutive nights of hourly ABPM and wrist-worn actigraphy. Activity counts during sleep, averaged across 5-minute bins, were compared in the 20 minutes before and after blood pressure cuff inflation using a four-level mixed model (bins within hours within nights within participants). Interactions of bin with night, sex, and race were examined. Covariates included age, sex, and race.

RESULTS

Activity counts in the 5-minute bin immediately after cuff inflation were 10% to 14% higher than all other bins before ( p < .001) and after ( p < .001) cuff inflation. This effect differed by night and sex, as activity levels during 5-minute post-cuff inflation were elevated only on night 1 ( p values < .001) and only in female participants ( p values < .001). Effects did not differ by race.

CONCLUSIONS

Cuff inflation during ABPM briefly increased adolescent female participants' restlessness during sleep. Habituation occurred after one night, so two nights of ABPM may minimize impact on sleep. If only one night of ABPM is feasible, excluding 5 minutes of actigraphy data after each cuff inflation may accommodate the impact of ABPM on restlessness during sleep.

Sampling rate influences measures of blood pressure variability in ambulatory blood pressure monitoring

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) is a valuable tool in the diagnosis and management of hypertension and it is a good predictor of future cardiovascular events. Lack of normal threshold values of ABPM parameters and inconsistency in the sampling rate of recording are hurdles in its wider usage. The aim of the present investigation was to study the influence of sampling rate on ABPM.

METHODS

ABPM was performed in 47 healthy subjects and the effect of different sampling rates was studied on ABPM parameters.

RESULTS

When data were down-sampled, there was a trend towards decreased concordance and increased dispersion with less frequent recordings. Percent dispersion of MESOR, 24-h average, 24 h standard deviation (SD), awake hours average and sleep hours average of systolic BP (SBP) were around 10% for a sampling interval of 1 h. While average real variability (ARV), morning surge and percent dip in SBP exhibited more than 30% dispersion at a sampling interval of 30 min.

CONCLUSION

24-h average blood pressure (BP) is less sensitive to sampling rate whereas BP variability parameters such as ARV, morning surge and percent dip in SBP are highly sensitive. We suggest that for improving the accuracy of BP variability parameters, a higher sampling rate is desirable around the time of awakening (~2 h before and after the expected time of awakening). At other times, a lower sampling rate may be used for maximizing patient comfort without compromising measurement accuracy.

The effect of tension variability for sleep quality in headache patients: A Holter monitoring study

BACKGROUND

Hypertension is one of the common causes of headaches. Disruption in the circadian rhythm of blood pressure (BP) also leads to some chronic diseases. Sleep disturbances have a relationship with neurologic and cardiac diseases. Our aim was to compare the sleep quality of patients with headaches showing dipper and nondipper BP patterns.

METHODS

This retrospective study included 57 patients who applied to a neurology clinic due to headaches and were referred to the cardiology department for Holter monitoring. Chronic diseases, drugs used, smoking and exercise habits, and physical examination findings were recorded. The 24-hour Holter monitoring results were classified as dipper and nondipper. The Pittsburgh Sleep Quality Index scores were determined for each patient. The Pittsburgh Sleep Quality Index scores of patients with dipper and nondipper patterns were compared.

RESULTS

The sleep quality of patients with dipper Holter patterns was better than that of patients with nondipper patterns (P < .001), and patients without chronic diseases had significantly better sleep quality compared with those with chronic diseases (P = .029). In the presence of chronic disease, the number of patients with a nondipper Holter pattern was higher (P = .024). There were no significant differences in Holter results or sleep quality between smokers and nonsmokers (P > .05).

CONCLUSION

Diagnoses of sleep disorders and BP abnormalities in the outpatient clinic are valuable in increasing the quality of life of patients and in preventing chronic diseases, especially cardiac diseases that may develop in the future.

