Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension

Home versus routine dialysis-unit blood pressure recordings among patients on hemodialysis

The optimal method for the diagnosis of hypertension among patients on hemodialysis remains a controversial issue. Using 44-h ambulatory blood pressure (BP) monitoring (ABPM) as the reference-standard, we assessed the diagnostic performance of home BP monitoring (HBPM) versus routine dialysis-unit BP recordings in hemodialysis patients. Over a period of 2 weeks, the following methods were used for the assessment of hypertension: (i) routine predialysis and postdialysis BP recordings averaged over 6 consecutive dialysis sessions; (ii) HBPM for 7 days (duplicate morning and evening measurements, Microlife WatchBP Home N); (iii) 44-h ABPM (20-min intervals over an entire interdialytic interval, Microlife WatchBPO3). The study included 70 patients (mean age: 65.3 ± 13.2 years; treated hypertensives: 87.1%; 44-h ambulatory systolic/diastolic BP: 120.6 ± 15.2/66.3 ± 10.1 mmHg). Mean (standard deviation) of the differences between ambulatory daytime systolic BP (SBP) and routine predialysis SBP was -11.4 (13.4) mmHg, routine postdialysis SBP -4.0 (15.1) mmHg and home SBP -8.6 (10.7) mmHg. The area under the receiver-operating-characteristic-curve (AUC) for the detection of an ambulatory daytime SBP ≥ 135 mmHg was higher for home SBP [AUC: 0.934; 95% confidence interval (CI): 0.871-0.996] relative to predialysis SBP (AUC: 0.778; 95% CI: 0.643-0.913) and postdialysis SBP (AUC: 0.766; 95% CI: 0.623-0.909) (P = 0.02 for both comparisons). Home SBP at the cut-off point of 141.0 mmHg provided the best combination of sensitivity (85.7%) and specificity (92.9%) in diagnosing hypertension. In conclusion, the present study shows that among hemodialysis patients, HBPM for 1 week is superior to 2-week averaged routine predialysis or postdialysis BP in predicting ambulatory hypertension.

Home Blood Pressure Monitoring

The diagnosis and management of hypertension have been based primarily on blood pressure (BP) measurement in the office setting. Higher out-of-office BP is associated with an increased risk of cardiovascular disease, independent of office BP. Home BP monitoring (HBPM) consists of the measurement of BP by a person outside of the office at home and is a validated approach for out-of-office BP measurement. HBPM provides valuable data for diagnosing and managing hypertension. Another validated approach, ambulatory BP monitoring (ABPM), has been considered to be the reference standard of out-of-office BP measurement. However, HBPM offers potential advantages over ABPM including being a better measure of basal BP, wide availability to patients and clinicians, evidence supporting its use for better office BP control, and demonstrated efficacy when using telemonitoring along with HBPM. This state-of-the-art review examines the current state of HBPM and includes discussion of recent hypertension guidelines on HBPM, advantages of using telemonitoring with HBPM, use of self-titration of antihypertensive medication with HBPM, validation of HBPM devices, best practices for conducting HBPM in the clinical setting, how HBPM can be used as an implementation strategy approach to improve BP control in the United States, health equity in HBPM use, and HBPM use among specific populations. Finally, research gaps and future directions of HBPM are reviewed.

Adherence to proper blood pressure measurements among interns at the university of Gondar specialized referral hospital

Introduction

Blood pressure is a lateral force exerted on the wall of arteries and is critical for the normal distribution of blood containing nutrients and oxygen to metabolic tissues. It is one of the vital signs often measured by interns, nurses, and physicians at doctor's offices, at bedside, and possibly at home. Accurate blood pressure measurement is essential for proper diagnosis and management of patients, especially those with hypertension. The aim of this cross-sectional survey study is to assess the practice of measuring blood pressure by interns.

Methods

This study was conducted in the form of a survey administered through face-to-face interviews. All the interns at the Univeristy of Gondar Specialized Referral Hospital were approached. The survey included questions about devices used, patient's information, and blood pressure measurement techniques. Epi-Data version 3.1 was used for data entry and exported to STATA 17 for data management and analysis. The Chi-square test was checked to assess the eligibility of variables for logistic regression. Finally, in the multivariable binary logistic regression analysis, variables with P-value < 0.05 were considered to be statistically significantly associated. The Adjusted Odds Ratio (AOR) with 95% CI was reported to declare the statistical significance and strength of association between blood pressure measurement and independent variables.

Result

The magnitude of appropriate measurement of blood pressure among interns was 10.1 (95% CI: 7.19, 13.9). A total of 318 interns participated in the current study. Of these study participants, 65.4% (208) were males. A increase in participants age (AOR: 1.48, 95% CI: 1.09, 2.01), being male interns (AOR: 5.51, 95% CI: 1.51, 8.97), and having patients who were familiar with the procedure (AOR: 2.95, 95% CI: 1.19, 7.03) were factors significantly associated with appropriate adherence to blood pressure measurement.

Conclusion and recommendation

Only 10% of six-year medical students (Interns) were successful in appropriately assessing blood pressure. Age, being male, and patient understanding were factors significantly associated to the adherence of blood pressure measurement. Considering the frequency of BP measurement and the impact of hypertension on morbidity and mortality, efforts are needed to maximize the quality of BP measurement by health professionals. This process should begin early during training and be consistent throughout their clinical practice, supplemented by ongoing education.

Effect of a digital blood pressure coach on hypertension management in primary care practices-a pragmatic, randomised controlled trial

Importance

Smartphone medical applications (apps) may improve blood pressure (BP) control in the primary care setting in patients with hypertension. However, real-world evidence from primary care is largely lacking.

Objective

To analyse, in primary care practices in Germany, the effect of a smartphone app on systolic BP compared to standard of care.

Design

A pragmatic, non-blinded randomized controlled trial with patients with a diagnosis of hypertension was conducted across 23 general practices in Germany, with a follow-up period of 3 months. Recruitment occurred from January 2022 to May 2023.

Intervention

The intervention group received access to the Manoa app, a smartphone coach integrating guideline-compliant home BP monitoring and lifestyle-coaching. All study participants received standard treatment for arterial hypertension at the discretion of the treating physician.

Main Outcomes

The primary outcome was office systolic BP (oSBP) after 90-150 days in participants with uncontrolled hypertension (oSBP ≥140 mmHg). Secondary outcomes included changes in systolic and diastolic BP, BP control and adherence to home blood pressure monitoring.

Results

A total of 606 participants from 23 general practices were randomized, after data clearance and review, 249 participants were assigned to the control group and 259 to the intervention group for analysis. The mean age (SD) of participants in the intervention group was 55.9 (12.9) years. At baseline, participants with uncontrolled hypertension had a mean oSBP (SD) of 152.6 (14.2) mmHg in the intervention group (n = 162) and 152.6 (14.1) mmHg in the control group (n = 147). After 120 ± 14 days, oSBP decreased to 137.4 (14.4) mmHg in the intervention group and to 137.7 (14.5) mmHg in the control group, with a between-group mean difference of -0.2 mmHg [95% CI (-3.9,3.5); P =.9]. At the follow-up appointment, 69.1% of participants in the intervention group submitted a BP-diary, compared to 36.1% in the control group [OR = 3.95; 95% CI (2.73,5.72); P = <0.001].

Conclusions and Relevance

Participants with uncontrolled hypertension randomized to an app in primary care achieved similar decreases in systolic BP but higher adherence to home BP monitoring compared to standard care. In this open-label, pragmatic trial, variability in hypertension management strategies and limited standardization across practices may have confounded the precise evaluation of digital intervention benefits.

Clinical Trial Registration

ClinicalTrials.gov, identifier, (DRKS00027964).

