Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review

Assessing blood pressure changes and hypertension-related outcomes in patients with migraine treated with erenumab: A systematic review and meta-analysis

OBJECTIVES/BACKGROUND

We aimed to systematically review and summarize evidence on the effects of erenumab on systemic blood pressure (BP) in patients with migraine (International Prospective Register of Systematic Reviews ID: CRD42024571056). US Prescribing Information for erenumab was updated to include the potential risk of hypertension, although randomized trials did not link it previously. The association of this monoclonal antibody with an elevated vascular risk remains uncertain.

METHODS

Embase, PubMed, and the Cochrane databases were searched up to June 18, 2024 for studies examining the impact of erenumab on BP in patients with migraine. I2 statistics and prediction intervals (PIs) were applied to assess heterogeneity, and sensitivity and subgroup analyses were used to explore it. Data were collected using mean difference (MD) or proportion of events. The risk of bias of the included studies was assessed with the Cochrane Risk of Bias tool.

RESULTS

Systolic (MD = 0.86, 95% confidence interval [CI] = -1.02 to 2.73, p = 0.370, I2 = 63%) and diastolic (MD = 1.33, 95% CI = -0.05 to 2.72, p = 0.060, I2 = 69%) BP measures did not significantly differ between after and before erenumab treatment. This lack of significant difference persisted at 3 and 12 months. The leave-one-out technique did not change heterogeneity. The proportion of participants presenting worsening BP appears to be 22.04% (95% CI = 11.12-38.98, PI = 0.54-93.60), with 56.40% corresponding to nonhypertensive individuals at baseline. The incidence of patients starting antihypertensive medications during the study was 3.96% (95% CI = 1.30-11.42, PI = 0.02-90.04), of which 62.88% corresponded to nonhypertensive patients at baseline.

CONCLUSION

We did not find an association of erenumab with significant increases in systemic BP. There is a considerable degree of fragility in the current evidence available. The decision to prescribe erenumab, especially for patients with multiple comorbidities and risk factors for hypertension, must be made weighing the risks and benefits. Further studies are needed to confirm these findings.

Quantitative analysis of the effect of clothing on the oscillometric waveform envelope and oscillometric blood pressure measurements

Purpose

To ensure accurate blood pressure (BP) measurement, it is important to follow guidelines, such as wearing the cuff on the bare arm. However, this recommendation is often challenging due to patients being dressed. This study quantitatively evaluates how wearing a cuff over clothing impacts BP accuracy using oscillometric waveform analysis.

Methods

BP was measured under three conditions: thick sleeve (3.5 mm), thin sleeve (1.5 mm), and bare arm. Oscillometric waveform envelopes (OMWE) were analyzed to extract features like maximum amplitude, width, and slope for each condition. BP measurements and extracted features from the bare arm condition were compared with those from each sleeve condition.

Results

The mean systolic blood pressure (SBP) and pulse pressure (PP) increased by 11.73 and 10.04 mmHg under thick sleeve conditions. These also increased by 4.308 and 4.731 mmHg under thin sleeve conditions (Thick: p < 0.001, Thin: p < 0.05). The mean of mean arterial pressure (MAP) and OMWE width increased by 5.039 and 5.059 mmHg under thick sleeve conditions (Thick: p < 0.025). The mean of maximum amplitude of OMWE under thick and thin sleeves decreased by 0.9428 and 0.4017 mmHg (Thick, Thin: p < 0.001). Diastolic blood pressure (DBP) increased under thick sleeve conditions; however, this was not statistically significant.

Conclusion

Wearing the cuff over clothing altered OMWE morphology, resulting in a lower, flatter shape similar to that seen in hypertensives. This significantly affected BP readings, particularly SBP. Therefore, following guidelines for cuff placement on bare arms is crucial for accurate BP measurement.

Trial registration number and date

Clinical Research Information Service (CRIS) KCT0008511, 22.05.2023.

Admission blood pressure and blood pressure variability in medical emergency predicts 3-month mortality and readmission

BACKGROUND

The admission systolic blood pressure (SBP) recorded at the emergency department is typically elevated and tends to decrease, while various degrees of blood pressure variability (BPV) remain. Whether admission SBP or mean SBP and BPV from resting beat-to-beat measurements are better associated with short-term outcome remains unknown.

METHODS

We conducted a prospective study, including adults acutely admitted to the emergency department at a larger Danish tertiary care Hospital in Copenhagen, Denmark from 2019 to 2023. We measured blood pressure (BP) at admission and beat-to-beat BP and BPV during 10-minute rest. We defined BPV as the standard deviation from the mean of the beat-to-beat SBP measurements. Primary outcome was defined as 3-month all-cause mortality or readmission, and secondary outcome as 3-month cardiovascular mortality or readmission for cardiovascular disease.

RESULTS

Among 951 patients included, mean age was 64 (standard deviation; 17) with 44% women. During 3-month follow-up, 284 (30%) patients met a primary outcome and 69 (7,2%) a secondary outcome. In adjusted Cox models, admission SBP, but neither mean SBP or BPV, was significantly associated with primary outcome [hazard ratio 0.971, 95% confidence interval (CI) 0.948-0.995, P = 0.017] for each 5 mmHg increase in SBP. When exploring both extremes of upper and lower quartiles, BPV greater than 10 mmHg was associated with increased cardiovascular events (hazard ratio 2.019, 95% CI 1.142-3.569, P = 0.016).

CONCLUSION

In this study, low admission SBP was associated with all-cause readmissions and mortality, while BPV above 10 mmHg was associated with 3-month risk of cardiovascular events.

Validation of the Microlife BP3T01-1B blood pressure monitoring device in adults and adolescents according to the ISO 81060-2:2018 protocol

BACKGROUND

Accurate measurement of blood pressure (BP) is crucial for the diagnosis and ongoing management of hypertension. Only devices that have been validated using an established protocol should be used to measure BP. The aim of this study was to validate the Microlife BP3T01-1B, an automated upper-arm BP measuring device, according to the DIN EN ISO 81060-2:2018-11 (ANSI/AAMI/ISO 81060-2:2018) standard protocol.

METHODS

BP measurements were performed in 85 adults and adolescents (age range: 13-86 years) using the same-arm sequential method of the DIN EN ISO 81060-2:2018-11 protocol, alternating between the test device and a reference mercury sphygmomanometer.

RESULTS

A total of 255 valid comparisons were available for the analysis of criterion 1. The mean ± SD difference between the test device and the reference device values was -2.56 ± 7.53 mmHg for SBP and -3.10 ± 5.65 mmHg for DBP. The mean differences met the pass criterion of less than or equal to ±5 mmHg and the SD values met the pass criterion of ≤8 mmHg. All 85 participants were included in the analysis of criterion 2. The mean ± SD intraindividual difference between the test and reference devices was -2.56 ± 6.15 mmHg for SBP and -3.10 ± 4.85 mmHg for DBP. Both were within the required pass range of SD ≤6.43 mmHg for SBP and SD ≤6.20 mmHg for DBP.

CONCLUSION

The Microlife BP3T01-1B BP monitoring device fulfilled the criteria of the DIN EN ISO 81060-2:2018-11 (ANSI/AAMI/ISO 81060-2:2018) protocol in a general population and can be recommended for the measurement of BP in adults and adolescents.

Blood pressure measurement practices in children and adolescents within primary care setting

Objective

Poor compliance to the technical aspects of blood pressure (BP) measurement procedure may lead to inaccurate estimation of BP and misclassification of patients. However, the latter have not been explored systematically. We aimed to assess real-life BP measurement practices in Lithuanian children and adolescents at the primary care setting, and their compliance with current European Society of Hypertension (ESH) guidelines.

Methods

Two cross-sectional surveys were conducted in Lithuania. The study population included parents, who have children aged 0-17 years, and was further enriched by adolescents aged 14-17 years. Original questionnaires were developed and used to survey the participants.

Results

Study included 1,504 parents and 448 adolescents. Median age of the surveyed parents' children and adolescents was 6 years and 50.2 percent were female. Overall, among all children aged 3 years or older only 55% of respondents reported BP measurements at least once. The rates of BP measurements increased with age and exceeded 80 percent from 14 years. Only 3.3 percent of respondents reported no issues with BP measurement procedure. The most common errors included single measurements of BP (81.4%), lack of feedback (60.2%), incorrect positioning (40.7%), miscuffing (39.2%) and lack of rest period (27.9%).

Conclusions

Our study reveals not only insufficient BP screening rates within Lithuanian primary care setting, but also high rates of technical errors during BP measurement procedure. Collectively, these issues likely contribute to misdiagnosing of arterial hypertension and suboptimal care of children who are at risk of inaccurate and imprecise BP results.