The B-Score is a novel metric for measuring the true performance of blood pressure estimation models

We aimed to develop and test a novel metric for the relative performance of blood pressure estimation systems (B-Score). The B-Score sets absolute blood pressure estimation model performance in contrast to the dataset the model is tested upon. We calculate the B-Score based on inter- and intrapersonal variabilities within the dataset. To test the B-Score for reliable results and desired properties, we designed generic datasets with differing inter- and intrapersonal blood pressure variability. We then tested the B-Score’s real-world functionality with a small, published dataset and the largest available blood pressure dataset (MIMIC IV). The B-Score demonstrated reliable and desired properties. The real-world test provided allowed the direct comparison of different datasets and revealed insights hidden from absolute performance measures. The B-Score is a functional, novel, and easy to interpret measure of relative blood pressure estimation system performance. It is easily calculated for any dataset and enables the direct comparison of various systems tested on different datasets. We created a metric for direct blood pressure estimation system performance. The B-Score allows researchers to detect promising trends quickly and reliably in the scientific literature. It further allows researchers and engineers to quickly assess and compare performances of various systems and algorithms, even when tested on different datasets.

The Role of Race, Sex, and Age in Circadian Disruption and Metabolic Disorders

Circadian rhythms are 24-hour internal biological cycles that play an important role in metabolism, and their disruption has been implicated in the development of diseases such as diabetes mellitus type 2, obesity, coronary artery disease, hypertension, and metabolic syndrome. This phenomenon is illustrated by increased rates of risk factors for cardiovascular disease in night shift workers. Race, sex, and age are factors that play a role in circadian rhythms and metabolic disorders. The focus of this review article is to assess the link between circadian rhythm physiology and metabolic disorders from a race, sex, and age perspective. Black Americans were noted to have shorter free-running circadian periods, or tau, increased cortisol levels, and poorer sleep habits compared to white Americans, possibly contributing to increased rates of obesity, hypertension, and hyperlipidemia. Women were also noted to have shorter tau, increased levels of proinflammatory gut bacteria, and reduced sleep quality compared to men, possibly leading to higher rates of obesity, metabolic syndrome, hypertension (in postmenopausal women), and nonalcoholic fatty liver disease. Older people were noted to have decreased expression of anti-inflammatory clock genes compared to younger people, possibly leading to increased rates of obesity, diabetes, hyperlipidemia, and hypertension. Groups that are at a higher risk for metabolic disorders such as black Americans, women, and the elderly may have internal time keeping systems that place them at a higher risk for developing abnormal hormonal and/or inflammatory pathways.

Effects of insomnia and restless legs syndrome on sleep arterial blood pressure: A systematic review and meta-analysis

Hypertension and blunted blood pressure (BP) dipping during nighttime sleep are associated with increased cardiovascular risk. Chronic insomnia and restless legs syndrome (RLS) may affect the 24-h BP profile. We systematically reviewed the association of insomnia and RLS with BP values during nighttime sleep and the relative BP dipping pattern. We searched relevant articles in any language with selection criteria including enrolment of subjects with insomnia or RLS and with obstructive sleep apnea comorbidity assessment. Of the 872 studies originally retrieved, seven were selected. Four studies enrolled subjects with insomnia. One study relied on sleep diaries to classify nighttime sleep BP, whereas three relied only on clock time. At meta-analysis, subjects with insomnia displayed an attenuated dipping of systolic BP (-2.00%; 95% confidence interval (CI): -3.61 - -0.39%) and diastolic BP (-1.58%; 95% CI: -2.66 ̶ -0.49%) during nighttime sleep compared to controls. Three studies enrolled subjects with RLS. One study relied on polysomnography to classify nighttime sleep BP, whereas two relied only on clock time. Subjects with RLS showed increases in nighttime sleep systolic BP (5.61 mm Hg, 95% CI 0.13̶-11.09 mm Hg) compared to controls. In conclusion, the limited available data suggest that insomnia and RLS are both associated with altered BP control during nighttime sleep. There is need for more clinical studies to confirm these findings, specifically focusing on measurements of BP during objectively defined sleep, on causal roles of leg movements during sleep and alterations in sleep architecture, and on implications for cardiovascular risk. PROSPERO ACKNOWLEDGEMENT OF NUMBER: CRD42020217947.

Screening for Hypertension in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Hypertension is a major risk factor for cardiovascular disease and can be modified through lifestyle and pharmacological interventions to reduce cardiovascular events and mortality.