Blood pressure variability: a review

Blood pressure variability (BPV) predicts cardiovascular events independent of mean blood pressure. BPV is defined as short-term (24-h), medium or long- term (weeks, months or years). Standard deviation, coefficient of variation and variation independent of the mean have been used to quantify BPV. High BPV is associated with increasing age, diabetes, smoking and vascular disease and is a consequence of premature ageing of the vasculature. Long-term BPV has been incorporated into cardiovascular risk models (QRISK) and elevated BPV confers an increased risk of cardiovascular outcomes even in subjects with controlled blood pressure. Long-acting dihydropyridine calcium channel blockers and thiazide diuretics are the only drugs that reduce BPV and for the former explains their beneficial effects on cardiovascular outcomes. We believe that BPV should be incorporated into blood pressure management guidelines and based on current evidence, long-acting dihydropyridines should be preferred drugs in subjects with elevated BPV.

Accuracy of the Combei BP880W Wrist Device for Self-Blood Pressure Measurements in General Population According to the International Organization for Standardization Universal Standard (ISO 81060-2:2018/AMD 1:2020) Protocol

Background

Scientific societies universally recommend evaluating the accuracy of electronic devices designed for blood pressure (BP) measurement using established validation protocols.

Objective

This study aimed to assess the accuracy of the Combei BP880W wrist device for BP measurement in the general population, according to the ISO 81060-2:2018/AMD 1:2020 Universal Standard.

Methods

The Combei BP880W is an oscillometric device designed to measure BP at the wrist. This study adhered to the ISO 81060-2:2018/AMD 1:2020 protocol and employed the same-arm sequential BP measurement method. A total of 85 participants, meeting protocol-specified age, gender, BP, and cuff distribution criteria, were included. The accuracy analysis utilized Criterion 1 (differences and standard deviations between reference and test device measurements) and Criterion 2 (intra-individual standard deviation of BP differences).

Results

Eighty-five participants were included. Mean BP differences between the simultaneous observer measurements were -0.2 ± 1.9 mmHg for systolic BP (SBP) and 0.1 ± 1.9 mmHg for diastolic BP (DBP). For Criterion 1, the mean difference ± standard deviation (SD) between the reference and test device measurements were -2.7 ± 5.9 mmHg (SBP) and -2.0 ± 3.9 mmHg (DBP), meeting the required threshold (≤ 5 ± 8 mmHg). For Criterion 2, intra-individual SDs were 4.6 mmHg (SBP) and 3.4 mmHg (DBP), both below the respective limits (≤ 6.39 mmHg for SBP and ≤ 6.65 mmHg for DBP).

Conclusion

The Combei BP880W wrist device meets the accuracy requirements of the ISO 81060-2:2018/AMD 1:2020 protocol, supporting its use for home BP monitoring in the general population.

Combination Antithrombotic Therapy for Reduction of Recurrent Ischemic Stroke in Intracranial Atherosclerotic Disease

BACKGROUND

Stroke secondary to intracranial atherosclerotic disease (ICAD) is associated with high recurrence risk despite currently available secondary prevention strategies. In patients with systemic atherosclerosis, a significant reduction of stroke risk with no increase in intracranial or fatal hemorrhage was seen when rivaroxaban 2.5 mg twice daily was added to aspirin. However, there are no trials in ICAD using this combination. To facilitate the design of future ICAD trials, the CATIS-ICAD study (Combination Antithrombotic Treatment for Prevention of Recurrent Ischemic Stroke in Intracranial Atherosclerotic Disease) assessed (1) the feasibility of recruitment, (2) the safety of low-dose rivaroxaban plus aspirin compared with standard-of-care antiplatelet therapy, and (3) trends toward efficacy.

METHODS

This was a prospective, randomized, open-label, blinded end point pilot trial conducted in 10 Canadian centers. Eligible participants aged ≥40 years, with acute ischemic stroke or high-risk transient ischemic attack, were randomly assigned in a 1:1 ratio to receive low-dose rivaroxaban plus aspirin or aspirin alone within 7 to 100 days of their index event. The primary safety outcome was hemorrhagic stroke. The main efficacy end point was the composite of ischemic stroke or covert brain infarct on magnetic resonance imaging at the end of the study.

RESULTS

A total of 101 participants were randomized. Average enrollment was 10 participants/site per year. Average follow-up was 20 months. Median time from index stroke to randomization was 67 days. The median age of participants was 67 years (±10.94), and 29% of participants were women. There was no hemorrhagic stroke in either arm. The composite efficacy outcome was less frequent in the combination arm (15.7%) compared with the aspirin arm (24.0%), with a hazard ratio of 0.78 ([95% CI, 0.32-1.93]; P=0.59) favoring the intervention.

CONCLUSIONS

A multicenter randomized trial comparing the combination of low-dose rivaroxaban and aspirin in patients with recent ischemic stroke or transient ischemic attack due to ICAD is feasible and appears safe without an increased risk of hemorrhagic stroke. A numerical trend toward efficacy for the composite primary end point of symptomatic ischemic stroke and covert infarcts was observed. These findings will inform the design of a phase III trial.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04142125.

Outcomes after medical treatment for primary aldosteronism: an international consensus and analysis of treatment response in an international cohort

BACKGROUND

Primary aldosteronism can be treated medically but there is no standardised method to evaluate treatment outcomes. We aimed to develop criteria for assessing the outcomes of targeted medical treatment of primary aldosteronism, analyse outcomes across an international cohort, and identify factors associated with a complete treatment response.

METHODS

An international panel of 31 primary aldosteronism experts used the Delphi method to reach consensus on the definition of complete, partial, or absent biochemical and clinical outcomes of medical treatment of primary aldosteronism. Clinical data at baseline and 6-12 months post-treatment were collected from patients with primary aldosteronism who started targeted medical treatment between 2016 and 2021 at 28 participating centres.

FINDINGS

Consensus was reached for defining complete, partial, or absent biochemical or clinical response. Of 1258 patients (with a mean age of 52 years [SD 11·5] and of whom 610 [48·5%] were female and 648 [51·5%] were male), 1057 (84·0%) had biochemical outcome data (559 [52·9%] had a complete biochemical response). The median daily dose of spironolactone was significantly higher for those with a complete biochemical response than for those without (40 mg [IQR 25-50] vs 25 mg [20-50]; p=0·011). Of the 1248 patients with clinical outcome data, 228 [18·3%] had a complete clinical response whereas 227 (18·2%) had an absent response. Patients with a complete clinical response were more likely than those with partial or absent clinical response to be women (OR 2·099, 95% CI 1·485-2·968; p<0·001), require lower doses of antihypertensive drugs at baseline (0·687, 0·603-0·782; p<0·001), and were less likely to have microalbuminuria or left ventricular hypertrophy (0·584, 0·391-0·873; p=0·009).

INTERPRETATION

The Primary Aldosteronism Medical Treatment Outcome (PAMO) criteria represent an internationally developed outcome standard that can guide clinical practice and research into primary aldosteronism. Efforts to optimise treatment intensity and minimise factors associated with an absent treatment response are needed to improve patient outcomes.

FUNDING

None.

TRANSLATIONS

For the Chinese (simple), Chinese (complex), Japanese, Korean, German, French, Spanish, Dutch, Swedish, Slovenian, Polish, Italian and Russian translations of the abstract see Supplementary Materials section.