Blood pressure measurement technique in clinical practice in the NHS Greater Glasgow and Clyde

Blood pressure (BP) measurement is a common procedure conducted in various disciplines and is widely available on clinical reports. The diagnosis and management of hypertension require reliable measurement of BP in outpatient clinics. Published studies suggest the standardised method for BP measurement is difficult to apply in routine clinical practice. This study aimed to assess the current practice of BP measurement in outpatient clinics in relevant secondary care clinical specialties across the 15 separate hospital sites of the NHS Greater Glasgow and Clyde region (population 1.2 million) compared to the recommended standardised method. An online questionnaire was developed and disseminated to the supervising clinician of each of 268 regular outpatient clinics. The questionnaire focused on the standardised BP method (patient preparation, environment, and BP measurement technique). The questionnaire was returned for 110 clinics. 73 (66.4%) of the participating clinics measure BP routinely and these formed the basis for further analysis. 3 clinics (4.1%) apply all components of the standardised BP method. 5 (6.9%) clinics deliver advice to patients prior to clinic attendance on how to prepare for BP measurement. 61 (83.6%) of participating clinics have a dedicated quiet environment for BP measurement. 50 (68.5%) clinics always place the cuff on bare upper arm and 63.0% use a cuff size appropriate to upper arm circumference. In a wide range of secondary care out-patient clinic settings, we found that BP measurement rarely adheres to the recommended standards. This has important implications for the quality of treatment decisions that are based on BP measurement.

The Influence of Commonly-Encountered Participant Behaviors on Cardiovascular Indices During Testing

BACKGROUND

During laboratory testing, participants rest quietly in a supine posture with little movement. However, it is rather common for participants to display various behaviors. The extent to which these common encounters influence cardiovascular measures is unknown.

METHODS

Fifty-five adults (36 ± 15 years) were studied during the following seven randomized conditions in the supine position: (i) quiet stationary rest (control), (ii) while drowsy, (iii) while and (iv) after talking to investigators, (v) while and (vi) after cell phone use for texting, and (vii) lying on the side.

RESULTS

Heart rate was greater when the participants were talking to investigators (+4 bpm) and texting on cell phones (+5 mm Hg) compared with quiet rest. Systolic blood pressure (BP) increased by 4 mm Hg and diastolic BP by 3 mm Hg while talking to investigators. Systolic BP was 6 mm Hg and diastolic BP was 5 mm Hg lower in the "side lying" position compared with quiet rest. In the side-lying condition, carotid-femoral pulse wave velocity (PWV) was not able to be measured in 38% (n = 16) of the participants while brachial-ankle PWV was not affected. Brachial-ankle PWV was greater while (+65 cm/s) and after (+29 cm/s) the participants were talking to investigators whereas carotid-femoral PWV was not able to be measured during talking. The drowsy behavior did not influence any of the BP and PWV measures.

CONCLUSIONS

Talking during the testing period significantly increases all the cardiovascular measures but cell phone use prior to the measures does not appear to influence them.

Effects of Noise and Public Setting on Blood Pressure Readings : A Randomized Crossover Trial

BACKGROUND

Guidelines emphasize quiet settings for blood pressure (BP) measurement.

OBJECTIVE

To determine the effect of noise and public environment on BP readings.

DESIGN

Randomized crossover trial of adults in Baltimore, Maryland. (ClinicalTrials.gov: NCT05394376).

SETTING

Study measures were obtained in a clinical research office and a public food market near Johns Hopkins University School of Medicine in Baltimore, Maryland.

PARTICIPANTS

108 community-dwelling adults from the Baltimore, Maryland, area recruited through measurement-screening campaigns, mailings to previous study participants, and referrals from hypertension clinics.

INTERVENTION

Participants were randomly assigned to the order in which they had triplicate BP measurements in each of 3 settings: 1) private quiet office (private quiet [reference]); 2) noisy public space (public loud); and 3) noisy public space plus earplugs (public quiet).

MEASUREMENTS

Differences in mean BP readings obtained in public loud and public quiet versus private quiet, overall and stratified by baseline systolic BP (SBP), age, and recent health care utilization.

RESULTS

Of the 108 randomly assigned participants, mean age was 56 years (SD, 17), 84% were self-reported Black, 41% were female, and 45% had an SBP of 130 mm Hg or more. The average noise level in public loud was 74 dB and in private quiet was 37 dB. Mean SBPs were: 128.9 mm Hg (SD, 22.3) in private quiet, 128.3 mm Hg (SD, 21.7) in public loud, and 129.0 mm Hg (SD, 22.2) in public quiet. Corresponding diastolic BPs (DBPs) were 74.2 mm Hg (SD, 11.4), 75.9 mm Hg (SD, 11.6), and 75.7 mm Hg (SD, 12.0), respectively. Public-loud and public-quiet BPs had minimal, non-clinically important differences from private quiet BPs: public loud: ΔSBP, -0.66 mm Hg (95% CI, -2.25 to 0.93 mm Hg) and ΔDBP, 1.65 mm Hg (CI, 0.77 to 2.54 mm Hg); public quiet: ΔSBP, 0.09 mm Hg (-1.53 to 1.72 mm Hg) and ΔDBP, 1.45 mm Hg (0.64 to 2.27 mm Hg). The patterns were generally consistent across subgroups.

LIMITATIONS

Single-center trial. Imbalance in the numbers and characteristics across the randomly assigned groups.

CONCLUSION

The BP readings obtained in public spaces were minimally different from BPs obtained in a private office, suggesting that public spaces are reasonable settings to screen for hypertension.

PRIMARY FUNDING SOURCE

Resolve to Save Lives.

Preventing troublesome variability in clinical blood pressure measurement

The importance of accurate blood pressure (BP) measurement is well-established. However, there is little quantitative comparative data on the influence of different measurement conditions on BP or the stability of the oscillometric pulse waveform from which BP is calculated. This study investigates the effect of six different measurement conditions (Quiet, Reading, Speaking, Deep Breathing, Moving, and Tapping) on BP readings in 30 healthy normotensive subjects. We hypothesize that non-standard conditions will result in significant deviations in BP measurements compared to the Quiet condition. Additionally, the quality and stability of the oscillometric waveform were assessed by evaluating the smoothness of the oscillometric pulse waveform characteristics during cuff deflation. Compared with the Quiet condition, all others resulted in significantly higher blood pressures, except for the respiratory condition, which resulted in significantly lower BPs. Average subject systolic BP (SBP) rose from 117.4 ± 6.0 mmHg for the Quiet condition to 129.7 ± 7.2 mmHg for the light finger tapping condition, P < 0.00001. Overall, changes for diastolic BP (DBP) were not significant. For the quality Noise indicator, all conditions in comparison with the Quiet condition were significantly noisier, increasing from 0.144 ± 0.024 to 1.055 ± 0.308 mmHg, P < 0.00001. Changes in SBP were significantly correlated to changes in quality Noise (r = 0.965, P < 0.001). This study confirms the importance of following international BP measurement guidelines, providing quantitative data showing significant changes in BP when guidelines are not followed. A method for assessing the quality of the measurement is also demonstrated, and shows that BP changes are significantly related to changes in the quality indicator.

Clinical practice guideline for the management of hypertension in China

In China, hypertension is the most common chronic non-communicable disease and the most significant risk factor for cardiovascular mortality among urban and rural residents. To standardize the clinical diagnosis and treatment of hypertension and to improve the prevention and control level of hypertension in China, Chinese Society of Cardiology, Chinese Medical Association; Hypertension Committee of Cross-Straits Medicine Exchange Association; Cardiovascular Disease Prevention and Rehabilitation Committee, Chinese Association of Rehabilitation Medicine, jointly collaborated to formulate the Clinical Practice Guideline for Hypertension Management in China. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to rate the quality of evidence and strength of recommendations, and the reporting items for practice guidelines in healthcare (RIGHT) were followed to establish the guideline. Detailed evidence-based recommendations for the diagnosis, evaluation, and treatment of 44 clinical questions in the field of hypertension, including essential and secondary hypertension, have been provided to guide clinical practice.

REGISTRATION

International Practice Guidelines Registry Platform, http://www.guidelines-registry.cn/ , No. IPGRP-2021CN346.

Arm Position and Blood Pressure Readings: The ARMS Crossover Randomized Clinical Trial

Importance

Guidelines for blood pressure (BP) measurement recommend arm support on a desk with the midcuff positioned at heart level. Still, nonstandard positions are used in clinical practice (eg, with arm resting on the lap or unsupported on the side).

Objective

To determine the effect of different arm positions on BP readings.

Design, Setting, and Participants

This crossover randomized clinical trial recruited adults between the ages of 18 and 80 years in Baltimore, Maryland, from August 9, 2022, to June 1, 2023.

Intervention

Participants were randomly assigned to sets of triplicate BP measurements with the arm positioned in 3 ways: (1) supported on a desk (desk 1; reference), (2) hand supported on lap (lap), and (3) arm unsupported at the side (side). To account for intrinsic BP variability, all participants underwent a fourth set of BP measurements with the arm supported on a desk (desk 2).