OBJECTIVE

To systematically review the benefits and harms of screening and confirmatory blood pressure measurements in adults, to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, Cochrane Collaboration Central Registry of Controlled Trials, and CINAHL; surveillance through March 26, 2021.

STUDY SELECTION

Randomized clinical trials (RCTs) and nonrandomized controlled intervention studies for effectiveness of screening; accuracy studies for screening and confirmatory measurements (ambulatory blood pressure monitoring as the reference standard); RCTs and nonrandomized controlled intervention studies and observational studies for harms of screening and confirmation.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction; meta-analyses and qualitative syntheses.

MAIN OUTCOMES AND MEASURES

Mortality; cardiovascular events; quality of life; sensitivity, specificity, positive and negative predictive values; harms of screening.

RESULTS

A total of 52 studies (N = 215 534) were identified in this systematic review. One cluster RCT (n = 140 642) of a multicomponent intervention including hypertension screening reported fewer annual cardiovascular-related hospital admissions for cardiovascular disease in the intervention group compared with the control group (difference, 3.02 per 1000 people; rate ratio, 0.91 [95% CI, 0.86-0.97]). Meta-analysis of 15 studies (n = 11 309) of initial office-based blood pressure screening showed a pooled sensitivity of 0.54 (95% CI, 0.37-0.70) and specificity of 0.90 (95% CI, 0.84-0.95), with considerable clinical and statistical heterogeneity. Eighteen studies (n = 57 128) of various confirmatory blood pressure measurement modalities were heterogeneous. Meta-analysis of 8 office-based confirmation studies (n = 53 183) showed a pooled sensitivity of 0.80 (95% CI, 0.68-0.88) and specificity of 0.55 (95% CI, 0.42-0.66). Meta-analysis of 4 home-based confirmation studies (n = 1001) showed a pooled sensitivity of 0.84 (95% CI, 0.76-0.90) and a specificity of 0.60 (95% CI, 0.48-0.71). Thirteen studies (n = 5150) suggested that screening was associated with no decrement in quality of life or psychological distress; evidence on absenteeism was mixed. Ambulatory blood pressure measurement was associated with temporary sleep disturbance and bruising.

CONCLUSIONS AND RELEVANCE

Screening using office-based blood pressure measurement had major accuracy limitations, including misdiagnosis; however, direct harms of measurement were minimal. Research is needed to determine optimal screening and confirmatory algorithms for clinical practice.

Effects of ambulatory blood pressure monitoring on sleep in healthy, normotensive men and women

OBJECTIVES

To determine the effect of ambulatory blood pressure monitoring (ABPM) on sleep quality among healthy adults and to explore possible effect modification by demographics.

METHODS

We examined data from 192 relatively healthy young (median age: 31; 33% men, 18% with clinic BP >130/80 mmHg) participants in an observational study of sleep and arterial stiffness. Demographic/health questionnaires were completed. A wrist-based accelerometer assessed sleep for seven nights, and sleep duration, wakefulness after sleep onset (WASO), fragmentation (physical restlessness), midpoint, and efficiency were estimated. ABPM was conducted for one 36-h period, including one actigraphy night.

RESULTS

Within-subject comparisons indicated that WASO and fragmentation were higher, midpoint was later, and efficiency was lower on the ABPM night (Ps < 0.001-0.038). Neither age nor sex moderated these associations. Among older adults, a later midpoint and worse fragmentation were observed with ABPM (Ps = 0.002-0.010). There was also a main effect of sex: men demonstrated shorter sleep duration, greater WASO and fragmentation, and less efficiency than women (Ps = 0.002-0.046). With ABPM, women had worse fragmentation and a later midpoint (Ps = 0.002-0.049); for men, WASO and fragmentation were worse (Ps = 0.003-0.023). Importantly, this study does not address whether the effect of wearing ABPM on sleep in turn affects BP during sleep.

CONCLUSIONS

ABPM appears to modestly disturb actigraphy-assessed sleep among healthy adults. Researchers and clinicians should consider the downstream effects of performing ABPM and whether these effects are more pronounced in those who typically experience sleep disturbance.

Short- and Long-Term Reproducibility of Nighttime Blood Pressure Phenotypes and Nocturnal Blood Pressure Reduction

[Figure: see text].