Home blood pressure stability score is associated with better cardiovascular prognosis: data from the nationwide prospective J-HOP study

A home blood pressure (BP)-centered strategy is emerging as the optimal approach to achieve adequate BP control in individuals with hypertension, but a simple cardiovascular risk score based on home BP level and variability is lacking. This study used prospective data from the Japan Morning Surge-Home Blood Pressure (J-HOP) extended study to develop a simple home BP stability score for the prediction of cardiovascular risk. The J-HOP extended study included 4070 participants (mean age 64.9 years) who measured home BP three times in the morning and evening for 14 days at baseline. During the mean 6.3-year follow-up, there were 260 cardiovascular events. A home BP stability score was calculated based on the average of morning and evening systolic BP (SBP; MEave), and three home BP variability metrics: average real variability (average absolute difference between successive measurements); average peak (average of the highest three SBP values for each individual), and time in therapeutic range (proportion of time spent with MEave home SBP 100-135 mmHg). There was a curvilinear association between the home BP stability score and the risk of cardiovascular events. Compared with individuals in the optimal home SBP stability score group (9-10 points), those in the very high-risk group (0 points) had significantly higher cardiovascular event risk during follow-up (adjusted hazard ratio 3.97, 95% confidence interval 2.22-7.09; p < 0.001), independent of age, sex, medication, cardiovascular risk factors, and office BP. These data show the potential for a simple home BP-based score to predict cardiovascular event risk in people with hypertension.

I Brazilian guideline on hypertension in dialysis of the Brazilian Society of Nephrology

Hypertension in dialysis patients (HTND) has a high prevalence, affecting at least 80% or more of patients, and its management in the nephrology practice is heterogeneous and often empirical. Knowing how to define, understand the pathophysiology, diagnose, monitor and treat with lifestyle changes, and adjust antihypertensive drugs to achieve the recommended blood pressure (BP) target - to reduce morbidity and mortality - requires specific knowl-edge and approaches within the contexts of hemodialysis (HD) and peritoneal dialysis (PD). This document is the first guideline of the Brazilian Society of Nephrology, developed by the departments of Hypertension and Dialysis. It aims to guide physicians who provide care in dialysis centers on how to manage patients with HTND, in a comprehensive and individualized manner, based on the critical appraisal of the best available scientific evidence. When such evidence is scarce or unavailable, the opinion of specialists should be recommended. The different topics covered include HTND definition (pre-HD BP ≥ 140/90 mmHg and post-HD BP ≥ 130/80 mmHg), epidemiology, and pathophysiology; diagnosis of HTND preferably with BP measurements outside the dialysis setting (BP ≥ 130/80 mmHg); complementary assessment; blood pressure targets; non-pharmacological treatment; use of the most appropriate antihypertensive medications; special situations; and complications of HTND, predominantly cardiovascular ones.

User engagement with home blood pressure monitoring: a multinational cohort using real-world data collected with a connected device

OBJECTIVE

Connected blood pressure (BP) monitors provide reliable data when used properly. Our objective was to analyse the engagement of real-world users with self-measurements.

METHODS

We included adult first-time users of a connected BP monitor from July 2019 to March 2021. They were categorized as persistent users if they continued to use the device between 311 and 400 days after inclusion. We defined a criterion to analyse the timing of self-measurements: at least 12 measurements performed within three consecutive days, at least once every 90 days. Persistent users were clustered by state sequence analysis according to the consistency of their BP monitor measurement timing with this criterion during 1 year of follow-up.

RESULTS

Among the 22 177 included users, 11 869 (54%) were persistent during the first year. Their use was consistent with the timing criterion 25% (median) of this time (first and third quartiles: 0%, 50%) and four patterns of use were identified by clustering: 5215 persistent users (44%) only performed occasional sparse measurements, 4054 (34%) complied at the start of follow-up up to eight cumulated months, 1113 (9%) complied at least once during later follow-up up to eight cumulated months, and the remaining 1487 (13%) complied nine or more cumulated months of follow-up.

CONCLUSION

Although connected BP monitors can collect a high volume of data, the real-life timing of self-measurements is far from recommended schedules. We must promote the use of BP monitors as recommended by guidelines and/or learn to analyse more occasional and sparse measurements.

Evaluation of self-monitoring of blood pressure in the PERHIT study and the impact on glomerular function

BACKGROUND

Although intensive blood pressure (BP) control has not been shown to slow the progression of chronic kidney disease (CKD), intensive BP control has been shown to reduce the risk for adverse cardiovascular outcomes in the CKD population. The aim of this post-hoc study was to study the interplay between a self-monitoring BP system and glomerular function.

METHODS

In all, 949 participants with hypertension underwent visits at baseline, after eight weeks and 12 months. Half of the participants received a BP monitor and installed a program on their mobile phone. During eight weeks, they measured daily and reported their BP values.

RESULTS

Within the intervention group, BP and systolic BP (SBP) decreased from baseline to eight weeks and 12 months (p < .001). Pulse pressure (PP) and mean arterial blood pressure (MAP) decreased from baseline to eight weeks (p = .021 and p = .004) vs 12 months (p = .035 and p = .008). Within the control group, a decrease was observed from baseline to 12 months for SBP, diastolic BP (DBP) and PP (p = .025, p = .023 and p = .036). In the intervention group, we observed an association between a decrease in SBP, DBP, PP and MAP and a decrease in eGFR (estimated glomerular filtration rate), (p < .001, p < .001, p = .013 and p < .001). In the control group, similar results were observed for PP only (p = .027). Within the intervention group, eGFR decreased (p < .001) but within the control group, the decrease was non-significant (p = .051).

CONCLUSION

We observed an association between a decrease in all BP components and eGFR decline within the normal range in the intervention group but not in the controls.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov [NCT03554382].

[Cardiovascular preventive recommendations. PAPPS 2024 thematic updates]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of vascular diseases (VD) are presented. New in this edition are new sections such as obesity, chronic kidney disease and metabolic hepatic steatosis, as well as a 'Don't Do' section in the different pathologies treated. The sections have been updated: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; vascular risk (VR) and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

The association of home blood pressure with all-cause mortality in hemodialysis patients: A prospective observational study

INTRODUCTION

Prior observational studies conducted in the hemodialysis population have suggested a reverse association between dialysis-unit blood pressure (BP) and mortality. The present study aimed to investigate the prognostic association of home versus dialysis-unit BP with all-cause mortality in hemodialysis patients.

METHODS

At baseline, 146 patients receiving maintenance hemodialysis underwent assessment of their BP with the following methods: (i) 2-week averaged routine predialysis and postdialysis BP measurements; (ii) home BP monitoring for 1 week that included duplicate morning and evening BP measurements with the use of validated devices.

RESULTS

Over a median follow-up period of 38 months (interquartile range [IQR]: 22-54), 44 patients (31.1%) died. In Kaplan-Meier curves, predialysis and postdialysis systolic BP (SBP) was not associated with all-cause mortality, while home SBP appeared to be of prognostic significance (log rank p = 0.029). After stratifying patients into quartiles, all-cause mortality was lowest when home SBP was ranging from 128.1 to 136.8 mmHg (quartile 2). In univariate Cox regression analysis, using quartile 2 as a referent category, the risk of all-cause mortality was 3.32-fold higher in quartile 1, 1.53-fold higher in quartile 3 and 3.25-fold higher in quartile 4. The risk-association remained unchanged after adjustment for several confounding factors (adjusted hazard ratio: 4.79, 1.79, 3.63 for quartiles 1, 3, and 4 of home systolic BP, respectively).

CONCLUSION

Our findings suggest that among hemodialysis patients, 1-week averaged home SBP is independently associated with all-cause mortality. In sharp contrast, SBP recorded either before or after dialysis over 2 weeks is not prognostically informative.

Proposal of reference value for day-to-day blood pressure variability based on two outcomes: the Ohasama study

BACKGROUND

This study aimed to propose reference values for day-to-day home blood pressure (BP) variability that align with the established hypertension threshold of home BP for the risk of two different outcomes: cardiovascular mortality and cognitive decline.