Main Outcomes and Measures

The primary outcomes were the difference in differences in mean systolic BP (SBP) and diastolic BP (DBP) between the reference BP (desk 1) and the 2 arm support positions (lap and side): (lap or side - desk 1) - (desk 2 - desk 1). Results were also stratified by hypertensive status, age, obesity status, and access to health care within the past year.

Results

The trial enrolled 133 participants (mean [SD] age, 57 [17] years; 70 [53%] female); 48 participants (36%) had SBP of 130 mm Hg or higher, and 55 participants (41%) had a body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 or higher. Lap and side positions resulted in statistically significant higher BP readings than desk positions, with the difference in differences as follows: lap, SBP Δ 3.9 (95% CI, 2.5-5.2) mm Hg and DBP Δ 4.0 (95% CI, 3.1-5.0) mm Hg; and side, SBP Δ 6.5 (95% CI, 5.1-7.9) mm Hg and DBP Δ 4.4 (95% CI, 3.4-5.4) mm Hg. The patterns were generally consistent across subgroups.

Conclusion and Relevance

This crossover randomized clinical trial showed that commonly used arm positions (lap or side) resulted in substantial overestimation of BP readings and may lead to misdiagnosis and overestimation of hypertension.

Trial Registration

ClinicalTrials.gov Identifier: NCT05372328.

Cuff-based blood pressure measurement: challenges and solutions

OBJECTIVE

Accurate measurement of arterial blood pressure (BP) is crucial for the diagnosis, monitoring, and treatment of hypertension. This narrative review highlights the challenges associated with conventional (cuff-based) BP measurement and potential solutions. This work covers each method of cuff-based BP measurement, as well as cuffless alternatives, but is primarily focused on ambulatory BP monitoring.

RESULTS

Manual BP measurement requires stringent training and standardized protocols which are often difficult to ensure in stressful and time-restricted clinical office blood pressure monitoring (OBPM) scenarios. Home Blood pressure monitoring (HBPM) can identify white-coat and masked hypertension but strongly depends on patient adherence to measurement techniques and procedure. The widespread use of nonvalidated automated HBPM devices raises further concerns about measurement accuracy. Ambulatory blood pressure measurement (ABPM) may be used in addition to OBPM. It is recommended to diagnose white-coat and masked hypertension as well as nocturnal BP and dipping, which are the BP values most predictive for major adverse cardiac events. Nonetheless, ABPM is limited by its non-continuous nature and susceptibility to measurement artefacts. This leads to poor overall reproducibility of ABPM results, especially regarding clinical parameters such as BP variability or dipping patterns.

CONCLUSIONS

Cuff-based BP measurement, despite some limitations, is vital for cardiovascular health assessment in clinical practice. Given the wide range of methodological limitations, the paradigm's potential for improvement is not yet fully realized. There are impactful and easily incorporated opportunities for innovation regarding the enhancement of measurement accuracy and reliability as well as the clinical interpretation of the retrieved data. There is a clear need for continued research and technological advancement to improve BP measurement as the premier tool for cardiovascular disease detection and management.

Validation of the FF680 upper-arm blood pressure monitor according to the ISO 81060-2:2018

This study evaluated the accuracy of blood pressure measurement in adults using FF680 electronic blood pressure monitors with the Korotkoff-Sound method, in accordance with the ISO 81060-2:2018. The study was conducted at Shijiazhuang People's Hospital and lasted 56 days, from 26 May to 21 July 2023. Participants, drawn from an adult demographic, underwent data verification and analysis with strict adherence to the trial protocol. For the FF680 electronic blood pressure monitor using the Korotkoff-Sound method, data from 85 valid participants were analyzed. The findings revealed mean differences (SDs) of -0.66 mmHg (2.45 mmHg) for SBP and -0.28 mmHg (2.09 mmHg) for DBP. SBP and DBP had SDs of ≤6.9 and ≤6.95 mmHg, meeting the standard requirements. FF680 devices are recommended for adult blood pressure monitoring because they meet the ISO 81060-2:2018.

Symptom clusters and resting cardiovascular autonomic measures in adolescents: From acute concussion to recovery

Sport-related concussion (SRC) is associated with cardiovascular autonomic nervous system (ANS) dysfunction. This study examines resting cardiovascular ANS activity in adolescents with SRC compared to controls early post-injury and after clinical recovery, analyzing its correlation with symptom severity and recovery outcomes. Cardiovascular ANS function was evaluated using heart rate variability (HRV), systolic blood pressure variability (SBPV) and baroreflex sensitivity (BRS). Symptoms were assessed via the Post-Concussion Symptom Scale, and recovery outcomes were categorized by recovery duration. Following acute SRC, no significant differences in HRV, SBPV or BRS were found between SRC and control groups, nor between those with delayed or normal recovery. Post-recovery, SRC participants had higher low frequency (LF) SBPV than controls and their initial assessment. When concussed participants were symptomatic, LF SBPV correlated directly with overall, cognitive, and fatigue symptom severity, while high frequency (HF) HRV inversely correlated with affective symptoms (Spearman's rho: 0.4-0.6). Resting cardiovascular ANS function remains unchanged in adolescent athletes acutely after SRC, suggesting it has limited diagnostic and prognostic potential. Although some correlations between individual symptom domains and ANS activity were observed, they were not significantly different from asymptomatic controls, limiting the ability to interpret these findings.

Arterial hypertension-clinical trials update 2024

Arterial hypertension remains the most important modifiable cardiovascular risk factor for morbidity and mortality worldwide. This review summarizes and discusses major clinical trials published in 2023 and early 2024 in hypertension research. These trials include new epidemiological data, studies investigating the impact of blood pressure cuff size on blood pressure measurements, benefits of salt substitutes, and novel antihypertensive treatment options, including pharmacotherapy and bariatric surgery in patients with obesity. This summary reviews the major clinical trials published in 2023 and early 2024. AHT arterial hypertension, BP blood pressure, HR hazard ratio, OBP office blood pressure, PRA plasma renin activity, SBP systolic blood pressure.

Innovations in blood pressure measurement and reporting technology: International Society of Hypertension position paper endorsed by the World Hypertension League, European Society of Hypertension, Asian Pacific Society of Hypertension, and Latin American Society of Hypertension

Blood pressure (BP) is a key contributor to the lifetime risk of preclinical organ damage and cardiovascular disease. Traditional clinic-based BP readings are typically measured infrequently and under standardized/resting conditions and therefore do not capture BP values during normal everyday activity. Therefore, current hypertension guidelines emphasize the importance of incorporating out-of-office BP measurement into strategies for hypertension diagnosis and management. However, conventional home and ambulatory BP monitoring devices use the upper-arm cuff oscillometric method and only provide intermittent BP readings under static conditions or in a limited number of situations. New innovations include technologies for BP estimation based on processing of sensor signals supported by artificial intelligence tools, technologies for remote monitoring, reporting and storage of BP data, and technologies for BP data interpretation and patient interaction designed to improve hypertension management ("digital therapeutics"). The number and volume of data relating to new devices/technologies is increasing rapidly and will continue to grow. This International Society of Hypertension position paper describes the new devices/technologies, presents evidence relating to new BP measurement techniques and related indices, highlights standard for the validation of new devices/technologies, discusses the reliability and utility of novel BP monitoring devices, the association of these metrics with clinical outcomes, and the use of digital therapeutics. It also highlights the challenges and evidence gaps that need to be overcome before these new technologies can be considered as a user-friendly and accurate source of novel BP data to inform clinical hypertension management strategies.

Blood Pressure Estimation Based on the Timing of the Arterial Reflected Waves by Oscillometric Pulse Wave Decomposition

Recent innovations in oscillometric blood pressure (BP) estimation leveraging pulse transit time (PTT) show promise even when pulse amplitude is compromised. However, current PTT methods often require multiple sensors. This study introduces a novel approach for oscillometric BP estimation utilizing only a single sensor. Our method simplifies PTT measurement through decomposing oscillometric pulses into forward and reflected wave components. Notably, we found that the time interval between the forward and first reflected wave is shortest when cuff pressure is at the systolic level, while the interval between the first and second reflected waves is longest when the cuff pressure corresponds to the diastolic level. To validate our method, we extensively analyzed two datasets: the first comprised 150 arm oscillometric recordings from 10 healthy individuals, and the second included 425 wrist oscillometric recordings from 85 healthy individuals. Our analysis revealed minimal standard deviation errors for BP measurements: 7.03 mmHg (systolic) and 5.96 mmHg (diastolic) for arm recordings, and 7.98 mmHg (systolic) and 5.39 mmHg (diastolic) for wrist recordings. Across both datasets, the mean error for both systolic and diastolic BP measurements was merely 0.01 mmHg, underscoring the precision of the method. Comparative analysis against established methodologies further affirmed the superior performance of our approach, which also met the ANSI/AAMI/ISO81060-2 standard. While our dataset primarily comprises recordings from healthy individuals, further validation on diverse datasets encompassing challenging cases such as obesity, arterial stiffness, and atrial fibrillation is imperative to evaluate its applicability across various clinical scenarios.

Standardisation of Blood Pressure Measurement Among Patients Attending an Urban Primary Health Centre: A Quality Improvement Initiative

Accurate blood pressure (BP) measurement is essential for detecting, diagnosing, treating, and monitoring hypertensive individuals. This qualitative improvement initiative study is aimed at improving adherence to standardised BP measurement protocols in an urban primary health centre in Delhi, India. This study was conducted using a checklist based on World Health Organisation (WHO) guidelines. Baseline assessment revealed low adherence to standardised procedures. Interventions included crowd management, infrastructure and equipment, standard operating procedures (SOPs) development, and staff training. After two plan-do-study-act (PDSA) cycles conducted within six weeks, the adherence to standardised BP measurement significantly increased from 0.4% (n=1) to 86.2% (n=119). This study highlights the potential for targeted quality improvement in healthcare delivery.

Improving Hypertension and Diabetes Mellitus Control with a Dedicated Patient Navigator

OBJECTIVES

Hypertension and diabetes mellitus (DM) are the leading causes of cardiovascular, cerebrovascular, and chronic kidney diseases. They affect an estimated 47% and 11% of Americans, respectively. In this study, we assessed whether a dedicated patient navigator embedded within a patient-centered medical home (PCMH) using a structured panel management and patient outreach strategy could improve blood pressure and glycemic control in primary care patients with uncontrolled hypertension and DM.

METHODS

We performed a prospective study comparing blood pressure and glycemic control in primary care patients before and after implementation of a patient navigator executing a hypertension and DM-focused panel management plan.

RESULTS

From January 2014 to October 2019, inclusion criteria were met 5164 times, which comprised 1958 unique patients within a PCMH. Multivariate regression analysis reveals a significant decrease in uncontrolled systolic blood pressure (SBP) over time, with an actual decrease of roughly 40% of uncontrolled episodes of SBP becoming controlled by 12 months. Multivariate regression analysis reveals a significant decrease in uncontrolled hemoglobin A1c (HbA1c) over time for each plot (P < 0.0001), with an actual decrease of roughly 30% of uncontrolled episodes of HbA1c becoming controlled by 12 months.

CONCLUSIONS

This study demonstrated the benefit of a dedicated patient navigator embedded within a PCMH on improving BP and glycemic control in primary care patients with uncontrolled hypertension and DM. Glycemic control was achieved, with 30% of episodes reaching an HbA1c of <8% and BP control achieved for 40% of episodes with SBP <140 mm Hg at 12 months. There were no differences by the social determinants of race and poverty.

Absolute cardiovascular risk assessment using 'real world' clinic blood pressures compared to standardized unobserved and ambulatory methods: an observational study

Clinic blood pressure (BP) is recommended for absolute cardiovascular disease (CVD) risk assessment. However, in 'real-world' settings, clinic BP measurement is unstandardised and less reliable compared to more rigorous methods but the impact for absolute CVD risk assessment is unknown. This study aimed to determine the difference in absolute CVD risk assessment using real-world clinic BP compared to standardised BP methods. Participants were patients (n = 226, 59 ± 15 years; 58% female) with hypertension referred to a BP clinic for assessment. 'Real-world' clinic BP was provided by the referring doctor. All participants had unobserved automated office BP (AOBP) and 24-h ambulatory BP monitoring (ABPM) measured at the clinic. Absolute CVD risk was calculated (Framingham) using systolic BP from the referring doctor (clinic BP), AOBP and ABPM, with agreement assessed by Kappa statistic. Clinic systolic BP was 18 mmHg than AOBP and daytime ABPM and 22 mmHg higher than 24-h ABPM (p < 0.001). Subsequently, absolute CVD risk scores using clinic BP were higher compared to AOBP, daytime ABPM and 24-h ABPM (10.4 ± 8.1%, 7.8 ± 6.4%, 7.8 ± 6.3%, and 7.3 ± 6.1%, respectively, P < 0.001). As a result, more participants were classified as high CVD risk using clinic BP (n = 89, 40%) compared with AOBP (n = 44, 20%) daytime ABPM (n = 38, 17%) and 24-h ABPM (n = 38, 17%) (p < 0.001) with weak agreement in risk classification (κ = 0.57[0.45-0.69], κ = 0.52[0.41-0.64] and κ = 0.55[0.43-0.66], respectively). Real-world clinic BP was higher and classified twice as many participants at high CVD risk compared to AOBP or ABPM. Given the challenges to high-quality BP measurement in clinic, more rigorous BP measurement methods are needed for absolute CVD risk assessment.

Breast Adiposity: Menopausal Status Impact and its Influence on Glycemic and Anthropometric Metabolic Parameters

CONTEXT

Ectopic fat depots are related to the deregulation of energy homeostasis, leading to diseases related to obesity and metabolic syndrome (MetS). Despite significant changes in body composition over women's lifespans, little is known about the role of breast adipose tissue (BrAT) and its possible utilization as an ectopic fat depot in women of different menopausal statuses.

OBJECTIVE

We aimed to assess the relationship between BrAT and metabolic glycemic and lipid profiles and body composition parameters in adult women.

METHODS

In this cross-sectional study, we enrolled adult women undergoing routine mammograms and performed history and physical examination, body composition assessment, semi-automated assessment of breast adiposity (BA) from mammograms, and fasting blood collection for biochemical analysis. Correlations and multivariate regression analysis were used to examine associations of BA with metabolic and body composition parameters.

RESULTS

Of the 101 participants included in the final analysis, 76.2% were in menopause, and 23.8% were in premenopause. The BA was positively related with fasting plasma glucose, glycated hemoglobin, homeostasis model assessment of insulin resistance, body mass index, waist circumference, body fat percentage, and abdominal visceral and subcutaneous fat when adjusted for age among women in postmenopause. Also, the BA was an independent predictor of hyperglycemia and MetS. These associations were not present among women in premenopause.

CONCLUSION

The BA was related to different adverse body composition and metabolic factors in women in postmenopause. The results suggest that there might be a relevant BrAT endocrine role during menopause, with mechanisms yet to be clarified, thus opening up research perspectives on the subject and potential clinical implications.

Artificial intelligence-enhanced patient evaluation: bridging art and science

The advent of digital health and artificial intelligence (AI) has promised to revolutionize clinical care, but real-world patient evaluation has yet to witness transformative changes. As history taking and physical examination continue to rely on long-established practices, a growing pipeline of AI-enhanced digital tools may soon augment the traditional clinical encounter into a data-driven process. This article presents an evidence-backed vision of how promising AI applications may enhance traditional practices, streamlining tedious tasks while elevating diverse data sources, including AI-enabled stethoscopes, cameras, and wearable sensors, to platforms for personalized medicine and efficient care delivery. Through the lens of traditional patient evaluation, we illustrate how digital technologies may soon be interwoven into routine clinical workflows, introducing a novel paradigm of longitudinal monitoring. Finally, we provide a skeptic's view on the practical, ethical, and regulatory challenges that limit the uptake of such technologies.

Numerical values and impact of hypertension in Spain

In Spain, 33% of adults aged 30 to 79 years (10 million) were hypertensive in 2019. Among them, 68% were diagnosed, 57% received drug therapy, and effective therapeutic coverage (control) reached 33%. Both diagnosis and control show geographical and social disparities. Approximately 46 000 cardiovascular deaths per year are attributable to hypertension. In recent decades, the control of hypertension has increased, due to improvements in lifestyle measures and increased use of polytherapy, coinciding with a reduction in stroke mortality. There are several modifiable determinants of the lack of hypertension control: a) white-coat phenomenon affects 22% to 33% of treated individuals, partly due to the limited availability of ambulatory blood pressure monitoring (ABPM) (49%) and self-measured BP (SMBP) (78%); b) inadequate patient adherence to medication and healthy lifestyles (weight loss, the most effective measure, is the least used, ≈40%); and c) insufficient use of polytherapy (≈55%). The remaining challenges include: a) technological aspects, such as measuring BP with more accurate techniques (ABPM, SMBP) and using cardiovascular-risk estimation tools (eg, SCORE); b) clinical challenges, such as reducing therapeutic inertia (≈59%), involving patients in their own management (medication adherence, ≈62%) and effectively implementing clinical guidelines); and c) public health challenges, such as reducing the burden of obesity (≈24%), monitoring progress with updated surveys, and setting national BP control targets.