METHODS

This prospective study was conducted in Ohasama town, Japan, with 1212 participants assessed for cardiovascular mortality risk (age: 64.7 years, 33.6% men). Additionally, 678 participants (age: 62.7 years, 31.1% men) were assessed for cognitive decline risk (Mini-Mental Scale Examination score <24). The within-individual coefficient of variation (CV) of home morning SBP (HSBP) was used as the index of day-to-day BP variability (%). Adjusted Cox regression models were used to estimate the HSBP-CV values, which provided the 10-year outcome risk at an HSBP of 135 mmHg.

RESULTS

A total of 114 cardiovascular deaths and 85 events of cognitive decline (mean follow-up:13.9 and 9.6 years, respectively) were identified. HSBP and HSBP-CV were associated with increased risks for both outcomes, with adjusted hazard ratios per 1-standard deviation increase of at least 1.25 for cardiovascular mortality and at least 1.30 for cognitive decline, respectively. The adjusted 10-year risks for cardiovascular mortality and cognitive decline were 1.67 and 8.83%, respectively, for an HSBP of 135 mmHg. These risk values were observed when the HSBP-CV was 8.44% and 8.53%, respectively.

CONCLUSION

The HSBP-CV values indicating the 10-year risk of cardiovascular mortality or cognitive decline at an HSBP of 135 mmHg were consistent, at approximately 8.5%. This reference value will be useful for risk stratification in clinical practice.

Comparison of Home Blood Pressure Monitoring with and without Training: Does Adherence to the Recommended Instructions Overlook Hypertension?

BACKGROUND

Home blood pressure monitoring (HBPM) is commonly used to diagnose hypertension (HT), with a diagnostic threshold of ≥135/85 mm Hg, the same as daytime ambulatory BP monitoring (ABPM). This study hypothesizes that training and adherence to HBPM guidelines will yield more accurate BP readings compared to ABPM.

METHODS

The study involved 129 patients with elevated office BP but no prior HT diagnosis. After a two-week observation period with lifestyle advice, HBPM was conducted over a week before and after structured measurement training, with ABPM performed in each period. Adherence to instructions post-training was also assessed.

RESULTS

Post-training, mean systolic and diastolic home BP values significantly decreased (from 128 ± 13.1/84.9 ± 8.2 to 122.6 ± 12.7/81.8 ± 7.8; P < 0.001 for both), while daytime ABPM values remained unchanged (131.7 ± 11.1/86.7 ± 9.3 before vs. 130.7 ± 11.7/85.9 ± 8.6 after; P = 0.185). Although HBPM values were consistently lower than ABPM values, the discrepancy grew post-training. The number of patients reaching the HT threshold via HBPM decreased significantly post-training [71 (55%) to 54 (41.9%); P = 0.006], whereas the number via daytime ABPM remained similar [82 (64.3%) vs. 84 (65.1%); P = 1.000].

CONCLUSION

Training and adherence to HBPM guidelines led to lower BP readings and fewer HT diagnoses. Contrary to the hypothesis, this method under "ideal conditions" underestimated HT prevalence when compared to daytime ABPM. Further studies with clinical endpoints are needed to refine HBPM methods and establish new BP thresholds for more accurate HT detection.

A Cross-Sectional Survey of Fixed-Dose Combination Antihypertensive Medicine Prescribing in Twenty-Four Countries, Including Qualitative Insights

Background

Treatment inertia, non-adherence and non-persistence to medical treatment contribute to poor blood pressure (BP) control worldwide. Fixed dose combination (FDC) antihypertensive medicines simplify prescribing patterns and improve adherence. The aim of this study was to identify factors associated with prescribing FDC antihypertensive medicines and to understand if these factors differ among doctors worldwide.

Methods

A cross-sectional survey was conducted online from June 2023 to January 2024 to recruit doctors. We collaborated with an international network of researchers and clinicians identified through institutional connections. A passive snowballing recruitment strategy was employed, where network members forwarded the survey link to their clinical colleagues. The survey instrument, developed through a literature review, interviews with academic and clinical researchers, and pilot testing, assessed participants perspectives on prescribing FDC antihypertensive medicines for hypertension. Participants rated their level of agreement (5-point Likert scale) with statements representing six barriers and four facilitators to FDC use.

Findings

Data from 191 surveys were available for analysis. 25% (n = 47) of participants worked in high-income countries, 38% (n = 73) in upper-middle income, 25% (n = 48) in lower-middle income, 6% (n = 10) in low-income countries. Forty percent (n = 70) of participants were between 36-45 years of age; two thirds were male. Cost was reported as a barrier to prescribing FDC antihypertensive medicines [51% (n = 87) agreeing or strongly agreeing], followed by doctors' confidence in BP measured in clinic [40%, (n = 70)], access [37%, (n = 67)], appointment duration [35%, (n = 61)], concerns about side-effects [(21%, n = 37)], and non-adherence [12%, (n = 21)]. Facilitators to FDC antihypertensive polypills prescribing were clinician facing, such as access to educational supports [79%, (n = 143)], more BP measurement data [67%, (n = 120)], a clinical nudge in health records [61%, (n = 109)] and patient-facing including improved patient health literacy [49%, (n = 88)]. The levels of agreement and strong agreement across all barriers and facilitators were similar for participants working in higher or lower income countries. Across all countries, participants rated FDC antihypertensive medications highly valuable for managing patients with non-adherence, (82% reported high or very high value), for patients with high pill burden (80%).

Interpretation

Cost and access were the most common barriers to prescribing FDCs across high- and low-income countries. While greater educational support for clinicians was perceived as the leading potential facilitator of FDC use, this seems unlikely to be effective without addressing access.

Blood pressure measurement and assessment of arterial structure and function: an expert group position paper

Measuring blood pressure (BP) and investigating arterial hemodynamics are essential in understanding cardiovascular disease and assessing cardiovascular risk. Several methods are used to measure BP in the doctor's office, at home, or over 24 h under ambulatory conditions. Similarly, several noninvasive methods have been introduced for assessing arterial structure and function; these methods differ for the large arteries, the small ones, and the capillaries. Consequently, when studying arterial hemodynamics, the clinician is faced with a multitude of assessment methods whose technical details, advantages, and limitations are sometimes unclear. Moreover, the conditions and procedures for their optimal implementation, and/or the reference normality values for the parameters they yield are not always taken into sufficient consideration. Therefore, a practice guideline summarizing the main methods and their use in clinical practice is needed. This expert group position paper was developed by an international group of scientists after a two-day meeting during which each of the most used methods and techniques for blood pressure measurement and arterial function and structure evaluation were presented and discussed, focusing on their advantages, limitations, indications, normal values, and their pragmatic clinical application.

Exercise blood pressure, cardiorespiratory fitness, fatness and cardiovascular risk in children and adolescents

Cardiovascular disease remains the leading cause of mortality on a global scale. Individuals who possess risk factors for cardiovascular disease, such as high blood pressure (BP) and obesity, face an elevated risk of experiencing organ-specific pathophysiological changes. This damage includes pathophysiological changes in the heart and peripheral vascular systems, such as ventricular hypertrophy, arterial stiffening, and vascular narrowing and stenosis. Consequently, these damages are associated with an increased risk of developing severe cardiovascular outcomes including stroke, myocardial infarction, heart failure, and coronary heart disease. Among all the risk factors associated with cardiovascular disease, high blood pressure emerges as the most prominent. However, conventional resting BP measurement methods such as auscultatory or oscillometric methods may fail to identify many individuals with asymptomatic high BP. Recently, exercise BP has emerged as a valuable diagnostic tool for identifying real (high) blood pressure levels and assessing underlying cardiovascular risk, in addition to resting BP measurements in adults. Furthermore, numerous established factors, such as low cardiorespiratory fitness and high body fatness, have been confirmed to contribute to exercise BP and the associated cardiovascular risk. Modifying these factors may help reduce high exercise BP and, consequently, alleviate the burden of cardiovascular disease. A significant body of evidence has demonstrated cardiovascular disease in later life have their origins in early life. Children and adolescents with these cardiovascular risk factors also possess a greater propensity to develop cardiovascular diseases later in life. Nevertheless, the majority of previous studies on the clinical utility of exercise BP have been conducted in middle-to-older aged populations, often with pre-existing clinical conditions. Therefore, there is a need to investigate further of the factors influencing exercise BP in adolescence and its association with cardiovascular risk in early life. Our previously published work showed that exercise BP is a potential useful method to detect adolescents with increased cardiovascular risk. Children and adolescents with cardiovascular risk factors are more likely to develop cardiovascular diseases later in life. However, previous studies on the clinical utility of exercise BP have largely focused on middle-to-older aged populations with pre-existing clinical conditions. Therefore, there is a need to investigate further the factors influencing exercise BP in adolescence and its association with future cardiovascular risk. Our previous studies, which focused on exercise BP measured at submaximal intensity, have shown that exercise BP is a potentially useful method for identifying adolescents at increased cardiovascular risk. Our previous findings suggest that improving cardio-respiratory fitness and reducing body fatness may help to reduce the risk of developing cardiovascular disease and improve overall cardiovascular health. These findings have important implications for the development of effective prevention and early detection strategies, which can contribute to improved public health outcomes.

Home blood pressure measurement self-reporting in real-life practices using the Hy-Result app: self-monitoring and digital pathway

Background

Little real-life information is available on the clinical characteristics of information and communication technologies (ICTs) users, particularly in the context of hypertension and home blood pressure measurement (HBPM). This retrospective observational study describes HBPM practices obtained through the Hy-Result® system, a validated app designed to help patients perform HBPM and understand their results through an automatic interpretation of the readings using web interface.

Methods

We analyzed 19,176 HBPM reports (sequence of 1 to 7 days of measurements; 3 in the morning, 3 in the evening) collected in real life circumstances from two groups of users: primary care (Prim) and hypertension center (Hosp).

Results

Population: among the 19,176 reports, 63.2% declared receiving antihypertensive medication, having diabetes (15.2%), chronic kidney disease (9.7%) or history of stroke (7.6%). Treated users were older than normotensives [mean ± standard deviation (SD) age 64±12 vs. 58±14 years] with higher prevalence of comorbidities. Compliance with the HBPM schedule: the majority of reports (90.2%) totaled 15 systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings or more, of which 96.1% were Hosp users and 89.3% Prim users, with a significant difference between both groups (P<0.001). The compliance rate for 7 days of measurement was higher in the Hosp group (57.6% vs. 30.5%; P<0.001). Blood pressure (BP) levels: in the 17,289 reports with a minimum of 15 readings, 42.7% had an average SBP and/or DBP above the recommended thresholds (below 135 and/or 85 mmHg), among whom, 36.8% were untreated subjects. Hosp users had better BP control than Prim (P<0.001). Users that are followed in the European Society of Hypertension (ESH) excellence center (Hosp) had better BP control than those in a Prim setting (P<0.001). HBPM oscillometric devices: in both groups, treated patients and untreated users, used the arm cuff devices more frequently than the wrist device.

Conclusions

Our real-life study shows that 90% of the HBPM reports include the required minimum number of BP readings to allow the calculation of a reliable average among whom 40% have uncontrolled BP levels. The self-management Hy-Result web app demonstrates significant potential for inclusion in the patient care process and reinforces the patient's engagement to independently monitor and self-reported their BP. When the mean BP is not within the recommended range, the users were automatically prompted by text messages to seek medical advice by the software. Further research should determine the extent to which users adhere to text messages advice.

Exploring primary care physicians' challenges in using home blood pressure monitoring to manage hypertension in Singapore: a qualitative study

Objective

Hypertension guidelines recommend using home blood pressure (HBP) to diagnose, treat and monitor hypertension. This study aimed to explore the challenges primary care physicians (PCPs) face in using HBP to manage patients with hypertension.

Method

A qualitative study was conducted in 2022 at five primary care clinics in Singapore. An experienced qualitative researcher conducted individual in-depth interviews with 17 PCPs using a semi-structured interview guide. PCPs were purposively recruited based on their clinical roles and seniority until data saturation. The interviews were audio-recorded, transcribed verbatim and managed using NVivo qualitative data management software. Analysis was performed using thematic analysis.

Results

PCPs identified variations in patients' HBP monitoring practices and inconsistencies in recording them. Access to HBP records relied on patients bringing their records to the clinic visit. A lack of seamless transfer of HBP records to the EMR resulted in an inconsistency in documentation and additional workload for PCPs. PCPs struggled to interpret the HBP readings, especially when there were BP fluctuations; this made treatment decisions difficult.

Conclusion

Despite strong recommendations to use HBP to inform hypertension management, PCPs still faced challenges accessing and interpreting HBP readings; this makes clinical decision-making difficult. Future research should explore effective ways to enhance patient self-efficacy in HBP monitoring and support healthcare providers in documenting and interpreting HBP.

Variability in home blood pressure and its association with renal function and pulse pressure in patients with treated hypertension in primary care

Blood pressure variability (BPV) represents a cardiovascular risk factor, regardless of mean level of blood pressure (BP). In this post-hoc analysis from the PERson-centredness in Hypertension management using Information Technology (PERHIT) study, we aimed to explore BPV in daily home measurements in hypertensive patients from primary care, to identify factors associated with high BPV and to investigate whether estimated glomerular filtration rate (eGFR) and pulse pressure, as markers of target organ damage (TOD), are associated with BPV. For eight consecutive weeks, 454 participants reported their daily BP and heart rate in their mobile phone, along with reports of lifestyle and hypertension-related factors. Systolic BP (SBP) values were used to calculate BPV with coefficient of variation (CV) as primary estimate. Background characteristics and self-reports were tested between fifths of CV in a linear regression model, adjusted for age and sex. Associations between BPV and eGFR and pulse pressure were tested with linear and logistic regression models. Higher home BPV was associated with higher age, BP, heart rate, and smoking. BPV was lower for participants with low alcohol consumption and treatment with calcium channel blockers. There was a significant association between BPV and pulse pressure (P = 0.015), and between BPV and eGFR (P = 0.049). Participants with high BPV reported more dizziness and palpitations. In conclusion, pulse pressure and eGFR were significantly associated with home BPV. Older age, high BP, heart rate, and smoking were associated with high BPV, but treatment with calcium channel blockers and low alcohol consumption was associated with low BPV. Trial registration: The study was registered with ClinicalTrials.gov [NCT03554382].

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

Objective

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

Methods

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

Results

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

Conclusions

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

A low dose of daily licorice intake affects renin, aldosterone, and home blood pressure in a randomized crossover trial

BACKGROUND

Licorice, through the effects of glycyrrhizic acid (GA), raises blood pressure (BP). The World Health Organization has suggested that 100 mg GA/d would be unlikely to cause adverse effects, but of 13 previously published studies none have been randomized and controlled and independently quantified the GA content.

OBJECTIVE

Our aim was to analyze the effects on home BP of a daily licorice intake containing 100 mg GA.

METHODS

Healthy volunteers were randomly assigned to start with either licorice or a control product in a nonblinded, 2 × 2 crossover study. Home BP was measured daily, and blood samples were collected at the end of each 2-wk period.