The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association

Over the past 3 decades, a substantial body of high-quality evidence has guided the diagnosis and management of elevated blood pressure (BP) in the outpatient setting. In contrast, there is a lack of comparable evidence for guiding the management of elevated BP in the acute care setting, resulting in significant practice variation. Throughout this scientific statement, we use the terms acute care and inpatient to refer to care received in the emergency department and after admission to the hospital. Elevated inpatient BP is common and can manifest either as asymptomatic or with signs of new or worsening target-organ damage, a condition referred to as hypertensive emergency. Hypertensive emergency involves acute target-organ damage and should be treated swiftly, usually with intravenous antihypertensive medications, in a closely monitored setting. However, the risk-benefit ratio of initiating or intensifying antihypertensive medications for asymptomatic elevated inpatient BP is less clear. Despite this ambiguity, clinicians prescribe oral or intravenous antihypertensive medications in approximately one-third of cases of asymptomatic elevated inpatient BP. Recent observational studies have suggested potential harms associated with treating asymptomatic elevated inpatient BP, which brings current practice into question. Despite the ubiquity of elevated inpatient BPs, few position papers, guidelines, or consensus statements have focused on improving BP management in the acute care setting. Therefore, this scientific statement aims to synthesize the available evidence, provide suggestions for best practice based on the available evidence, identify evidence-based gaps in managing elevated inpatient BP (asymptomatic and hypertensive emergency), and highlight areas requiring further research.

Resonance sonomanometry for noninvasive, continuous monitoring of blood pressure

Cardiovascular disease is the leading cause of death worldwide. Existing methods for continuous, noninvasive blood pressure (BP) monitoring suffer from poor accuracy, uncomfortable form factors, or a need for frequent calibration, limiting their adoption. We introduce a new framework for continuous BP measurement that is noninvasive and calibration-free called resonance sonomanometry. The method uses ultrasound imaging to measure both the arterial dimensions and artery wall resonances that are induced by acoustic stimulation, which offers a direct measure of BP by a fully determined physical model. The approach and model are validated in vitro using arterial mock-ups and then in multiple arteries in human subjects. This approach offers the promise of robust continuous BP measurements, providing significant benefits for early diagnosis and treatment of cardiovascular disease.

Inter-observer reliability and anatomical landmarks for arm circumference to determine cuff size for blood pressure measurement

Accurate arm circumference (AC) measurement is required for accurate blood pressure (BP) readings. Standards stipulate measuring arm circumference at the midpoint between the acromion process (AP) and the olecranon process. However, which part of the AP to use is not stipulated. Furthermore, BP is measured sitting but arm circumference is measured standing. We sought to understand how landmarking during AC measurement and body position affect cuff size selection. Two variations in measurement procedure were studied. First, AC was measured at the top of the acromion (TOA) and compared to the spine of the acromion (SOA). Second, standing versus seated measurements using each landmark were compared. AC was measured to the nearest 0.1 cm at the mid-point of the upper arm by two independent observers, blinded from each other's measurements. In 51 participants, the mean (±SD) mid-AC measurement using the anchoring landmarks TOA and SOA in the standing position were 32.4 cm (±6.18) and 32.1 cm (±6.07), respectively (mean difference of 0.3 cm). In the seated position, mean arm circumference was 32.2 (±6.10) using TOA and 31.1 (±6.03) using SOA (mean difference 1.1 cm). Kappa agreement for cuff selection in the standing position between TOA and SOA was 0.94 (p < 0.001). The landmark on the acromion process can change the cuff selection in a small percentage of cases. The overall impact of this landmark selection is small. However, standardizing landmark selection and body position for AC measurement could further reduce variability in cuff size selection during BP measurement and validation studies.

Comparing blood pressure measurements between sitting in chairs and sitting on the floor

BACKGROUND

The current standard approach to measuring home blood pressure (BP) involves taking measurements while sitting in a chair. In cultures where floor sitting is common, including Korea, assessing BP while sitting on the floor would be more feasible. However, there is still a lack of research investigating whether BP measurements obtained while seated in a chair and while sitting on the floor can be regarded as interchangeable. The aim of the study was to evaluate whether there is a difference between BP measurements taken while sitting in a chair and while sitting on the floor in a Korean adult.

METHODS

Among the participants who visited for evaluation of pulse wave velocity, a total of 116 participants who agreed to participate in the study were randomly selected. All subjects rested for 5 min, and BP measurements were taken at 1-min intervals according to a randomly assigned order of standard method (chair-sitting) and BP in a seated on the floor (floor-sitting).

RESULTS

Of the 116 participants, the median age was 68 (with an interquartile range of 59 to 75), and 82% were men. There were no significant differences in systolic BP (SBP, 129.1 ± 17.8 mmHg in chair-sitting and 130.1 ± 18.9 mmHg in floor-sitting, P = 0.228) and diastolic BP (DBP, 73.9 ± 11.4 mmHg in chair-sitting and 73.7 ± 11.4 mmHg in floor-sitting, P = 0.839) between the two positions. In addition, there was a high level of agreement between BP measurements taken in the two positions (intraclass correlation coefficients: 0.882 for SBP and 0.890 for DBP).

CONCLUSION

These findings provide important insights into securing the reliability of home BP measurements through the commonly practiced floor-sitting posture in cultures where floor sitting is common. Furthermore, this could serve as substantial evidence for providing specific home BP measurement guidelines to patients who adhere to a floor-sitting lifestyle.

Measuring blood pressure from Korotkoff sounds as the brachial cuff inflates on average provides higher values than when the cuff deflates

Objectives. In this study, we test the hypothesis that if, as demonstrated in a previous study, brachial arteries exhibit hysteresis as the occluding cuff is deflated and fail to open until cuff pressure (CP) is well below true intra-arterial blood pressure (IAPB), estimating systolic (SBP) and diastolic blood pressure (DBP) from the presence of Korotkoff sounds (KS) as CP increases may eliminate these errors and give more accurate estimates of SBP and DBP relative to IABP readings.Approach. In 62 subjects of varying ages (45.1 ± 19.8, range 20.6-75.8 years), including 44 men (45.3 ± 19.4, range 20.6-75.8 years) and 18 women (44.4 ± 21.4, range 20.9-75.3 years), we sequentially recorded SBP and DBP both during cuff inflation and cuff deflation using KS.Results. There was a significant (p< 0.0001) increase in SBP from 122.8 ± 13.2 to 127.6 ± 13.0 mmHg and a significant (p= 0.0001) increase in DBP from 70.0 ± 9.0 to 77.5 ± 9.7 mmHg. Of the 62 subjects, 51 showed a positive increase in SBP (0-14 mmHg) and 11 subjects showed a reduction (-0.3 to -7 mmHg). The average differences for SBP and DBP estimates derived as the cuff inflates and those derived as the cuff deflates were 4.8 ± 4.6 mmHg and 2.5 ± 4.6 mmHg, not dissimilar to the differences reported between IABP and non-invasive blood pressure measurements. Although we could not develop multiparameter linear or non-linear models to explain this phenomenon we have clearly demonstrated through ANOVA tests that both body mass index (BMI) and pulse wave velocity are implicated, supporting the hypothesis that the phenomenon is associated with age, higher BMI and stiffer arteries.Significance. The implications of this study are that brachial sphygmomanometry carried out during cuff inflation could be more accurate than measurements carried out as the cuff deflates. Further research is required to validate these results with IAPB measurements.

Noninvasive pediatric blood pressure assessment: exploring the clinicians' perspective

BACKGROUND

Obtaining accurate and reliable blood pressure (BP) readings in pediatric patients is challenging, given difficulties in adhering to measurement guidelines, limited device validation and variable patient cooperation. This study aimed to investigate clinicians' perspectives surrounding noninvasive pediatric BP assessment to identify opportunities for improvement in BP technology and clinical practice.

METHOD

Based on an adapted version of the extended Technology Acceptance Model 2, semi-structured interviews were conducted with clinicians involved in noninvasive pediatric BP assessment in a major Australian children's hospital. Transcripts were analyzed thematically and guided by Technology Acceptance Model 2.

RESULTS

Clinician responses ( n  = 20) revealed that poor patient tolerance of BP measurement resulting from excessive cuff inflation is a major hindrance to reliable pediatric BP assessment. Clinicians described low trust in BP readings from automated devices, often relating to poor patient tolerance to cuff inflation, thereby diminishing the clinical utility of these readings in informing treatment decisions. Auscultatory measurement was regarded as more trustworthy and better tolerated, but less convenient to perform as compared with oscillometric measurement.

CONCLUSION

A dissonance exists between (1) low trust and clinical utility of the most common and easy-to-use BP measurement approach (automated devices), versus (2) higher trust and clinical utility, but efficiency and user-related impediments, for the auscultatory method. Based on our results, we have developed the Blood Pressure Acceptance Model, which can be used to explain and predict clinicians' acceptance of BP technology. Further work is needed to improve the tolerability and accuracy of automated BP devices in real-world pediatric settings.