RESULTS

There were 28 participants and no dropouts. The median age was 24.0 y (interquartile range 22.8-27.0 y). During the licorice compared with control intake period, the systolic home BP increased [mean difference: 3.1 mm Hg (95% confidence interval [CI]: 0.8, 5.4 mm Hg) compared with -0.3 mm Hg (95% CI: -1.8, 1.3 mm Hg); P = 0.018] and renin and aldosterone were suppressed [mean change: -30.0% (95% CI: -56.7%, -3.3%) compared with 15.8% (95% CI: -12.8%, 44.4%); P = 0.003; and -45.1% (95% CI: -61.5%, -28.7%) compared with 8.2% (95% CI: -14.7%, 31.1%); P <0.001, respectively]. In the quartile of participants with the most pronounced suppression of renin and aldosterone, N-terminal prohormone of brain natriuretic peptide concentration increased during the licorice compared with control period [mean change: 204.1% (95% CI: -11.6%, 419.7%) compared with 72.4% (95% CI: -52.2%, 197.1%); P = 0.016].

CONCLUSIONS

We found licorice to be more potent than previously known, with significant increases in BP, after a daily intake of only 100 mg GA. Thus, the safe limit of intake of this substance might need to be reconsidered. This trial was registered at clinicaltrials.gov as NCT05661721 (https://clinicaltrials.gov/study/NCT05661721).

ACHIEVE conference proceedings: implementing action plans to reduce and control hypertension burden in Africa

The prevalence of hypertension, the commonest risk factor for preventable disability and premature deaths, is rapidly increasing in Africa. The African Control of Hypertension through Innovative Epidemiology, and a Vibrant Ecosystem [ACHIEVE] conference was convened to discuss and initiate the co-implementation of the strategic solutions to tame this burden toward achieving a target of 80% for awareness, treatment, and control by the year 2030. Experts, including the academia, policymakers, patients, the WHO, and representatives of various hypertension and cardiology societies generated a 12-item communique for implementation by the stakeholders of the ACHIEVE ecosystem at the continental, national, sub-national, and local (primary) healthcare levels.

Comparison of office, home and ambulatory blood pressure measurements in hypertensive and suspected hypertensive SWICOS participants

PURPOSE

Hypertension should be confirmed with the use of home BP measurement (HBPM) or 24h ambulatory BP measurement (ABPM). The aim of our study was to compare measurements obtained by OBPM, HBPM and ABPM in individuals with elevated OBPM participating in the population-based Swiss Longitudinal Cohort Study (SWICOS).

MATERIAL AND METHODS

Participants with OBPM ≥140/90 mmHg assessed their BP using HBPM and ABPM. The cut-off for hypertension was ≥135/85 mmHg for HBPM, ≥130/80 mmHg for ABPM. White-coat hypertension (WCH) was defined as normal HPBM and ABPM in participants not taking antihypertensive drugs. Uncontrolled hypertension was defined as hypertension in HBPM or ABPM despite antihypertensive treatment.

RESULTS

Of 72 hypertensive subjects with office BP ≥140/90 mmHg and valid measurements of HBPM and ABPM, 39 were males (aged 62.8 ± 11.8y), 33 were females (aged 57.4 ± 14.2y). Hypertension was confirmed with HBPM and ABPM in 17 participants (24%), with ABPM only in 24 further participants (33%), and with HBPM only in 2 further participants (3%). Participants who had hypertension according to ABPM but not HBPM were younger (59 ± 11 y versus 67 ± 16 y; p < 0.001) and more frequently still working (83% versus 23%; p < 0.001). The prevalence of WCH was 28%. Among the 32 subjects taking antihypertensive drugs, uncontrolled hypertension was found in 49%.

CONCLUSION

This population-based study found a high prevalence of WCH and potential uncontrolled hypertension among individuals with elevated OBPM. This study, therefore, supports the ESH recommendations of complementing OBPM by ABPM or HBPM. The use of HBPM instead of ABPM for the confirmation of hypertension in individuals with elevated OBPM might lead to underdiagnosis and uncontrolled hypertension, in particular in the younger working population. In these individuals, this study suggests using ABPM instead of HBPM.

GeogRaphic and socioecoNomic Distribution of real-world Indian data of home blood pressure monitoring (GRAND Study): Study protocol for an observational study in 18 medical centers across India

One-fourth of death in India is attributed to cardiovascular disease (CVD) and more than 80% is related to ischemic heart disease and stroke. The main risk factor for CVD is hypertension. Every third person in India suffers from hypertension and the prevalence increased drastically in the past 20 years, especially among the youngest age group of 20 and 44 years. Regardless of being under anti-hypertension medication, the blood pressure (BP) control rate in the country is still low ranging between 6% and 28% only. Assessing the "true BP control rate" should be performed using both clinic BP measurement and out-of-office BP measurement as the latter shows better prognosis for patients' hypertension and CVD outcomes. Home blood pressure monitoring (HBPM) shows superiority over ambulatory BP measurement as multiple measurements can be collected at the patient's convenience. Only limited evidence on HBPM in India is available and it's either lacking in hypertension participants or of a small sample size. This study will investigate the real BP control status among 2000 hypertensive patients from 18 centers in 12 states across Pan-India. The outcome of this study will emphasize the value of establishing BP control management practice guidelines suitable for physicians and help policymakers in building proper strategies for hypertension management to reduce the CVD burden on the health situation in India.

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Requirements for design and function of blood pressure measuring devices used for the management of hypertension: Consensus Statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability and STRIDE BP

OBJECTIVE

To develop scientific consensus recommendations for the optimal design and functions of different types of blood pressure (BP) measuring devices used in clinical practice for the detection, management, and long-term follow-up of hypertension.

METHODS

A scientific consensus meeting was performed by the European Society of Hypertension (ESH) Working Group on BP Monitoring and Cardiovascular Variability and STRIDE BP (Science and Technology for Regional Innovation and Development in Europe) during the 2022 Scientific Meeting of the ESH in Athens, Greece. Manufacturers were also invited to provide their feedback on BP device design and development. Thirty-one international experts in clinical hypertension and BP monitoring contributed to the development of consensus recommendations on the optimal design of BP devices.

STATEMENT

International consensus was reached on the requirements for the design and features of five types of BP monitors, including office (or clinic) BP monitors, ambulatory BP monitors, home BP monitors, home BP telemonitors, and kiosk BP monitors for public spaces. For each device type "essential" requirements (must have), and "optional" ones (may have) are presented, as well as additional comments on the optimal device design and features.

CONCLUSIONS

These consensus recommendations aim at providing manufacturers of BP devices with the requirements that are considered mandatory, or optional, by clinical experts involved in the detection and management of hypertension. They are also directed to administrative healthcare personnel involved in the provision and purchase of BP devices so that they can recommend the most appropriate ones.

Hypertension in chronic kidney disease-treatment standard 2023

Hypertension is very common and remains often poorly controlled in patients with chronic kidney disease (CKD). Accurate blood pressure (BP) measurement is the essential first step in the diagnosis and management of hypertension. Dietary sodium restriction is often overlooked, but can improve BP control, especially among patients treated with an agent to block the renin-angiotensin system. In the presence of very high albuminuria, international guidelines consistently and strongly recommend the use of an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker as the antihypertensive agent of first choice. Long-acting dihydropyridine calcium channel blockers and diuretics are reasonable second- and third-line therapeutic options. For patients with treatment-resistant hypertension, guidelines recommend the addition of spironolactone to the baseline antihypertensive regimen. However, the associated risk of hyperkalemia restricts the broad utilization of spironolactone in patients with moderate-to-advanced CKD. Evidence from the CLICK (Chlorthalidone in Chronic Kidney Disease) trial indicates that the thiazide-like diuretic chlorthalidone is effective and serves as an alternative therapeutic opportunity for patients with stage 4 CKD and uncontrolled hypertension, including those with treatment-resistant hypertension. Chlorthalidone can also mitigate the risk of hyperkalemia to enable the concomitant use of spironolactone, but this combination requires careful monitoring of BP and kidney function for the prevention of adverse events. Emerging agents, such as the non-steroidal mineralocorticoid receptor antagonist ocedurenone, dual endothelin receptor antagonist aprocitentan and the aldosterone synthase inhibitor baxdrostat offer novel targets and strategies to control BP better. Larger and longer term clinical trials are needed to demonstrate the safety and efficacy of these novel therapies in the future. In this article, we review the current standards of treatment and discuss novel developments in pathophysiology, diagnosis, outcome prediction and management of hypertension in patients with CKD.