Structural and functional cardiac parameters across occupations: a cross-sectional study in differing work environments

Previous investigations have highlighted notable variations in cardiovascular risk indicators associated with various professional categories. However, only a few studies have examined structural and functional cardiac parameters using echocardiography within distinct occupational groups. Hence, this study endeavored to assess cardiac structural and functional parameters in three additional occupations: firefighters (FFs), police officers (POs), and office workers (OWs). This prospective study encompassed 197 male participants (97 FFs, 54 POs, and 46 OWs) from Germany. All participants underwent 2D and Doppler echocardiography in resting conditions; standard parasternal and apical axis views were employed to evaluate structural (diastolic and systolic) and functional (systolic and diastolic function, and strain) cardiac parameters. All three occupational groups exhibited a tendency towards septal hypertrophy. Notably, OWs exhibited the largest diastolic interventricular septum diameter (IVSd), at 1.33 ± 0.25 cm. IVSd significantly varied between POs and OWs (p = 0.000) and between POs and FFs (p = 0.025). Additionally, during diastole a substantially larger left ventricular posterior wall diameter (LVPWd) was observed in OWs compared to FFs (p = 0.001) and POs (p = 0.013). The left ventricular diastolic cavity diameter (LVIDd) and the left ventricular systolic cavity diameter (LVIDs) were significantly higher in POs than they were in FFs (LVIDd: p = 0.001; LVIDs: p = 0.009), and the LVIDd was notably higher in FFs (p = 0.015) and POs compared to OWs (p = 0.000). FFs exhibited significantly better diastolic function, indicated by higher diastolic peak velocity ratios (MV E/A ratio) and E/E' ratios, compared to POs (E/A ratio: p = 0.025; E/E' ratio: p = 0.014). No significant difference in diastolic performance was found between OWs and FFs. Significantly higher E'(lateral) values were noted in POs compared to FFs (p = 0.003) and OWs (p = 0.004). Ejection fraction did not significantly differ among FFs, POs, and OWs (p > 0.6). The left ventricular mass (LV Mass) was notably higher in POs than it was in FFs (p = 0.039) and OWs (p = 0.033). Strain parameter differences were notably improved in two- (p = 0.006) and four-chamber (p = 0.018) views for FFs compared to POs. Concentric remodeling was the predominant change observed in all three occupational groups. Significant differences in the presence of various forms of hypertrophy were observed in FFs, POs, and OWs (exact Fisher test p-values: FFs vs. OWs = 0.021, POs vs. OWs = 0.002). OWs demonstrated notably higher rates of concentric remodeling than FFs did (71.77% vs. 47.9%). This study underscores disparities in both functional and structural parameters in diverse occupational groups. Larger prospective studies are warranted to investigate and delineate differences in structural and functional cardiac parameters across occupational groups, and to discern their associated effects and risks on the cardiovascular health of these distinct professional cohorts.

Serum Brain Natriuretic Peptide Levels Correlate with the Severity of Hypertension in a Population of Nigerian Patients

Background

Hypertension is a major global health concern requiring precise risk assessment. Brain Natriuretic Peptide (BNP) has emerged as a potential biomarker, but its relationship with hypertension severity requires exploration to evaluate its potential as a risk prediction tool. This study aimed to assess the relationship between serum BNP levels and the severity of hypertension in a population of Nigerian patients.

Methodology

This was an analytical cross-sectional case-controlled study involving 103 hypertensive patients and 98 controls. Participants were grouped based on World Health Organization (WHO) criteria for diagnosis of Hypertension and the severity of hypertension was categorized based on blood pressure readings. The mean BNP levels were assessed among different hypertension grades, while logistic regression was used to assess the odds of higher severity with elevated BNP.

Results

Serum BNP levels were significantly higher in hypertensive individuals (616.5 ± 66.3 pg/mL) compared to controls (501.1 ± 84.6 pg/mL) and varied significantly across different hypertension grades (p = 0.000). A positive correlation was observed between serum BNP and hypertension severity (r = 0.736, p < 0.001). Logistic regression analysis indicated increasing odds of higher severity with elevated BNP from Grade 1 to Grade 3 hypertension.

Conclusion

This study established a positive correlation between serum BNP levels and hypertension severity, indicating its potential as a predictive biomarker for risk stratification in hypertensive individuals.

Comparison of routine office blood pressure measurement versus standardized attended manually activated oscillometric office blood pressure measurement in patients with chronic kidney disease

Context

Erroneous blood pressure measurement could lead to improper treatment and hence progression of chronic kidney disease (CKD). In routine clinical practice, there is poor adherence to the various steps to be followed during blood pressure measurement. Automated oscillometric BP measurement is difficult to perform in routine clinical practice due to several practical limitations.

Aims

To evaluate the quality of blood pressure measurement and to compare routine office blood pressure measurement with standardized attended manually activated oscillometric blood pressure measurement in patients with CKD attending the nephrology outpatient department (OPD) of a tertiary care referral center.

Settings and Design

This cross-sectional study was conducted in patients aged more than 18 years with CKD stage 3-5ND, and previously diagnosed hypertension, in the nephrology OPD of a tertiary care referral center between July 2022 and September 2022.

Methods and Material

The quality of blood pressure measurement was evaluated using a questionnaire. The study participants had their blood pressure checked by both methods-routine office blood pressure and standardized attended manually activated oscillometric blood pressure.

Results

Standardized attended manually activated oscillometric blood pressure measurement yielded a significantly higher systolic blood pressure (SBP) compared to routine office blood pressure measurement (Mean SBP: 139.53 ± 29.1 vs 132.57 ± 23.59; P < 0.001). However, the diastolic blood pressure did not differ significantly between the two methods of measurement.

Conclusions

Standardized attended manually activated oscillometric BP measurement yields a higher systolic BP compared to routine office BP measurement. Further studies are required to compare the standardized attended oscillometric BP measurement used in this study with unattended automated oscillometric BP measurement and ambulatory BP measurement.

Simultaneous 24-h ambulatory blood pressure measurement on both arms: a consideration for improving hypertension management

OBJECTIVE

Arterial hypertension is one of the common treatment goals in today's medicine. 24-h ambulatory blood pressure measurement (ABPM) performed by oscillometric cuff-based devices is considered as the gold standard in hypertension diagnostics. This study aims at examining the measurement accuracy of a widely used, ABPM device.

METHODS

Fifty-two young and healthy participants underwent simultaneous 24-h ABPM on the left and the right upper arm using two Boso/A&D TM-2430 oscillometric cuff-based devices. Pressure curves of the cuffs, as well as hydrostatic pressure difference between the cuffs were recorded.

RESULTS

The mean differences between both simultaneous measurements were 1.16 mmHg with limits of agreement of 36.23 mmHg for SBP and 1.32 mmHg with limits of agreement of 32.65 mmHg for DBP. Excluding measurements where the pressure curves were disturbed and correcting for hydrostatic pressure difference between the cuffs, reduced the measurement error. However, limits of agreement remained around 20 mmHg. There were large differences in hypertension grading and dipping pattern classification between simultaneous measurements on the left and right arm.

CONCLUSION

The cuff-based ABPM device reveals notable measurement uncertainties, influencing hypertension grading, dipping pattern classification and blood pressure variability. These effects are attributed in part to disturbances during cuff deflation and hydrostatic influences. Nonetheless, ABPM has shown its clinical values in several studies, while this study underscores its still unlocked potential to improve hypertension management.

Polygenic risk scores associate with blood pressure traits across the lifespan

AIMS

Hypertension is a major modifiable cause of morbidity and mortality that affects over 1 billion people worldwide. Blood pressure (BP) traits have a strong genetic component that can be quantified with polygenic risk scores (PRSs). To date, the performance of BP PRSs has mainly been assessed in adults, and less is known about polygenic hypertension risk in childhood.

METHODS AND RESULTS

Multiple PRSs for systolic BP (SBP), diastolic BP (DBP), and pulse pressure were developed using either genome-wide significant weights, pruning and thresholding, or Bayesian regression. Among 87 total PRSs, the top performer for each trait was applied in independent cohorts of children and adult to assess genotype-phenotype associations and disease risk across the lifespan. Differences between those with low (1st decile), average (2nd-9th decile), and high (10th decile) PRS emerge in the first years of life and are maintained throughout adulthood. These diverging BP trajectories also seem to affect cardiovascular and renal disease risk, with increased risk observed among those in the top decile and reduced risk among those in the bottom decile of the polygenic risk distribution compared with the rest of the population.

CONCLUSION

Genetic risk factors are associated with BP traits across the lifespan, beginning in the first years of life. Given the importance of exposure time in disease pathogenesis and the early rise in BP levels among those genetically susceptible, PRSs may help identify high-risk individuals prior to hypertension onset, facilitate primordial prevention, and reduce the burden of this public health challenge.