Cardiorespiratory dynamics during respiratory maneuver in athletes

Introduction: The modern practice of sports medicine and medical rehabilitation requires the search for subtle criteria for the development of conditions and recovery of the body after diseases, which would have a prognostic value for the prevention of negative effects of training and rehabilitation tools, and also testify to the development and course of mechanisms for counteracting pathogenetic processes in the body. The purpose of this study was to determine the informative directions of the cardiorespiratory system parameters dynamics during the performing a maneuver with a change in breathing rate, which may indicate the body functional state violation.

Methods: The results of the study of 183 healthy men aged 21.2 ± 2.3 years who regularly engaged in various sports were analyzed. The procedure for studying the cardiorespiratory system included conducting combined measurements of indicators of activity of the respiratory and cardiovascular systems in a sitting position using a spiroarteriocardiograph device. The duration of the study was 6 min and involved the sequential registration of three measurements with a change in breathing rate (spontaneous breathing, breathing at 0.1 Hz and 0.25 Hz).

Results: Performing a breathing maneuver at breathing 0.1 Hz and breathing 0.25 Hz in comparison with spontaneous breathing leads to multidirectional significant changes in heart rate variability indicators–TP (ms2), LF (ms2), LFHF (ms2/ms2); of blood pressure variability indicators–TPDBP (mmHg2), LFSBP (mmHg2), LFDBP (mmHg2), HFSBP (mmHg2); of volume respiration variability indicators - LFR, (L×min-1)2; HFR, (L×min-1)2; LFHFR, (L×min-1)2/(L×min-1)2; of arterial baroreflex sensitivity indicators - BRLF (ms×mmHg-1), BRHF (ms×mmHg-1). Differences in indicators of systemic hemodynamics and indicators of cardiovascular and respiratory systems synchronization were also informative.

Conclusion: According to the results of the study, it is shown that during performing a breathing maneuver with a change in the rate of breathing, there are significant changes in cardiorespiratory parameters, the analysis of which the increments made it possible to determine of the changes directions dynamics, their absolute values and informative limits regarding the possible occurrence of the cardiorespiratory interactions dysregulation.

Cardiorespiratory dynamics during respiratory maneuver in athletes

Introduction: The modern practice of sports medicine and medical rehabilitation requires the search for subtle criteria for the development of conditions and recovery of the body after diseases, which would have a prognostic value for the prevention of negative effects of training and rehabilitation tools, and also testify to the development and course of mechanisms for counteracting pathogenetic processes in the body. The purpose of this study was to determine the informative directions of the cardiorespiratory system parameters dynamics during the performing a maneuver with a change in breathing rate, which may indicate the body functional state violation. Methods: The results of the study of 183 healthy men aged 21.2 ± 2.3 years who regularly engaged in various sports were analyzed. The procedure for studying the cardiorespiratory system included conducting combined measurements of indicators of activity of the respiratory and cardiovascular systems in a sitting position using a spiroarteriocardiograph device. The duration of the study was 6 min and involved the sequential registration of three measurements with a change in breathing rate (spontaneous breathing, breathing at 0.1 Hz and 0.25 Hz). Results: Performing a breathing maneuver at breathing 0.1 Hz and breathing 0.25 Hz in comparison with spontaneous breathing leads to multidirectional significant changes in heart rate variability indicators-TP (ms2), LF (ms2), LFHF (ms2/ms2); of blood pressure variability indicators-TPDBP (mmHg2), LFSBP (mmHg2), LFDBP (mmHg2), HFSBP (mmHg2); of volume respiration variability indicators - LFR, (L×min-1)2; HFR, (L×min-1)2; LFHFR, (L×min-1)2/(L×min-1)2; of arterial baroreflex sensitivity indicators - BRLF (ms×mmHg-1), BRHF (ms×mmHg-1). Differences in indicators of systemic hemodynamics and indicators of cardiovascular and respiratory systems synchronization were also informative. Conclusion: According to the results of the study, it is shown that during performing a breathing maneuver with a change in the rate of breathing, there are significant changes in cardiorespiratory parameters, the analysis of which the increments made it possible to determine of the changes directions dynamics, their absolute values and informative limits regarding the possible occurrence of the cardiorespiratory interactions dysregulation.

Blood Pressure Variability as a Risk Factor for Cardiovascular Disease: Which Antihypertensive Agents Are More Effective?

Blood pressure oscillations during different time scales, known as blood pressure variability (BPV), have become a focus of growing scientific interest. BPV can be measured at long-term (seasonal variability or visit-to-visit), at mid-term (differences in consecutive days or weeks) or at short-term (day-night differences or changes induced by other daily activities and conditions). An increased BPV, either at long, mid or short-term is associated with a poor cardiovascular prognosis independently of the amount of blood pressure elevation. There is scarce evidence on the effect of different antihypertensive treatments on BPV, but some observational and interventional studies suggest that calcium channel blockers in general, and particularly amlodipine, either in monotherapy or combined with renin-angiotensin system blockers, can reduce BPV more efficiently than other antihypertensive drugs or combinations. Nevertheless, there are several aspects of the relationship between BPV, antihypertensive treatment, and clinical outcomes that are still unknown, and more work should be performed before considering BPV as a therapeutical target in clinical practice.

Peak home blood pressure as an earlier and strong novel risk factor for stroke: the practitioner-based nationwide J-HOP study extended

While home blood pressure (BP) measurement is recommended for hypertension management, the clinical implications of peak home BP values have not been well studied. This study investigated the association between pathological threshold or frequency of peak home BP and cardiovascular events in patients with ≥1 cardiovascular risk factor. The Japan Morning Surge-Home Blood Pressure (J-HOP) study enrolled participants from 2005-2012 with extended follow-up from December 2017 to May 2018, which generated the dataset for this analysis. Average peak home systolic BP (SBP) was defined as average of the highest three BP values on 14-day measurement period. Patients were divided into quintiles of peak home BP, and the risk of stroke, coronary artery disease (CAD) and atherosclerotic cardiovascular disease (ASCVD; stroke+CAD) was determined. In 4231 patients (mean 65 years) followed for 6.2 years there were 94 strokes and 124 CAD events. The adjusted hazard ratio (HR) (95% CI) for the risk of stroke and ASCVD in patients with average peak home SBP in the highest versus lowest quintile was 4.39 (1.85-10.43) and 2.04 (1.24-3.36), respectively. Risk was greatest for stroke in the first 5 years: HR 22.66 (2.98-172.1). The pathological threshold of average peak home SBP for 5-year stroke risk was 176 mmHg. There was a linear association between the number of times peak home SBP > 175 mmHg and stroke risk. Peak home BP was a strong risk factor for stroke, especially within the first 5 years. We propose exaggerated peak home SBP > 175 mmHg as an early and strong novel risk factor for stroke.

Telemedicine and Digital Medicine in the Clinical Management of Hypertension and Hypertension-Related Cardiovascular Diseases: A Position Paper of the Italian Society of Arterial Hypertension (SIIA)

High blood pressure is the leading cause of death and disability globally and an important treatable risk factor for cardiovascular, cerebrovascular and chronic kidney diseases. Digital technology, including mobile health solutions and digital therapy, is expanding rapidly in clinical medicine and has the potential to improve the quality of care and effectiveness of drug treatment by making medical interventions timely, tailored to hypertensive patients' needs and by improving treatment adherence. Thus, the systematic application of digital technologies could support diagnosis and awareness of hypertension and its complications, ultimately leading to improved BP control at the population level. The progressive implementation of digital medicine in the national health systems must be accompanied by the supervision and guidance of health authorities and scientific societies to ensure the correct use of these new technologies with consequent maximization of the potential benefits. The role of scientific societies in relation to the rapid adoption of digital technologies, therefore, should encompass the entire spectrum of activities pertaining to their institutional role: information, training, promotion of research, scientific collaboration and advice, evaluation and validation of technological tools, and collaboration with regulatory and health authorities.

Validation of the Withings BPM Core Device for Self-Blood Pressure Measurements in General Population According to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization Universal Standard

Background

Most of the scientific societies recommend assessing the accuracy of electronic devices for blood pressure (BP) measurements using established validation protocol.

Objective

To determine the accuracy of the BP measurements using the Withings BPM Core device in the general population according to the "Universal Standard (ISO 81060-2:2018/AMD 1:2020)".

Methods

The Withings BPM Core is an oscillometric device measuring BP at the brachial level. The study was performed according to the "Universal Standard (ISO 81060-2:2018/AMD 1:2020) protocol" using the same-arm sequential BP measurement method. Subjects (n ≥ 85) fulfilling the age, gender, BP, and cuff distribution criteria of the protocol were included. Analysis was performed as required by the Universal protocol using Criterion 1 - differences between observers' mercury sphygmomanometer reference measurements and test device BP values (test versus reference) and their standard deviation (SD); and Criterion 2 - The SD of the mean BP differences between the test device and reference BP per subject.

Results

Eighty-six subjects were selected, 85 of whom were included. The mean BP differences between the simultaneous two observers' measurements were -0.2 ± 2.1 mmHg for systolic BP (SBP) and 0.3 ± 2.1 mmHg for diastolic BP (DBP). For validation criterion 1, the mean difference ± SD between the reference and device BP values was -0.6 ± 4.8 mmHg for SBP and 0.1 ± 3.7 mmHg for DBP (≤5 ± 8 mmHg for both SBP and DBP). For criterion 2, the SD of the mean BP differences between the test device and reference BP per subject was 3.2/2.6 mmHg for SBP and DBP (≤6.91/6.95 mmHg).

Conclusion

The results of this study showed that the Withings BPM Core oscillometric device for home BP measurement fulfilled the accuracy requirements of the (ISO 81060-2:2018/AMD 1:2020) Universal protocol in the general population.

Masked hypertension in a middle-aged population and its relation to manifestations of vascular disease

BACKGROUND

Masked hypertension is associated with cardiovascular disease (CVD). However, previous large studies have not used the same device to measure office and home blood pressure (BP) and adhered to current home BP measurement recommendations of the European Society of Hypertension. We aimed to characterize masked hypertension and explore its relation to manifestations of CVD.

METHODS

A randomly selected cohort of 5057 participants aged 50-64 years from the Swedish CardioPulmonary BioImage Study (SCAPIS) was evaluated with office and home BP using the semi-automatic Omron M10-IT oscillometric device. Additional analyses included pulse wave velocity (PWV) and coronary artery calcium score (CACS).

RESULTS

Of participants, 4122 did not have current antihypertensive treatment, and were thus included in our analyses. Of these, 2634 (63.9%) had sustained normotension, and 172 (4.2%) had masked hypertension. Participants with masked hypertension vs. sustained normotension were more often men (66.9 vs. 46.2%, P  < 0.001). Those with masked hypertension had higher mean PWV [9.3 (95% confidence interval, 95% CI 9.1-9.5) vs. 8.3 (95% CI 8.2-8.4) m/s, P  < 0.001] and odds ratio for CACS at least 100 [1.65 (95% CI 1.02-2.68), P  = 0.040]. These associations were similar in a posthoc analysis of masked hypertension and sustained normotension, matched for age, sex and systolic office BP.

CONCLUSION

Masked hypertension was associated with markers of CVD. This suggests that home BP is a better predictor of risk, even when the recordings are performed with the same measurement device, in a population-based setting with randomized recruitment.

Obesity-related hypertension: Implications for advanced nursing practice

ABSTRACT

Obesity increases the risk of hypertension and other cardiometabolic comorbidities. Lifestyle modifications are usually recommended, though lasting effects on weight and BP reduction are limited. Weight-loss medications, especially incretin mimetics, are effective for short- and long-term treatment. Metabolic surgery provides cure of obesity-related hypertension in some patients. NPs are well positioned to manage obesity-related hypertension to improve clinical outcomes of affected individuals.

Development and Initial Use of an Evidence-Based Home Blood Pressure Monitoring mHealth Platform

Home blood pressure monitoring (HBPM) has been shown to provide a more reliable assessment of blood pressure (BP) than in-office measurement and may lead to improved BP control. While many mHealth apps are available to help users track their blood pressure (BP), no apps incorporate the full set of evidence-based HBPM recommendations for ensuring accurate measurement at home. Through an agile development approach employing user stories, we translated an evidence-based standardized protocol for BP measurement and monitoring over a recommended 3-7 day monitoring period into a mHealth app and corresponding clinician portal. We then pilot tested this platform to assess its feasibility for guiding users to measure BP over multiple days according to this protocol. During this pilot testing, one hundred and twenty five users created an app account; 75 (60.0%) of these users recorded at least one BP reading and 47 (37.6%) completed at least one monitoring period. Through this work, we have demonstrated how a series of guidelines can be systematically translated into a mHealth platform for HBPM. Such platforms may be accessible resources to facilitate standardized HBPM and sharing of readings with providers.

Accuracy of a smartphone application for blood pressure estimation in Bangladesh, South Africa, and Tanzania

Undetected and unmonitored hypertension carries substantial mortality and morbidity, especially during pregnancy. We assessed the accuracy of OptiBPTM, a smartphone application for estimating blood pressure (BP), across diverse settings. The study was conducted in community settings: Gaibandha, Bangladesh and Ifakara, Tanzania for general populations, and Kalafong Provincial Tertiary Hospital, South Africa for pregnant populations. Based on guidance from the International Organization for Standardization (ISO) 81,060-2:2018 for non-invasive BP devices and global consensus statement, we compared BP measurements taken by two independent trained nurses on a standard auscultatory cuff to the BP measurements taken by a research version of OptiBPTM called CamBP. For ISO criterion 1, the mean error was 0.5 ± 5.8 mm Hg for the systolic blood pressure (SBP) and 0.1 ± 3.9 mmHg for the diastolic blood pressure (DBP) in South Africa; 0.8 ± 7.0 mmHg for the SBP and -0.4 ± 4.0 mmHg for the DBP in Tanzania; 3.3 ± 7.4 mmHg for the SBP and -0.4 ± 4.3 mmHg for the DBP in Bangladesh. For ISO criterion 2, the average standard deviation of the mean error per subject was 4.9 mmHg for the SBP and 3.4 mmHg for the DBP in South Africa; 6.3 mmHg for the SBP and 3.6 mmHg for the DBP in Tanzania; 6.4 mmHg for the SBP and 3.8 mmHg for the DBP in Bangladesh. OptiBPTM demonstrated accuracy against ISO standards in study populations, including pregnant populations, except in Bangladesh for SBP (criterion 2). Further research is needed to improve performance across different populations and integration within health systems.