Impact of sleep quality and physical activity on blood pressure variability

Increased blood pressure variability (BPV) is linked to cardiovascular disease and mortality, yet few modifiable BPV risk factors are known. We aimed to assess the relationship between sleep quality and activity level on longitudinal BPV in a cohort of community-dwelling adults (age ≥18) from 17 countries. Using Withings home measurement devices, we examined sleep quality and physical activity over one year, operationalized as mean daily step count and number of sleep interruptions, both transformed into tertiles. The primary study outcome was high BPV, defined as the top tertile of systolic blood pressure standard deviation. Our cohort comprised 29,375 individuals (mean age = 58.6 years) with 127.8±90.1 mean days of measurements. After adjusting for age, gender, country, body mass index, measurement days, mean blood pressure, and total time in bed, the odds ratio of having high BPV for those in the top tertile of sleep interruptions (poor sleep) was 1.37 (95% CI, 1.28-1.47) and 1.44 (95% CI, 1.35-1.54) for those in the lowest tertile of step count (physically inactive). Combining these exposures revealed a significant excess relative risk of 0.20 (95% CI, 0.04-0.35, p = 0.012), confirming their super-additive effect. Comparing individuals with the worst exposure status (lowest step count and highest sleep interruptions, n = 2,690) to those with the most optimal status (highest step count and lowest sleep interruptions, n = 3,531) yielded an odds ratio of 2.01 (95% CI, 1.80-2.25) for high BPV. Our findings demonstrate that poor sleep quality and physical inactivity are associated with increased BPV both independently and super-additively.

Implementation of Video Blood Pressure Visits in the Veterans Health Administration

Introduction: Almost half of veterans (44.6%) seen in the U.S. Department of Veterans Affairs outpatient setting are diagnosed with hypertension (HTN). Because of the widespread nature of HTN, use of virtual visits has the potential to improve blood pressure (BP) management. This evaluation assessed the effectiveness of video blood pressure visits (VBPVs) in the management of HTN in veterans enrolled in Veterans Health Administration primary care. Methods: The program was implemented within the existing veteran-centered medical home. VBPVs are scheduled where the nurse observes veterans taking their BP and provides teaching or counseling. A national training curriculum was delivered to local nurse champions through Microsoft Teams. We analyzed improvement in BP over a 2-year period. We also captured actions taken by nurses during the VBPV by searching the electronic notes. Ratings of training and comments were summarized using feedback forms completed after training. Results: In total, 81,476 veterans participated in VBPVs over 2 years. Of those, 44,682 veterans had an existing ICD-10 code related to HTN. Of the 18,078 veterans who had a pre- and post-VBPV BP, the average change to systolic measurement was -10.6 mm Hg (range -82 to 78). Average change to diastolic measurement was -4.61 mm Hg (range -59 to 55). Most interventions addressed medication management (77%). Nurses' evaluations of the program were positive. Conclusions: Video visits provide reliable and convenient veteran-centered care. Such visits enable care when unanticipated interruptions occur such as the coronavirus disease 2019 pandemic. In addition to medication management, nurse-led interventions such as counseling on lifestyle changes can be effective in HTN management.

Calibration-free blood pressure estimation based on a convolutional neural network

In this study, we conducted research on a deep learning-based blood pressure (BP) estimation model suitable for wearable environments. To measure BP while wearing a wearable watch, it needs to be considered that computing power for signal processing is limited and the input signals are subject to noise interference. Therefore, we employed a convolutional neural network (CNN) as the BP estimation model and utilized time-series electrocardiogram (ECG) and photoplethysmogram (PPG) signals, which are quantifiable in a wearable context. We generated periodic input signals and used differential and thresholding methods to decrease noise in the preprocessing step. We then applied a max-pooling technique with filter sizes of 2 × 1 and 5 × 1 within a 3-layer convolutional neural network to estimate BP. Our method was trained, validated, and tested using 2.4 million data samples from 49 patients in the intensive care unit. These samples, totaling 3.1 GB were obtained from the publicly accessible MIMIC database. As a result of a test with 480,000 data samples, the average root mean square error in BP estimation was 3.41, 5.80, and 2.78 mm Hg in the prediction of pulse pressure, systolic BP (SBP), and diastolic BP (DBP), respectively. The cumulative error percentage less than 5 mm Hg was 68% and 93% for SBP and DBP, respectively. In addition, the cumulative error percentage less than 15 mm Hg was 98% and 99% for SBP and DBP. Subsequently, we evaluated the impact of changes in input signal length (1 cycle vs. 30 s) and the introduction of noise on BP estimation results. The experimental results revealed that the length of the input signal did not significantly affect the performance of CNN-based analysis. When estimating BP using noise-added ECG signals, the mean absolute error (MAE) for SBP and DBP was 9.72 and 6.67 mm Hg, respectively. Meanwhile, when using noise-added PPG signals, the MAE for SBP and DBP was 26.85 and 14.00 mm Hg, respectively. Therefore, this study confirmed that using ECG signals rather than PPG signals is advantageous for noise reduction in a wearable environment. Besides, short sampling frames without calibration can be effective as input signals. Furthermore, it demonstrated that using a model suitable for information extraction rather than a specialized deep learning model for sequential data can yield satisfactory results in BP estimation.

Mechanistic Assessment of Cardiovascular State Informed by Vibroacoustic Sensors

Monitoring blood pressure, a parameter closely related to cardiovascular activity, can help predict imminent cardiovascular events. In this paper, a novel method is proposed to customize an existing mechanistic model of the cardiovascular system through feature extraction from cardiopulmonary acoustic signals to estimate blood pressure using artificial intelligence. As various factors, such as drug consumption, can alter the biomechanical properties of the cardiovascular system, the proposed method seeks to personalize the mechanistic model using information extracted from vibroacoustic sensors. Simulation results for the proposed approach are evaluated by calculating the error in blood pressure estimates compared to ground truth arterial line measurements, with the results showing promise for this method.

A Survey on Blood Pressure Measurement Technologies: Addressing Potential Sources of Bias

Regular blood pressure (BP) monitoring in clinical and ambulatory settings plays a crucial role in the prevention, diagnosis, treatment, and management of cardiovascular diseases. Recently, the widespread adoption of ambulatory BP measurement devices has been predominantly driven by the increased prevalence of hypertension and its associated risks and clinical conditions. Recent guidelines advocate for regular BP monitoring as part of regular clinical visits or even at home. This increased utilization of BP measurement technologies has raised significant concerns regarding the accuracy of reported BP values across settings. In this survey, which focuses mainly on cuff-based BP monitoring technologies, we highlight how BP measurements can demonstrate substantial biases and variances due to factors such as measurement and device errors, demographics, and body habitus. With these inherent biases, the development of a new generation of cuff-based BP devices that use artificial intelligence (AI) has significant potential. We present future avenues where AI-assisted technologies can leverage the extensive clinical literature on BP-related studies together with the large collections of BP records available in electronic health records. These resources can be combined with machine learning approaches, including deep learning and Bayesian inference, to remove BP measurement biases and provide individualized BP-related cardiovascular risk indexes.

Prevalence of postprandial hypotension in older adults: a systematic review and meta-analysis

BACKGROUND

Older adults with postprandial hypotension (PPH) increase susceptibility to falls, syncope, stroke, acute cardiovascular diseases and even death. However, the prevalence of this condition varies significantly across studies. We aimed to determine the prevalence of PPH in older adults.

METHODS

Web of Science, PubMed, Cochrane Library, Embase and CINAHL were searched from their inception until February 2023. Search terms included 'postprandial period', 'hypotension' and 'postprandial hypotension'. Eligible studies were assessed using the Joanna Briggs Institute tool. Meta-analyses were performed among similar selected studies.

RESULTS

Thirteen eligible studies were included, and data from 3,021 participants were pooled. The meta-analysis revealed a PPH prevalence of 40.5% [95% confidence interval (CI): 0.290-0.519] in older adults, and this was prevalent in the community (32.8%, 95% CI: 0.078-0.647, n = 1,594), long-term healthcare facility (39.4%, 95% CI: 0.254-0.610, n = 1,062) and geriatrics department of hospitals (49.3%, 95% CI: 0.357-0.630, n = 365). The pooled results showed significant heterogeneity (I2 > 90%), partially related to the different ages, sex, pre-prandial systolic blood pressure levels of participants, or the different criteria and methodology used to diagnose PPH.

CONCLUSIONS

PPH is a prevalent condition in older adults. Further research is needed to confirm this result, and priority should be given to establishing international consensus on PPH diagnostic criteria and designing its diagnostic procedure.

Comparison of blood pressure measurements on the bare and sleeved arms - what does it uncover?

Accurate office blood pressure (BP) measurement remains crucial in diagnosing and managing hypertension. In this study, we aimed to compare BP measurements done over a bare arm versus a sleeved arm, while controlling all other possible sources of variance. We collected BP measurements of 100 hypertensive patients visiting a nephrology and hypertension clinic between January 2019 and December 2023. Measurements were taken by a single operator and according to the updated guidelines. BP measurements were performed first with one arm bare, and the other arm sleeved, with measurements taken simultaneously. Then, measurements were again taken simultaneously after exposing the arm which was first sleeved, and dressing the arm which was bare at first. A nonparametric Wilcoxon test was performed to compare each patient's measurements on each arm. No statistically significant differences were found between the sleeved and the bare arm measurements, with one exception of SBP measured on the left arm (slightly lower SBP on the bare arm). While looking at the absolute value of differences, the median difference was impressive with a 7-8 mmHg systolic difference and 5.5 mmHg diastolic difference. Our study revealed a robust and unpredicted effect of clothing on BP; in some patients, BP was increased while in others decreased. Therefore, we believe there is importance in measuring BP on bare skin, regardless of clothing or sleeve type.

Quality in screening and measuring blood pressure in China's primary health care: a national cross-sectional study using unannounced standardized patients

Background

This study aims to evaluate primary care providers' adherence to the standard of measuring blood pressure for people aged 35 or above during their initial visit, as per Chinese guidelines, and to identify factors affecting their practices.

Methods

We developed 11 standardized patients (SP) cases as tracer conditions to evaluate primary care, and deployed trained SPs for unannounced visits to randomly selected providers in seven provinces of China. The SPs used a checklist based on guidelines to record whether and how blood pressure was measured. Data were analyzed descriptively and regression analysis was performed to examine the association between outcomes and factors such as provider, patient, facility, and clinical case characteristics.

Findings

The SPs conducted 1201 visits and found that less than one-third of USPs ≥35 had their blood pressure measured. Only 26.9% of migraine and 15.4% of diabetes cases received blood pressure measurements. Additionally, these measurements did not follow the proper guidelines and recommended steps. On average, 55.6% of the steps were followed with few providers considering influencing factors before measurement and only 6.0% of patients received both-arm measurements. The use of wrist sphygmomanometers was associated with poor blood pressure measurement.

Interpretation

In China, primary care hypertension screening practices fall short of guidelines, with infrequent initiation of blood pressure measurements and inadequate adherence to proper measurement steps. To address this, priority should be placed on adopting, implementing, and upholding guidelines for hypertension screening and measurement.

Funding

National Natural Science Foundation of China, Swiss Agency for Development and Cooperation, Doctoral Fund Project of Inner Mongolia Medical University, China Postdoctoral Science Foundation.

Blood pressure variability supersedes heart rate variability as a real-world measure of dementia risk

Blood pressure variability (BPV) and heart rate variability (HRV) have been associated with Alzheimer's Disease and Related Dementias (ADRD) in rigorously controlled studies. However, the extent to which BPV and HRV may offer predictive information in real-world, routine clinical care is unclear. In a retrospective cohort study of 48,204 adults (age 54.9 ± 17.5 years, 60% female) receiving continuous care at a single center, we derived BPV and HRV from routinely collected clinical data. We use multivariable Cox models to evaluate the association of BPV and HRV, separately and in combination, with incident ADRD. Over a median 3 [2.4, 3.0] years, there were 443 cases of new-onset ADRD. We found that clinically derived measures of BPV, but not HRV, were consistently associated with incident ADRD. In combined analyses, only patients in both the highest quartile of BPV and lowest quartile of HRV had increased ADRD risk (HR 2.34, 95% CI 1.44-3.81). These results indicate that clinically derived BPV, rather than HRV, offers a consistent and readily available metric for ADRD risk assessment in a real-world patient care setting. Thus, implementation of BPV as a widely accessible tool could allow clinical providers to efficiently identify patients most likely to benefit from comprehensive ADRD screening.

Screening for hypertension in adults: protocol for evidence reviews to inform a Canadian Task Force on Preventive Health Care guideline update

PURPOSE

To inform updated recommendations by the Canadian Task Force on Preventive Health Care on screening in a primary care setting for hypertension in adults aged 18 years and older. This protocol outlines the scope and methods for a series of systematic reviews and one overview of reviews.

METHODS

To evaluate the benefits and harms of screening for hypertension, the Task Force will rely on the relevant key questions from the 2021 United States Preventive Services Task Force systematic review. In addition, a series of reviews will be conducted to identify, appraise, and synthesize the evidence on (1) the association of blood pressure measurement methods and future cardiovascular (CVD)-related outcomes, (2) thresholds for discussions of treatment initiation, and (3) patient acceptability of hypertension screening methods. For the review of blood pressure measurement methods and future CVD-related outcomes, we will perform a de novo review and search MEDLINE, Embase, CENTRAL, and APA PsycInfo for randomized controlled trials, prospective or retrospective cohort studies, nested case-control studies, and within-arm analyses of intervention studies. For the thresholds for discussions of treatment initiation review, we will perform an overview of reviews and update results from a relevant 2019 UK NICE review. We will search MEDLINE, Embase, APA PsycInfo, and Epistemonikos for systematic reviews. For the acceptability review, we will perform a de novo systematic review and search MEDLINE, Embase, and APA PsycInfo for randomized controlled trials, controlled clinical trials, and observational studies with comparison groups. Websites of relevant organizations, gray literature sources, and the reference lists of included studies and reviews will be hand-searched. Title and abstract screening will be completed by two independent reviewers. Full-text screening, data extraction, risk-of-bias assessment, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) will be completed independently by two reviewers. Results from included studies will be synthesized narratively and pooled via meta-analysis when appropriate. The GRADE approach will be used to assess the certainty of evidence for outcomes.

DISCUSSION

The results of the evidence reviews will be used to inform Canadian recommendations on screening for hypertension in adults aged 18 years and older.

SYSTEMATIC REVIEW REGISTRATION

This protocol is registered on PROSPERO and is available on the Open Science Framework (osf.io/8w4tz).

The Role of a Smart Health Ecosystem in Transforming the Management of Chronic Health Conditions

The effective management of chronic conditions requires an approach that promotes a shift in care from the clinic to the home, improves the efficiency of health care systems, and benefits all users irrespective of their needs and preferences. Digital health can provide a solution to this challenge, and in this paper, we provide our vision for a smart health ecosystem. A smart health ecosystem leverages the interoperability of digital health technologies and advancements in big data and artificial intelligence for data collection and analysis and the provision of support. We envisage that this approach will allow a comprehensive picture of health, personalization, and tailoring of behavioral and clinical support; drive theoretical advancements; and empower people to manage their own health with support from health care professionals. We illustrate the concept with 2 use cases and discuss topics for further consideration and research, concluding with a message to encourage people with chronic conditions, their caregivers, health care professionals, policy and decision makers, and technology experts to join their efforts and work toward adopting a smart health ecosystem.

Is the Blood Pressure-Enabled Smartwatch Ready to Drive Precision Medicine? Supporting Findings From a Validation Study

Background

The popular wrist-worn wearables recording a variety of health metrics such as blood pressure (BP) in real time could play a potential role to advance precision medicine, but these devices are often insufficiently validated for their performance to enhance confidence in its use across diverse populations. The accuracy of BP-enabled smartwatch is assessed among the multi-ethnic Malaysians, and findings is discussed in comparison with conventional automated upper-arm BP device.

Methods

Validation procedures followed the guidelines by the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Universal Standard (ISO 81060-2:2018). Quota sampling was employed to obtain eligible patients with normal and abnormal BP as per guideline. The measurements of BP were taken at wrist using HUAWEI WATCH D (test BP); and the readings were assessed against reference BP by the mercury sphygmomanometer. Agreement statistics and linear regression analyses were performed.

Results

BP measurements (234 data pairs) from 78 patients that fulfilled AAMI/ESH/ISO protocol were analyzed. The BP readings taken by the HUAWEI WATCH D were comparable to reference BP by sphygmomanometer based on 1) Criterion 1: systolic blood pressure (SBP) = -0.034 (SD 5.24) and diastolic blood pressure (DBP) = -0.65 (SD 4.66) mm Hg; and 2) Criterion 2: SBPs = -0.034 (SD 4.18) and DBPs = -0.65 (SD 3.94) mm Hg. Factors of sociodemographic characteristics, anthropometric measurements, cardiovascular comorbidities, and wrist hair density were not significantly associated with the mean BP differences.

Conclusions

HUAWEI WATCH D fulfilled criteria 1 and 2 of the AAMI/ESH/ISO Universal Standard (ISO 81060-2:2018) guidelines. It can be recommended for clinical use across a wider population. The rich data from real-time BP measurements in concurrent with other health-related parameters recorded by the smartwatch wearable offer opportunities to drive precision medicine in tackling therapeutic inertia by personalizing BP control regimen.